Hematology - Case Studies Flashcards
A 69-year-old woman has been monitored at out hematologic ambulance for 3 years because
of an accidentally discovered, abnormal CBC result. She has a negative cardiovascular anamnesis. She takes 100 mg aspirin daily.
Parameter Value Abn Reference interval
WBC 7.37 G/l 4–10 G/l
Neutrophil 62.1 % 40–70 %
Neutrophil (abs) 4.58 G/l 1.8–7.0 G/l
Lymphocyte 27.3 % 20–40 %
Monocyte 8.6 % H 2–6 %
Eosinophil 1.7 % 0–5 %
Basophil 0.3 % 0–1 %
RBC 4.83 T/l 4.0–5.2 T/l
Hemoglobin 138 g/l 120–150 g/l
HCT 0.42 0.34–0.45
MCV 87.2 fl 80–99 fl
MCH 28.5 pg 27–34 pg
MCHC 327 g/l 315–360 g/l
RDW 15.3 % H 11.5–15.0 %
PLT 791 G/l H 150–400 G/l
MPV 8.1 fl 7.0–12.5 fl
LDH 207 U/l H < 170 U/l
CRP 1.2 mg/l < 8 mg/l
- LDH↑ and PLT↑ → Thrombocytosis and Cellular Turnover
- Regular use of aspirin (No platlet agregation)
- Could be:
- Essential Thrombocythemia: Female and Old age fit, Test -JAK2 Mutation (In 50% of cases),
- Secondary Thrombocythemia (Reactive): here it could be due to a Malignancy - Thrombopoietin
- Tx: Aspirin for conrol, Chemotherapy if Progresses
A 77-year-old woman was admitted to the hospital due tohaving a temperature (occasionally fever) for many months, weight loss and bad headaches on both sides in the frontal area.
Parameter Value Abn Reference interval
WBC 6.28 G/l 4–10 G/l
Neutrophil 62.2 % 40–70 %
Neutrophil (abs) 3.91 G/l 1.8–7.0 G/l
Lymphocyte 26.8 % 20–40 %
Monocyte 7.5 % H 2–6 %
Eosinophil 2.7 % 0–5 %
Basophil 0.8 % 0–1 %
RBC 3.18 T/l L 4.0–5.2 T/l
Hemoglobin 93 g/l L 120–150 g/l
HCT 0.30 L 0.34–0.45
MCV 94.3 fl 80–99 fl
MCH 29.2 pg 27–34 pg
MCHC 310 g/l L 315–360 g/l
RDW 13.0 % 11.5–15.0 %
PLT 456 G/l H 150–400 G/l
MPV 11.2 fl 7.0–12.5 fl
Reticulocyte 1.9 % 0.5–2 %
Reticulocyte (abs) 60.7 G/l 30–100 G/l
Iron 17.5 μmol/l 11–32 μmol/l
Transferrin 1.53 g/l L 2.0–3.6 g/l
Transferrin saturation 53 % H 16–45 %
Ferritin 231 μg/l H 10–120 μg/l
LDH 264 U/l H <170 U/l
CRP 153.56 mg/l H <8 mg/l
ESR 115 mm/h H 1–20 mm/h
ESR↑ and CRP↑ with RBC↓
Acute Phase Proteins: Ferritin↑ and Transferrin ↓
Anemia of Chronic Disease - here it is Temporal Arteritis
Mechanism: Hepcidin - ↓ Iron absorption (by degrading ferroportin) and ↓ Iron release (from macrophages)
Treatment: Corticosteroids
A 77-year-old man who has been monitored in the hematological ambulance since 2009. There is no palpable lymphadenopathy or splenomegaly. There are no general symptoms like weight loss, sweating or fever. There is no increased susceptability for infections. Drug therapy was not required for him yet.
