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FBC Cases

FBC Cases. Vernon Louw Clinical Haematology 2010. For each of the following patients, select the most likely finding from the analysis of the peripheral blood. A patient with infectious mononucleosis. A Anaemia B Lymphocytosis C Lymphopenia D Neutropenia E Neutrophilia

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FBC Cases

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  1. FBC Cases Vernon Louw Clinical Haematology 2010

  2. For each of the following patients, select the most likely finding from the analysis of the peripheral blood.

  3. A patient with infectious mononucleosis. • A Anaemia • B Lymphocytosis • C Lymphopenia • D Neutropenia • E Neutrophilia • F Pancytopenia • G Polycythaemia • H Reticulocytosis • I Thrombocytopenia • J Thrombocytosis

  4. Answer • B. Lymphocytosis. Many viral infections, including infectious mononucleosis, cause a lymphocytosis.

  5. A patient who just started treatment with B12 and folate for megaloblasticanaemia. • A Anaemia • B Lymphocytosis • C Lymphopenia • D Neutropenia • E Neutrophilia • F Pancytopenia • G Polycythaemia • H Reticulocytosis • I Thrombocytopenia • J Thrombocytosis

  6. Answer • H. Reticulocytosis. The administration of haematinics results in a brisk increase in erythropoiesis with a transient rise in the peripheral blood reticulocyte count.

  7. Reticulocytes • Juvenile RBCs • Contain remnants of RNA and ribosomes • # reticulocytes reflects erythropoietic activity

  8. Pearl A reticulocyte count is one of the most underused, yet one of the most valuable tests to decide on the cause of an anaemia!!

  9. The “shift” phenomenon • Young, very large reticulocytes, that usually remains in the BM 2 or 3 days before release, are shifted out into the PB under the stimulus of high levels of erythropoietin • “Shift cells” are common when anemia is severe and develops rapidly

  10. “Shift cells” • Shift cells are bigger than RBCs • May result in an elevated MCV • Reported as polychromasia

  11. Reticulocyte Production Index • Reticulocyte count is used to assess the appropriateness of the BM response to anemia. • It must be corrected for the anemia to give a value known as the reticulocyte production index (RPI)

  12. Reticulocyte index Hct (%) Marrow retics (days) PB retics (days) 45 3.5 1.0 3.0 1.5 35 25 2.5 2.0 15 1.5 2.5

  13. Reticulocyte Production Index patient HCT RPI = Reticulocyte count x normal HCT

  14. Hypoproliferative Renal failure Aplastic Anemia MDS Bone Marrow infiltrate Bone Marrow suppression or failure Sepsis Chemotherapy or radiotherapy Blood transfusion !! Maturation disorder Iron Deficiency Anemia Vitamin B12 Deficiency Folate Deficiency Anemia of Chronic Disease Endocrine deficiencies Thalassaemia Sideroblastic Anemia RPI < 1% (Decreased RBC production)

  15. RPI > 3% (Increased RBC production) 1. Acute blood loss 2. Acute hemolytic anemia • E.g. Autoimmune hemolytic anemia • Usually ARC > 100 x10^6/L and Retic Count >2% 3. Post-Anemia Treatment • Folate Supplementation • Iron Supplementation • Vitamin B12 Supplementation 4. Post-Splenectomy 5. Hemoglobinopathy • Sickle Cell Anemia • Thalassemia major 6. Discontinuation of marrow suppression • e.g. withdrawal of alcohol

  16. A patient with chronic renal failure. • A Anaemia • B Lymphocytosis • C Lymphopenia • D Neutropenia • E Neutrophilia • F Pancytopenia • G Polycythaemia • H Reticulocytosis • I Thrombocytopenia • J Thrombocytosis

  17. Answer • A. Anaemia. There are several mechanisms that may result in anaemia in patients with chronic renal failure, the most important being a reduced production of erythropoietin. Other mechanisms include iron deficiency due to blood loss from the gastrointestinal or genitourinary tracts, folate loss into the dialysate and shortened red cell survival.

