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Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

A 78 year old lady is admitted for investigation of watery diarrhoea and weight loss of 6 kg since last 5 months. In the last one month she developed peripheral edema and SOB on minimal exertion.

O/E--- Pale, puffy eyelids, glossitis+

Temp---38.3degs celsius.

pulse---90bpm,regular.

BP---126/84mmHg.

B/L pedal edema++, ascitis+, B/L pleural effusion+.

Flexible sigmoidoscopy---normal.

Upper GI scopy----Normal.

Duodenal biopsy--- subtotal villous atrophy.

No rsponse to gluten-free diet, corticosteroids and nutritional supplements.

Hb----------------------9.4g/dl.

WCC-------------------7.6 x 109/l

PLt---------------------247 x 109/l

MCV----------------------87fl.

CRP----------------------6mg/l

folate-------------------9.4nmol/l

Vit B12-----------------105pmol/l

ferritin----------------64microgram/l

Na----------------------133mmol/l

K----------------------4.7mmol/l

Urea------------------3.9mmol/l

Creatinine-------------73micromol/l

Bilirubin---------------17micromol/l

Alb----------------------18g/l

globulin------------------26g/l

ALT---------------------37u/l

ALP-------------------143u/l

Ca---------------------2.3mmol/l

TSH-------------------0.44mU/l

Urinalyis-------------Normal

ECG--------------------normal

CXR-------------------B/L pleural effusions.

ECHO---------------good LV function.

USG abd---------------ascites, no organomegaly.

Stool culture------------negative.

Auto-ab--- anti-gliadin,anti-endomysial,anti parietal, Intrinsic factor---ALL NEGATIVE.

What is the diagnois?

Bye,
Jerry.

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

This is a really odd question since it is giving very little clues.In exam I would choose lymphoma.The patient manifests hypoalbouminemia which resulted in oedema,puffy eyelids , bilateral pleural effusions and ascites as well.The patient also manifests fever which could be a systemic symptom of a lymphoma,and not enlarged spleen or liver which is common in a diffuse small bowel lymphoma.Duodenal biopsy revealed subtotal villous atrophy,which also can be a result of lymphoma.Finally we can rule out whipple disease since not PAS positive bodies were found and nephrotic syndrom because urine analysis is normal.Of course we can also rule out not tropical sprue because of abscence of antigliadin antibodies,no improvement with gluten free diet etc.
Glossitis is due to anemia because of low B12 although MCV is not increased.Anemia is also not due to iron defficiency since ferritin is normal.
Jerry,once more thank you.I couldnt find the book you said.Could you please tell me the publisher?

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

it is protein loosing entopathy ferritin is inflammatory and can not depend here the border folate and the lower B12 can cause macrocytosis bec.of iron def.giving normal mcv now let's come to the real problem the protein loss can be explained be lymphangeictasia caused by secondary lymphoma thats whyno organomegaly which is amust for the diagnosis of primary intestinal lym.adding to this the dud.biopsywith villous atrophy....int. lymphoma affects the distal intestine..the illium more than juj. an dud.as acause of villous atrophy without lamnia propria infiltration of lymphocytes what I want to say it is coeliac complicated by secondary lymphoma which is one of the causes of diarrhoea not responding to gluten free diet what I can not explain the -ev ab profile may be due to the severe protein loss or lymphoma itself thnk u verry much jerry still the bes to this dying forum

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

agree it is protein loosing enteropathy. though lymphoma can present like that and question offers less clues to differentiate. but intresting question. makes you think a bit. endomyseal antibodies may still be found in coeliacs complicated by lymphoma. partial villous atrophy can be associated with many other conditions too! here again there may be no improvement on gluten free diet. your opinion appreciated.
thanks for trying to resuscitate this forum in refractory asystole!!
good luck, take care!

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

The answer is lymphoma of small bowel with protein losing enteropathy.

Increased protein loss compared to synthesis causes hypoalbuminemia. The commonest presenting complaint is peripheral edema,coz of hypoalbuminemia.

Now... protein losing enteropathy can b caused by:

1. Mucosal damage--Ex. IBD, Ca Stomach, Pseudomembranous colitis, Coeliac disease, Whipple's,Amyloidosis.............

2. Lymphatic obstruction---Ex. CCF, Constrictive pericarditis, Lymphoma, TB, Sarcoid,.................

Protein losing enteropathy is demonstrated by:

I/V radio-labelled albumin studies.

Stool alpha-1 antitrypsin studies.

I am sorry that i dont know the publisher of the book that i last quoted...coz i got a copy of it from the library where the initial pages were torn off or not xeroxed by some well-wisher... anyway.. i will let u know as soon as i can lay my hands n the book again....this is Ramadam season and the library too has inconvenient timings.....

Bye and take care,
Jerry.

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

Well age of the patient and absence of visceromegaly is against primary intestinal lymphoma which present in 20's and 30's.
It can be Enteropathy associated T Cell Lymhpoma(ass with celiac) which presents in old age and many pts do not have H/O celiac B4.Howver negative autoAbs r difficult to explain unless the pt has concomitant IgA deficiency.
Another possibility is Mantle Cell Lymhoma.
Other D/D may include Giardiasis which can cause villous atrophy and malabsorption.

Well S/Ca is high considering degree of hypoalbuminemia? ?

I am planning to be more active during the coming days.The best way to enliven the forum is for all to contribute Qs and not to wait for Jerry.
I'll soon start posting Qs.
But have to say that if there r only few contributing Qs,things will not improve

Guest · Credits: 79379 My Scrapbook My Reading List 262569 Books

Jerry thanks a lot.I will really appreciate that.
Wellcome back an.As a matter of fact the new forum doesnt inspire me much,but if you start discussing qs I will also try to contribute a couple of interesting ones I remember. 8)

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