C . PATEL ( F/54 yr ,

A case of 54 year old,Hindu,married housewife Manjulaben Chhaganbhai Patel residing at Karakhadi, Ta: Padra ,Di: Baroda ( Guj, India ) who is coming from middle socioeconomy class presented to us in S.S.G. Hospital, Baroda on 26th Nov, 2002 with chief complaints of….. c/o easy fatiguability for 3 months c/o fever for 3 months On elaborating origin,duration,progress patient is symptomatically alright three months back, then she began to experience easy fatiguability,early tiredness on routine housework . As complaints were progressing gradually in severity over a month making her in bed for taking rest most of the day time, she was taken to near Physician in Padra. She was admitted there for 7 days & her Hb was found tobe around 7.0 gm%. She received three whole blood units during her hospital stay, her Hb improved came around 9.0gm% & she was discharged from hospital with oral haematinics & tab metformin 500 mg bd po as she was found tobe Diabetic. Although patient was on oral haematinics , patient had no much improvement in her symptoms. She also started complaint of continuous low grade fever relieved temporary with tab paracetamol. As symptoms were untolerable again, she was taken to another Physician in Baroda admitted from 7th oct to 17th oct,2002. During this period,Hemogram showed…… Hb: 5.8 gm% WBC: 3800/cmm ( 4000-11000) DC: N 56 L 44 PCV:18.5%(37-47) MCV:90.7 fl(76-96) MCH:28.2 pg(27-32) MCHC:31.1 gm%(30-35) ESR: 20 mm(0-20) PS: RBC:- predominantly macrocytic,severe anisopoikilocytosis;Normoblasts seen WBC: normal Platlets:adequate PSMP: negative After analyzing hemogram, Physician investigated patient as follows : Stool : Occult blood strongly positive(++++);Rest:normal Urine: Sugar 1+ ;Bacilli: 3 + ; Rest : normal Bl.urea, S.creat : Normal USG Abdomen : no abnormality seen TSH : 2.18 microIU/ml ( 0.27-5.0) Patient received two PCVs and repeat Hb was 6.0gm% on 16th Oct,’02( PCV : 18.2 ; MCV:85.4 ; MCHC : 32.8 ; PSMP: negative).She was also received empirical antibiotic treatment( tab gatifloxacin 400mg for seven days). She was given discharge from there with advise to consult Gastroenterologist for futher evaluation.

After discharge from clinic, she has developed high grade fever daily with severe malaise to make her in bed all the time. Hence she is again admitted to our hospital ( S.S.G. Hospital , Baroda ) on 26th Nov,2002 in emergency department. On admission she showed Hb of 5.8 gm%;ESR :140 mm & PSMP suggestive of severe P.falsiparum parasitemia. Considering malaria, she was received inj arte ether( EMAL ) 100mg IM od for 3 days. For persistent fever despite radical treatment for Malaria, series of investigations under PUO has been done all came negative.Meanwhile empirical antibiotic treatment in form of cefotaxime & metronidazole has been started & fever subsided after 2-3 days of starting antibiotic treatment,treatment is continued for next seven days thenafter.Patient has also received one PCV on 2nd day of admission. Hemogram done on next day of blood transfusion showed Hb 3.8 gm% with serial hemograms showing thrombocytopenia, high retic count(8%), PS showing anisocytosis,polychromasia with late normoblasts,MCV:avg 86.0 fl(78-99) ,investigations to rule out hemolytic process been carried out( please see investigation sheet ).With the initial Coomb’s test positive(both direct & indirect),on the other hand first time on 1st Dec patient complained of passing black stool(with separation of red colour on flushing stool),immediate stool been tested for occult blood came strongly positive(++++). Patient is referred to consultant gastroenterologist Dr Prashant Buch & following workup is carried out: Colonoscopy : normal ( done twice ) OGD scopy : normal ( done twice ) Barium follow-through: normal USG abdomen : normal As per advise of Dr Buch(putting clinical impression of hemolytic anaemia) & patient has improved symptomatically(no c/o fever,malaise,black stool) she has given discharge from hospital on 6th Dec,2002 with total three blood transfusion,Hb of 8.0 gm% & advised to discontinue oral iron, weekly Hb , report immediately if c/o passing black stool. After week of discharge her Hb came 8.5 gm%. On 18th Dec she again has c/o passing black stool(with separation of red colour on flushing stool),occult blood in stool test on the same day showed strong positive reaction(++++). Her Hb dropped to7.5 gm%. Two more such episodes are noted on 24th & 25th of Dec.Patient again c/o malaise( Hb on 4th jan,’03 was 7.0 gm%), so Dr Buch was consulted & enteroclysis been carried out revealing no abnormality. Patient is advised to go for further G. I .Workup in Mumbai. By the time, patient has received two PCVs from S.S.G. Hospital on 10th Jan,’03. Last occult blood in stool test is negative on 11th jan,2003. Patient is currently taking only anti-diabetic drug( tab metformin 500 mg bd po ). Patient on 16th Jan ,2003 complained of passing blood in stool which was seen clearly by her & relatives . Plan been made to investigate patient further at Mumbai , so patient was taken to Mumbai on 18th January . Immediately on arrival ( about 8:30 am ) in Mumbai , she has passed massive frank blood in stool around 300-400 ml as seen by accompanying medical student . She has been immediately sent for mesenteric angiography in Hinduja national hospital & research center, Mumbai . Pre-procedure investigations revealed no abnormality of coagulation system except platlet count of 153,000/cmm & INR of 1.33 ; Hb was 7.5 gm% . Angiography was peformed around 12:30 pm and report was showing suspicious angiodysplasia in proximal colon & caecum area . However there was no active bleeding . So for sake of confirmation , radio labeled Tc 99

