scholarly journals Estimation of Serum Ferritin Levels in Blood Donors and its Association with Frequency of Blood Donation and Blood Indices

2021 ◽  
Author(s):  
Amrita S Kumar ◽  
A Geetha ◽  
Jim Joe ◽  
Arun Mathew Chacko
Keyword(s):  
Serum Ferritin ◽  
Blood Donors ◽  
Blood Donation ◽  
Iron Status ◽  
Previous History ◽  
P Value ◽  
Blood Indices ◽  
Iron Stores ◽  
Group I ◽  
History Of

Introduction: Blood donation is one of the most significant contributions that a person can make towards the society. A donor generally donates maximum 450 mL of blood at the time of donation. If 450 mL of blood is taken in a donation, men lose 242±17 mg and women lose 217±11 mg of iron. Hence, adequate iron stores are very important in maintenance of the donor’s health. Aim: To assess the influence of frequency of blood donation on iron levels of blood donors by estimating Haemoglobin (Hb) and other blood indices which reflect iron status of blood and serum ferritin which reflects body iron stores. Materials and Methods: The present study was a cross-sectional analytical study, conducted on 150 blood donors, 18-40 years of age presenting to the Blood Bank in Government Medical College, Kottayam, Kerala, India, between December 2016 to December 2017. Total of 150 donors were divided into four groups according to the number of donations per year. Group I were the first time donors with no previous history of blood donation, Group II- included those with history of donation once in the previous year, Group III- those donors with history of donation twice in the previous year and Group IV- those having history of donation thrice in the previous year. Six ml of whole blood collected from each donor, two ml was used for estimating Haemoglobin (Hb), Packed Cell Volume (PCV), Mean Corpuscular Volume (MCV), Mean Corpuscular Hb (MCH), Mean Corpuscular Haemoglobin Concentration (MCHC) in haematology analyser. Serum separated from remaining four mL of blood underwent ferritin analysis by Chemiluminescence Immunoassay (CLIA) method. Iron stores were considered normal at serum ferritin value from 23.9-336ng/mL in males and 11-307ng/mL in females. Statistical analysis was performed in Statistical Package for the Social Sciences (SPSS) version 16.0. Analysis of Variance (ANOVA) test and Pearson correlation test were used to find association between various parameters and collected data. The p-value <0.05 was considered as statistically significant. Results: There was no significant correlation between serum ferritin level and frequency of blood donation. MCH, MCHC showed significant association (p-value 0.039 and 0.007, respectively) with frequency of blood donation. Low positive correlation was seen between Hb and PCV with serum ferritin levels (r=0.381, p-value <0.001 and r=0.354, p-value <0.001, respectively). Conclusion: There is no significant association between frequency of blood donation and serum ferritin levels.

scholarly journals HYPOTHYROIDISM;

2017 ◽  
Vol 24 (01) ◽  
pp. 36-41
Author(s):  
Shafat Khatoon ◽  
Aijaz Ahmed ◽  
Nighat Jabeen ◽  
Erum Rehman
Keyword(s):  
Serum Lipids ◽  
Previous History ◽  
Young Patients ◽  
P Value ◽  
Age Group ◽  
Active Life ◽  
Group I ◽  
History Of ◽  
Hypothyroid Patients ◽  
Significant Health

Cardiovascular diseases (CVDs) are the number one cause of death globally:more people die annually from CVDs than from any other cause. An estimated 17.5 millionpeople died from CVDs in 2012, representing 31% of all global deaths. Although CVDs areuncommon entity in young patients, it constitutes significant health problem due to itsdyslipidemia cases and devastating effects on active life style of young patients, it is thereforeimportant to identify diseases in young that are associated with or a cause of dyslipidemia1.Hypothyroidism is an important cause of dyslipidemia in young that can significantly increasethe risk of CVDs2. Objectives: This study is designed “to determine frequency of dyslipidemiain young hypothyroid patients”. Place and duration of Study: Study conducted at MedicalOPD JPMC, Karachi (outpatient) in six months duration from 25th May 2009 to 24th November2009. Patients and Methods: Study is performed on 100 newly diagnosed cases of primaryhypothyroidism between ages 25 to 55 years, non-smokers, having no previous history ofIschemic Heart Disease (IHD) or family history of premature CVD, diabetes mellitus (DM), hepaticor renal disease, not on drugs which could alter serum lipids. Selected case undergone 14hours fasting lipid profile check. Results: Out of 100 hypothyroid cases, 91% had dyslipidemiawhich was directly proportional to severity of hypothyroidism. Out of 100 hypothyroid cases,95 (95%) were of young age group i-e from 25-49 years, and all of them were dyslipidemic,while 05 (5%) hypothyroid patients were of age group more than 50 years and none of themhad dyslipidemia. (0.00%) and this distribution of dyslipidemic in young hypothyroid patientsis statistically significant (p value 0.031) Conclusion: Hypothyroidism is associated with highfrequency of dyslipidemia in young patients which significantly predisposes them to risks ofCVDs.

