Conjunctival Pallor Research Articles

Diagnostic Accuracy of Clinical Pallor to Detect Anemia among Pregnant Females Seeking Antenatal Care in a Tertiary Care Hospital

Background: One-third of the world's population is affected by anemia, and the vast majority of those who suffer from it live in developing countries. Eye, nail bed, facial, and palmer wrinkle coloration are some of the most classic indicators used to diagnose anemia in patients. This study is design to determine diagnostic accuracy of clinical pallor to detect anemia among female. If results of this study show high accuracy for clinical pallor to detect anemia, with different ethnic background and color complexion, testing for pallor can be used as an effective alternative method. Objective: The goal of this study is to investigate the usefulness of clinical pallor in identifying anemia in pregnant women who attend the outpatient department of a tertiary care hospital, with the level of blood hemoglobin serving as the gold standard. Methodology: Settings: Department of Gynecology and Obstetrics Ward 8, Jinnah Postgraduate and Medical Centre, Karachi. Duration: 06 Months from 29-03-2017 to 29-09-2017 Design: Cross sectional Validation Study Subject and Methods: There were 393 pregnant women that participated in this study. They all sought prenatal care at the Emergency Clinic or the Outpatient Department. Hemoglobin concentrations in the patient's blood were recorded in the investigation's chart as the reference variable. On the same day five milliliters of blood was drawn for assessment of iron deficiency anemia. Tubes were transported to the laboratory of the hospital. Results of the laboratory tests were evaluated when available. Results: The average age of the patients was 28.17±5.07 years. Sensitivity, specificity, PPV, NPV and accuracy of clinical pallor was 94.1%, 51.9%, 40.7%, 96.2% and 62.8% respectively. Conclusion: Finally, even if hemoglobin or hematocrit levels cannot be measured directly, clinical pallor examination can still be performed. This is a good way to tell if a person is suffering from severe anemia. Clinical pallor of the palms is superior than clinical pallor of the buccal mucosa, nail bed, or conjunctiva in the diagnosis of mild and severe anemia in children. Nail bed and conjunctival clinical pallor is less common. Medical professionals who are new to clinical pallor might learn about its diagnosis and management by observing it from multiple angles.

Current scenario of ocular morbidity in severe acute childhood malnutrition in central part of India

The study aimed to assess the prevalence of ocular involvement in children 6 months to 5 years attending tertiary care centre with Severe Acute Malnutrition and to detect the associated risk factors for ocular morbidity in severe acute malnutrition.: This hospital based observational study was carried out at Gandhi Medical College, during the study period of 2 years on children diagnosed with SAM belonging to 6 months to 5 years of age. Detailed history was obtained and physical, systemic and ocular examination was done. : A total of 100 severe acute malnourished children were included. Prevalence of ocular involvement in severe acute malnourished children was 72%. Conjunctival pallor was observed in 71.5% eyes and retinal hemorrhages were most common posterior segment finding. Vitamin A deficiency signs were observed in 17 eyes (8.5%). Higher birth order and number of sibling was significantly associated with higher incidence of ocular manifestations (p<0.05). However, other variables showed no significant association between other variables and ocular manifestations (p>0.05). Training should be given to health workers at the primary health care level and health centers on counseling mothers on feeding, growth monitoring, the preventable eye blinding diseases and hygiene during the vaccination sessions and early referral of children with eye signs to hospitals. Also education of couple regarding proper nutrition of mother and child should be encouraged and couples should be insisted to have not more than two children.

REMARKABLE RESULT TOWARDS RETINOPATHY ASSOCIATED AUTOIMMUNE HEMOLYTIC ANEMIA

Introduction: To present the clinical findings of Autoimmune hemolytic anemia (AIHA) Retinopathy and its rapid resolutions following treatment with steroid. 
 Case report: A 14-year-old female patient presented with decreased vision in the left eye. There was history of AIHA. Visual acuity was 1/60 in LE and 6/6 in RE. There was conjunctival pallor, and the other anterior segment were unremarkable. Fundus examination of left eye revealed flame shaped and dot blot hemorrhage, roth’s spots, optic disc swelling, venous turtuosity, and elevated macula. There were afferent pupil defect, red green deficiency, and contrast sensitivity decline. Hematological evaluation revealed anemia. A MRI Head and Orbital examination were unremarkable.
 Discussion: This patient was assessed with LE Anemic retinopathy due to AIHA. The patient’s visual acuity improved as the retinopathy resolved after 1 month of oral steroid therapy.
 Conclusion: Anemia may play a role in the occurrence of retinopathy. The diagnosis of retinopathy can be made by linking ophthalmic fndings with positive serological test. Accurate comprehensive examination can establish the systemic diagnosis, and control of systemic parameters will improve retinopathy, reverse vision loss, and avoid permanent blindness

