Pediatric-Congenital BM failure disorders Flashcards

1
Q

What is the differential diagnosis for congenital bone marrow failure?

A
  1. FA (Fanconi Anemia)
  2. DBA (Diamond-Blackfan Anemia)
  3. DC (Dyskeratosis Congenita)
  4. SDS (Shwachman-Diamond Syndrome)
  5. SCN (Severe Congenital Neutropenia)
  6. CAMT (Congenital Amegakaryocytic Thrombocytopenia)
  7. TAR (Thrombocytopenia Absent Radii Syndrome)
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2
Q

NWhat is the differential diagnosis for Acquired Neoplastic bone marrow failure?

A
  1. Hypocellular MDS
  2. Hairy cell leukemia
  3. Aleukemic leukemia
  4. PNH, T-LGL
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3
Q

List 5 medication can cause BM failure marrow failure?

A

Drugs:
* Chemicals, ionizing radiation
* Toxins (e.g., benzene, glue vapors, arsenic)
* Anti-seizure agents (carbamazepine, phenytoin)
* Antibiotics (sulfonamides, chloramphenicol)
* NSAIDs (phenylbutazone, indomethacin)
* Anti-thyroid medications (methimazole, propylthiouracil)
* Gold

Miscellaneous:
PNH, thymoma, pregnancy, anorexia nervosa, B12 deficiency

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4
Q

List 4 infection can cause BM failure marrow failure?

A

Infection:
Epstein-Barr virus, HIV, other herpes viruses
Seronegative hepatitis
Immune disorders:
Eosinophilic fasciitis, systemic lupus erythematosus, GVHD

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5
Q

List 2 immune diseases can cause BM failure marrow failure?

A
  • Eosinophilic fasciitis
  • systemic lupus erythematosus,
  • GVHD
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6
Q

Miscellaneous:

A
  • PNH
  • thymoma
  • pregnancy
  • anorexia nervosa
  • B12 deficiency
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7
Q

What are the clinical features of Fanconi anemia?

A
  • Bone marrow failure (80% by age 20)
  • No physical findings (~20%)
  • More likely to be diagnosed in adulthood
  • Short stature
  • Microcephaly
  • Cafe au lait spots (intense patchy brown pigmentation)
  • Kidney and thumb malformations

Increased:
MCV, ADA, HbF
Macrocytic anemia

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8
Q

What is the pathophysiology of Fanconi anemia?

A
  • Hypersensitivity to genetic damage due to mutations affecting the Fanconi anemia core complex (FANC) or other proteins in the DNA repair pathway.
  • Progressive DNA damage causing aplastic anemia is uncertain, but it is thought to involve the accumulation of DNA damage in hematopoietic progenitors (HP).
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9
Q

What are the genetics of Fanconi anemia?

A
  • At least 15 different genes can be affected.
  • 8 FA proteins make up the core complex (A, B, C, D, E, F, G, L, and M).
  • > 80% of cases involve mutations in FANC-A, C, or G.
  • FANCD1 is associated with a severe phenotype.
  • The FA pathway coordinates DNA repair in response to genotoxic insults (e.g., detecting interstrand crosslinks).
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10
Q

What is the inheritance pattern of Fanconi anemia?

A
  • Autosomal recessive (usually)
  • or X-linked recessive (FANCB) (rare).
  • FANCR is autosomal dominant (AD).
  • Homozygosity or double heterozygosity is required to cause disease.
  • Very heterogeneous phenotype
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11
Q

What is the lab diagnosis for Fanconi anemia?

A
  • Chromosome breakage studies on phytohemagglutinin-stimulated peripheral blood lymphocytes, cultured with and without clastogenic agents.
  • Report results by comparing chromosomal aberrations to control populations.
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12
Q

What are two clastogenic agents used in Fanconi anemia testing?

A

Mitomycin C
Diepoxybutane

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13
Q

Compare and contrast Fanconi anemia, Ataxia telangiectasia, and Nijmegen breakage syndrome:

A
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14
Q

Name 3 syndromes associated with chromosome fragility.

