Question of the Week # 106

106) A 46 year old man is seen in your office for complaints of severe fatigue over the last one week. The patient was diagnosed with chronic Hepatitis – C infection 2 weeks ago for which he was started on Interferon and Ribavirin. On examination, his vitals are stable and he is afebrile. Conjunctivae are notable for pallor.  Abdominal examination is benign except for mild splenomegaly.

Laboratory investigations :

WBC count of 3,ooo/µl

Hemoglobin of 5.8gm%

Platelet count of 60k/µl.

Total protein 6.8gm%

Albumin 3.2gm%

Total Bilirubin 3.2gm%

Direct bilirubin 0.8gm%

SGPT 52 U/L

SGOT 66 U/L

Alkaline Phosphatase 110U/L

Haptoglobin < 5.8

Reticulocyte count of 6.0%

Lactic Dehydrogenase 1200 IU/L

Serum creatinine 1.0

Peripheral blood smear reveals reduced platelets, polychromasia and anisocytosis. His laboratory tests 4 weeks ago were normal except for mild elevations in his liver enzymes.  The immediate next step in managing this patient is :

A) Parvo virus B19 antibodies

B) Endoscopy

C) Plasmapheresis

D) Stop Ribavrin

E) Intravenos Methylprednisolone

 

9 Responses

  1. D.Stop Rivavirin
    Ribavirin causes hemolytic Anaemia in 10 % cases

    Recommendation-Check Hct pretreatment,2 wks & 4 wks
    ***Highly Teratogenic

    ***Parvovirus B19 causes Aplastic Crisis in Sicle cell disease or other Hemoglobinopathies

  2. C it is interferon induced TTP

  3. c

  4. ddd

  5. Empiric Therapy for Community-Acquired Pneumonia
    Patient group Initial therapy

    Previously healthy outpatients; no antibiotic use in past three months

    A macrolide or doxycycline

    Outpatients with comorbidities* or antibiotic use in past three months†

    A respiratory fluoroquinolone (levofloxacin [Levaquin], gemifloxacin [Factive], or moxifloxacin [Avelox]), or a beta-lactam antibiotic (high-dose amoxicillin, amoxicillin/clavulanate [Augmentin], or cefpodoxime) plus a macrolide‡

    Inpatients, non-ICU

    A respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide

    Inpatients, ICU

    A beta-lactam antibiotic (ceftriaxone [Rocephin], cefotaxime [Claforan], or ampicillin/sulbactam [Unasyn]), plus azithromycin (Zithromax) or a respiratory fluoroquinolone§

    Special considerations

    Risk factors for Pseudomonas species

    A beta-lactam antibiotic (piperacillin/tazobactam [Zosyn], cefepime, imipenem/cilastatin [Primaxin], meropenem [Merrem], or doripenem [Doribax]), plus either ciprofloxacin (Cipro) or levofloxacin

    or

    The above beta-lactam antibiotic plus an aminoglycoside and azithromycin

    or

    The above beta-lactam antibiotic plus an aminoglycoside and an antipneumococcal respiratory fluoroquinolone

    Risk factors for methicillin-resistant Staphylococcus aureus

    Vancomycin or linezolid (Zyvox)

    Influenza virus

    Oseltamivir (Tamiflu) or zanamivir (Relenza)

    ICU = intensive care unit.

    *—Chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; asplenia.

    †—Antibiotic from a different class should be used.

    ‡—Also recommended in regions with a rate of high-level macrolide-resistant Streptococcal pneumoniae of greater than 25 percent.

    §—For patients allergic to penicillin, a respiratory fluoroquinolone plus aztreonam (Azactam) are recommended.

  6. sorry wrong post

    • Reading questions with out answers while exam is approaching feels like no Good Archer .

  7. Inclined to go with answer D.

    Albumin fraction of proteins = 6.8-3.2=3.6 (upper limit of normal range for globulins) – can generally assume that it’s not an autoimmune-mediated process.
    Since he was recently started on ribavirin, this seems like the likely mechanism for hemolytic anemia (increased indirect bilirubin and LDH). I would stop ribavirin altogether since his Hb is < 8.5 (as per the PDF below).

    http://www.hcvadvocate.org/hepatitis/factsheets_pdf/SEM_anemia.pdf

  8. clearcut case of HUS. it is TTP only if fever and neurological sings are added to HUS. plasmapheresis is the treatment for HUS.

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