Hematology QuizCase 41

A 62-year-old man was admitted to our clinic because of fever of 15 days duration, malaise and dyspnoea on moderate exertion. The patient had not been well for a two months period before admission when he had initially experienced weakness and fatigue. He had then thought his symptoms were attributed to physical stress and so didn’t seek for medical assistance. Twenty days before admission, pain, which aggravated by movements, occurred in his left lower costal region. A few days later fever started, invading with chills and often reaching 38.5 o C. Productive cough and mild dyspnoea accompanied it on slight exertion. Amoxicillin was then administered, but the patient finally presented to the hospital due to deterioration of his general condition. Previous medical history revealed a benign hypertrophy of the prostate and was otherwise unremarkable. On examination, the patient appeared ill and pale. The temperature was 37.8 o C, pulse rate 108/min, blood pressure 120/75 mmHg and the respirations were 22/min. Lung auscultation revealed fine rales in the right lower pulmonary region. The left lower costal area appeared tender on palpation. A mild epistaxis could be seen. No hepatosplenomegaly or lymphadenopathy could be observed. A normocytic normochromic anemia (Ht: 30%, Hb: 9.8 g/dL) was a characteristic feature of his hematological tests. White blood cells (WBCs) were 4.100/μL (P=55%, L=35%, M=8%, Eo=2%), PLTs count were 95.000/μL. On microscopic examination, red blood cells showed a tendency to agglutinate in a rouleaux formation. The ESR was 105 mm/1h and coagulation studies were normal. Serum biochemistry was as follows: BUN 65 mg/dL, creatinine 1.4 mg/dL, electrolytes normal, SGOT 39 IU/L, SGPT 49 IU/L, LDH 850 IU/L, γGT 55 IU/L, ALP 163 IU/L, total bilirubin 1.14 mg/dL. Direct Coombs test was negative and ferrum, ferritin, B 12 , and follic acid values were within normal limits. Serum proteins were 8.1 g/dL (globulins 3.9 g/dL). A serum electrophoretic pattern unveiled a band in the γ-globulins area. A radiograph of the chest revealed a restricted consolidation containing an air bronchogram within the right lower lobe. Diffuse osteoporosis, as well as a lytic lesion of the left costal region could be detected.