Tuesday, 18 March 2008

Answer To Recent Case

Dear Bloggers

Here are the answers to the recent case.

Question 1: Taking into account the history and examination what other feature from the CBC do you think is abnormal in this case?

The other abnormal feature is the platelet count. In fact, she had only 3,000 per microlitre of platelets hence, Severe thrombocytopaenia. Her WBC count was normal, as was her haemoglobin and other coagulation studies.

Question 2: Why are her legs most affected and what is likely to be the likely diagnosis ?

Her legs were most affected because of the effect of gravity and venous pooling. The blood being under a column of pressure and with low platelets resulted in severe petechial haemorrhage.

In view of the recent infection, and no other sinister findings being found on examination such as lymphadenopathy, the suspected diagnosis was a viral induced thrombocytopaenia. ITP was also considered strongly in view of the patient's presentation, her female gender, a normal sized spleen and absence of other symptoms.

Of course, malignancy e.g. MDS, leukaemia, other autoimmune diseases e.g. SLE, were considered, but in view of an otherwise normal blood differential and no other features consistent with these pathologies, they were not really considered to be likely as the cause.

Question 3: Why might the BUN be raised?

The BUN may have been raised because of asymptomatic gastric haemorrhage.

Question 4: Would you admit this patient into hospital even though she feels well or would you let her go home?

This patient is high risk for parenchymal haemorrhage. Initially, low platelets results in cutaneous petechiae. If the platelet count worsens, then mucosal bleeding occurs. At this point, one should be highly suspicious of potential severe bleeding ensuing e.g. intracranial haemorrhage, GI bleeding.

Hence, the patient should not be sent home and should be admitted to hospital for investigation and prompt treatment.

Question 5: What other tests would you like to perform?

  • The patient should have viral titres taken e.g. Adenovirus, Parvo Virus, Hep C, CMV, EBV, Mumps, Rubella Autoimmune profile e.g. Anti-DS DNA, ANA Abs for SLE
  • Blood smear to look for abnormal cell morphology
  • Anti-platelet antibodies (if available)
  • Bone Marrow Examination-- essential to aid in the diagnosis
  • Ultrasound of the abdomen to look for splenomegaly
  • Ultrasound of the knee to look for haemarthrosis-- aspiration is not safe with profoundly low platelet counts.
  • Rectal examination for occult bleeding (easy to do and often avoided!!)
  • Gastroscopy and colonoscopy
  • Treatment here would be to transfuse platelets and treat the underlying cause (if known)
The bone marrow examination revealed: increased numbers of megakaryocytes of normal morphology. There was also a slight increase in the erythroid precursors.

The serology revealed: a normal panel autoimmune profile e.g. normal levels of ANA.

Her viral serology showed past infection with CMV and EBV and Parvovirus and HCV were negative. Other viral serology was unfortunately no performed.

Abdominal ultrasound revealed a normal spleen.

Anti-platelet antibodies were positive with a level of 75 (normal <5).

Hence, in view of the clinical history, physical examination, the bone marrow examination and positive anti-platelet antibodies, it was considered that the diagnosis was:

Immune Thrombocytopaenic Purpura.

She received prednisolone at a dose of 1mg/kg/day -- 50mg in total, and her platelet count increased to 30,000 within 3 days with no new bleeding problems. However, despite high dose steroids, the platelet count did not increase much beyond this level thereby prompting the use of other treatment modalities (see description and treatment of ITP below)

Here is a most excellent response from Professor Masami Matsumura of Kanazawa University School of Medicine with his opinion on the case.

This is interesting case for approaching the diagnosis.

ID/CC: 50-year-old woman with a diffuse skin eruption

Problem list:

1. Episodes of URTI
2. Diffuse skin eruption, suspect petechiae
3. Oral mucosal bleeding
4. Left knee acute monoarthritis without trauma history
5. Oedema of both ankles
6. Mildly raised BUN (20.1)
7. Mild monocytosis
8. Mildly raised CRP


After episodes of URTI, she had left knee acute monoarthritis, diffuse skin eruption, and oral mucosal bleeding. These issues are consistent with Immune Thrombocytopenic Purpura (ITP). Another differential diagnosis is Henoch-Schonlein purpura. Acute polyarthritis is observed in this disorder. However, oral mucosal bleeding is not observed in Henoch-Schonlein purpura. Moreover, palpable purpura is characteristic of this disease. I think ITP is most likely in this case.

