Thanks to Edward Kearney for suggesting this case.
An 11-year old girl, seeing her Family Doctor. Clinical information is
'TATT' 'tired all the time'.)
Serum results are
Sodium: 142 mmol/L
Potassium: 4.9 mmol/L
Creatinine: 53 umol/L (adult, 62 - 133)
Glucose: 4.2 mmol/L
Bilirubin: 16 mmol/L
AST: 1044 IU/L (<41)
Alkaline phosphatase: 68 IU/L (adult, < 126)
Albumin: 35 g/L
Globulins: 29 g/L
This Case attracted 38 participants.
I particularly liked 'absolutely no idea' (thank you, Helen), and 'assuming
the patient has not been treated with recombinant AST' (thank you, Graham).
9 participants would attempt to phone the Family Doctor to discuss the
Case. [+1.5]
8 queried skeletal muscle origin for the ALT, [1.0]
7 queried infective hepatitis, [1.3]
6 mentioned a hepatocellular problem, [1.3]
6 queried a toxic drug effect on the liver, [1.0]
2 queried a possible paracetamol overdose, [-0.2*]
6 thought the patient was possibly hypothyroid. [0.8]
4 said that the alkaline phosphatase was low for age, [0.5]
2 queried the patient's nutritional status, [0.5]
1 thought the albumin was low for age, and queried chronic disease. [0.3]
17 would suggest measuring CK, [1.5]
17 would ask for a repeat sample for AST and ALT, [1.0*]
(4 would also add GGT) [0.0]
13 would suggest hepatitis serology, [1.7]
9 would suggest thyroid function tests, [1.3]
1 each would suggest measuring/ carrying out
serum caeruloplasmin and urine copper [-0.3]
protein electrophoresis [-0.8]
paracetamol [-0.3]
phosphate, magnesium and zinc [-0.3]
urine myoglobin [-0.3]
toxoplasma serology [0.5]
abdominal ultrasound [0.1]
1 would suggest referral to a physician [0.1]
1 would suggest referral of results to a laboratory dealing with paediatric
inborn errors of metabolism. [-1.0]
Edward 'phoned the GP. Symptoms were very vague and drug abuse was not
suspected. Hepatitis A and B serology were negative. A repeat sample gave
AST 965 IU/L; ALT 717 IU/L; and CK 21,793 IU/L. The patient was admitted to
a children's ward, where a Rheumatologist made the diagnosis of juvenile
dermatomyositis, based on biochemistry together with lilac dicolouration to
the upper eyelids and face with a patchy erythematous rash on the forearms.
Best wishes
Gordon Challand
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