A
  • Fanconi anemia
  • Ataxia telangiectasia
  • Nijmegen breakage syndrome
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15
Q

What is the association between Fanconi anemia and AML?

A

700-fold increased risk of AML.
30% of FA patients have a solid tumor by age 45.

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16
Q

Fanconi

What are the main problems with HSCT in Fanconi anemia?

A

Only treatment for BM failure and risk of MDS/AML, but doesn’t address non-hematopoietic malignancies.
Inherent chromosomal fragility limits chemotherapy and radiation options, increasing the risk of other cancers.
Difficult to find related stem cell donors without familial disease.

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17
Q

What are the diagnostic criteria for dyskeratosis congenita?

A

1) Two out of four classic features:
* Abnormal reticular skin pigmentation
* Nail dystrophy
* Leukoplakia
* Bone marrow failure (BM failure)
2) Two or more other somatic features associated with DC

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18
Q

What is the underlying pathophysiology of dyskeratosis congenita?

A

Telomeropathy
9 genetic abnormalities affecting telomere maintenance have been identified.
Defective telomere maintenance leads to cellular senescence (aging).

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19
Q

What is the inheritance pattern of dyskeratosis congenita?

A
  • Can be X-linked (DKC1)
  • Can be autosomal dominant or autosomal recessive
  • Genetic heterogeneity
  • Genetic anticipation is prominent (phenotype worsens and appears earlier in second-generation patients)
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20
Q

What is the male to female ratio of dyskeratosis congenita?

A

10:1 (more common in males)

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21
Q

What are the consequences of telomeropathy in dyskeratosis congenita?

A
  • Genomic instability
  • Stem cell loss
  • Defective cellular repair and regeneration → Leads to liver fibrosis and pulmonary fibrosis.
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22
Q

How is dyskeratosis congenita diagnosed?

A

Flow FISH is used to identify telomere shortening in lymphocytes.
Sequencing is done to identify specific mutations.

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23
Q

What are the four main genes involved in dyskeratosis congenita and their inheritance patterns?

A

* X-linked gene:
DKC1 (best characterized form of DC)
Autosomal dominant genes:
TERC, TERT, TINF2
TERT and TERC can also be autosomal recessive

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24
Q

What is Hoyeraal-Hreidarsson syndrome?

A

A severe X-linked form of dyskeratosis congenita
Associated with cerebellar hypoplasia.

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25
Q

What is the most common clinical manifestation of dyskeratosis congenita that is NOT part of the classic triad?

A

Idiopathic pulmonary fibrosis
Patients can also develop hepatic fibrosis.

TRIAD: oral leukoplakia, nail dystrophy, and reticular hyperpigmentation

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26
Q

What is the main cause of mortality in dyskeratosis congenita?

A

60-70% die of bone marrow failure.

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27
Q

What are the two main treatment options for dyskeratosis congenita?

A

Hematopoietic stem cell transplantation (HSCT)
Oxymetholone (an anabolic steroid that improves hematopoietic function in 2/3 of patients)

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28
Q

What is Diamond-Blackfan anemia (DBA)?

A

A congenital bone marrow failure syndrome that causes red cell aplasia (congenital pure red cell aplasia).
No other cytopenias are present.
The underlying genetics are poorly understood.

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29
Q

What are the two treatment options for Diamond-Blackfan anemia?

A

Low dose steroids
Transfusion support

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30
Q

What are the 4 diagnostic criteria for DBA?

A

Age < 1 year
Macrocytic anemia with no other significant cytopenias
Reticulocytopenia
Normal marrow cellularity with a paucity of erythroid precursors

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31
Q

What are the supportive criteria for diagnosing DBA in patients who do not meet the main criteria?