Parameter Value Abn Reference interval
WBC 100.9 G/l H 4–10 G/l
Neutrophil 6.6 % L 40–70 G/l
Neutrophil (abs) 6.71 G/l 1.8–7.0 G/l
RBC 4.41 T/l L 4.5–5.9 T/l
Hemoglobin 133 g/l L 135–170 g/l
HCT 0.39 0.39–0.52
MCV 87.6 fl 80–99 fl
MCH 30.3 pg 27–34 pg
MCHC 346 g/l 315–360 g/l
RDW 15.3 % H 11.5–15.0 %
Reticulocyte 1.8 % 0.5–2 %
Reticulocyte (abs) 77.7 G/l 30–100 G/l
PLT 104 G/l L 150–400 G/l
MPV 8.8 fl 7.0–12.5 fl
Peripheral blood flow cytometry:
There is a lymphocytosis of 74% in the peripheral blood. 63% of all the cells coexpress CD19–CD5–CD23, they are κ monoclonal B cells with low intensity of CD20 expression. These cells are practically free of the CD38 epitope.
WBC↑↑↑, RBC↓, PLT↓ - Malignancy
FACS :
CD19+ and CD5+: CLL
CD23+: NOT Mantel cell Lymphoma
Chronic Lymphocytic Leukemia
Treatment - “Watchfull waiting”, upon symptoms arrival starting the drug supplementation
A 48-year-old woman is referred to the clinic because of anemia. Her hair is thinning and it is brittle. Her nails are flattened and brittle. Her period lasts 8–9 days, during which she loses significant amount of blood, and suffers from cramps.
Parameter Value Abn
Reference interval
WBC 11.04 G/l H 4–10 G/l
Neutrophil 51.3 % 40–70 %
Neutrophil (abs) 5.67 G/l 1.8–7.0 G/l
Lymphocyte 33.9 % 20–40 %
Monocyte 11.8 % H 2–6 %
Eosinophil 1.9 % 0–5 %
Basophil 1.1 % H 0–1 %
RBC 4.26 T/l 4.0–5.2 T/l
Hemoglobin 71 g/l L 120–150 g/l
HCT 0.26 L 0.34–0.45
MCV 61.0 fl L 80–99 fl
MCH 16.7 pg L 27–34 pg
MCHC 273 g/l L 315–360 g/l
RDW 19.8 % H 11.5–15.0 %
PLT 1174 G/l H 150–400 G/l
MPV 9.8 fl 7.0–12.5 fl
Reticulocyte 0.9 % 0.5–2 %
Reticulocyte (abs) 39.2 G/l 30–100 G/l
Iron 2.8 μmol/l L 11–32 μmol/l
Transferrin 4.12 g/l H 2.0–3.6 g/l
Transferrin saturation 3 % L 16–45 %
Soluble TfR 12.6 mg/l H 1.9–4.4 mg/l
Ferritin 9 μg/l L 10–120 μg/l
LDH 176 U/l H <170 U/l
CRP 1.2 mg/l <8 mg/l
Reticulocytes are not elevated - Bone marrow is not compesating !
Microcytic and Hypochromic Anemia
Transferrin ↑ and Ferritin ↓
Most likely to be IDA!
Treatment is related the cause - probably long period related.
*In inflammation Transferrin and Ferritin are going to change opposite way from IDA; Soluble TfR not influenced by Inflammation
A 56-year-old woman is referred to the hospital by the family doctor due to having “too thick blood”. She is a heavy smoker. She has a plethoric complexion and acrocyanosis. Her spleen is
6 cm below the ribs. SatO2: 95%
Parameter Value Abn Reference interval
WBC 23.43 G/l H 4–10 G/l
Neutrophil 91.5 % H 40–70 %
Neutrophil (abs) 21.42 G/l H 1.8–7.0 G/l
Lymphocyte 6.7 % L 20–40 %
Monocyte 1.5 % L 2–6 %
Eosinophil 0.1 % 0–5 %
Basophil 0.2 % 0–2 %
RBC 7.98 T/l H 4.0–5.2 T/l
Hemoglobin 235 g/l H 120–150 g/l
HCT 0.70 H 0.34–0.45
MCV 88 fl 80–99 fl
MCH 29 pg 27–34 pg
MCHC 334 g/l 315–360 g/l
RDW 14.3 % 12–18 %
Reticulocyte 1.4 % 0.5–2 %
Reticulocyte (abs) 110.8 G/l H 30–100 G/l
PLT 947 G/l H 150–400 G/l
MPV 9.6 fl 7.0–12.5 fl
LDH 657 U/l H < 170 U/l
Se uric acid 631 μmol/l H 150–400 μmol/l
ESR 1 mm/h < 20 mm/h
Smoker with Good Oxygen Saturation - Not COPD
Pancythemia - All Blood Cells↑ specifically RBCs
High turnover rate and Tumor Burden - LDH↑ and Uric Acid↑
Acrocyanosis - Relatively too much Hb is not oxygenated (Abs)
Polycythemia Vera - PCR/FISH for JAK2 mutation
tx - Aspirin, Blood draining
A 59-year-old man complains of being very weak and having significant pain in the lower back. He had a long lasting pneumonia two months ago.