Another differential diagnoses are follows:
  • Hematologic malignancies including CLL
  • MDS
  • SLE
  • Viral infection including hepatitis C and HIV
  • Evans’s syndrome
Question 1: Taking into account the history and examination what other feature from the CBC do you think is abnormal in this case?

This patient has mucosal bleeding. I think her platelet count is under 10,000/m(micro)L.

Question 2: Why are her legs most affected and what is likely to be the likely diagnosis ?

Her physical examination revealed acute monoarthritis in left knee. When we see acute monoarthritis, Gout, Pseudogout, Infectious arthritis, Bleeding, and Trauma (PIG TB is my mnemonics) must be differentiated. She denied trauma episode. Bleeding is most likely in this case.

Question 3: Why might the BUN be raised?

I suspect GI tract bleeding. GI tract bleeding can cause elevated BUN.

Question 4: Would you admit this patient into hospital even though she feels well or would you let her go home?

This patient must be admitted into hospital for close examination and treatment!!

Question 5: What other tests would you like to perform?
  • Fundoscopy for examination retinal bleeding
  • Peripheral blood cell morphology for detecting large platelets
  • Coagulation studies including PT and APTT
  • ANA, HCV antibody assay
  • Abdominal echo for evaluate spleen size
  • Bone marrow aspiration
An anonymous response was received as follows:

1.? Platelets>low; stool occult blood +
2. Henoch Schoelein, Behcet [pathergy from your History], Parvo 19, R/O DVT, anti-phospholipid syndrome
3. ^ BUN from GI bleed
4. In Japan, admit; in North America follow-up in clinic
5. Skin Bx, Fiber Colon/gastro filber if stool blood +; L knee OA

Immune Thrombocytopenic Purpura (ITP)

This is a bleeding disorder resulting from low platelets not associated with another systemic disease. For the diagnosis to be made, other disorders should be excluded through other tests. Autoantibodies are usually produced against the platelet resulting in the low platelet level. In children, a viral infection can also result in ITP.

The spleen is usually normal size except if there is co-existent viral infection.

The symptoms and signs are of petechiae and mucosal bleeding e.g. in the mouth, GI tract etc. Examination of the blood reveals an isolated reduction in platelets but an other normal morphology and differential of white cells and red levels.

Bone Marrow examination reveals normal or increased numbers of megakaryocytes with other bone marrow elements being normal.
Other pathologies should be excluded as described above and HIV testing should be performed in those individuals considered to be at risk because this infection can appear in an identical way to ITP.

Treatment consists of corticosteroids e.g. Prednisolone 1mg/kg/day. In those patients who respond to treatment, the platelet count should increase to normal in 2-6 weeks. The steroid dose is then tapered accordingly. In patients who do not respond to treatment and in who have a high risk of haemorrhage, splenectomy is considered.

Other immunomodulatory treatments are sometimes used such as immune globulin transfusions, cyclophosphamide, azathioprine and the anti-CD20 antibody (Rituximab).

Many thanks for all those doctors who contributed to give their opinions on this case.

There will be more great cases coming....stay tuned!!! :-)

A Case For You To Answer

Dear Bloggers

This case was provided to me by another physician and it has been anonymised for purposes of confidentiality.

A 50 year old female was seen in another hospital's out patient clinic because of a diffuse skin eruption.

She had been mildly unwell for 2 months with symptoms of an upper respiratory tract infection, the symptoms that included sore throat, mild fever, chills and nasal congestion. He was initially seen and given acetaminophen and multivitamins. Her throat examination at that time was red but with no exudate. No antibiotics were prescribed. No throat swabs were taken.

Her symptoms initially improved but there was a recrudescence of the same symptoms prompting a return to the hospital outpatient clinic. Again, medications for control of symptoms were prescribed and no antibiotics.

Two weeks before her current presentation, the URTI symptoms had completely resolved and she was feeling otherwise well.

However, after several days, her left knee began to hurt and she found it difficult to walk properly. There was no apparent swelling of the joint or preceding injury as mentioned by the patient.

A reddish-blue eruption began to emerge on her arms, legs and trunk. The eruption was composed of apparently very small areas of haemorrhage which were non-blanching and over approx 1-2m in diameter. The worse affected areas were her lower limbs. She also described other areas erupting after scratching her skin.

She denied visual disturbance, headaches, rectal bleeding or haematuria. Her other joints were non-painful.

She had described noticing blood in her mouth when cleaning her teeth and recent nose bleeds when blowing her nose hard several days before admission.