P092 Infantile osteopetrosis: a case report Traduction en Anglais

Abstract Background Infantile osteopetrosis is a rare genetic disorder characterized by increased bone density due to defective osteoclastic resorption. Case report We report the case of a 6 years old girl, born of a consanguineous marriage, hospitalized in our department for bone deformations and visual disturbances. On clinical examination, there was conjunctival pallor, thoracic deformity, genu-valgum and dentigenesis disorder as well as nystagmus and severe loss of visual acuity. The complete blood count showed regenerative normochromic normocytic anaemia as well as thrombocytopenia. Assessment for infectious disorders was negative. The skeletal X-ray revealed diffuse osteocondensation of the skeleton. The CT scan of the rock bones of cranial bases revealed bilateral segmental stenosis of the facial canal with densification of the ossicular chain and thickening of the stapes. Cranio-orbital MRI revealed bilateral optic duct stenosis with atrophy of the optic nerves and chiasma. The diagnosis of osteopetrosis was retained according to this set of clinical and radiological arguments. Unfortunately, the genetic study could not be performed. Histocompatible bone marrow transplant may be curative but was not available for our patient. Genetic counseling was offered for the family as well as dental and orthopedic care. Conclusion Infantile osteopetrosis is a rare but serious pathology that can have severe functional repercussion and even be life-threatening, requiring early diagnosis and management.

S2322 Tighten Your Pantalones for This Pantaloon Bleed

Introduction: Diverticula can develop anywhere along the small bowel, most commonly in the duodenum. While most patients with duodenal diverticula are asymptomatic, some develop complications such as obstruction, diverticulitis, obstructive jaundice, and bleeding. Here, we present a unique manifestation of bleeding within a periampullary diverticulum. Case Description/Methods: A 66-year-old male with a history of hypertension, diabetes mellitus, end-stage renal disease, atrial fibrillation, and recent four-vessel coronary artery bypass grafting (CABG) presented with unstable angina and fatigue. Following his CABG 2 months ago, he was placed on warfarin and aspirin. His exam revealed hypotension, conjunctival pallor, active bowel sounds, and melena. His hemoglobin (Hb) was 5 g/dL compared to a baseline of 9.2 g/dL two months prior. Blood urea nitrogen was 154 mg/dL and creatinine was 3.47 mg/dL, elevated from his baseline. INR was 6.9 and troponin-I was 66.9 ng/mL. An electrocardiogram did not show ST-segment elevation. After medical management of his myocardial infarction, an upper endoscopy was only remarkable for a large periampullary diverticulum (PAD) containing a clot. Over the next 3 days, his Hb continued to downtrend despite transfusion. A repeat endoscopy showed blood in the gastric body and antrum, blood clots in the duodenal bulb, and oozing blood from the diverticulum. At this time, a side-viewing scope was utilized for better visualization and showed a large pantaloon diverticulum straddling a ridge overlying the common bile duct (CBD) with an ulcer and visible vessel (Figure 1). Hemostatic clip placement led to the cessation of the bleed. (Figure 2). His hemodynamics stabilized and he was maintained on twice-daily pantoprazole. There was a transient rise in his AST and ALT, which resolved spontaneously. The patient did not re-bleed. Discussion: Our patient had an ulcer within a pantaloon PAD that was only appreciated with a side-viewing duodenoscope. Thus, if there is any suspicion of blood within a large duodenal diverticulum such as a clot, the use of a side-viewing scope is warranted. Furthermore, treatment of this lesion was challenging as the ridge overlayed the CBD, raising concern for injuring the CBD or causing obstruction through endoclips or cautery, so the former was employed taking care not to grasp excess tissue other than the visible vessel. While the transient rise in the transaminases suggested a CBD obstruction, this was short-lived and no clinical sequelae ensued.

