Mr. BANGUOE Thierry Lothaire, 68 years old, consulted for asthenia, anorexia, unexplained weight loss, abdominal pain, redness of the palms. Clinical examination revealed hepatomegaly, splenomegaly with palpable liver, hard consistency with irregular lower border, conjunctival and cutaneous jaundice, palmar erythema predominantly on the upper part of the thorax, white nails and stellate angiomas, ascites. He weighs 48 kg. His blood pressure is 220/140.
The biological workup prescribed is as follows: CBC, AST, ALT, GGT, alkaline phosphatases, bilirubin Prothrombin rate (or INR), blood ionogram, creatinine, urea, fasting blood glucose, Cholesterol, triglycerides, LDL and HDL Cholesterol, protein electrophoresis, serum iron, transferrin saturation coefficient, ferritin, mycobacteriology examination of an ascites puncture, CRP, HBV5, HVC antibodies.
1. Define the terms used to describe the symptoms and clinical signs.
2. What is the biological significance of each of these tests?
3. Justify the biological prescription in view of the symptoms and clinical signs (Why did the consultant order these tests, establish the link between the biological tests and the symptoms + clinical signs)
4. What are the sampling conditions? Which sampling tubes do you use? What is the order of filling the tubes?
The results in the laboratory are:
CBC
Erythrocytes: 2 970 000/mm3
Hemoglobin: 8.8 g/dl
Hematocrit: 31 L/L
Reticulocytes: 55×109/l
Leukocytes: 14,8×109/l
Platelets: 33×109/l
Poly. Neutrophils: 21
Poly. Eosinophils: 02
Poly. Basophils: 01
Lymphocytes: 54
Monocytes: 22%.
Microscopic examination of the MGG-stained blood smear reveals the following morphological abnormalities: anisocytosis, poikilocytosis, microcytosis, hypochromia.
Prothrombin level 31% INR 4.3
Blood biochemistry
AST: 890 IU/L
ALAT: 1144 IU/L
GGT 300 IU/L
Alkaline phosphatase: 403 IU/L
Total bilirubin: 153 mg/L
Conjugated bilirubin: 34 mg/L
Natremia: 125 mmol/L
Kalemia: 4.5 mmol/L
Chloremia: 95 mmol/L
Creatinine: 12 mg/L
Urea: 6 g/L
Fasting blood glucose: 1.07 g/L
Cholesterol: 1.4 g/L
Triglycerides: 1.30 g/L
LDL cholesterol: 0.88 g/L
HDL cholesterol: 0.27 g/L
Serum iron: 50 µg/dl
Ferritin: 10 ng/mL
Transferrin saturation coefficient: 13
Protein electrophoresis on cellulose acetate strip
Bacteriology of ascites fluid
Macroscopic appearance: cloudy liquid
Biochemical study: protein level 8 g/l .
Cytological study:
– 1080 leukocytes mm3 with 90% neutrophils 10% lymphocytes
– 120 red blood cells / mm3
– Absence of yeast-like elements
Examination after Gram staining: Presence of a large number of Gram-negative bacilli, absence of spores.
Cultures, after 24 hours of incubation at 37°c aerobic :
Negative culture on Chapman,
Positive on :
1. Sabouraud
2. Blood agar
3. EMB
4. Negative Lowenstein – Jensen culture after 6 weeks in micro aerophilic atmosphere
Serology
CRP determination < 6 mg/L
Anti-HCV antibody test: negative
Search for viral hepatitis B markers:
– Hbs Ag test: negative
– Anti-Hbs Ac test: negative
– Hbe Ag test: negative
– Anti-HbAb test: negative
– Total anti-Hbc assay: positive
Pathological anatomy
Anatomocytopathology results show bands of fibrosis, of variable thickness, forming nodules with destruction of the normal lobular architecture
Liver biopsy after Sirius Red staining
5. Calculate erythrocyte constants
6. Calculate leukocytes in absolute values
7. Interpret the CBC results
8. What is the relationship between prothrombin time and prothrombin level? How do you convert from one to the other?
9. What is the INR?
10. Interpret the PT result
11. Calculate free bilirubin
12. Calculate atherogenicity indices
13. What does the presence of a beta-gamma block on protein electrophoresis indicate? What is its mechanism of appearance?
14. Interpret each of the biochemistry results
15. Observe the culture media
16. What is the purpose of the Lowenstein – Jensen medium
17. What can explain the positive culture on Sabouraud?
18. Interpret the results of Bacteriology.
19. What is the most likely bacterium?
20. What is the mechanism of onset of ascites?
21. Interpret the serology results
22. What does the isolated presence of anti-Hbc antibodies indicate?
23. Interpret the results of pathological anatomy
24. What is the most likely pathology? Explain your choice
25. Explain the biological parameters disturbed in relation to the pathology found
26. Calculate the severity scores of this pathology (MELD score, CHILD-PUGH score)
27. To avoid biopsy, which is an invasive method, what other tests would you suggest?
28. The fibrotest result is 0.64 and the actite result 0.62. What can you conclude?
29. Are these results consistent with each other? Argue
30. What advice do you give the consultant?