Parameter Value Abn Reference interval
WBC 7.29 G/l 4–10 G/l
Neutrophil 56.3 % 40–70 %
Neutrophil (abs) 4.10 G/l 1.8–7.0 G/l
Lymphocyte 29.1 % 20–40 %
Monocyte 9.7 % 2–6 %
Eosinophil 4.4 % 0–5 %
Basophil 0.5 % 0–1 %
RBC 3.16 T/l L 4.5–5.9 T/l
Hemoglobin 94 g/l L 135–170 g/l
HCT 0.29 L 0.39–0.52
MCV 92.4 fl 80–99 fl
MCH 29.7 pg 27–34 pg
MCHC 322 g/l 315–360 g/l
RDW 13.8 % 11.5–15.0 %
PLT 258 G/l 150–400 G/l
MPV 8.9 fl 7.0–12.5 fl
ESR 103 mm/h H < 20 mm/h
Glucose 5.3 mmol/l 4.1–5.9 mmol/l
Sodium 129 mmol/l L 135–146 mmol/l
Potassium 4.4 mmol/l 3.5–5.1 mmol/l
BUN 7.4 mmol/l H 3.5–7.0 mmol/l
Creatinine 89 μmol/l 40–130 μmol/l
eGFR 81.5 ml/min L > 60 ml/min
Se uric acid 496 μmol/l H 150–400 μmol/l
Calcium 2.18 mmol/l L 2.20–2.65 mmol/l
ALP 69 U/l < 120 U/l
LDH 176 U/l < 170 U/l
Total protein 122.6 g/l H 66–83 g/l
β2-microglobulin 4.5 mg/l H 0.9–2.0 mg/l
CRP 3.61 mg/l < 8 mg/l
Immunoglobulins and SPEP (serum protein electrophoresis):
Parameter Value Abn Reference interval
IgG 76.87 g/l H 7.0–16.0 g/l
IgA 0.24 g/l L 0.7–4.0 g/l
IgM 0.10 g/l L 0.4–2.3 g/l
Albumin 30.5 % L 60–71 %
α1-globulin 2.0 % 1.4–2.9 %
α2-globulin 7.8 % 7–11 %
β-globulin 7.7 % L 8–13 %
γ-globulin 52.0 % H 9–16 %
A/G 0.44 L 1.5–2.0
There is an M-component in the γ-fraction: 62.04 g/l
Normocytic Anemia
Hyperproteinemia - could lead to hyperviscosity therfore (A/G ratio is low) ESR ↑
BUN↑ - May indicate Renal Insufficiency
Should run a Gel-Electrophoresis: IgG↑↑↑ and X-ray: Lytic Bone lesions
Bone Marrow Biopsy to determine: if > 10% Plasma cells = Multiple Myeloma
No Hypercalcemia - Idiotypic (CRAB)
A 50-year-old woman. She is known to have SLE, lupus nephritis for 20 years. She is complaining about the sudden appearance of purpura on the legs and hypermenorrhea.
