Pra Stase

Nutritional Deficiency in UTI and

sepsis patient with Conjugated
Hyperbilirubinemia
Rima Aurelia Dimpudus

Pembimbing :
dr. Dian Sukma Hanggara, Sp.PK, M.Biomed
 Data Base
Female, 58 y.o
Chief complaint : general weakness
• The patient has complained of general weakness for 4
days. She has also a fever for 2 days and saying that
there were red spots occurring on her skin this and she
also said that her eyes colour has turned into yellow for
these last 2 days.
• She had a nosebleed 2 days ago. Her urine was dark
yellowed coloured and her faeces was brown coloured
but she said that it has stopped now.
• There was no complained of nausea and vomiting
2
Past medical history :
• DM, Hypertension, Asthma, Heart disease, and
Allergy were denied

Family History :
• -

Social history :
• Married
• Housewife

3
 Physical Examination
General Composmentis, GCS : 4-5-6 (15)
status Normoweight
Vital sign BP : 90/40 mmHg HR : 105 bpm
RR : 24 tpm T : 37°C (axilla)
Head & Anemic conjunctiva +/+, Icteric sclera +/+
Neck JVP : R+0 cmH2O
Thorax P : symetric, VBS +/+, Rh -/-, Wh -/-
C : ictus at 5th ICS, MCL, single S1/S2, murmur –
Abdomen Flat, BS (+), liver span 8 cm, traube space tympani
shifting dullness (-)
Extremities Petechie (+) on her skin 4

Warm, capillary refill < 2s

 LABORATORY RESULTS
Complete Blood Count 14/12 Reference range
Hb 2.40 11.4-15.1 g/dl
Erythrocytes 0.89 4.0-5.0 x106/µl
Leucocytes 18.83 4.3-10.3 x103/µl
Platelet 3 142-424x 103/µl
Hct 10.10 40-47 %
MCV 113.50 80-93 fl
MCH 27.00 27-31 pg
RDW 23.40 11.5-14.5 %
Reticulocyte 34.56 (8.3) 0.5 – 2.5%
Diff 0/0/70/5/25 0-4/0-1/51-67/
(eo/bas/neut/lym/mo) 25-33/2-5
 Coombs’ test Negative

Peripheral Blood Smear Evaluation

14/12
Erytrocytes Normochrom anisopoikilocytosis, macrocytic
Leukocytes Increased amount, neuthrophillia, hypersegmented
neuthrophil (+)
Diff count: 0/0/11/79/3/3
Myelocyte 2%, metamyelocyte 2%
Thrombocytes Very decreased amount
BMA Examination (17/12/2018)
Cellularity Hypercellular
M:E Ratio 3:1
Erythropoiesis Increased activity,
Granulopoiesis Increased activity,
dysgranulopoiesis (+),
hypersegmented neuthrophil (+)
Megakaryopoiesis Increased activity,
dysmegakariopoiesis < 10%,
hyperlobulated megakaryocyte (+)
Iron Storage Negative
Others There were megaloblastic
changes in all three hematopoietic
lineages 7
Bone Marrow
8
Clinical Chemistry 14/12 Reference range

AST
9 13 0-40 U/L

ALT 5 0-41 U/L

RBS 101 < 200 mg/dL

Bilirubin total 2.42 < 1.0 mg/dL

Bilirubin direct 1.68 < 0.25 mg/dL

Bilirubin indirect 0.74 < 0.75 mg/dL

Albumin 2.14 16.6-48.5 mg/dl

 10
Urinalysis
Examination 14/12 Reference
Turbidity Turbid
Color Brown
pH 6.0 4.5-8.0
SG 1,015 1,005-1,030
Glucosa negative Negative
Protein 2+ Negative
Keton Negative Negative
Bilirubin Negative Negative
Urobilinogen 16 < 17 µmol/L
 11

