Laboratory Investigations and Diagnosis:
The patient had a significantly decreased Hemoglobin concentration (Hb),
Hematocrit (HCT), Mean Corpuscular Volume (MCV), Mean Corpuscular
Hemoglobin (MCH), and Mean Corpuscular Hemoglobin Concentration (MCHC)(Table 1) . In addition, his Peripheral Smear revealed
Hypochromic Microcytic Anisocytosis with Teardrop cells. In addition,
his Coagulation Profile was significant for a minutely low Activated
Partial Thromboplastin Time. However, the Prothrombin Time and
International Normalized Ratio were within the expected parameters.
After five days of admission at the hospital, the Liver Profile showed
severely deranged Bilirubin Levels, compared to his pre-admission Liver
Profile (Table 2) . Notably, his serum indirect bilirubin was
markedly increased throughout his stay at the hospital, consequently
showing an exponential rise in serum total bilirubin levels and an
increase in serum direct bilirubin to a lesser degree. After
administration of phenobarbitone, the patient’s serum total bilirubin
declined significantly along with his indirect bilirubin (Table
2) . In addition, there was also a slight decline in his serum GGT and
ALP levels post administration of phenobarbitone. In addition to the
mildly improved Liver Profile post-administration of phenobarbitone, his
scleral icterus also showed marked improvement (Figure 2) .
CN-type two was identified based on the patient’s history, clinical
examination, laboratory findings, and phenobarbital administration
outcomes after ruling out other differential diagnosis such as hemolytic
anemia, gilbert’s syndrome and Chronic Liver Disease(CLD).
Further evaluation revealed a markedly low Serum Ferritin, total
iron-binding capacity, and Serum Vitamin D3 levels. In addition, the
patient blood culture and sensitivity were significant for the growth of
Enterobacter, which was sensitive to Polymixin B, Meropenem, and
Amikacin. On X-Ray examination, The boy’s bony ossification appeared to
give an estimated bone age between 11-12 years. His Upper
Gastrointestinal endoscopy revealed mild astral gastritis(Figure 3) . Duodenal Biopsy showed focal partial villous
blunting, increased intraepithelial lymphocytes, and milk chronic
non-specific inflammation in the lamina propria, subsequently supporting
the diagnosis of Celiac Disease.
Treatment Plan:
The patient was prescribed 2mg/kg of Phenobarbitol twice daily and
vitamin D3 and was scheduled for a follow-up four weeks later which he
did not show up .The patient was discharged from the hospital with
adequate counseling for his condition and lifestyle.