  18. Hypoproliferative Renal failure Aplastic Anemia MDS Bone Marrow infiltrate Bone Marrow suppression or failure Sepsis Chemotherapy or radiotherapy Blood transfusion !! Maturation disorder Iron Deficiency Anemia Vitamin B12 Deficiency Folate Deficiency Anemia of Chronic Disease Endocrine deficiencies Thalassaemia Sideroblastic Anemia RPI < 1% (Decreased RBC production)

  19. A patient with chronic obstructive pulmonary disease. • A Anaemia • B Lymphocytosis • C Lymphopenia • D Neutropenia • E Neutrophilia • F Pancytopenia • G Polycythaemia • H Reticulocytosis • I Thrombocytopenia • J Thrombocytosis

  20. Answer • G. Polycythaemia. Chronic hypoxia stimulates the production of erythropoietin causing an increase in the red cell mass.

  21. A patient with disseminated intravascular coagulation. • A Anaemia • B Lymphocytosis • C Lymphopenia • D Neutropenia • E Neutrophilia • F Pancytopenia • G Polycythaemia • H Reticulocytosis • I Thrombocytopenia • J Thrombocytosis

  22. Answer • I. Thrombocytopenia. The intravascular coagulation depletes peripheral blood of platelets.

  23. A 60 year-old woman with a history of thyrotoxicosis complains of easy bruising and recurrent blood blisters in her mouth. Her white cell count is 1 x10^9/L, platelets 20 x10^9/L and the haemoglobin is 6 g/dl. • A Aplasticanaemia • B Folic acid deficiency • C Iron deficiency • D Multiple myelomatosis • E Myelofibrosis • F Peptic ulcer disease • G Pernicious anaemia • H Rheumatoic arthritis • I Vitamin B12 deficiency • J Vitamin C deficiency

  24. Answers • A. Aplasticanaemia. This patient’s pancytopeniasuggess marrow failure (aplasticanaemia). A bleeding tendency is the most common presentation of this disorder. In about half the cases, there is a history of exposure to an incriminating drug. The history of thyrotoxicosis was relevant in that this woman was taking carbimazole.

  25. Hypoproliferative Renal failure Aplastic Anemia MDS Bone Marrow infiltrate Bone Marrow suppression or failure Sepsis Chemotherapy or radiotherapy Blood transfusion !! Maturation disorder Iron Deficiency Anemia Vitamin B12 Deficiency Folate Deficiency Anemia of Chronic Disease Endocrine deficiencies Thalassaemia Sideroblastic Anemia RI < 1% (Decreased RBC production)

  26. Aplastic anaemia • Usually pancytopenia

  27. A 35 year-old woman with irregular periods complains of fatigue. She has aHbof 8 g/dl with a low MCV and a low MCHC. Gastroscopy is normal. • A Aplasticanaemia • B Folic acid deficiency • C Iron deficiency • D Multiple myelomatosis • E Myelofibrosis • F Peptic ulcer disease • G Pernicious anaemia • H Rheumatoic arthritis • I Vitamin B12 deficiency • J Vitamin C deficiency

  28. Answers • C. Iron deficiency. This patient’smenorrhagia resulted in excessive blood loss and iron deficiency anaemia. The low mean corpuscular volume and mean corpuscular haemoglobin concentration are in keeping with that diagnosis.

  29. Laboratory findings • MCV (microcytosis) • MCH (hypochromia) • ferritin •  BM iron stores

  30. A 65-year-old man complains of low back pain and fatigue. He has a haemoglobin of 9 g/dl with a normal mean corpuscular volume and mean corpuscular haemoglobin concentration. His ESR is 120 mm/h. • A Aplasticanaemia • B Folic acid deficiency • C Iron deficiency • D Multiple myelomatosis • E Myelofibrosis • F Peptic ulcer disease • G Pernicious anaemia • H Rheumatoic arthritis • I Vitamin B12 deficiency • J Vitamin C deficiency

  31. Answers • C. Multiple myeloma. • The low back pain is a key symptom and the high ESR a key sign suggestive of meylomatosis in this patient. • The former is caused by vertebral fracture resulting from bone destruction due to the lyticmyeloma lesions. The anaemia is usually normocytic and normochromic.