A

Major criteria:
Presence of a gene mutation associated with DBA
Positive family history
Minor criteria:
Elevated ADA activity
Congenital anomalies associated with DBA
Elevated Hgb F
No evidence of another inherited bone marrow failure syndrome

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32
Q

What are the clinical features of Diamond-Blackfan anemia?

A

Progressive reticulocytopenia, usually macrocytic anemia in infancy or early childhood.
Normal cellularity of the BM with decreased or absent erythroid precursors.
Congenital malformations in 50% of patients (craniofacial, thumb or upper limb abnormalities, cardiac defects, urogenital malformations, cleft palate).
Increased risk of malignancies.
Increased risk of endocrine dysfunction.

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33
Q

hat are the bone marrow features of Diamond-Blackfan anemia?

A

Presents in the first year of life with macrocytic anemia.
Paucity of red cell precursors on bone marrow examination.
Normal cellularity with markedly decreased or absent erythroid precursors.

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34
Q

What are the genetics of DBA? Name 5 genes and specify which is most common and which is X-linked.

A

AD genes:
RPS19 (most common, 25%)
RPS7, RPS10, RPS17, RPS24, RPL35A, RPL11, RPS26
XLR gene:
GATA1
Mutations in genes encoding ribosomal subunit proteins, leading to increased p53, favoring apoptosis.

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35
Q

What is the underlying pathophysiology of Shwachman-Diamond syndrome?

A

90% of cases have a mutation in the SBDS gene at 7q11.
The SBDS gene plays an important role in the maturation of the 60S ribosomal subunit, making SDS a disorder of ribosome biogenesis.

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36
Q

What are the bone marrow features of Shwachman-Diamond syndrome?

A

Hypocellular bone marrow with granulocytic hypoplasia.

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37
Q

What are the clinical features of Shwachman-Diamond syndrome?

A

Pancytopenia (often), but primarily neutropenia, which may be cyclical.
Pancreatic exocrine insufficiency.
Growth retardation.
Skeletal abnormalities.

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38
Q

What is severe congenital neutropenia (SCN)?

A

A group of disorders that affect granulopoiesis.
* Typically presents in infancy with severe life-threatening bacterial infections.

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39
Q

1-How many types of severe congenital neutropenia are there?
2- What is the most common type of severe congenital neutropenia, and what gene is involved?

A

1-At least 7 genetic lesions have been identified, each causing different clinical phenotypes.

2- SCN1 is the most common form, accounting for 60-80% of cases.
It is an autosomal dominant disorder caused by mutations in the ELANE gene on chromosome 19p13.3, which encodes neutrophil elastase.

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40
Q

What is the typical inheritance pattern of severe congenital neutropenia?

A

It is variable, but the most common type (SCN1) is autosomal dominant.

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41
Q

SCN

What is the treatment for severe congenital neutropenia?

A

Most cases of SCN respond to treatment with G-CSF (Granulocyte Colony-Stimulating Factor).

42
Q
A
43
Q

TAR

What is TAR syndrome?

A
  • Thrombocytopenia Absent Radii syndrome
  • Genetic disorder characterized by the absence of the radius bone and thrombocytopenia.
44
Q

What are common physical findings in TAR syndrome?

A
  • Absence of the radius bone
  • Thrombocytopenia
  • Other findings: anemia, heart problems, renal conditions.
45
Q

What is the platelet volume in TAR syndrome?

A

Thrombocytopenia with normal platelet volume.

46
Q

What is the mutation in TAR syndrome?

A

Most cases have a variant and a rare null allele at the RBM8A locus.

47
Q

What is Pearson syndrome?

A
  • A multiorgan mitochondrial DNA disorder associated with marrow failure and pancreas dysfunction.
  • Treatment is supportive, and most patients die in infancy.
  • Part of mitochondrial DNA deletion syndromes with overlapping phenotypes:
  • Kearns-Sayre syndrome (KSS)
  • Pearson syndrome
  • Progressive external ophthalmoplegia (PEO)
48
Q

Do we differentiate RCMD from RCUD in children?

