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22nd May 2023
A 48-year-old Greek man presents to the acute medical unit with jaundice and lethargy
A 48-year-old Greek man presents to the acute medical unit with jaundice and lethargy. He has no recent history of fevers or weight loss. His past medical history includes epilepsy, hypertension, and hyperlipidaemia. His regular medications include sodium valproate, ramipril and atorvastatin. He saw his GP last week due to dysuria. Urine dip showed:
| Nitrites | + |
| Leucocytes | + |
| Glucose | ++ |
| Ketones | Neg |
Random blood glucose was 14mmol/L and HbA1c was 60mmol/mol. He was given a course of nitrofurantoin for a urinary tract infection and started on metformin for a new diagnosis of diabetes.
Blood tests today show:
| Hb | 115 g/L | Male (135-180 g/L) |
| WBC | 8.3 x 10⁹/L | (4.0-11.0 x 10⁹/L) |
| Platelets | 200 x 10⁹/L | (150-500 x 10⁹/L) |
| MCV | 90 fL | (82-100 fL) |
| Bilirubin | 30 μmol/L | (3-17 μmol/L) |
| ALP | 85 μmol/L | (30-100 μmol/L) |
| ALT | 25 IU/L | (3-40 IU/L) |
| GGT | 40 IU/L | (8-60 IU/L) |
| LDH | 350 U/L | (100-250 U/L) |
| Direct antiglobulin test | Negative |
Blood film shows bite cells and Heinz bodies.
Given the likely underlying diagnosis, what was the most likely trigger for his symptoms?
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