Case Study - Mariana Flashcards
(35 cards)
What is relevance of her travel history
Tattoo, potential unprotected sex, heavy drinking - Hep. B/C
Length of stay in high TB prevalence areas.
Jungle travel, exposure to mosquitoes - dengue fever, malaria.
Possible exposure to contaminated water - leptospirosis.
Repeated food poisoning/poor diet - Iron, B12, folate deficiency, anaemia.
What is relevance of Asian ethnicity
TB - more common in Asian’s.
Hep. B - more common in Asian’s.
G6PD deficiency - more common in Asian’s.
Ethnicity doesn’t cause symptoms but can influence disease susceptibility, diagnostic considerations and risk factors.
What is ruled out in initial testing?
- Acute bacterial infection as normal WBC and no sign of inflammatory response
- Acute malaria - platelet count is normal.
- Sever parasitic infections - no eosinophilia
Why test a faeces sample, although there was no mention of diarrhoea.
- Detecting parasitic infections.
- Checking for gastrointestinal bleeding (F. occult blood test)
- Liver and bilary infections from raw fish and contaminated water
What conclusiosn from initial haem and clinical chem results?
- TB possible, as mild anaemia, weight loss, fatigue.
- Hep B/C possible, as fatigue, weight loss, mild anaemia, prolonged APTT.
- Chronic GI infection possible.
- Liver failure possible
What tests do we reccommed for Mariana after the initial testing?
Liver function tests - for chronic infection
Clotting screen - repeat APTT with coagulation profile, to investigate clotting time.
FBC
2nd visit to GP symptoms
pale orange urine, tenderness of lower abdomen and a number of bruises on her leg (mentioned she bruises easily)
Liver Function Tests results
Bilirubin - raised.
ALP - highly raised
AST - v. highly raised.
ALT - v. highly raised.
Albumin - normal
2nd visit. Which results are abnormal.
- high lymphocytes
- low platelets
- high PT
- high serum bilirubin
- v. high ALP
- v. high AST
- v. high ALT
2nd visit. Differential diagnosis
Damage to liver - as 10x higher AST and ALT levels. also AST:ALT is <1, indicates hep.-causing virus.
Clinical jaundice - slight yellow in eye and hyperbilirumia (high bilirubin levels)
Possible viral cause - high lymphocytes.
Explain link between liver inflammation and elevated lymphocytes
viral infections like hep a/b, cause a lymphatic response and therefore reflects body’s system immune system reacting to a viral pathogen.
Explain link between low platelets (thrombocytopenia)
so liver produces thrombopoietin (hormone that regulates platelet productions.
in liver inflammation, thrombopoietin production reduces so therefore platelet count reduces too.
also explains her bruising as platelets help with clotting and reduced levels can cause easy bruising/bleeding.
Explain link between liver inflammation and prolonged PT
PT = measure of how fast blood clots.
the liver synthesises clotting factors (e.g. II, VII, IX) and if inflamed it can’t make enough of them and reduces clotting.
Also why bruising occurs, impaird coagulation due to your dysfunction.
Narrowed differential diagnosis:
- Acute viral hep.
- Drug/toxin-induced hep.
- Autoimmune hep.
What further investigations after the 2nd trip is needed?
Hep. B serology screening.
Assessing for HBsAg
What is the method for assessing for HBsAg, IgM Anti-HBc, Anti-HBc, Anti-HBs
ELISA
What does HBsAg indicate if +ve
active infection (>6mths)
What does a +ve Anti-HBs test indicate
immunity from past infection/vacc.
What does a +ve Anti-HBc test indicate?
Previous/current infection
What does a +ve IgM anti-HBc test indicate?
acute/recent infection. (>6mths)
What were Mariana’s ELISA results
HBsAg= +ve, Hep. B surface Ag present and therefore has current HBV infection
IgM Anti-HBc = borderline, possible early acute infection or flare of chronic HBV
Anti-HBc = +ve, has been exposed to virus (past/current)
Anti-HBs = -ve, has no protective immunity yet, no vacc./recovered.
Treatment for acute hepatitis vs chronic
Acute:
close monitoring to see whether infection resolves/becomes chronic.
repeat HBsAg, ALT, AST every 3 mths for next 6-12. no immediate cantiviral therapy unless ALT remains elevated/develops worsening liver function
Chronic:
antiviral therapy.
monitor for cirrhosis - screen with ultrasound & AFP every 6mths.
H&E Stain:
Difference in healthy liver tissue and diseased liver tissue
Hepatocytes - H(uniform, blue central nuclei, pink eosinophillic cytoplasm). D(ballooned, degenerate, ground glass appearance. Less nuclei and more pink cytoplasm).
Lobular structure = H(preserved, clear arrangement around central veins and portal triads), D(disrupted, fibrous septa.). Necrosis/fibrosis = H(none). D(spotty N, councilman bodies, varying degrees of F, depending on stage).
Other special stains
Orecin, Masson’s Trichrome, Reticulin, PAS+/- Diastase, Prussian Blue, Rhodanine, IHC
