CASE PRESENTATION ON PANCYTOPENIA

WITH ANASARCA 2° TO HYPOALBUMINEMIA

WITH HERPES ZOSTER

PRESENTED BY:
MALIHA MUZAFFER
PHARM D 6TH YEAR
Demographic data

 NAME: XYZ
 AGE: 38 YEARS
 GENDER: Female
 DOA: 22/04/2024
Subjective data

Chief Complaint:-
➢ 38 years old female k/c/o SLE with APS came with chief complaints of -
▪ c/o B/L pedal edema since 3 days. c/o generalised weakness since 20 days.
➢ Patient was apparently asymptomatic then she developed-
▪ c/o fever since 20 days, High grade, not decreasing on taking medication, ↑ during
evening time.
▪ c/o yellowish discolouration of eyes since 20 days, sudden onset, reached up to the
present stage.
▪ c/o haematuria since 20 days, subsided now, occasional haematuria +
History Of Present Illness:-
• K/c/o SLE with AIHA went to NIMS for management.
• Patient was started on steroids, IV methylprednisolone was not shown response
then started on IVIG for 2 days (90 gm) were given. Patient was given Inj
cyclosporine to which she responded.
• Patient was discharged on 23/3/24. Patient was referred to Osmania i/v/o
financial constraints.
 H/o 1 abortion @ 24 weeks of gestational age.
 H/o skin rash from 20 days on left thigh.
 H/o B/L lower limb swelling since 3 days.

Medication History:
• H/o herbal medications 1 month back for about 1 month.
 Objective data

DAY 1 DAY 2
O/E patient is conscious/ coherent, afebrile.
O/E patient is c/c/c, afebrile. Epistaxis ↓ed. B/L
Healed pustule like lesion over nose bridge + LL swelling.
Scarred rash over right thigh + Pallor +, Icterus +, Pedal edema +
GRBS:- 376 mg/dl GRBS: 190 mg/dl
Pallor +, Icterus +, Pedal edema + BP:- 110/80 mmHg
c/o epistaxis PR:- 95 bpm
P/A : Splenomegaly + CVS:- S1, S2+
Right radial pulse is feeble than left radial pulse R/S:- BAE +
CVS: S1, S2+ P/A :- Soft, NT
R/S : BAE +. Clear. SPO2: 98% ↓ RA CNS:- B/L pupils, NSRL
DAY 2-(continued) DAY 3
No fresh c/o
Patient after 3 RDP
O/E pt is c/c/c, afebrile.
↓
Pallor +, Icterus +, B/L Pedal edema + Up to
undergone transfusion reaction knee
↓ GRBS: 112 mg/dl
C/o itching, red rash . C/o chest BP: 110/80 mmHg
discomfort.
PR:- 98 bpm
↓
CVS:-S1, S2 +
Inj Avil 10 mg IV stat
R/S:- BAE +
Inj Hydrocort 100 mg IV stat
P/A :- Soft, NT
↓
CNS:- B/L pupils, NSRL
Resolved & stopped RDPs
Cutaneous Exam: Multiple discrete ill
defined hyperpigmented scaly plaque
patches with few are crusted + over Rt
thigh and lower back. Few ulcers are +
Day 4 Day 5 Day 6

No fresh complaints No fresh complaints No fresh complaints

O/E patient is c/c Pedal edema + Afebrile
Afebrile Afebrile BP: 110/70 mmHg
GRBS: 102 mg/dl GRBS: 112 mg/dl PR: 81 bpm
BP: 100/60 mmHg BP: 100/70 mmHg CVS:-S1, S2 +
PR: 86/min PR: 96 bpm R/S:- BAE +
CVS:-S1, S2 + CVS:-S1, S2 + P/A :- Soft, NT
R/S:- BAE +, fine basal crepts+ R/S:- BAE +, basal CNS:- B/L pupils, NSRL
P/A :- Soft, NT crepts+
CNS:- B/L pupils, NSRL P/A :- Soft, NT
CNS:- B/L pupils, NSRL
Lab investigations

Outside reports :-

Test Result Normal range

Haemoglobin 5.9 12-16 g/dl
WBC 4500 4.0-10 x 109/L
Platelets 18,000 150-350 x109/L
Total Bilirubin 7.4 0.3-1.2 mg/dl
• ANA – 58.5
• DSDNA- 113
• ANA blot ribosomal ‘p’ positive.
• DCT 4+
• Beta-2 glycoprotein +
• Anti-cardiolipin +
Test Result Normal range
22/4 23/4 25/4
Haemoglobin 4.9 g/dl 3.2 3.2 14-17 g/dl
WBC 2.7k 2.4k 2.4k 4.0-10 x 109/L
Platelets 14,000 10,000 10,000 150-350 x109/L
HCT 16.1% 10.9% - 36%-47%
MCV 96.4 fL 100 fL - 80-100 fL
MCH 29.3 pg 29.4 pg - 28-32 pg
MCHC 30.4 g/dl 29.4 g/dl - 32-36 g/dl
PT 15 sec 18 sec - 11-13 sec
INR 1 1.5 - 1.1 or below
T4 - 2.7 2.9 6.09-12.23 µg/dl
TSH - 1.64 2.85 0.34-5.60 µIU/ml
Ferritin - - 715.2 10-291 ng/ml

