Anemia, CPC, Complete History Examination and Follow up of a case of Intrinsic Factor Deficiency

2. WELCOME TO THE DEPT. OF
PEDIATRICS

3. CASE PRESENTATION
Dr. Zain Ul Abidin
LIAQUATCOLLEGE OF MEDICINE & DENTISTRY
(PAEDRIATIC DEPARTMENT)

5. Name: Zeeshan.
S/O: Malik Fayaz.
Age: 10 years.
Residence: Majeed Colony.

6. • The 10 yr oldchild with past medical
history of recurrent illnesses was
admitted in this hospital 1.5 month back
through OPD with the following
complains of;
 Fever& headache,
 Fatigue & dizziness
 Shortness of breath on exertion
 Weight loss with loss of apetite
 Loss of Taste sensation.
 Tingling and numbness.

7. • According to his mother he has suffered
different illnesses in the last 3 months
for which different diagnosis were made
and treated.
• He once suffered from an episode of
bleeding for which hemophilia was
considered by the doctor but not proven.
• According to the mother he was also
diagnosed as nephrotic syndrome by one
doctor , because of puffiness of the
face. But no record was available
HISTORY OF
PRESENTING
ILLNESS:-

8. • 2 months ago he presented with the
symptoms of fever, motion, vomiting.
Which was eventually subsided in
hospital by palliative treatment.
• 1.5 month back he got admitted in this
hospital
• & On the very vague history and varying
diagnosis a Detailed physical examination
& Laboratory Investigations were done
to rule out nephrotic syndrome and
Haemophilia
HISTORY OF
PRESENTING
ILLNESS:-

9. SYSTEMIC REVIEW:-
• No other significant findings on systemic
review in CVS, RESP SYSTEM, GIT
SYSTEM, URINARY SYSTEM.
MUSCULOSKELETAL SYSTEM &
NEUROLOGICAL SYSTEM.

10. PAST MEDICAL HISTORY:-
• He experienced generalized fits 3 yrs
back, for 2-3 minutes, followed by
unconsciousness, associated with urinary
incontinence & frothing. For which he
got admitted in civil hospital where he
received injections for 15 days & blood
transfusion.No record of final diagnosis

11. BIRTH HISTORY:-
• According to the birth history, his mode
of delivery was via scissarion, full term
delivery, normal breath & cry.
• The child was not vaccinated at birth.
• Breast feed for 2.5 years
• Weaning at 3rd month with semisolid diet.

12. DEVELOPMENTAL
HISTORY:-
• Milestones were normal:
•Smile – 4th week.
•Neck holding – 3rd month.
•Sitting – 8th month.
•Crawling – 8th month.
•Walking – 11th month.
• He is the student of 3rd Standard.
• Inappropriate vaccination, with no record.

13. FAMILY HISTORY:-

14. SOCIOECONOMIC
HISTORY:-
• 4 rooms house.
• 10 people , 1 earning hand.
• Gud hygeine.
• Use of boil water.

15. PERSONAL HISTORY:-
• No addiction.
• Normal sleep.
• Decreased appetite.
• Inappropriate diet (strict VEGETARIAN)
• Disturbed bowel habits.
• Normal micturation.

18. VITAL STATISTICS:
Both height and weight of the child is
below 5th centile.
VITALS:
•Pulse  87 BPM.
•Resp. rate  22.
•B.P.  117/78 mmHg
•Temp.  99 F.
• Puffiness of the face
• Anaemia +++
• Jaundice +
• Cyanosis Nil
• Oedema Nil

19. • On Oral cavity examination; lips were dry
with angular cheilitis.

21. • No significant findings.
• On Inspection, chest is normal in shape,
moves with resp. (abdomino-thoracic
pattern), bilaterally symmetrical, no scar,
striae, pigmentation, mass, visible
pulsation, surgical mark or any deformity.

22. • On Palpation, trachea was centrally
placed, apex beat on 5th intercoastal
space medial to mid-clavicular line, no
tapping & heaving, no parasternal heave,
chest expansion is normal on both sides,
vocal fremitus is equal on both sides.
• On Percussion, percussion note normal
bilateraly
• On Auscultation, normal air entry, vocal
resonant & heart sounds.
• Peripheral pulses, were normally palpable
with normal rate, rhythm, volume, &
character.

24. • On Inspection, abdomen is of normal
shape, bilaterally symmetrical, moving
with respiration, umblicus centrally
placed, no abnormal pulsation, scar &
striae, mass or swellling.

25. • On Palpation, Liver is palpable 3cm
below Right costal margin with smooth
surface,rounded border with no
tenderness. Upper border of the liver is
in the 5th intercoastal space.
• On Percussion, normal.
• On Auscultation, normal gut sounds.

27. • In Nervous system, higher mental
functions were normal.
• There were the findings of paresthesia
in fingers.
• Other than that Cranial nerves & motor
& sensory system were intact. There
were no extrapyramidal signs, & signs of
meningeal irritation were absent.

