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| Case of the Week Thursday 14/3/2006 |
Presented by Dr. Mahmoud Abdo.
Coeliac Disease
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Staff round presentation
Unit of Professor Dr. Afaf Farrag
Professor Dr. Magdy El Serafy.
Professor Dr. Yasser El Boraey.
Dr. Shereen Hunter.
Dr. Mohammad Mahmoud.
Dr. Hanan Abdel Hafez.
Dr. Yahia El Sharif.
Dr. Alaa Haseeb.
Dr. Mohammad El Said.
Resident:Hany Shehab.
Resident: Mahmoud Abdo.
Personal history
Asmaa Abdelrehim Mahmoud.
21 years old.
Single.
Working in a cloth factory .
Born in Sohag and living in Cairo .
No history of contact with canal water or receiving anti-schistosomal therapy.
Menarche at 11 years , regular ,average in amount and duration.
No special habits of medical importance.
Complaint
Easy fatigability
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Present history
The condition started since childhood with easy fatiguability ,headache ,dizziness,lack of concentration , palpitation ,dyspnea on mild exertion.
These symptoms showed partial remissions and exacerbations and are mainly precipitated by effort and partially relieved by rest.
No history of bleeding from any orifices.
The condition is associated with painful cramps especially affecting upper and lower limbs.
These cramps occurr spontaneously ,last for minutes and wane spontaneously over hours.
The condition is associated with recurrent attacks of diffuse colicky abdominal pain with no precipitating or relieving factors and not associated with change in bowel habits
No history of bleeding from any orifices.
No history of leg ulceration or abnormal skin pigmentation.
No history of fever or perception of any body swellings.
No history of skin rash or joint pains.
No history of orthopnea ,PND or cough.
No symptoms suggestive of other system affection.
Not known to be diabetic or hypertensive.
No history of specific drug intake .
Past history
No history of previous operation.
No history of blood transfusion.
Family history
Negative
General examination
The patient is fully conscious ,of average intelligence , lying comfortably in bed
BMI :
Pulse :120 bpm ,regular ,equal on both sides ,large volume (water hammer).
Blood pressure: 110/60 mmHg.
Temperature : afebrile althrough the hospital stay.
Severely pale .
Tinge of jaundice .
No lymphadenopathy.
No thyroid or parotid enlargement.
Neck veins are not congested.
Upper and lower limb examination are free apart from mild bone tenderness.
Abdominal examination
Free
Cardiovascular examination
(soft systolic murmur not propagating and not associated with thrill “ grade II ” )
Chest, neurological and fundus examination:
Free
Summary
A 21-year-old female patient presenting with:
1- Easy fatigability .
2- Painful cramps .
3- Recurrent attacks of abdominal pain.
4- Tinge of jaundice.
Urinalysis
Normal
Stool analysis
Repeatedly normal
C.B.C
W.B.Cs: 10,200 / µL
B : 0 %
E : 3 %
St: 5 %
Seg: 78 %
L : 12 %
M: 2 %
HGB : 5.4 g/dl
HCT :19.9 %
MCV :55.3 fl
MCH :15 pg
MCHC:27 g/dl
Platelets : 652,000 / µL
E.S.R
First hour :
87 mm/hour
Secondhour :
118 mm/hour
Corrected E.S.R
First hour :
31 mm/hour
Iron and T.I.B.C
Serum iron :
20 µg/dl (37-145)
T.I.B.C :
627 µg/dl (274-385)
Occult blood in stools
Repeatedly negative.
Liver biochemical profile
Bilirubin :
- total :1.77 mg/dl
- direct :0.6 mg/dl
AST :
120 U/L
ALT :
77 U/L
ALP :
399 U/L (35 – 104)
GGT :
169 U/L (8 – 61 )
Abdominal ultrasound
Liver : average size ,rather coarse texture,smooth surface and attenuated hepatic veins.no focal lesions or IHBR dilatation.P.V is not dilated.
G.B : average size and wall thickness,no stones or mud inside .CBD is not dilated.
Spleen : mildly enlarged (14.8 cm) homogenous echopattern.
Kidneys : both are normal.
Pancreas : free.
No ascites.
Conclusion :
-diffuse parenchymal liver disease.
-splenomegaly.
Reticulocytes :
2.1 % (post-transfusion)
LDH :
582 U/L (240 – 480)
Haptoglobin :
128 mg/dl (30 – 200)
Direct Coomb ’ s test :
negative.
HB electrophoresis
A1 : 97.4 % (96.5 – 98.5)
A2 : 2.6 % (1.5 – 3)
Hepatitis markers
HBsAg :
negative
HBsAb :
negative
HBc total & IgM :
negative
HCV Ab :
negative
HCV RNA by PCR
Negative.
Auto-immune profile
A.N.A :
negative
A.S.M.A :
negative
Anti-L.K.M Ab :
negative
A.M.A :
negative
Metabolic screen
α 1 anti-trypsin :
164 mg/dl (90 - 200)
Ceruloplasmin :
41.9mg/dl (20 - 60)
Serum copper :
82 µg/dl (70 – 160)
24-hour urinary copper :
7 µg/24 hours (<50 µg/24 hours)
Serum protein electrophoresis
Kidney function
Urea :
12 mg/dl
Creatinine :
0.67 mg/dl
Blood sugar & electrolytes
Within normal range.
Mineral profile
Serum magnesium :
1.5 mg/dl (1 – 2.6)
Serum total calcium :
6.4 mg/dl (8.4 – 10.4)
Serum ionized calcium :
0.71 mmol/L (1.1 – 1.2)
Serum phosphorus :
4.7 mg/dl (2.7 – 4.5)
Parathormone
Serum parathyroid hormone :
167.5 ng/ml (15 -65)
Plain X-ray hands
Osteoporotic texture of the examined bones.
Preserved small joints of the hands and the wrists.
No evidence of osteophytic lipping ,erosions or pseudocyst formation.
No gross deformity ,dislocation or sublaxation.
Serology for coeliac disease
Anti-endomysial Abs:
positive
N.B :Total serum IgA :
294 mg/dl (70 – 400)
Upper G.I endoscopy
Esophagus :
normal lining mucosa .cardia is competent.
Stomach :
the mucosa of the antrum is hyperemic. Normal mucosa of the fundus and the body .
Pyloric ring :
rounded and active.
Duodenum :
free down to the second part.multiple biopsies were taken for histopathological examination.
Conclusion :
Mild antral gastritis.
Histopathology of duodenal biopsies.
Sections examined from biopsy received revealed tiny fragments of duodenal mucosa with surface erosions showing broadening and focal flattening of the villi.
The lamina propria showed heavy infiltration by chronic inflammatoy cells (lymphocytes and plasma cells)
No evidence of specific infection or malignancy.
Conclusion :
Chronic nonspecific duodenitis.
villous atrophy (grade II – III)
Thank you
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