OTHER INVESTIGATIONS:
➢ ECG- Normal
Test Result Normal range
22/4 23/4 25/4 26/4
Total Bilirubin 1.98 2.58 2.02 2.78 0.3-1.2 mg/dl
AST 5 6.19 4.43 4.54 0-35 units/L
ALT 11 9.20 6.55 5.52 0-35 units/L
ALP 86 59.29 47.25 41.91 36-92 U/L
Na 138 132 - 141 135-145 mEq/L
K 5.4 4.80 - 3.25 3.5-5 mEq/L
Cl 114 106.7 - 115 95-105 mEq/L
Sr. creatinine 0.92 1.06 - 0.6-1.2 mg/dl
BUN 42 - - 8-20 mg/dl
Urea 89.8 94 75.0 51.6 15-40 mg/dl
TP 3.75 3.65 3.8 6-7.8 g/dl
Albumin 1.71 1.60 1.90 3.5-5.5 g/dl
LDH 147 123.6 - <130 mg/dl
ASSESSMENT

Provisional Diagnosis:
38 years female p/w AFI 2° to SLE with APLA syndrome with autoimmune
hemolytic anemia with rt radial artery thromboses with pancytopenia with
hyperkalemia with sepsis (recovered).

Final Diagnosis:
K/C/O SLE with AIHA with APS with radial artery thromboses. P/w pancytopenia
with Anasarca 2° to hypoalbuminemia with herpes zoster (resolving).
 Treatment

Drug Generic name Indication Dose Freq Roa Days

INJ IVIG IV IG AIHA 2g/kg OD IV 1 day

Tab Cyclosporine Cyclosporine Immunosuppres 50 mg BD PO 1 day

sant

Tab pan Pantoprazole PPI 40 mg OD PO 2 days

Tab zofer Ondansetron Anti-emetic 4 mg BD PO 6 days

INJ Ca+2 gluconate Ca+2 Hypocalcemia 1 amp in 100 stat IV 1 day

gluconate ml
INJ R insulin Regular insulin Hypoglycemia 15 u in 25% D Stat IV 1 day
Drug Generic Indication Dose Freq Roa Days
name
Neb with Salbutamol Bronchodilator - QID IN 1 day
Asthalin
INJ piptaz Piperacillin Antibiotic 4.5 gm- L.D TID IV 4 days
tazobactam 2.25 g- M.D
INJ Albumin Albumin Hypoalbuminemia 100 ml OD IV 4 days
20%
Tab Acyclovir Anti-viral 400 mg 6th PO 4 days
Acyclovir hourly
Calamine Calamine Skin protectant - - E/A 4 days
lotion
INJ rantac Ranitidine H2 receptor 2cc BD IV 4 days
antagaonist
3 RDP’s transfusion

1 whole blood transfusion- 4th day (350 ml)

IVF- 1 NS, 1 RL @75 cc/hr for 4 days

Plan

• To start steroids and IVIG

• 1 whole blood transfusion
• Inj Piptaz 2.25 ML IV TID
• Inj Human albumin 20% 100 ml
• TAB acyclovir 400 mg PO 6th hourly
• Inj Rantac 2cc IV BD
• Inj Zofer 4 mg IV BD
• Monitor vitals
Pharmacist intervention

 DRUG-DRUG INTERACTIONS:
No interactions were found.
 ADVERSE DRUG REACTIONS:
• Reaction to RDP transfusion- Itching, red rash and chest discomfort.
• Inj Avil 10 mg IV stat given
• Inj Hydrocort 100 mg IV stat given
(Resolved)
Patient counselling

• Follow a balanced diet rich in iron, vitamins, and nutrients to support

recovery from anemia and maintain overall health.
• Limit activities that may increase the risk of bleeding or injury.
• Stay hydrated.
• Practice good hand hygiene to prevent infections, especially while
recovering from herpes zoster.
• Avoid close contact with individuals who have active infections, and
consider wearing a mask in crowded or high-risk settings.
• Take all prescribed medications as directed by your doctor.
• Keep a record of any symptoms, changes in condition, or side effects from
medications, and report them without any delay.