scholarly journals Effect of blood donation on iron stores as evaluated by serum ferritin

Blood ◽  
1977 ◽  
Vol 50 (3) ◽  
pp. 441-447 ◽  
Author(s):  
CA Finch ◽  
JD Cook ◽  
RF Labbe ◽  
M Culala
Keyword(s):  
Iron Deficiency ◽  
Serum Ferritin ◽  
Blood Donors ◽  
Serum Ferritin Level ◽  
Blood Donation ◽  
Ferritin Level ◽  
Geometric Mean ◽  
Iron Stores ◽  
High Incidence ◽  
First Time

Serum ferritin was measured in 2982 blood donors. First-time male donors had a geometric mean of 127 microgram/liter and female donors 46 microgram/liter. While values were essentially constant in the women between the ages of 18 and 45, there was a rapid increase in the men between 18 and 30 years of age consistent with the establishment of iron stores during that time. Blood donation was associated with a decrease in serum ferritin. One unit per year, equivalent to an increased requirement of 0.65 mg/day, halved the serum ferritin level in the male. More frequent donations were associated with further decreases. From the data obtained it would appear that male donors, while depleting their iron stores, were able to donate 2–3 U/yr without an appreciable incidence of iron deficiency. Women could donate only about half that amount, and more frequent donations were associated with a high incidence of iron deficiency and donor dropout. These data have provided information on the effect of graded amounts of iron loss through bleeding on iron balance.

The Effect of Repeated Blood Donations on the Iron Status of Iranian Blood Donors Attending the Iranian Blood Transfusion Organization

2006 ◽  
Vol 76 (3) ◽  
pp. 132-137 ◽  
Author(s):  
Mahmoud Djalali ◽  
Tirang R. Neyestani ◽  
Jamil Bateni ◽  
Fereydoun Siassi
Keyword(s):  
Iron Deficiency ◽  
Blood Transfusion ◽  
Serum Ferritin ◽  
Blood Donors ◽  
Blood Donation ◽  
Iron Status ◽  
Iron Loss ◽  
Healthy Controls ◽  
Blood Donations ◽  
Group Frequency

