Question

A 36 year old African-American male comes to the clinic complaining of fatigue and dark, cola-colored urine for the past five days. He denies fever, nausea or vomiting, recent travel, and i.v. drug use. Past medical history includes ulcerative colitis. Medications include sulfasalazine as well as trimethoprim/sulfamethoxazole which the patient began taking one week ago for a presumed Staphylococcal skin infection. Vital signs are temperature 36.8 C (98.2 F), pulse 78, blood pressure 118/72, respirations 14/min. Physical examination shows scleral icterus and a nontender abdomen without organomegaly. Laboratory evaluation shows: WBC 8.6; Hgb 9.1; Hct 27.3; Platelets 212; MCV 88 fL; Na⁺ 144; K⁺ 4.8; Cl⁻ 101; HCO³⁻26; BUN 14; Creatinine 1.0; Glucose 101; LDH 410 U/L; Haptoglobin 8 mg/dL. Which of the following is the most appropriate next step in management of this patient?

A. Quantitative IgM for hepatitis A virus
B. Begin darbopoietin injections
C. Begin methylprednisolone
D. Discontinue trimethoprim/sulfamethoxazole E. Immediate transfusion of packed red blood cells

Answer 1

The appropriate management for the patient's symptoms is to discontinue trimethoprim/sulfamethoxazole, the drug likely causing hemolytic anemia, especially considering the possibility of underlying G6PD deficiency.

Step-by-step explanation:

The patient presents with signs and symptoms that are suggestive of hemolytic anemia, such as fatigue, dark urine, scleral icterus, and low haptoglobin levels.

Considering his recent commencement of trimethoprim/sulfamethoxazole and his medical history of ulcerative colitis, the most appropriate next step in management would be to discontinue trimethoprim/sulfamethoxazole.

This medication can lead to hemolytic anemia, particularly in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is more prevalent in African-American populations. Discontinuing the drug that is likely causing the hemolysis is the initial management approach.