FUNGAL DECEIT IN THE SETTING OF MYELODYSPLASTIC SYNDROME

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myelodysplastic syndrome (MDS) refers to an heterogenous group of clonal hematopoietic disorders, characterized by peripheral blood cytopenia. This disorder may present with clinical manifestations of anemia, thrombocytopenia or neutropenia, including symptomatic anemia, progression to acute myeloid leukemia or infections. Patients with MDS and severe neutropenia are at high risk for bacterial infections, however infections may rarely occur secondary to fungal invasion. CASE PRESENTATION: This is a 71-year-old female with history of hypertension, hyperlipidemia, coronary artery disease and MDS with positive RAEB2 and p53, treated with decitabine. She was initially admitted with diagnosis of symptomatic anemia, after developing general malaise, with associated shortness of breath and lightheadedness 2 days prior. Denied fever, cough, chest pain, abdominal pain, hematemesis, hematochezia, melena, insect bites or recent travel. Vital signs showed temperature of 37°C, heart rate in 109 bpm and blood pressure of 115/70 mmHg. Initial physical exam was remarkable for conjunctival pallor. Laboratories revealed leukocytopenia of 0.7 x10^3/uL, anemia of 6.1 g/dL, thrombocytopenia in 95 x10^3/ uL and absolute neutrophil count in 0 cells/uL. Chest x-ray revealed no acute cardiopulmonary pathologies. She underwent transfusion of 2 units of PRBCs, after which hemoglobin levels reached 8.2 g/dL. Nevertheless, on the third day, she developed fever of 39.4C and non-productive cough, for which ongoing diagnosis of neutropenic fever was considered. Cultures were taken and was started on cefepime. Upon examination, she had decreased breath sounds and developed 1.5cm circular violaceous lesion on the left cheek, circular violaceous lesion on the hard palate, as well as, multiple 0.5cm circular violaceous lesions on the left lower extremity and abdomen. Chest CT scan exhibited bilateral upper consolidations, raising concern for possible disseminated Fusarium fungal infection, for which amphotericin B was started. Biopsies of the lower extremity's lesion, revealed cutaneous hemorrhage, however biopsy of the hard palate's lesion revealed aspergillus spp. These findings were consistent with invasive aspergillosis. DISCUSSION: Invasive aspergillosis refers to illness caused by pulmonary or extrapulmonary dissemination of Aspergillus spp. This condition is uncommon and occurs primarily in immunocompromised patients associated with therapy for hematologic malignancies, hematopoietic cell transplant or solid organ transplantation. Management should focus on prevention, prompt diagnosis, as well as early initiation of antifungal therapy. Surgery is reserved for severe cases. CONCLUSIONS: Tissue invasion is an unusual presentation of invasive aspergillosis, however its appearance in an immunocompromised individual should raise suspicion of fungal dissemination and further evaluation should be pursued. REFERENCE #1: M. Kousha, et al. European Respiratory Review 2011 20: 156-174 DISCLOSURES: No relevant relationships by Zulmarie Maisonet, source=Web Response No relevant relationships by Ivanisse Ortiz Velez, source=Web Response No relevant relationships by Francisco Tirado-Polo, source=Web Response No relevant relationships by Beltran Torres, source=Web Response No relevant relationships by Sharon Velez-Maymi, source=Web Response

REFRACTORY THROMBOTIC THROMBOCYTOPENIC PURPURA DUE TO COVID-19

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thrombotic Thrombocytopenic Purpura (TTP) is a hematologic emergency with a mortality of 90% if left untreated. Its is formerly characterized by a pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia (MAHA), acute kidney injury (AKI), and neurologic deficits. These were classic before the routine use of therapeutic plasma exchange (PEX) because the majority of patients developed progressive thrombotic microangiopathy(TMA) and died from untreated disease. There are multiple etiologies associated with TTP and among those rarely reported is COVID-19. SARS-CoV-2 can result in the production of platelet-rich microthrombi and decrease the level of ADAMTS13. This can precipitate TMA and rarely result in TTP. CASE PRESENTATION: A 44-year-old African-American Female with no medical history presented to our facility complaining of vomiting and diarrhea associated with bleeding gums and easy bruising. On presentation, she was calm with stable vital signs. On physical exam, she had scleral icterus and conjunctival pallor associated with petechial rash and localized ecchymosis. Initial labs were remarkable for anemia(8.6g/dL), severe thrombocytopenia(3x103/µL), AKI(creatinine 1.70mg/dL), elevated lactate-dehydrogenase(1297Units/L), and high D-dimer(636ng/mLDDU). Hemolysis workup revealed MAHA and schistocytes were confirmed on blood smear. The PCR for COVID-19 was positive. All stool studies and other workup was unremarkable. Her PLASMIC score was 6 indicating high risk for severe ADAMTS13 deficiency, and therefore she was immediately admitted to the ICU and started on steroids, rituximab, and PEX. After 5-days of PEX, her platelet count improved to 199x103/µL and was deemed responsive to initial therapy. The following day the platelet count dropped to 8x103/µL and the patient was restarted on PEX. She failed to improve despite appropriate therapy and the disease was deemed to be refractory. A multidisciplinary decision was made to initiate Caplacizumab. She completed a total of 17 PEX sessions and significant improvement in her clinical course was achieved. She was eventually discharged home in stable condition on a tapered course of steroids. DISCUSSION: When ADAMTS13 is deficient, von Willebrand factor multimers accumulate and increase platelet aggregation causing TTP. Since its activity testing has a prolonged turnaround time, the PLASMIC score is validated to identify patients at risk for severe ADAMTS13 deficiency and facilitate timely management. Our patient ADAMTS13 activity was 2.2% correlating with a severe deficiency. PEX is associated with a significant decline in mortality as it replaces the deficient ADAMTS13 and removes the inhibitory autoantibodies from the circulatory system. CONCLUSIONS: TTP is a hematologic emergency that requires prompt therapy. It's important to include COVID-19 as a potential etiology and to explore other therapeutic approaches for a refractory TTP. REFERENCE #1: Sayani, F. A., & Abrams, C. S. (2015). How I treat refractory thrombotic thrombocytopenic purpura. Blood, 125(25), 3860–3867 REFERENCE #2: Bendapudi PK, Hurwitz S, Fry A, et al. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol 2017; 4:e157. REFERENCE #3: Sweeney, J. M., Barouqa, M., Krause, G. J., Gonzalez-Lugo, J. D., Rahman, S., & Gil, M. R. (2021). Low ADAMTS13 Activity Correlates with Increased Mortality in COVID-19 Patients. TH open : companion journal to thrombosis and haemostasis, 5(1), e89–e103 DISCLOSURES: No relevant relationships by Joel Brooks, source=Web Response No relevant relationships by Ruben Cabrera, source=Web Response No relevant relationships by Jorge Cruz, source=Web Response No relevant relationships by Nathalie De paz, source=Web Response No relevant relationships by Tarig Elhakim, source=Web Response No relevant relationships by Jose Gascon, source=Web Response No relevant relationships by Daniel Gonzalez, source=Web Response No relevant relationships by Carlos Guida, source=Web Response No relevant relationships by Robert Hernandez, source=Web Response No relevant relationships by Ilde Lee, source=Web Response No relevant relationships by Daniel Zapata, source=Web Response