Objective: Blood donation leads to substantial iron loss, as about 0.5 mg iron is lost per each milliliter of blood donated. If not compensated for efficiently, the iron loss may eventually lead to anemia, though non-anemic iron deficiency per se may be problematic. The aim of this study was to evaluate the effects of blood donation, and its frequency over a year’s time, on iron status of Iranian male blood donors attended blood transfusion stations of the Iranian Blood Transfusion Organization (IBTO). Design and setting: A cross-sectional, descriptive, and analytic study was conducted. 91 male volunteer blood donors aged from 20 to 50 years attending three IBTO stations located in central areas of Tehran, and 63 apparently healthy controls that were matched for age, gender, monthly income, height, and weight, were included in the study. Blood donors were divided into 4 groups according to the frequency of blood donation per year; i.e. 1, 2, 3, and 4 with 20, 30, 26, and 15 persons in each group, respectively. Just before blood donation, 10 mL venous blood sample was taken and divided into heparinized and non-heparinized tubes for determination of hemoglobin (Hb), hematocrit (Hct), serum iron (SI), total iron binding capacity (TIBC), ferritin, transferrin saturation (TS), and mean corpuscular hemoglobin concentration (MCHC). Dietary assessment was also done using 3 different questionnaires; i.e. general health, food frequency, and 24hr recall. Results: The levels of Hb, Hct, and iron status indices were all significantly lower in the subjects than in controls and a gradual but significant decrease in iron status indices in each time of blood donation was found. Serum ferritin showed significant correlations with age (r = 0.33, p < 0.001) and body-mass index (BMI) (r = 0.26, p = 0.03) only in the control group. Frequency of blood donation per year was also inversely correlated with Hb (r = -0.67, p < 0.001), Hct (r = -0.65, p < 0.001), MCHC (r = -0.56, p < 0.001), serum ferritin (r = -0.38, p < 0.001), SI (r = -0.62, p < 0.001), and TS (r = -0.61, p < 0.001), but was directly correlated with TIBC (r = 0.56, p < 0.001). Interestingly in blood donors, but not in healthy controls, serum ferritin levels showed weak but statistically significant correlations with daily intake of iron (r = 0.17, p < 0.05) and energy (r = 0.20, p = 0.03). Conclusion: Though repeated blood donations might diminish iron status, it could be safe to donate 2–3 U/year without an appreciable incidence of iron deficiency, provided that the pre-donation Hb and ferritin values are ≥ 14.7 g/dL and 58.9 μg/L, respectively. The male volunteers with Hb ≥ 14.2 g/dL and serum ferritin ≥ 57.2 μg/L could donate 1–2 U/year and those with Hb ≥ 13.1 g/dL and serum ferritin ≥ 35.3 μg/L could donate just once a year. Volunteers who undergo (repeated) blood donation should receive special nutritional care, especially in terms of iron and energy.

scholarly journals TAMPANG JENUH TRANSFERIN PENDONOR DARAH ANEMIA

2018 ◽  
Vol 15 (3) ◽  
pp. 78
Author(s):  
Christina Roosarjani ◽  
Titis Wahyuono ◽  
J B Suparyatmo
Keyword(s):  
Blood Transfusion ◽  
Blood Donors ◽  
Blood Donation ◽  
Iron Status ◽  
Transferrin Saturation ◽  
Red Cross ◽  
Blood Donations ◽  
Group Iii ◽  
Group I ◽  
Group Ii

Iron deficiency remains one of the most frequent adverse effects of blood donation. Iron status test used on blood donor screeningis haemoglobin concentration. Other iron status parameters are transferrin saturation. The study aims to determine the profile oftransferrin saturation among certain groups of blood donors at the Blood Transfusion Unit of the Indonesian Red Cross SurakartaBranch. The samples were drawn from blood donors at the Blood Transfusion Unit from June to December 2005. A total of 148 specimenswere classified into 3 groups consist of 49 first time blood donations as group I, 50 of fifth time blood donations as group II, and 49of tenth time blood donations as group III. Transferrin saturation was measured by ratio between serum iron and Total Iron BindingCapacity (TIBC). The data analysed by Anova test to distinguish the difference of transferrin saturation among three groups. The resultsshowed the transferrin saturation decreased from group I to group II and from group II to group III. The transferrin saturation amongthree groups showed significantly difference (p=0.000). It can be concluded that there is a decrease in transferrin saturation accordingto the blood donation frequency among blood donors at the Blood Transfusion Unit of the Indonesian Red Cross Surakarta Branch.Transferrin saturation measurement is needed for another parameter of iron deficiency anaemia among blood donors.

The TMPRSS6 Ala736 Val Polymorphism Is Associated With Decreased Hemoglobin and Iron Status In Females Undergoing Repeated Phlebotomy

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 787-787 ◽  
Author(s):  
Alan E. Mast ◽  
John C Langer ◽  
Walter Bialkowski ◽  
Simone Glynn ◽  
Tzong-Hae Lee ◽  
...  
Keyword(s):  
Blood Donors ◽  
Iron Absorption ◽  
Blood Donation ◽  
Iron Status ◽  
Dietary Iron ◽  
Body Iron ◽  
Iron Stores ◽  
First Time ◽  
Average Body ◽  
Average Hemoglobin

