19 y/o male with breathlessness

A 19-year-old male complaints of breathlessness and malaise since 2 months. Patient is diabetic. No other present medical history. He was lacto vegetarian, non-smoker, non-alcoholic with unremarkable past history or drug history. On examination he was extremely pale, had mild icterus, glossitis, lusterless hair and splenomegaly. Romberg’s sign was positive and he had bilateral loss of vibration and position sense. Patient had generalized increased skin pigmentation, however characteristically the patient had prominent bilateral knuckle hyperpigmentation (Figure 1). The investigations revealed severe pancytopenia; the hemoglobin was 2.01g/dl, platelets were 44,000/mm3, total leucocyte count 3200/mm3. MCV was 122fl and MCHC was 38g/dl. The reticulocyte count was 0.5%. The peripheral blood film revealed anisocytosis, hypersegmented neutrophils, macrocytes. Severe megaloblastic erythropoisis noted. What should be the next step?

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This patient has juvenile diabetes which is caused by autoimmune disease, therefore he is at high risk of another autoimmune disease - in this case it is likely to be pernicious anemia which is caused by inability to absorb vitamin B 12 because of loss of intrinsic factor of castle. A lack of B12 damages the myelin sheath that surrounds and protect nerves. Without this protection, nerves cease to function properly and conditions such as peripheral neuropathy occur. This is the reason this patient has loss of proprioception. This patient has knuckle pigmentation - which is common manifestation of vitamin B 12 deficiency He has severe anemia with megaloblast seen and side of RBC is indicated by MCV is highly raised - this is pointing to megaloblastic Anemia Pancytopenia is also observed in B 12 deficiency All these finding are pointing towards pernicious anemia causing megaloblastic Anemia Adv Serum Vitamin B 12 levels Iron profile HbA1c Antiintrinsic factor Antibody Anti parietal cell Antibody Treatment involves Injectable vitamin B 12 or more a days vitamin B 12 is available as nasal spray which is absorbed through mucosa

Thanks doctor for the wonderful observation and treatment
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It's a classical case of megaloblastic anemia. Adv sr b12 and folic acid level. Bone marrow study. Anti gastric Parietal cell antibodies / intrinsic factor antibodies . Sos injectable b12 replacement Initially whole blood transfusion.

Megaloblastic Anaemia Needs further investigation and evaluation to conclude and line of treatment. B12 and folic acid. Good nutritious balanced Greenleaf food.

Megaloblastic anemia Severe anemia, icterus, glossitis, splenomegaly, Posterior column involvement , all indicate VIT B12 deficiency anemia ( Pernicious anemia ) with Subacute Combined Degeneration of Cord . Inj B12 and Folic acid assay, stomach acid assay to rule out atrophic gastritis , needed . Bone marrow aspirate analysis can be done for confirmation INJ Methycobalamine ,1000 mcg IM weekly once . To avoid folic acid supplement till Vit B12 deficiency is corrected in view of SCDC

Give PRBC, DO SERUM B12, S FOLIC ACID, HBAIC, FULL WORK UP FOR T2DM, AFTER SAMPLING, GIVE INJ B12 1500 MCG IM OD 7days, followed by alternate day 1 week followed by every weeks x 4 eks monthly by once life long, FOLIC ACID 5 MG ONCE DAILY, CSP AUTRINE 1 BD BEFORE MEALS, RETIC COUNTS AFTER 1 WEEK, CBC TOO, ADMIT HER INITIALLY INFUSION REGULAR INSULIN FOR SAY 24 HRS CALCULATE INSULIN REQUIREMENTS, GIVE HALF BASAL, GIVE HALF IN YHREE DIVIDED DOSES, DO BASE LINE ABG ECG, ELECTROLYTES. BE IN TOUCH

DKA POSSIBLE ALSO

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