MO697TUBERCULOUS PERITONITIS WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT ON CONTINUOUS AMBULATORY PERITONEAL DIALYSIS: A CASE REPORT

Abstract Background and Aims Tuberculosis is a leading cause of morbidity and mortality worldwide. Tuberculous peritonitis in patients on Continuous Ambulatory Peritoneal Dialysis (CAPD), though uncommon, has been reported from different parts of the world. Hemophagocytic lymphohistiocytosis (HLH) is a rare systemic inflammatory disorder characterized by uncontrolled proliferation of lymphocytes & histiocytes and is reported to have high mortality. Secondary forms of HLH have been described for various diseases. Here, we report a case of HLH secondary to Tuberculous peritonitis in a patient of End Stage Renal Disease (ESRD) on CAPD. Method A 49 years old male ESRD patient, on CAPD presented with peritonitis and was initially managed with antibiotics. He required catheter explantation in view of refractory peritonitis and was switched to haemodialysis. The patient continued to have low grade fever, yellowish discharge from infra-umbilical CAPD catheter explantation surgical wound along with lower abdominal pain & tenderness. He was lost to follow up and presented again after 1 month with fever, weight loss, multiple cutaneous ecchymotic spots and copious amount of yellowish discharge from infra-umbilical surgical wound. On examination, he had fever, conjunctival pallor, hepatosplenomegaly and a 5 cm infra-umbilical midline poorly healed discharging surgical scar with surrounding skin erythema and induration. Blood investigations revealed Hb 5.1 gm/dl, TLC 1500/uL, Plts 32000/uL, Ferritin 1053 ng/ml, TG 350 mg/dl, LDH 650 U/l, Bil T/D 1.3/1.0 mg/dl, OT/PT 160/174 IU/l, ALP 219 U/l, GGT 238 U/l, TP/Alb 5.2/2.5 gm/dl, APTT C/T 27.9/63.0, INR 1.27. NCCT abdomen revealed hepatosplenomegaly, loculated collection in right subphrenic region extending into the abdominal and pelvic cavity, anterior abdominal wall defect infero-right lateral to the umbilicus and generalised increased density in mesenteric fat. Diagnostic sub-phrenic fluid Aspirate analysis revealed a yellow turbid fluid with TLC 22300, ADA 106 U/L and positive Real Time PCR for Mycobacterium tuberculosis complex. Aspirate pyogenic and fungal cultures were sterile. Bone marrow evaluation revealed marked degree of histiocytic hemophagocytosis. Patient fulfilled six out of eight criteria for diagnosis of HLH. He was started on Anti Tubercular Treatment along with dexamethasone. He gradually became afebrile with resolution of infra-umbilical wound discharge, improvement in clinical and laboratory parameters. Results We report a case of HLH secondary to Tuberculous peritonitis in a patient of ESRD. The patient was on CAPD and required catheter explantation in view of Refractory peritonitis. Despite explantation and adequate antibiotics, he continued to have fever, discharge from surgical wound, pain abdomen, weight loss and poor appetite. Further evaluation revealed evidence of Tuberculous Peritonitis. In addition, the patient fulfilled six out of eight criteria for diagnosis of HLH. The patient was managed with Anti Tubercular Treatment along with Dexamethasone and he showed a gradual improvement in overall clinical and laboratory parameters. Conclusion Secondary HLH may occur after Tuberculous peritonitis in patient of ESRD on CAPD. Refractory peritonitis with hyperferritenemia, cytopenias, hypertriglyceridemia should raise the suspicion for HLH. Timely identification and treatment of HLH may improve patient outcomes.

