WELCOME TO THE DEPT. OF PEDIATRICS

CASE PRESENTATION

Dr. Zain Ul Abidin

LIAQUAT COLLEGE OF MEDICINE & DENTISTRY

(PAEDRIATIC DEPARTMENT)

HISTORY TAKING

Case:-

Name: Zeeshan.

S/O: Malik Fayaz.

Age: 10 years.

Residence: Majeed Colony.

• The 10 yr oldchild with past medical history of recurrent illnesses was admitted in this hospital 1.5 month back through OPD with the following complains of;

Fever& headache, Fatigue & dizziness Shortness of breath on exertion Weight loss with loss of apetite Loss of Taste sensation. Tingling and numbness.

•

• According to his mother he has suffered different illnesses in the last 3 months for which different diagnosis were made and treated.

• He once suffered from an episode of bleeding for which hemophilia was considered by the doctor but not proven.

• According to the mother he was also diagnosed as nephrotic syndrome by one doctor , because of puffiness of the face. But no record was available

HISTORY OF

PRESENTING

ILLNESS:-

• 2 months ago he presented with the symptoms of fever, motion, vomiting. Which was eventually subsided in hospital by palliative treatment.

• 1.5 month back he got admitted in this hospital

• & On the very vague history and varying diagnosis a Detailed physical examination & Laboratory Investigations were done to rule out nephrotic syndrome and Haemophilia

HISTORY OF

PRESENTING

ILLNESS:-

SYSTEMIC REVIEW:-

• No other significant findings on systemic review in CVS, RESP SYSTEM, GIT SYSTEM, URINARY SYSTEM. MUSCULOSKELETAL SYSTEM & NEUROLOGICAL SYSTEM.

PAST MEDICAL HISTORY:-

• He experienced generalized fits 3 yrs back, for 2-3 minutes, followed by unconsciousness, associated with urinary incontinence & frothing. For which he got admitted in civil hospital where he received injections for 15 days & blood transfusion.No record of final diagnosis

BIRTH HISTORY:-

• According to the birth history, his mode of delivery was via scissarion, full term delivery, normal breath & cry.

• The child was not vaccinated at birth.

• Breast feed for 2.5 years

• Weaning at 3rd

month with semisolid diet.

DEVELOPMENTAL HISTORY:-

• Milestones were normal:• Smile – 4

th week.

• Neck holding – 3rd

month.• Sitting – 8

th month.

• Crawling – 8th

month.• Walking – 11

th month.

• He is the student of 3rd

Standard.

• Inappropriate vaccination, with no record.

FAMILY HISTORY:-

SOCIOECONOMIC HISTORY:-

• 4 rooms house.• 10 people , 1 earning hand.• Gud hygeine.• Use of boil water.

PERSONAL HISTORY:-

• No addiction.• Normal sleep.• Decreased appetite.• Inappropriate diet (strict VEGETARIAN)• Disturbed bowel habits.• Normal micturation.

EXAMINATION

GEN ERAL PHYSICAL EXAMINATION

VITAL STATISTICS:

Both height and weight of the child is below 5th

centile.

VITALS:• Pulse 87 BPM.• Resp. rate 22.• B.P. 117/78 mmHg• Temp. 99 F.

• Puffiness of the face• Anaemia +++• Jaundice +• Cyanosis Nil• Oedema Nil

• On Oral cavity examination; lips were dry with angular cheilitis.

RESPIRATORY & CVS SYSTEM

• No significant findings.

• On Inspection, chest is normal in shape, moves with resp. (abdomino-thoracic pattern), bilaterally symmetrical, no scar, striae, pigmentation, mass, visible pulsation, surgical mark or any deformity.

• On Palpation, trachea was centrally placed, apex beat on 5th

intercoastal space medial to mid-clavicular line, no tapping & heaving, no parasternal heave, chest expansion is normal on both sides, vocal fremitus is equal on both sides.

• On Percussion, percussion note normal bilateraly

• On Auscultation, normal air entry, vocal resonant & heart sounds.

• Peripheral pulses, were normally palpable with normal rate, rhythm, volume, & character.

ABDOMINAL EXAMINATION

• On Inspection, abdomen is of normal shape, bilaterally

symmetrical, moving with respiration, umblicus centrally placed,

no abnormal pulsation, scar & striae, mass or swellling.

• On Palpation, Liver is palpable 3cm below Right costal margin

with smooth

surface,rounded border with no tenderness. Upper border of the

liver is in the 5th

intercoastal space.

• On Percussion, normal.

• On Auscultation, normal gut sounds.

CNS EXAMINATION

• In Nervous system, higher mental functions were normal.

• There were the findings of paresthesia in fingers.

• Other than that Cranial nerves & motor & sensory system were

intact. There were no extrapyramidal signs, & signs of meningeal

irritation were absent.

