case presentation renal vein thrombosis in IBD

cpr

1. Case Presentation and Review of Literature By - Dr Mohit Bhardwaj ( UNIT 4 )

2. Patient Profile Mrs Shabeena 23 year , female Resident of Bilaspur Homemaker

3. Chief Complaints : (Presented on 22/06/24) Fever } 1.5 month documented upto 101 F , once every 2-3 days , not associated with chills and rigor Pain abdomen } 2 weeks diffuse , intermittent , colicky , no exagarrating and relieving factor loss of weight I/f/O loosening of clothes loss of apetite

4. history of passage varying consistency of stool ranging from watery for few days to semisolid to normal with normal frequency from 1.5 month last episode of 2-3 episode loose stools for 2 days 10 days back No history of blood and mucus in stool , tenismus , vomiting No history of cough with or without sputum , night sweats No history of distension abdomen No history of abnormal urinary habits

5. PERSONAL HISTORY Married , Homemaker , Consumes mixed diet , Studied till 12 th Past History No Relevant Past history Family History No Relevant Family history

6. Obstetric and Menstrual History Married for 2 months LMP : 7/6/24 PMC : Regular , 2-5 days , moderate flow , associated with dysmennorhea UPT : NEGATIVE

7. Treatment History Patient went to medical college mandi 1 week back where she was advised blood test and some medication but no improvement and patient did not follow up .

8. GENERAL PHYSICAL EXAMINATION Calm , concious , cooperative oriented to time place person VITALS } BP 112/76 Pallor Pulse 96bpm Icterus SpO2 95% @ RA Cyanosis RR 18 / min Clubbing RBS 102 mg /dl JVP BMI : 21 .8 LAP no signs of dehydration Pedal edema

9. Per Abdomen Uniformly distended All quadrants moving equally with respiration Umbilicus central and inverted Soft No guarding no rigidity no tenderness Liver edge not palpable Spleen not palpable No shifting dullness Bowel Sounds present

10. CVS Precordium Normal S1 S2 Normal intensity no added sounds

11. Respiratory System Bilateral Vesicular breath sounds No Crept s No Rhonchi

12. Nervous system HMF WNL CN WNL SPEECH WNL SENSORY WNL MOTOR WNL B/L PLANTAR DOWN

13. 69 bpm , normal axis , no significant st and t wave changes , QTc 408 msec , PR 126 msec ECG

14. CXR

15. 09/06/23 Hb 7.1 MCV / RDW 70/25 TLC 7600 DLC N/L 72/18 Platelet 4,67,000 ESR 46 QCRP 38 UREA 17 CREAT 1 .6 Bilirubin T/C 0.20/0.10 ALT 14 AST 12 ALP 42 Protein T/A 5.2 / 2.5 S. Na 138 S. K 3.81

16. Investigation Value S. Cl 101 HIV NR HCV NR HBSAG NR

17. Day 1 Pyrexia constitutional symptoms with Anemia Microcytic Hypochromic with AKI EGFR 46 ML / MIN / 1.73 M2 ? Vasculitis ? Tuberculosis ? Inflammatory bowel Disease

18. PLAN Anemia workup : Chg with P/S with retic count Iron Studies S.B12 stool for occult blood ICT/DCT S. LDH URINE ROUTINE URINE CULTURE , URINE FOR CASTS

19. C ANCA P ANCA STOOL ROUTINE STOOL CALPROTECTION USG ABDOMEN , KUB , PELVIC ORGAN S calcium , magnesium MOUNTOUX TEST

20. TREATMENT INJ Ceftriaxone 2 gm iv BD Tab Metronidazole 400mg tds TAB Albendazole 400 MG STAT TAB Paracetamol 500 mg sos inj buscopan i /m sos plenty of fluids

21. USG ABDOMEN KUB PLUS PELVIS Normal Study S B12 236 PG/ML IRON FERRITIN TIBC 65 UG/DL 38 NG/ML 247 SVIT D 8.1 NG/ML P/S DIMORPHIC MICROCYTIC HYPOCHROMIC ANISOCYTOSIS + MACROCYTES + STOOL FOR OCCULT BLOOD POSITIVE STOOL ROUTINE 30-40 PUS CELL /HPF STOOL CALPROTECTIN > 800 UG/G Calcium magnesium 9.1 mg/dl 2.8 mg/dl ICT/DCT NEGATIVE URINE ROUTINE WNL LDH 215U/L

22. Day 2 Pyrexia I/O 2200ML/1600ML constitutional symptoms with Anemia BP : 112/70 dimorphic B12 DEFICIENCY PR 72/MIN IDA ( occult GI blood loss ) SPO2 96% With hypovitaminosis D TEMP 100.6 ( EVENING ) with AKI EGFR 46 ML / MIN / 1.73 M2 ? Vasculitis ? Tuberculosis ? Inflammatory bowel Disease

23. TREATMENT INJ Ceftriaxone 2 gm iv BD TAB Albendazole 400 MG STAT TAB Paracetamol 500 mg sos inj buscopan i /m sos plenty of fluids inj optineuron 1 amp in 50 ml ns iv OD inj vit d 3 600000iu i /m stat

24. PLAN UGI ENDOSCOPY IF NORMAL THEN COLONOSCOPY REPEAT SE ,RFT , CHG

25. Investigation Value UREA 16 > 18 S.CREAT 1.4 > 1.1 C ANCA NEGATIVE P ANCA NEGATIVE MOUNTOUX NEGATIVE ANA NEGATIVE URINE C/S STERILE STOOL C/S STERILE

26. Diagnosis PYREXIA Constitutional symptoms Dimorphic Anemia AKI (improved ) ETIO – ? Inflammatory bowel disease ( uc vs crohns ) with bilateral renal vein thrombosis

27. RENAL VEIN TROMBOSIS

28. CLINICAL FEATURES ACUTE :- symptoms – flank pain , hematuria USG KUB – enlarged kidneys AKI CHRONIC – ASYMPTOMATIC Can lead to Pulmonary Thromboembolism Can present as worsening proteinuria in nephrotic syndrome

29. Plan Antiphospholipid antibody Protein c and s S HOMOCYSTIEN ANTITHROMBIN 3 ACTIVITY S. HOMOCYSTEINE

30. Investigation Value LUPUS ANTICOAGULANT absent ANTI CARDIOLIPIN negative ANTI B2 GLYCOPROTIEN negative PROTIEN C 77 (70-130) PROTIEN S 68 (77-143) ANTITHROMBIN 3 84 (80-120) S. HOMOCYSTEINE 9 UMOL/L BLOOD C/S STERILE STOOL C/S STERILE

31. C/D/W CONSULTANT GASTROENTEROLOGY PLAN REPEAT COLONOSCOPY AFTER 2 WEEK REPEAT COLONOSCOPY S/O SIMILAR ULCER OR PROGRESSION LIKELY IBD ( LIKELY CROHNS ) C/D/W CONSULTANT NEPHROLOGY TAB APIXABAN 2.5 MG BD } 2 DAYS IF NO BLEED OR FALL IN HB 5MG BD } 6 MONTHS

32. REVIEW OF LITERATURE Inflammatory bowel disease with Bilateral Renal vein thrombosis