What's wrong with this patient?
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What's wrong with this patient?
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At the weekends I cover our high dependency unit, the chest unit, and also the infectious diseases unit. This weekend I found a very interesting patient, with an interesting constellation of sym
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Forums » Open clinical » General clinical » What's wrong with this patient?
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Re: What's wrong with this patient?
posted at 1/7/2012 7:51 PM BST
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
In Response to Re: What's wrong with this patient?: without clinical history or photograph,it is very difficult to comment. Posted by neuromedicine I don't have his consent to take photos. I'm giving the clinical history in response to questions posed by the good people of D2D. Any specific tests you want? |
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Re: What's wrong with this patient?
posted at 2/7/2012 11:09 AM BST
on bmj.com
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Posts: 27
First: 25/9/2011 Last: 13/2/2013 |
You said Hb was normal but what does the blood film show? Any sign of Spherocytes or Elliptocytes, MCV? Haemoglobin electrophoresis result? May need to explain longstanding possible tissue iron overload with normal iron stores and abnormal LFTs. |
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Re: What's wrong with this patient?
posted at 2/7/2012 1:50 PM BST
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
ANC ENA ANCA normal so this presumably rules out SLE [systemic lupus erythematosis] and primary biliary cirrhosis. I think it is some sort of immunological disease with the vitiligo, tanned complexion and liver disease. But what is the special test....? would electrophoresis and immunoglobulin level be normal ? I wonder how long he has had the slightly raised bilirubin and does this account for his tanned complexion. I think I would ask an immunologist. Sorry this GP needs more clues. |
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Re: What's wrong with this patient?
posted at 6/7/2012 12:45 AM BST
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
In Response to Re: What's wrong with this patient?: You said Hb was normal but what does the blood film show? Any sign of Spherocytes or Elliptocytes, MCV? Haemoglobin electrophoresis result? May need to explain longstanding possible tissue iron overload with normal iron stores and abnormal LFTs. Posted by ionabottom Blood film shows a few target cells, but is otherwise unremarkable. No haemoglobin electrophoresis done. MCV is 101
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Re: What's wrong with this patient?
posted at 6/7/2012 12:47 AM BST
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
In Response to Re: What's wrong with this patient?: ANC ENA ANCA normal so this presumably rules out SLE [systemic lupus erythematosis] and primary biliary cirrhosis. I think it is some sort of immunological disease with the vitiligo, tanned complexion and liver disease. But what is the special test....? would electrophoresis and immunoglobulin level be normal ? I wonder how long he has had the slightly raised bilirubin and does this account for his tanned complexion. I think I would ask an immunologist. Sorry this GP needs more clues. Posted by Pat Lush I think this GP is exactly on the right lines! The test I was hoping someone would ask for is the Plasma Viscosity (or an ESR, in old money, I suppose). PV was 2.17. You're spot on with teh electrophoresis and Ig request too: Electrophoresis - polyclonal increase in Ig IgG - 23 IgA - 9 (!!!!) IgM - 5 Any new thoughts???? |
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Re: What's wrong with this patient?
posted at 6/7/2012 7:24 PM BST
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
IgA is very high a quick internet search gave me gamma A myeloma, SLE, sarcoid and Wiskott Aldrick syndrome as possible causes of raised IgA. I think SLE and sarcoid would both give relative low WBC , I am sure SLE gives very high Plasma viscosity and ESR ( but I think also high CRP). So I think SLE a possibility. |
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Re: What's wrong with this patient?
posted at 6/7/2012 7:36 PM BST
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
I think we're near enough there. Causes of such high immunoglobulins: Myeloma - no, myelona screen normal. Liver abscess - no, CT was normal. Lymphoma - no, CT was normal. SLE - certainly could be.... Sjogrens - doesn't fit clinically. So I did some more specific immunology - anti RNP was positive, strongly suggesting SLE. The tanned skin? He told me he always tans a lot, and his 'hidden skin' areas (sub swimming trunks) were of normal hue. His liver? I asked his wife, who said he had a few drinks on holiday, so I think it was alc hep. Off to the rheumatologists!
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Forums » Open clinical » General clinical » What's wrong with this patient?