Parameter Value Abn Reference interval
WBC 6.0 G/l 4–10 G/l
Neutrophil 67.1 % 40–70 %
Neutrophil (abs) 4.0 G/l 1.8–7.0 G/l
Lymphocyte 16.9 % L 20–40 %
Monocyte 10.6 % H 2–6 %
Eosinophil 4.7 % 0–5 %
Basophil 0.7 % 0–1 %
RBC 4.27 T/l 4.0–5.2 T/l
Hemoglobin 102 g/l L 120–150 g/l
HCT 0,33 L 0.34–0.45
MCV 78.2 fl L 80–99 fl
MCH 23.9 pg L 27–34 pg
MCHC 305 g/l L 315–360 g/l
RDW 15.9 % H 11.5–15.0 %
PLT 10 G/l L 150–400 G/l
MPV 14 fl H 7.0–12.5 fl
Reticulocyte 0.9 % 0.5–2.0 %
Reticulocyte (abs.) 38.0 G/l 30–100 G/l
Glucose 5.6 mmol/l 4.1–5.9 mmol/l
Sodium 139 mmol/l 135–146 mmol/l
Potassium 4.1 mmol/l 3.5–5.1 mmol/l
BUN 7.3 mmol/l H 3.5–7.0 mmol/l
Creatinine 197 μmol/l H 40–130 μmol/l
eGFR 24.7 ml/min L >60 ml/min
LDH 236 U/l H <170 U/l
CRP 5.54 mg/l < 8 mg/l
- Reticulocyte Value is Normal: This is probably not acute leukemia or bone marrow lesion.
- Lupus Nephritis - Chronic Renal Failure
- Anemia: Hypermennorhea / EPO↓
- PLT↓ and MPV ↑→ Thrombocytopenia (with Accelerated production)
- Diagnosis by exculsion : Idiopathic Thrombocytopenic Purpora: Secondary to SLE
- Conformation: Anti-Platelet Antibodies and FNA
- Tx: IVIG (Overwhelm Spleen) and Splenectomy + Glucocorticoids
An 85-year-old woman has been treated with several antibiotics due to a respiratory infection for the last few weeks. She is having a diarrhea as well, that is getting gradually worse and worse. She has watery, greenish and mucous stools. At the time of admission she in a severe condition due to her fever, abdominal pain and meteorism. Clostridium difficile antigen and
toxin are positive in her fecal sample.
Parameter Value Abn Reference interval
WBC 50.09 G/l H 4–10 G/l
Neutrophil 94.3 % H 40–70 %
Neutrophil (abs) 47.22 G/l H 1.8–7.0 %
Lymphocyte 1.8 % L 20–40 %
Monocyte 3.7 % 2–6 %
Eosinophil 0.1 % 0–5 %
Basophil 0.1 % 0–1 %
RBC 4.35 T/l 4.0–5.2 T/l
Hemoglobin 123 g/l 120–150 g/l
HCT 0.36 0.34–0.45
MCV 83.7 fl 80–99 fl
MCH 28.3 pg 27–34 pg
MCHC 338 g/l 315–360 g/l
RDW 15.0 % 11.5–15.0 %
PLT 401 G/l H 150–400 G/l
MPV 10.6 fl 7.0–12.5 fl
CRP 347.80 mg/l H < 8 mg/l
Procalcitonin 13.90 μg/l H < 0.50 μg/l
Infection with Left Shift - Histology
Toxic Granulation
CRP, Calcitonin, Antigen and Toxins - C. Diff Infection and Inflammation markers
RBC, HCT and Hemoglobin are NORMAL!
Leukemoid Reaction
A middle aged woman. She has been feeling weaker and more tired for two weeks. Her family doctor performed some lab test. and referred her to the hospital based on the results.
