Summary 15

Madam AT, a 45-yeard-old Malay female, presented with hemolytic anemic symptoms of 5 days duration.

Question: What are the symptoms of hemolytic anemia (as opposed to symptoms of anemia)?

The patient was well until five days ago where she started to experience lethargy, reduce effort tolerance and exertional dyspnea. She also experienced dizziness, headache and presyncope attack. She noticed that her urine become dark colored for the past 5 days. Her husband and children noticed that she looked pale. There was no abdominal pain, no loss of weight, no loss of appetite or pale stool. No history of blood transfusion or history of taking traditional medication. No family history of bleeding disorder.

Question: In the context of a rapidly developing anemia, what does the history of dark coloured urine imply?

On examination, the patient was pale and mildly jaundice.

Question: Why is there jaundice in hemolytic anemia?

She was tachycardic and tachypnoic with pulse rate of 124 beats per minute and respiratory rate of 22 breaths per minute respectively.

Question: Suggest a reason for her tachycardia and tachypnoea

The blood pressure was normal 120/78 mmHg. There was no lymphadenopathy, no pedal edema or rashes seen. Upon examination of the abdomen, the abdomen was soft and non-tender. There was no hepatomegaly. The spleen was not palpable but the traube’s space was dull on percussion. The cardiovascular and respiratory examinations were normal.

Question: What are implications of dullness in the Traube's space?

Upon further investigations, the patient was having severe macrocytic hyperchromic anemia, reticulocytosis and raised lactate dehydrogenate. The hemoglobin was 3.9g/dL, reticulocyte count was 43.19% and lactate dehydrogenase was 665 U/L. The total bilirubin was raised, 51.1 umol/L with direct bilirubin of 11.1umol/L and indirect bilirubin of 40umol/L. Peripheral blood film showed macrocytosis. Direct coombs test was positive with positive anti-IgG and negative anti C3d. Antinuclear antibody (ANA) was positive with dilution of 1:640 but the anti-double stranded DNA was negative. Rheumatoid factor was negative. The hepatitis B, hepatitis C and HIV screening were negative.

Question: Why is there reticulocytosis in hemolytic anemia? How do you explain the combination of low hemoglobin in the blood and hyperchromia (which means more hemoglobin per red cell)? What is the significance of the raised serum LDH value? How does the colour of the urine help you to differentiate between conjugated (direct) hyperbilirubinemia and unconjugated (indirect) hyperbilirubinemia?

In the ward, the patient was transfused with 3 packets of packed cell.

Question: What is the volume of each packet of packed cells?

She was given intravenous hydrocortisone 100mg STAT and TDS, tablet hematinic 1/1 OD and subcutaneous vitamin B12 1mg OD for five days duration.

Question: Why is vitamin B12 not given orally? Are injections of Vit B12 usually given subcutaneously? Why is she being given "hematinic" tablets?

The patient was discharged home six days after admission. Upon discharge, the patient was well. The vital signs were stable with blood pressure of 130/84mmHg, pulse rate of 86 beats per minute, respiratory rate of 18 breaths per minute and temperature of 37 degrees Celsius. The hemoglobin was 9g/dL, total bilirubin was 23.8umol/L, lactate dehydrogenase was 466 U/L and reticulocyte count was 44.46%. The patient was discharged with tablet Prednisolone 50mg OD for two weeks and appointment to the outpatient clinic 2 weeks later.

Question: Based on the treatment, what is the disease she is being treated for?

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