1. VITAMIN B12 DEFICIENCY PRESENTING AS PYREXIA DR.PRAVEEN NAGULA

2. JULY 1 ,2011 HAPPY DOCTOR’S DAY

3. DR.BIDHAN CHANDRA ROY July 1st- 1882-july1st 1962

4. DR.TINSLEY.R.HARRISON

5. PHYSICIAN IS THE BEST No greater opportunity ,responsibilty,or obligation can fall to the lot of a human being than to become a physician.In the care of the suffering ,the physician needs technical skill,scientificknowledge,and human undersatnding…tact sympathy ,and understanding are expected of the physician,for the patient is no mere collection of symptoms,signs,disorderedfunctions,damagedorgans,and disturbed emotions.the patient is human,fearful,andhopeful,seekingrelief,help and reassurance…. HARRISON’s 18 th edition to come at the end of AUGUST 2011

6. INTRODUCTION MEGALOBLASTIC ANEMIA ,though rare ,is a treatable cause of pyrexia. To be considered in any patient who presents with pyrexia and pancytopenia. Department of medicine,Indira Gandhi Medical College,shimla.

7. Case history 18 yr old male,pure vegetarian since birth,having regular fasts for two months. Prsented with easy fatiguability for one month and high grade pyrexia 104 F for the last three days. No h/o cough,headache,rash,arthralgia,urinary,bowel disturbances. No h/o visit to malaria endemic area. No significant past history. Exclusion of infective,inflammatory or endocrine causes.

8. Clinical features Pulse 118/min BP -110/60 mm of Hg Temp -103.6 F Marked pallor No icterus ,lypmhadenopathy,rashes,eschar. Bald glossy tongue Hyperpigmentation of knuckles. Loud S1 Ejection systolic murmur in pulmonary area. Mild spleenomegaly Chest,nervous system normal. Dimorphic anemia with pancytopenia Biochemical examination was normal Urine,gramstain,ZNstain,koh mount normal

9. Blood and urine cultures were sterile. Weil felix test negative. Cxr normal Usg abdomen l-mild spleenomegaly. Managed with broad spectrum antibiotics. 3rd day epistaxis- 2 units platelet concentrates. BM examination- severe dimorphic anemia,pancytopenia,noparasites,granuloma. Was febrile on 5th day also. Vitamin B 12 level was 105pg/ml (140-180),folate level was 5.05ug/l normal. ANA ,CRPlevels were normal Injcyanocobalamin 1000 mcg od. 72 hrs later afebrile-thereafter diashcarged after three days

10. Patient followed up after two weeks –correction of anemia and thrombocytopenia.

11. DISCUSSION PYREXIA is a feature of megaloblastic anemia. More common in patients with moderate to severe anemia,thrombocytopenia. Exact cause is not known. Defect in oxygenation to the temperature regulatory centres in the brain.—why not seen in other severe anemias Hyperplasia of bone marrow-systemic pyrexia-mechanism ? Level of pyrexia  degree of anemia Resolves in three days –immediate improvement in ineffective erythropoiesis. Measurement of vitamin b12 levels are required in patients presenting with megaloblastic anemia and pyrexia.

12. Take home message Megaloblastic anemia is a known and treatable cause of pyrexia when all other causes ruled out,particularly with pancytopenic picture-who are routinely treated as febrile neutropenia with BSAb. Measurement of levels and treatment -response

13. questions How did a pure vegetarian present with fever and pancytopenia at 18 yrs…reserve for 18 yrs? How was his nervous system normal ? Should all cases of pancytopenia to be sent for vit b12 levels.. Cost effective ?

14. ENDOCRINE CHANGES IN MALE HIV PATIENTS DR.PRAVEEN NAGULA

15. INTRODUCTION Functional derangement of every endocrine organ in HIV infection Attibuted to cytokines,oppinfections,neoplasm,complication of treatment. Most common involved is adrenal gland – clinical adrenal dysfucntion is uncommon. Clinical thyroid disease is rare but altered TFT s are common. Gonadal dysfunction –male No reports from india of these changes.

16. Group A – HIV POSITIVE CD4 <200 cells/mm3 Group B – HIV POSITIVE CD4 200-350 cells/mm3 Group C – HIV POSITIVE CD4 >350 Cells/mm3 Basal cortisol TSH Serum testosterone Serum LH/FSH --8-9 am,3 samples Serum for hormonal assay -20 c Immulite for measurement

17. results Mean age is 35 .8 yrs BMI 17.38 kg/m2 Basal cortisol levels rose as the disease progressed. Serum TSH INCREASED with progression of disease. Mean serum testosterone levels low in group A – Basal cortisol,TSH – negative correlation with CD4 Testosterone – direct correlation with CD4 Level of LH/FSH inversely proportional to CD4 not significant. Hypogonadism—serum testosterone <200 ng/dl 50 pts –44% had elevatedLH,24% HAD elevated FSH --primary hypogonadism

18. discussion Cause of endocrinopathy was not evaluated Cross sectional study only Mean basal cortisol levels –inverse relation –as in other studies. Stress related,infections –cause for raised basal cortisols 4 pts had low basal cortisol –TUBERCULOSIS –adrenal dysfunction – 49 % infected with TB 30% subclinical hypothyroidism— 16% primary – asymptomatic comparable to ketsmathi et al Oppurtunistic infections may be the cause in advanced disease –supported by autopsy welch et al 20% prevalence of hypogonadism recent trends Low testosterone – BMI coodley et al

19. Testosterone levels – correlated with results of elefthrious 2001. Hypogonadism –IL1,TNF,Ois MAI ,CMV in testes –in pts with disseminated tuberculosis. 25% of disseminated tuberculosis – hypogonadism -chabon et al Only thyroid dysfunction was high in the prsent study.

21. Take home message Endocrine dysfunction common in HIV infection Role of cytokines,Ois TSH ,BASAL CORTISOL levels inversely related Testosterone –directly correlative with CD4 count Effect on morbdity and mortality of patients TSH levels high -- to be supported by large group studies. All other findings were correlative