Case presentation
32 yrs old female patient came to my clinic on Wednesday
-ve pmh
وصلتني تشكي من فيفر
1 month duration!
ecchymosis
dicytopenia
Hb 9
Plt 9
Film = MAHA and leucoerythroblastic picture
اول شي الTTP جتي ببالي بس جانت الرتك مو عالية وهذا معناته البون مرو بي مشكلة بحيث مدتطلع رتك
المفروض بالTTP البون مرو شغال والرتك كلش تصعد
Direct bilirubinemia
وهذا ايضا ما يمشي ويا هيمولسس
Dyspnea & hypoxia 60% and till now i don’t know why (bleeding, embolism?)
بالفحص عدها axillary LAP
So ttp in less likely
Next day further inx
Pt & ptt prolonged, fibrinogen 2 (DIC)
Now ttp is excluded.
حولتها انتقالية اشتباه حمى نزفية لان عدها هستري مال كونتاكت
Why she has dic? Why there’s LAP? Lymphoma doesn’t cause DIC at presentation
Screen for malignancy (solid)
Mucin secreting tumors especially gastric, pancreatic, ovarian are commonly associated with DIC.
Abd US showed free fluid, ct with contrast was still pending
Tumors markers especially ovarian marker is high
So the dx is malignancy with bone marrow metastasis. Needs assessment by oncologist but unfortunately she passed away this morning due to bleeding.
32 yrs old female patient came to my clinic on Wednesday
-ve pmh
وصلتني تشكي من فيفر
1 month duration!
ecchymosis
dicytopenia
Hb 9
Plt 9
Film = MAHA and leucoerythroblastic picture
اول شي الTTP جتي ببالي بس جانت الرتك مو عالية وهذا معناته البون مرو بي مشكلة بحيث مدتطلع رتك
المفروض بالTTP البون مرو شغال والرتك كلش تصعد
Direct bilirubinemia
وهذا ايضا ما يمشي ويا هيمولسس
Dyspnea & hypoxia 60% and till now i don’t know why (bleeding, embolism?)
بالفحص عدها axillary LAP
So ttp in less likely
Next day further inx
Pt & ptt prolonged, fibrinogen 2 (DIC)
Now ttp is excluded.
حولتها انتقالية اشتباه حمى نزفية لان عدها هستري مال كونتاكت
Why she has dic? Why there’s LAP? Lymphoma doesn’t cause DIC at presentation
Screen for malignancy (solid)
Mucin secreting tumors especially gastric, pancreatic, ovarian are commonly associated with DIC.
Abd US showed free fluid, ct with contrast was still pending
Tumors markers especially ovarian marker is high
So the dx is malignancy with bone marrow metastasis. Needs assessment by oncologist but unfortunately she passed away this morning due to bleeding.
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33 yr old male patient with negative past medical and surgical hx, non alcoholic has indirect bilirubinemia and mild anemia, suffered from epigastric pain, treated as Gilbert for a while.
Referred to me when Hb starts dropping, blood film showed megaloblastic picture with frequent hypersegmented neutrophils.
B12 was low 85.
Sent for intrinsic factor Ab which came high and serum gastrin level which also was high.
Dx: Pernicious anemia due to autoimmune gastritis.
Rx: lifelong B12
Referred to me when Hb starts dropping, blood film showed megaloblastic picture with frequent hypersegmented neutrophils.
B12 was low 85.
Sent for intrinsic factor Ab which came high and serum gastrin level which also was high.
Dx: Pernicious anemia due to autoimmune gastritis.
Rx: lifelong B12
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من تنطي B12 وفولك اسد لمريض megaloblastic anemia وورا العلاج رجع ال cbc نورمال ،هنا لازم ما تغلط وتوقف العلاج .. لأن راح يرجع النقص وممكن irreversible neurological damage
العلاج لازم يستمر لحد ميتعالج السبب الي ادى الى نقص الB12 ، وغالباً اسبابه irreversible فلا توقفه بس باعد بالفترة او حوله اورال وحسب السبب .
هذا مثال لمريض مسوي gastrectomy قبل وبعد العلاج وخلال شهرين.. بقيته maintenance كل شهر ابرة B12
العلاج لازم يستمر لحد ميتعالج السبب الي ادى الى نقص الB12 ، وغالباً اسبابه irreversible فلا توقفه بس باعد بالفترة او حوله اورال وحسب السبب .
هذا مثال لمريض مسوي gastrectomy قبل وبعد العلاج وخلال شهرين.. بقيته maintenance كل شهر ابرة B12
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Recurrent thrombosis despite anticoagulation, think of :
1. Cancer
2. Antiphospholipid syndrome
3. Anatomical site of thrombosis
1. Cancer
2. Antiphospholipid syndrome
3. Anatomical site of thrombosis
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٣٠٪ من مرضى الDVT يبقى عدهم
Chronic extremity swelling, pain, parasthesia, fatigue, heaviness, dryness, erythema, dark pigmentation..
يسموها Post thrombotic syndrome
شنو علاجها؟
مالها علاج
Chronic extremity swelling, pain, parasthesia, fatigue, heaviness, dryness, erythema, dark pigmentation..
يسموها Post thrombotic syndrome
شنو علاجها؟
مالها علاج
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Definition of Hypersplenism
1. Enlargement of spleen (any size, usually moderate to massive)
2. Reduction in one or more cell lineages (rarely severe)
3. Normal bone marrow
4. Response (correction of cytopenia) after splenectomy
Causes:
Portal hypertension
Infection
Hematological malignancies
Autoimmune disorders
1. Enlargement of spleen (any size, usually moderate to massive)
2. Reduction in one or more cell lineages (rarely severe)
3. Normal bone marrow
4. Response (correction of cytopenia) after splenectomy
Causes:
Portal hypertension
Infection
Hematological malignancies
Autoimmune disorders
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Size of spleen by imaging, uptodate
The upper limits of normal for the tallest females and males were approximately 12.3 and 14.5 cm (4.8 and 5.7 inches), respectively. The authors noted that use of an upper limit of normal of 12 cm, which is common in many radiology departments, would inadvertently classify 6 percent of women and 26 percent of men in the cohort as having splenomegaly when in fact they did not.
The upper limits of normal for the tallest females and males were approximately 12.3 and 14.5 cm (4.8 and 5.7 inches), respectively. The authors noted that use of an upper limit of normal of 12 cm, which is common in many radiology departments, would inadvertently classify 6 percent of women and 26 percent of men in the cohort as having splenomegaly when in fact they did not.
❤6
It takes >3-4 weeks of steroids (any dose >5 mg prednisone /d) to pose risk of adrenal insufficiency – Hence, Endocrine Society Guideline says short-term glucocorticoid therapy of <3-4 wks, irrespective of dose, DOES NOT require steroid tapering
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