A case discussion in Medicine with a diagnostic challange.

1. Case discussion
Dr W.A.P.S.R.Weerarathna
. Medicine
Registrar in
THJ

2. • 72 yrs old lady from Jaffna presented with a
H/O intermittent fever for 3/12,multiple joint
pains with difficulty in walking for last 1/12.
• Fever-mild to moderate,continuous fever with
episodes of defeverance of few days+, no
associated rashes with febrile episodes, no
h/o sorethroat
• She has a noticable LOW of about 10kg during
the coures of her illness.she claims that she
has moderate LOA.

3. • Initially she developed pain in left KJ & over
several weeks she experienced pain over right
KJ,pelvic & shoulder girdles then she had
difficulty in walking.
• She experienced a back pain & involment of
small joints of hands including left WJ where her
ADL were affected.
• No H/O morning stiffness,
• No H/O headache-genaralized or localized,no
sugestive H/O claudication including arms,legs or
jaw.
• Though she had moderate fatigue there is no H/O
musle aches,soreness or stiffness.

4. • She denies a H/O drenching night sweats,bone
pains or pathalogical fractures or lower limb
weakness.
• There is no sugestive H/O any haemorragic
diastheses including easy bruising,
• Fever was not associated with concomittent
body rashes involving the trunk or
extremities,no H/O photosensitivity, alopecia
or oral ulcers.
• No H/O chronic cough ,haemoptysis,past
histroy or contact histroy of PTB.

5. • She denies a H/O alterd bowel habbits
including abdominal pain,bleeding
PR, tenesmus ,passage of mucus or chronic
dysentry.
• Fever was not associated with gen.body
pruritus,passage of dark urine or pale stools.
• UOP had been normal with no H/O
haematuria,pyuria or incontinance.
• No H/O PV bleeding or passage of any
offensive PV discharges.
• She had not been to any malarial endemic
area in the recent past.

6. • No contact H/O domestic pets,birds or cattle
& she was not engaged In farming.
• She usually doesn’t consume food from
outside & she is a vegetarian.
• With this Hx she got admitted to CNTH
Ragama where she was investigated
extensively with laboratory investigations &
she was subjected to several invasive
procedures .
• According to her knowledge most of the
investigations were found to be normal.

7. • Despite being subjected to a battery of various
investigations and continous theraphy along
with blood transfusions she remained
symptomatic.
• PMH- no H/O DM,HTN,IHD,BA,any
rhumatological diseases
• PSH-underwent B/L LRT 20 yesrs back
• DH-not been on any regular medications
• Allergy HX-no food,drug allergies
• FH-no significant illnesses run among family
members

8. • SH-mother of 10 children,lives with her
daughter &has a good family support,due to
her illness she is unable to attend her ADL
including toileting & taking meals with her
own.

9. •
EXAMINATION• She is wasted,BMI-20.1Kg/m moderate
pallor+,not icteric, febrile to touh,
• No clubbing ,no body rashes involving the
peripheris or over the trunk including any
haemorrhagic manefestations or eschar marks.
• No peripheral stigmata of IE.
• ENT-normal
• No oral ulcers,significant alopecia or no evidence
of photosensitivity
• B/L temporal arterial pulse palpable with no scalp
tenderness.
• No bone tenderness,deformities or evidence of
pathological fractures

10. • Tendeness was elicited over B/L shoulder &
pelvic girdles,KJ & left WJ
• B/L KJ effusions were detected with positive
patellar tap,
• No dactylitis or small joint tenderness in
hands,no rheumatoid nodules
• Single group of firm L/S posterior cervical LN
were palpable, B/L axillary LN were palpable.
• Mild hirsutism detected
• Fundoscopy- normal despite R/S hard
exudates near the optic disc-9 o’clock position.

11. • Examination of the breast & thyroid gland
were normal
• AS- mild hepatomegaly ,2 fingers breath
below the costal margin,firm,spleen not
palpable & kidneys were not ballotable,no
ascites detected.
• CVS- BP 140/80 mmhg, PR
96/min, regular, Grade 2 PSM + best heard
over the apex
• RS-unremarkable
• CNS-gait difficult to elicit, tone & power
normal,reflexes not exagerated,no focal
neurological deficites.

