VITAMIN B12 DEFICIENCY PRESENTING AS PYREXIA<br />DR.PRAVEEN NAGULA<br />
JULY 1 ,2011<br /> HAPPY DOCTOR’S DAY <br />
DR.BIDHAN CHANDRA ROY<br />  July 1st- 1882-july1st 1962    <br />
DR.TINSLEY.R.HARRISON<br />
PHYSICIAN IS THE BEST<br />No greater opportunity ,responsibilty,or obligation can fall to the lot of a human being than t...
INTRODUCTION<br />MEGALOBLASTIC ANEMIA ,though rare ,is a treatable cause of pyrexia.<br />To be considered in any patient...
Case history<br />18 yr old male,pure vegetarian since birth,having regular fasts for two months.<br />Prsented with easy ...
Clinical features<br />Pulse 118/min<br />BP -110/60 mm of Hg<br />Temp -103.6 F<br />Marked pallor<br />No icterus ,lypmh...
Blood and urine cultures were sterile.<br />Weil felix test negative.<br />Cxr normal<br />Usg abdomen l-mild spleenomegal...
Patient  followed up after two weeks –correction of anemia and thrombocytopenia.<br />
DISCUSSION<br />PYREXIA is a feature of megaloblastic anemia.<br />More common in patients with moderate to severe anemia,...
Take home message<br />Megaloblastic anemia is a known and treatable cause of pyrexia when all other causes ruled out,part...
questions<br />How did a pure vegetarian present with fever and pancytopenia at 18 yrs…reserve for 18 yrs?<br />How was hi...
ENDOCRINE CHANGES IN MALE HIV PATIENTS<br />DR.PRAVEEN NAGULA<br />
INTRODUCTION <br />Functional derangement of every endocrine organ in HIV infection<br />Attibuted to cytokines,oppinfecti...
Group A – HIV POSITIVE CD4 <200 cells/mm3<br />Group B – HIV POSITIVE CD4 200-350 cells/mm3<br />Group C – HIV POSITIVE CD...
results<br />Mean age is 35 .8 yrs<br />BMI 17.38 kg/m2<br />Basal cortisol levels rose as the disease progressed.<br />Se...
discussion<br />Cause of endocrinopathy was not evaluated<br />Cross sectional study only<br />Mean basal cortisol levels ...
Testosterone levels – correlated with results of elefthrious 2001.<br />Hypogonadism –IL1,TNF,Ois<br />MAI ,CMV in testes ...
Take home message<br />Endocrine dysfunction common in HIV infection<br />Role of cytokines,Ois<br />TSH ,BASAL CORTISOL l...
Vitamin b12 deficiency presenting as pyrexia
Vitamin b12 deficiency presenting as pyrexia
Vitamin b12 deficiency presenting as pyrexia
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Vitamin b12 deficiency presenting as pyrexia

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Vitamin b12 deficiency presenting as pyrexia

