A Patient With Anemia, Lymphadenopathy, and Hepatosplenomegaly
Medical Student, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
Janani Mohan, MD, CPPS
Clinical Assistant Professor, Rutgers Robert Wood Johnson Medical School
Hospitalist, St. Peter’s University Hospital, New Brunswick, New Jersey
Patel J, Mohan J. A patient with anemia, lymphadenopathy, and hepatosplenomegaly [published online January 9, 2019]. Consultant360.
A 47-year-old man presented to the emergency department with 5 days of intermittent dizziness and fatigue. He described the sensation as if the room were spinning while he was standing. He reported that the sensation would last for approximately 2 minutes and was relieved on sitting. He reported increasing fatigue and feeling tired with routine activity in the previous 2 weeks. He did not have any history of vertigo, head trauma, loss of consciousness, seizures, fever, chills, cough, recent illness, or tinnitus.
History. The patient was originally from Ghana, where he had had an anemia workup a few years prior for an abnormally low hemoglobin level of 8 g/dL, for which he had received a 1-unit blood transfusion. However, he did not know the type or cause of the anemia. The patient’s wife reported that she had noticed decreased body weight in the patient at that time. The patient then moved from Ghana to Italy, where he had had a pacemaker inserted after having become short of breath, with a heart rate of 45 beats/min.
The patient did not currently smoke. He had no history of alcoholism. He was sexually active with his wife. He did not report engaging in any high-risk behaviors. The patient had worked as a stonecutter for several years.
Physical examination. At presentation, his vital signs were normal, with a heart rate of 73 beats/min, blood pressure of 143/77 mm Hg, temperature of 36.2°C, respiratory rate of 16 breaths/min, and oxygen saturation of 99% on room air. His height was 177 cm and his weight was 82.4 kg, resulting in a calculated body mass index of 26.3 kg/m2. He was anicteric, and the conjunctivas were pink. A chest-wall pacemaker was noted. The cardiac examination showed regular rate and rhythm, normal S1 and S2 only, and no murmurs. The lungs were clear to auscultation bilaterally. The abdomen was soft and nontender but with notable hepatosplenomegaly. No cervical, supraclavicular axillary, or inguinal adenopathy was present.
Diagnostic tests. The hemoglobin level was 9.1 g/dL (reference range, 13.0-17.0 g/dL) with a mean corpuscular volume of 62.9 µm3 (reference range, 80-100 µm3). Iron studies showed ferritin at 22.9 ng/mL (reference range, 18.0-464.0 ng/mL), iron at 24 µg/dL (reference range, 65-175 µg/dL), direct iron-binding capacity at 427 µg/dL (reference range, 261-462 µg/dL), and transferrin saturation at 6% (reference range, 20%-50%). The alkaline phosphatase level was 242 U/L (reference range, 53-128 U/L). The remainder of the findings of a complete blood cell count, a basic metabolic panel, and liver function tests were within normal limits. Lactate dehydrogenase was normal at 193 U/L. Hemoglobin electrophoresis showed hemoglobin A1 at 69.8%, hemoglobin A2 at 2.5%, hemoglobin F at 0%, and hemoglobin S at 27.7%, corresponding with an AS pattern of sickle-cell trait. Initial HIV test results were negative. A chest radiograph and a computed tomography (CT) scan of the abdomen were taken, the results of which are shown in Figures 1-3.