Question of the week # 310

310) A 28 year old man is admitted with abdominal pain and diarrhea of one day duration. Abdominal pain is diffuse in nature, mild to moderate and is associated with cramps and vomiting. He reports having had recurrent attacks of abdominal pain and diarrhea for several months. His past medical history is significant for Vitiligo and Hypothyroidism. He denies any allergies, atopy or Asthma. Family history is unremarkable. On examination, his mucous membranes and dry and he appears moderately dehydrated. He is afebrile, Blood pressure is 90/60 mm HG, heart rate 120/min, Respiratory rate 18/min. There is no peripheral lymphadenopathy. Skin examination reveals hypopigmented patches consistent with Vitiligo on his chest and the extremities. Abdominal examination is benign , Spleen is not palpable. CT scan of the chest, abdomen and pelvis are normal. Stool anlaysis performed several times during his previous episodes did not reveal any evidence of parasitic infection or leukocytes or blood. Laboratory investigations and peripheral smear are shown below:

WBC 6.0k/µl

Differential: Neutrophils 45%, Lymphocytes 34% ( N = 20 to 40%), Monocytes 6%, Eosinophils 15% ( normal range 1 to 4%)

Hemoglobin 14.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Stool Ova and Parasites negative

TSH 4 μIU/ml ( 0.3 – 5.0 uIU/ml)

Which of the following diagnoses is most likely explanation for the patient’s clinical presenation?

A) Giardiasis

B) Addison’s disease

C) Vitiligo

D) Chronic Myeloid Leukemia

E) Lymphoma

33 Responses

  1. confused with A and B…..giardiasis requires more than 3 stool samples to be ruled out other supporting feature is inc eosinophils low BP can be due to dehydration………but can be chronic diarrhoea due to addisons disease known to be associated with vitiligo low BP will support this eosinophillia may be just a autoimmunity feature…….

  2. most likely b ??

  3. he has various autoimmune disorders and vitiligo may point to Addisons

  4. b, many auto immune dz, low bp and de blood sample

  5. b0 wbc in stools normal.. most prob that will rule out giardiasis, also gas is common with giardiasis.. most prob this is Addison disease.. the only thing is that abdominal pain.. i am trying to identify the reason for it…

  6. its addisonian crisis..presence of ither autoimmune diseases along with the clinical picture points towards it…his serum electrolyte analysis would show hyponatremia and hyperkalemia..needs to be treated with intravenous steroids and appropriate fluids

  7. giardiasis

  8. may be also low grade lymphoma wich is MALT type … this kind of lymphoma affects the GIT and gives chronic GIT symptoms with no LAP nor splenomegaly .. Also MALT is asociated with Hashimotos thyroiditis ( Autoimmune ) .

  9. I dont think it is Addison’s disease as Addison is asociated with neutropenia and lymphocytosis .
    Lymphoma HL and NHL is asociated with eosinophilia

  10. E. Probably coeliac disease and related small intestinal lymphoma

  11. e

  12. B… The WBC’s present appear to be Eosinophils.

  13. addison disease

  14. I guess ‘A’

  15. eosinophilia with lymphocytosis, with hypotension, and abdominal pain in a patient with several autoimmune conditions (vitiligo and hypothyroidism) points to Addisonian crisis. No splenomegaly, no increase in myeloid cells in peripheral smear, no lymphadenopathy and no parasite in stool excludes CML/lymphoma and giardiasis, respectively.

  16. the answer is B) Addison’s disease ,as the patient has hypotension,abdominal cramps,vomiting,other autoimmune disorders as vitiligo, hypothyrodism refere to autoimmne pathogenesis of Addison’s disease in that patient

  17. bbb

  18. B) Addison’s disease

  19. ~B
    Addison’s disease

  20. B

  21. B

  22. Acute onset and increase of eosinophil are consistent with Giardiasis, i.e. A. Addison’s is a long-term disease that develops over months to years. Without chronic weakness, fatigue, anorexia, weight loss, and hyperpigmentation as the primary symptoms, the dx of B is a shot in the dark.

  23. Vignette says He reports having had recurrent attacks of abdominal pain and diarrhea for several months.
    So B??

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