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Morbidity And Mortality Meeting
By Farshid
Case History
•Admitted via clinic on 25-06-2007 for
•Fever off and on-------- 8-9 months
•Abdominal Pain --------- 2-3 weeks
In Gilgit she was being treated as a case of genital Tuberculosis without any objective genitourinary complaints or symptoms
She took ATT for 2 months and then stopped b/c of drug induced Acute Hepatitis.
Fever
8-9 months off and on
High grade up to 103-104 F, no chills/rigors
No urinary or chest complaints but she had upper abd. Pain, moderate in intensity, no radiation, no vomiting but nausea was present with ass. Weight loss.
Clinical Examination:
Alert awake oriented, toxic look
Pulse Rate: 90 beats/minute regular
Blood Pressure: 160/80 mmHg
Resp. Rate: 20 b/minute
Temp: 36.8 centigrade
Pallor with Icteric
Malar Flush but no rash
B/L pitting pedal edema
Clinical Examination:
RHC tenderness, hepatomegaly 2 fingers below Rt costal margin, splenomegaly 1 finger, positive shifting dullness.
S1 and S2 audible, Panystolic murmur in mitral area radiating to axilla, no gallop.
Chest: B/L symmetrical shape and resp movements, equal chest expansion B/L, with NVB except at Rt basal region which had decrease air entry.
Clinical Examination:
•CNS: Alert, OrientedX3, no focal sensory or motor deficit, plantars normal.
•Musculoskeletal System: No positive findings
Labs:
11-06-2007
Hb: 10.2 gm/dl (NN)
Hct: 27.8
Wbc: 7.4
Neutrophils: 73.8%
Lymphocyte: 21.4%
Plat: 30
Retic=6.8
FBS: 110mg/dl
LDH: 8752
Labs
PTT=25.3/12 TB=5.9 Coombs ++
INR=2.12 DB=3.7 CRP = 8.3
APTT=68.7/30 IB=2.2
D-Dimer=0.87 GGT=81
MP –ve SGPT=53
MP ICT –ve ALP=348
Urine DR:
Dark yellow Protein +3, bil +3, Hb trace, rest normal
24 hrs urinary protein was 7080 mg/24hrs
She was started on broad spectrum ABx, IV
hydration and supportive management initially
CXR
Rt. Lower lung consolidation with possible
consolidatory changes in the Lt lower lung field,
findings are suspicious for pneumonia.
she was already being treated for pneumonia.
US Abd:
Fatty infiltration of liver, sludge filled
Gallbladder, mild ascites.
Her CT Abd and Pelvis
with contrast was done considering
disseminated TB which showed mild B/L
pleural effusion with mild to moderate
ascites, no paraaortic lymphadenopathy
•Ascitic Fluid DR
Glu=70
prot=814
TLC=100
N=10
L=90
RBC +++
•During the hospital stay
•She became short of breath(14/06/2007)
•Her CXR showed Pulmonary edema
ABG
7.49/37.8/70.8/28.9/+5.9/95.3 on 6L Fio2
Trop I x2 were negative
She was treated with IV diuretics
Cardiology service was involved they
continued IV diuretics
Echo:
EF 60%, moderately dil. Lt Atrium
LVDD grade II
Mod-severe MR, mild TR
Mild PHTN, no vegetations/clots
Her Autoimmune profile was sent, and in the mean
while bone marrow was done to send TB CS and
cause for worsening Bicytopenia (dropping PLTs &
Hb) under cover of FFPs.
GI service was also involved for deranged LFTs
They suggested to send autoimmune workup
Which was already sent.
•6-8 hrs after bone marrow Pt started having heavy bleeding from bone marrow procedure site and she was Tx with FFPs & platelets and with in next 12 hrs she started bleeding from every site (GI, oral cavity, Nose), Hematology was involved they suggested DIC workup Which was sent and which turned out to be negative
•Twice daily IV omeprazole was converted into infusion.
Bone marrow aspirate:
•hypocellular/dilute specimen
•Few erythroid and myeloid precursors.
•No megakaryocyte seen
Results of bone trephine (H&E) section:
•Erythroid hyperplasia with nuclear to cytoplasmic asynchrony.
•Few large cell seen ?early precursors. normal myeloid precursors.
•Adequate megakaryocytes. No metastatic infiltrate to granuloma seen.
Final Report:
Autoimmune hemolytic anemia ?cause.
megaloblastic features on bone trephine can be due to folate deficiency (secondary to hemolysis).
Pt was already kept on folic acid.
Her bleeding continued and ENT
service was involved for nasal packing
She was transfused with multiple
PRBC, FFPs, CryoPPT and was given factor VII (novoseven) on the advice of hematologist
•Multiple blood CS, Ascitic fluid CS, BM CS including AFB CS were sent which were negative.
•Her CCHF was sent which was also negative
•Her Ascitic fluid cytology was negative and so was
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