1) A 33-year-old female presented with shortness of breath for 4 months. She reported a history of recurrent epistaxis, abdominal pain and distension, and vitiligo. 2) On examination, her liver and spleen were enlarged. Laboratory tests showed pancytopenia and elevated liver enzymes. 3) Imaging found an enlarged liver with irregular borders and thickened portal veins, as well as an enlarged spleen with varices. Bone marrow biopsy revealed pancytopenia due to peripheral sequestration.

1. Case Presentation
By
Mustafa Abdelhalim Fathy
Resident of Tropical Medicine
Minia University Hospital

2. Female patient,S. K. A,33 yrs old,from rural
village,Samalout,Al-Minia,single,housewife,with no
special habits of medical importance.
Personal History
Complaint:
Shortness of breath for 4 months

3. The condition has started by
dyspnea of 4 months
duration,gradual onset,progressive
course,exertional,of functional
classification G (dyspnea occurs‖
on ordinary work), associated with
easy fatigability interfering wth her
daily home duties.
History of present history:

4. 1.5yr,pt gave history of recurrent attacks of severe
epistaxis,she saught medical advice,nasal
packing done many times,and diagnosed as
there's no local cause of bleeding.
7yrs ago,pt gave history of abdominal
distension,left hypochondrial pain,of insidious
onset intermittent course,dragging in
character,increase by exertion.
8yrs ago,areas of white patches appeared at many
areas of her body,she saught medical advice,and
diagnosed as(Vitiligo),she received topical
treatment for 2 yrs and failed.

5. She underwent sessions of
laser(phototherapy) due to failure of topical
therapy.
--pt not known to be diabetic nor
hypertensive.
Menstrual history:
regular,D/C:5/29,excessive in amount,no
intermenstrual spotting.

6. Family history:
 +ve consanguinity
 No similar conditions
Past history:
 History of contact to water,no history of
operation nor drug intake.
 No history of previous hospital admission.
 No history of Bilharziasis,nor TB.

7. On Examination:
Generally:
pt is concious,oriented to
time,place and persons.
Lies comfortable in bed,not dyspnic not
orthopnic.
Looks pale,no jaundice,no cyanosis.
BP 100/60 measured in supine position
Pulse 90 bpm,regular,average volume,equal
on both sides.
-No palpable LN

8.  Back:large area of vitiligo
 LL:lax calf muscles intact peripheral
pulsation,area of vitiligo
 Chest examination:NAD
 Cardiac examination:NAD

9. Abdominal Examination:
 Liver:left lobe palpable,2 fingers,firm in
consistency.
 Spleen:3 fingers below costal margin.
 Area of vitiligo.

10. Investigations:
 Lab:
 ALT: 61
 AST:73
 Sr.creatinine: 0.4 mg/dl
 Bl.urea:21 mg/dl
 sr.albumin:4.9 gm/dl
 Total protein:6.9 gm/dl
 Triglycerides:65
 Total cholesterol:142
 Total bilirubin:0.7
 Direct bilirubin:0.3

11. CBC
 Hb:10.3 gm/dl
 MCV:82 fl/dl
 MCH:27.8
 MCHC:33.7
 TLC: 2600
 Neutrophils 77%
 Lymphocytes 22%
 Platelets: 39.000

12. CBC repeated after 10 days
 Hb:10.3 gm/dl
 MCV:82 fl/dl
 MCH:27.8
 MCHC:33.7
 TLC: 1800
 Neutrophils 70%
 Lymphocytes 25%
 Monocytes 2%
 Platelets: 39.000

13.  ESR
 1ST
hour:30
 2nd
hour 65
 Prothrombin concentration:76%
 INR 1.16
 Sr. uric acid 1.7
 Alkaline phosphatase 189
 Anti bilharzial antibodies:1/80
 HCV-Ab :-ve
 HBs-Ag:-ve
 HIV :-VE

14. Abdominal u/s:
 Liver:Rt lobe average size,enlarged Lt
lobe,wavy surface,granular echopattern.
 PV:13mm,with periportal thickening.
 Spleen: enlarged ,19cm,with multiple
varices seen at the hilum.
 No ascites

15. Bone Marrow Examination
Pancytopenia due to peripheral
sequestration.