Introduction:The common presentations of primary pulmonary lymphoma are a lung mass and small nodules.Objective: To describe a case of primary pulmonary lymphoma who was initially diagnosed and treated as the lung abscess.

When patients have mild microcytic hypochromic anemia with slightly increased hemoglobin (Hb) A2 fraction, the most likely diagnosis is beta-thalassemia heterozygosity. But herein we found a patient who had all these hematological parameters but did not have beta-thalassemia heterozygosity. He was a 14-year-old Thai who presented with fatigue and heat intolerance for 2 weeks. His physical examination revealed mild diffuse enlargement of thyroid gland. Blood tests showed Hb 120 g/L, mean corpuscular volume (MCV) 72.1 fL, mean corpuscular hemoglobin (MCH) 23.3 pg/cell, free triiodothyronine (FT3) > 20 pg/mL, free thyroxine (FT4) > 5.0 ng/dL, thyrotropin < 2.5 mIU/L, serum ferritin 51.3 µg/L, Hb A2 3.8%. Besides primary hyperthyroidism, he was diagnosed with beta-thalassemia heterozygosity. After being treated with antithyroid drug for 6 months, his blood tests showed subclinical hyperthyroidism, Hb 146 g/L, MCV 83.3 fL, MCH 26.3 pg/cell, Hb A2 3.0%. Not only the thyroid hormones levels but also the Hb concentration, MCV, and the Hb A2 percentage became normal. Due to this inconsistency, the DNA analysis for beta-thalassemia genes was performed and found negative for numerous common and rare beta-thalassemia genes meanwhile beta-globin gene sequencing appeared normal. It should be concluded that hyperthyroidism could induce slightly elevated Hb A2 percentage and mild hypochromic microcytic anemia in a normal individual, leading to the misdiagnosis of beta-thalassemia heterozygosity. In other words, Hb analysis should not be performed during hyperthyroidism and it should be delayed till achievement of the euthyroid stage.

Either dengue fever or diabetic ketoacidosis can cause the high hemoglobin concentration due to intravascular volume loss. When both entities were found together as in our case, the hemoglobin concentration could access the strikingly high level until either of them could not contribute it. She was a Thai woman with 46 years of age presenting with fever, fatigue and severe sore throat for a few days. The physical examination showed she had mild dyspnea and oral thrush, the temperature was 36.4 degree Celsius, and her pulse rate was 102/min. Her blood tests showed: Hb 18.3 g%, WBC 9,850/mm3, atypical lymphocyte 10%, platelet 16,000/mm3, MCV 89.2 fl, Dengue NS1 antigen-positive, dengue IgG-positive, IgM-weakly positive, KOH preparation of curd from buccal mucosa-positive for budding yeasts and pseudo-hyphae, blood sugar 442 mg%, triglyceride 578 mg%, Na 122.8 mEq/L, K 6.28 mEq/L, Cl 90.6 mEq/L, CO2 9.2 mEq/L, blood ketone 53.6 mmol/L, lactate 4.5 mmol/L, pH 7.257, pCO2 27.4 mmHg, HCO3 11.9 mmo/L, BUN 22.9 mg%, creatinine 0.64 mg%, AST 375 U/L, ALT 224 U/L, alkaline phosphatase 151 U/L. She was diagnosed as having diabetes with diabetic ketoacidosis, dengue fever and polycythemia. She was immediately treated with intravenous fluid therapy to correct the metabolic acidosis, electrolyte imbalance and dehydration, insulin for hyperglycemia, clotrimazole for oral thrush and platelet transfusion. Her high hemoglobin level was dramatically lowered until became normal within one day of therapy whereas she also recovered from DKA although the platelet was progressively lowered every day. It suggested that transient polycythemia was solely contributed by DKA that was triggered by dengue fever hence DKA from dengue fever should be added in the list of unusual causes of transient polycythemia.

Introduction: Iron deficiency anemia has not only been rarely seen among hemoglobin H disease patients but can mask the diagnosis of hemoglobin H disease also.Case Presentation: A 50-year-old Thai woman had marked and progressive anemia with just splenomegaly on the physical examination. Her blood tests showed: Hb 3.8 g%, MCV 50.4 fl, MCH 15.4 pg, ferritin 5.0 ng/ml, serum iron 33 ug/dl, TIBC 123 ug/dl, the Hb analysis using the high-performance liquid chromatography method found only A 2 A, Hb A 2 2.1 %. Iron deficiency anemia was diagnosed and continuously treated with the oral iron tablets. After two months of treatment, her blood showed: Hb 7.7 g%, MCV 69.3 fl, MCH 20.5 pg, reticulocyte 6.0 %, ferritin 6.2 ng/ml, Hb analysis showed: A 2 AH Bart, Hb A 2 1.7 %. The diagnosis of Hb H disease was added. Later Hb H was confirmed by the positive PCR for alpha thalassemia-1, Southeast Asian deletion and alpha thalassemia-2, 3.7 kb deletion, genes. After five months of the iron treatment, Hb 8.8 g%, MCV 59.3 fl, MCH 16.7 pg, ferritin 110.7 ng/ml, Hb analysis: A 2 ABartH, Hb A 2 1.4 %. The band of Hb H was found after Hb concentration was raised even though the ferritin level was still low. Conclusion:The absence or presence of Hb H band of the Hb H disease patient on Hb electrophoresis seemingly depended on the hemoglobin concentration more than the sufficiency of the iron storage.

Hemoglobin Constant Spring (CS) is an abnormal alpha hemoglobinopathy with 172 amino acids. For Hb CS disease, the patients mostly have mild anemia with normocytosis. So far it is very unusual for Hb CS disease to present with acute hemolytic crisis during febrile illness. This paper was aimed to present a case of acute hemolytic crisis during having pneumonia that was later proved to harbor Hb CS disease. A 59-year-old Thai woman presented with fever, dry cough and pallor for 3 days. The physical examination revealed body temperature 38.5 degree Celsius, frank anemia and jaundice. The blood tests showed: Hb 5.1 g%, WBC 18,540/mm 3 , platelet 193,000/mm 3 , MCV 82.3 fl, polychromasia 1+, AST 25 U/L, ALT 18 U/L, direct bilirubin 1.8 mg%, indirect bilirubin 13.5 mg%, sputum C/S yielded H. parainfluenzae and K. pneumoniae, negative direct anti-globulin tests. The chest film was compatible with pneumonia. She responded well to antibiotics and blood transfusion. Four months later, her blood tests showed: Hb 10.5 g%, MCV 82.3 fl, Hb analysis: A 2 ACS, Hb CS 5.8%, Hb A 2 1.4%, indirect bilirubin 4.8 mg%. The alpha-thalassemia-1 (SEA and Thai deletions) was not found. She was finally diagnosed as Hb CS disease that was complicated by acute hemolytic crisis during pneumonia. Although there is no proper explanation why few Hb CS disease patients behave like Hb H disease patients, viz., having mild anemia at the steady state and sudden development of hemolytic crisis during fever, different genetic background of Hb CS is suspected to play role.