That ring on her eyes

A story of a girl 

Trishna, a 19 year old innocent girl from remote salyan gets pregnant in her late teens only to  find herself the changes during her pregnancy that she didn't expect.  She had eloped with a guy, whom she met in a mela. They instantly  fell in love with each other. The unacceptability of intercaste marriage in the home of the boy pressurized their brains ,overwhelmed with dopamine ,to marry each other despite any threats.   It is  often forgotten that Love is a blind chemical phenomenon for the brain when one is in love.  The hormone,  oxytocin creates commitment. The hormones,  oestrogen and  testosterone establishes the attraction. Hypothalamus sits on the throne of pleasure , which cant be dethroned easily. 

Her underprivileged life was crawling smoothly till seventh month of pregnancy. She often had thrilling kicks of the baby that would send her assurance of the baby being well. She was assured to be normal on her antenatal visits. She was happy with the atmosphere except for some malaise and fatigue.  Her destiny had an ugly turn when  she noticed yellow discoloration of urine ,and her beautiful eyes gradually turned deep yellow in a few days. Lethargy, feeling of unwell and pounding sensation in ears and heart kept tormenting her from the full moon of last fortnight. She would be short of breath if she climbed a few stairs.  Her tummy had an ache. It ached distinctly on her right upper tummy. She didn’t feel like eating anything, even her favorite Jilebi. She had occasional vomiting.   She never complained of itching. She never knew the taste of alcohol in her life. 

On her visit to the district hospital, she was given four pints of blood. On contrary to common belief of ill fate after letting blood down in a blood bag for transfusion , her husband stood surprisingly as a radical man by letting his blood down  to transfuse. It was a rare phenomenon in that orthodox society.   Buildings and doctors only don’t make a complete health service. It requires trust of people and adequate investigations in the area.  

With great hopes ,she arrived at emergency room in teaching hospital, a well trusted tertiary centre. To her disgust, she accommodated with three patients in a single bed. It was quite a sight to portray plight of common people like her. One sitting on corner of the bed, one with head on one end and next one with head on the opposite of the bed.  Pregnancy awakened sympathy in service providers . Fortunately , she got quickly admitted on next day of arrival. It  was an occasional occurrence. 

She was  ill looking and pale. Her deep yellow eyes caught obvious attention.  Doctors came in the morning rounds as a routine. The fixed bed with green bed sheet didn’t seem to suffice her health condition.   The doctors shifted her to a bed with monitor. Her life lines on ECG appeared normal that provided a sigh of relief to them. She had her heart beat beating quite slower than usual ,only 56 bpm, though regular. Her jaundice was assumed to be the sole culprit for the lazy heart. 

After a good discussion, it was concluded that she had red cells breaking on her body causing the yellowish pee and complexion of body.  Her blood pressure was normal and so was her oxygen level in her body.  The fatigue and lethargy was attributed to the low hemoglobin, the carrier of oxygen in human body.  She winced with pain on touching her abdomen. The doctors could feel her soft tender  liver a palm breadth below the costal margin.  Was it pregnancy related illness .? That was the prime question. She had normal platelet number and normal clotting property on her blood test. The kidneys were working  fine. She was alert and talking relevant. 

Meanwhile, we can’t forget the  baby inside her , can we ? She had fewer kicks than before. The baby appeared to meditate  well inside. However, the risk of baby not getting awake from meditation was not a good news to mother. Did she have virus causing hepatitis ? She threw spikes of fever as well.  However it wasn’t convincing for the jaundice to last that long with same intensity and Red blood cells don’t break that sadly in viral hepatitis. Everyone was running for an alternative explanation.  The doctors from eye department found yellowish eyes only.  The radiologist didn’t find any explanation in her abdomen scan. By then, the  major diseases affecting liver in pregnancy were excluded. She had no kins suffering from such a disease. What would have been your next step ? 

The labs didn’t show any viral cause. Neither she had malaria nor any infectious cause.  Did she have stones in her gall bladder ?  It didn’t seem so with normal abdominal scan. But,  amateurs could potentially miss the stones in bile duct.  CT scan was not a pleasant  option with a baby in her uterus.  Fever, pain and jaundice couldn’t be explained even after two weeks quest for diagnosis. She didn’t have pus in her liver. She didn’t have stones in path of bile that could mount ascending infection in bile ducts. She didn't´t have collections in her body  cavities. So ,where  was the crux of the disease ? 

The doctors couldn’t establish lupus also. She didn’t have antibodies conspiring against herself.  She had normal iron status in her body.  It´s a fact that the liver does partiality on protein synthesis in pregnancy. It was no surprise she  had subnormal  albumin and normal ceruloplasmin.  

The attention was focused on some rare causes with simpler tests. It wouldn't´t be a popular decision to put a needle in her liver to get a tissue for biopsy. She was asked to collect urine for 24 hrs. Her urine flew by air to India for the test. The result showed that  she was excreting plenty of copper in urine exceeding 100 mcg.  Could copper overload in liver be the cause of her illness ?  The leading doctor was however not convinced with the initial normal eye  finding. So, he again asked opthalmologist  to look precisely for  a ring on cornea. That time, she was found to have ring in her eyes, popularly known as Kayeser Fleischer Ring.

 The culprit copper was confidently blamed for the illness.  Copper on liver,  eyes and red blood cells created such a  fuss in her body. However, the books mention the famous ring to be present only on 40 pc cases with liver disease.  She was started on zinc tablets and penicillamine immediately. She fully recovered from her illness slowly with the very simple treatment. She has been doing fine till now. So, what was she suffering from ?

Comments

  1. Very well expressed case. And A beautiful medical literature, very good for educational purpose. Seems she was suffering from Wilson`s disease ? Can We write Case study for journal of this case ?. Please keep writing such articles.

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  2. Ring on her eyes . Its really interesting topic.

    ReplyDelete
  3. Very interesting doc. Lets write a case report if you think it can be written

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    1. File lost. No records. Records in memory only

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