The Syndrome of High-titre Cold Haemagglutination
Authors: M. G. Nelson, R. J. Marshall
Journal: BMJ (1953)

Case 3A man aged 43 was well until December, 1949, when he first noticed swelling of both ankles.This subsided spontaneously during the next few weeks.In October, 1950, he first complained of diarrhoea, characterized by four or five frothy, yellowish, watery stools a day.This continued intermittently for eleven months and he was admitted to the Royal Infirmary, Edinburgh, on September 14, 1951, for investigation.During the preceding months he had lost 42 lb.(19 kg.) in weight in spite of a reasonably good appetite.There was no history of abdominal pain.The family, social, occupational, and past histories revealed no information of diagnostic value.On examination he was seen to be a thin, pale, middle- aged man.The tongue was atrophic.The respiratory, nervous, and cardiovascular systems were normal except for the presence of hypotension; his blood pressure was 90/60.The liver and spleen were not palpable and no abdominal masses were felt.He had gross clubbing of the fingers.There was minimal sacral oedema, but a moderate degree of bilateral ankle swelling.X-ray exanination of the chest, urine analysis, and the stool benzidine test were negative.The initial blood count was haemoglobin, 69% ; red cells, 4,600,000; colour index, 0.75; mean corpuscular volume, 86.9 I3.The serum calcium was 7.7 mg. per 100 ml., and Trousseau's sign was positive.The serum sodium equalled 136 mEq./l.(312 mg. per 100 ml.); serum potassium, 4.1 mEq./l.(16 mg. per 100 ml.); plasma albumin, 2.37 g.%;and plasma globulin 2.21 g. %.Liver-function tests were negative.The Robinson-Kepler-Power water test gave a positive result.The glucose-tolerance curve was flat.17ketosteroid excretion was 8.4 mg. per 24 hours.A threeday fat-balance study showed that there was only 66% fat absorption and a barium meal gave evidence of a "defi- ciency" pattern.About a month after admission the patient developed frank tetany with carpal spasm.This was relieved with antitetanic therapy, including calcium gluconate, " parathor-mone," and vitamin D. The Sulkowitch test consistently revealed the absence of calcium from the urine.A diagnosis of idiopathic steatorrhoea -was made and he was given folic acid, 20 mg.daily, ferrous sulphate, 4 gr.(0.26 g.) thrice daily, multivitamin therapy, added salt (10 g. daily), and added protein (" casinal "), 100 g. daily.A total of 100 mg. of intravenous iron was given during his last week in hospital.At the time of his discharge (December 11) he was subjectively much improved.Moreover he had gained 28 lb.(12.7 kg.) in weight, the blood pressure had risen to 100/74 and the serum calcium to 11.3 mg. per 100 ml.The haemoglobin level was 77%.He was having only one or two stools a day and was completely free of oedema.He returned to work during January and February, 1952, but had to stop because of weakness.In May he developed colicky abdominal pain which gradually increased in severity.Laparotomy was carried out in another centre, and a tumour of the ileum was found completely obstructing the intestinal lumen.Microscopically this was a reticulosarcoma which had invaded the adjacent mesenteric glands.The tumour was resected.Although relieved of his obstruc- tive symptoms the patient continued to feel tired and was readmitted to the Royal Infirmary, Edinburgh, in September.The liver was now palpable three fingerbreadths below the right mid-costal margin and a chest x-ray film showed consolidation in the left lower lobe with a large hilar shadow on the left side, suggesting metastatic tumour formation.The patient has continued to become progressively weaker. Summary and ConclusionsTwo cases of tumour of the small intestine are pre- sented in order to emphasize that an obscure anaemia may exist for months or years before obstructive symp- toms occur, an abdominal mass is felt, or positive radio- logical evidence is obtained.The difficulty in arriving at an early correct diagnosis is evident.It is suggested