30yrs male c/o fever with chills on and off since 1mnth..c/o heaviness of head..no h /o cough/vomitings/loose stools/burning micturition..nonalcoholic nonsmoker..no h/o bleeding through any sites.vitals stable..PBS and Sr.vitamin B12 levels pending..start emipirical iv antibiotics along with udiliv..management?

3 Likes

LikeAnswersShare
Approach to this case....... 1.Fever : Infection, Immunological, Cell damage, Connective tissue disorder 2.Increased Echogenesity : Hepatitis, Lymphoma,Cirrhosis, Fibrosis, Lipidosis, Amyloidosis, Hepatocellular - or Metastatic Carcinoma, Necrosis, Liver abcess. 3.Pancytopenia : Aplastic anaemia, Megaloblastic anaemia, Lymphoma, Myeloma, Myelofibrosis, Hypersplenism, SLE, PNH, Disseminated TB, Overwhelming Sepsis. 4.Widal Positive : Nonspecific 5.Macrocytic anaemia : Vit B12 or Folate Def., Myelodysplasia, Liverdisease, Reticulocytosis, Hypothyroidism, Bone marrow faliures (Aplastic anaemia, marrow infiltrate disorders etc) 6.Hypochromic anaemia : Iron Def., Thalassemia, Sideroblastic anaemia, Lead toxicity, Anaemia of chronic disease. 7.High RDW : Iron Def., Thalassemia major, Vit B12 and Folate Def., Sickle cell anaemia, Sideroblastic anaemia,Autoimmune haemolysis 8.Unconjugated hyperbilirubunemia : Isolated = Haemolytic disorders, Gilbert, CriglarNajar, Rifampicin, Probenecid, Ineffective erythropoesis. Raised ALT /AST = Viral or toxic hepatitis, Cirrhosis, Wilsons disease, Cirrhosis. Raised Alkaline Phosphatase = Cholestatis Probability :Chronic hepatitis >Anemia of chronic disease (Iron Def. Anaemia) and Liverdisease (Macrocytic anaemia) >Pancytopenia (due to macrocytes) PD : CHRONIC HEPATITIS OTHER DDs : Lymphoma, Myelodysplasia, Myelofibrosis, Myeloma, SLE, Liver abcess, Autoimmune Haemolytic anaemia Investigations suggested : 1.Complete viral panel for hepatis (Most necessary) 2.Direct coombs test 3.ANA /Anti smith antibody 4.liver Biopsy 5.Bonemarrow pic.
This is a syndrome of FUO and pancytopenia....Now the issue is whether fever and pancytopenia is because of the same process or due to two different issues... Regarding pancytopenia...The causes are 1.b12,folate deficiency 2.marrow involvement due to infection/infiltration... 3.increased breakdown...As in massive splenomegaly.. Now here the fact that there is macrocytosis and indirect bilirubin levels are little higher(indirect bilirubin will b higher in B12 deficiency due to premature hemolunii) with pancyotopenia suggest that it may b due to B12/folate deficiency...High LDH,low B12/folate levels would suggest... Now that if on workup it's due to B12 or folate deficiency then the common causes of fever going for 1 month from 1 month would b 1.enteric fever...Ask 2 sets of blood cultures 2.scrub typhus...Ask for if m scrub elisa Start on ceftriaxone and doxy.... If the patients pancytopenia is not due to B12 or folate deficiency the causes of FUO with pancytopenia are 1.enteric/scrub typhus 2.brucellosis(ask for unpasteurized milk intake and ask for igm Brucella) 3.tuberculosis... 4.marrow disorders like aplastic/aleukaemic leukaemia/HLH...Bone marrow would help... So in summary if pancytopenia is due to B12 def...Consider scrub and enteric and treat with doxy/ceftriaxone e....If not start on the same and if donot improve go in the living e of above mentioned differentials
Thankyou sir for your valuable advice
0
Hb is less so improve that via some iron prep, renal calculi of 4mm use flush therapy to remove that, fever with chills can be uti or malaria get malaria done again and get urine routine. Use antibiotics which cover uti for now and anti pyretics for flu like symptoms
Macrocyctosis with high MCV is suggestive of vit B12 deficiency. But there is Pancytopenia with doubtfull widal result. One can go for Typhi dot. And Peripheral smear for cell morphology to rule out any haemolytic disorder(specialy Aplastic anaemia)
Sir I think he may not have B12 deficiency. Here Raised MCV due to chronic liver disease and probably the liver disease is the result of viral hepatitis. Pancytopenia is due to Megaloblastic anaemia.
1
Anemia n hemolysis of Rbc leucopenia indicate enteric fever.give broad spectrum antibiotic with iron,folic acid,methylcobalamin,and vitamin-C n remaining give symptomatically Rx
Low hb and hct . Posotive for enteric fever in low dilution. To be treated for enteric fever. Correct hb. With packed cell transfusion. Iv .fluids. etc .
Looks like pancytopenia and fever.. 1month duration. Needs full evaluation of PUO. May be Infective etiology but needs rule out malignancy
Sir I think he may not have B12 deficiency. Here Raised MCV due to chronic liver disease and probably the liver disease is the result of viral hepatitis. Pancytopenia is due to Megaloblastic anaemia. So need complete viral Hepatitis panel. Must one should exclude autoimmune hemolytic anaemia by direct coomb test.
0
Inj B12 im once daily for 1wk Once a week for one month Tab B12 od for 1month (Trade names: Inj Neurobione forte (or) Inj Optineurone)
Sir I think he may not have B12 deficiency. Here Raised MCV due to chronic liver disease and probably the liver disease is the result of viral hepatitis. Pancytopenia is due to Megaloblastic anaemia.
0

View 2 other replies

D/D ; 1.Enteric fever 2.Amoebic liver abscess (to be considered as there is increased echogenicity of liver with abnormal liver enzymes ) Investigation required : 1.Blood culture 2.Urine culture 3.CT abdomen Treat according to the outcome of the reports. PLEASE LET IS KNOW THE REPORTS n PROGRESS OF THE PATIENT. ..
Thankyou sir and i will let u know and it seems liver enzymes are normal..peripherel blood smear and Sr.vitamin b12 reports are pending and planning to do bone marrow biopsy as per peripherel blood smear findings
0
Performing bone marrow biopsy nd blood culture would b wise in dis case... nd azithromycin iv can b considered along with ceftriaxone iv... nd vitB12 inj. Im
Sir I think he may not have B12 deficiency. Here Raised MCV due to chronic liver disease and probably the liver disease is the result of viral hepatitis. Pancytopenia is due to Megaloblastic anaemia.
0
Load more answers

Cases that would interest you