Abstract Background Iron depletion and deferral for low hemoglobin occur rapidly in some donors while others can repeatedly donate without deferral. This variation may be partly explained by significant genetic differences that affect regulation of dietary iron absorption and/or hemoglobin level following blood donation. Previous studies have found that the C282Y and H63D hemochromatosis mutations do not improve dietary iron absorption following donation. TMPRSS6 is a membrane-associated serine protease that degrades hemojuvelin, thereby decreasing hepcidin production with consequent increase in dietary iron absorption. Its physiological importance is best demonstrated by the development of iron resistant iron deficiency anemia in those with TMPRSS6 mutations. A common TMPRSS6 polymorphism, A736V (rs855791), is associated with lower hemoglobin, MCV and transferrin saturation. Its correlation with iron status and hemoglobin production was examined in blood donors undergoing repeated phlebotomy. Methods Three sample sets from blood donors with well-characterized demographics, blood donation history, hemoglobin and iron parameters enrolled in the approximately 2-year longitudinal Retrovirus Epidemiology Donor Study-II (REDS-II) Iron Status Evaluation Study (RISE) were selected from the NHLBI BioLINCC repository: (Set 1) a random sample of 200 male and 200 female first-time donors and donors reactivated at study enrollment (no donations for 2 years); (Set 2) 114 first-time females who became “frequent” donors by donating at least 4 times in a 2-year period; and (Set 3) 33 repeat male donors, who were deferred for low hemoglobin during the study. Genetic testing for the TMPRSS6 A736V polymorphism was performed on donors in all 3 sets. Variation of hemoglobin and iron status among genotypes, adjusted for donor age, weight, race/ethnicity, number of donations in the previous 12 months and length of time between donations, was assessed using linear models. Results Genotypic frequencies in Set 1 were 40% AA, 42% A/V and 18% VV. The prevalence was not statistically different in the other two sets of donors, although there was a trend for higher prevalence of VV (30%) in Set 3. Hemoglobin, log-transformed ferritin and body iron stores (calculated based on ferritin and soluble transferring receptor) varied among TMPRSS6 genotypes in females but not in males. For females, average hemoglobin was 0.75 and 0.53 g/dL higher in AA (p<0.0001) and A/V (p=0.0057) than in VV. Average ferritin was 75% and 53% higher in AA (p=0.0024) and A/V (p=0.022) than in VV. Average body iron stores were 2.2 mg/kg and 1.8 mg/kg higher in AA (p=0.0045) and AV (p=0.022) than in VV. For males, average hemoglobin was only 0.13 g/dL higher in AA (p=0.47) and 0.035 g/dL lower in A/V (p=0.83) than in VV. Average ferritin was only 15% higher in AA (p=0.46) and was 8% lower in A/V (p=0.83) than in VV. Average body iron stores were 0.84 mg/kg higher in AA (p=0.10) and 0.15 mg/kg lower in A/V (p=0.75) than in VV. Due to the differences found in females, the longitudinal models were repeated using Set 2 subjects, which confirmed a significant association of the TMPRSS6 polymorphism with hemoglobin in females; 0.50 and 0.35 g/dL higher in AA (p<0.0037) and A/V (p=0.0255) than in VV. However, trends for effects on ferritin and body iron stores did not reach significance. Plasma hepcidin values were also available for Set 2 subjects, but significant differences among TMPRSS6 genotypes were not found. Conclusions The A736V TMPRSS6 polymorphism is associated with significant differences in hemoglobin and iron status of first-time female blood donors after undergoing iron loss from repeated phlebotomy. The apparent difference between males and females in variation among genotypes may be the result of greater baseline iron depletion in females rather than a gender difference per se. This is the first demonstration of an association between a common polymorphism of iron metabolism and altered individual responses to blood donation. The findings are consistent with a model in which the TMPRSS6 genotypes differ in proteolytic activity towards hemojuvelin, thereby altering hepcidin production and dietary iron absorption in otherwise healthy, but iron depleted individuals. Disclosures: Mast: Novo Nordisk: Honoraria, Research Funding.

scholarly journals Correlation of serum level and selective blood indices in children with feberile seizures in Chittoor district, India

2020 ◽  
Vol 7 (6) ◽  
pp. 1337
Author(s):  
Rajesh Kumar V. ◽  
Ande Penchalaiah
Keyword(s):  
Serum Ferritin ◽  
Iron Status ◽  
Ferritin Level ◽  
Febrile Seizures ◽  
Blood Indices ◽  
Pediatric Age Group ◽  
Iron Deficient ◽  
History Of ◽  
The Mean ◽  
The Brain

