MBBS UM (malaya) EXTENDERS

This post is a follow up on a case which i discuss earlier. In case if you wanna know a bit about the patient history or you are lost, care to click here.

Patient currently on week 2 and currently on day 4 of oral augmentin course change from previous IV augmentin due to development of rashes based on Prof MT Koh saying that the cause of the rashes which raised on the patient trunk and the limbs could be from the antibiotic given. I'm start to think, patient was already on IV augmentin for 12 days and if the rashes really due to the antibiotics given, shouldn't it comes early? And if the patient really have the rash problem due to antibiotic, is the route of administration of the drug makes the rash goes away eventhough it using the same antibiotics? but anyway, the rashes was still there for the past 3 days.

Currently, oncology team lead by Prof MT Koh, makes the working diagnosis as Haemophagocytic Lymphohistiocytosis, which is a rare disorder of the immune system. The disease clinically manifests as fever, hepatosplenomegaly, pancytopenia(which the patient's platelet is normal), lymphadenopathy, and rash(and no rashes initially) often comprise the initial presentation.


Hemophagocytic Lymphohistiocytosis

The diagnostic criteria set forth by the Histiocyte Society for inclusion in the International Registry for Hemophagocytic Lymphohistiocytosis (HLH) is as follows. All 5 criteria must be met to establish a diagnosis of hemophagocytic lymphohistiocytosis:


* Fever - Seven or more days of a temperature as high as 38.5°C (101.3°F)
* Splenomegaly - A palpable spleen greater than 3 cm below the costal margin
* Cytopenia - Counts below the specified range in at least 2 of the following cell lineages:
o Absolute neutrophils less than 1000/µL
o Platelets less than 100,000/µL
o Hemoglobin less than 9.0 g/dL
* Hypofibrinogenemia or hypertriglyceridemia - (1) Fibrinogen less than 1.5 g/L or levels greater than 3 standard deviations below the age adjusted reference range value or (2) fasting triglycerides greater than 2 mmol/L or levels greater than 3 standard deviations above the age-adjusted reference range value
* Hemophagocytosis - Must have tissue demonstration from lymph node, spleen, or bone marrow without evidence of malignancy
* Rash - Skin findings in more than half of patients;1 scaly and waxy lesions; rashes on the scalp and behind the ear
* Other - Swollen or hemorrhagic gums that can result in tooth loss; feeding problems (especially prominent in infants); abdominal pain, vomiting, diarrhea, and weight loss




Discussion

I don't know why they were searching for all those rare things. If i answer this HLH in my long case final exam, sure GG. They are currently planning to have some blood investigations to confirm the HLH by doing fasting TG, fibrinogen, and waiting for trephine report.



When i ask one of the doctor there, why would they haven't done their lymphnode biopsy, the answer somewhat like this

"This is a generalised lymphadenopathy. How could we biopsy all the lymphnodes?????"

I don't know wether its true or not, but currently there is no plan for lymphnode biopsy yet.

A big suprise where today was the first time the patient is 24 hour free from fever. Maybe an oral antibiotic is working after all..

Today i've managed to present one case of a 4 year old child with fever for 4 weeks with no other clinical symptom except loss of appetite, lost of wt of 1 kg and a bit lethargic and less active. There was no RTI, GIT, CNS symptom. Fever was reduce by antibiotics. No night sweat. Then later was referred from a GP due to fever and palpable cervical lymphnodes. Got a history contact to TB patient(grandmother). Vaccination was complete.

Physical examination reveals fever, palor, with hepatomegally (1cm) and generalised lymphadenopathy. No bcg scar noted


So differentials would be
1) Tuberculosis
Points favour - History contact with TB, loss of wt and appetite. PE reveals fever, palor, hepatospleenomegally and also generalised lymphadenopathy and no BCG scar.
points agains - No cough, haemoptysis, and night sweat.