MO242RECTAL ADENOCARCINOMA IN TUBEROUS SCLEROSIS: A CASE REPORT

Abstract Background and Aims Tuberous sclerosis (TS) is an autosomal dominant genetic disorder that is characterized by a neurocutaneous syndrome. Usually, the disease is diagnosed in childhood but there are frustrates form of tuberous sclerosis with or without genetic mutation. Method This clinical case is about a women with tuberous sclerosis on hemodialysis who is diagnosed a colonic polyposis and a rectal adenocarcinoma. Results We report the case of a 64-year-old patient with no particular family history, followed for renal failure discovered at the end stage with TS. She was treated with intermittent hemodialysis. During his follow-up, she presented melena stools and she reported lightheadedness when standing. Physical examination revealed conjunctival pallor. The patient’s heart rate was normal; her blood pressure was 120/80 mmHg supine and 120/70 mmHg standing. There was no distention or peritoneal irritation. The hemoglobin level was 78 g/L; three weeks previously, it had been stable at 106 g/L. The platelet count, prothrombin time and partial thromboplastin time were all normal. The patient was admitted to hospital. Two units of packed red blood cells were transfused. Gastroscopy was performed and it was normal. Colonoscopy revealed a fixed, circumferential rectal tumor at 6 cm and multiple colorectal polypes. Rectal biopsy confirmed a moderate to poorly differentiated adenocarcinoma of large bowel type. Computed tomography scan showed no metastases. She was operated and actually she is receiving chemotherapy cures. Conclusion In the literature, there is a case of invasive rectal adenocarcinoma in a 17-year-old girl with TS. We do not yet have enough data on the other types of polyps encountered. In the two small series described, the prevalence of colonic polyps is high unlike cancer which could be an isolated event. In view of all these data, it seems judicious to us to carry out a national register of patients with TS and to specify the prevalence of digestive disorders in order to organize a systematic screening if it is high, in the same way as the familial polyposis as well as to confirm or refute the hypothesis of the link between polyposis of TS and colorectal cancer.

Assessment of nutritional status of adolescent girls from 15-18 years in private high schools in Raipur, Chhattisgarh

Background: Adolescent period is a phase of human development comprising the change fromchildhood to adulthood. Nutritional requirements increase to a great extent during this period ascompared to the previous years of growth. Adolescence may represent a window of opportunity toprepare nutritionally for healthy adult life. The present study was intended to assess the nutritionalstatus of school-going adolescent girls. Materials and Methods: This one-year community-based,cross-sectional study was conducted in private high schools in an urban area of Raipur, Chhattisgarhamong 480 adolescent girls of 15-18 years. All the selected adolescent girls were personallyinterviewed with the help of a pre-designed and pre-tested questionnaire regarding age, type offamily, dietary habits and socioeconomic status. A three-day recall method was used to assessnutrient intake. The nutrient intake was calculated using tables of nutritive value of Indian foods.Results: As per WHO nutritional measurement criteria, children were classified as per theiranthropometric criteria as, 31.46% had moderate stunting and 4.38% were severely stunted. 2.71%had severe thinness, 27.92% were thin and 7.71% were overweight. The major morbidity amongstudy subjects was, 19.6% had conjunctival pallor(anaemia), 8.75% had dental caries, 6.46% hadVitamin B complex deficiency, 4.8% had angular stomatitis and 0.84% had Vitamin A deficiency.Conclusion: The present study recommends that efforts should be made to reduce the prevalenceof malnutrition among adolescent girls. For this regular health check-ups should be done at schoolswith the help of school authorities and hospitals.

Assessment of the nutritional status of adolescent girls aged between 15 to 18 years studying in government high school in Raipur, Chhattisgarh, India

Introduction: The prevalence of malnutrition among adolescent girls is high in India. Malnutritionhas long term effects on the physical and mental health of adolescents. Objectives: To find out theprevalence of underweight, overweight and stunting and correlate with a dietary pattern, socio-demographic profile and prevalence of clinical anemia and signs of vitamin and mineral deficiency.Method: This is a community-based cross-sectional observational study conducted for 1 year (Jan2019 – Dec 2019), including a total of 480 adolescent girls who were attending government highschool. Observations and Result: 480 girls were interviewed. As per WHO nutritional measurementcriteria, adolescent girls were classified as per their anthropometric criteria, 50.63% of girls weremoderately stunted and 7.29% had severe stunting. 7.29% of girls were in the category of severethinness, 36.04% had thinness and 9.37% were overweight. 28.12% had conjunctival pallor(anaemia), 4.80% had dental caries, 1.46% had vitamin B complex deficiency and 1.04% had signsof vitamin A deficiency. Conclusion: More than half of the (57.92%) late adolescent school girlswere stunted, 43.33% were having some form of thinness and 28.12% had clinical anaemia.Effective implementation of government programs such as the RKSK and Sabla Yojana program willbe a paradigm shift from the existing clinic-based services to promotion and prevention and reachingadolescents in their environment, such as in schools, families and communities. Skills-basednutrition education for the family and effective infection control and routine health assessment ofschool-going girls should be done.

Acute Erythroleukemia in a Trauma Patient. A Case Report.