Parameter Value Abn Reference interval
WBC 62.71 G/l H 4–10 G/l
Neutrophil % 40–70 %
Neutrophil (abs) 27.59 G/l H 1.8–7.0 G/l
Lymphocyte % 20–40 %
Monocyte % 2–6 %
Eosinophil % 0–5 %
Basophil % 0–1 %
RBC 2.49 T/l L 4.0–5.2 T/l
Hemoglobin 81 g/l L 120–150 g/l
HCT 0.25 L 0.34–0.45
MCV 99.5 fl H 80–99 fl
MCH 32.7 pg 27–34 pg
MCHC 328 g/l 315–360 g/l
RDW 18.3 % H 11.5–15.0 %
Reticulocyte 1.0 % 0.5–2 %
Reticulocyte (abs) 25.0 G/l L 30–100 G/l
PLT 77 G/l L 150–400 G/l
MPV 12.1 fl 7.0–12.5 fl
Prothrombin 77 % 70–120 %
INR 1.13 0.85–1.20
aPTI 30.3 s 28–40 s
Fibrinogen 2.57 g/l 1.5–4.0 g/l
Glucose 5.8 mmol/l 4.1–5.9 mmol/l
Sodium 140 mmol/l 135–145 mmol/l
Potassium 3.8 mmol/l 3.5–5.1 mmol/l
BUN 5.5 mmol/l 3.5–7.0 mmol/l
Creatinine 70 μmol/l 40–130 μmol/l
eGFR 78.2 ml/min > 60 ml/min
Se uric acid 565 μmol/l H 150–400 μmol/l
Calcium 2.59 mmol/l 2.20–2.65 mmol/l
T. bilirubin 7.1 μmol/l < 20 μmol/l
GOT 23 U/l < 50 U/l
GPT 17 U/l < 50 U/l
ALP 89 U/l < 120 U/l
LDH 638 U/l H < 170 U/l
CRP 0.92 mg/l < 8 mg/l
Bone Marrow Dysfunction: WBC↑ + Reticulocyte↓ + PLT↓
Turnover of Blood Cells↑ :Uric Acid↑
Malignancy related Glycolysis - Tumor Burden: LDH↑
AML : Bone Marrow Aspiration, Immunophenotyping, FCM, FISH- all for conformation, prognosis and treatment decision.
A middle aged man complains of reduced tolerance of physical activity and effort dyspnea.His general appearance, however, is fine. His hair and beard are white, throughout his body hehas hypopigmented areas. He noticed to develop hypopigmentated areas 30 years ago, whichgot larger and more numerous. His tongue is smooth, shiny and sensitive. (Vitligo)
Parameter Value Abn Reference interval
WBC 4.13 G/l 4–10 G/l
Neutrophil 57.4 % 40–70%
Lymphocyte 37.5 % 20–40 %
Monocyte 1.2 % L 2–6 %
Eosinophil 3.9 % 0–5 %
Basophil 0.0 % 0–1 %
RBC 1.09 T/l L 4.10–5.10 T/l
Hemoglobin 48 g/l L 123–153 g/l
HCT 0.13 L 0.35–0.45
MCV 122.9 fl H 80–99 fl
MCH 44.0 pg H 27–34 pg
MCHC 358 g/l 315–360 g/l
RDW 18.9 % H 11.6–14.8 %
PLT 114 G/l L 150–400 G/l
MPV 11.1 fl 6.5–12.0 fl
Reticulocyte 1.4 % 0.5–2.0 %
Reticulocyte (abs) 15.3 G/l L 30–100 G/l
Iron 40.3 μmol/l H 13–32 μmol/l
Transferrin 2.0 g/l 2.0–3.6 g/l
Transzerrin saturation 79 % H 16–45 %
Soluble TfR 4.7 mg/l 2.2–5.0 mg/l
Ferritin 421 μg/l H 20–250 μg/l
Vitamin B12 <61 pmol/l L 138–652 pmol/l
Folic acid 34.6 nmol/l 7.0–46.4 nmol/l
T. bilirubin 30.8 μmol/l H <20 μmol/l
D. bilirubin 6.9 μmol/l H <3.4 μmol/l
LDH 2777 U/l H <170 U/l
Haptoglobin < 0.2 g/l L 0.3–2.0 g/l
Direct Coombs test negative
Bone Marrow function impaired- Reticulocytes↓
Hyperchromic Macrocytic Anemia - MCV↑ and MCH↑
Megaloblastic Anemia - Vit. B12↓
Prenicious Anemia - Vitligo could predispose (Autoimmunity moves from organ to organ) with Hunter’s Glossitis.
Ineffective Erythropoesis - Hemolysis↑
+ Iron↑ cause of the large size of RBC, In Bone marrow.
A 19-year-old young man who has had a sore throat and a fever for a week. The is greyishwhite coating on the swollen tonsils. There is lymphadenopathy on the neck. Spleen is palpable.