12. summary

13. • 72 years old lady presented with a H/O
continous fever with polyarthralgia & girdle
pains with impaired ADL, marked LOA,LOW for
3/12.O/E moderate pallor,mild hirsutism, L/S
posterior cervical LN & B/L axillary LN were
enlarged.AS-mild,firm hepatomegaly no other
organomegaly. L/S WJ arthritis with B/L KJ
effusions with no rheumatoid nodules or skin
manefestations.fundus-R/S hard exudates+
with no background Hx of DM or HTN.she has
a Gd 2 MR without periphrral stigmata of IE.
she remaines symptomatic despite
extensinsive Ix & therapeutic interventions.

14. investigations

15. • FBCDATE
10/28
11/25
01/09
01/23
01/28
01/31
02/10
Hb
6.9
7.5
7.4
6.8
6.9
8.4
7.6
RBC
3.76
2.72
3.09
7.81
2.78
3.27
3.16
PCV
22.3
22.2
24.1
21.1
21.8
26.0
23.7
MCV
80.6
82.07
78.0
75.2
78.4
79.5
75.0
MCH
26.55
27.2
23.9
24.1
24.8
26.0
24.1
MCHC
32.9
32.9
30.7
32.1
31.7
32.7
32,1
PLT
52300
0
45000
0
63400
0
60500
0
53800
0
53900
0
17900
0
WBC
15800
14300
16300
18300
12300
24100
10600
N
87
86
87
86
76.4
87.3
80.4
L
10
13
12
13
1.2
5.3
8.2
E
2
1
1
2
0.3
1.9
1.6

16. • BP• RBC-normochromic normoctic with moderate
rouleaux formation.
• WBC-normal total count with a
reactivemonocytosis.some neutrophiles show
hypolobulation.
• PLT-mild thrombocytosis with clumps.

17. • BMA•
•
•
•
Site-R posterior superior iliac spine
Bone consistancy-osteoporosis
Cellularity-normocllular marrow fragments & cell traits
Erythropoisis-mildly hypocellular with normoblastic
maturation
• Granulopoisis-mildly hypercellular with
occational giant metamyelocytes.blasts< 3
• Megakaryopoisis-NL in no.&morphology
• Plasma cells-3%of nucleated marrow cells are normal
plasma cells
• Lymphocytes-3%of nucleated marrow cells are
normallymphocytes
• Histeocytes-histeocytic activity is increased

18. • ESR-
DATE
15/10
LEVEL 104
11/02
12/03
01/12
28/01
90
154
116
120

19. • CRP-
DATE
10/24
LEVEL 49
01/23
148
108
30
88.2 114

20. • LFTsDATE
10/22
12/05
1/29
T.PRO
6.46
6.87
6.6
S.ALB
2.95
2.80
3.2
S.GLOB
3.56
4.07
3.4
T.BILI
N/R
0.6
ALP
193
204
346
(38-126)
AST
20
28.93
41
(3-42)
ALT
24.59
39.17
19
(14-50)
89
157
(11-50)
G-GT
A/G
0.94

21. • CXR-

22. • 2D ECHO CARDIOGRAME/ TOE
•
•
•
•
EDD-3.8
ESD-2.7
NO RWMA,EF=60%,AMVL-myxomatous
Mild MVP,trivial MR,Novegetations seen,AV
normal,No AS/AR
• No significant PHT
• Nopedunculated masses seen.
• TOE-NO evidence of vavular destruction/IE
seen.

