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:
- 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
- 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
- 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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