Case Presentation Febrile Neutropenia Nizar

Case presentation:
Hemolytic Anaemia
NIZAR I.J, MBBS
INTERN OF INTERNAL MEDICINE
HMG OLAYA COMPLEX
 
Content
History of presenting illness
Physical examination
Investigations
Differential Diagnosis
Conclusion
 

Chief complaint
A 65 years old Diabetic Pakistani female,

complaining of fever, difficulty in breathing and
desaturation since 5 days before admission
History of presenting illness
Actually the condition started when the patient had an

episodes fever and shevering for 5 days, after coming from
Pakistan temperature was 39 - 40C
Then the patient complained of Shortness of Breath at

rest and was desaturated with respiratory distress

PAST MEDICAL HISTORY
Systemic Review:
- patient complained of drowsiness and dizziness
Decreased urine output, other Systems are all clear
Past Medical History:
- type II - DM on metformin and Sitagliptin
- No PMH of similar condition

 

Family History:
- No family history of similar condition
Positive family history of chronic diseases DM, HTN
Drug History:
- patient on metformin and sitagliptin
- patient is allergic to dry foods and nuts. And also allergic to some antibiotics
which was not specified by her
Social History:
- no bad habits, no home animals, have medical insurance
 

Physical examination
General look : looks ill, excessive sweating,
alert, slightly confused, not in distress now
Hands: regular pulse, no clubbing of fingers
Eyes: No pale or Jaundice
Mouth : No Central cyanosis
Neck: No LN enlargements

Chest Examination
Chest wall is symmetric. Without deformity
No tenderness is appreciated upon palpation of the chest

wall
The patient doesn't exhibit respiratory distress, but was

distressed in the ICU
Slight bibasal crackles
Resonance is normal upon percussion of all lung fields
Systemic examination
CVS: S1, S2 +0
Abdomen: Soft and lax, mild epigastric tenderness
CNS: conscious, oriented, intact motor and sensor across all
limbs, with right calf muscle swelling and hotness
Vital signs
TEMPERATURE: 38.3 C
PULSE RATE: 80/min

RESPIRATORY RATE: 20/min
BLOOD PRESSURE: 120/80

SPO2: 95%
WEIGHT: 70 kg
HIGHT: 152 cm
investigations
LABORATORY:
Total = 6.8
WBC
Neutrophils = 2.5 normal
Lymphocytes = 0.20
CRP 121
RBC = 3.8 low

CBC
HBG = 11 low
LDH 300 unit/ L
Bilirubin total 2 mg/dl

investigations
Cultures:
Stool : Occult blood, no ova or parasites
Malaria Smear - negative
Plan
Septic Workup
Perfalgan 1gm IV Q6H
Pantozol prophylactic 40mg IV once daily
Clexane prophylactic 60mg once daily
Insuline 4 Units SC Q4H
Lornoxicam (NSAID) 8 GM BID IV
Zyrtec 5 mg OD PO
Sulfa-metho-xazole (bactrime) 1 tab BID PO
Doxycycline 1 tab BID PO
Deferential diagnosis
Falciparum Malaria
Salmonella Typhoid
Brucellosis
Fungal infection
Abdominal TB
HIV
Hemolytic Anaemia
Hemolysis: is the premature breakdown of RBCS
It classified as: intravascular (occurs in the circulation) or

extravascular (in the reticuloendothelial system, ie macrophages of
liver, spleen, and bone marrow)
may be asymptomatic, but if the bone marrow does not compensate

sufficiently, a hemolytic anaemia results

How to Approach
to confirm hemolysis and then find the cause try to answer these
four questions:
1) is there increased red cell breakdown?
• Anaemia with normal or increased MCV.
• increased Bilirubin: unconjugated
• increased Urinary urobilinogen
• increased Serum LDH
How to Approach
2) Is there increased red cell production?
• increased Reticulocytes, causing increased MCV (reticulocytes

are large immature RBCS)
How to Approach
3) Is the hemolysis mainly extra- or intravascular?
Extravascular hemolysis = splenic hypertrophy and splenomegaly
intravascular hemolysis =
• free plasma hemoglobin: released from RBCS.
• Methaemalbuminaemia:
• Plasma haptoglobin: mops up free plasma Hb, then removed by the liver.
• Hemoglobinuria: causes red-brown urine, in absence of red blood cells.
• Haemosiderinuria

How to Approach
4) What is the cause of the hemolysis?