Parameter Value Abn Reference interval
WBC 15.89 G/l H 4–10 G/l
Neutrophil % 40–70 %
Neutrophil (abs) 3.44 G/l 2.0–6.9 G/l
Lymphocyte % 20–40 %
Monocyte % 2–6 %
Eosinophil % 0–5 %
Basophil % 0–1 %
RBC 5.61 T/l 4.5–5.9 T/l
Hemoglobin 166 g/l 135–170 g/l
HCT 0.49 0.39–0.52
MCV 86.9 fl 80–99 fl
MCH 29.6 pg 27–34 pg
MCHC 340 g/l 315–360 g/l
RDW 14.8 % 11.5–15.0 %
Reticulocyte 1 % 0.5–2 %
Reticulocyte (abs) 56.1 G/l 30–100 G/l
PLT 195 G/l 150–400 G/l
MPV 8.2 fl 7.0–12.5 fl
Glucose 5.2 mmol/l 3.5–5.9 mml/l
Sodium 138 mmol/l 135–146 mmol/l
Potassium 4.1 mmol/l 3.5–5.1 mmol/l
Creatinine 82 μmol/l 40–130 μmol/l
eGFR >90.0 ml/min > 60 ml/min
Se uric acid 365 μmol/l 150–400 μmol/l
T. bilirubin 21.7 μmol/l H < 20 μmol/l
D. bilirubin 8.4 μmol/l H < 3.4 μmol/l
GOT 383 U/l H < 50 U/l
GPT 627 U/l H < 50 U/l
ALP 386 U/l H < 120 U/l
GGT 291 U/l H < 55 U/l
LDH 892 U/l H < 170 U/l
CRP 25.92 mg/l H < 8 mg/l
WBC ↑ but normal RBC and PLT - Not Malignancy
Liver damage and Inflammation - GOT↑ GGT↑ CRP↑
Most probably Infection!
EBV -Infectious Mononucleosis (or CMV )
Monospot test should be done!
Supportive Care Treatment
*Downey cells should be present
A 68-year-old man has been admitted to a neurological ward for having recurrent epileptic seizures. He has been having fever for 3 days. Purpura and suffusion are seen throughout the body. Cranial CT is negative, there is no no sign of ischemia or bleeding.
Parameter Values Abn Reference interval
WBC 13.6 G/l H 4–10 G/l
Neutrophil granulocyte 83.1 % H 40–70 %
Neutrophil granulocyte (abs) 11.3 G/l H 1.8–7.0 G/l
Lymphocyte 13.5 % L 20–40 %
Monocyte 3.1 % 2–6 %
Eosinophil 0.1 % 0–5 %
Basophil 0.2 % 0–1 %
RBC 3.43 T/l L 4.5–5.9 T/l
Hemoglobin 92 g/l L 135–170 g/l
HCT 0.26 L 0.39–0.52
MCV 76.0 fl L 80–99 fl
MCH 27.0 pg L 27–34 pg
MCHC 354 g/l 315–360 g/l
RDW 19.7 % H 11.5–15.0 %
PLT 17 G/l L 150–400 G/l
MPV 6.8 fl 7.0–12.5 fl
Reticulocyte 3.9 % H 0.5–2 %
Reticulocyte (abs) 133 G/l H 30–100 G/l
Prothrombin 96 % 75–125 %
INR 1.03 0.85–1.20
aPTI 30.4 s 28–40 s
Fibrinogen 2.8 g/l 1.5–4.0 g/l
Sodium 137 mmol/l 135–146 mmol/l
Potassium 4.1 mmol/l 3.5–5.1 mmol/l
BUN 16.0 mmol/l H 3.5–7.0 mmol/l
Creatinine 123 μmol/l 40–130 μmol/l
eGFR 53.2 ml/min L > 60 ml/min
Calcium 1.98 mmol/l L 2.20–2.65 mmol/l
T. bilirubin 61.3 μmol/l H < 20 μmol/l
D. bilirubin 30.3 μmol/l H < 3.4 μmol/l
GOT 58 U/l H < 50 U/l
GPT 1 U/l < 50 Ul
Alkaline phosphatase 47 U/l < 120 U/l
GGT 23 U/l < 55 U/l
LDH 918 U/l H < 170 U/l
Total protein 69.3 g/l 66–83 g/l
Albumin 30.1 g/l L 35–52 g/l
CRP 13.79 mg/l H < 8 mg/l
Procalcitonin 0.20 μg/l < 0.50 μg/l
Haptoglobin too low to measure 0.3–2.0 g/l
Direct Coombs negative
Thrombotic Thrombocytopenic Purpora - Involves:
- Renal Insuffeciancy = BUN↑ and eGFR↓
- CNS Abnormalities = Clinical Picture
- Sterile Infalmmation = WBC↑ and CRP↑
- Intravascular Hemolytic Anemia = Haptoglobulin↓, LDH↑, Bilirubin↑, Reticulocytes↑
- Mechanism: ADAMTS13↓→vWF↑→Microthrombi!
