Upload
bogdan-urichianu
View
20
Download
0
Embed Size (px)
DESCRIPTION
anemia cases physio
Citation preview
5/24/2018 Anemia Cases
1/35
ANEMIA CASES
5/24/2018 Anemia Cases
2/35
1. A 70-year-old woman presented with progressive weakness and fatigue.
The symptoms had begun about a month earlier, and she no longer feltwell enough to do her housework or take her daily walk. Although herbreathing was normal at rest, she was too short of breath to walk morethan two or three blocks.
The results of the complete blood cell count (CBC) performed in herphysician's office were:
hemoglobin, 5.4 gm/dL;
mean corpuscular volume (MCV), 103 m3;
red cell distribution width (RDW), 19.8% (normal, 12%-15%),
white blood cell count, 3,900/mm3 (48% neutrophils, 43% lymphocytes,8% monocytes, 1% eosinophils);
and platelets, 62,000/mm3.
Based on these results, the patient was hospitalized.
5/24/2018 Anemia Cases
3/35
She had no history of recent bleeding, jaundice, fever, anemia, or heart
disease. She had not been exposed to medications (other than occasional
vitamins and aspirin) or toxins. She had not abused alcohol and had no
previous hospitalizations. Findings on the physical examination wereunremarkable except for mild tachycardia at rest (96 bpm), a blood
pressure of 146/84 mm Hg recumbent and 142/78 mm Hg standing, pallor,
external hemorrhoids, and trace pitting edema of the feet. Neither the
liver nor spleen were palpable. The stool was negative for occult blood.
A chest x-ray was normal, and an electrocardiogram showed only sinus
tachycardia. The blood urea nitrogen (BUN) level was 15 mg/dL; glucose,
108 mg/dL; and total bilirubin, 1.2 mg/dL (normal,
5/24/2018 Anemia Cases
4/35
A 57-year-old woman presents to the clinic for evaluation ofataxia, weakness. The patient has been taking a multivitaminpreparation.
Hematocrit is 38%
white blood cell count 4,000; platelet count 100,000
What tests would you order next ?
What are th?
2.
5/24/2018 Anemia Cases
5/35
3. A 39-year-old woman was referred to our institution for evaluation of anemia.
She was known to have multiple comorbidities and had a baseline hemoglobinconcentration of approximately 10.5 g/dL. About 6 months before her referral,the patient began having recurrent episodes of severe anemia, withhemoglobin values as low as 3.5 g/dL. She had become transfusion-dependentand had received about 30 units of packed red blood cells (RBCs) in thepreceding 3 months. The patient denied any history of easy bruisability,menorrhagia, or overt evidence of bleeding from any site. Additionally, she
denied any change in the appearance or color of her urine and had no historyof jaundice. There was no family history of anemia or any other hematologicdisorder. As an outpatient, she had undergone an extensive evaluation atanother institution, but results failed to provide an explanation for heranemia.
The patient's medical history was remarkable for severe asthma, thought to be
due to Churg-Strauss syndrome. She had a tunneled central venous catheterfor self-administration of intravenous corticosteroids at the earliest sign of anasthmatic exacerbation. Her other medications included bronchodilators,weekly erythropoietin injections, intravenous iron therapy, an antidepressant,and an anxiolytic.
5/24/2018 Anemia Cases
6/35
At presentation, the patient's vital signs were normal. Physical
examination was unremarkable except for mild generalized pallor. A
complete blood count on the day of admission revealed the following
(reference ranges shown parenthetically): hemoglobin, 4.9 g/dL (12.0-15.5
g/dL); mean corpuscular volume (MCV), 94.4 fL (81.6-98.3 fL); hematocrit,
13.4% (34.9%-44.5%); leukocyte count, 6.0 109/L (3.5-10.5 109/L); and
platelet count, 203 109/L (150-450 109/L). The patient's partial
thromboplastin time and prothrombin time (PT)/international normalized
ratio were normal. These results were obtained within 24 hours of her last
transfusion.
5/24/2018 Anemia Cases
7/35
Which one of the following is the least likely in the differential diagnosis of
this patient's anemia?
Chronic blood loss
Acute hemolysis
Chronic disease Myelodysplastic syndrome
Acquired pure red cell aplasia
5/24/2018 Anemia Cases
8/35
With the observation that the patient's anemia was normocytic with an
MCV of 94.4 fL, the next task was to narrow the list of differential
diagnoses and establish whether this was due to premature destruction or
acute loss of RBCs vs decreased bone marrow production.
