Question

Case Study

Case History

Abioye Akachi, a 5 y.o. boy, recently arrived in Australia from East Africa. Brought to the Emergency Dept. by his worried parents, who state that he has frequent infections, a poor appetite, appears to be in pain, is pale and lethargic.

On examination the clinician finds an irritable child with jaundice, splenomegaly and failure to thrive. The clinician requests an FBE, ESR, CRP, Haptoglobin, Blood film, Malaria screen, Renal and Liver function tests and to crossmatch one unit of blood.

FBE Results

FBE parameter Measured Result WCC (x109/L) 8.9 RCC (x1012/L) 2.6 Hb (g/L) 77 Hct (L/L) 0.22 MCV (fL) MCH (pg) MCHC (g/L) RDW (%) 22.4 Platelet Count (x109/L) 137 DWCC (%)                        Neutrophils 40                             Lymphocyte 54                        Monocyte 4                        Basophils 1 nRBC/100WBC   7

Blood film & other results

Test Parameter	Measured Result
Blood film	Marked polychromasia & sickle cells.  Moderate anisocytosis and target cells. Mild spherocytosis, some nucleated red cells & occasional Howell-Jolly bodies noted.
Malarial screen	ICT card test was equivocal and no malarial parasites were seen on the thin/thick films.
ESR	Elevated/above the reference range.
CRP	Elevated/above the reference range.
RFT	Within reference range.
LFT	Elevated bilirubin and ALT.
Haptoglobin	Within reference range.

1. Define ‘signs’ & ‘symptoms’. Discuss the clinical findings of the case and correlate to any physiological or pathophysiological processes.
2. Discuss the laboratory results in detail and discuss and correlate to any physiological or pathophysiological processes.
3. State your Provisional Diagnosis.
4. State your Differential Diagnosis/es.
5. Discuss your chosen Provisional Diagnosis and Differential Diagnosis/es with justifications for your selections?
6. List all the Further Tests and Results for the PD and DDs? Tabulate your result.
7. Describe the aetiology & pathophysiology for the chosen PD.

Answer 1

WCC (x109/L)	8.9	4 - 11
RCC (x1012/L)	2.6	4.5-6.5
Hb (g/L)	77	138 to 172
Hct (L/L)	0.22	Low
MCV (fL)
MCH (pg)
MCHC (g/L)
RDW (%)	22.4
Platelet Count (x109/L)	137	Low
DWCC (%)
Neutrophils	40	40% to 60%
Lymphocyte	54	20-40%
Monocyte	4	2% to 8%
Basophils	1	<1%
nRBC/100WBC	7	100–200 WBC

• Define ‘signs’ & ‘symptoms’. Discuss the clinical findings of the case and correlate to any physiological or pathophysiological processes.

Sign is objective evidence of a disease that can be observed by others. Whereas symptom is subjective sensed only by parents.

• Discuss the laboratory results in detail and discuss and correlate to any physiological or pathophysiological processes.

There is low Hb, hematocit value indicates anemia. High lymphocyte count and low platelet count is observed in the case. It correlates with sickle shaped RBC or drepanocytes , polychromasia or increased reticulocytes, anisocytosis  or irregular RBC and low nRBC/WBC indicate severe hymolytic anemia.

• State your Provisional Diagnosis.

High bilirubin levels accompanied by elevated ALT is an indicative of hepatitis or cirrhosis. It is also accompanied by CRP.

• State your Differential Diagnosis/es.

Thrombocytopenia caused by hemolytic anemia. Also accompanied by high ESR.

CLL or Chronic lymphocytic leukemia (CLL).A cancer of blood and bone marrow.

• Discuss your chosen Provisional Diagnosis and Differential Diagnosis/es with justifications for your selections?

CLL is indicated by high lymphocytes, low Hg, low Hct and morphological changes in blood cells like Spherocytosis and Howell–Jolly bodies.

Thrombocytopenia caused by hemolytic anemia indicated by low platelet count and high ESR.