A

No, all are categorized as Refractory Cytopenia of Childhood (RCC).

49
Q

What is the most common cytogenetic abnormality in Refractory Cytopenia of Childhood (RCC)?

A

Monosomy 7

50
Q

What is the unique feature of RCC cellularity compared to adults?

A

75% of cases are hypocellular (usually 5-10% of normal cellularity).
Easily confused with aplastic anemia (AA).

51
Q

What are 9 disorders that can mimic Refractory Cytopenia of Childhood (RCC)?

A
  • Aplastic anemia
  • PNH
  • Congenital bone marrow failure syndromes
  • Mitochondrial deletions (Pearson syndrome)
  • Autoimmune disease (ALPS, Rheumatic disease)
  • Metabolic disorders (Mevalonate kinase deficiency)
  • Vitamin deficiencies (B12, Folate, E)
  • Infections (CMV, Parvo, Herpes)
52
Q

What is WHIM syndrome, and what cytopenia is it associated with?

A
  • Warts, Hypogammaglobulinemia, Immunodeficiency, and Myelokathexis.
  • Associated with neutropenia, caused by mutations in** CXCR4.**
53
Q

What is myelokathexis?

A

A congenital disorder causing severe chronic leukopenia and neutropenia.

54
Q

What are the hematologic effects of copper deficiency?

A

Common: Anemia and neutropenia.
Uncommon: Thrombocytopenia.
Can show dysplastic changes (ring sideroblasts, vacuolated erythroids and granulocytes), and mimic MDS.

55
Q

What is Acquired Red Cell Aplasia?

A
  • Acquired production defect in red blood cells due to various etiologies.
  • Results in near absence of erythroid lineage in bone marrow, with normochromic normocytic anemia and reticulocytopenia.
56
Q

What is the MCV in Acquired Red Cell Aplasia?

A

Normochromic normocytic anemia with reticulocytopenia.

57
Q

What are the Medications can cause of Acquired Red Cell Aplasia?

A
  • Recombinant EPO for CRD
  • Antiepileptic medications
  • Azathioprine
  • MMF
  • Chloramphenicol
  • Sulfonamides
  • Isoniazid
  • Procainamide
58
Q

Name 4 infection causes of Acquired Red Cell Aplasia?

A

Parvovirus B19, HSV, HIV, Hepatitis

59
Q

Name 2 collagen vascular causes of Acquired Red Cell Aplasia?

A

SLE, Scleroderma, Dermatomyositis, Polymyositis, Rheumatoid arthritis, Polyarteritis nodosa

60
Q

Name 4 neoplasms causes of Acquired Red Cell Aplasia?

A
  • Thymoma
  • T-cell large granular lymphocytic leukemia (esp. in China)
  • Chronic lymphocytic leukemia
  • MDS (infrequent)
61
Q

Name other causes of Acquired Red Cell Aplasia?other causes

A
  • ABO-incompatible stem cell transplant:
  • Major ABO group mismatch of donor
  • Pregnancy
  • Idiopathic, immune-mediated
62
Q

Is the aplasia caused by viral infections transient or chronic?

A
  • Parvovirus: Transient and self-limited aplastic crisis
  • HIV & immunosuppressed: May be more chronic
63
Q

What is the mechanism of PRCA in Thymoma?

A

** Possible mechanism: Altered function of T lymphocytes.**

  • Abnormal thymus unable to suppress autoreactive T-cell clones, leading to suppression of erythropoiesis.
  • Thymectomy can lead to systemic autoimmune disorders over time.
64
Q

How does the disease course for pure red cell aplasia differ between adults and children?

A

In children: Acute, self-limited form is more common.
In adults: Chronic, persistent forms are more common, often secondary to an underlying disease.

65
Q

???

The work-up for pure red cell aplasia should always include investigation of?

A

Various underlying secondary causes.

66
Q

What are the peripheral blood findings in pure red cell aplasia?