29. Provisional Diagnosis
ANEMIA

30. DIFFERENTIAL
DIAGNOSIS
Anemia
Peripheral neuropathy
Viral hepatitis
Chronic Liver disease
Nephrotic Syndrome
Chr. Renal failure
Hemophilia

31. Anaemias
• Hypochromic Microcytic
• Nutritional(Iron Deficiency Anaemia)
• Thalassaemia Major
• Thalassaemia Minor
• Chronic Blood loss
• Macrocytic
ANEMIAANEMIA
MICROCYTIC ANEMIA. [MCV <80fl]
MACROCYTIC ANEMIA. [MCV >96fl]
NORMOCYTIC ANEMIA. [MCV 80-96 fl]

33. CBC:
• RBC= 1.91
• MCV= 113.2 µm³
• RDW%= 26.1 %
• PLT= 367 10³/mm³
• MPV= 9.4 µm³
• LYM= TM 10³/mm³
• GRAN= TM 10³/mm³
• MID= TM 10³/mm³
• WBC= 12.610³/mm³
• HGB= 7.3 g/dl
• HCT= 21.7 %
• MCH= 38.2 pg
• MCHC= 33.7 g/dl
• LYM= TM %
• GRAN= TM %
• MID= TM %

34. Urine & Stool d/r  normal.
Electrolyte, Urea & Creatinine  normal.
Ultrasound KUB normal
PT & APTT & Factor 8 levels normal.
 LFT  Normal

35. Macrocytic
anaemia
Vit B-12
deficiency
Folate deficiency
Cytotoxic drugs
Mylodysplasia

36. BIOCHEMISTRY
•Follic Acid 3.66 (2.6-12.2 ng/ml)
•Vitamin B12 185.4 (206-678 pg/ml)

37. Salient Features of this
Disease
• Strict Vegetarian child
• Recurrent illnesses
• Failure to thrive
• Fatigue, loss of apetite,Tingling & numbness
• Anaemia & Jaundice with hepatomegaly

38. POSITIVE INVESTIGATIONS:
 CBC:
RBC= 1.91 MCV= 113.2 µm³ HGB= 7.3 g/dl
BIOCHEMISTRY:
Vitamin B12 185.4 (206-678 pg/ml)
Salient Features of this
Disease

40. VITAMIN B12
DEFICIENCY

42. Macrocytic
anaemia
Vit B-12
deficiency
Folate deficiency
Cytotoxic drugs
Mylodysplasia

43. • VIT –B 12 DEFICENCY anemia is a
low red blood cells count due to lack
of VIT –B 12

44. For vitamin B12 to be sufficiently
absorbed by the body, it must bind to
intrinsic factor, a protein released by
parietal cells in the stomach.
The combination of vitamin B12
bound to intrinsic factor is absorbed
in the final part of the small intestine.

47.  Patient may present with
Malaise (90%)
paraesthesiae(80%)
breathlessness( 50%)
sore mouth(20%)
Smooth, sore tongue with
atrophy of papillae

48. • DEPRESSION AND
HALLUCINATION
• VISUAL DISTURBANCE
• WEIGHTLOSS

49. • PERIPHERAL NERVES
GLOVES AND STOCKING
PARAESTHSIAE
LOSS OF ANKEL REFLEXES
• SPINAL CORD
LOSS OF VIBRATION SENCE AND
PROPRIOCEPTION
UPPER MOTOR NEURON SIGNS
• CEREBERUM
DEMENIA
OPTIC ATROPY
• AUTONOMIC NEUROPATHY

50. 1-HISTORY
 Good and proper history is very important
to identify the possible cause
 Any surgery of stomach and intestine,
chronic diarrhea should be asked
 Ask if the patient is taking any proton
pump inhibitors, and what r the dietary
habits etc

51. • 2-LABORATORY INVESTIGATIONS :
CBC:
Hb reduced
MCV raised >120fL
LEUCOCYTE COUNT low/normal
PLATELET COUNT low/normal
SERUM FOLATE AND B12 LEVEL:
BLOOD FILM:
oval macrocytosis
red cell fragmentation
hyper segmented neutrophiL

52. BONE MARROW biopsy:
increased cellularity
Megaloblastic cells

53. • INTRAMUSCULAR THEARPY
• Hydroxycobalamine 1000 micro grams in
five doses 2-3 days apart
• MANTAINANCE THEARPY
• 1000 microgram every 3 months for life
• If dimorphic blood film ,additional iron
therapy is given

55. Follow up after therapy
• Treatment.Weekly IM injection of
Cyncobolamine given for 4 weeks
• Follow up after 4 weeks.
• Symptoms improved.Apetite
increased.Fatigue and tiredness
has gone and so the numbness and
tingling.

56. • Liver size reduced.No more
palpable below Rt Costal Margin.
Follow up after therapy

57. Follow up after therapy
CBC:
RBC= 2.35 MCV= 71.2 µm³ HGB= 8.0 g/dl
VIT B12 :
was done but reports are still to awaited.

58. ANY
QUESTION