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A 31-year-old female with anaemia and jaundice

Presenter

DR.KAZI FAZLUR RAHMAN

Resident, phase-B

Haematology

BSMMU

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Particulars-

  • Name- Mrs. poly
  • Age- 31y
  • Sex-Female
  • Religion- Islam
  • Occupation- House wife
  • Address-kustia

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Presentations-

  • Generalized weakness for 1 year
  • Yellowish discolouration of eye for 1 year

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  • Generalized weakness :
  • Progressive
  • Associated with -
  • Exertional shortness of breath .
  • Paipitation.
  • Dizziness.

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Yellowish discolouration:

  • Is not fluctuating or non progressive.
  • Associated with yellowish urine .
  • Not associated with-
  • Abdominal discomfort
  • Nausea
  • Vomiting or itching

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On query – H/O

  • Fever - Low grade , persist all over the day , highest recorded temperature 101 F not associated with chill & rigor , subsided by anti pyretic .
  • Joint pain – More likely small joint . Associated with morning stiffness, symmetrical , improved in activity.

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  • Photosensitivity.
  • Lossening of hairs
  • Haematuria

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No history of-

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  • Bleeding from other site
  • Headache
  • Abdominal pain or swelling
  • Leg swelling (DVT)
  • Black urine

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Past history

  • She is a diagnosed case of chronic rheumatic heart disease ,for which she under went valve replacement surgery in 2014.

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Treatment history -

  • Since valve replacement surgery she is on regular:
  • Penvik 250mg (1+0+1)
  • Warin 5mg(1+0+1/2)

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Blood transfusin history -

  • Last one year she received at least 2-3 units of RCC in each months,which temporarily alleviated her symtoms but no permanent cure.

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  • She is married, having no viable issue
  • She has no H/O miscarriage.

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General examination-

  • Appearance : Ill looking
  • Body built: Average
  • Anaemia : Severe
  • Jaundice : Present
  • Oedema : Present
  • Bony tenderness: Absent
  • Lymphadenopathy: Absent

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  • Pulse : 100b/min
  • Bp : 90/60 mmhg
  • Temp : 98.6
  • Butter fly rash sparing the nasolabial fold.

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Systemic examinations-

Abdomen

  • No organomegaly

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Cardiovascular

  • Apex beat –shifted to left 6th ICH
  • P2-loud
  • Metalic sound in mitral and aortic area.
  • Other systemic examinations-reveal no abnormality

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Salient features-

  • Mrs. poly , 31year, female has been presented with H/O progressive generalized weakness and yellowish discolouratin of sclera and urine for 1 year. On query she gave H/O multiple joint pain, photosensitivity, loosening of hairs and haematuria. But gave no H/O fever, black urine, leg swelling.

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  • She has H/O of valve replace ment surgery in 2014 for CRHD .
  • Since then she is receiving 2-3 units of RCC in each month.

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  • O/E:
  • She is severely anaemic,
  • Icteric
  • Lymhadenopathy - absent
  • Bony tenderness – absent
  • Butter fly rash - present.
  • Vitals are within normal limit.

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  • Apex beat-shifted, p2-loud ,metallic sound present in mitral and aortic area .
  • No organomegaly.
  • Other systemic examinations are normal.

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24.11.21

2.1.22

11.1.22

18.1.22

7.2

5.7

4.9

​

8

3.5

7.65

11

7

180

550

950

695

N-80

L-06

M-08

B-00

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ESR-7

84

13

3

O

​

25

75

12

5

0

​

45

94

5

1

0

​

10

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PBF

RBC : anisocytosis with anisochromia with dimorphic , target cells ,schistocytes ,elongated cells.

WBC : mature with above count and distribution.

Platelet : Increased .

Comment : Features are suggestive of Haemokytic anaemia with thrombocytosis.

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  • Echocardiogram :
  • Post DVR status (metallic prosthetic valve in mitral and aortic area)
  • No para or peri valvular leakage.
  • Good BV function
  • Severe TR and severe PHTN.

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  • USG of W/A :
  • Hepatomegaly
  • Bilateral renal parenchymal disease.
  • Right sided mild pleural effusion

​

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URINE R/E

Glucose -NIL

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Protein - +

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UROBILINOGEN ++

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RBC 0-1/HPF

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24 hours UTP

8.56g/day

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Thyroid function test

TSH-4.1 mcl/L

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​

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S. Bilirubin ( Total)

5.8mg/dl

( Direct)

2.43

Serum LDH

3878 U/L

Iron

228ug/dl

TIBC

351ug/dl

FERRITIN

1174ng/ml

HBsAg

NEGATIVE

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Anti HCV

NEGATIVE

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HIV 1&2

NEGATIVE

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​

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RA

NEGATIVE

Anti CCP

NEGATIVE

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ANA

STRONGLY POSITIVE

Anti ds DNA

NEGATIVE

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Anti phospholipid and anti cardiolipin ab

NEGATIVE

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Coombs test

Direct – negative

Indirect – positive

Haemoglobin electrophoresis

Hb E trait

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*Diagnosis ??

  • Cardiac haemolytic anemia with SLE , Lupus Nephritis , Hb E trait
  • AIHA with SLE ,Lupus Nephritis ,Hb E trait.

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CARDIOLOGY REFERAL

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NEPHROLOGY REFERAL

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RHEUMATOLOGY REFERAL

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TREATMENT

  • Steroid started from 1st january.
  • Carva
  • Reconil
  • Penvik

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  • Irrespective of this treatment the condition of the patient is not improved

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Problem lists:

  • 1.What may the diagnosis ?
  • 2.What investigations can be done to establish the diagnosis?
  • 3.What will be the treatment options?

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