Case presentation By Shimaa Gamal

Personal history: male patient named Abd-Elgawad Shokry Elsayed ,22 years old , from zefta ,student , single , no special habit of medical importance .

Complaint: Bleeding per gums 1 week ago. Bleeding per nose 5 days ago.

Present history: The condition started 1 week by gradual onset progressive coarse of bleeding per gums started with teeth brushing then gradually progressed to become spontaneous . 2 days later , he developed epistaxis associated with blood clots ,not preceded by trauma & was bilateral & painless .

The condition was associated with purpuric eruption. in L The condition was associated with purpuric eruption in L.Ls which was non raised , non painful , violacious , small sized skin rash . This condition was not associated with prior drug intake . The condition was associated with dyspnea of gradual onset , progressive course , increase with exertion , partially relieved by rest & associated with easy fatigability but he denied having orthopnea , PND or chest pain .

The patient saught medical advice at benha university hospitals at ED where ENT consultation was done & there was no local cause for epistaxis & packing was done then the patient was admitted to internal medicine department . No history of alopecia , malar photosensitivity . No history of arthralgia or arthritis . No history of abdominal pain or jaundice . No history suggesting DVT . No history of dysuria ,hematuria or dark urine. No history of motor , sensory , cranial nerve or sphencteric affection. No history suggesting swelling at anatomical sites of L.N. The patient is neither diabetic nor hypertensive .

past history: No history of operation ,no history of drug intake or blood transfusion No history of T.B or Bilharziasis. No history of allergies.

Family history: No similar condition in his family. -ve consanguinity.

Examination: Vital signs: Pt is cooperative , fully conscious ,lying flat in bed, oriented to time, place and persons. He looks ill . MMS 28/30 . Complexion : pallor. BMI:60/1.70 (20.8) Vital signs: Blood pressure: 110/70 mmHg in supine position in Rt arm. Pulse: 95 beat/min, regular, equal on both side, average volume, no special ch.ch ,peripheral pulsations are felt. RR: 16 cycle /min. Temperature: 39˚c by oral route.

Head & neck: pallor . Lt sided sub conjunctival hemorrhage . No cyanosis, no jaundice. No congested neck veins. No thyroid swelling. Trachea is central. No L.N enlargement.

Upper limb: Lower limb: Pallor. Bilateral ecchymotic patches which are variable in size ,dark blue in color ,non elevated ,non tender & associated with purpuric eruption small sized ,violacious in color ,non elevated ,non tender . No clubbing , no cyanosis . No deformity. Lower limb: Ecchymotic patches & purperic eruption as discribed in upper limbs. No signs of DVT ,no edema ,no clubbing. No L.N enlargment.

Chest examination Inspection: Palpation: Symmetrical. No scars, No pigmentation. No dilated veins. No sternal tenderness. Palpation: Trachea is central. No tenderness. Normal TVF

Percussion: Auscultation: No dullness . Upper border of liver at 5th intercostal space MCL Auscultation: Fair and equal air entery , No additional sounds.

Cardiac examination Inspection &palpation: Apex at lt 5th intercostal space MCL. No pulsations are felt. Percussion: No dullness outside apex, pulmonary , aortic areas Auscultation: accentuated heart sounds , no additional sound, no murmur.

Abdominal examination Inspection: No scars, No pigmentation Normal abdominal contour Umbilicus is inverted Normal subcostal angle No divercation of recti No visible vessels or masses No pigmentation or scratching marks. Palpation: No tenderness or rebound tenderness. No organomegally. Percussion: No ascites.

Neurological examination: Free . Locomotor systym examination: Free.

Investigations CBC Hb: 6.7gm/dl MCV: 90FL MCH: 30pg WBCs: 2200 ( neutrophils : 500 , lymphocytes :1500 ) PLT: zero (manual count 1000) ESR: 150 mm/h RBS: 103

S.creatinine: 1.2 mg/dl Bl. Urea: 32 S.Na: 139 meq/dl s.k: 3.8 meq/dl s.albumin: 3.7 PT:13.9 PTT:41 INR: 1 ALT: 22 AST: 26 CMV Igm : -ve EBV Igm : -ve Hebatitis markers : -ve

Blood film : RBC`s : normocytic normochromic anemia. WBC`s: leucopenia with severe neutropenia & relative lymphocytosis. platelet: severe thrombocytopenia. No blasts could be seen.

Bone marrow : hypo cellularity of all series A picture suggestive of aplastic anemia

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