Introduction: Acute erythroid leukemia (AEL) is a rare type of acute myeloblastic leukemia. Acute erythroid leukemia is characterized by a predominant erythroid proliferation, there are 2 subtypes: erythroleukemia (erythroid/myeloid leukemia) and pure erythroid leukemia…
 Myelodysplastic syndromes (MDS) are a group of biologically and clinically heterogeneous clonal disorders characterized by ineffective hematopoiesis and peripheral cytopenia due to high apoptosis
 The purpose to presenting this case is how to differentiate an acute erythroleukemia (AEL) from myelodysplastic syndrome (MDS).
 Case report. A 74-year-old man came to emergency room after he falling down from the stairs and then was hospitalized with a two weeks history of severe weakness, anorexia, weight loss. He suffered of diabetes mellitus type II insulin dependent, and HTA. The physical examination showed cutaneous and conjunctival pallor, large ecchymosis in the low extremities and hepatosplenomegaly. CBC showed: pancytopenia and macrocytosis, neutrophils 60%, normoblasts 4:100 and reticulocyte count 3%.
 Conclusions: The diagnosis was Acute Erythroid Leukemia. The % of myeloblasts in bone marrow was > 20% of non-erythroid cells. Erythroleukemia characterizes from hepatomegaly this is found and in our case. Differential diagnosis is based mainly in bone marrow aspiration, immunophenotyping (flow cytometry).

SHEMO: Smartphone Spectroscopy for Blood Hemoglobin Level Monitoring in Smart Anemia-Care

Anemia occurs due to low blood hemoglobin levels, and for its mass screening, both invasive and smart anemia-care techniques are used. However, significant drawbacks include high costs, lack of state-of-the-art facilities, invasive techniques, and lack of smartphone implementation, using additional equipment and non-autonomous functioning, for smart anemia-care techniques. The paper proposes a novel, autonomous, smart anemia-care technique to address these problems in the form of a spectroscopy based blood hemoglobin level monitoring model. This approach uses a smartphone camera as a sensor. It quantifies the hemoglobin level based on the region of interest’s color spectroscopy, which is the conjunctival pallor, extracted autonomously. Anemia is diagnosed if the predicted hemoglobin level is < 11.5 g dL−1. For easy smartphone implementation, the proposed model uses image analysis techniques to estimate the hemoglobin level. Our model reports an accuracy of ±0.32 g dL−1, sensitivity of 89% compared to the actual blood hemoglobin levels (n = 65 participants). Also, the model remains robust to a wide range of illumination and the type of device used. It thereby establishes itself as a reliable and suitable replacement for the blood-based laboratory hemoglobin tests by leveraging the feature of at-home diagnosis of anemia.

Pre-retinal haemorrhage: A complication of anemic retinopathy in a patient of microcytic hypochromic anemia

A 20-year old Indian female reported dimness of vision in both eyes since 5-6 days. Her best corrected visual acuity [BCVA] in right eye 6/24 (OD) and left eye 6/6 (OS). Anterior segment evaluation revealed conjunctival pallor. An ophthalmological evaluation revealed bilateral hyperemic disc with venous tortuosity and arterial attenuation, Roth spots in entire periphery in both eye. Pre-retinal haemorrhage over macula in right eye and flame shaped haemorrhage around macula in left eye.Hematological evaluation revealed the presence of anemia due to heavy blood loss in menstruation(with haemoglobin~2.1 gm%). General examination showed severe pallor. Other causes of anemia have been ruled out. She was treated with blood transfusion of four packed cell volume[PCV]. This case documents the rare occurrence of anemic retinopathy in patient of anemia due to menorrhagia.

S3414 Esophageal Dysfunction in Systemic Sclerosis: A Rare Etiology of Heartburn

INTRODUCTION: Heartburn is a prevalent condition with obesity, old age, and smoking identified as common risk factors. Systemic sclerosis with esophageal involvement is a rare etiology. Here we present a case of systemic sclerosis which presented with the symptoms of heartburn and regurgitation. CASE DESCRIPTION/METHODS: A 40-year-old female patient presented to our clinic with complaints of persistent heartburn and regurgitation for the last 1 month. She had a past medical history of rheumatoid arthritis and systemic sclerosis. Her medications included methotrexate, leflunomide, and piroxicam. She was also given daily oxygen therapy for her lung complaints. For the past 6 months, she had on and off heartburn symptoms which were relieved by over the counter antacids. However, for the last 1 month, she had a persistent burning sensation in her chest and epigastric region. She also complained of regurgitation and occasional vomiting. These symptoms worsened after food intake and at night which caused her to avoid meals. There was no history of hematamesis, black-colored stools or dysphagia. Her vitals were normal. She walked with short steps, had skin tightness and conjunctival pallor. Her Hemoglobin was 9.8 g/dl with mean corpuscular volume 66 fL. Her endoscopy showed dilated esophagus proximal to stricture at the lower end of the esophagus (Figure 1). The lower third of the esophagus showed changes consistent with reflux esophagitis. Other positive findings included incompetent lower esophageal sphincter, hyperemic stomach mucosa and dilated second portion of the duodenum. Based on these findings, the patient was diagnosed as a case of peptic stricture most likely due to reflux esophagitis. Systemic sclerosis probably contributed to her esophageal problems. She was treated with high dose proton pump inhibitors and prokinetics. She was advised to elevate the head end of the bed and abstain from lying down immediately after her meals. Follow-up after 2 weeks showed improvement in her symptoms. DISCUSSION: Systemic sclerosis is a multisystem connective tissue disorder. Its pathogenesis revolves around inappropriate immunological responses which result in excessive collagen deposition in the skin and internal organs like the esophagus. Esophageal involvement is diagnosed by endoscopy and esophageal pH monitoring. This condition is usually managed by lifestyle changes and medical treatment by prokinetics and proton pump inhibitors.Figure 1.: Endoscopy image shows a dilated esophagus proximal to a stricture at the lower end of esophagus. The lower esophageal sphincter is also incompetent.

