Cholangiocarcinoma With Sepsis Associated With Percutaneous Transhepatic Biliary Drainage (PTBD)

Percutaneous transhepatic biliary drainage (PTBD) can be an alternative palliative treatment in resectable cholangiocarcinoma. One of the most common complications of PTBD is infection, with a prevalence of 3.6 – 67.4% in patients undergoing PTBD procedure, with mortality rate of 0.05-7%. We report a case of a 46-year old male with a history of fever 14 days after undergoing PTBD procedure. Physical examination revealed tachycardia, tachypnea, febris, jaundice, and decreased urine output. Laboratory results revealed hypochromic-microcytic anemia, leukocytosis, decreased renal function, elevated liver enzymes, obstructive icterus, hypoalbuminemia, and hyperkalemia. Blood and gall culture revealed a growth of Eschericia coli. The patient was given fluid resuscitation and antibiotic suitable to microbial sensitivity test, and treatment of acute kidney injury and hyperkalemia, including hemodialysis. The patient’s general condition improved after ten days of care, and was discharged on the twentieth day. Cholangitis is one of the most infectious complications following PTBD procedure. The prevalence of sepsis in biliary drainage procedures was reported 2.5-2.7%, with enteral bacteria gram-negative bacilli being the most common pathogen found in blood and bile. The administration of prophylactic antibiotics was not proven to decrease prevalence of infection. Bacterial translocation via portal vein due to loss of mucosal integrity in the intestines may contribute to bacteremia following PTBD procedure.

Red cell distribution width’s role in differentiating iron deficiency anemia from other hypochromic microcytic anemias

Background and objective: The red cell distribution width is suggested to be a more sensitive indicator for microcytic hypochromic anemia. Therefore, this study aimed to determine the role of red cell distribution width in the diagnosis of iron deficiency anemia from other causes of hypochromic microcytic anemia. Methods: This cross-sectional study involved the children patients who attended Rapareen Teaching Hospital in Erbil city in 2019 and were diagnosed with hypochromic microcytic anemia. Results: The red cell distribution width was determined in a group of 70 children with iron deficiency anemia and 30 cases with a non-iron deficiency (other hypochromic microcytic anemias). Patients with a higher socio-demographic status were more likely to have iron deficiency anemia than those with low socio-demographic status; 82.61% vs. 76.60%, respectively. The patients with symptoms were more likely to be diagnosed with iron deficiency anemia (P = 0.024). The mean red cell distribution width value was 14.38%, 15.73%, and18.02% among mild, moderate, and severely anemic children (P <0.001). Increasing red blood cells (r=-0.271), hemoglobin (r=-0.454), serum iron (r=-0.601), and serum ferritin (r=-0.560) lead to decrease red cell distribution width. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of red cell distribution width in diagnosing iron deficiency anemia in children patients were 77.14%, 63.33%, 83.08%, 54.29%, and 73.0%, respectively. Conclusions: This study showed that red cell distribution width has good sensitivity and specificity in diagnosing iron deficiency anemia. Keywords: RDW; IDA; RBC indices; Microcytic anemia; Serum iron.

Nutrition and Metabolism of Minerals in Fish

Aquatic animals have unique physiological mechanisms to absorb and retain minerals from their diets and water. Research and development in the area of mineral nutrition of farmed fish and crustaceans have been relatively slow and major gaps exist in the knowledge of trace element requirements, physiological functions and bioavailability from feed ingredients. Quantitative dietary requirements have been reported for three macroelements (calcium, phosphorus and magnesium) and six trace minerals (zinc, iron, copper, manganese, iodine and selenium) for selected fish species. Mineral deficiency signs in fish include reduced bone mineralization, anorexia, lens cataracts (zinc), skeletal deformities (phosphorus, magnesium, zinc), fin erosion (copper, zinc), nephrocalcinosis (magnesium deficiency, selenium toxicity), thyroid hyperplasia (iodine), muscular dystrophy (selenium) and hypochromic microcytic anemia (iron). An excessive intake of minerals from either diet or gill uptake causes toxicity and therefore a fine balance between mineral deficiency and toxicity is vital for aquatic organisms to maintain their homeostasis, either through increased absorption or excretion. Release of minerals from uneaten or undigested feed and from urinary excretion can cause eutrophication of natural waters, which requires additional consideration in feed formulation. The current knowledge in mineral nutrition of fish is briefly reviewed.

