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A 48 Year Old Male with Jaundice and Exertional Chest Pain Mohammad Mizanur Rahman, Md

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A 48 Year Old Male with Jaundice and Exertional Chest Pain Mohammad Mizanur Rahman, Md | Case Presentation | No. 03-2017 | A 48 year old male with jaundice and exertional chest pain Mohammad Mizanur Rahman, Md. Monirul Islam, Susane Giti, Mimi Parvin, Arif Ahmed Khan and Debashish Saha Article Info Presentation of Case cardiac centre of a tertiary care military hospital, Dhaka on 4th May, 2017. The attending Departet of Heatolog, Ared Dr. Md. Monirul Islam: A 48 year old male atten- physician took detailed history of the patient, re Fores Istitute of Patholog, Dhaka Catoet, Dhaka, Bagladesh MMR, ded the cardiac outpatient department with the -examined and evaluated the results of all MMI; Departet of Patholog, Co- complaints of chest pain on exertion. Two years investigations so far done. Here, the history ied Militar Hospital, Chittagog, back, he developed chest pain on exertion. The also unveiled that he is a smoker, taking indige- Bagladesh SG; Departet of Chei- pain was retrosternal, dull in nature, non- nous cigarettes (Biri), about 10 sticks per day, al Patholog, Ared Fores Istitute of Patholog, Dhaka Catoet, Dhaka, radiating, aggravated on exertion and relieved non-diabetic and also suffering from the peptic Bagladesh MP, DS; Departet of by rest. There was no relation with food intake ulcer disease for which he is regularly taking H2 Miroiolog, Ared Fores Istitute of and not relieved by taking H2 blocker. The blocker and also had family history of coronary Patholog, Dhaka Catoet, Dhaka, patient was a known case of hypertension for artery disease. On general examination, all Bagladesh AAK the last 10 years. He was on antihypertensive parameters were within normal limits inclu- medication and his blood pressure was ding blood pressure (130/60 mm Hg) except controlled with therapy. There was no history mild anemia and jaundice. Systemic examina- of respiratory distress and cough. With these tion revealed no abnormality. He also advised For Correspondene: Mohaad Mizaur Raha complaints, he at first attended to a nearby to repeat all previous investigations including [email protected] Government medical college hospital in Barisal coronary angiogram and requested to do some (South central division of Bangladesh). In that more additional investigations such as peri- Reeied: Septeer hospital, the patient was diagnosed as coronary pheral blood film examination, reticulocyte Aepted: Otoer Aailale Olie: Noeer artery disease after performing first line investi- count, hemoglobin electrophoresis and renal gations and referred to the capital city for function tests including eGFR as well as thyroid further evaluation and management. function tests to resolve the problem of hyper- ISSN: - Olie bilirubinemia as well as to see the anesthetic - Prit In a private clinic in Dhaka, he underwent nece- and operation fitness. On the basis of history, ssary routine and special investigations inclu- DOI: ./suj.i. physical findings and results of previous inves- ding full blood count, random blood sugar, tigations carried out in a private clinic. The liver function tests, hepatitis viral profile (anti- attending cardiac surgeon made the provisional HAV, anti-HEV, HBsAg, anti-HCV, anti- HIV, diagnosis. coagulation testing such as bleeding time, Cite this artile: Raha MM, Isla MM, Giti S, Pari clotting time, prothrombin time and activated M, Kha AA, Saha D. A ears old ale partial thromboplastin time, VDRL, TPHA, X- ith jaudie ad eertioal hest pai. ray chest and KUB region, ultrasonogram of Provisional Diagnosis Bagaadhu Sheikh Muji Med Ui J. whole abdomen and coronary angiogram. ; : -. Double vessel coronary artery disease with Results of all investigations revealed mildly hyperbilirubinemia reduced hemoglobin (11.0 g/dL) and mildly Copyright: raised serum bilirubin (3.4 mg/dL). Coronary The opright of this artile is retaited angiogram detected double vessel coronary - the authors [Atriutio CC B .] artery disease. After analyzing the history, Differential Diagnosis clinical findings and the results of all investi- Dr. Mohammad Mizanur Rahman: This patient Availale at: gation, the patient was diagnosed as a case of reported to the hospital for a problem related to .aglajol.ifo double vessel coronary artery disease with mild cardiovascular system and after investigations, jaundice. As the prime problem of the patient A Joural of Bagaadhu Sheikh Muji his diagnosis was almost confirmed as double was related to the cardiovascular system, so the Medial Uiersit, Dhaka, Bagladesh vessel coronary artery disease. But mild hyper- treating physician focused on double vessel bilirubinemia with mild anemia in this patient coronary artery disease and decided to perform indicated the presence of a second pathology coronary