This document presents the case of a 10-year-old boy who was admitted to the hospital with recurrent illnesses over the past few months. His symptoms included fever, fatigue, dizziness, shortness of breath, weight loss, loss of appetite, loss of taste, and tingling/numbness. His medical history revealed previous episodes of bleeding and fits. Laboratory tests found macrocytic anemia with low vitamin B12 levels. Based on his strict vegetarian diet and symptoms, he was diagnosed with vitamin B12 deficiency anemia. Treatment with vitamin B12 injections led to improvement of his symptoms and normalization of red blood cell levels on follow up testing.

2. WELCOME TO THE DEPT. OF
PEDIATRICS

3. CASE PRESENTATION
Dr. Zain Ul Abidin
LIAQUATCOLLEGE OF MEDICINE & DENTISTRY
(PAEDRIATIC DEPARTMENT)

5. Name: Zeeshan.
S/O: Malik Fayaz.
Age: 10 years.
Residence: Majeed Colony.

6. • 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.

7. • 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:-

8. • 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:-

9. SYSTEMIC REVIEW:-
• No other significant findings on systemic
review in CVS, RESP SYSTEM, GIT
SYSTEM, URINARY SYSTEM.
MUSCULOSKELETAL SYSTEM &
NEUROLOGICAL SYSTEM.

10. 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

11. 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.

12. DEVELOPMENTAL
HISTORY:-
• Milestones were normal:
•Smile – 4th week.
•Neck holding – 3rd month.
•Sitting – 8th month.
•Crawling – 8th month.
•Walking – 11th month.
• He is the student of 3rd Standard.
• Inappropriate vaccination, with no record.

13. FAMILY HISTORY:-

14. SOCIOECONOMIC
HISTORY:-
• 4 rooms house.
• 10 people , 1 earning hand.
• Gud hygeine.
• Use of boil water.

15. PERSONAL HISTORY:-
• No addiction.
• Normal sleep.
• Decreased appetite.
• Inappropriate diet (strict VEGETARIAN)
• Disturbed bowel habits.
• Normal micturation.

18. 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

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

21. • 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.

22. • 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.

24. • On Inspection, abdomen is of normal
shape, bilaterally symmetrical, moving
with respiration, umblicus centrally
placed, no abnormal pulsation, scar &
striae, mass or swellling.

25. • 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.

27. • 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.

29. Provisional Diagnosis
ANEMIA

30. DIFFERENTIAL
DIAGNOSIS
Anemia
Peripheral neuropathy
Viral hepatitis
Chronic Liver disease
Nephrotic Syndrome
Chr. Renal failure
Hemophilia

31. 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]

33. 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 %

34. Urine & Stool d/r  normal.
Electrolyte, Urea & Creatinine  normal.
Ultrasound KUB normal
PT & APTT & Factor 8 levels normal.
 LFT  Normal

35. Macrocytic
anaemia
Vit B-12
deficiency
Folate deficiency
Cytotoxic drugs
Mylodysplasia

36. BIOCHEMISTRY
•Follic Acid 3.66 (2.6-12.2 ng/ml)
•Vitamin B12 185.4 (206-678 pg/ml)

37. Salient Features of this
Disease
• Strict Vegetarian child
• Recurrent illnesses
• Failure to thrive
• Fatigue, loss of apetite,Tingling & numbness
• Anaemia & Jaundice with hepatomegaly

38. 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

40. VITAMIN B12
DEFICIENCY

42. Macrocytic
anaemia
Vit B-12
deficiency
Folate deficiency
Cytotoxic drugs
Mylodysplasia

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

44. 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.

47.  Patient may present with
Malaise (90%)
paraesthesiae(80%)
breathlessness( 50%)
sore mouth(20%)
Smooth, sore tongue with
atrophy of papillae

48. • DEPRESSION AND
HALLUCINATION
• VISUAL DISTURBANCE
• WEIGHTLOSS

49. • 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

50. 1-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

51. • 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

52. BONE MARROW biopsy:
increased cellularity
Megaloblastic cells

53. • 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

55. 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.

56. • Liver size reduced.No more
palpable below Rt Costal Margin.
Follow up after therapy

57. 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.

58. ANY
QUESTION