Aplastic Anemia

ANITA ANGGITIA PERMANA

CO-ASSISTANT

IDENTITY

Name : Mr. EAge : 47 yearsGender : MenAdress : Citaman, KarawangOccupation : Labour Religion : MoslemMarital status : MarriedRace : SundaneseEducation : Junior High School

Admisson to hospital at 23th October 2012

ANAMNESE

Autoanamnese

on 23th October 2012 at 12.00

History of present disease

Patient came to RSUD Karawang with complaint immense Weakness with palpitations and fatigue since 4 days before admitted to hospital. His breathing was very fast which was worsened by walking fast, climbing stairs, and by any kind of exertion. He also got dizzy when he stand up from sitting or squatting.

He felt nausea and vomited when the dizziness attacks. he wasn’t felt that the environment is moving or spinning, and when the dizziness attacks he haven’t felt hearing ringing or buzzing on his ears. His appetite was markedly less. There’s no body weight loss, He also complained of paleness of lips and hands for the past 3 months. Fever , cough denied by him.

History of present disease

History of present disease

• Patient never had history of nose bleed,gum bleed, and swelling in both of lower extremities.He also complained of tingles in the legs for the past 6 months but He haven’t feel burning and pain too in his legs. He has noticed that, in the past 6 month, she is increasingly thirsty. he gets up several times a night to urinate, and finds herself gulping down glassfulls of water. Itchies on skin denied

History of past disease

He was hospitalized twice for the same complaint on October, September 2012

Past medical history

Family history

• No one in his family got a symptom or disease like him• Hypertension (-), Liver disease (-), Kidney disease (-),

Cancer (-), Diabetes Mellitus (-), heart disease (-)

• Eat three times a day• Sweet tea 4-5 cups/day since he was young • Smoking 1packs for 2 days• Eat “jeroan” almost everyday since he was young • Drugs (-), Alcohol (-) coffee (-)• Tatoo (-)

HABIT HISTORY

PHYSICAL EXAMINATION

Picture of patient

General condition

THORAX HEART

Inspection : Symmetrical Palpation : Equal vocal resonancePercussion : Sonor in both lungsAuscultatiom : Vesicular breath sound in

both lung,ronchi (-/-),

wheezing (-/-)

THORAXLUNG

• INSPECTION– brown skin, flat, supple– Icteric (-) ,pale (-) hematom (-) ptechie(-)

• AUSCULTATION– Bowel sound (+) normal 2x/minute , venous hum (-), – arterial bruit (-)

• PERCUSSION– Tymphany in all abdomen regio

• PALPATION– turgor normal – Hepatomegali (-), splenomegali (-)

ABDOMEN

Warm acral

Edema

Deformation (-), brown skin , icteric (-), flapping tremor (-), palmar eritema (-), pale nails(+)

EXTREMITY

Haematology Result NormalHemoglobin 5,1 12-17 gr/dL

Eritrocite 3.8 – 5.8 jt/mm2

Leukocytes 1900 5.000 – 10.000

Trombocytes 25.000 150.000 – 450.000

Hematocrite 15 37-43%

Diff. Count :

