MPHA 4305 -SBT V Case Study 5 Group 5

Group Members:
Lau Li Wenn Lee Suo Ying Lau Wai Hoong Lee Soo Mei Lee Yee Ling Lee Ming Keat BPM 1109 1317 BPM 1109 1311 BPM 1109 1146 BPM 1109 1044 BPM 1109 1036 BPM 1109 1310

Case History 1

A 44-year-old man who had lost his job because of absenteenism, presented to his physician complaining of loss of appetite, fatigue, muscle weakness, and emotional depression. The physician examination revealed a somewhat enlarged liver that was firm and nodular, and there was a hint of jaundice in the sclerae and a hint of alcohol in his breath. The initial laboratory profile included a hematological analysis that showed that he had an anemia with enlarged red blood cells (macrolytic). A bone marrow aspirate confirmed the suspicion he had a megaloblastic anemia because it showed a greater than normal number of red and white blood cell precursors, most of which were larger than normal. Further analyses revealed that his serum folic acid level was 1.2ng/mL (normal 2.5 to 20), his serum B12 level was 253 ng/mL (normal 200-900), but his serum iron level was normal.

Patient Background
Gender : Male Age : 44 years old Symptoms: loss of appetite fatigue muscle weakness Emotional depression

 Physical examination: Enlarged liver (firm & nodular) Hint of jaundice in the sclerae Hint of alcohol in his breath

Initial laboratory profile

Hematological Analysis: Anemia with enlarged RBC ( Macrocytic ) Bone Marrow Aspirate: no.RBC& WBC precursor >normal Size LARGER than normal

 Serum level of Folic acid : 1.2ng/mL ( normal 2.5-20 ) B12 : 253 ng/ml (normal 200-900) Iron : NORMAL

Diagnosis:

Megablastic Anemia

What is megaloblastic anemia?

Enlargement of the red blood cells, and thus they are dysfunctional Common causes are, Vitamin B12 and folic acid deficiency results from Malabsorption Dietary deficiency Gastric diseases Liver diseases Medication Alcoholism

What is the cause of megaloblastic anemia in this patient? What is its correlation with alcoholism?
I. Deficiency of folic acid (which may cause by liver disease or alcoholism) Liver disease: Cell necrosis, which decreases the livers ability to metabolize and excrete bilirubin, thus unconjugated bilirubin in the blood lead to jaundice. Interfere with the production and metabolism of red blood cells, thus abnormal RBC are produced Impairs with the absorption and also diminish hepatic storage of folic acid

Alcoholism: Interfere with the enterohepatic cycle Decrease the absorption of folic acid, because usually alcoholism will lead to malnutrition and thus to the deficiency of many nutrients. Why deficiency of nutrients? Poor diet Intestinal malabsorption Decrease hepatic uptake Increase body excretion, mainly via urine

Failed in the production of normal RBC Jaundice Alcoholism Liver disease Folic acid deficiency Megaloblastic anemia

Case History 2

Patient is, a malnourished-appearing woman in her second trimester of pregnancy, presents to the local health clinic for her regular checkup. She is a multiparous, 22-year-old woman who ran away from home when she was 16. She has a 7-year history of excessive alcohol intake and has been using cocaine frequently for 3 years. She lives with her boyfriend and her 19-monthold daughter. During both pregnancies, T.J. lost 8 to 10 Ib during the first trimester secondary to nausea, vomitting, and aneroxia. Her only complaints are dyspnea on exertion, palpitations, and diarrhea.

Pertinent laboratory values include the following: Hct, 25.5% (normal, 40 to 44%); MCV 112m3 (normal, 76 to 100); MCH, 34 pg (normal, 27 to 33);RBC, 1.1 X 106 /mm3(normal, 3.5 to 5.0); folate, 30ng/mL (normal, in RBC 140 to 960); serum vitamin B12, 250 pg/mL (normal, 200 to 1,000); reticulocytes, 1% (normal, 0.5 to 1.5); platelets, 75,000/mm3 (normal 130,000 to 400,000); WBC count, 2,000/mm3 (normal, 3,200 to 9,800 ) with hypersegmented PMN; LDH, 450 U/L (normal, 50 to 150); and bilirubin, 1.5 mg/dl. Normal, 0.1 to 1).

Patient Background
Name : T.J. Gender: Female Age : 22 years old Malnourished-appearing Stage of pregnancy : 2nd trimester Has 19-month-old daughter Excessive alcohol intake ( 7 years) Cocaine administration (3 years)

 In both pregnancies: lost 8-10 Ib in 1st trimester (Nausea, vommitting & anorexia) Symptoms: Dsypnea on exertion, palpitations & diarrhea

Pertinent laboratory value:

Blood Serum level
Hct RBC Folate Platelets WBC (Hypersegmented polymorphonuclear leukocytes) 25.5% 1.1 X 106 /mm3 30 ng/mL 75,000 /mm3 2,000/mm3

Normal Range
40-44% 3.5-5.0 /mm3 140-960 ng/mL Less Less Less

130,000-400,000/mm3 Less 3,200-9,800 /mm3 Less

MCV
MCH LDH Vitamin B12 Recticulocytes

112 m3
34 pg 450 U/L 250 pg/mL 1%

76-100 m3
27-33 pg 50-150 U/L 200-1000 pg/mL 0.5-1.5%

Greater
Greater Greater Normal Normal

Diagnosis?