- Blood smear should reveal Schistocytes!
- Tx: Plasmapheresis and Glucocorticoids
An 18-year-old woman has been admitted to the ED. She has been complaining of a very intense abdminal pain and weakness for a day. She is a refugee who arrived two weeks ago from a Sub-Saharan country. Orthochromatic Normoblasts in Blood.
Parameter Value Abn Reference interval
WBC 15.63 G/l H 4–10 G/l
Neutrophil 46.0 % 40–70%
Neutrophil (abs) 7.19 G/l H 2.0–6.9 G/l
Lymphocyte 36.5 % 20–40 %
Monocyte 8.5 % H 2–6 %
Eosinophil 8.6 % H 0–5 %
Basophil 0.4 % 0–1 %
RBC 2.30 T/l L 4.1–5.1 T/l
Hemoglobin 72 g/l L 123–153 g/l
HCT 0.21 L 0.35–0.45
MCV 90.9 fl 80–99 fl
MCH 31.2 pg 27–34 pg
MCHC 344 g/l 315–360 g/l
RDW 23.5 % H 11.6–14.8 %
PLT 443 G/l H 150–400 G/l
MPV 7.9 fl 6.5–12.0 fl
Reticulocyte 18.3 % H 0.5–2 %
Reticulocyte (abs) 421.5 G/l H 30–100 G/l
T. bilirubin 33.0 μmol/l H <20 μmol/l
D. bilirubin 5.8 μmol/l H <3.4 μmol/l
LDH 540 U/l H <170 U/l
Haptoglobin too low to measure 0.3–2.0 g/l
Direct Coombs test negative
Hyperegenertaive Anemia - Normoblasts in blood, Loss of RBCs
Intravascular Hemolysis - Haptoglobulin↓
Possible Parasitic Acute Inflammation: by Hypoxia - WBC↑, PLT↑, Eosinophils↑
Sickling of RBCs by Hypoxia - Sickle Cell Anemia
tx- Hydration and Blood Transfusion
(Coombs test to make sure no autoantibodies)
A 50-year-old man. He was anemic all the time as a child, his sclera was frequently yellowish. His father and grandfather was anemic as well. He had splenectomy at the age of 16, he is less
anemic since then.
Parameter Value Abn Reference interval
WBC 5.62 G/l 4–10 G/l
Neutrophil 36.2 % L 40–70 %
Neutrophil (abs) 2.04 G/l 1.8–7.0 G/l
Lymphocyte 47.9 % H 20–40 %
Monocyte 13.7 % H 2–6 %
Eosinophil 2.0 % 0–5 %
Basophil 0.2 % 0–1 %
RBC 4.36 T/l L 4.5–5.9 T/l
Hemoglobin 124 g/l L 135–170 g/l
HCT 0.38 L 0.39–0.52
MCV 86.5 fl 80–99 fl
MCH 28.4 pg 27–34 pg
MCHC 329 g/l 315–360 g/l
RDW 17.4 % H 11.5–15.0 %
PLT 434 G/l H 150–400 G/l
MPV 9.2 fl 7.0–12.5 fl
Reticulocyte 2.6 % H 0.5–2 %
Reticulocyte (abs) 113.4 G/l H 30–100 G/l
T. bilirubin 40.7 μmol/l H <20 μmol/l
D. bilirubin 2.6 μmol/l <3,4 μmol/l
LDH 275 U/l H <170 U/l
Haptoglobin 0.25 g/l L 0.3–2.0 g/l
Haptoglobulin ↓ - Intravascular Hemolysis
LDH and T.Billi ↑ - Hemolytic Anemia
Heredetery Spherocytosis: Round cells are not removed because of the Splenectomy.