DIAGNOSIS

Provisional Diagnosis

ANEMIA

DIFFERENTIAL DIAGNOSIS

AnemiaPeripheral neuropathyViral hepatitisChronic Liver diseaseNephrotic SyndromeChr. Renal failureHemophilia

Anaemias

• Hypochromic Microcytic

• Nutritional(Iron Deficiency Anaemia)

• Thalassaemia Major• Thalassaemia Minor• Chronic Blood loss• Macrocytic

ANEMIAANEMIA

MICROCYTIC ANEMIA. [MCV <80fl]

MACROCYTIC ANEMIA. [MCV >96fl]

NORMOCYTIC ANEMIA. [MCV 80-96 fl]

INVESTIGATION

CBC:

• RBC= 1.91

• MCV= 113.2 µm³

• RDW%= 26.1 %

• PLT= 367 10³/mm³

• MPV= 9.4 µm³

• LYM= TM 10³/mm³

• GRAN= TM 10³/mm³

• MID= TM 10³/mm³

• WBC= 12.610³/mm³

• HGB= 7.3 g/dl

• HCT= 21.7 %

• MCH= 38.2 pg

• MCHC= 33.7 g/dl

• LYM= TM %

• GRAN= TM %

• MID= TM %

BASE-LINE INVESTIGATIONS

Urine & Stool d/r normal.

Electrolyte, Urea & Creatinine normal.

Ultrasound KUB normal

PT & APTT & Factor 8 levels normal.

LFT Normal

BASE-LINE INVESTIGATIONS

Macrocytic anaemia

Vit B-12 deficiency

Folate deficiency

Cytotoxic drugs

Mylodysplasia

BIOCHEMISTRY•Follic Acid 3.66 (2.6-12.2 ng/ml)

•Vitamin B12 185.4 (206-678 pg/ml)

Salient Features of this Disease

• Strict Vegetarian child• Recurrent illnesses• Failure to thrive• Fatigue, loss of apetite,Tingling &

numbness• Anaemia & Jaundice with hepatomegaly

POSITIVE INVESTIGATIONS: CBC: RBC= 1.91 MCV= 113.2 µm³ HGB= 7.3

g/dl

BIOCHEMISTRY: Vitamin B12 185.4 (206-678 pg/ml)

Salient Features of this Disease

FINAL DIAGNOSIS

VITAMIN B12

DEFICIENCY

MACROCYTIC ANEMIA

• A macrocytic type of anaemia is an anaemia in which the erythrocytes are larger than their normal volume

• MCV is >100 Fl

Macrocytic

anaemia

Vit B-12 deficiency

Folate deficiency

Cytotoxic drugs

Mylodysplasia

VIT-B12 DEFICENCY ANEMIA

• VIT –B 12 DEFICENCY anemia is a low red blood cells count due to lack of VIT –B 12

VIT B-12 ABSORPTION

For vitamin B12 to be sufficiently absorbed by the body, it must bind to intrinsic factor, a protein released by parietal cells in the stomach.

The combination of vitamin B12 bound to intrinsic factor is absorbed in the final part of the small intestine.

CLINICAL PRESENTATION Patient may present withMalaise (90%)paraesthesiae(80%)

breathlessness( 50%)

sore mouth(20%) Smooth, sore tongue with

atrophy of papillae

• DEPRESSION AND HALLUCINATION

• VISUAL DISTURBANCE

• WEIGHTLOSS

NEROLOGOCAL FINDINGS IN

VIT-B12 DEFICENCY• PERIPHERAL NERVES GLOVES AND STOCKING

PARAESTHSIAE LOSS OF ANKEL REFLEXES• SPINAL CORD LOSS OF VIBRATION SENCE AND

PROPRIOCEPTION UPPER MOTOR NEURON SIGNS• CEREBERUM DEMENIA OPTIC ATROPY• AUTONOMIC NEUROPATHY

MANAGEMENT OF MEGALOBLASTIC ANEMIAS1-HISTORY Good and proper history is very

important to identify the possible cause

Any surgery of stomach and intestine, chronic diarrhea should be asked

Ask if the patient is taking any proton pump inhibitors, and what r the dietary habits etc

• 2-LABORATORY INVESTIGATIONS : CBC: Hb reduced MCV raised >120fL LEUCOCYTE COUNT low/normal PLATELET COUNT low/normal SERUM FOLATE AND B12 LEVEL:

BLOOD FILM: oval macrocytosis red cell fragmentation hyper segmented neutrophiL

BONE MARROW biopsy: increased cellularity

Megaloblastic cells

TREATMENT• INTRAMUSCULAR THEARPY

• Hydroxycobalamine 1000 micro grams in five doses 2-3 days apart

• MANTAINANCE THEARPY

• 1000 microgram every 3 months for life

• If dimorphic blood film ,additional iron therapy is given

FOLLOW UP OF THE CASE

Follow up after therapy

• Treatment.Weekly IM injection of Cyncobolamine given for 4 weeks

• Follow up after 4 weeks.• Symptoms improved.Apetite

increased.Fatigue and tiredness has gone and so the numbness and tingling.

• Liver size reduced.No more palpable below Rt Costal Margin.

Follow up after therapy

Follow up after therapy

CBC:

RBC= 2.35 MCV= 71.2 µm³ HGB= 8.0 g/dl

VIT B12 : was done but reports are still to awaited.

ANY

QUESTION