Table 1.
The lab findings showed a drastic increase in the number of WBCs (97,610 cells /cumm) along with derangements in PCV, MCV, ESR/CRP, RBC count, platelet count and abnormal iron studies. Electrolytes measurement showed hypokalemia with typical ECG features [Fig. 3.].Ultrasonography showed splenomegaly of size 15cm. The patient was then admitted to the medicine ICU where the serial CBC and electrolytes monitoring was done the results of which are tabulated in Table 2. The peripheral smear performed on the day of admission showed 97,600 cell counts with 36% hyper-segmented neutrophils, 14% band cells, 10% promyelocytes, 20% myelocytes, 8% metamyelomyelocytes, 8% lymphocytes, 4% basophil with microcytic hypochromic anemia and anisocytosis with giant platelets likely thrombocytosis and left shift suggestive of leukemoid reaction [Fig.4.] . The patient had total 3 spikes fever for 2 days post admission, with max documented temperature of 102.2 F. No source of infection was clinically identified. Tests for infective etiology like Scrub typhus, dengue fever, and malaria tests reported negative. Blood culture, high vaginal swab and urine culture did not show growth of any organisms after 48 hours. At ICU, she received 2 pints whole blood transfusion and was managed with injectible antibiotics for covering post-operative sepsis.
Since 4th day of admission, she started complaining of a burning sensation in her hands and feet and headache, following which Inj Clexane was prescribed. Other signs of hyperviscosity syndromes were absent. The patient was under constant monitoring for signs of hyperviscosity and was mobilized. On the 5thDOA, the lab parameters showed hemoglobin of 7.6 gm/dl, WBC count - of 1,66,690 cells/cumm and platelet count of 1,111,000 cells/cumm, thus in order to rule out leukaemia, bone marrow aspiration was planned. Fluid intake was increased. The patient was under further management but due to some financial problems, the patient’s caregivers requested discharge against medical advice. She was advised to follow-up.