Arteriovenous Malformations in Proximal Part of Ileum: A Case Report

Arteriovenous malformations in the ileum are a rare cause of gastrointestinal bleeding in young adults with few reported cases and pose difficulty in diagnosing. They usually present with chronic gastrointestinal bleed. A 30-year-old woman presented with an acute episode of hematochezia with a history of intermittent melena for 1.5 years. Complete blood count revealed a low hemoglobin level of 3.5g/dl and hypochromic microcytic anemia. Oesophago-gastro-duodenoscopy was normal; however, a colonoscopy revealed the terminal ileum and colon filled with blood. Computed tomography-Angiogram showed local intraluminal contrast extravasation in the ileum. Explorative laparotomy and on-table enteroscopy were performed identifying a small elevated, pigmented, and eroded mucosa (5 to 6 mm) in proximal ileum; resection and primary anastomosis were performed. The patient was followed after surgical resection and her symptoms improved dramatically with no additional episodes of melena and with the normalization of hemoglobin.

A CASE REPORT: HYPOCHROMIC MICROCYTIC ANEMIA IN GENERALIZED SARCOPTIC MANGE INFECTED DOG

Skabies merupakan penyakit kulit yang disebabkan oleh infeksi tungau Sarcoptes sp. Tujuan penulisan artikel ini untuk memberikan informasi mengenai dampak dari infeksi skabies pada anjing yang menyebabkan anemia mikrositik hipokromik serta pengobatan dan penanganan yang tepat diberikan kepada anjing kasus skabies. Seekor anjing kasus berjenis kelamin jantan, dan berumur empat tahun, dengan bobot badan 9,4 kg dan memiliki masalah kulit berupa eritema pada bagian telinga, hiperkeratosis pada bagian kepala, kaki depan, abdomen, hiperpigmentasi, squama, skar, krusta dan alopesia. Masalah kulit pada anjing telah berlangsung selama delapan bulan sebelum dilakukan pemeriksaan. Dari hasil pemeriksaan kerokan kulit dengan metode superficial skin scraping ditemukan adanya larva tungau Sarcoptes sp dan hasil pemeriksaan laboratorium menunjukkan anjing mengalami anemia mikrositik hipokromik, neutofilia dan limfositopenia. Berdasarkan serangkaian pemeriksaan yang telah dilakukan, hewan didiagnosis menderita infeksi skabiosis. Pengobatan dilakukan dengan pemberian ivermectin 0,2 mL dan sabun belerang/sulfur sebagai terapi kausatif. Chlorpheniramine maleate (CTM) satu tablet dan hematodin 1,8 mL sebagai terapi simptomatik, minyak ikan/fish oil satu kapsul sebagai terapi suportif memberikan hasil yang baik dengan ditandai perubahan pada area lesi yang menunjukkan kesembuhan. Pengobatan yang telah dilakukan selama 42 hari menunjukan kondisi anjing mengalami kesembuhan ditandai dengan hilangnya squama, crusta, eritema, hiperkeratosis pada daerah punggung, wajah, telinga, leher, kaki depan, kaki belakang, pelvis dan rambut anjing tumbuh kembali normal.

