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Old 11-01-2012
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Arrow Gyrus Daily Questions; Internal Medicine #64

A 3-year-old child whose parents immigrated from a third world country 6 months ago is found to have a 16 mm induration on his arm 48 hours after the administration of purified protein derivative He is prescribed isoniazid and sent home. Two days later, the parents are concerned because the child is not as active as he was before He does not want to eat or play with his toys. Temperature is 37.1 C (98 7 F). pulse is 120/min. and RR 20/min HEENT conjunctiva is icteric. Heart. systolic ejection murmur Lungs: clear to auscultation Abdomen soft. nontender Skin jaundice noted on upper anterior thorax Neurological examination- confused, no focal deficits Laboratory reports include

Hemoglobin 8 g/dL
Hematocrit 22%
Platelets 180.000/mm 3
White blood cells 6.500/mm 3

MCV 85 um 3
MCHC 34 pg/cell
Reticulocytes 5%
PT 10 seconds
PTT 35 seconds
Total bilirubin 3 mg/dL
Direct bilirubin 0.1 mg/dL
Haptoglobin Low
UA Hemoglobin +

Peripheral smear Presence of bite cells

G6PDH level Normal

Direct Coombs test Negative
Which of the following is the most likely diagnosis'?

A. Drug induced hemolytic anaemia
b. Glucose 6 phosphate deficiency
c. Heriditary elliptocytosis
d. Phophofructokinase deficiency
e. Pyruvate kinase deficiency
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Old 11-01-2012
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Even if G6PD levels are normal this dude has the disease, it takes more than 4 weeks in order for the levels to start to decrease, also INH is one of the drugs that causes oxidative stress to RBC's

Remember that the most common cause of oxidative stress and thus episodes of hemolysis is infection.
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Old 11-02-2012
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Yes the Answer i Glucose 6 phosphate dehydrogenase deficiency.

Condition with reduced capacity to oxidative stress neutrilize.

Common drugs implicated in hemolysis are.. Sulfa drugs, primaquine, dapson quinidine , IND and nitrofuraintoin.

Clinical patient are normal untill exposed to sudden stress.A sudden severe intravascular hemolysis including jaundice dark urine weakness and tachycardia.History of recent drug intake is a clue.

The usual finding of an intravascular hemolysis including high LDH, bilirubin and reticulate count with a normal MCV , low haptoglobulin and hemoglobinuria.

The definitive test is the G6PD level which can be falsely normal immediately after an episode of hemolysis.
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