Swelling, Pain, and Pancytopenia: An Elusive Diagnosis

Stephen Paget, MD


April 04, 2011

My Evaluation

When I saw the patient I was impressed by her normal vital signs, stable weight, marked abdominal distension with mild direct tenderness, muscle tenderness in the thighs and calves, 4+/5 strength in the legs and arms, mild edema to the mid calves (she notes that her legs swell as the days goes on), lack of synovitis, and the absence of rash or adenopathy. Cardiac, pulmonary, ophthalmologic, neurologic (except for the muscle examination), and HEENT examinations were normal.

Laboratory Tests: WBC 2200 with an ANC of 1000, hemoglobin 10.2 with normal red cell volumes and peripheral smear, platelets 120,000, ESR 20, CRP 0.7. AST was 180 and ALT 200, with a normal GGTP 20, alkaline phosphatase, and bilirubin. Albumin was 4.0.

Overview at This Time

Obviously, in a patient with a chronic, systemic illness like this, the usual differential needs to include infection, cancers, and autoimmune disorders. Immediately, though, infection and cancer go down on the list as likely causes of her illness simply because of the disease duration of 3 years.

Key findings included:

  1. Personal/social: She seemed quite reliable, bright, and frustrated. She had to stop working as a teacher mostly because of her severe abdominal pain and distension.

  2. Muscle: Clearly, she presents with muscle weakness and tenderness along with abnormal muscle tests including AST and ALT. I call them muscle tests in this situation because they do arise in both the muscle and the liver, and the rest of her liver function tests were normal.

  3. Leg edema without signs or symptoms of congestive heart failure, renal disease, or protein loss.

  4. Prominent abdominal distension; no organomegaly, weight loss, or history of diarrhea.

  5. Lack of synovitis.


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