The patient has Hypothyroidism, Hypertension, Type 2 Diabetes, & Vitiligo.
He had an episode of SIADH 2 months ago.
Can someone help interpret his investigations?
His CBC is as follows:
White Blood Cells 10.15x103/uL
Red Blood Cells 4.34x106/uL
Hemoglobin 13.1 g/dL
Hematocrit 40.9 %
MCV 94.2 fL
MCH 30.1 pg
MCHC 31.9 g/dL
RDW 14.6 %
Platelets 349x103/DL
MPV 9.5 fL
Neutrophils 72.7 %
Lymphocytes 19.7 %
Monocytes 4.3 %
Eosinophils 0.5 %
Basophils 1.1 %
Large Unstained Cells 1.6 %
Neutrophils Abs 7.38x103/uL
Lymphocytes Abs 2.00x103/uL
Monocytes Abs 0.44x103/uL
Eosinophils Abs 0.06x103/uL
Basophils Abs 0.11x103uL
LUC Abs 0.16 103/uL [*] 0.00 0.50
His Chemistry
Glucose 129 mg/dL
Phosphorus 3.4 mg/dL
Uric Acid 7.7 mg/dL
Creatinine Serum 0.95 mg/dL
Urea 22.1 mg/dL
Total Protein 7.68 g/dL
Albumin 4.70 g/dL
Globulin 2.98 g/dL
SGOT(AST) 28 U/L
SGPT(ALT) 33 U/L
Gamma GT 14 U/L
Alkaline Phosphatase 85 U/L
LDH 356 U/L
Bilirubin Total 0.56 mg/dL
CPK 61 U/L
Calcium 10.56 mg/dL
Sodium 140 mmol/L
Potassium 5.0 mmol/L
Chloride 100 mmol/L
His Lipid Profile:
Cholesterol Total 173 mg/dL
Triglycerides 120 mg/dL
HDL Cholesterol 53.9 mg/dL
LDL (Calculated) 95 mg/dL
This is borderline hypercalcemia so it's hard to know its significance. At his age, transient back pain could be so many things more likely benign than sinister (e.g. myeloma). His normal serum total protein level could argue against overt myeloma but is not that sensitive or specific. Would be interesting to know if serum calcium is persistently elevated. PTH check may be useful but given the borderline level of calcium, may not be too informative. However, his current thyroid status would be useful to know, as uncommonly uncontrolled severe hyperthyroidism can be associated with slight elevations in serum calcium. Was the SIADH diagnosis definite? His medication and dietary history would be useful to know if there is anything contributing to his slightly high calcium. Also curious to know that those large unstained cells refer to, particularly in the setting of slightly raised LDH - is it worth different stains?
Any bone lesions? Clinical or in images? What about proteins electrophoresis?
Dear Dr Lim,
He was on Thiazide Diuretics until he had SIADH. Right now he is on Levothyroxine 125mg daily. His TSH was 4.1 two weeks ago. He is on Glimipiride 1mg/daily for his Diabetes. His hyponatremia could have been caused by all or some of the following Colonic Irrigation, or the use of several drugs ( Diuretics & Xanax), or by encephalitis. The cause was never determined. Paraneoplastic Syndrome was suspected because of an elevated CEA, but a full body work up revealed nothing but a 7mm sessile polyp in the sigmoid colon to be checked soon. He has no weight loss, and no anorexia. He had a fever at the time he developed SIADH.
Dear Dr Moreno,
CT scans done 45 days ago didn't reveal any. Protein Electropheresis was not done.
Calcium at 10.56 and Calcium corrected according to Total Proteins at 10.4 seems below ULN, no current pain, no other symptoms, I'd had a watchful waiting approach; with the exception of the solved SIADH episode, and a mild anisocytic anemia, that could be explained by the Colon Polip, just the high LDH deserves follow up, but transient events as an hemolysis during sample work-up may induce this. A mild Leukocytosis is present, that may come form an acute intercurrent illnes, or be somehting to check in follow-up
No comments exist about the kind of Anti-Hypertensive Therapy, with a T2DM, a good choice may be an ACEI, I like specially Fosinopril, it has a long half-life, a double way of elimination, renal and hepatic, and it induces less cough than others, adding a Calcium Antagonist if BP is not controlled sounds good, as Diuretics, even when being the drug class that most reduces stroke incidence in HT, is connected to a slow but steady decline in renal function in long term use.
If you request a Plasma Electrophoresis, you know that above 50 yo, presence of MGUS is around 2% of population, if you want screening for something having no indication for drug therapy, an Oligo-Secretory/ Quiescent MM is another thing, and want having the associated expenses in follow up and nuisances to the patient, that may include difficulties in finding a Venous Punction site for Blood sampling, you can go ahead with this part of work up. Please keep us updated, good season, + salut
Dear Dr Graymer,
Thank you for your answer. It is very helpful.
Will do.
Thank you, I wish you a good season as well.
Back pain can be due to mechanical causes , which is common or due to inflammatory diseases or malignancy . The investigations are fine . In case , you are worried about calcium level , please check for Parathyroid hormone ( PTH ) level . His back pain seems to have improved & he is asymptomatic at present .
I had some cases of back pain where positive Ab tests for Brucella and/or Salmonella were detected, pain responded to Antibiotics, but in this case, backache seems a past episode, unless it recurs with no clear cut connection to a mechanical cause, I won't consider very much this issue in the differential diagnosis. Would you have CRP measured? Thanks, + salut
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