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* Pearls:
  malak - 11/04/06 13:48
1. Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia. ull evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.

2. Esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida is most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day.

3. Cryptococcal meningitis in HIV: minority of p atients have meningeal signs; most have only fever and headache. Obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)—can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions. How do you treat? Treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life.

4. LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV ).

5. Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; Pneumocystis carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP.

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