persistent hypoalbuminaemia and anaemiabsmedicine.org/congress/2008/dr._sonia_nasreen_ahmad.pdf ·...
TRANSCRIPT
![Page 1: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/1.jpg)
A case of persistent
hypoalbuminaemia and anaemia
Dr Sonia Nasreen Ahmad
Department of Medicine
BSMMU
![Page 2: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/2.jpg)
Patient Profile
Mrs Aleya Begum
39 year old female
Married
Housewife
City dweller
Lower middle class socio-economic income group
![Page 3: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/3.jpg)
Presenting complaints
Repeated episodes of joint pain over 4 years
Swelling of the legs and abdomen over the past one month
![Page 4: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/4.jpg)
Joints involved: Small and large joints of upper and lower limbs and low back
Symmetrical
Morning stiffness
Relieved by taking NSAIDs
Intervening time pain free.
![Page 5: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/5.jpg)
Associated features
Lightheaded
Fatigue
Often not able to carry out daily activities due to tiredness
![Page 6: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/6.jpg)
Diagnosed in March 2007
Hypothyroid – Subclinical (Thyroxine commenced)
![Page 7: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/7.jpg)
Current episode
Swelling of legs and abdomen
Face not involved
![Page 8: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/8.jpg)
No history of Dyspnoea
Orthopnea
Chest pain
Scanty micturition
Haematemesis/Malaena
Oral ulcer
Red eyes
Nail changes
Bowel disturbances
Weight loss
![Page 9: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/9.jpg)
Drug History:
Thyroxine 100 micrograms/day (withdrawn)
Repeated blood transfusions
NSAIDs (Diclofenac)
Paracetamol
![Page 10: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/10.jpg)
Past medical history: Nothing remarkable
Family history: Not known to suffer from any chronic disease
![Page 11: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/11.jpg)
Examination Findings
Oedematous Pulse : 108/min
Blood Pressure: 90/60mmHg
Afebrile
Weight: 55kg
![Page 12: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/12.jpg)
Examination Findings (Cont.d)
Grade 2 tenderness – MCP, PIP, DIP, MTP, SI joints (on admission)
No swelling
No deformities
Ascites
No organomegaly
![Page 13: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/13.jpg)
Investigations
Hb (gm/dl):
April 2006: 8.8, 11.6 (BT)
September 2007: 4.92
February 2008: 8.8, 13.25 (BT)
March 2008: 10.6
ESR: 15-40 mm in the first hour
CRP: 22.6mg/l
![Page 14: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/14.jpg)
Peripheral blood film
April 2006: Microcytic hypochromic anaemia with neutrophil leucocytosis
March 2007: Non-specific morphology (Normocytic normochromic
September 2007: Non-specific morphology (Normocytic normochromic)
February 2008: Non-specific morphology (Anisocytosis and anisochromia)
March 2008: Anisochromia and anisocytosis, microcytic hypochromic cells seen
![Page 15: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/15.jpg)
Bone Marrow Study
Hypercellular marrow with increased M:E ratio
Erythropoiesis active and shows micronormoblastic changes
Granulopoiesis is hyperactive and maturing into segmented forms
Megarkaryopoiesis is normal
Plasma cells and lymphocytes normal
No ectopic cells or parasites seen
Comment: Myeloid Hyperplasia
![Page 16: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/16.jpg)
14.2.08: Hb electrophoresis: Beta thalassemia trait
Urine microscope examination: Normal
![Page 17: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/17.jpg)
S.bilirubin: 10 micromol/l (5-20)
SGPT: 48 U/l
Prothrombin time:10.8 (11.6)
HBsAg: Negative
Anti-HCV: Negative
S. Creatinine: 0.7mg/dl
Urinary total protein: 0.14gm/day
![Page 18: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/18.jpg)
Serum Albumin
March 2007: 2.94 g/dl (3.8-4.4)
August 2007: 1.88g/dl
Feb 2008 :23.4g/L (35-50);{S.Total Protein-53.2 ( 35-57)}
March 2008 : 2.8g/dl; {S.Total Protein- 5 (6.4-8.3)}
![Page 19: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/19.jpg)
Thyroid Function Test
March 2007
TSH: 9.52 mIU/L (0.3-5)
FT3: 2.43 pmol/L (2.8-9.5)
FT4: 10.23 pmol/L (9.5-25.5)
February 2008
TSH: 5.34 mIU/L (0.3-5)
![Page 20: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/20.jpg)
Chest X-ray (P/A view): Normal
![Page 21: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/21.jpg)
Ultra sonogram of abdomen:
Presence of free fluid in the pelvic cavity
No organomegaly
![Page 22: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/22.jpg)
X-ray Lumbo-sacral spine (Oblique view): Marginal sclerosis of left sacroiliac joint
![Page 23: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/23.jpg)
Iron Profile
S. Total iron: 78 microgram/dl ( 50-170)
S. TIBC: 289 microgram/dl ( 250-425)
S. Ferritin: 111.09 microgram/l (22-120)
![Page 24: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/24.jpg)
ANA : Negative
Anti DS DNA : Negative
Anti- CCP : Negative
RA : Negative
Coomb’s test: Negative (D&I)
![Page 25: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/25.jpg)
Occult blood test (Stool):
Positive
![Page 26: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/26.jpg)
Endoscopy of Upper GIT: Normal
Biopsy (duodenum): Chronic duodenitis
![Page 27: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/27.jpg)
Colonoscopy upto terminal ileum: Normal
Biopsy (terminal ileum): Chronic ileiitis
![Page 28: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/28.jpg)
Barium Follow through of Small Intestine
Barium passed through ileo-coecal junction
Spasm in terminal ileum
Spasm of coecal pole which is at a higher level
![Page 29: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/29.jpg)
![Page 30: Persistent Hypoalbuminaemia and Anaemiabsmedicine.org/congress/2008/Dr._Sonia_Nasreen_Ahmad.pdf · A case of persistent hypoalbuminaemia and anaemia Dr Sonia Nasreen Ahmad Department](https://reader034.vdocument.in/reader034/viewer/2022042809/5f928eddfae35931a86b3760/html5/thumbnails/30.jpg)
Dilemmas
Hb (gm/dl) has dropped from 13.25 to 10.6 in two weeks. Source?
Patient remains hypoalbuminaemic. Why?