LOTUS - Institute Of Haematology, Oncology and Bone Marrow Transplantation 


 

Vol 7 Issue 1 Jan 2016.



Feb 20, 2016

Vol 7   Issue 1     Jan 2016.

Happy new year to all my colleagues and seniors,

We will continue our newsletter series into the 7th year. I thank you all for the feedback on my previous newsletters. Learning is continues process and that is the beauty of practicing medicine! Each case has the potential to teach us if we want to. In my speciality for example anaemia can have any underlying cause? In this newsletter I am going to dwell onrecurrent oral ulcers.

Case 1:

24 year old female presented with weakness, hyperpigmentation and recurrent oral ulcers for 6 months prior to presentation. I had treated he elder sister for anaemia and hence she came to me. She had no skin rash but had occasional joint pain. She had no gastrointestinal upset. CBC revealed Hb of 9.5 (microcytic hypochromic). Wbc and platelets were normal. ESR was 82.  Based on history and raised ESR we did autoimmune screen which showed ANA positive and ANA blot(This test detects 14 antibodies against various antigens on our cells and is helpful in differentiating collagen vascular diseases) showed Sjogren’s syndrome(autoimmune multisystem disease). She was treated with oral steroids (short course) and other immunomodulators. She responded in 10 days and as of now is not on steroids. She had one relapse with oral ulceration and received 7 days of low dose oral prednisolone. Sjogren’s syndrome is a multisystem collagen vascular disease which can present to any sub speciality!! 

Case 2:

7 year old male was referred for recurrent stomatitis by a dentist. The dentist had seen him for atleast 6-7 times and correctly thought of a systemic cause as he was not responding to local measures. The family were reluctant to see a specialist as they were afraid of the costs! the child was the second born out of non consanguineous marriage. History revealed recurrent ulcers mainly on tongue and soft palate since he was 3-4 years old. He use to get it every month and lasted for 4-5 days. His family physician use to give him hematinics and becozinc tablets. He use to bleed easily after brushing his teeth with soft tooth brush. He also had one episode of dysphagia when he was 5 yr old which was diagnosed as candidiasis (probable oesophageal candidiasis). He had no joint pain or recurrent fever. On examination he had oral ulcers mainly on lateral aspect of tongue and had bad oral hygiene with bad breath. He had no palpable lymphadenopathy or hepatosplenomegasly. He had no sternal tenderness(this clinical test is very helpful in cases of acute leukemia) CBC (my bread and butter test!!) showed Hb of 11.2 (microcytic hypochromic with features of iron deficiency) wbc of 1200 (only) and platelets of 6.1 lakhs (probable reactive thrombocytosis). Differential wbc count revealed neutrophils of 22% only (Absolute Neutrophil Count: 250)

 What are the differential diagnosis at this stage?

1. Bone marrow disease like leukemia (but his history was chronic)

2. Congenital immunodeficiency disorders (where the patient’s immune cells are either abnormal in quantity or quality!)

3. Recurrent viral infections where leucopenia occurs and one can get oral ulcers.

4. Autoimmune disease where there is excessive autoimmune neutrophil kill and hence neutropenia.

His bone marrow showed maturation arrest at myelocyte stage (this means that there was a problem in the final stage of neutrophil maturation and hence neutropenia). ANA was negative. Immunodeficiency disorder was suspected and we did his cbc every week for next 3 months. This showed that his wbc count use to “dip” approx every 21-23 days for 2-4 days and at this time he use to get oral ulcers (stomatitis). When his neutrophil went “up” his ulcers use to heal on their own.

Final diagnosis: Cyclical neutropenia causing recurrent stomatitis. This is a congenital immune deficiency disease of neutrophil maturation. The wbc goes down every 21-22 days!

Treatment: patients are given GCSF injections (growth factor to stimulate neutrophils so the wbc rises) when they have ulcers or severe infections. This disease can lead to life threatening complications in some patients.

Take home message:

1. Oral ulcers can be due to nutritional deficiencies in our country and they may respond to “Vitcofol”, but if they donot respond then they need workup to rule out underlying systemic illness.

2. Oral ulcerations should be taken seriously and followed up closely panerai replica watches.

3. Every age group have different causes for oral ulcers ranging from bad dentures to underlying malignancy!!

 Lotus Institute of Regenerative Medicine:

We have treated successfully chronic foot ulcers with platelet rich plasma (PRP) therapy. These patients did not respond to local measures and had long standing ulcers (2 patients had diabetic ulcers and 3 other had sickle cell anaemia). We can also treat oral sub mucous fibrosis(can be seen secondary to chronic tobacco use) using the patient’s own platelets which are activated.


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