2) Leukaemia
Points favour - Lethargy, fever, palor, hepatomegally, lymphadenopathy
Points against - No bleeding tendency, no family history of blood malignancy, no spleenomegaly

3) Lymphoma
Points favour - B symptom? (must really need to clarify is there any night sweat because patient was in an aircond when sleeping) and also lymphadenopathy
Points agains - i couldn't think of... maybe u can give me a comment

4) HIV - fever
points against - No hx of blood transfusion,

5) Thyphoid/thyphus
Points favour - PUO, lymphadenopathy, hepatomegally
Points against - no spleenomegally, no

6) autoimmune? connective tissue disease?


Investigation that was done and some I think should be done base on the differentials given are:

1)FBC
Investigation fbc reveals hb low, white cell low, but platelet and wcc differentials are normal.

2)PBF shows normocytic and normochromic anaemia. No blast cell seen

3)Mantoux test
negative

4)Chest xray
No mediastinal lmphadenopathy noted.

5)Bone marrow film
No abnormal/malignant cell noted. Comment said that we should look for viral causes.

6)Lymphnode biopsy
Not done yet

7) HIV screening (permission should be taken 1st when doing HIV screen), Hepatitis screening
-ve

8) Toxoplasmosis?
No plan yet for this toxoplasma screen

9) Infectious Mononucleosis??

10) Blood culture
-ve for all bacteria, virus,

11) Thyphoid/Thyphus
-ve

12)



Diagnosis

PUO and currently on investigation.


Comment

Currently, patient on IV antibiotics, fever are up and down, and relief with PCM. Antibiotics given shown to have positive result, but they are trying to off it to let see if the fever spike up again.

Platelet count was normal despite HB and WBC low. wbc was low until 2 and this is what we call febrile neutropaenia. Prof Amir has said that if a patient come with febrile neutropaenia, we should do a septic screen (blood culture, urine culture, oral swab etc..). However all the test was negative.

Mantoux test was negative however it doesn't mean that the diagnosis should be exclude. there was no BCG scar showing that

Bone marrow was also negative of malignant cell, however, if the bone marrow is negative we can do a lymph node biopsy. Correct me if I'm wrong.



I will follow-up the patient progress and post it on here later. Anything in mind can contact me. Thanks in advance.

Mama called just now.. she said that someone sent me a check! I ask, how much? she said RM71! lolz.. This must be nuffnang. For your info, i've applied it 27th June and they send it at 6th June!! wow.. That's FAST! I was a bit shock when this current situation where economy is turning down, they still paying!

Click here
http://mbbs-extender.blogspot.com/2009/06/sorry-guys-were-back.html



If u haven't register at nuffnang, now is the time for u to apply it! it's not a scam. Later I'll post my check for u guys to see the proof. but anyway, there's a lot of evidence where nuffnang is paying. Just google it!

Thanks NUFFNANG... i'll used that money to blanje makan to my group members.

Ibu baru bersalin korban pertama di Sarawak

KUALA LUMPUR 3 Ogos - Seorang wanita berusia 23 tahun yang baru dua minggu bersalin menjadi korban ketujuh virus selesema babi atau influenza A (H1N1) di negara ini.

Mangsa merupakan kes kematian pertama H1N1 di Sarawak.

Ketua Pengarah Kesihatan, Tan Sri Dr. Mohd. Ismail Merican berkata, mangsa meninggal dunia pada pukul 4 pagi ini setelah dimasukkan ke Unit Rawatan Rapi (ICU), Hospital Miri, Sarawak sejak 22 Julai lalu.

''Dia dimasukkan ke ICU kerana mengalami komplikasi pada paru-paru dan disahkan dijangkiti H1N1 pada 23 Julai lalu. Dia telah bersalin di hospital sama dua hari sebelum itu,'' katanya dalam kenyataan di sini hari ini.

Beliau berkata, wanita itu didapati menghidap pneumonia yang teruk selepas bersalin selain mengalami simptom demam dan batuk empat hari sebelum bersalin.

''Bayi wanita itu didapati selamat dan disahkan bebas daripada H1N1. Penyebab kematian direkodkan sebagai pneumonia akibat jangkitan H1N1,'' jelas beliau.

