A young female aged 18 yrs presented with history of Fever with chills , breathlessness since 5-6 days and altered sensorium since 1 day.....On taking history from attendants, it was revealed that She has had 2-3 episodes of Jaundice in last 2 yrs and 3 PRBC transfusions were also done 8 months back due to severe anemia....She was foundto have clubbing...Discuss this interesting case and possible differentials...

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Based on history there appears to be a hemolytic anaemia with an acute episode of fever..fever may be due to pneumonia(xray showing rt lower zone consolidation with cardiomegaly), infective endocarditis(clubbing and cardiomegaly with mostl probably rt atrial enlargement) Differentials are malarial fever with rt pneumonia with febrile delirium, infective endocarditis with pneumonia, meningitis due to septic emboli in infective endocarditis, hepatic encephalopathy due to acute episode of hemolysis in haemoglobinopathy with congenital heart disease..kindly also.elicit drug history for probable contribution to hemolysis in this acute episode.cbc with esr, lft, rft, se ldh and haptoglobin, peripheral smear for malarial parasite and cell morphology, dct and ict, hb electrophoresis, lt lateral chest xray, 2 d echo, csf, blood cultures(3), ct brain..antibiotic(3 rd generation cephalosporin-empirically), hydration, bowel evacuation(lactulose via rt or enema),.

Thank you doctor
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It may b malaria parasite. Severe a plastic anaemia.sickle cell anaemia or auto immune hemolytic anaemia so adv pt aptt kft.lft and iron profile and csf and ct scan and transfuse whole blood

Peripheral smear findings.. general blood picture.. should also be done..
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Since there is h/o 2 to3 episodes of jaundice she may have land as a c/o hepatic failur with encephalopathy. This can be associated rt lower lobe congestion with mild ascitis

Thanx dr Dr Malikender patel patel
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Spleen size? Urine colour? H/o blood in stool, urine? Agree with Dr Sumit Gupta listed DDs. Peripheral blood picture, reticulocyte count, IEP, CUE, USG abdomen along with other mentioned. ICU admission and hydration is priority along with simultaneous evaluation. Involve hematologist.

Agree with @Dr Annu
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DD are hemoglobinopaties, thalassemia,sickle cell disease in sicklecell anemia due to auto splenectomy pts are, susceptible to pneumococcal and salmonella infections.in hepatitis viral infection patients are prone to aplastic anemia.

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Clubbing is the feature of obstructive jaundice and altered sensorium is there so this can be due to hepatic encephalopathy but interstitial lung diseases to be ruled out for cause of breathlessness

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The patient is now having right lower love consolidation s/o pneumonia with septicemia, it may be due to decreases immunity as splenomegaly might be clearing all the b and t cells.routine blood with peripheral smear and reticulocyte count will help I think.is she having jaundice now?also some occult congenital heart disease might be there.

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Patient has ascites so fluid examination should be done And rule out for focus of infection CBC,thallessemia,sickle cell anaemia ESR ,mountux test must be done Subacute bacterial endicarditis developed so patient presenting such sign and symptoms Treat patient symptomatically till reports come

Idiopathic noncirrhotic portal hypertension (INCPH) with with hypersplenism and right lower lobe pneumonia with septicaemia

Fever may be due to malaria, pneumonia, enteric of even meningoencephalitis. Patient has some hemolytic anemia which needs to be evaluated if sickle cell then the fever may not be malaria. Per se clubbing can be due to hepatocellular failure or congenital heart disease or even lung pathology like abscess, I am against endocarditis bcoz of short history. Another thing is that sonographer didn't comment on Portal vein size keeping in mind CLD. In hemolytic anemia liver can't have hyperechoic texture.

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