Case 78 – Update 1

Thank for all the suggestions so far. We followed your advice and the lady has had her surgery postponed and we have established the following:

History:

  • Chronic anaemia since 2011 stable at around 90.
  • No history of bleeding/Malena
  • No weight loss
  • No night sweats
  • Neutropenia since Jan 2016, progressive but no history of infections.
  • RA diagnosed thirty years ago following birth of third child previously on Methotrexate, stopped at patient request as stable for several years.
  • PMHx: Hypertension, Previous gastric ulcer secondary to NSAIDs 20 years ago, Rheumatoid arthritis with previous knuckle replacements 20 years ago and a previous left hip replacement 10 years ago.
  • Medications: Amlodipine for hypertension and Co-codamol for hip.
  • No alcohol intake
  • Non-smoker

Examination:

  • No features of acute joint inflammation noted however she has rheumatoid nodules at elbows and deformity of hands due to previous failed knuckle replacements for rheumatoid arthritis of hands (see pictures).
  • Noted to have spleen tip palpable on examination
  • No lymphadenopathy

Investigations:

  • Normal B12/folate
  • Serum Ferritin 500
  • Imunoglobulin screen Normsl and Normal SFLC Ratio
  • HIV/Hepatiitis screen – negative
  • Rheumatoid factor positive and Anti CCP antibodies positive
  • CRP 30
  • ESR 50
  • Negative DAT, Normal LDH, Normal Haptoglobins and Retic count
  • Normal LFTs and Renal function
  • Film: Re-reviewed noted to have many large lymphocytes some with granulation – sample sent for flow cytometry.
  • USS confirms mild splenomegaly

 

What is the possible diagnosis in this case?

Is the history of Rheumatoid arthritis relevant to the case? – if so how?

What flow results may you expect given the possible diagnosis? 

 

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