CASE HISTROY OF Mrs. MANJULABEN C .

PATEL ( F/54 yr ,
BARODA)
A case of 54 year old,Hindu,married housewife Manjulaben Chhaganbhai Patel
residing at Karakhadi, Ta: Padra ,Di: Baroda ( Guj, India ) who is coming from middle socio-
economy class presented to us in S.S.G. Hospital, Baroda on 26th Nov, 2002 with chief
complaints of…..
c/o easy fatiguability for 3 months
c/o fever for 3 months
On elaborating origin,duration,progress patient is symptomatically alright three months
back, then she began to experience easy fatiguability,early tiredness on routine housework .
As complaints were progressing gradually in severity over a month making her in bed for
taking rest most of the day time, she was taken to near Physician in Padra. She was admitted
there for 7 days & her Hb was found tobe around 7.0 gm%. She received three whole blood
units during her hospital stay, her Hb improved came around 9.0gm% & she was discharged
from hospital with oral haematinics & tab metformin 500 mg bd po as she was found tobe
Diabetic.
Although patient was on oral haematinics , patient had no much improvement in her
symptoms. She also started complaint of continuous low grade fever relieved temporary with
tab paracetamol. As symptoms were untolerable again, she was taken to another Physician in
Baroda admitted from 7th oct to 17th oct,2002. During this period,Hemogram showed……
Hb: 5.8 gm%
WBC: 3800/cmm ( 4000-11000) DC: N 56 L 44
PCV:18.5%(37-47)
MCV:90.7 fl(76-96)
MCH:28.2 pg(27-32)
MCHC:31.1 gm%(30-35)
ESR: 20 mm(0-20)
PS: RBC:- predominantly macrocytic,severe anisopoikilocytosis;Normoblasts
seen
WBC: normal
Platlets:adequate
PSMP: negative
After analyzing hemogram, Physician investigated patient as follows :
Stool : Occult blood strongly positive(++++);Rest:normal
Urine: Sugar 1+ ;Bacilli: 3 + ; Rest : normal
Bl.urea, S.creat : Normal
USG Abdomen : no abnormality seen
TSH : 2.18 microIU/ml ( 0.27-5.0)

Patient received two PCVs and repeat Hb was 6.0gm% on 16th Oct,’02( PCV : 18.2 ; MCV:85.4
; MCHC : 32.8 ; PSMP: negative).She was also received empirical antibiotic treatment( tab
gatifloxacin 400mg for seven days). She was given discharge from there with advise to consult
Gastroenterologist for futher evaluation.
 After discharge from clinic, she has developed high grade fever daily with severe
malaise to make her in bed all the time. Hence she is again admitted to our hospital ( S.S.G.
Hospital , Baroda ) on 26th Nov,2002 in emergency department. On admission she showed Hb
of 5.8 gm%;ESR :140 mm & PSMP suggestive of severe P.falsiparum parasitemia.
Considering malaria, she was received inj arte ether( EMAL ) 100mg IM od for 3 days. For
persistent fever despite radical treatment for Malaria, series of investigations under PUO has
been done all came negative.Meanwhile empirical antibiotic treatment in form of cefotaxime &
metronidazole has been started & fever subsided after 2-3 days of starting antibiotic
treatment,treatment is continued for next seven days thenafter.Patient has also received one
PCV on 2nd day of admission. Hemogram done on next day of blood transfusion showed Hb
3.8 gm% with serial hemograms showing thrombocytopenia, high retic count(8%), PS
showing anisocytosis,polychromasia with late normoblasts,MCV:avg 86.0 fl(78-99)
,investigations to rule out hemolytic process been carried out( please see investigation sheet
).With the initial Coomb’s test positive(both direct & indirect),on the other hand first time on 1st
Dec patient complained of passing black stool(with separation of red colour on flushing
stool),immediate stool been tested for occult blood came strongly positive(++++). Patient is
referred to consultant gastroenterologist Dr Prashant Buch & following workup is carried out:
Colonoscopy : normal ( done twice )
OGD scopy : normal ( done twice )
Barium follow-through: normal
USG abdomen : normal

As per advise of Dr Buch(putting clinical impression of hemolytic anaemia) & patient has
improved symptomatically(no c/o fever,malaise,black stool) she has given discharge from
hospital on 6th Dec,2002 with total three blood transfusion,Hb of 8.0 gm% & advised to
discontinue oral iron, weekly Hb , report immediately if c/o passing black stool.
After week of discharge her Hb came 8.5 gm%. On 18th Dec she again has c/o passing
black stool(with separation of red colour on flushing stool),occult blood in stool test on the
same day showed strong positive reaction(++++). Her Hb dropped to7.5 gm%. Two more such
episodes are noted on 24th & 25th of Dec.Patient again c/o malaise( Hb on 4th jan,’03 was 7.0
gm%), so Dr Buch was consulted & enteroclysis been carried out revealing no abnormality.
Patient is advised to go for further G. I .Workup in Mumbai. By the time, patient has received
two PCVs from S.S.G. Hospital on 10th Jan,’03. Last occult blood in stool test is negative on
11th jan,2003. Patient is currently taking only anti-diabetic drug( tab metformin 500 mg bd po ).

