AM report PEARLS 11/24: pericarditis, Wellen’s sign, and a touch of nasopharyngeal cancer

3 totally unrelated take-home PEARLS from today:

  1. Daily ditty PEARL on hypercalcemia: thanks to Peter for sharing our favorite phosphate to calcium ratio pearl when we think about hypercalcermia: a serum chloride/phos ratio of >33 has very high sensitivity and specificity for hyperparathyroidism! Check out the attached article.
    1. Then, thank you to Brad for reminding us that this can be very helpful in guiding our initial w/u and management, with the reminder that in steroids can be helpful in the treatment of hypercalcemia from granulomatous disease.
  2. PEARL from the case: young women with SLE have 55x greater risk for CAD than young, healthy women! They are also at increased risk of pericardial, myocardial, and valvular heart disease. Pericarditis is the most common way that lupus affects the heart.
  3. PEARL from image of nasopharyngeal cancer: always think about EBV-association, particularly in patients from Southeast Asia, North Africa and the Middle East!! Can be CURED with chemo and radiation* (*depending on type of NPC – see below!!)


A few other teaching points from the case:


  • 4 stages of EKG changes in pericarditis (thanks Greg)!
  1. Diffuse STE (in first 2 weeks)
  2. Normalization of STE, flattening of T waves (1-3 weeks)
  3. TW inversion (3+ weeks)
  4. Return to baseline EKG
  • Wellen’s sign:
    • 2 patterns of abnormality of V2-3 (and can extend to V1-6) (here is a great website: thanks Kevin!
      1. Type A: biphasic, with initial positivity and terminal negativity (25% of cases)
      2. Type B: deeply and symmetrically inverted (75% of cases)
    • 3 things on ddx (don’t miss!)
      1. Critical stenosis of LAD
      2. Intracrancial hemorrhage
      3. Takatsubo’s

And just a bit more about nasopharyngeal cancer (so fascinating!):

  • Classic triad (rare to have all 3): neck mass, nasal obstruction with epistaxis, and serous otitis media
  • 3 WHO histopathologic types:
    • Keratinizing SCC (sporadic form)
    • Nonkeratinizing carcinoma – strongly associated with EBV and has a more favorable prognosis! Interestingly, pretreatment EBV DNA levels may have prognostic value and there is emerging evidence that monitoring post-treatment may have a role in monitoring response/recurrence
    • Basaloid SCC – rare, aggressive, poor prognosis
  • Screening for EBV?! Interestingly, because of high rates of NPC in some geographic regiosn + high cure rate for early stage cancer, screening is offered to first-degree relatives with NPC by a few onc centers in Southern China! But, this is still debatable.




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