(Noromocytic Normochromic Anemia)
No Treatment since it is not severe and spleen is already removed.
A 72 year-old-man lost 5 kg of body weight in 2 months. He complains of having a temperature and sweating. He looks pale. There is no lympadenopathy, however, his spleen is 8 cm below the ribs.
Parameter Value Abn Reference interval
WBC 166.2 G/l H 4–10 G/l
RBC 2.23 T/l L 4.5–5.9 T/l
Hemoglobin 69 g/l L 135–170 g/l
HCT 0.21 L 0.39–0.52
MCV 93.3 fl 80–99 fl
MCH 30.8 pg 27–34 pg
MCHC 330 g/l 315–360 g/l
RDW 20.0 % H 11.5–15.0 %
PLT 359 G/l 150–400 G/l
MPV 9.6 fl 7.0–12.5 fl
Prothrombin 65 % L 75–125 %
INR 1.23 H 0.85–1.20
aPTI 32.1 s 28–40 s
Fibrinogen 3.08 g/l 1.5–4.0 g/l
Glucose 4.9 mmol/l 4.1–5.9 mmol/l
Sodium 135 mmol/l 135–146 mmol/l
Potassium 3.8 mmol/l 3.5–5.1 mmol/l
Creatinine 97 μmol/l 40–130 μmol/l
eGFR 71.9 ml/min > 60 ml/min
Se uric acid 762 μmol/l H 150–400 μmol/l
T. bilirubin 12.1 μmol/l < 20 μmol/l
GOT 13 U/l < 50 U/l
GPT 7 U/l < 50 U/l
ALP 138 U/l H < 120 U/l
LDH 628 U/l H < 170 U/l
CRP 7.25 mg/l < 8 mg/l
CML - Chronic Phase
Splenomegaly and Blasts in periphery
WBC↑, Uric Acid↑and LDH↑ - Cell turnover
Conformation: Bone Marrow Aspiration, Immunophenotyping, FCM, FISH, PCR- (also prognosis and treatment decision)
A 45-year-old man was admitted to hospital because an increased waist circumference and edema of the legs. He has been drinking 10 cans of beer and 5 shots per day for 15 years.
Parameter Value Abn Reference interval
WBC 7.03 G/l 4–10 G/l
Neutrophil 63.9 % 40–70 %
Neutrophil (abs) 4.49 G/l 1.8–7.0 G/l
Lymphocyte 18.9 % L 20–40 %
Monocyte 15.8 % H 2–6 %
Eosinophil 0.7 % 0–5 %
Basophil 0.7 % 0–1 %
RBC 3.3 T/l L 4.5–5.9 T/l
Hemoglobin 127 g/l L 135–170 g/l
HCT 0.38 L 0.39–0.52
MCV 113.6 fl H 80–99 fl
MCH 38.5 pg H 27–34 pg
MCHC 339 g/l 315–360 g/l
RDW 13.7 % 11.5–15.0 %
PLT 116 G/l L 150–400 G/l
MPV 9.8 fl 7.0–12.5 fl
Reticulocyte 1.0 % 0.5–2 %
Reticulocyte (abs) 33.0 G/l 30–100 G/l
Prothrombin 46 % L 75–125 %
INR 1.49 H 0.85–1.20
T. bilirubin 123.0 μmol/l H <20 μmol/l
D. bilirubin 51.7 μmol/l H <3.4 μmol/l
GOT 119 U/l H <50 U/l
GPT 49 U/l <50 U/l
GGT 362 U/l H <55 U/l
ALP 226 U/l H <120 U/l
LDH 232 U/l H <170 U/l
ESR 38 mm/h H 1–20 mm/h
Vitamin B12 703 pmol/l H 138–652 pmol/l
Folic acid 13.4 nmol/l 7.0–46.4 nmol/l
Albumin 27.5 g/l L 35–52 g/l
MCV and MCH ↑ - Macrocytic and Hyperchromatic
No Elevation in Reticulocytes - Underproduction Anemia
B12/Folate are Normal!
Alcoholic Damage to the Liver and Bone Marrow Pruduction - Albumin↓, Billirubin↑ and INR↑+PLT↓
Macrocytic Anemia of Alcoholic Origin
