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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

Hct 1
RI  Retic %  
45 Maturation Time
Retic Index Response
<2 Inappropriate
2–3 Not sure
>3 Appropriate
Adjust Retic % for “Shift”
Hct Bone marrow Blood
45 3.5 1.0
35 3.0 1.5
25 2.5 2.0
15 1.5 2.5
Maturation Time
42 yo CF with chronic diarrhea

What test? Hct 34


MCV 118
Retic 3.4%
RI = 1.7
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 Anemia
Megaloblastic
• All have in common a problem with DNA
• Five possibilities
– Folate deficiency
– B12 deficiency
– Drugs/Toxins
– Unusual inherited disorders
– Erythroleukemia
Macrocytic Anemia
Non-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
100000

10000

1000
Upper
Lower
100

10

1
10 20 30 40 50 60 70
Hct
62 yo AAF with fatigue

Hct 30
MCV 104
Retic 5.8%
RI = 2.2
Case 9
• 55yo CM with • 8 years later…..
headaches • Headaches again
• Hgb 21 g/dL • Hgb 7.1
• WBC 22.0 /uL • WBC 8.9 /uL
• Plt 783 /uL • Plt 111 /uL
Most likely diagnosis?
43 yo AsF woman with myalgias 2
years after chemo for breast CA

Hct 32
MCV 90
Retic 2.4%
RI = 1.1
67 yo with CLL

Best initial treatment?


Hct 22
MCV 112
Retic 16%
RI = 3.2
23 yo with recent URI

Hct 32
MCV 154
Retic 8.1%
RI = 3.8
Case 13
• 21 yo police officer with fatigue
• Hct 42
• Plt 142
• WBC 133.4 Best initial treatment?
• MCV 87
• INR 1.2
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 • Median Survival


• Cytogenetics – Low Risk
• 5.7 years
– Y-, 5q-, 20q-
• good – Low Intermediate
• 3.5
– chr 7 or multiple
• bad – High Intermediate
• 1.2
• Cytopenia
– High
– 0 or 1 good
• 6 months
– 2 or 3 bad
22 yo AsM feeling well. Has enlarged spleen.

Hct 35
MCV 62
Retic 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 13. CML
2. Folate deficiency 14. Sideroblastic anemia
3. B12 deficiency 15. MDS
4. TTP 16. Hbg E
5.  thal trait 17. G6PD
6. Myeloma 18. Parvovirus
7. Renal insufficiency 19. HS
8. MDS 20. Mono
9. P. vera with fibrosis 21. CLL
10. Metastatic breast cancer 22. Hairy Cell
11. Autoimmune hemolysis 23. APL
12. Cold agglutinin 24. LGL leukemia