Case History Theme : Pruritis

 Case History

Theme : Pruritis

A 55 year old female presents to you with complaints of pruritis and rash over her lower legs.

According to her she has also lost weight recently.

She says that that she took ponston forte tablet and afterwards she developed pruritis and lesions on skin.

She also complains of developing constipation at times as well and abdominal distension.

You look at her investigations and find Anti HCV test positive in one of lab reports.

On asking about Anti HCV result , she says she received some treatment for it for about 6 months but has no record of it/.

What is the most likely cause of her pruritis ?

Which investigations would you like to order?

Answers given in comments section

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Question 1 :

What is the most likely cause of her pruritis ? There are two possibilities :

1. Allergic reaction due to Ponstan forte / Mefenamic acid

2. Chronic liver disease causing raised bile salts leading to pruritis.

Question 2 : Which investigations would you like to order?

1. Ultrasound of abdomen

2. HCV by ELISA method

3. HCV PCR qualitative.

As is given in the history, the patient has Anti HCV Serology positive. However she has not told anything about her treatment whether she was given proper treatment with antiviral medications or just supportive treatment was given .

Hence it is important that her investigations need to be done including HCV PCR and ELISA methods to confirm definite diagnosis of hepatitis C Infection.

Also , we need to exclude chronic liver disease by examining for presence of ascites and ordering an ultrasound of abdomen which will show presence of cirrhosis/ coarse echo texture and ascites , splenomegaly and increased portal vein diameter.

Intense itching could be due to bile products being deposited in the skin . The scarring of the liver in chronic liver disease causes an increase in blood levels of a coloured pigment called bilirubin that is normally secreted by liver cells.

Also advise patient against use of ponstan forte in future as it could be very likely this was just an allergic reaction to Ponston forte in case all investigations for hepatitis C are found to be negative ie ELISA and PCR and Ultrasound abdomen is normal.