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help case managementFrom: Dragos Nemescu (dnemescu@eth-d.tuiasi.ro)Thu Apr 30 12:49:40 1998
A 26 y.o. woman (2 gesta, 0 para) pediatric resident. In previous pregnancy, in November 97, at 5 weeks of gestation she developed a sudden febrile syndrome, characterized by: - abrupt onset of sustained fever (39-40 oC), chills, malaise - 4 days later, - parotids became enlarged and painful - painful, non fixed adenopathy (cervical, occipital, axilar bilateral). In a few days all anterior cervical zone became enlarged and edematiated - breasts were under tension with maculo-papular erithema, non pruriginous Admitted into hospital with mumps presumption she received NSAID without any effect. 2 weeks after the onset, parotids and cervical edema gradually returned to normal. At that moment she presented hypogastric pain and small methroragia, but after another 3 days spontaneous abortion has begun. After that, fever disappeared gradually. Laboratory findings: ESR 105 mm/1h Leukocytes 11.8x109/l Differential white cell count NG 77%, Ly 11%, M 10%, E 2% hemoglobin, BUN, creatinine, AST, urine exam, all US exams - normal Now she is having a new pregnancy. At 15 weeks of gestation she developed the same syndrome like the first time (fever, parotiditis, adenopathy, breast tenderness, papular erithema), but cervical symptoms were not so marked. Moreover, was presented inflamation (with swelling) of left knee and left ankle articulation. After about 3 weeks of evolution, without any treatment, the symptoms dissapeared spontaneously. Now she has 19 weeks of gestation, without any complaints, with a normal fetal US. Laboratory findings: -anemia (Hb 7mg/dl, Ht 25%, normochromic, normo-isocytosis, normal serum Fe, normal serum ferritin), Reticulocytes 0.5% -ESR 106mm/h -CRP 144mg/dl -WBC 6.2x109/l, Diff. white cell count NG 74%(segm) 6%(non sgm), Ly 12%, M 6%, E 2% -ALT 26ui, AST 21ui -BUN, creatinine, electrolytes, urine exam - normal -total cholesterol 225 mg/dl -total proteins 7.2g/l albumin 34.04% alpha1 9.42% alpha2 15.54% beta 13.78% gamma 28.22% -IgG 2944mg/dl (800-2000mg/dl) -IgM 160mg/dl (60-280 mg/dl) -IgA 364mg/dl (90-450 mg/dl) -tuberculin test negative -ASLO 100 -C3 54mg/dl (55-120mg/dl) -CIC 16(geq/ml (<20 (geq/ml) -lupic cells absent -rheumatoid factor 75mg/dl (<15 mg/dl) -Waller Rose 84mg/dl (<6 mg/dl) -ANA d.s. DNA 78ui/ml (<100 ui/ml) -pANCA/MPO 2.3 U/ml ( <6U/ml) -cANCA/PR3 15.4 U/l (<10U/l) -AgHBs positive once and negative in other two consecutive tests. This is a hepatitis or connective tissue disease (vasculitis, sjogren's) ? The couple want to preserve the pregnancy. What should I can do for them?
-- Dr.Dragos Nemescu "Cuza Voda" Obs&Gyn Hospital Iasi Romania
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