vitamin b12 deficiency presenting as pyrexia
TRANSCRIPT
VITAMIN B12 DEFICIENCY PRESENTING AS PYREXIA
DR.PRAVEEN NAGULA
JULY 1 ,2011
HAPPY DOCTOR’S DAY
DR.BIDHAN CHANDRA ROY
JULY 1ST- 1882-JULY1ST 1962
DR.TINSLEY.R.HARRISON
PHYSICIAN IS THE BEST
No greater opportunity ,responsibilty,or obligation can fall to the lot of a human being than to become a physician.In the care of the suffering ,the physician needs technical skill,scientific knowledge,and human undersatnding…tact sympathy ,and understanding are expected of the physician,for the patient is no mere collection of symptoms,signs,disordered functions,damaged organs,and disturbed emotions.the patient is human,fearful,and hopeful,seeking relief,help and reassurance….
HARRISON’s 18 th edition to come at the end of AUGUST 2011
INTRODUCTION
MEGALOBLASTIC ANEMIA ,though rare ,is a treatable cause of pyrexia.
To be considered in any patient who presents with pyrexia and pancytopenia.
Department of medicine,Indira Gandhi Medical College,shimla.
Case history
18 yr old male,pure vegetarian since birth,having regular fasts for two months.
Prsented with easy fatiguability for one month and high grade pyrexia 104 F for the last three days.
No h/o cough,headache,rash,arthralgia,urinary,bowel disturbances.
No h/o visit to malaria endemic area.No significant past history.Exclusion of infective,inflammatory or endocrine causes.
Clinical features
Pulse 118/minBP -110/60 mm of HgTemp -103.6 FMarked pallorNo icterus ,lypmhadenopathy,rashes,eschar.Bald glossy tongueHyperpigmentation of knuckles. Loud S1Ejection systolic murmur in pulmonary area.Mild spleenomegalyChest,nervous system normal.Dimorphic anemia with pancytopeniaBiochemical examination was normalUrine,gram stain,ZN stain,koh mount normal
Blood and urine cultures were sterile. Weil felix test negative. Cxr normal Usg abdomen l-mild spleenomegaly. Managed with broad spectrum antibiotics. 3rd day epistaxis- 2 units platelet concentrates. BM examination- severe dimorphic anemia,pancytopenia,no
parasites,granuloma. Was febrile on 5th day also. Vitamin B 12 level was 105pg/ml (140-180),folate level was 5.05ug/l normal. ANA ,CRPlevels were normal Inj cyanocobalamin 1000 mcg od. 72 hrs later afebrile-thereafter diashcarged after three days
Patient followed up after two weeks –correction of anemia and thrombocytopenia.
DISCUSSION
PYREXIA is a feature of megaloblastic anemia.More common in patients with moderate to severe
anemia,thrombocytopenia.Exact cause is not known.Defect in oxygenation to the temperature regulatory centres in
the brain.—why not seen in other severe anemiasHyperplasia of bone marrow-systemic pyrexia-mechanism ?Level of pyrexia degree of anemiaResolves in three days –immediate improvement in ineffective
erythropoiesis.Measurement of vitamin b12 levels are required in patients
presenting with megaloblastic anemia and pyrexia.
Take home message
Megaloblastic anemia is a known and treatable cause of pyrexia when all other causes ruled out,particularly with pancytopenic picture-who are routinely treated as febrile neutropenia with BSAb.
Measurement of levels and treatment -response
questions
How did a pure vegetarian present with fever and pancytopenia at 18 yrs…reserve for 18 yrs?
How was his nervous system normal ?Should all cases of pancytopenia to be sent for vit b12 levels..Cost effective ?
ENDOCRINE CHANGES IN MALE HIV PATIENTS
DR.PRAVEEN NAGULA
INTRODUCTION
Functional derangement of every endocrine organ in HIV infection
Attibuted to cytokines,opp infections,neoplasm,complication of treatment.
Most common involved is adrenal gland – clinical adrenal dysfucntion is uncommon.
Clinical thyroid disease is rare but altered TFT s are common.Gonadal dysfunction –maleNo reports from india of these changes.
Group A – HIV POSITIVE CD4 <200 cells/mm3Group B – HIV POSITIVE CD4 200-350 cells/mm3Group C – HIV POSITIVE CD4 >350 Cells/mm3Basal cortisolTSHSerum testosteroneSerum LH/FSH --8-9 am,3 samplesSerum for hormonal assay -20 cImmulite for measurement
results
Mean age is 35 .8 yrsBMI 17.38 kg/m2Basal cortisol levels rose as the disease progressed.Serum TSH INCREASED with progression of disease.Mean serum testosterone levels low in group A – Basal cortisol,TSH – negative correlation with CD4Testosterone – direct correlation with CD4Level of LH/FSH inversely proportional to CD4 not significant.Hypogonadism—serum testosterone <200 ng/dl 50 pts –44% had
elevatedLH,24% HAD elevated FSH --primary hypogonadism
discussion
Cause of endocrinopathy was not evaluatedCross sectional study onlyMean basal cortisol levels –inverse relation –as in other studies.Stress related,infections –cause for raised basal cortisols4 pts had low basal cortisol –TUBERCULOSIS –adrenal dysfunction
– 49 % infected with TB30% subclinical hypothyroidism—16% primary – asymptomatic comparable to ketsmathi et al Oppurtunistic infections may be the cause in advanced disease –
supported by autopsy welch et al 20% prevalence of hypogonadism recent trends Low testosterone – BMI coodley et al
Testosterone levels – correlated with results of elefthrious 2001.Hypogonadism –IL1,TNF,OisMAI ,CMV in testes –in pts with disseminated tuberculosis.25% of disseminated tuberculosis – hypogonadism -chabon et al
Only thyroid dysfunction was high in the prsent study.
Take home message
Endocrine dysfunction common in HIV infectionRole of cytokines,OisTSH ,BASAL CORTISOL levels inversely relatedTestosterone –directly correlative with CD4 countEffect on morbdity and mortality of patientsTSH levels high -- to be supported by large group studies.All other findings were correlative
