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Case presentation:
21 yr old female resident of Nalgonda came to casualty with complaints of generalised weakness and easy fatigue since 10 days. Sob on exertion (grade 2 - on walking 100 meters ) since 3 days .
Pt had history of fever at 10 years of age ,when they took her to local rmp ..but did not subside and later she developed generalised edema and sob (grade 3) and orthopnea .
They visited kamineni hospital here back then and was treated for few days . Later she was told she requires surgery and was referred to hyderbad for ASD closure and Chronic rheumatic heart disease (s/p - ASD closure and mitral valve replacement surgery in 2008 ) .
Since then patient is on acitrom 4 mg od and tab ecosprin 75 mg od .
Inj benzathine pencillin 1.2 MIU every 3 weeks.
According to pt attenders ,Pt was having Anemia during surgery period also where they transfused 2 units of prbc . After 15 days of surgery they discharged her on acitrom and ecosprin .
Pt was not on regular follow up since then and continued taking acitrom 3mg and ecosprin.
4 years back she went for regular check up again , where they told she had anemia and requires transfusion , but they neglected as she was not having any symptoms.
8 months ago pt stopped taking pencillin injections .
6 months ago she got married and complaints of gum bleeds intermittently since 4 months.
No history of hematuria,black stools , petechiae.
Since 10 days generalised weakness and easily fatigability and sob on exertion since 3 days .
No history of pedal edema , palpitations,chest pain ,fever ,cough , yellowish discoloration of eyes.
Menstrual history - Regular ,3/30 ,normal flow and no clots .
Appetite is normal and has mixed diet .
Bowel and bladder movements are regular .
No history of DM/HTN/TB/ASTHMA/EPILEPSY.
O/E :
Pt c/c/c
BP - 110/70 mmhg
pr - 105 bpm .
No raised jvp.
no pedal edema .
CVS - S1 S2 present .No murmurs
RS - BAE present .
p/a - soft ,non tender
splenomegaly present .
Reports :
Hb - 4.7 g/dl ; Tlc - 5,300 ; plt - 2.82 lakhs.
mcv - 59.2(low) ; mch - 16.7 ; pcv - 16.7
RDW - 19.5 FL ( increased) .
Anisopikilocytosis with hypochromasia with microcytes and pencil forms .
microcytic hypochromic anemia .
S. ferritin - 1.4 ( very low )
Retic count - 0.7 % . ARI - 0.3 - HYPO PROLIFERATIVE PICTURE .
PT- 18 SEC ;APTT - 42 SEC
INR - 1.5 .
Rft - normal
Lft - TB - 1.19 ; DB - 0.39 ; AST - 27 ; ALT - 16
ALP - 248 ; ALB - 3.96
B/G/T - A positive .
As serum ferritin is low and its microcytic hypochrmic anemia with high RDW ,
D/D - ? Iron deficiency anemia but doesn't explain splenomegaly .
So could be Beta thalassemia minor along with IDA .
( Menzers index - 20.9) .
