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Cases and problems
Case(1)
Wendy is a 23- years old photographer for a local
newspaper. Over the last 8 months, she experienced
strange symptoms. She had severe eye strain when she
read for longer than 15 minutes. She become tired when
she chew her food, brush her teeth or dried her hair and
she had extreme fatigue on job. Despite her strong work
ethics Wendy has to excuse herself from several shoots
because she simply could not carry heavy equipment..
She was evaluated by the physician who suspected
myasthenia gravis. While waiting the results of serum
antibody test the physician initiated a trial of
prostigmine, Wendy immediately felt better while
taking the drug , her strength returned almost normal.
Meanwhile the results of antibody test were positive
confirming the diagnosis of myasthenia gravis.
1- What antibody measured in Wendy's serum?
Against what protein is this antibody
directed?
2- Why prostigmine improve muscle strength in
myasthenia gravis ?
3- Why severe muscle weakness occurs in this
case?
4- Considering the following drugs that act at
various steps in neuromuscular transmission
.What is the action of each drug and which
drugs are contraindicated in myasthenia
gravis ?
-Botulinus toxins
- Curare
- Neostigmine
Case (2)
A 35 year old woman is seen for easy fatigue for
many months. She is now 24 weeks pregnant with
her 3rd child in 3 years. She does not see any
obstetrician and does not take any vitamins.
Lately, she has developed dyspnea. She has no
other complaint. Family and past history are
negative. She does not smoke or drink.
Physical examination is positive for pale conjunctiva, mild
spooning of nails, and a systolic murmur at left lower
sternal border. Stools are negative for occult blood.
Labs: Complete blood count (CBC):



Hg (7.1 gm/dl)
Hct (23%)
WBC (5.400/mm3)
Platelets (450.000/mm3)
Photo of Spooning of nails
1- What is your provisional diagnosis? Why?
2- How reliable is physical examination in
diagnosing anemia?
3- What is the cause of murmur in this case?
4- What is the main functions of RBC's?
Case (3):
Justin Mather, a 23-year-old man, presented to the physician with a
long medical history dating back to 1983 when, as a 6-year-old, he
was referred to a pediatrician by a dentist. At that time, the dentist
was about to administer an anesthetic drug by injection prior to
extracting a tooth when he elicited a history of easy bruising in the
boy as well as a history of a brother who died at age one from an
intracranial hemorrhage after falling from a crib.
Photo of Bruises
In addition, Justin has had several instances of severe bruising
following minor
trauma.
Interestingly, Justin's
maternal
grandfather died at age 27 of a bleeding complication following
an appendectomy.
Lab findings in Justin at that time (1983) were as follows:

Platelet (280.000 / mm3)

Bleeding time (4 minutes)

Prothrombin time (PT) (11 seconds)

Partial thromboplastin time (PTT) (58 seconds)
In the past two years, Justin's health has deteriorated,
starting with fatigue, a sore throat, and swollen lymph
nodes in the neck and groin. This was followed a few
weeks later by a diarrheal illness with marked weight
loss. Six months ago, Justin developed a severe parasitic
pneumonia
which
antibiotic treatment.
subsided
only
after
intensive
In the past week, Justin has progressively weakened,
suffering from chills, weakness, and a high fever that
has left him bedridden. Laboratory studies revealed a
white blood cell count of 2.800 / mm3; with a
markedly reduced number of T-helper cells.
1. Why does Justin bleed so easily? What is
significant his family history?
2. Why is the PTT elevated? Why isn't the PT
elevated?
3. The bleeding time was normal. What general types
of disorders are ruled out by the normal value of
this test?
4. What precautions do you think were taken prior to
extracting Justin's tooth?
5. What has been the primary cause of Justin's poor
health in the past two years? Is his illness of the
past two years related in any way to the "blood
disease" diagnosed in 1983?
6. What specifically might have caused pneumonia?
7. How is Justin's immune system affected by a
deficiency in T-helper cells?
Case (4)
A 60-year-old Caucasian female noticed the sudden appearance of
multiple petechiae on her extremities and mild epistaxis. She
had no other symptoms and denied taking any medications. Lab.
Results performed by her primary-care physician showed the
following :




RBC's (5 millions/mm3)
WBC's (8000/mm3)
platelet count (75.000/mm3)
BT (30 minutes)
CT (8 minutes)
Photo of petechiae
She was referred to a hematologist who did an extensive work-up
revealing no other significant abnormalities. A bone marrow
biopsy was unremarkable.
1- What is your provisional diagnosis?
2- What cytokine is important in the pathogenesis of this case is?
A- Erythropoietin
C- Thrombopoietin
B- Granulocyte colony-stimulating factor
D- IL-12
Case (5)
A 2-year old boy was brought to the emergency
department by his mother for oozing blood from his
mouth following a fall nearly 6 hours ago. His mother
related that he tended to bleed for prolonged periods
from his immunization sites, but there was no history of
bruising or hematomas. The patient was on antibiotics
for a recent ear infection. There was no known family
history of a bleeding disorder.
Laboratory findings
Hemoglobin
12.3 g/dl (10.5-13.5)
WBC
7.9 x 10^9/L (6.0-17.5)
Platelets
368 x 10^9/L (156-369)
PT
11.3 s (10.0-12.8)
CT
30 minutes (5-10 m)
BT
20 minutes (2-4 m)
APTT
49.6 s(28.0-38.0)
FACTOR VIII
0.16 U/ml(0.60-1.50)
VWF 0.16
(0.78-1.53 )
FACTOR IX
0.82 U/ml (0.60-1.50)
1-What is the most likely cause of prolonged
bleeding in this case? Explain your answer.
2- What is the function of VWF?