Clinical Case Presentation: Pancytopenia

Question 1

case 1: 48 yo man

• presents to doc with malaise
• recent social history: wide died 11 months ago +++ personal stressors.

PE: pallor.

labs as shown:

interpret and what other tests should be done?

Answer 1

hb low, = anemia

mcv= macrocytic

platelet low= thrombocytopenic

WBc = leukopenic

he is pancytopenic.

pancytopenica can be due to decreased production, increased destruction (bleeding or infection) or sequestration in spleen.

- should look for reticulocytes: may indicate aplastic anemia.

Question 2

case 1 continued: his WBC differential came in. interpret

Answer 2

he still follows the NLMEB, so it’s organized but pancytopenic.

Question 3

Case 1 continued: after Wbc differential, his other labs came in: interpret.

Answer 3

retic count is high– it’s not aplastic anemia. BM is trying to compensate for loss

• bili is high and LDH is high– hemolysis or bleeding? but what accounts for the other aspects of pancytopenia?

Macrocytic– still could be nutritional deficinecy, myelodysplastic, hematological malignancy or metastasis. R/o aplastic anemia.

Question 4

Case 1; nutrititonal tests came in as:

on the slide, what is displayed? what could be the reason behind his pancytopenia?

Answer 4

B12 is very low, anti-IF is positive = pernicious anemia

multinucleated/hypersegmented neutrophil is characteristic of B12/folate deficiency.

pancytopenia is due to pernicious anemia.

Question 5

physical exam features of pernicious anemia

Answer 5

1. macroglossia
2. lemon yellow skin
3. sensory polyneuropathy
4. liver/spleen mild enlargemetn.

Question 6

case 2:

• history of rheumatoid arthritis
• took methotrexate on/pff over years
• no current meds

Hb 49, MCV 88, WBC 3.4, ANC1.6, platelets 20, retics 4.4%

interpret. what would you do next?

Answer 6

anemic, normocytic (probably due to Anemia of chronic of disease from arthritis), WBC lower. ANC is low.

platelets low.

retics high.

her bone marrow is okay because retics are seen… pancytopenia can be due to decreased production, increased consumption/destruction, or sequestration.

decreased production could be due to nutritional, infiltration, or stem cell issue (toxin, chemo).

- may need a bone marrow biopsy.

Question 7

case 2: bone marrow biopsy comes in and shows <20% cellularity. cytogenetics are normal. mild dyserythropoiesis seen (Dyserythropoiesis refers to the defective development of red blood cells, also called erythrocytes. This problem can be congenital, acquired, or inherited.)

what is the dx?

Answer 7

diagnosis: idiopathic aplastic anemia.

even though retics are high, the cellularity is very low.

Question 8

congenital causes of pancytopenia/bone marrow failure

Answer 8

• fanconi’s anemia
• dyskeratosis congenita

Question 9

nutritonal causes of pancytopenia

Answer 9

B12, folate, starvation.

Question 10

infectious/inflammation causes of pancytopenia

Answer 10

HIV, Tb, mycobacterium, fungal infections

• hepatitis
• sarcoidosis.

Question 11

neoplastic causes of pancytopenia/bone marrow failure

Answer 11

Hematological malignancy: AML, ALL, lymphomas, hairy cell leukemia (seen in pts with HIV), myelofibrosis, myelodysplastic syndrome

non hematological malignancy: carcinoma invading bone marrow.

aplastic anemia

toxins causing stem cell death

• chemotherapy
• alcohol
• anti-psychotics/anti-drugs
• radiation.

Question 12

Answer 12

A