A

Isolated normochromic normocytic anemia
Low reticulocyte count
Unremarkable red cell morphology

67
Q

What are the bone marrow findings in pure red cell aplasia (PRCA)?

A
  • Normocellular bone marrow
  • Normal numbers of granulocytes and megakaryocytes
  • Near absence of erythroid cells (pure red cell aplasia)
  • No significant dysplasia in any cell lineage
68
Q

How does parvovirus B19 cause transient arrest in erythropoiesis or PRCA?

Besides erythrocytes, where else is P antigen expressed?

A

*** Virus selectively enters erythroid progenitors **and is toxic to them.
* P antigen is the receptor for parvovirus B19.
* Normal individuals produce antibodies to destroy the virus and resolve infection.
* In patients with hemolytic disorders (e.g., HS, SS), it can cause transient aplastic crisis.
* In immunosuppressed patients who can’t produce antibodies, it can cause chronic PRCA.

Platelets, heart, liver, lung, kidney, endothelium, synovium.

69
Q

Why is parvovirus resistant to heat/detergent inactivation?

A

Lack of envelope.

70
Q

How is parvovirus transmitted?

A

Respiratory droplets (community-acquired, most common).
Blood products (rare transmission via transfusion).

71
Q

How is parvovirus normally cleared in healthy individuals?

A

By antibody-mediated rapid clearance

72
Q

What is the issue with parvovirus in immunocompromised individuals?

A

Unable to produce virus-neutralizing antibodies and clear the virus.
Develops persistent infection and chronic hypoproliferative anemia.

73
Q

What is the incidence of parvovirus?

A
  • Very common in the general population, with seroprevalence increasing with age.
  • Up to 80% of adults have been exposed.
74
Q

How quickly do immunocompetent individuals clear a parvovirus infection?

A

Within 5-10 days.

75
Q

What are the peripheral blood findings in parvovirus-induced red cell aplasia?

A

Normochromic normocytic anemia
Normal erythrocyte morphology
Markedly reduced reticulocyte count

76
Q

What are the 9 categories of presentation for parvovirus B19?

A
  • Subclinical
  • Transient aplastic crisis (immunocompromised)
  • Transient red cell aplasia (HbSS patients)
  • Sustained pure red cell aplasia (immunocompromised)
  • Erythema infectiosum (slapped cheek or fifth disease)
  • Hydrops fetalis (congenital red cell aplasia)
  • Migratory polyarthropathy (adult women)
  • Onset of autoimmune/CVD
  • Meningoencephalitis
77
Q

What is erythema infectiosum?

A

Parvovirus B19 infection (fifth disease), characterized by a “slapped-cheek” rash.
No anemia or other sequelae.

78
Q

What is the classic bone marrow finding in parvovirus-related PRCA?

A
  • Paucity of erythroid precursors (especially late-stage)
  • Pronormoblasts with viropathic changes, including large size and nuclear pseudoinclusion (lantern cell)

No significant erythroid maturation
Normal myeloid and megakaryocytic lineages
Markedly increased M/Eratio due to erythroid hypoplasia

79
Q

Who is at risk for sustained red cell aplasia in parvovirus infection?

A

Immunocompromised patients (hematologic malignancies, HIV/AIDS, SLE, SCID, bone marrow transplant).

80
Q

What are the lab tests for parvovirus B19?

A

CBC: Normocytic, normochromic anemia, low/absent reticulocytes.
Serology: IgG and IgM.
PCR for parvovirus.

81
Q

What is the treatment for parvovirus-induced red cell aplasia?

A

No specific medication.
IVIG for immunocompromised/pregnant patients.
Vaccine research is ongoing.

82
Q

What is the prognosis for parvovirus-induced red cell aplasia?

A

Full recovery in immunocompetent individuals.
Relapse/persistence in immunocompromised individuals.

83
Q

What additional test can be performed on bone marrow to look for parvovirus?