Background: A seizure or convulsion is a paroxysmal, time-limited change in motor activity and/or behavior that result from abnormal electrical activity in the brain. Seizures are common in the pediatric age group and occur in approximately 10% of children. Most seizures in children are provoked by somatic disorders originating outside the brain, such as high fever, infection, syncope, head-trauma, hypoxia, toxins, or cardiac arrhythmias. To study the association between iron deficiency and the first febrile seizure.Methods: The present study is a retrospective study conducted at the teaching hospital, Chittoor district from August 2019 to December 2019. In this study to detect low iron status as a possible risk factor for first febrile seizures, 63 cases, and 63 age and sex-matched controls are studied and analyzed.Results: In this study family history of febrile seizures is seen only in 28.5% of cases. The mean serum ferritin level in this study is 14.5ng/ml. Thus the mean serum ferritin, HB, and MCV are found to be signed on the lower side among children with febrile seizures.Conclusions: Plasma ferritin level and blood indices are significantly lower in children with febrile seizures as compared to children without febrile seizures suggesting that iron-deficient children are more prone to febrile seizures.

scholarly journals Clinical and epidemiological profile of blood donors with positive serology for viral hepatitis in southern Brazil

2011 ◽  
Vol 44 (3) ◽  
pp. 269-273 ◽  
Author(s):  
Luciana da Silveira ◽  
Leonardo de Lucca Schiavon ◽  
Kerley Pereira da Silva ◽  
Thiago Barbieri Lopes ◽  
Marcos da Rocha Zaccaron ◽  
...  
Keyword(s):  
Viral Hepatitis ◽  
Blood Donors ◽  
Blood Donation ◽  
Previous History ◽  
Southern Brazil ◽  
Positive Serology ◽  
Serological Tests ◽  
History Of ◽  
Epidemiological Profile ◽  
Epidemiological Characteristics

INTRODUCTION: Positive serological tests for hepatitis viruses B and C at blood banks are an important reason for blood deferral. Additionally, high residual risk for transfusing hepatitis-contaminated blood has been estimated in southern Brazil. This study aimed to identify risk factors for positive serological tests for viral hepatitis (VH) in blood donors (BD). METHODS: A case-control study included consecutive BD with positive serology for VH, between 2008 and 2009. Cases and controls (BD with negative serology for VH) were paired 1:1 by sex and donation date. Assessment of clinical and epidemiological characteristics related to viral hepatitis was conducted. RESULTS: Among 1,282 blood donors (641 cases and 641 controls), those with positive serology for viral hepatitis had higher mean age (p<0.001); higher proportion of replacement donation (p<0.001); first donation (p<0.001); and interviewer deferment (p=0.037), compared to controls. Furthermore, donors with positive tests were less regular donors (p<0.001), had less previous history of rejection (p=0.003) and showed lower hematocrit median before donation (p=0.019). Multivariate analysis demonstrated that age (OR=1.056, 95%CI 1.042-1.069, p<0.001), replacement donation (OR=1.545, 95%CI 1.171-2.038, p=0.002) and first donation (OR=9.931, 95%CI 7.486-13.173, p<0.001) were independently associated with positivity of serological tests for viral hepatitis. CONCLUSIONS: Specific characteristics of blood donors were associated with positive serology for viral hepatitis. These peculiarities should be taken into account when assessing candidates for blood donation.

scholarly journals Effect of blood donation on iron stores as evaluated by serum ferritin

Blood ◽  
1977 ◽  
Vol 50 (3) ◽  
pp. 441-447 ◽  
Author(s):  
CA Finch ◽  
JD Cook ◽  
RF Labbe ◽  
M Culala
Keyword(s):  
Iron Deficiency ◽  
Serum Ferritin ◽  
Blood Donors ◽  
Serum Ferritin Level ◽  
Blood Donation ◽  
Ferritin Level ◽  
Geometric Mean ◽  
Iron Stores ◽  
High Incidence ◽  
First Time

