Hematology Cases Mark Juckett MD April 28, 2004. Case 1 82 yo AAF admitted with anemia Hemoglobin 8.8 g/dl MCV 80 fLRetic 3.8% WBC 12.0/uL –86% PMN –10%

Hematology Cases

Mark Juckett MD

April 28, 2004

Case 1

• 82 yo AAF admitted with anemia• Hemoglobin 8.8 g/dl• MCV 80 fL Retic 3.8%• WBC 12.0/uL

– 86% PMN– 10% lymphs– 4% monocytes

• Platelets 676/uL

Retic Index

Time Maturation

1

45

Hct % Retic RI

Retic Index Response

< 2 Inappropriate2 – 3 Not sure> 3 Appropriate

Adjust Retic % for “Shift”

3.5

3.0

2.5

1.5

Bone marrow Blood

2.5

2.0

1.5

1.045

35

25

15

Hct

Maturation Time

42 yo CF with chronic diarrhea

Hct 34MCV 118Retic 3.4%RI = 1.7

What test?

Case 3

• 80 yo CM admitted for diarrhea, anorexia, fall

• PMH EtOH, hemicolectomy for CA

• Hgb 9.4 g/dL LDH 400 U/L

• MCV 124 fL

• WBC 3.4

• Plt 144

• Retic 2.4%

Macrocytic AnemiaMegaloblastic

• All have in common a problem with DNA

• Five possibilities– Folate deficiency– B12 deficiency– Drugs/Toxins– Unusual inherited disorders– Erythroleukemia

Macrocytic AnemiaNon-Megaloblastic

• Accelerated Erythropoiesis

• Most Liver Diseases

• Chronic Alcohol Use

• Myelodysplastic Syndromes

• Hypothyroidism

• Chronic Obstructive Pulmonary Disease

Case 4

• 32 yo AAM admitted for SZ• Hgb 8.0g/dL• MCV 98 fL• WBC 15.0• Plt 4/uL

Next Step?

Case 5

• 22 yo AAF referred for iron def anemia• PMH G1P1, pregnant now(10 wks)• Meds: PO FeSO4 x one year, prenatal• Hct 30 Retic 4.1%• MCV 68 Hgb electroph A2 5.1%• Plt 178• WBC 6.1

Microcytic Anemia

• All have in common problems making hemoglobin– Hemoglobin requires iron, protoporphyrin, and globin

• Basic DDx: Iron deficiency vs. ACD vs. thalassemia

• Sideroblastic anemias uncommon• Always consider GI cancer in adults with

microcytic anemia

Case 6

• 72 yo AAM referred for fatigue, mucosal bleeding, bruising

• Frequent URI, 20lb wgt loss, DM, HTN

• Hgb 9.0 g/dL MCV 90 fL

• WBC 3.2 Retic 3.4%

• Plt 132 TP 9.2

• Creat 3.2 Alb 2.8

Case 7

• 85 yo CF with fatigue, poor appetite, wgt 55kg

• PMH DM, HTN, Hyperlipidemia

• Hgb 10.1 g/dL Creat 1.8

• WBC 4.5 LDH 180

• Plt 235 /dL Retic 3.4%

• MCV 92 fL Alb 4.0

Expected EPO Levels in Uncomplicated Anemia

1

10

100

1000

10000

100000

10 20 30 40 50 60 70

UpperLower

Hct

62 yo AAF with fatigue

Hct 30MCV 104Retic 5.8%RI = 2.2

Case 9

• 55yo CM with headaches

• Hgb 21 g/dL• WBC 22.0 /uL• Plt 783 /uL

• 8 years later…..• Headaches again• Hgb 7.1• WBC 8.9 /uL• Plt 111 /uL

Most likely diagnosis?

43 yo AsF woman with myalgias 2 years after chemo for breast CA

Hct 32 MCV 90Retic 2.4%RI = 1.1

67 yo with CLL

Hct 22MCV 112Retic 16%RI = 3.2

Best initial treatment?

23 yo with recent URI

Hct 32MCV 154Retic 8.1%RI = 3.8

Case 13

• 21 yo police officer with fatigue• Hct 42• Plt 142• WBC 133.4• MCV 87• INR 1.2

Best initial treatment?

Case 14

• 48 yo factory worker with fatigue

• PMH: hyperlipidemia, HTN

• SH: heavy EtOH, smoking

• Hct 28

• WBC 4.5

• Plt 390

• MCV 79

Case 15

• 75 yo CM with easy bruising

• PMH: CHF, CAD, DM

• Meds: digoxin, lasix, ASA

• Hgb 8.1 g/dL WBC 2.1 (N1.0, L0.6)

• Plt 37 Retic 0.8%

• Vit B12 740 Folate 12

Myelodysplasia - Prognosis

• Blasts• Cytogenetics

– Y-, 5q-, 20q- • good

– chr 7 or multiple• bad

• Cytopenia– 0 or 1 good

– 2 or 3 bad

• Median Survival– Low Risk

• 5.7 years

– Low Intermediate• 3.5

– High Intermediate• 1.2

– High• 6 months

22 yo AsM feeling well. Has enlarged spleen.

Hct 35MCV 62Retic 6.8%

Case 17

• 42 yo with fatigue, bruising

• PMH: AIDS, PCP, toxo

• Meds: zidovudine, pyrimethamine, TMP/sulfa

• Hct 25 Retic 2.3%

• WBC 1.8

• Plt 32

Case 18

• 36 yo AAM with fever, rash, arthralgias, pain, DOE

• PMH: SS dz

• Hgb 5.2 LDH 612

• MCV 88 Bili 4.5

• WBC 5.0

• plt 130

Case 19

• 26 yo CM presents after “failing” insurance H & P.

• Hct 36 Meds: none

• WBC 5.6 PMH: none

• Plt 214 ROS: feeling good

• LDH nl

• Hapto <6

Case 20

• 24 yo high school teacher

• Malaise, fatigue, sore throat

Case 21

• 42 yo high school teacher

• WBC 14

• Hgb 13.0

• Plt 175

Case 22

• 47 yo cheese maker– Hgb 12.1– Plt 176– WBC 2.6

• 43% PMN

• 56% lymphs

• 2% eos

• 0% mono

Case 23

• 48 yo in ER with epistaxis, petechia– Hgb 6.2– Plt <5– WBC 1.1– PTT 63 secs– D-dimer elevated

FISH for what?

Case 24

• 62 yo with recent dx of RA– Hgb 8.1– WBC 2.1– Plt 28

What Tests?

Index

1. Iron deficiency

2. Folate deficiency

3. B12 deficiency

4. TTP

5. thal trait

6. Myeloma

7. Renal insufficiency

8. MDS

9. P. vera with fibrosis

10. Metastatic breast cancer

11. Autoimmune hemolysis

12. Cold agglutinin

13. CML

14. Sideroblastic anemia

15. MDS

16. Hbg E

17. G6PD

18. Parvovirus

19. HS

20. Mono

21. CLL

22. Hairy Cell

23. APL

24. LGL leukemia