CPC Immunology Department October 28 th 2009. 14 year old male Case history. JG, 14 year old male...
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Transcript of CPC Immunology Department October 28 th 2009. 14 year old male Case history. JG, 14 year old male...
![Page 1: CPC Immunology Department October 28 th 2009. 14 year old male Case history. JG, 14 year old male Intermittent diarrhoea x 3 years Occasional abdominal.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e5c5503460f94b53e95/html5/thumbnails/1.jpg)
CPC
Immunology Department
October 28th 2009
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14 year old male Case history. JG, 14 year old male Intermittent diarrhoea x 3 years Occasional abdominal pain Mild abdominal distension Fatigue, arthralgia
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PHOTOGRAPH OF PATIENT
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Clinical history (continued) Past history – well until 11 years old
Family history – mother has
rheumatoid arthritis; aunt is hypothyroid
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Physical examination Examination – Thin; weight – 6 stone (38 kg); height – 4
feet, 10 inches (147 cm) Pre-pubertal Pale facies; pulse 85/min, regular; chest clear Abdomen – mild distension, slight tenderness Joints – no synovitis; Skin – no rashes
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Early blood test results Hgb – 9g/dl; MCV – 75fl WCC – 11 x 109/l; platelets 500 x 109/l ESR – 45mm/hr; CRP 80 mg/l Albumin 28g/l; GGT 93 IU/l; Alk phos. –
140 IU/l Urea, creatinine, electrolytes normal
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Further blood test results Complement levels – C3 – 80 g/l; (normal); C4 – 12
g/l (normal 0.16 – 0.70) Immunoglobulins – IgG – 18g/l; IgM – 2g/l; IgA <
0.05 g/l ANA +, titre 320; Smooth muscle antibody +, titre
80 ANCA +, perinuclear pattern, titre 80 Gliadin antibodies +, 30 units (normal range < 5
units)
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Discussion issues
What additional information would you like to have about the patient’s history?
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Discussion issues
What further physical findings would you look for?
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Discussion issues
What further diagnostic tests should be considered?
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Discussion issues
How would you interpret the above findings? What would you include in the differential diagnosis? What early investigations are warranted? What specific tests would you perform?
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Coeliac disease
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Endomysial antibody test
> 99% specific for coeliac disease
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Dermatitis Herpetiformis
Found in occasional patients with coeliac disease
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Inflammatory bowel disease
Crohn’s disease Ulcerative colitis
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Small bowel barium studies
Crohn’s disease -stricture of terminal ileum
Coeliac disease“coin stacking”
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Crohn’s - endoscopy
Normal small bowel Crohn’s small bowel with linear ulcers
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Crohn’s histology
Classic granulomatous inflammation
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Capsule endoscopy – Crohn’s
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Outcome in patient JG 1. This patient was incorrectly diagnosed
with coeliac disease, on the basis of raised gliadin antibodies, a non-specific test for coeliac disease
He failed to improve on a gluten free diet
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Outcome in patient JG 2. A barium follow through examination
showed narrowing of the terminal ileum This was resected and Crohn’s
pathology confirmed He has had several further resections
and now has a short bowel syndrome