Which one of the following would be the next best test to narrow the list of
differential diagnoses?
Peripheral blood smear
Absolute reticulocyte count
Serum ferritin
Erythropoietin
Bone marrow biopsy and aspiration
5/24/2018 Anemia Cases
9/35
The reticulocyte count is a good indicator of this and is the only test listed
that could have directly provided this necessary piece of information.
Our patient had a reticulocytosis of 13.3% (0.60%-1.83%), with an
absolute reticulocyte count of 238.8 109/L (29.5-87.3 109/L).
At this time, which one of the following series of tests would be most
helpful in further narrowing the differential diagnosis?
Total and indirect bilirubin levels, haptoglobin, lactate dehydrogenase
(LDH)
Peripheral blood smear
Direct Coombs test
Indirect Coombs test
Activated partial thromboplastin time (aPTT), PT, fibrinogen, soluble fibrin
monomer complex, and D-dimers
5/24/2018 Anemia Cases
10/35
In this patient with an absolute reticulocytosis, ie, an adequate bone marrow response,the next step would be in differentiating between hemolysis and acute blood loss.
Hemolysis is usually characterized by elevated indirect bilirubin concentrations,decreased serum haptoglobin concentrations (with intravascular hemolysis inparticular), and increased serum LDH levels, and this series of tests would be mostuseful in narrowing the differential diagnoses at this point.
The peripheral blood smear is less specific, but in the presence of hemolysis, it mayreveal abnormally shaped RBCs, including fragmented RBCs (schistocytes, helmet cells),spherocytes, elliptocytes, or RBC inclusions, which may be seen in certain hemolysis-
producing infections, such as malaria, babesiosis, and Bartonella.
Hemolytic anemias may be acquired and immune, in which case there is immunologicdestruction of RBCs mediated by autoantibodies directed against antigens on thepatient's RBCs.
The direct and indirect Coombs tests detect antibodies on the surface of the patient'sRBCs and in the patient's serum, respectively. However, the presence of hemolysis mustfirst be established, especially since a patient may have a mildly positive Coombs testthat is clinically insignificant if not associated with ongoing hemolysis.
5/24/2018 Anemia Cases
11/35
The patient had a mildly reduced haptoglobin level at 14 mg/dL (30-200mg/dL), likely secondary to her multiple transfusions. However, her LDHlevel was normal at 205 U/L (122-222 U/L), as were her total and direct
bilirubin levels at 0.4 mg/dL (0.1-1.0 mg/dL) and 0.1 mg/dL (0.0-0.3mg/dL), respectively.
A peripheral blood smear showed no abnormally shaped RBCs. The overallpicture was not in keeping with hemolysis. On the first day of her
evaluation, the patient's hemoglobin concentration was 11.1 g/dL.
By day 2 of her outpatient work-up, it had decreased to 5.6 g/dL, and shereceived 4 units of packed RBCs.
Despite the transfusions, her hemoglobin concentration decreased furtherwithin 24 hours to 4.9 g/dL. At this point, the patient was admitted andreceived 3 more units of packed RBCs. During this time, she wasasymptomatic, and her vital signs remained stable.
5/24/2018 Anemia Cases
12/35
At this point, which one of the following would be the best step in the
management of this patient?
Esophagogastroduodenoscopy
Colonoscopy
Computed tomography (CT) of the abdomen and pelvis
Transfer to the intensive care unit
Angiography of the gastrointestinal (GI) tract
5/24/2018 Anemia Cases
13/35
The patient had no overt signs or symptoms of bleeding, and it would be unlikely forher to have occult GI bleeding that resulted in such dramatic decreases in herhemoglobin concentration.
Also, results of fecal occult blood testing were negative. Therefore, neither upper norlower GI endoscopy would be expected to reveal any useful information.
However, the patient could have occult intra-abdominal bleeding, and noncontrast CTof her abdomen and pelvis would be crucial in ruling this out.
The patient's mental status remained normal, and she was exhibiting no overt evidenceof decreased perfusion or hemodynamic instability other than mild tachycardia.
Therefore, she could be deemed clinically stable, and transferring her to the intensivecare unit would be unnecessary at this time.
She was well compensated despite the severity and acuteness of the anemia, no doubtin part due to her age and lack of other cardiac comorbidities. In this patient who isexhibiting no overt evidence of GI bleeding, angiography would not be the next beststep.
5/24/2018 Anemia Cases
14/35
Noncontrast CT of her abdomen and pelvis revealed normal findings.During the night of hospital day 2, an astute nurse noticed what appearedto be bloodstains on the patient's gown.
