We report a female patient presenting with headache, fatigue, ecchymoses and recent, excessive vaginal bleeding. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia. Thrombotic thrombocytopenic purpura (TTP) was suspected. Plasma exchange and corticosteroids were started urgently. The patient responded favourably to the treatment. Subsequently, positive serological markers returned and were compatible with systemic lupus erythematosus (SLE). A disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13 (ADAMTS 13) activity was remarkably low with a positive inhibitory ADAMTS 13 antibody. Mycophenolate and hydroxychloroquine were started along with a prolonged course and taper of corticosteroids. These medications have been maintained with an excellent response in 14 months of follow-up.
Objective: To discuss the case of a woman and her father with autosomal dominant hypocalcemia (ADH), a rare disorder caused by an activating mutation of the calcium-sensing receptor (CaSR). Methods: Previous ADH case reports were obtained by Medline search and from an updated CaSR database. Results: A 37-year-old female presented with intermittent leg cramps and hypocalcemia. Her father had been previously diagnosed with asymptomatic hypocalcemia at age 54. Genetic analysis in both individuals revealed identical missense mutations in nucleotide c.2489G>A that resulted in a glycine to aspartic acid change at codon 830 (G830D) in the CaSR. Conclusion: The same mutation of the CaSR gene was identified in a woman and her father. This warrants the need for genetic testing in adults with mild hypocalcemia and a family history of hypocalcemia.
Objective: To evaluate the discordance between blood glucose and hemoglobin A1c (HbA1c) levels in a patient with hemoglobin (Hb) Leiden and type 2 diabetes.Methods: Case report. Results: Measurement of HbA1c levels by immunoturbidimetric assay and boronate affinity high-performance liquid chromatography revealed values of 4.6 (26.8 mmol/ mol) and 4.8% (29.0 mmol/mol), respectively, while his fasting plasma glucose was 170 mg/dL and fructosamine was 345 mmol/L. Hb Leiden accounted for 27% of total hemoglobin, and the patient had splenomegaly and elevated hemolytic indices.Conclusion: The discrepancy between normal HbA1c and high blood sugar levels is attributed to chronic hemolysis. Treatment and monitoring options for this patient's diabetes and diabetes-related comorbid conditions will require careful management. (AACE Clinical Case Rep. 2016;2:e307-e310) Abbreviations: FPG = fasting plasma glucose; Hb = hemoglobin; HbA1c = hemoglobin A1c; RBC = red blood cell; SMBG = self-monitoring of blood glucose e308 Hb Leiden and Glycemic Assessment, AACE Clinical Case Rep. 2016;2(No. 4)
Cancer Control 233 guidelines 9 and deemed to be an intermediate risk with regard to recurrence as defined by the National Comprehensive Cancer Network and the American Urologic Association (AUA). 10,11 Treatment options, including radical prostatectomy, external beam radiation therapy, and interstitial brachytherapy, were discussed with the patient in detail. After he opted for external beam radiation therapy, the patient agreed to a treatment protocol inclusive of intensity-modulated radiation therapy (IMRT) and the prerequisite placement of gold fiducial markers. Thus, 3 months following prostatic biopsy, he was given an oral dose of 500 mg of levofloxacin prior to the transrectal ultrasound (TRUS)-guided placement of four gold fiducial markers within the prostate gland. He also received levofloxacin 500 mg daily by mouth for two days after the procedure. Two days following the placement of fiducial markers, he returned to our facility complaining of fever, nausea, and vomiting. He was also experiencing perineal discomfort, awakening chills, and malaise. He denied difficulty with voiding. On physical examination, the patient was febrile (101.8° F), exhibited regular tachycardia (125 beats per minute), was normotensive (140/78 mmHg), and was without tachypnea (20 breaths per minute). His abdomen was benign and the bladder was not palpable. No costovertebral angle tenderness was present. A gentle DRE demonstrated a firm, nontender prostate without masses. There was no gross blood in the rectal vault. Serological evaluation noted a slight leukocytosis (12,500 k/μL) with the differential noting a left shift. The patient was not anemic (16.6 g/dL), and he was slightly thrombocytopenic (86 k/μL). Urinalysis displayed yellow urine with a high specific gravity (1.080) consistent with dehydration, a normal pH (6.0), trace protein (30 mg/dL), negative nitrites, large leukocyte esterase, pyuria (51-100 white blood cells/ high-powered field), and trace bacteria consistent with an infectious process, and microscopic hematuria.
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