RBC scan was performed ( without giving details of angiography ) which shown pooling of contrast without extravasation in right iliac & mid abdomen region suggesting vascular malformation rather than active bleeding. Patient was given one PCV there and advised to go for treatment of ? angiodysplasia either by APC(argon plasma coagulation) or right hemicolectomy . Later option been selected by patient & her relatives. Patient was taken back to Baroda for surgery of the same. After a week of lag, patient was admitted to Swadia surgical hospital , Baroda on 29/01/2003 three days before planned operation . Patient was switched on to insulin injections for her diabetic control from metformin tablets . After all pre-op. preparations(including Hb brought upto 10gm%), patient was operated on 2/2/2003 for riht hemicolectomy with resection of distal 30 cm ileum . No gross abnormality detacted during operation in abdomen surgery was completed with end-to-end anastomosis . Immediately post-op. patient bllod sugar was 537 gm% & patient was unable to recover from general anesthetic effect, she lost her respiratory drive( probably she was developed diabetic ketoacidosis) . Patient was put on mechanical ventilator for abround 6 hours. Her aspirate from stomach showed frank blood of about 200-300 ml. Simultaneouly she was gone into hypovoluemic shock(In early, compensatory stage) with severe anaemia . However she was managed effectively(with IV fluids,blood,insulin,electrolyte correction) and returned to spontaneous breathing after 910 hrs of operation . She was given one whole blood & two PCVs. Stomach aspirate showing clear fluid on next day. She was well in general condition from second post-op. day . She was on post-op. antibiotic treatment in form of inj.ceftazidime,inj. Tobramycin. Her bowel movement returned to normal on 3rd post-op. day and she was given oral fluids from same day . She was absolutely well clinically till 9th post-op. day . Post-op. Hb was 11.5 gm%; s.electrolytes,blood sugar :normal . On 10th post-op. day, from morning onwards, she started altered behaviour & speech pattern with continuous repeating of sentences: “give me water”,”having ghabharaman(fear of dying)”,”why I am not getting well?”,”I will never get well “… Doctor had examined her and found mild icteric tinge in sclera with pedal edema & slight fall in urine output . Primary investigation showed Hb 11.5gm%, TC :16,000 /cmm , Dc: P56/L43/M1/E0/B0 ; ESR : 60 mm/1st hr; Platlets : 16,000/cmm (repeat platlet on 10/02 was 14000/cmm) Blood urea: 83 mg/dl S.creatine : 2.83 mg/dl LFTs: S/o Active hepatitis with heaptic jaundice Direct Coomb’s : negative S. LDH : 3186 IU/L With dilemma in coming to diagnosis, case report was shown to onco-hematologist Dr Chirag Shah,Ahemadabad on 11th Feb advised to repeat bone marrow biopsy/aspiration. Meanwhile patient was put on supportive Rx with empirical inj. Ceftazidime & received two PRPs. Patient was gone into coma state from early morning of 11th Feb,she was put on

nasal oxygen, jaundice was worsened & urine output dropped to much lower value( less than 100 ml in 12 hrs) with resulting ascites & pedal edema . Patient on 11th evening developed severe jaundice with hepatic encephalopathy with ARDS with hemolytic-uremic syndrome. Patient died at 21:30 on 11th February , 2003. Case remained mystery for all of us here. Samir B . Amin B/38,New medical hostel, Baroda-390001(India) 16/02/2003 14:45


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