  32. Plasma cells in Bone Marrow

  33. Myeloma - diagnosis • Monoclonal band serum and/or • Monoclonal band urine (Bence-Jones proteinuria) • BM plasmacytosis • CRAB criteria (one of the following): • C – Calcium increased (hypercalcaemia) • R – Renal failure • A – Anaemia • B – Bone disease

  34. Myeloma– vertebral fracture

  35. Myeloma–osteolytic lesions

  36. Myeloma - Investigations • FBC + smear • Normochromic normocytic anemia • Pancytopenia • Rouleaux • ESR • Raised ESR (often >100)

  37. Myeloma - Investigations • Serum protein electrophoresis

  38. Myeloma–rouleaux on blood smear

  39. A 38-year-old woman who had a resection of her terminal ileum for Crohn’s disease 6 years ago presents with breathlessness and fatigue. She has a megaloblasticanaemia with a haemoglobin concentration of 7 g/dl. • A Aplasticanaemia • B Folic acid deficiency • C Iron deficiency • D Multiple myelomatosis • E Myelofibrosis • F Peptic ulcer disease • G Pernicious anaemia • H Rheumatoic arthritis • I Vitamin B12 deficiency • J Vitamin C deficiency

  40. Answers • I. Vitamin B12 deficiency. • B12 is absorbed in the terminal ileum. • Resection of terminal ileum 6 years before has caused vitamin B12 deficiency leading to megaloblasticanaemia. • Pernicious anaemia is the term applied to B12 deficiency specifically due to an autoimmune destruction of the intrinsic factor producing cells in the stomach.

  41. Megaloblastic anaemias • Most commonly due to: • B12 or folate deficiency

  42. Laboratory findings • Macrocytic anaemia • Oval macrocytes,hypersegmentedneutrophilsandmegaloblasts • Often wbc and plts • BM – erythroid hyperplasia • Nuclear-cytoplasmic asynchrony • B12 and/or folate • Parietal cell and Intrinsic Factor antibodies

  43. Hypoproliferative Renal failure Aplastic Anemia MDS Bone Marrow infiltrate Bone Marrow suppression or failure Sepsis Chemotherapy Radiotherapy Blood transfusion !! Maturation disorder Iron Deficiency Anemia Vitamin B12 Deficiency Folate Deficiency Anemia of Chronic Disease Endocrine deficiencies Thalassaemia Sideroblastic Anemia RPI < 1% (Decreased RBC production)

  44. A 30-yr-old man presents with a1 monthh/olethargy, malaise and shortness of breath. On exam, he is pale and has bruising on his skin. His Hbis 8,0 g/dl, WBC 89 x 109/l, platelets40 x 109/l. A BM biopsy shows >30% blast cells with Auer rods in the cytoplasm. • A Acute lymphocytic leukaemia • B Acute myeloblasticleukaemia • C Chronic lymphocytic leukaemia • D Chronic myeloid leukaemia • E Essential thrombocythaemia • F Hodgkin’s lymphoma • G Monoclonal gammopathy of uncertain significance • H Multiple myeloma • I Myelofibrosis • J Non-Hodgkin’s lymphoma

  45. Answers • B. Acute myeloblasticleukaemia (AML). • The patient is relatively young with quite a short history, making an acuteleukaemia more likely than a chronic disease. • The marrow shows large numbers of blast cells and the presence of Auer rods. The latter are slender, fusiformcytoplasmic inclusions that stain red with Wright-Giemsa stain and are virtually pathognomonic of AML.

  46. Leukemia

  47. Bone marrow blasts – myeloid or lymphoid?

  48. Why is patient pancytopaenic? Failure of cell maturation Proliferation of immature cells Accumulation of useless cells in bone marrow

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