1 of 48

A 17 years old female presented with weakness and Jaundice

Dr. Suraiya Akter

MD Resident (Phase-A)

Haematology

BSMMU

2 of 48

Particulars of the patient

  • Name: Sabrina Islam
  • Age: 17 years
  • Sex: Female
  • Religion: Islam
  • Occupation: Student
  • Marital status:unmarried
  • Address: Hatia,Noakhali,Chattagram
  • Date of Admission: 16th March, 2021
  • Date of Examination:18th March,2021

3 of 48

Chief complaints

  • Generalized weakness and tiredness for 15days
  • Yellowish discoloration of skin and sclera for 15days
  • Fever for 5days

4 of 48

H/O present illness:

According to the statement of the patient,she was reasonably well 15 days back, then she noticed that she was gradually becoming weak and pale. Initially she could perform all activities with little discomfort but she became tired while she did usual daily activities. Along with weakness she occasionally experienced palpitation specially during strenuous activities which was relieved by taking rest.

5 of 48

  • She denied weakness in any specific part of body. She also noticed yellowish discoloration of skin and sclera for last 15 days which was gradual and progressive,associated with loss of appetite.it was not associated with nausea,vomiting,abdominal pain,itching,pale stool,haematemesis,melaena, and alteration of bowel habit.

6 of 48

She also complained of fever for last 5days which was low grade and intermittent in nature ,highest recorded temperature was 100 F.it was not associated with chills and rigor and profuse sweating,subsided by taking paracetamol.dietary habit was normal. Her bladder and bowel habit were normal.

7 of 48

No history of

  • Sore throat, cough
  • Bleeding manifestations, skin rash
  • Oral ulcer,photosensitivity
  • Joint pain and swelling
  • Nodular swelling
  • Night sweat
  • Wight loss
  • Increased frequency of micturition
  • Burning sensation during micturition
  • Limb weakness
  • Abdominal pain

8 of 48

Continued. . .

  • With these complains, she visited to physician and admitted in our department for better management.

9 of 48

History of past illness she had similar episode of attack for 3 to 4 times in last 2 years and for that she had to admit in hospital for 2 times and treated with some medications and several units of washed red cell concentrate .No previous history of radiation therapy,any operation, or other significant chronic illness.

10 of 48

Family history

She was unmarried and had two sisters.no family history of such illness .all her family members were in good health.

11 of 48

Personal History: She was a student.no history of betel nut chewing,smoking or taking alcohol.

Drug history:She took some medications for her illness which she could not mention.

Travel history:No history of travelling in Mymensingh ,Netrokona, Sherpur and hill tract areas.

12 of 48

Menstrual history:Her period was regular with average flow and duration,cycle was 28days.

Socioeconomic condition: She belonged to a middle class family.she used to drink deep tubewell water.sanitation system was good.

Immunization history: She was immunized under EPI schedule and TT schedule.

13 of 48

Cushingoid facies of this patient

14 of 48

Physical examination

  • General examination:

  • Appearance: Depressed and cushingoid facies
  • Body built: Average
  • Co-operation:Co-operative
  • Decubitus:On choice
  • Intelligence:Intelligent
  • Height:163cm
  • Weight:66 kg
  • BMI:24.84
  • Anaemia: Severe
  • Jaundice: Present

15 of 48

  • Cyanosis:Absent
  • Clubbing: Absent
  • Koilonychia: Absent
  • Leukonychia: Absent
  • Oedema: Absent
  • Dehydration:Absent
  • Thyroid gland:Not enlarged
  • Lymphadenopathy: Absent

16 of 48

Contd:

  • Bony tenderness: Absent
  • Generalized skin condition: Normal
  • JVP:Not raised
  • Temp: 98.4F
  • Pulse:110 b/min
  • Resp. rate: 18 b/min
  • BP: 110/70 mm of Hg

17 of 48

Systemic examination:

  • Abdominal examination:
  • Abdomen was scaphoid in shape
  • Umbilicus was centrally placed and inverted
  • Flanks were normal
  • No scar mark,pigmentation,no visible mass,no visible peristalsis or any other pulsation
  • Hernial orifices were intact

18 of 48

Local temperature was normal,no tenderness,no rigidity.

Spleen was 3cm enlarged from left costal margin along left anterior axillary line towards right iliac fossa,moved with respiration,surface was smooth,border was sharp,non tender,firm in consistency,splenic notch was present in anterior border,incination test was negative.no other organomegaly were present.

19 of 48

  • Percussion note was tympanic but dull over spleen,no fluid thrill, no shifting dullness were present.
  • Bowel sound was present, no splenic rub,no hepatic bruit,no renal or aortic bruit .