  1. 1. VITAMIN B12 DEFICIENCY PRESENTING AS PYREXIA<br />DR.PRAVEEN NAGULA<br />
  2. 2. JULY 1 ,2011<br /> HAPPY DOCTOR’S DAY <br />
  3. 3. DR.BIDHAN CHANDRA ROY<br /> July 1st- 1882-july1st 1962 <br />
  4. 4. DR.TINSLEY.R.HARRISON<br />
  5. 5. PHYSICIAN IS THE BEST<br />No greater opportunity ,responsibilty,or obligation can fall to the lot of a human being than to become a physician.In the care of the suffering ,the physician needs technical skill,scientificknowledge,and human undersatnding…tact sympathy ,and understanding are expected of the physician,for the patient is no mere collection of symptoms,signs,disorderedfunctions,damagedorgans,and disturbed emotions.the patient is human,fearful,andhopeful,seekingrelief,help and reassurance….<br />HARRISON’s <br />18 th edition to come at the end of AUGUST 2011<br />
  6. 6. INTRODUCTION<br />MEGALOBLASTIC ANEMIA ,though rare ,is a treatable cause of pyrexia.<br />To be considered in any patient who presents with pyrexia and pancytopenia.<br />Department of medicine,Indira Gandhi Medical College,shimla.<br />
  7. 7. Case history<br />18 yr old male,pure vegetarian since birth,having regular fasts for two months.<br />Prsented with easy fatiguability for one month and high grade pyrexia 104 F for the last three days.<br />No h/o cough,headache,rash,arthralgia,urinary,bowel disturbances.<br />No h/o visit to malaria endemic area.<br />No significant past history.<br />Exclusion of infective,inflammatory or endocrine causes. <br />
  8. 8. Clinical features<br />Pulse 118/min<br />BP -110/60 mm of Hg<br />Temp -103.6 F<br />Marked pallor<br />No icterus ,lypmhadenopathy,rashes,eschar.<br />Bald glossy tongue<br />Hyperpigmentation of knuckles.<br />Loud S1<br />Ejection systolic murmur in pulmonary area.<br />Mild spleenomegaly<br />Chest,nervous system normal.<br />Dimorphic anemia with pancytopenia<br />Biochemical examination was normal<br />Urine,gramstain,ZNstain,koh mount normal<br />
  9. 9. Blood and urine cultures were sterile.<br />Weil felix test negative.<br />Cxr normal<br />Usg abdomen l-mild spleenomegaly.<br />Managed with broad spectrum antibiotics.<br />3rd day epistaxis- 2 units platelet concentrates.<br />BM examination- severe dimorphic anemia,pancytopenia,noparasites,granuloma.<br />Was febrile on 5th day also.<br />Vitamin B 12 level was 105pg/ml (140-180),folate level was 5.05ug/l normal.<br />ANA ,CRPlevels were normal<br />Injcyanocobalamin 1000 mcg od.<br />72 hrs later afebrile-thereafter<br />diashcarged after three days<br />
  10. 10. Patient followed up after two weeks –correction of anemia and thrombocytopenia.<br />
  11. 11. DISCUSSION<br />PYREXIA is a feature of megaloblastic anemia.<br />More common in patients with moderate to severe anemia,thrombocytopenia.<br />Exact cause is not known.<br />Defect in oxygenation to the temperature regulatory centres in the brain.—why not seen in other severe anemias<br />Hyperplasia of bone marrow-systemic pyrexia-mechanism ?<br />Level of pyrexia  degree of anemia<br />Resolves in three days –immediate improvement in ineffective erythropoiesis.<br />Measurement of vitamin b12 levels are required in patients presenting with megaloblastic anemia and pyrexia. <br />
  12. 12. Take home message<br />Megaloblastic anemia is a known and treatable cause of pyrexia when all other causes ruled out,particularly with pancytopenic picture-who are routinely treated as febrile neutropenia with BSAb.<br />Measurement of levels and treatment -response<br />
  13. 13. questions<br />How did a pure vegetarian present with fever and pancytopenia at 18 yrs…reserve for 18 yrs?<br />How was his nervous system normal ?<br />Should all cases of pancytopenia to be sent for vit b12 levels..<br />Cost effective ?<br />
  14. 14. ENDOCRINE CHANGES IN MALE HIV PATIENTS<br />DR.PRAVEEN NAGULA<br />
  15. 15. INTRODUCTION <br />Functional derangement of every endocrine organ in HIV infection<br />Attibuted to cytokines,oppinfections,neoplasm,complication of treatment.<br />Most common involved is adrenal gland – clinical adrenal dysfucntion is uncommon.<br />Clinical thyroid disease is rare but altered TFT s are common.<br />Gonadal dysfunction –male<br />No reports from india of these changes.<br />
  16. 16. Group A – HIV POSITIVE CD4 <200 cells/mm3<br />Group B – HIV POSITIVE CD4 200-350 cells/mm3<br />Group C – HIV POSITIVE CD4 >350 Cells/mm3<br />Basal cortisol<br />TSH<br />Serum testosterone<br />Serum LH/FSH --8-9 am,3 samples<br />Serum for hormonal assay -20 c<br />Immulite for measurement <br />
  17. 17. results<br />Mean age is 35 .8 yrs<br />BMI 17.38 kg/m2<br />Basal cortisol levels rose as the disease progressed.<br />Serum TSH INCREASED with progression of disease.<br />Mean serum testosterone levels low in group A – <br />Basal cortisol,TSH – negative correlation with CD4<br />Testosterone – direct correlation with CD4<br />Level of LH/FSH inversely proportional to CD4 not significant.<br />Hypogonadism—serum testosterone <200 ng/dl 50 pts –44% had elevatedLH,24% HAD elevated FSH --primary hypogonadism<br />
  18. 18. discussion<br />Cause of endocrinopathy was not evaluated<br />Cross sectional study only<br />Mean basal cortisol levels –inverse relation –as in other studies.<br />Stress related,infections –cause for raised basal cortisols<br />4 pts had low basal cortisol –TUBERCULOSIS –adrenal dysfunction – 49 % infected with TB<br />30% subclinical hypothyroidism—<br />16% primary – asymptomatic comparable to ketsmathi et al <br />Oppurtunistic infections may be the cause in advanced disease –supported by autopsy welch et al <br />20% prevalence of hypogonadism recent trends <br />Low testosterone – BMI coodley et al <br />
  19. 19. Testosterone levels – correlated with results of elefthrious 2001.<br />Hypogonadism –IL1,TNF,Ois<br />MAI ,CMV in testes –in pts with disseminated tuberculosis.<br />25% of disseminated tuberculosis – hypogonadism -chabon et al<br />Only thyroid dysfunction was high in the prsent study.<br />
  20. 20.
  21. 21. Take home message<br />Endocrine dysfunction common in HIV infection<br />Role of cytokines,Ois<br />TSH ,BASAL CORTISOL levels inversely related<br />Testosterone –directly correlative with CD4 count<br />Effect on morbdity and mortality of patients<br />TSH levels high -- to be supported by large group studies.<br />All other findings were correlative<br />

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