Cryptogenic hepatic insult, failing heart and advancing age: a case report
© Agrawal et al; licensee BioMed Central Ltd. 2008
Received: 11 September 2008
Accepted: 19 December 2008
Published: 19 December 2008
Weakness and fatigue are accepted as normal accompaniments of aging. Usually, older individuals are not investigated with much enthusiasm but a treatable cause is discernible on several occasions.
We had a 67 year old hypertensive lady with a mitral stenosis, presenting in ischemic or hypertensive heart failure with underlying valvular disease, without pulmonary hypertension in sinus rhythm. She had pancytopenia with severe anemia and raised liver enzymes. Bone marrow examination showed aplastic anemia. She was treated with ATG and improved subsequently to become transfusion free. However, she succumbed to an unrelated sudden cardiac death.
Our patient is unique in her uncommon presentation, complex management issues and a favorable outcome after a long and persevering therapeutic intervention and finally her sudden death.
In December, 2007 a 67 year old hypertensive lady, with a known rheumatic mitral stenosis, presented with insidious onset, gradually progressive fatigue of one month, which had decompensated acutely. There was no history of peptic ulcer, use of NSAIDs or change in bowel habits. She had no previous blood transfusions or jaundice. She denied smoking or taking alcohol. There was no suggestion of long standing liver or kidney disease, diarrhea or infection. She took amlodipine and atenolol for hypertension. There was no history of intake of any other drugs that could have had a toxic potential.
She was pale, anicteric, normotensive and tachypneic with pulse of 100/minute. Her neck veins were engorged and she had pedal edema. She was afebrile, did not have any clubbing, and had no signs of rheumatic activity or infective endocarditis. She had a loud first heart sound, a normal second heart sound, an opening snap and a mid-diastolic murmur at apex. She had a resonant percussion note, equal air entry, and vesicular breath sounds on both sides. Coarse rales were heard in the infrascapular and infraaxillary areas. She had an enlarged tender, firm liver with sharp margins and a span of 10 cms. No splenomegaly or ascites were noted. Here, we had an old hypertensive lady with a mitral stenosis, presenting in ischemic or hypertensive heart failure with underlying valvular disease, without pulmonary hypertension, rheumatic activity or infective endocarditis in sinus rhythm. An infective pathology causing acute deterioration or a pulmonary embolism was also considered.
Echocardiography showed mild mitral stenosis (MVOA 1.8 sqcm) with normal left ventricular ejection fraction, and no signs of infective endocarditis. Serum and urine electrophoresis did not detect any abnormal bands. Bone marrow biopsy from the iliac crest showed profound hypoplasia with overall cellularity of less than 5%. She had osteoporosis with a bone mineral density of 0.714 g/sqcm. Her liver function tests rapidly returned to normal levels.
Progression of the hematological parameters of the patient over time
Total Leukocyte Count
Weakness and fatigue are accepted as normal accompaniments of aging. Usually, older individuals are not investigated with much enthusiasm but a treatable cause is discernible on several occasions. Here, anemia with CHF was evident at presentation. Chronic disease, iron deficiency, vitamin B12 or folate deficiency, gastrointestinal bleeding and myelodysplastic syndrome are commonly identified. Aplastic anemia, remains rare in older persons. Older patients are usually ineligible for allogeneic bone marrow transplantation, owing to absence of a donor, advanced age and frail phenotype. Immunosuppression with cyclosporin and antithymocyte globulin (ATG) is often contemplated but infrequently tried in older individuals.[2, 3] It is known that 50% younger patients respond within 3 months of immunosuppression, and about 75% by 6 months, and become transfusion independent, but some may have a persistently hypoproliferative marrow. In the current case, bone marrow suppression followed a transient cryptogenic hepatitis, likely of a viral etiology. Aplastic anemia has been reported between 3–6 months following cryptogenic hepatitis in younger patients.[4, 5] A more protracted course might be seen in older patients following immunosuppression. Our patient is unique in her uncommon presentation, complex management issues and a favorable outcome after a long and persevering therapeutic intervention and finally her sudden death.
Consent could not be taken from the patient before publication because she expired before this could be done. Care has been taken to preserve the confidentiality of patient identity
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