Previous medical history was nothing in particular apart from seasonal rhinitis.

She was taking no medications

She had no relevant family history and was a non-drinker and non-smoker.

On further questioning, she had no weight loss, a good appetite, no night sweats. No abdominal pains or other GI symptoms. In fact, she was otherwise feeling well.

On examination

Temp 36 C, Pulse 80 regular, BP 120/80, RR- 12, Sats 98% on RA. No Jaundice, Anaemia, Clubbing, Cyanosis, or Lymphadenopathy (JACCL)

She looked well but had a diffuse rash (as described above). Mouth- blue-black raised vesicle on the right lateral border of the tongue and on the buccal mucosa bilaterally. Elevation of the tongue revealed fresh blood in the lateral gutter at the junction of the floor of the mouth and the medial aspect of the gums.

CVS: JVP not raised. Heart sounds were normal. No evidence of DVT.

RESP: Percussion resonant, breath sounds vesicular.

ABDO: Soft, non-tender, no hepatosplenomegally. No ascites. Bowel sounds increased. Rectal examination not performed.

Left knee- mildly swollen. Not warm or tender. Bruising over infra-patella region. No patella tap. Crepitus on extending knee joint.

Oedema of both ankles.

Initial screening bloods were entirely normal except for a mild monocytosis, mildly raised CRP and BUN (20.1) but normal creatinine PLUS one other feature.

Question 1: Taking into account the history and examination what other feature from the CBC do you think is abnormal in this case?

Question 2: Why are her legs most affected and what is likely to be the likely diagnosis ?

Question 3: Why might the BUN be raised?

Question 4: Would you admit this patient into hospital even though she feels well or would you let her go home?

Question 5: What other tests would you like to perform?


Monday, 17 March 2008

Clinical Skills

Dear Bloggers

Now is the season when medical students visit various hospitals around Japan for a 3-day period to see what each institution has to offer for the purposes of future training in the respective residency programmes.

In Japan, most medical students do not have any clinical 'hands on' experience until the beginning of the 4th or 5th year of medical school.

From my previous interactions with several students and residents at different institutions, the general consensus is that the teaching of clinical skills at university is not optimal for what they need to examine patients. Of course, some medical schools have many sessions for teaching on real patients and there is the newly introduced OSCE system to ensure that there is a basic minimum standard. Hence, training can be variable depending on the institution in question.

Some UK medical schools have the medical students learning clinical skills from their very first year by placing them with a community general practitioner who can select for them well patients with chronic illness, who attend the clinic to have their history taken in full in addition to examination by the student. The general practitioner then listens to the history and demonstrates the examination to reinforce good practical skills and to advise on additional history which can help to make a bedside diagnosis.

My medical school was one of the first to do this in the UK and that was nearly two decades ago.

Although the basic knowledge of medicine was still to be learnt, by intercalating the learning from each system, over time it was then possible to gain deeper understanding plus having the background knowledge of how to examine for signs.

Hence, when it comes to the official clinical years, which start from the third or fourth year in the UK system, the medical student already knows the basics such as percussion, auscaultation etc...

One method that is very informative is the ward round system and listening to the consultants taking extra history and examining the patient. The UK medical system is somewhat adversarial in its way towards medical students because invariably they get picked on to be asked the various causes of XYZ disease or how to examine for ABC sign. Although this can sometimes be a stressful process, it forces the medical student to read about the patients they see. Moreover, the consultants invariably ask the medical students again at various stages of their attachment to a firm. Knowing the answer shows that medical student has taken the time to find out what the consultant wants to know.

By joining ward rounds and seeing the patients 'hands on' is the best way to learn clinical skills rather than just from a book in the class room. Patients do not write the books and there can be any number of possible combinations of acute and chronic diseases to provide a challenge to the doctor. This cannot be found in detail to any great extent in a book.

To really understand clinical medicine, you have to do clinical medicine.

Although these 3-day snap shot visits by medical students provide a mere glimpse of how hospital life operates, it is in my opinion, insufficient to learn new clinical skills.

At this hospital, there is the opportunity to do short term externships of several weeks to a month whereby the medical student can be exposed to the daily rigors of clinical medicine and how to treat the common acute problems and the difference of how to treat chronic diseases.

They get the opportunity to take histories from patients and to learn clinical examination in depth.

Such students who have done this in the past with me have learned a lot and their experiences have been very positive.

If you are interested in such an externship at this institution, then please contact me at the email address at the bottom of the blog page.