Abstract Serum ferritin was measured in 2982 blood donors. First-time male donors had a geometric mean of 127 microgram/liter and female donors 46 microgram/liter. While values were essentially constant in the women between the ages of 18 and 45, there was a rapid increase in the men between 18 and 30 years of age consistent with the establishment of iron stores during that time. Blood donation was associated with a decrease in serum ferritin. One unit per year, equivalent to an increased requirement of 0.65 mg/day, halved the serum ferritin level in the male. More frequent donations were associated with further decreases. From the data obtained it would appear that male donors, while depleting their iron stores, were able to donate 2–3 U/yr without an appreciable incidence of iron deficiency. Women could donate only about half that amount, and more frequent donations were associated with a high incidence of iron deficiency and donor dropout. These data have provided information on the effect of graded amounts of iron loss through bleeding on iron balance.

scholarly journals An Emulation of Randomized Trials of Administrating Antipsychotics in PTSD Patients for Outcomes of Suicide-Related Events

2021 ◽  
Vol 11 (3) ◽  
pp. 178
Author(s):  
Noah R. Delapaz ◽  
William K. Hor ◽  
Michael Gilbert ◽  
Andrew D. La ◽  
Feiran Liang ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Previous History ◽  
Current Treatment ◽  
Careful Consideration ◽  
P Value ◽  
Post Traumatic Stress ◽  
Increased Risk ◽  
History Of ◽  
Almost All

Post-traumatic stress disorder (PTSD) is a prevalent mental disorder marked by psychological and behavioral changes. Currently, there is no consensus of preferred antipsychotics to be used for the treatment of PTSD. We aim to discover whether certain antipsychotics have decreased suicide risk in the PTSD population, as these patients may be at higher risk. A total of 38,807 patients were identified with a diagnosis of PTSD through the ICD9 or ICD10 codes from January 2004 to October 2019. An emulation of randomized clinical trials was conducted to compare the outcomes of suicide-related events (SREs) among PTSD patients who ever used one of eight individual antipsychotics after the diagnosis of PTSD. Exclusion criteria included patients with a history of SREs and a previous history of antipsychotic use within one year before enrollment. Eligible individuals were assigned to a treatment group according to the antipsychotic initiated and followed until stopping current treatment, switching to another same class of drugs, death, or loss to follow up. The primary outcome was to identify the frequency of SREs associated with each antipsychotic. SREs were defined as ideation, attempts, and death by suicide. Pooled logistic regression methods with the Firth option were conducted to compare two drugs for their outcomes using SAS version 9.4 (SAS Institute, Cary, NC, USA). The results were adjusted for baseline characteristics and post-baseline, time-varying confounders. A total of 5294 patients were eligible for enrollment with an average follow up of 7.86 months. A total of 157 SREs were recorded throughout this study. Lurasidone showed a statistically significant decrease in SREs when compared head to head to almost all the other antipsychotics: aripiprazole, haloperidol, olanzapine, quetiapine, risperidone, and ziprasidone (p < 0.0001 and false discovery rate-adjusted p value < 0.0004). In addition, olanzapine was associated with higher SREs than quetiapine and risperidone, and ziprasidone was associated with higher SREs than risperidone. The results of this study suggest that certain antipsychotics may put individuals within the PTSD population at an increased risk of SREs, and that careful consideration may need to be taken when prescribed.

scholarly journals 6. The Stillness after the storm: a challenging diagnostic and therapeutic case of adult-onset Still’s disease

2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Owen Cronin ◽  
Euan McRorie
Keyword(s):  
Myasthenia Gravis ◽  
Serum Ferritin ◽  
Previous History ◽  
Adult Onset Still’S Disease ◽  
Recurrent Fever ◽  
Adult Onset ◽  
Still’S Disease ◽  
Still's Disease ◽  
History Of ◽  
Adult Onset Still's Disease

