Tiredness And Lethargy

A 45-year-old Malay woman presented with increasing tiredness and lethargy of 5 days duration. She also complained of reduced effort tolerance, dizziness, headache and near-fainting spells. 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. On examination, the patient was pale and mildly jaundiced. She was tachycardic and tachypnoic with pulse rate of 124 beats per minute and respiratory rate of 22 breaths per minute respectively. The blood pressure was normal at 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‚Äôs space was dull on percussion. The cardiovascular and respiratory examinations were normal. On investigations, her hemoglobin was 3.9 g/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 Coomb's test was positive. 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.

  1. What is a likely reason for her anemia?
  2. Why does she have tachycardia and tachypnoea?
  3. How do you interpret the positive ANA test with negative anti ds DNA test?
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