23. • USS ABDOMEN•
•
•
•
•
•
•
LIVER-AP diameter=10.1cm
Gb/cbd=NORMAL
SPLEEN/PANCREAS=NORMAL
KIDNEYS=R/S-9.5 ,L/S-9.5 CM
BLADDER=partially filled
PARAAORTIC LN=NORMAL
INTRA ABDOMINAL MASSES-NILL
• CONCLUSION-NORMAL STUDY

24. • S.FERRITIN-NR=20-400(>50 years)
DATE
12/07
1/29
LEVEL
4427
5994

25. • S.LDH-NR-(230-460)
DATE
LEVEL
11/26
444

26. • S.CPK-NR-(26-140 U/L) Females
• 55.0 U/L (normal)

27. • RF- NEGATIVE (<8 IU/ML)
DATE
10/18
12/23
LEVEL
<8
<8

28. • ANTI CCP Ab-negative=<25/positive=>25
• <25 units/ml

29. X-RAY B/L HANDS-AP

30. • SPEP-prominent alpha-2 band,no abnormal
monoclonal bands,?acute infection
T.PRO
70.0
(60-85)
ALPHA-1 GLOB.
3
(1-4)
ALPHA-2
15
(5-11)
BETA GLOB.
7
(6-12)
GAMMA GLOB.
10
(5-15)
ALBUMIN
35
(30-50)
A/G
1
(1-2)

31. • ANF- NEGATIVE

32. • BF MP- NEGATIVE

33. CT-ABDOMENMILD HEPATOMEGALY,REGULAR OUTLINE,NO
FOCAL LEASIONS.SLEEN,PANCREAS,GB,BOTH
KIDNES-NORMAL.
FEW PROMINENT PARAAORTIC LNCOELIAC/SUP.MESCENTRIC/RENAL GROUPS.
NO BOWEL MASSES,NO ASCITES,NO BONE
LEASIONS.CALCIFIED UTERINE
FIBROID+
SUGEST-FOLLOWUP SCAN.

34. •
•
•
•
•
•
REPEAT CT SCAN-ABD-contrastNo enlarged para aortic,aoroto garval nodes,
Liver,spleen,supra renal,kidneys are NORMAL
NO evidence of bowel obstruction
NO ascires,NO pleural effusions
Bones NORMAL.
• IMPRESSION-NO SIGNIFICANT ABNOMALITIES
SEEN.

35. • AXILLARY LN BIOPSY• Microscopy-vague follicular archtecture
displaying a polymorphus population of
lymphoid celles including scattered
polymorphs.
• There is no evidence of primary
haematolymphoid malignancy or metastatic
disease.
• AXILLARY LN Bx-REACTIVE LYMPH
NODES.

36. • SPUTUM FOR AFF *3-NEGATIVE
• TB-PCR-NEGATIVE
• TB CULTURE BONE MARROW-NEGATIVE
(Lowenstein Jenson medium)
• MANTOUX TEST- NEGATIVE

37. • LIPID PROFILETC
163
HDL-C
33
TG
94
LDL-C
111.2
VLDL-C
18.8
TC/HDL-C ratio
4.94

38. • UFR•
•
•
•
•
•
•
•
App-clear
PRO-Nill
SUGAR-Nill
PC-Occational
RBC-Occ
CAST-Nill
EC-+
Bacteria-Nill
• UC/ABST- NEGATIVE (2 times)

39. • RETRO VIRAL SCREEN NEGATIVE

40. • BUDATE
10/22
11/12
LEVEL
22.23 34
12/01
01/25
46
33

41. • SEDATE
10/23
10/31
11/16
12/12
O1/20
S.Na+
134
129
134
148
135
S.K+
4.6
4.1
3.5
3.7
4.1

42. • S CREATININEDATE
10/22
11/28
12/11
01/21
LEVEL
0.67
0.84
O.9
0.8

43. • CLOTTING PROFILE• PT/INR-1.3-1.2
• APTT-NORMAL
• BT/CT=NORMAL

44. • X RAR L/S KT-AP view

45. • BLOOD CULTURE/ABSTNEGATIVE (2 TIMES)

46. • OTHER INVESTIGATIONSDATE
S.Calcium
11.2
9.5
S.Posphate 4.1
5.3
S.Mg
2.3
2.4

47. • BRUCELLA Ab levels-

48. • QHT-

49. • Patient was started on a trial of
steroides(Prednesolon 60mg daily & since she
was responding the fever seems to be
setteling,she was discharged.
• She will be reviewed in the clinic in 2 weeks
time with repeat S.Ferritin,CRP,FBC.
• Dx ? Adult onset Still’s disease