Aashi
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A 52-year-old woman is admitted to the hospital with fever up to 102 F, shortness of breath, and a cough with production of yellowish sputum for the past three days. She has a history of severe arthritis for the past twenty years. Over the past two years, she has lost about thirty pounds. She has a history of frequent admissions to the hospital with recurrent pneumonias and skin abscesses. Her medications include celecoxib, omeprazole, and methotrexate. Physical examination reveals a pale, thin, ill-looking woman. Her temperature is 101.6 F, blood pressure is 110/68 mm Hg, and respiratory rate is 24/min. Submandibular and cervical lymph nodes are two centimeters is size and are mobile, soft, and painless on palpation. The wrists, elbows, knees, ankles, metacarpophalangeal joints, and proximal interphalangeal joints are severely deformed bilaterally and have restriction in the range of motion. Palpation of elbows and Achilles tendons reveals small, subcutaneous nodules. There are multiple ulcerations, ecchymoses, and skin hyperpigmentation of both lower extremities. Lung auscultation reveals rales and dullness on percussion over the right lung base. The chest x-ray reveals right lower lobe pneumonia. The spleen is palpable, and the liver has a span of 15 cm. Her white cell count is 2,500/mm3 with a hemoglobin of 6.8 mg/dL, a hematocrit of 20.6%, and platelets of 80,000/mm3. Which test would be most helpful to determine the right initial mode of treatment?
(A) Bone-marrow biopsy
(B) Peripheral smear examination
(C) Lymph node needle biopsy
(D) Synovial fluid analysis
(E) Skin biopsy
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| robin082006
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| prathapdoctor
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i would go for peripheral smear examination first.
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| Aashi
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Answer:
(A) Bone-marrow biopsy
Explanation:
This patient presents with Felty's syndrome, which consists of a triad of chronic, seropositive rheumatoid arthritis, splenomegaly, and neutropenia. Two-thirds of affected patients are women with severe extraarticular manifestations of rheumatoid arthritis. Felty's syndrome is also accompanied by lymphadenopathy, hepatomegaly, fever, weight loss, anemia, and thrombocytopenia. Hyperpigmentation and leg ulcers may also occur. The syndrome typically appears late in the course of destructive arthritis. Recurrent infections with gram-positive organisms constitute the most severe clinical problems. Hypersplenism and immune-mediated destruction of white blood cells are believed to cause the neutropenia. The bone marrow is usually hyperplastic. The treatment is aimed at controlling the activity of rheumatoid arthritis with disease-modifying drugs and to use G-CSF in cases of frequent infections from neutropenia. Splenectomy is reserved for refractory cases.
Large lymphocyte syndrome is also associated with neutropenia and may mimic Felty's syndrome in patients with rheumatoid arthritis. It is probably a premalignant disorder of T lymphocytes and is characterized by clonal expansion of large cells that have cytotoxic and natural-killer activity. Examination of peripheral smear is a good idea, but the bone-marrow biopsy is always the most accurate way of assessing a pancytopenia. This is the only truly exact way to exclude an infiltrative disease of the marrow and to determine whether this is a production or peripheral destruction problem or splenic sequestration. If there are concerns about lymphoma, an excisional biopsy should be performed, not a needle biopsy. Even if there is a lymphoma, the bone-marrow biopsy will tell you whether the patient can be treated with local radiation or whether systemic chemotherapy for stage IV disease is needed.
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| khaddori
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this is very nice Aashi
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