A 42-year-old diabetic woman presented with 2 months of high fever. She had been previously admitted twice for the same symptoms and diagnosed with a urinary tract infection and suspected myelodysplastic syndrome. On current admission, she displayed pancytopenia. Bone marrow biopsy revealed features suggestive of chronic idiopathic myelofibrosis. Her fever, pancytopenia, hepatosplenomegaly, and bone marrow findings indicate a diagnosis of chronic idiopathic myelofibrosis exacerbating her diabetes.

1. Dr. Nobody
IMO, Medicine Unit-1
X Medical

2.  Mrs. Shintu Dey, a 42yrs diabetic lady
hailing from Raozan got admitted in
our ward through emergency dept. on
17-12-2017 at 12pm with the complaint
of-
 Fever for 2 months

3.  According to pt’s statement, she was
resonably well 2 month’s back. Then
she developed fever which was high
grade, continued in nature associated
with evening rise of temp. and night
sweat. Highest recorded temp. was
105 ̊ F. The intensity of the fever
diminishes with antipyretics but does
not reach the normal baseline. She also
complaints of generalized bodyach and
vomiting during her febrile period.

4.  The fever was not associated
with any chest pain, cough,
haemoptysis, Epistaxis,
hematemesis, malena, rash,
joint pain,Headach,blurring of
vision, abdominal pain, weight
loss or any other bowel bladder
abnormalities.

5.  She is Diabetic for 4 years and was
taking tab. Dimerol twice daily. now
she is on insulin according to her
doctor advice.Her diabetes is well
controlled.

6.  On query she states that, for the same
complaint she got admitted in this
hospital twice. During her 1st admission
she was diagnosed as a case of Urinary
tract infection and treated accordingly.
Her fever subsided and she discharged
on request.

7.  After a while she again developed the
same problem and got admitted in this
hospital.She was suspected as a case of
myelodysplastic syndrome. Lots of
investigation were done including bone
marrow examination.But the report
was inconclusive.Trephine biopsy was
done.report is pending. Then she got
discharged on request.

8.  Few days later, for the same problem
she consulted with an medicine
specialist who advised her to admit in
the hospital again for further
evaluation. hence pt. got admitted this
time.

9.  There was no history of TB or TB
contact or any other significant drug
history. No history of previous blood
transfusion.
 She lives with her husband,1 son and 1
daughter. All are in good health.
 There was no significant travel history

10.  She is amenorrhoeic for 4 months. She
states that, she was taking OCP for
couple of years and her menstruation
was regular and normal.
 Her para- 3 + 3
Gravida- 6
Age of her last child is 10 years.

11.  Appearance: ill looking
 Body built: normal
 Co-operative
 Decubitus on choice
 Mildly anaemic
 There was no jaundice, cyanosis, clubbing,
edema, koilonychia or leuconychia.
 No lymphadenopathy or thyromegaly
 No bony tenderness

12.  Pulse: 110b/min
 BP: 90/60 mm of Hg
 Temp.: 102 ̊ F
 RR: 22 breath/min

13.  GIT
Lips, gum, teeth, oral cavity-normal
Tongue- smooth and pale
 Abdomen
There are 2 incisional scar marks
present over lower abdomen. One is
longitudinal and another is
horizontal. Multiple hyperpigmented
patches present over lt. side of the
umbilicus. Striae gravidarum present.

14.  Liver is enlarged about 3 cm from Rt
costal margin in the midclavicular
line. Margin is sharp, Surface is
smooth, non tender, upper border of
liver dullness is in Rt 5th intercostal
space. There is no hepatic Bruit/Rub.
 Spleen- not palpable.

15.  Examination of other systems
reveal no abnormalities.

16.  Disseminated TB with DM

17.  Lymphoma with DM

18. Date 1-11-17 28-11-17 4-12-17 16-12-17 20-12-17 24-12-17 27-12-17
Hb 9.8 7.4 7.9 7.8 6.4 11.0 14.3
ESR 26 46 60 20 30 30 10
WBC 4200 3700 3100 2700 2200 2700 3500
Platelet 50000 90000 120000 80000 30000 30000 35000
Neutrophil 36% 63% 38% 41% 42% 60% 50%
Lymphocyte 60% 35% 45% 55% 52% 27% 32%
Atypical Cell 00 00 00 00 00 00 00
MCV 76.2 81.3 78.5 80.5 78.6 79.7
MCH 26.2 26.6 26.2 27.2 25.8 27.6
MCHC 34.4 32.7 33.3 33.8 32.8 34.6

19. DATE PUS CELL ALBUMIN
01-11-17 7-10/HPF ++
04-12-17 2-4/HPF ++
26-12-17 2-4/HPF TRACE
Microalbumin

20. DATE 01-11-17 20-12-17 27-12-17
BILIRUBIN 2.0 mg/dl 3.4 mg/dl
2.76 mg/dl
Direct: 1.23
Indirect:1.53
SGPT 85 U/L 135 U/L 76 U/L
CREATININE 2.2 mg/dl 0.7 mg/dl 1.0 mg/dl

21.  RBS: 105 mg/dl
 S.ALP: 360 U/L
 S.ELECTROLYTE:
 Na: 127 mmol/l
 k: 4.0 mmol/l
 cl: 97 mmol/l
 hco3: 22 mmol/l
 RDT for malaria : NEGATIVE
 ANTI HBc TOTAL: NEGATIVE
 ANTI HCV : NEGATIVE
 ANTI HIV : NEGATIVE

22.  COOMB’S TEST: NEGATIVE
 DENGUE IgG & IgM: NRGATIVE
 CHICKUNGUNYA IgG & IgM:
NEGATIVE
 S.ANA: NEGATIVE
 CRP with TITRE: 1.24 mg/dl
 S.LDH: 1580 U/L
 BLOOD CULTURE: NO GROWTH

23. DATE 03-11-17 29-11-17 27-12-17
PBF
Thrombocytopenia
with dimorphic
blood picture
PANCYTOPENIA PANCYTOPENIA

24.  01-11-17:
 HEPATOSPLENOMEGALY
 CHOLELITHIASIS
 INCREASED RENAL PARENCHYMAL
ECOTEXTURE
 26-12-17:
 HEPATOMEGALY
 CHOLELITHIASIS
 BULKY UTERUS

25.  NORMAL
 ANTEROSEPTAL HYPOKINESIA
 MILD LV SYSTOLIC DYSFUNCTION

26.  BLOOD TAP

27.  Showing hypercellular Marrow
 Myeloid series of cells show maturation
 Megakaryocytes are slightly increased in
number
 Special stains reveal increased reticulin fibre
 Features are suggestive of -
CHRONIC IDIOPATHIC MYELOFIBROSIS