Abstract Introduction Auto-immune and auto-inflammatory disorders are believed to cause approximately 20% of cases of pyrexia of unknown origin. Rheumatological opinion is often sought when an infectious source has not been detected. Assessment of recurrent fever is challenging for fear of initiating immunosuppression in the presence of undetected infection. This challenge is even greater in patients with a previous history of auto-immune or infectious disorders. Here, we discuss the investigation and management of a challenging case of recurrent fever, ultimately diagnosed as adult-onset Still’s disease, complicated by the previous occurrence of pulmonary tuberculosis and myasthenia gravis. Case description Our 34-year-old female patient, originally from India, had lived in the UK for 8 years. Her background included previous treatment for pulmonary TB in 2011 and myasthenia gravis diagnosed in 2015 with subsequent thoracoscopic thymectomy in 2016. She was admitted to the infectious diseases unit in October 2016 with 3 weeks of recurrent fever and an itchy rash which had commenced 1-week after holidaying in Spain. Pyrexiae were quotidian, occurring nocturnally and would usually last 1 hour with associated malaise and tachycardia. The rash affected the upper arms, buttocks and face but was not consistent in appearance; initially urticarial and later described as maculopapular. Polyarthralgia of the joints of the hands was reported. Extensive infection screening including blood cultures and serology was negative. A CT-CAP revealed changes of old TB and borderline axillary lymphadenopathy. Immunology revealed a negative ANA and ENA screen along with normal levels of anti-PR3, MPO, DsDNA and CCP antibodies. Further investigations included a CRP of 213, ESR of 75 and serum ferritin of 450mcg/l (15-200). A provisional diagnosis of a periodic fever syndrome was made and the patient agreed to a trial of anti-interleukin 1 therapy (Anakinra 100mg SC OD) while awaiting genetic testing. Immediate defervescence of fever occurred with an improvement in the rash and dramatic reduction in inflammatory indices. Two months later the patient represented with malaise, tachycardia, periorbital odema, widespread rash, diarrhoea and a marked peripheral eosinophilia (5.69 x109/L). Skin biopsy demonstrated vacuolar inflammation and prominent eosinophils. A diagnosis of DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome was made and anakinra was withdrawn. However, the patient’s condition deteriorated with a rebound elevation in inflammatory markers, pyrexia and development of synovitis. Repeat serum ferritin during this period was recorded at > 40,000mcg/ml and a diagnosis of adult-onset Still’s disease was made. Discussion This case was challenging on two particular fronts. Firstly, the arrival of a confident and definitive diagnosis was difficult. On initial review and again on deterioration 2 months later, the patient’s previous history of TB, recent travel history and presence of lymphadenopathy led to significant concern of an alternative primary diagnosis. A large number of investigations for occult infection (e.g. TB recurrence) and malignancy (e.g. lymphoma) were conducted. Likewise, the absence of a history of a sore throat, the atypical skin rash, a very modest elevation in serum ferritin, and the absence of synovitis made adult-onset Still’s disease less likely. However, the rapidity and magnitude of the response to Interleukin-1 inhibition with anakinra supported our suspicion of an auto-inflammatory syndrome. The second hurdle in this case was the problematic pharmaceutical management once adult-onset Still’s disease was diagnosed. The occurrence of DRESS syndrome secondary to anakinra is not something we had previously experienced nor does it appear to have been reported in the literature before despite a relatively high incidence of anaphylaxis and localized skin reactions with anakinra. Subsequent interleukin-6 blockade with tocilizumab was partially effective in improving symptoms and clinical parameters but did lead to significant derangement in liver function tests and treatment was stopped. There was an incomplete response to TNF-α inhibition with weekly subcutaneous etanercept injections in combination with high dose oral corticosteroids. Subsequently there was a good response to the monoclonal antibody canakinumab (anti-IL-1β). Our patient remains on 10mg of oral prednisolone but has largely remained in remission for 18 months in combination with canakinumab. Remaining concerns relate to the long-term efficacy of canakinumab for this patient and the limited therapeutic options if recurrent relapses occur. Furthermore, the risk of TB re-activation remains an unavoidable risk with a high degree of clinical suspicion required. Key learning points This was a challenging case complicated by the patient’s past medical history of TB, myasthenia gravis and thymoma, in addition to the occurrence of DRESS syndrome which led to a period of diagnostic uncertainty. While the input of many specialties (i.e., respiratory, infectious diseases, haematology, and dermatology) were required and critical to the overall management of the patient, extensive and prolonged investigation can lead to significant delays in treatment. In such situations, an open discussion with the patient as to the risks and benefits of delaying treatment versus pursuing further investigation is advised. Furthermore, we have learnt from this case to appreciate that focused repetition of some investigations, in the setting of diagnostic uncertainty, can be beneficial. In this case repetition of serum ferritin levels, skin biopsy and cross-sectional CT imaging all led to important diagnostic conclusions and decisions that ultimately resulted in the correct diagnosis and successful management of this patient. Conflict of interest The authors declare no conflicts of interest.

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