Patient on 16th Jan ,2003 complained of passing blood in stool which was seen
clearly by her & relatives . Plan been made to investigate patient further at Mumbai , so
patient was taken to Mumbai on 18th January . Immediately on arrival ( about 8:30 am ) in
Mumbai , she has passed massive frank blood in stool around 300-400 ml as seen by
accompanying medical student . She has been immediately sent for mesenteric
angiography in Hinduja national hospital & research center, Mumbai . Pre-procedure
investigations revealed no abnormality of coagulation system except platlet count of
153,000/cmm & INR of 1.33 ; Hb was 7.5 gm% . Angiography was peformed around 12:30
pm and report was showing suspicious angiodysplasia in proximal colon & caecum area .
However there was no active bleeding . So for sake of confirmation , radio labeled Tc 99
RBC scan was performed ( without giving details of angiography ) which shown pooling
of contrast without extravasation in right iliac & mid abdomen region suggesting vascular
malformation rather than active bleeding. Patient was given one PCV there and advised
to go for treatment of ? angiodysplasia either by APC(argon plasma coagulation) or right
hemicolectomy . Later option been selected by patient & her relatives. Patient was taken
back to Baroda for surgery of the same.

After a week of lag, patient was admitted to Swadia surgical hospital , Baroda on
29/01/2003 three days before planned operation . Patient was switched on to insulin
injections for her diabetic control from metformin tablets . After all pre-op.
preparations(including Hb brought upto 10gm%), patient was operated on 2/2/2003 for riht
hemicolectomy with resection of distal 30 cm ileum . No gross abnormality detacted
during operation in abdomen surgery was completed with end-to-end anastomosis .
Immediately post-op. patient bllod sugar was 537 gm% & patient was unable to
recover from general anesthetic effect, she lost her respiratory drive( probably she was
developed diabetic ketoacidosis) . Patient was put on mechanical ventilator for abround 6
hours. Her aspirate from stomach showed frank blood of about 200-300 ml.
Simultaneouly she was gone into hypovoluemic shock(In early, compensatory stage) with
severe anaemia . However she was managed effectively(with IV
fluids,blood,insulin,electrolyte correction) and returned to spontaneous breathing after 9-
10 hrs of operation . She was given one whole blood & two PCVs. Stomach aspirate
showing clear fluid on next day.

She was well in general condition from second post-op. day . She was on post-op.
antibiotic treatment in form of inj.ceftazidime,inj. Tobramycin. Her bowel movement returned
to normal on 3rd post-op. day and she was given oral fluids from same day . She was
absolutely well clinically till 9th post-op. day . Post-op. Hb was 11.5 gm%; s.electrolytes,blood
sugar :normal . On 10th post-op. day, from morning onwards, she started altered behaviour
& speech pattern with continuous repeating of sentences: “give me water”,”having
ghabharaman(fear of dying)”,”why I am not getting well?”,”I will never get well “…

Doctor had examined her and found mild icteric tinge in sclera with pedal edema
& slight fall in urine output . Primary investigation showed Hb 11.5gm%, TC :16,000
/cmm , Dc: P56/L43/M1/E0/B0 ; ESR : 60 mm/1st hr;
Platlets : 16,000/cmm (repeat platlet on 10/02 was 14000/cmm)
Blood urea: 83 mg/dl
S.creatine : 2.83 mg/dl
LFTs: S/o Active hepatitis with heaptic jaundice
Direct Coomb’s : negative
S. LDH : 3186 IU/L

With dilemma in coming to diagnosis, case report was shown to onco-hematologist Dr

Chirag Shah,Ahemadabad on 11th Feb advised to repeat bone marrow biopsy/aspiration.
Meanwhile patient was put on supportive Rx with empirical inj. Ceftazidime & received two
PRPs. Patient was gone into coma state from early morning of 11th Feb,she was put on
nasal oxygen, jaundice was worsened & urine output dropped to much lower value( less
than 100 ml in 12 hrs) with resulting ascites & pedal edema .

Patient on 11th evening developed severe jaundice with hepatic encephalopathy

with ARDS with hemolytic-uremic syndrome. Patient died at 21:30 on 11th February ,
2003.

Case remained mystery for all of us here.

Samir B . Amin drsbamin@yahoo.com

B/38,New medical hostel, http://www.sbamin.com
Baroda-390001(India) 16/02/2003 14:45

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