Question 1:
T.J is not taking any presciption medications. What factors make T.J. at risk for folate deficiency???

1. Pregnancy
Increased need for folic acid Require more folate to meet the needs of her developing baby. If she dont have sufficient folate intake, she may become folate deficient and her unborn baby may develop a neural tube defect. This happens when unborn baby's nerves and spinal cord do not develop properly in the first months of pregnancy.

2. Malnutrition
Poor dietary intake of folic acid (does not eat enough foods that contain folic acid) Diets lacking of fresh fruits and vegetables, or consistently overcook food Imbalance and unhealthy diet

3. Chronic Alcoholism

Inadequate dietary intake of folic acid interferes with the absorption of folate. Drinking too much alcohol can reduce T.J. body's ability to absorb and use folate.

Question 2
Which laboratory values support the diagnosis of folate deficiency ? How should T. J be treated and monitored?

 The folate concentration in the RBC is only 30 ng/mL, which is much lower than the normal range. The Vitamin B12 is at normal range. The MCV or MCH has increased in the patients, with folate deficiency, indicates the patient diagnosed with megaloplastic anemia. The platelets count are low, and the white blood cells count are low with hypersegmented polymorphonuclear leukocytes. Hypersegmented polymorphonuclear leukocytes are the earliest and most specific signs of megaloblastic anemia.

Treatment
Oral folic acid therapy can be given, because it is inexpensive and stable. 15mg daily for 4 months due to the malabsorption states.

Monitoring the Condition

Around 10 days after starting treatment, the blood test is taken to check whether the levels has started to rise. Approximately 8 weeks is required for another blood test to confirm the treatment has been successful. The blood test is taken again after the treatment has finished.

Case study 3
A 65-year-old woman presents to the medical out-patient department with a history of fatigue. She has in the last few months been undergoing adjuvant cytotoxic chemotherapy for a nodepositive resected breast cancer. The patient is pale, but no other abnormalities are noted. Her full blood count shows a haemoglobin level of 9.8 g/dL with a mean corpuscular volume of 86 fL; other haematological indices and serum transferrin are normal. Her faecal occult blood is negative. She is started on oral iron sulphate and given weekly injections of erythropoietin 40 000 U subcutaneously. Three months later, her haemoglobin level has risen to 13.5 g/dL, but she presents to the Accident and Emergency Department with acute-onset dysphasia and weakness of her right arm. Her supine blood pressure is 198/122mmHg. Her neurological deficit resolves over 24 hours and her blood pressure settles to 170/96 mmHg. She has no evidence of cardiac dyshythmias or of carotid disease on ultrasonic duplex angiography, and her serum cholesterol concentration was 4.2 mmol/L.

Summary
Gender: woman Age: 65 yrs old History: fatigue Therapy received before: adjuvant cytotoxic chemotherapy : node-positive resected breast cancer. Haemoglobin level: 9.8 g/dL with a mean corpuscular volume of 86 fL other haematological indices and serum transferrin: normal faecal occult blood: negative

 Treatment: oral iron sulphate & inject erythropoietin 40 000U (SC) weekly. Haemoglobin level after 3 months: risen to 13.5 g/dL
Accident & emergency department: due to acuteonset dysphasia and weakness of her right arm. Supine blood pressure: 198/122mmHg. After 24 hours, blood pressure- 170/96 mmHg, neurological deficit resolves Cardiac dyshythmias / carotid disease in ultrasonic duplex angiography- negative Serum cholesterol conc. 4.2 mmol/L

Question 3
What led to this patients acute neurological episode? Does she require further therapy?

Question 3
The 65-year-old woman is diagnosed for a node-positive resected breast cancer. She had been undergoing cytotoxic chemotherapy in the last few months.

1) Filgrastim (granulocyte colony-stimulating factor; G-CSF). 2) Sargramostim (granulocyte-macrophage colony-stimulating factor; GM-CSF). Both stimulate the production of neutrophils and accelerate the recovery of neutrophils after cancer chemotherapy.

4) Oprelvekin

(interleukin-11 [IL-11]) increases the number of peripheral platelets. It is used for the treatment of thrombocytopenia patients after had cancer chemotherapy. 5) It reduces the need for platelet transfusions. Common adverse effects of IL-11 are fatigue, headache, dizziness, and fluid retention.

 Serum cholesterol concentration= 4.2 mmol/L. Total Cholesterol [mmol/L (mg/dl)] a) Risk indicated if greater than 4.5 b) Desirable: <5.2 (<200) c) Borderline High: 5.2 - 6.2 (200 - 239) d) High: >=6.2 (>=240) The first steps in treating high cholesterol levels are regular physical activity and healthy eating.