Anesthesia and Hematological and Electrocardiographic Changes in the Emergency Care of a Hooded Capuchin (Sapajus cay)

Background: The hooded capuchin that occurs in the Brazilian states of Mato Grosso and Mato Grosso do Sul belongs to the species Sapajus cay. This robust species of capuchin monkey is characterized by its highly varied diet. Although it is well adapted to the natural environment, the survival of this species has come under increasing threat. In fact, several animals have been rescued and taken into veterinary medical care, where its correct capture and restraint minimize the occurrence of adverse effects to the animal and to veterinary anesthesiologists. This paper reports on the emergency care of a hooded capuchin (S. cay) rescued by the Environmental Police of the state of Mato Grosso do Sul, Brazil, and sent to veterinary medical care. Case: An adult female hooded capuchin, weighing 1.6 kg, was subjected to veterinary care to treat trauma probably caused by being run over. The animal exhibited intense prostration, 10% dehydration, pale and slightly jaundiced oral and ocular mucous membranes, impaired consciousness, cachexia, muscle weakness, sarcopenia, a probable fracture in the proximal portion of the left tibia and a laceration and possible fracture of the right metatarsus. The patient was stabilized by subjecting her to fluid therapy with Ringer’s lactate solution supplemented with glucose and vitamins. The animal was anesthetized with an intramuscular injection of 11 mg/kg ketamine and 0.6 mg/kg midazolam, and blood count, serum biochemistry and electrocardiography were performed. Blood tests revealed hypochromic microcytic anemia, liver disease and a slight increase in urea to 56 mg/dL (reference: 14.4-48.9 mg/dL). The electrocardiogram revealed the following: HR: 260 b.p.m; P axis: -115.36º; QRS axis: 50.17º; T duration: 36 ms; R amplitude: 0.68 mV; P amplitude: 0.17 mV; P duration: 44 ms: PR interval: 52 ms; S amplitude: -0.12 mV; T amplitude: 16 ms; ST elevation: -0.05 mV; QT interval: 106 ms; Q amplitude: -0.2 mV; QRS duration: 54 ms. The patient exhibited tachycardia and sinus rhythm. Antibiotic treatment was administered via intravenous (IV) injection with 50 mg/kg ceftriaxone and 25 mg/kg metronidazole, while analgesia was administered subcutaneously (SC) with 2 mg/kg tramadol hydrochloride and 25 mg/kg sodium dipyrone and intramuscularly (IM) with 0.2 mg/kg meloxicam. The patient was stabilized and transferred by the Environmental Police to the Wild Animal Rehabilitation Center (CRAS) located in the municipality of Campo Grande, Mato Grosso do Sul, to continue its treatment, perform complementary tests such as radiography of the fractured limb and clinical and surgical treatment.Discussion: Proper physical restraint is essential to the success and quality of biological samples that are collected. Surgical procedures, simple clinical exams and the collection of biological material may all require the use of anesthetics, and the type most commonly used for the restraint of wild animals are dissociative anesthetics. Ketamine is an neuroleptanalgesic drug widely used in primates, and can be administered separately or in combination with other anesthetics, such as midazolam, to increase chemical restraint and anesthesia and enable handling of the patient. As for hematological changes, female nonhuman primates are known to undergo blood loss during their menstrual cycle, which reduces the parameters of the erythrogram. In the case of this capuchin, the blood count revealed hypochromic microcytic anemia, which may be related to the menstrual cycle of the species. With regard to biochemistry serum levels, liver function showed the greatest change, with altered aspartate aminotransferase - AST (368 U/L) and alanine aminotransferase - ALT enzyme levels (151 U/L), indicating possibly chronic liver damage. On the other hand, research involving Cebus flavius found that adult males had higher ALT levels than juveniles.

Thalassemia

Defects in protein structure or synthesis of hemoglobin are called hemoglobinopathies. Thalassemia is the most common hemoglobinopathy, and it is estimated that 5% of the world population carries at least one variant allele of thalassemia. The thalassemias can be classified as alpha or beta thalassemias. Beta thalassemia may present as silent carriers with normal hematological parameters, while beta thalassemia carriers have hypochromic microcytic anemia, associated with a high HbA2. However, patients with beta thalassemia intermedia and beta thalassemia major need transfusion intermittently or regularly and they are called non-transfusion dependent thalassemias or transfusion-dependent thalassemias, respectively. This review focuses on pathophysiology, clinical, laboratory features of thalassemias along with their treatment and follow-up.