Work up
FBC, reticulocytes, bilirubin, LDH, haptoglobin, urinary urobilinogen. Thick and thin lms for malaria screen if
history of travel. The blood lm may show poly chromasia and macrocytosis due to reticulocytes, or point to the
diagnosis:
Further tests (if the cause is sti not obvious)
• Osmotic agility testing wi con rm the presence of membrane abnormalities which have been identi ed on the
lm.
• Hb electrophoresis wi detect haemoglobinopathies.
• The direct antiglobulin (Coombs) test
• Enzyme assays when other causes have been excluded.

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What are the causes
Acquired Hereditary
1. Immune-mediated/direct
antiglobulin test +ve Coombs test: 1. Enzyme defects: (G6PD, Pyruvate
(Drug-induced, Autoimmune kinase de ciency)
haemolytic anaemia) 2. Membrane defects: (Hereditary
2. Direct antiglobulin/Coombs Ωve spherocytosis, Hereditary
AIHA: (autoimmune hepatitis) elliptocytosis, Hereditary ovalocytosis
3. Microangiopathic haemolytic and stomatocytosis
anaemia (MAHA)
fi
What are the causes
Acquired Hereditary
4. Infection: Malaria
3. Hemoglobinopathy:
• Sickle-cell disease
5. Paroxysmal nocturnal
• Thalassaemia
hemoglobinuria
“ Give me problems, give me work, I crave for mental
exaltation, that’s why I have chosen my own particular
profession”
— Sherlock Holmes

Case Presentation Febrile Neutropenia Nizar

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Case presentation:

History of presenting illness

A 65 years old Diabetic Pakistani female,

Actually the condition started when the patient had an

Then the patient complained of Shortness of Breath at

PAST MEDICAL HISTORY

- patient complained of drowsiness and dizziness

Decreased urine output, other Systems are all clear

Past Medical History:

- type II - DM on metformin and Sitagliptin

- No PMH of similar condition

- No family history of similar condition

Positive family history of chronic diseases DM, HTN

- patient on metformin and sitagliptin

Hands: regular pulse, no clubbing of fingers

Eyes: No pale or Jaundice

Mouth : No Central cyanosis

No tenderness is appreciated upon palpation of the chest

The patient doesn't exhibit respiratory distress, but was

Slight bibasal crackles

Resonance is normal upon percussion of all lung fields

PULSE RATE: 80/min

BLOOD PRESSURE: 120/80

RBC = 3.8 low

LDH 300 unit/ L

Bilirubin total 2 mg/dl

Stool : Occult blood, no ova or parasites

Malaria Smear - negative

Perfalgan 1gm IV Q6H

Pantozol prophylactic 40mg IV once daily

Clexane prophylactic 60mg once daily

Insuline 4 Units SC Q4H

Lornoxicam (NSAID) 8 GM BID IV

Sulfa-metho-xazole (bactrime) 1 tab BID PO

Doxycycline 1 tab BID PO

Hemolysis: is the premature breakdown of RBCS

It classified as: intravascular (occurs in the circulation) or

may be asymptomatic, but if the bone marrow does not compensate

1) is there increased red cell breakdown?

• Anaemia with normal or increased MCV.

• increased Bilirubin: unconjugated

• increased Urinary urobilinogen

• increased Serum LDH

2) Is there increased red cell production?

• increased Reticulocytes, causing increased MCV (reticulocytes

Extravascular hemolysis = splenic hypertrophy and splenomegaly

• free plasma hemoglobin: released from RBCS.

• Hemoglobinuria: causes red-brown urine, in absence of red blood cells.

4) What is the cause of the hemolysis?

Further tests (if the cause is sti not obvious)

• Hb electrophoresis wi detect haemoglobinopathies.

• The direct antiglobulin (Coombs) test

• Enzyme assays when other causes have been excluded.

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