artery bypass graft operation. other than the liver disease and was taken into The brother in law of the patient has been consideration for differential diagnosis in this serving in Bangladesh Military, so the patient is present case presentation. Therefore, I would entitled to get treatment in military hospital. like to focus on the following differential Therefore, the patient got admitted into the diagnoses related to mild hyperbilirubinemia 228 BSMMU J 2017; 10: 227-233 with mild anemia. Palestinians and people of Palestinian descent and Asians. In the world, the incidence of beta globin Chronic Malaria chain defect with a carrier rate of 18% of the The history of man and malaria is thought to be population in Maldives is found and the evaluated educed together. A number of genetic conditions frequency is 15% in people from Cyprus, 1% in such as hemoglobin C and red cell Duffy negativity Thailand and 3–7% in populations from Bangla- provide some form of defense or resistance to desh, China, India, Malaysia and Pakistan.9 Plasmodium falciparum and P. vivax respectively and Symptoms of beta thalassemia can vary and may be these conditions are more prevalent in West Africa completely asymptomatic to the signs and symp- and West and Central Africa indicating the original toms of mild anemia (e.g., feeling tired and pale root of malaria in these regions.1 skin) as well as mild jaundice and dark urine. Individuals with beta thalassemia minor may have It is difficult to define chronic malaria as there is some shield against malaria and such phenomenon differences of opinion about its definition. How- explains its high incidence in areas of the world ever, in semi-immune individuals without fever or where plasmodium infections exist.10 Beta thalasse- any other symptoms pertaining to malaria persis- mia heterozygosity is associated with a reduced risk ting for a considerable period may be the features of against advanced coronary artery disease. Indivi- chronic malaria but some authors argues that duals with beta thalassemia have such lipoproteins asymptomatic or chronic malaria does not exist.2, 3 and blood rheology profile that may be the under- Chronic presence of malarial parasites is the cause lying causes of this safeguard effect.11 There is a of mild hemolysis leading to asymptomatic anemia possibility of this patient is being thalassemic as and inclines the affected individuals to other mild anemia and jaundice are present but early infections.4 Patient with malaria may present with development of coronary artery disease is against mild jaundice which is frequently missed clinically. heterozygous beta thalassemia because it has mild Such jaundice is quite common and may be protective effect against coronary artery disease. detected in 20–40% of the cases. Severe P. falciparum malaria is usually associated with deeper jaundice This patient, presented with mild anemia and and serum bilirubin level may be more than 3 mg/ jaundice, favors the diagnosis of inherited hemo- dL and is consociated with anemia, hyperparasite- lytic anemia that may be hemoglobin, red cell mia and malarial hepatitis with elevated serum membrane or enzyme disorders. But age of the enzymes. In all cases of mild jaundice, malaria must patient and absent family history of inherited be considered as a differential diagnosis, preferably hemolytic disorders are the possible points against in a malarious zone.5 In this patient, mild anemia the diagnosis of inherited hemolytic anemia. and jaundice favor the diagnosis of chronic malaria but absence of splenomegaly, previous history of Hemoglobin E: A single point mutation in beta () malaria and residing in non-malarious zone are globin chain at position 26 causing substitution of against the diagnosis of malaria. glutamic acid to lysine results in the formation of an abnormal hemoglobin called HbE. HbE is most Inherited Hemolytic Anemias prevalent among peoples of South Asian countries 12 Mild hyperbilirubinemia is caused by an increased including Bangladesh. Among hemoglobin- rate of hemolysis. The prime cause of unconjugated pathies and thalassemias, HbE is in the second hyperbilirubinemia is the escalated red blood cell position in terms of its frequency among hemo- destruction and accumulation of such bilirubin into globin disorders in the world and also common in 13 various tissues can lead to yellowish or jaundiced Bangladesh. HbE is the most common in mainland appearance. Certain genetic red cell disorders, such Southeast Asia (Thailand, Myanmar, Cambodia, as thalassemia and hemoglobinopathies, spherocy- Laos and Vietnam). In Northeast India, the carrier tosis as well as red cell enzyme defects like pyru- rate of HbE reach approximately 60% of the vate kinase and glucose 6-phosphate dehydroge- population. Its incidence is also very high in 14 nase deficiency can lead to mild hyperbilirubine- Bangladesh.
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