Case for discussion: March 2017

A 11-year-old male with a history of polyarthritis presented to the clinic with a complaint of pain in the left foot from past 5 days. The patient history revealed generalised weakness, and dry skin and mouth. The systemic examination of the patient including cardiovascular, respiratory, per abdomen and central nervous system was normal. The patient underwent open reduction internal fixation (ORIF) around 7 years ago for a fracture in the left lower end of the humerus. The previous laboratory investigations revealed: hemoglobin: 12.7gm/dL, total WBC count, 11500 cells/cumm, neutrophils: 59%, lymphocytes: 32%, eosinophils: 6%, monocytes: 3%; ESR: 14 mm/hour; platelet count: 5.01 lakh/ cu.mm; and ASLO: 625.6.

The patient was on non-vegetarian diet, had normal appetite and sleep. He was afebrile on examination. His bladder frequency and bowel movement was normal. He was moderately built. The drug history indicated that he was on amoxicillin clavulanate 375 mg, acetaminophen 500 mg tablet, and Nutrolin B syrup. The results of clinical and lab investigations are given in table 1.

Table 1: Results of clinical and laboratory investigations done during the current consultation

Parameters evaluated

Results

First visit

 

Second visit

 

Hemoglobin (gm/dL)

12.3

11.6

Total WBC count (cells/cumm)

13500

13740

Neutrophils (%)

50.9

65.0

Basophils (%)

0.2

0.4

Lymphocytes (%)

35.0

20.4

Eosinophils (%)

3.5

3.9

Monocytes (%)

10.4

10.3

ESR (Westergren method) (mm/hour)

74

76

Platelet count (lakh/ cu.mm)

5.09

5.41

RBC count (g/dL)

5.1

4.7

Random blood sugar (mg/dL)

81

-

S.G.O.T [A.S.T] (IU)

18

-

S.G.P.T [A.L.T] (IU)

13

-

Creatinine (Kinetic Jaffe) (mg/dL)

0.9

0.8

C-reactive protein (Quantative immunoturbidimetric method)

-

51.2

ANA immunofluorescence (1:40 dilution)

Negative

-

CRP-NEPH

26.50

-

RF-Nephelometry

<20.0

-

Hepatitis b surface antigen (HBsAg) by CLIA (rapid)

Non-reactive

-

Hepatitis'c' virus antibody (rapid)

Non-reactive

-

Total bilirubin (Modified Jendrassik)

0.6

-

Direct bilirubin (Modified Jendrassik)

0.2

-

Indirect bilirubin

0.4

-

Alkaline phosphatase (Kinetic) (IU/L)

150

-

Gamma GT

24

-

Total protein (g/dL)

8.3

-

Serum albumin (g/dL)

4.3

-

Globulin (g/dL)

4.0

-

AG Ratio

1.0

-

Colour

Pale yellow

-

Appearance

Clear

-

Leucocytes (/hpf)

2-3

-

RBCs (/hpf)

Absent

-

Epithelial cells

3-4

-

Casts

Absent

-

Crystals

Absent

-

Reaction

5.5

-

Specific gravity

1.025

-

Protein

Trace

-

Sugar

Negative

-

Ketone bodies

Negative

-

Urobilinogen

Normal

-

Bile pigment

Negative

-

NIT

Negative

-

HLA- B27 (PCR)

-

Negative

HLA B-27 genotype not detected

Hematocrit (PCV)

35.9

34.4

MCV

71.1

73.2

MCH

24.4

24.7

MCHC

34.3

33.7

RDW

13.6

12.8

PDW

10.20

9.30

MPV

9.50

9.20

P-LCR

20.60

17.70

 

Please proceed for discussing the case..