Examination 14/12 Reference

Nitrit Positive Negative
Leucocyte 2+ Negative
Blood 3+ Negative
Epitel 0-1 ≤3/lpf
10x Cast negative
Granular - negative
Erythrocyte 1135.7 ≤3/hpf
Eumorphic 82%
Dysmorphic 18%
40x Leucocyte 78.9 ≤5/hpf
Crystal -
Bacteria 1514.0 ≤93x103 /ml
 PCCL PL IDx PDx
1. Female/58 yo 1.Severe 1.Severe • Serum
Laboratory Findings: anemia anemia and ferritin, SI,
BMA: and thrombocyto
-Increased TIBC
megakaryopoiesis thromb penia • Serum folic
activity, ocytop (Bisitopenia) acid
dismegakaryopoiesis < enia e.c
10%, hiperlobulated
• Serum
Nutritional
megakaryocyte (+) Vitamin B12
deficiencies
-Negative iron storage
(Fe, Folic acid • Monitoring:
-Megaloblastic changes CBC, blood
Coombs’ test (-) and/or
Anamnestic findings vitamin B12) smear
- Red spots and
nosebleed
Physical findings
- Petechie (+), anemic
conjungtiva(+) 12
 PCCL PL IDx PDx

2. Female, 58 y.o. Susp. Susp. - Urine

Laboratory : UTI culture
UTI
-Leucocytosis, - Ureum,
neuthrophillia
-Urinalysis: proteinuria
creatinine
(+), nitrit(+), - Monitoring
leucocyturia (+), urinalysis
hematuria (+),
bacteriuria (+)
Anamnesis :
Dark yellow urine
Px :
-Tachypnoe, tachycardia
13
 PCCL PL IDx PDx
3. Female, 58 y.o Sepsis Sepsis ec - Ureum,
Laboratory : Susp UTI Creatinine
-Leucocytosis, - Procalcitonin
neuthrophillia DD/RTI
- Blood
-Total biliribun 2.42 mg/dL
-Thrombocytopenia culture, urine
<20x103 µL culture
-Proteinuria, hematuria, - BGA
nitrituria, leucocyturia, - Lactid acid
bacteriuria - Thorax X-Ray
Physical :
- Monitoring
-GCS 15
-Hypotension (MAP CBC, Bilirubin
57mmHg) T/D/I
-Tachypnoe
-Tachycardia
14
 PCCL PL IDx PDx
4. Female/58 yo Conju Conjugated • ALP, GGT
Laboratory: gated hyperbilirubinem • HbsAg,
-Hiperbilirubinemia direct hyper ia due to antiHCV
> indirect biliru Suspected • Procalcitonin
-Hypoalbuminemia binem obstructive • Abdominal
-leukocytosis, ia
jaundice e.c USG
neuthrophillia cholestasis DD/ • Monitoring:
-Normal AST and ALT liver disease, AST, ALT,
Anamnesis:
sepsis CBC,
-Eye turning yellow
-Dark yellow urine
Urinalysis
-Brown faeces
Physical:
-Icteric sclera(+)
-Tachycardia, tachypnoea,
hypotension 15
16
• Diagnostic criteria for PV as per the 2016 revised World Health
Organization (WHO) guidelines include three major criteria and a minor
criterion. Diagnosis requires the presence of either all three major criteria
or the first two major criteria and the minor criterion. [5]
• Major WHO criteria are as follows:
• Hemoglobin >16.5 g/dL in men and >16 g/dL in women, or hematocrit
>49% in men and >48% in women, or red cell mass >25% above mean
normal predicted value
• Bone marrow biopsy showing hypercellularity for age with trilineage
growth (panmyelosis) including prominent erythroid, granulocytic, and
megakaryocytic proliferation with pleomorphic, mature megakaryocytes
(differences in size)
• Presence of JAK2V617F or JAK2 exon 12 mutation
• The minor WHO criterion is as follows:
• Serum erythropoietin level below the reference range for normal

17