Mohd. Ismail menambah, sebanyak 17 kes baru H1N1 termasuk satu kes kematian dilaporkan di negara ini menjadikan jumlah kes terkumpul H1N1 meningkat kepada 1,446 kes.

''Kesemua kes baru itu adalah jangkitan tempatan yang melibatkan rakyat Malaysia. Jumlah kematian akibat H1N1 di negara ini setakat ini adalah sebanyak tujuh orang,'' katanya.

Menurutnya, daripada 1,446 kes terkumpul H1N1, sebanyak 574 merupakan kes import dan 872 adalah kes jangkitan tempatan.

''Daripada jumlah ini, 1,408 kes telah sembuh, hanya 29 kes sahaja yang sedang menerima rawatan antiviral di hospital yang mana lapan daripadanya berada di ICU. Sembilan orang sedang menerima rawatan antiviral di rumah,'' katanya.

Beliau berkata, daripada lapan kes di ICU, empat daripada mereka mempunyai faktor risiko iaitu obesiti (1), wanita hamil (1) dan imuniti rendah (2).

Mohd. Ismail berkata, bagi 17 kes terpencil, tujuh kes dirawat di wad pengasingan hospital, satu kes di ICU dan sembilan orang menerima rawatan pesakit luar.

Merujuk kepada situasi global sehingga hari ini, beliau memberitahu, sejumlah 183,854 kes H1N1 dengan 1,307 kematian telah dilaporkan daripada 167 negara.

''Ia melibatkan peningkatan sebanyak 28 kes termasuk enam kes kematian berbanding dengan hari sebelumnya,'' katanya.

Beliau berkata, orang ramai yang mempunyai gejala jangkitan H1N1 berterusan dan bertambah teruk disaran mendapatkan rawatan di klinik serta hospital yang berdekatan.

''Kes-kes yang mempunyai simptom jangkitan influenza serta faktor risiko seperti mengandung, obesiti, asma, penyakit paru-paru kronik, diabetes dan golongan imuniti rendah akan diberi rawatan antiviral influenza serta-merta tanpa perlu membuat ujian pengesahan H1N1.

''Ini adalah untuk kes-kes yang dikesan dalam masa 48 jam selepas mereka mula mengalami simptom jangkitan influenza. Ujian pengesahan jangkitan influenza hanya perlu untuk kes-kes yang dirawat di hospital,'' katanya.

1) Today started my new posting - paediatric. Prof Asma was very critical to our history taking and i managed to get something from her class today this morning.

2) Although the first case was very simple, a respiratory infection, it seems that there are a lot we still don't know.

3) The way we should took a history is to let the patient tell the event from the beginning until the end without us interrupting in the middle.

4) After the patient finish talking, then we clarify the gaps and take further history which are relevant.

5) English, again are very important, enough say.

6) We don't create a history. Read back what we took. Is the history was really a logic event? If it not, clarify again with the patient.

7) Prior to admission, is the 'key' date. In the mean while, we can also use the 'day of illness' for associated symptom. How many days did the patient has admitted is also an important history.

8) 4C's should be in the history - chief complain, causes, complication, and course of the disease. Thus we really need to know how was the patient progress.

9) Current situation such we're having now - H1N1 should bear in our mind now.

10) The 2nd case is a dengue haemorrhagic fever.

11) I should admit it, this was the first time i saw the rashes like the patient had. If Prof Asma don't tell me it's rashes, i wont know.

12) The last time i saw a dengue rashes was a bit different from this. I should see and identify a lot of different presentations of dengue rashes.

13) There was 3 other differentials based on history - acute glomerulonephritis, hepatitis, and urinary tract infection.

14) Investigation that has been done are FBC - to see the platelet level, haematocrit, UFEME. Prof said we need to exclude the differential also by doing ASOT or ESR.

15) Treat dengue by giving IV maintenance half saline and check for heart rate, resp rate, urine output, and also sign of ascites and pleural effusion.

16) Lastly, thanks Prof Asma. I was hoping my URTI heals faster.