Health Awareness blog

• Diabetes mellitus – Patients usually present with polyuria (urinate a lot), polydipsia (drink a lot) and polyphagia (eat a lot). The patients usually has a concurrent weight loss.
• Hypothyroidism – fatigue is a prominent features apart of other symptoms like weight gain, cold intolerance dry skin, constipation and menstrual irregularities
• Drugs – beta blockers, reserpine, diuretics (mainly due to hypokalemia), antihistamine, antidepressants, tranquilizers, steroids, narcotics, alcohol, etc
• Chronic sleep deprivation
• Congestive heart failure – fatigue in this patients indicated reduce cardiac output.
• Occult infection
• Iron deficiency anemia
• Obstructive sleep apnea – excessive daytime somnolence
• Renal failure
• Chronic fatigue syndrome – the fatigue lasting longer than 6 months duration. The affected person usually has less than 50% reduction of their physical capacity.
• Cushing syndrome
• Occult cancer – common cancers associated with fatigue are leukemia, lymphoma and pancreatic cancer. The patients usually also have adenopathy, lymphadenopathy and night sweats.
• Addison disease
• Myasthenia gravis – early stage of illness involves the cranial muscles lead to ptosis, diplopia and chewing fatigue. Muscle weakness exacerbated by repeated use.
• Infectious mononucleosis – acute onset of prominent fatigue
• Depression – patients usually have symptoms of fatigue, sleep disturbance, anorexia and anhedonia (loss interest of any activity)
• Panic disorder
• Somatization disorder

Reference:

1. Murray Longmore et al. Oxford Handbook of Clinical Medicine. 7^th edition.
2. David S. Smith et al. Field Guide to Bedside diagnosis. 2^nd edition. 2007. Lippincott Williams and Wilkins.
3. Tao Le et al. First Aid for the Family Medicine Boards. McGraw Hill. 2008.

Renal cell carcinoma is the cancer of the kidney. The cancer is arises from the proximal renal tubular epithelium. It is also known as hypernephroma or Grawitz tumor. Renal cell carcinoma consist of 90% of all renal cancer. Mean age is 55 years old with male predominant to female by 2:1. About 15% patients on hemodialysis will end up with this disease.

The classic triad of the presentation symptoms are flank pain, palpable abdominal mass and hematuria (blood stained urine). However patient not usually present with all these three symptoms. Other non specific symptoms are anorexia, malaise (general feeling of being unwell), fatigue, weight loss and pyrexia of unknown origin. All of these symptoms may occur in isolation. About 50% of cases been diagnosed by incidental abdominal imaging for other reasons where the patients might not have any symptom at all. Rarely, the cancer will invade the left renal vein which later compresses the left testicular vein and results a left varicocele. Spreading of the disease may occur direct via the renal veins. It also may occur via the lymph nodes or hematogenous and cause metastases to bone, liver and lung.

Risk factors for renal cell carcinoma include smoking, obesity, end stage renal disease and hypertension. This type of cancer also noted to have association with von Hippel-Lindau gene mutation on chromosome 3 where it is found in more than 50% of sporadic cases. The mutation is the cause of hereditary clear cell renal carcinoma.
Investigation wise consist of blood investigation, urine analysis and imaging techniques. Full blood count (FBC) is send to look for polycythemia results by increase of erythropoietin secretion. Other tests are Erythrocyte Sedimentation Rate (ESR), urea and electrolytes and alkaline phosphatase (ALP) level. ALP will be high in bony metastases. Urine analysis is done to look for red blood cell (RBC) and urine cytology.

In diagnosing renal cell carcinoma, abdominal ultrasound is a very useful technique to distinguish between a benign cyst, complex cyst or tumor. CT scan and MRI of the abdomen will be superior to abdominal ultrasound where we can see a multinodular mass with thickened, irregular walls and septae. Contrast injection will enhance image. Occasionally, percutaneous biopsy is used in diagnosing a renal cell carcinoma. Renal angiography is indicated if partial nephrectomy or palliative embolization is considered. Intravenous Urography (IVU) is useful to look for the filling defect of the kidney with or without calcification. Chest X ray is send especially in suspicion of metastases to the lung where “cannon ball” lesion can be visualized.

In terms of treatment, radical nephrectomy is considered a gold standard. Partial or radical nephrectomy is usually offered to those which disease involving the kidney alone (renal carcinoma stage I and II). There may be a role for nephron sparing surgery in small cancer measure 4cm or less. In renal carcinoma stage III, where there is limited invasion of the cancer, radical nephrectomy should be done. In those with stage IV, where there is extensive invasion or metastases to other organs, nephrectomy can be done as palliative operation. So far, there is no chemotherapy regime that is found to be effective in management of stage IV renal cell carcinoma. On the other hand, we can consider immunotherapy with IFN-alpha or interlukin-2 to patient with metastases renal cell carcinoma. This therapy has been shown to induce an immune response against tumor cells.

Common paraneoplastic syndromes associated with this cancer is erythrocytosis, hypercalcemia and anemia. Hepatopathy and amyloidosis also associated with this type of cancer. 5 year survival rate is only 45%.

Reference:
1. Christine Dehlendoref, MD et al. First Aid for the Family Medicine Boards. 2008. McGraw Hill Medical
2. Murray Longmore et al. Oxford handbook of Clinical Medicine. 7th edition. 2008.