S1530 A Catastrophic Complication of Pancreatic Adenocarcinoma

INTRODUCTION: Gastrointestinal bleeding (GIB) is often times a medical emergency. Determining the source of bleed is important for management and treatment. Some common causes of upper GIB are known as peptic ulcers, Mallory-Weiss tears, esophageal varices, and gastric cancer. A less frequent cause of GIB occurs due to an extremely rare disease called hemosuccus pancreaticus (HP), defined as bleeding from ampulla of Vator through the pancreas. HP is caused by pancreatitis, arterial pseudoaneurysms, and pancreatic tumors causing bleeding from the pancreatic duct or adjacent vessels such as the splenic or gastric artery. We present a rare case of HP causing massive upper GIB in a patient with known pancreatic adenocarcinoma. CASE DESCRIPTION/METHODS: We describe a case of a 79 year old male with history of melena and stage IV pancreatic adenocarcinoma who presented to the hospital for fatigue. Upon arrival the patient was hypotensive and tachycardic. He complained of extreme generalized weakness above his baseline. He appeared pale with icteric sclera and conjunctival pallor. Intravenous fluids were started. Significant lab values showed hemoglobin 7.4 g/dL, which was 2 grams less from outpatient labs 1 day prior. Therefore, 1 unit of packed red blood cells was initiated. During the interview, he had sudden onset of profuse hematemesis and systolic pressure decreased to 60 mmHg. Patient was started on massive transfusion but blood pressure continued to fall and he went into cardiac arrest requiring cardiopulmonary resuscitation. Return of systemic circulation was achieved after 8 minutes. After stabilization, an esophagogastroduodenoscopy revealed active bleeding from the duodenal papilla, requiring endovascular treatment. Notably, there was recent sonographic evidence of tumor invasion into the celiac trunk likely causing rupture of a splenic pseudoaneurysm into the pancreatic duct causing HP. Despite interventional embolization, hemodynamic compromise continued leading to demise. DISCUSSION: HP remains a clinical and diagnostic challenge. The acuity of bleed can be massive and mortality rate remains high. The importance of this report is to include HP as a differential diagnosis, especially in patients with known pancreatic adenocarcinoma. A common manifestation of HP is melena, and if detected early in these patients, prior to massive bleeding with hemodynamic instability, it can allow safe intervention and life saving measures. The gold standard for diagnosis and treatment of HP remains angiography.Figure 1.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.Figure 2.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.

S1621 Bladder in the Colon: A Rare Case of Hematochezia

INTRODUCTION: Colorectal cancer is the most common malignancy in the GI tract. Metastatic lesion to the colon are uncommon, accounting for only 1% of all colorectal neoplasms. The most common form of metastatic spread to the bowel is through peritoneal spreading. Hematogenous and lymphatic spread to the colon is reported in breast carcinoma, lung carcinoma, and melanoma. We present a rare cause of colorectal neoplasm. CASE DESCRIPTION/METHODS: A 65yo male with a history of ESRD and urothelial carcinoma presenting with hematochezia for 2 day. Symptoms began abruptly and were painless. He reported dizziness. He denied prior history of similar episodes. Patient denied melena, constipation, or any other GI symptoms. He is not on blood thinners. Of note, patient has chronic hematuria related to his malignancy, requiring blood transfusions. His most recent outpatient labs 1 week prior revealed a hemoglobin of 8.6g/dL. Patient is on neoadjuvant pembrolizumab. Surgical history included a prior bladder biopsy. He had no reported of prior colonoscopy. He is a former smoker with no other toxic habits and no pertinent family history. On admission, HR 110, BP 85/50, and was afebrile, saturating 100% on room air. Exam was remarkable for conjunctival pallor. Rectal exam revealed red blood without notable masses or lesions. Labs were significant for a hemoglobin of 7.1g/dL, creatinine of 3.5 and BUN of 42. The remainder of his CBC and CMP were unremarkable. He was transfused 1unit packed red blood cells and given IV fluids with improvement in his BP. He underwent a colonoscopy which revealed a 4 × 3 cm cecal mass with an adherent clot. The mass was injected with epinephrine, clot was successfully removed, and the mass was biopsied. Additionally, there was blood throughout the colon, and non-bleeding diverticuli in the transverse and sigmoid colon. Pathology revealed high grade carcinoma consistent with metastatic urothelial carcinoma, morphologically similar to his prior TURP specimens. Patient had a follow-up CT C/A/P that showed no other notable metastatic disease with stable bladder mass noted on a surveillance CT scan 3 months prior. Patient went for a right hemicolectomy for further management. Patient had oncologic followup for treatment. DISCUSSION: Although colon malignancy is common, metastatic urothelial cancer isolated in the colon is rare. Managing such cases is difficult as literature is unavailable. Further research is needed to understand methods of metastasis, predicting outcomes, and managing patients.Figure 1.: Cecal mass with notable adherent clot.Figure 2.: Cecal mass status post epinephrine injection and clot removal.

