A 17-year-old male with generalized weakness and loose motion

DR. SHARMIN EASMIN

PHASE-B RESIDENT

RED UNIT

HAEMATOLOGY DEPARTMENT

BSMMU

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Objective

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Vitamin B12 absorption & metabolism

Evaluation & management of megaloblastic anaemia

Monitoring of treatment response of Megaloblastic anaemia

Case summary

Nazmul, a 17-year-old student,unmarried,normotensive,non-diabetic,hailing from Narsingdi admitted with complaints of

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• Generalized weakness for 6 months
• Recurrent mouth ulcer and Soreness of tongue for 1 year
• Frequent loose motion for 4 year

Generalized weakness

• Severe weakness and occasional dizziness
• Difficult to perform regular daily activities

Oral ulcer

• Recurrent painful mouth ulcer
• Soreness of tongue
• Painful angular ulcer

Loose motion

• Occasional loose motion, 4 to 6 times daily
• Oily, greezy, floating on pan, difficult to wash out
• Often mixed with mucus, but not blood
• Sense of incomplete evacuation of bowel and occasional abdominal pain
• It’s not related to any food or drug

• He also complaints of
• loss of appetite and significant weight loss
• History of taking 20 unit of blood transfusion during this period.

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�There is no history of �

• Fever
• Skin rash
• Cough
• Bleeding manifestation
• Any perianal pain
• Joint pain
• Contact with TB patient or TB
• H/O no drug or dietary restriction
• Family history

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On general examination

• The patient is emaciated and ill looking
• Severely anaemic
• No jaundice,cyanosis,clubbing,koilonychias,leukonychia,dehydration,oedema
• No lymphadenopathy or no thyromegaly
• Pulse : 110 beat/min
• BP: 100/60 mmHg
• Temperature: 98⁰F
• Respiratory rate : 20 breath/ min.

Systemic examination

• Gastrointestinal system:
• Lips - swelling
• Tongue - smooth ,loss of papillae, raw bee tongue.
• Oral cavity – few ulcer in the inner part of cheek ( aphthous ulcer )
• Painful angular stomatitis

Abdomen

• No abnormalities

Examination of the other systems reveals no abnormalities

Haematological parameter

Complete blood count

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Peripheral blood film

13/11/2022

• RBC – Dimorphic.
• WBC – Reduced with hypersegmented neutrophil.
• Platelet – Reduced

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• Comment: Pancytopenia

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• Reticulocyte count -0.19%

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25/05/2022

13/11/2022

Coagulation profile

Other :

• Serum Vitamin B₁₂ – 158 pg/ml
• Serum folate - > 20.0 ng/ml
• Serum iron -28 µg/dl
• Ferritin – 1074.99 ng/ml
• TIBC – 194 µg/dl
• T SAT – 14 %
• LDH -1291 U/L ( after treatment 311 U/L )
• Coombs test direct & indirect – Negative
• TSH,T3,T4 - normal

Cont….

• Serum electrolyte – Na⁺ : 143 mmol/L, K⁺ – 3.7 mmol/L
• Serum creatinine – 0.9
• Serum calcium – 8.8 mg/dl
• Magnesium – 1.2 mmol/L
• Serum bilirubin total & direct – 2.7 mg/dl & 0.98 mg/dl
• SGPT- 11U/L
• SGOT - 12U/L
• Fasting blood sugar – 4.21 mmol/L

Cont….

• Stool OBT – positive
• Faecal fat – negative
• Urine R/M/E – normal
• USG of whole abdomen – mild splenomegaly
• PCR for Covid-19 – negative
• Serum Antibody screening ( Ab to IF & Ab to parietal,gastrin receptor)

- Not done

• MMA & homocysteine level – not done
• Faecal calprotectin – not done

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GeneXpert for detection of Mycobacterium tuberculosis ( 01/12/2022 )

• Type of specimen – Ileal ulcer

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• Result – not detected

Before treatment

My provisional diagnosis is Megaloblastic anaemias

Treatment

• Considering his age, clinical symptoms & sign
• On the basis of investigation report he was treated with –
• Injection cyanocobalamin 1 mg weekly for 6 weeks

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After treatment

After treatment ( 27/11/2022 )

After treatment ( 27/11/2022 )

Peripheral blood film :

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• RBC – normocytic normochromic
• WBC – normal in count
• Platelet – normal

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• Comment: normocytic normochromic anaemia

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Evaluation, metabolism, treatment and monitoring after treatment

EVALUATION

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Davidson’s 24^th

Peripheral blood film

Bone marrow

Absorption

Metabolism

Mechanism of neurological menifestation

Treatment of megaloblastic anaemia

• Specific management:
• 6 dose 1mg Hydroxocobalamin / cyanocobalamin – weekly

According to up to date management

• 6 dose 1mg Hydroxocobalamin/ cyanocobalamin at 3 days interval

followed by

• 1 mg I/M 3 monthly interval ( Hoffbrand 7^th edition )

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Cont ….

• General management :

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• Severely ill – hospitalization
• Blood transfusion – usually unnecessary
• Exchange transfusion – if severe anaemia & Heart failure
• Platelet transfusion – spontaneous bleeding

(severe thrombocytopenia)

Monitoring after treatment

• LDH and Indirect bilirubin ( marker of haemolysis ) –

decline within fisrt 1-2 days

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• Reticulocyte count – Increased with in 3-4 days

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• Haemoglobin & haematocrit – improve at 1-2 weeks

normalized within 4-6 weeks

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Cont…

• Hypersegmented neutrophils – disappear with in 2 weeks

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• Leukopenia &/or thrombocytopenia – resolve within 2-4 weeks

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• Hypokalemia – initial 1^st week

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• Serum vitamin B₁₂ & folate – level increases into normal range

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•  Most patients are treated with cobalamin .

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• Dietary, life style modification & vitamin B12 supplementation is important.

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• Megaloblastic anemias develop gradually,

many patients adjust to low hemoglobin levels and do not require transfusions.

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Take home massage

Let our New Years resolution be this:

We will be there for one another as fellow members of humanity,

in the finest sense of the word..

Thank you