A

Immunohistochemistry for parvovirus B19:
Positivity in rare remaining erythroid precursors
Very high specificity
Moderate sensitivity (negativity does not exclude parvovirus)

84
Q

What investigations are useful in the work-up for PRCA?

A
  • History of medications and toxins
  • Evaluation for infections (e.g., parvovirus PCR, HIV, viral serologies)
  • Liver and kidney function tests
  • Immunologic evaluation (including autoantibodies)
  • Bone marrow examination to confirm red cell aplasia and investigate for leukemia/lymphoma
  • Chromosomal analysis for clonal malignancy
  • PCR-based T-cell gene rearrangement (for clonality in T-LGL)
  • Imaging to rule out thymoma or other solid tumors
85
Q

What are the treatment options for PRCA?

A
  • Corticosteroids
  • Cyclophosphamide
  • Cyclosporin A
  • Antithymocyte globulin
  • Rituximab (anti-CD20 monoclonal antibody)
  • Alemtuzumab (anti-CD52 monoclonal antibody)
  • Intravenous immunoglobulin (IVIG) (treatment of choice for parvovirus B19-related PRCA)
    *
  • Surgical approaches:
    Thymectomy (if thymoma is the cause, but often requires adjuvant immunosuppressive therapy)
86
Q

What are the therapy for refractory cases of PRCA?

A
  • Splenectomy
  • Plasmapheresis
  • Bone marrow transplant (rarely indicated)
87
Q

Which drug is favored for treating PRCA associated with parvovirus B19 infection?

A

Intravenous immunoglobulin (IVIG)

88
Q

What is the target of Alemtuzumab?

A

Anti-CD52 monoclonal antibody

89
Q

What is Transient Erythroblastopenia of Childhood (TEC) and what is the typical age of presentation?

A
  • Erythroblastopenia with anemia.
  • Median age of presentation: 18-26 months (can affect children aged 6 months to 10 years).
  • I**diopathic, self-limited red cell aplasia **characterized by:
  • Normocytic/normochromic anemia
  • Reticulocytopenia
  • Decreased erythroid lineage in the bone marrow
90
Q

What is the clinical course of Transient Erythroblastopenia of Childhood (TEC)?

A

Most patients recover completely within 1–2 months.
Some cases may last 18-24 months or longer.

91
Q

What is the etiology of Transient Erythroblastopenia of Childhood?

A

Unknown, but thought to be triggered by viral infection.
Possible immune-related disruption of erythropoiesis.

92
Q

Who gets TEC?

A

Rare disorder: 4.3 per 100,000 children ≤ 3 years.
Usual age = 1-4 years.
Equal male-to-female ratio.

93
Q

How long does TEC last and does it recur?

A

TEC is transient, with spontaneous recovery within 1-2 months.
NO recurrence.

94
Q

What is the long-term survival impact of TEC?

A

None. It is transient and has no effect on survival.

95
Q

What lab tests should be done in a suspected case of TEC?

A

CBC with reticulocyte count
Blood smear
EPO (increased)
Parvovirus PCR (negative)

96
Q

Is Parvovirus positive or negative in TEC?

A

Negative

97
Q

What is the treatment for TEC?

A

None, occasional transfusion may be required.

98
Q

What are the peripheral blood findings in TEC?

A

Normocytic normochromic anemia
Reticulocytopenia
Minimal anisopoikilocytosis
Platelets and WBCs are morphologically normal

99
Q

What are the bone marrow findings in TEC?

A
  • Markedly reduced erythroid lineage
  • Only scattered erythroblasts in marrow
  • No parvovirus cytopathologic effects (no lantern cells)
  • Hematogones may be abundant
100
Q

What is the differential diagnosis for TEC, and how is it differentiated?

A

Parvovirus
PCR testing
Viral inclusions/cytopathic effect (lantern cells)

Diamond-Blackfan Anemia
Genetic testing (RPS19, RPS7, GATA1)
Dysmorphic features, family history
DBA vs. Parvovirus-induced RCA vs. Acquired RCA

101
Q
A