- Basofil 0 0-1

- Eusinofil 0 1-3

- Batang 0 2-6

- Segmen 25 40-70

- Limfosit 70 20-40

- Monosit 5 2-8

LABORATORY23. 10. 2012

LABORATORY

Result Normal GDS / reduksj 295 80-140 mg/dl

GDN 70-100 mg/dl

GDPP <140 mg/dl

Ureum 16,1 10-45 mg/dl

Creatinin 1,03 0,4-1,5 mg/dl

MCV 84 82-92 mc/L

MCH 26 27-31 Pg

MCHC 32 32-35 %

RDW 13,2 12,8±1,2 %

24. 10. 2012

Haematology Result NormalHemoglobin 6,5 12-17 gr/dL

Eritrocite 2,4 3.8 – 5.8 jt/mm2

Leukocytes 2700 5.000 – 10.000

Trombocytes 8000 150.000 – 450.000

Hematocrite 21 37-43%

Reticulocytes 0,8 0,5-1,5 %

24. 10. 2012

Kimia darah Result Normal GDS / reduksj 285 80-140 mg/dl

GDN 405 70-100 mg/dl

GDPP 510 <140 mg/dl

Ureum 10-45 mg/dl

Creatinin 0,4-1,5 mg/dl

Cholesterol 205 <200 mg/dl

Total Bilirubin 0,70 <1,1 mg/dl

Direct bilirubin 0,18 <0,6 mg/dl

Indirect bilirubin 0,52 <0,5 mg/dl

25. 10. 2012

Haematology Result NormalHemoglobin 7,0 12-17 gr/dL

Eritrocite 3.8 – 5.8 jt/mm2

Leukocytes 2100 5.000 – 10.000

Trombocytes 7000 150.000 – 450.000

Hematocrite 20 37-43%

Reticulocytes 0,5-1,5 %

MCV 82-92 mc/L

MCH 27-31 Pg

MCHC 32-35 %

RDW 12,8±1,2 %

Peripheral Blood Smear

• Eritrocytes : normositic normocrom anisopoikilocitosis

• Leucocytes : decrease, there is no morphology abnormalities

• Trombocytes : decrease, trombocytes group

is negative, Giant trombocytes

is negative

Descripsition : Pansitopenia

23.10.2012 24.10.2012 25.10.20125,1 6,5 7,0

23.10.2012 24.10.2012 25.10.20121900 2700 2100

23.10.2012 24.10.2012 25.10.201225.000 8000 7000

Hemoglobin

Leukocytes

Trombocytes

RESUME

Blood pressure100/60MmHg

Heart rate88 x/min

Respiration rate18 x/min

Temperature36,2 C

Anemic conjungtiva +/+

Pale lip (+)

Pale nails (+)

No pitiing oedem in lower extremities

Anemia

Leukocitopenia

Trombocitopenia

Eritrocytes : Hipocrome anisopoikilocitosis

(ovalocytes, microcytes )

GDS 295 mg/dl

GDN 405 mg/dl

GDPP 510 mg/dl

American Association of Clinical Endocrinologist - 2011 (AACE-2011)

• FPG > 126 mg/dl, fasting means no caloric intake > 8 hours, or

• 2-h PG > 200 mg/dl after 75 g oral glucose load in the morning after an overnight fast of at least 8 hours, or

• Symptoms of uncontrolled hyperglycemia (e.g polyuria, polydipsia, polyphagia) and a random (casual, nonfasting) plasma glucose concentration > 200 mg/dl

DIFFERENTIAL DIAGNOSISMyelodisplasia hiposelular

Leukimia limfositik granular

Anemia aplastic and Nocturnal Paroksismal Hemoglobinuria

Anemia Hemolitik

Herediter Aplastic Anemia

Anemia with Idiopatic Trombocytopenia Purpura

Anemia e.c Viral infection

Anemia Aplastic e.c Drugs Induce (Cloramphenicol. Etc)

Treatments

• Pharmacology– Nacl 0,9 % 20 dpm– Methyl prednisolon

125mg 2 x 1– Lanzoprazole 1 x 1– Sangobion 2 x 1– Metformin 500 mg – PRC transfution

• Non pharmacology– Resting when he need to– Avoiding contact sports– Self - Protecting from germs– diet DM

KH : 60-70%

Protein : 10-15%

lipid : 20-25%

- Exercise continously,rhytmical,interval,progresisve 3-4 x/day

Suggested Treatments

Bone marrow stimulant (sagramostim, figrastim. Epoitin , etc)

• Trombocytes transfution

Suggested examination

•Bone marrow biopsy

PROGNOSIS

• Ad Vitam : Dubia ad Malam

• Ad Fungsionam : Dubia ad Malam

• Ad Sanasionam : Dubia ad Malam

ANITA ANGGITIA PERMANA

Presented by :

Anemia Aplastik

Bone marrow transplantatio

n

Imunosupresive therapy respons

Decrease CSA on 6 month Repeat ATG /ALG

Repeat munnosupresive

therapyFollow up

Hemapoietic growth factors

Age >35 yr orHLA not matched

Age >35 yr orHLA matched

No respon

No respon

Respon +

Respon +

Relaps + Relaps --