TO ASSESS THE ACCURACY OF CLINICAL PALLOR IN PEDIATRIC PATIENTS DIAGNOSED OF ANEMIA IN NORTH BIHAR REGION: AN OBSERVATIONAL STUDY.

Aim: to assess the accuracy of clinical pallor in pediatric patients diagnosed of anemia.&#x0D; Material and Methods: The present prospective observational study was conducted in the Department of Pediatrics Darbhanga Medical College and Hospital, Darbhanga, Bihar, India from August 2019 to March 2020 among 200 anemic children attained the age between 6 months to 5 years. Blood was drawn by venepuncture and hemoglobin estimation was done by cyanmethemoglobin method. Anemia was diagnosed when hemoglobin was less than 11g/dl.&#x0D; Results: anemia is less common among infants aged below 12 months. The moderate anemia was best detected by using palm pallor or pallor of the nail beds (sensitivity 92-95%), while conjunctival pallor was least useful (sensitivity 82%). &#x0D; Conclusion: This study demonstrates that clinical criteria can be used to identify children with anemia of moderate degree who need treatment with iron. Moderate anemia is associated with morbidity that may progress to severe anemia and death unless prevented by treatment with iron.&#x0D; Keywords: Anemia, Accuracy, Pallor, Infants

Ocular abnormalities in patients with chronic renal failure on haemodial-ysis: A study from a rural tertiary care teaching institute.

Background: Chronic Renal Failure (CRF) affects every organ system, including the eye. Potential vision-threatening ocular complications among patients with CRF can lead to irreversible visual impairment. Aims: We assess and report ocular abnormalities in patients with chronic renal failure on hemodialysis in a rural setup. Settings and Design: This is a cross-sectional hospital-based study conducted in a rural tertiary care institute. Methods and Material: One hundred twenty subjects undergoing dialysis in our institute for a period of 2 years were included in the study by convenient sampling. Statistical analysis used: Data were analyzed using Microsoft excel and represented using mean, standard deviation, ratio, and percentages. Results: Among the subjects, 16.7% of total eyes had vision &lt;6/60, and 35% had &lt; 6/24. The causes for visual impairment were maculopathy in 31 eyes, cataract in 20 eyes followed by proliferative diabetic retinopathy in 11 eyes. Lid edema was present in 22.5%, conjunctival pallor in 30.8%, and corneal calcification in 2.4% of total eyes. Retinopathy was the most important finding. Hypertensive retinopathy was present in 93 out of a total of 120 patients (98%). Diabetic retinopathy was present in 49 out of 85 diabetic subjects (72.3%). Seventeen out of 93 patients of hypertensive retinopathy and 11 out of 49 subjects of diabetic retinopathy were detected for the first time. Conclusions: This study highlights the importance of ocular examination in patients with metabolic disorders like Diabetes and Hypertension. Vision threatening complications in CRF patients were detected easily without any complicated procedures and any cost. And even screening was possible in bedridden patients. In this study, the patient was recognized to have the renal disease by looking at the ocular abnormalities and was referred to a physician in the same visit. This signifies easy accessibility of changes in the eye, to know disease in the other organs like kidney. Keywords: Chronic renal failure, retinopathy, corneal calcification, haemodialysis

Novel Biased Normalized Cuts Approach for the Automatic Segmentation of the Conjunctiva

Anemia is a common public health disease diffused worldwide. In many cases it affects the daily lives of patients needing medical assistance and continuous monitoring. Medical literature states empirical evidence of a correlation between conjunctival pallor on physical examinations and its association with anemia diagnosis. Although humans exhibit a natural expertise in pattern recognition and associative skills based on hue properties, the variance of estimates is high, requiring blood sampling even for monitoring. To design automatic systems for the objective evaluation of pallor utilizing digital images of the conjunctiva, it is necessary to obtain reliable automatic segmentation of the eyelid conjunctiva. In this study, we propose a graph partitioning segmentation approach. The semantic segmentation procedure of a diagnostically meaningful region of interest has been proposed for exploiting normalized cuts for perceptual grouping, thereby introducing a bias towards spectrophotometry features of hemoglobin. The reliability of the identification of the region of interest is demonstrated both with standard metrics and by measuring the correlation between the color of the ROI and the hemoglobin level based on 94 samples distributed in relation to age, sex and hemoglobin concentration. The region of interest automatically segmented is suitable for diagnostic procedures based on quantitative hemoglobin estimation of exposed tissues of the conjunctiva.