A case of persistent

hypoalbuminaemia and anaemia

Dr Sonia Nasreen Ahmad

Department of Medicine

BSMMU

Patient Profile

Mrs Aleya Begum

39 year old female

Married

Housewife

City dweller

Lower middle class socio-economic income group

Presenting complaints

Repeated episodes of joint pain over 4 years

Swelling of the legs and abdomen over the past one month

Joints involved: Small and large joints of upper and lower limbs and low back

Symmetrical

Morning stiffness

Relieved by taking NSAIDs

Intervening time pain free.

Associated features

Lightheaded

Fatigue

Often not able to carry out daily activities due to tiredness

Diagnosed in March 2007

Hypothyroid – Subclinical (Thyroxine commenced)

Current episode

Swelling of legs and abdomen

Face not involved

No history of Dyspnoea

Orthopnea

Chest pain

Scanty micturition

Haematemesis/Malaena

Oral ulcer

Red eyes

Nail changes

Bowel disturbances

Weight loss

Drug History:

Thyroxine 100 micrograms/day (withdrawn)

Repeated blood transfusions

NSAIDs (Diclofenac)

Paracetamol

Past medical history: Nothing remarkable

Family history: Not known to suffer from any chronic disease

Examination Findings

Oedematous Pulse : 108/min

Blood Pressure: 90/60mmHg

Afebrile

Weight: 55kg

Examination Findings (Cont.d)

Grade 2 tenderness – MCP, PIP, DIP, MTP, SI joints (on admission)

No swelling

No deformities

Ascites

No organomegaly

Investigations

Hb (gm/dl):

April 2006: 8.8, 11.6 (BT)

September 2007: 4.92

February 2008: 8.8, 13.25 (BT)

March 2008: 10.6

ESR: 15-40 mm in the first hour

CRP: 22.6mg/l

Peripheral blood film

April 2006: Microcytic hypochromic anaemia with neutrophil leucocytosis

March 2007: Non-specific morphology (Normocytic normochromic

September 2007: Non-specific morphology (Normocytic normochromic)

February 2008: Non-specific morphology (Anisocytosis and anisochromia)

March 2008: Anisochromia and anisocytosis, microcytic hypochromic cells seen

Bone Marrow Study

Hypercellular marrow with increased M:E ratio

Erythropoiesis active and shows micronormoblastic changes

Granulopoiesis is hyperactive and maturing into segmented forms

Megarkaryopoiesis is normal

Plasma cells and lymphocytes normal

No ectopic cells or parasites seen

Comment: Myeloid Hyperplasia

14.2.08: Hb electrophoresis: Beta thalassemia trait

Urine microscope examination: Normal

S.bilirubin: 10 micromol/l (5-20)

SGPT: 48 U/l

Prothrombin time:10.8 (11.6)

HBsAg: Negative

Anti-HCV: Negative

S. Creatinine: 0.7mg/dl

Urinary total protein: 0.14gm/day

Serum Albumin

March 2007: 2.94 g/dl (3.8-4.4)

August 2007: 1.88g/dl

Feb 2008 :23.4g/L (35-50);{S.Total Protein-53.2 ( 35-57)}

March 2008 : 2.8g/dl; {S.Total Protein- 5 (6.4-8.3)}

Thyroid Function Test

March 2007

TSH: 9.52 mIU/L (0.3-5)

FT3: 2.43 pmol/L (2.8-9.5)

FT4: 10.23 pmol/L (9.5-25.5)

February 2008

TSH: 5.34 mIU/L (0.3-5)

Chest X-ray (P/A view): Normal

Ultra sonogram of abdomen:

Presence of free fluid in the pelvic cavity

No organomegaly

X-ray Lumbo-sacral spine (Oblique view): Marginal sclerosis of left sacroiliac joint

Iron Profile

S. Total iron: 78 microgram/dl ( 50-170)

S. TIBC: 289 microgram/dl ( 250-425)

S. Ferritin: 111.09 microgram/l (22-120)

ANA : Negative

Anti DS DNA : Negative

Anti- CCP : Negative

RA : Negative

Coomb’s test: Negative (D&I)

Occult blood test (Stool):

Positive

Endoscopy of Upper GIT: Normal

Biopsy (duodenum): Chronic duodenitis

Colonoscopy upto terminal ileum: Normal

Biopsy (terminal ileum): Chronic ileiitis

Barium Follow through of Small Intestine

Barium passed through ileo-coecal junction

Spasm in terminal ileum

Spasm of coecal pole which is at a higher level

Dilemmas

Hb (gm/dl) has dropped from 13.25 to 10.6 in two weeks. Source?

Patient remains hypoalbuminaemic. Why?