Discussions By Condition: I cannot get a diagnosis.

hepatitis, pneumonia, thrombocytopenia

Posted In: I cannot get a diagnosis. 1 Replies
  • Posted By: Anonymous
  • September 27, 2009
  • 10:24 AM

Here is a patient's story I am seeking help for....
30 year old businessman presented with fever high grade for 5-6 days. abdominal pain poorly localised, of 1 day duration, severe since few hours, bodyache and weakness. Examination at admission, revealed tachycardia, icteric tinge. Abdomen was tender (diffuse), but no guarding, bowel sounds were normal. chest showed few bilateral crepts . CBC : Hb Normal, TLC 5300, Platelets: 65000/dL. S Bil 3 mg/dl, SGPT:3500 SGOT 2900 T Proteins and albumin: Normal. HAV, HBsAg, HCV, HEV Negative. ANA Negative. INR 1.7 X abd: Normal. USG abd: altered echotexture of liver, ascites and pleural effusion. Next day, patient complained breathlessness. CXR: bilateral lower lobe consolidation. As abdominal tenderness was unexplained, CT abdomen+angio :did not show any hepatic venous involvement. Biliary system was normal. There was ascites, and bilateral lower lobe consolidation (pneumonia). Though his creat was normal, urine showed albumin 4+. Cultures are awaited. Patient's condition deteriorated rapidly with requirement of mechanical ventilation.
Other historical information: non-alcoholic, No prior drug intake (aspirin, NSAID etc).
Epidemiological data: area is experiencing swine flue outbreak with few deaths due to respiratory illness. H1N1 screening is negative for the patient.
What are the DD:

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  • Could your pt have false neg Hep C with cryoglobulinemia induced vasculitis?See abstract by Tini GMHISTORY AND ADMISSION FINDINGS: A 72-year-old man with nausea, fever and elevated inflammatory parameters was transferred for further diagnostic assessment and treatment. On examination a palpable purpura was obvious without any signs of infection. INVESTIGATIONS: Creatininekinase was 350 mmol/l with a proteinuria of 20 g per day. Histological examination revealed hypersensitivity vasculitis in the cutis and a membranoproliferative glomerulonephritis. In addition there was a mixed cryoglobulinemia with a negative test for hepatitis C virus. Further investigation revealed hepatitis C virus RNA genotype 1 b in the cryoprecipitate. DIAGNOSIS AND TREATMENT: The patient was successfully treated with with interferon alpha for 12 month. The nephrotic syndrome improved and the proteinuria ceased CONCLUSION: Mixed cryoglobulinemias are associated with hepatitis C virus infection in over 80% of cases. Normally it is easy to make the diagnosis serologically with an ELISA test. But in a few cases the virus RNA is only detectable in the cryoprecipitate. If there is a high suspicion of an hepatitis C infection with cryoglobulinemia but HCV serology is negative, it is essential that virus antigen and antibodies are searched for in the cryoprecipitate.
    Anonymous 42789 Replies
    • September 28, 2009
    • 11:36 PM
    • 0
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