A young female aged 14 years presented with complaints of jaundice (on/off), severe fatigue and weakness since 2 months....On examination she was found to have severe anemia along with Jaundice....CBC showed Pancytopenia....A diagnosis of Hemolysis was made...Comment on the clinical approach and investisgations required to treat the patient...



Here jaundice is all unconjugated / Indirect... Mostly hemolysis.. Blood picture suggestive of pancytipenia with usg wise splenomegaly... Here MCV is also high.. So probability of Vit B12 deficency is more likely... I have seen some patients like this who responds to Vit B12 injections with reversal of pancytopenia and hemolysis... I would suggest do Screening gor hemolytic anemia or aplastic anemia by hematology consultation if not responding to abovr methylcobalamine therapy after 7 days...

In this case might be Haemolysis is the cause along with Severe B12 deficiency. The Hb-6 RBC-1.38 Esr-98 platelet-48000Mcv- 112 TLC- 3000 s.bilurubin3.2 are some of the worried key factors should be focus. Rising ESR suggestive of some infective pathology also. PCV 19.0 it's very low. No doubt B12 deficiency might there but just order some investigation like MP & DENGUE IgG & IgM whether she have fever or not. Spleenomegally- Anaemia- Haemolytic jaundice may be suggestive of MP. She might have in STAGE of second week of plasmodium vivax infection . Either DENGUE positive. Order only for DENGUE IgG & IgM as it will give correct idea if she have early days infection of dengue in past also. - As per management is concern it should be very prompt . It's good to see that she is hospitalised.- Start inj. cefotaxime dosage adjust as per wt- maintain fluid balance- close watch on PCV-PLATELET-ESR.- rest of treatment based on other investigation.- if Hb decreases less than 4.5 - 5.0 blood transfusion . If thrombocytopenia increases start platelet.- if pt respond nicely Anaemia can be manageable post discharge also by inj.Vit.B12- Nothing to worry about Haemolytic jaundice as we will manage B12 level & correct anaemia s.Bilurubin will be get normal. - If still high essential phospholipids can be started for few days will correct the liver parameters.

This patient is having classical presentation of falciparum malaria. More number of RBCs invaded by falciparum, more haemolysis, leading to Anaemia & Jaundice. Please note that we should not expect classical paroxysm in falciparum due to overlapping of multiple generations of parasites undergoing multiplication simultaneously. Many a times now a days we don't find much fever particularly in falciparum because of diminution of gamma delta T cells in malaria endemic regions.

Maybe the case of sickle cell anemia so do the sickling test, poor hygiene or impuer water maybe the cause of repeated jaundice. Give the high nutrition diet,leafy vegetables,iron folic acid supliment with deworming

1 pbf would be of immense help in directing whether simple megaloblastic picture is there or evidence of hemolysis also present 2 urine for myoglobin 3 Gilbert to be ruled out Evaluate liver fully 4 rule out multiple myeloma also or evaluation for raised ESR needed 5 chronic malaria is also a strong possibility 6 G6PD deficiency work up needed 7 treat only after evaluating 8 haptoglobin can help differentiating intra or extra vascular hemolysis if needed 9 while treating with B12 iron supplement must considering dietary deficiency or mal absorption or ch loss

Megaloblastic anaemia.......have seen many such patients who respond to the injectabke Vitamin B 12 .

Most likely case of megaloblastic anemia. Close DD is AIHA. but spleen is mild and mild hyperbilirubunemia so it most likely megaloblastic... Go for reticulocyte count and coombs test.

Anemia,pancytopenia: no reticulocyte:macrocytic picture & no gall stones with spleenomegaly: folic acid,B12 deficiency : ineffective erythropoiesis; myelofibrosis?

Adv BT,look for cause of hemolysis like MP,any viral infection,drug intake

First go for Direct Coombs test If its positive Identify and quantify the culprit Ab with indirect Coombs Test and Coombs titration ESR and liver Enzymes Osmotic Fragility test to R/o Spherocytosis Look for an infective cause like MP or Dangue ALP and LDH scores Sr Calcium Lastly Bone marrow aspiration and Biopsy to Rule out BM Aplasia Start Treating with Combination of Follic acid 5mg Bd Injectable Cyanocolamin daily for two weeks Add Steriods when infective Pathology is ruled out

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