20 of 48

  • Other Systemic examination:

Cardio-Vascular system

Respiratory system NAD

Nervous system

Musculoskeletal system

21 of 48

Salient features

  • Sabrina Islam 17 years old female, student, nondiabetic, normotensive, came from Hatia,Noakhali and admitted in BSMMU with complains of generalized weakness and tiredness for 15days. she stated that she was reasonably well 15days back, then she noticed that he was gradually becoming weak and pale. Initially she could perform all activities with little discomfort but after some days she used to become tired while she did usual daily activities. Along with weakness she occasionally experienced palpitation specially during strenuous activities and relieved by taking rest.

22 of 48

  • She denied weakness in any specific part of body. She also noticed yellowish discoloration of skin and sclera for last 15 days which was gradual and progressive,associated with loss of appetite.it was not associated with nausea,vomiting , abdominal pain,itching ,pale stool,haematemesis,melaena,and alteration of bowel habit.

23 of 48

  • She also complained of fever for last 5days which was low grade and intermittent in nature ,highest recorded temperature was 100 F.it was not associated with chills and rigor and profuse sweating,subsided by taking paracetamol.dietary habit was normal. Her bladder and bowel habit were normal.

24 of 48

  • She had no history of sore throat, cough, sputum, joint pain and swelling, oral ulcer, photosensitivity,skin rash, nodular swelling, night sweat, weight loss. she took some medications and washed red cell concentrate transfusion for her illness.no significant family history, personal history and socioeconomic history .On examination patient was depressed,cushingoid facies,severely anaemic, icteric. There was no lymphadenopathy, bony tenderness, petechiae,purpura. vitals were pulse 110b/min ,blood pressure 110/70mm of Hg,temperature 98.4F,respiratory rate 18b/min.on abdominal examination mild splenomegaly was found.other Systemic examination revealed no abnormality.

25 of 48

What will be the diagnosis ?

26 of 48

Differential diagnosis

1.Autoimmune haemolytic anaemia

2.Hereditary haemolytic anaemia

3. Acute viral hepatitis

27 of 48

Investigations

  • Haematology:

01/06/19

15/03/21

18/03/21

Hb(g/dl)

3

3.2

8.1

ESR(mm 1st hr)

30

26

25

T. RBC count(mill/cumm)

1

0.9

2.98

MCV(fl)

112

97

87.9

MCH(pg)

37

30

27.2

MCHC(g/dl)

33

31

30.9

T. WBC count(/cumm)

11,000

18,300

15.5

N(%)

66

72

86

L(%)

30

23

11

M(%)

02

03

3

E(%)

02

02

0

Ba(%)

0

0

0

Reticulocyte %

08

8.15

Platelet(/cumm)

200

165

PBF

Severe normocytic normocromic anaemia

Dimorphic anaemia

28 of 48

Investigations

  • Reticulocyte count: 8.15%
  • S. Bilirubin(Total): 2.2 mg/dl
  • S. Bilirubin( Direct): 0.88 mg/dl
  • S. Bilirubin(Indirect): 0.52 mg/dl
  • S. LDH : 823 U/L
  • ANA:.68
  • Coombs test: Direct: Positive

Indirect: Positive

29 of 48

  • Blood group: B+ve
  • RBS:6.7mmol/L
  • S.Albumin:33.4gm/L
  • S. creatinine: 0.6mg/dl
  • S.iron:141ug/dl
  • S.TIBC:176ug/dl
  • S. Ferritin:1873 ng/ml

30 of 48

Investigations:

  • ALT:36U/L
  • ALP:823U/L
  • HBsAg : Positive
  • HBeAg:Negative
  • Anti HCV : Negative
  • Anti HIV Antibody: Negative
  • Urine R/M/E: normal
  • TSH:4.75uIU/ml
  • Prothrombin time:12s
  • INR:1.34

31 of 48

  • What further evaluation should be done for relapse and remission course in this case?

  • What should be the management of this patient?

32 of 48

Now topic discussion on Autoimmune

haemolytic anaemia

33 of 48

Definition:Autoimmune haemolytic anaemia is a rare red blood cell disorder and an immune disorder. It happens when the body produces antibodies that destroy the red blood cells.

34 of 48

35 of 48

36 of 48

  • Investigation results indicating active haemolysis:
  • Hallmarks of haemolysis:
  • Decrease haemoglobin
  • Increase unconjugated bilirubin
  • Increase lactate dehydrogenase
  • Increase reticulocytes
  • Increase urinary urobilinogen

37 of 48

  • Additional features of intravascular haemolysis:
  • Decrease haptoglobin
  • Increase methaemalbumin
  • Positive urinary haemosiderin
  • Haemoglobinuria

38 of 48

39 of 48

40 of 48

41 of 48

������������ Thank you

42 of 48

  • +

43 of 48

��

44 of 48

45 of 48

46 of 48

47 of 48

48 of 48

‘;./�������������������������������������