CASE 54: TIREDNESS
History
A 22-year-old woman complains of tiredness for 6 months. Her only other symptom is a
gradual increase in frequency of bowel movements from once a day in her teens to two to
three times daily. She has no abdominal pain and has no change in appetite. She says that
the bowel movements can be difficult to flush away on occasions but this is not a consist-
ent problem. She is a non-smoker and drinks rarely. She has been a vegetarian for 5 years
but eats dairy foods and fish regularly. She thinks that her grandmother, who lived in
Ireland, had some bowel problems but she died 3 years ago, aged 68. She is an infant-
school teacher and spends a lot of her spare time in keep-fit classes and routines at a local
gym. She enjoys her work and socializes regularly with a wide circle of friends.
Examination
She is 1.62 m (5 ft 4 in) tall and weighs 49 kg. She looks a little pale and thin. Examination
of her abdomen showed no abnormalities and there are no other significant abnormalities
to find in any other system.
NormalHaemoglobin 10.7 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 98 fL 80–99 fL
White cell count 6.5% 109 /L 3.5–11.0% 109 /L
Platelets 247 % 109 /L 150–440% 109 /L
Red cell folate 44 mg/L #160 mg/L
Vitamin B 12 280 ng/L 176–925 ng/L
Thyroid-stimulating hormone 3.5 mU/L 0.3–6.0 mU/L
Free thyroxine 12.9 pmol/L 9.0–22.0 pmol/LThe blood film is reported as a dimorphic film with remnants of nuclear material
(Howell–Jolly bodies) in some of the red blood cells.INVESTIGATIONS
Questions
- How do you interpret these findings?
- What is the likely diagnosis and how might this be confirmed?