The patient reported that she had spilled cranberry juice on the gown.Closer inspection of her room revealed several blood-soaked tissues andStyrofoam cups filled with fresh blood in her wastebasket.
The patient was also found to have dried, crusted blood all over her
fingernails, and a blood-stained 10-mL syringe, most of its labeling wornaway by overuse, was found in her gown pocket
Which one of the following is the most likely cause of this patient's anemia?
Factitious disorder
Munchausen by proxy
Somatization disorder
Hypochondriasis
5/24/2018 Anemia Cases
15/35
With the discovery made in the patient's room, in particular the syringe, the patient'sself-phlebotomy became evident, leading to a diagnosis of factitious anemia.
The most chronic and extreme form of factitious illness, Munchausen syndrome,typically includes travel from hospital to hospital combined with the willingness tosubmit to multiple procedures for self-fabricated signs of illness, as occurred with ourpatient before her presentation at our institution.
In Munchausen by proxy, caregivers (usually mothers) induce illness in their children toobtain care and support for themselves.
Somatization refers to the tendency to experience psychological distress in the form of
somatic symptoms not intentionally produced, thus differentiating this disorder fromfactitious illness or malingering.
Hypochondriasis refers to a preoccupation with believing one is ill as a result ofmisconstruing physical symptoms that are not self-generated.
The patient was seen by the psychiatry service, and although she was obviously at risk
of purposeful self-harm, she denied suicidal or homicidal ideation.
It became evident that she had a history of severe depression, borderline personalitydisorder, chemical dependency, and a history of repeated episodes of parasuicide bymeans of wrist cutting.
5/24/2018 Anemia Cases
16/35
4.
a 33-year-old, well-conditioned male athlete who presented to a referring
hospital with a 4-day history of fatigue, lethargy, fever, chills, jaundice,
dark urine, and abdominal pain.
His medical history included ocular toxoplasmosis in childhood. Several
years before admission, he had become acutely anemic and was
successfully treated with red blood cell (RBC) transfusions andimmunosuppression.
He was then lost to follow-up until the onset of this illness. He took
vitamins and nutritional supplements, used smokeless tobacco, and
denied alcohol or drug abuse.
He had recently started a job working with refrigerated and frozen food.
5/24/2018 Anemia Cases
17/35
Sodium: 134 mEq/L (136-142)Potassium: 4 mEq/L (3.8-5.0)
Chlorine: 104 mEq/L (95-103)
Carbon dioxide: 22 mmol/L (24-30)
Glucose: 172 mg/dL (70-110)
Creatinine: 1.4 mg/dL (0.6-1.2)
Blood urea nitrogen: 39 mg/dL (8-23)
Calcium: 8.4 mg/dL (9.2-11.0)
Magnesium: 1.9 mg/dL (1.8-3.0)Serum iron: 267 g/dL (60-150)
Total iron-binding capacity: 291 g/dL (250-
400)
Transferrin: 208 mg/dL (215-380)
Sedimentation rate: 119 mm/h (10-12)
Acute hepatitis panel: negative
White blood cell count: 16,200 cells/L
Hemoglobin: 3.6 g/dL
Hematocrit: 10.6%
Mean corpuscular volume: 104.7 fL
Platelet count: 340,000 cells/L
Reticulocyte count: 8.4% (0.5%-2.3%)
Haptoglobin: 6 mg/dL (36-195)
Lactate dehydrogenase (LDH): 943 U/L(91-180)
Aspartate aminotransferase: 100 U/L
(8-33) Alanine aminotransferase: 35 U/L (4-36)
Total bilirubin: 7.0 mg/dL (0.1-1.0)
Direct bilirubin: 0.9 mg/dL (< 0.3)
Albumin: 3.4 g/dL (3.2-4.5)
Total protein: 7.0 g/dL (6.0-7.8)
5/24/2018 Anemia Cases
18/35
Upon admission to our hospital, the patient's hemoglobin level was 4.6
g/dL, and all other laboratory results were consistent with those from the
referring hospital.
Blood and urine cultures were negative.
Peripheral smears demonstrated RBC agglutinates, microspherocytes,
polychromasia, and nucleated RBCs.
The patient had mixed-type warm IgG/IgM-mediated AIHA.
The combination of massive intravascular hemolysis, vasoconstriction, and
vaso-occlusion caused prolonged inadequate tissue oxygenation leading
inexorably to multiple organ failure and death.
5/24/2018 Anemia Cases
19/35
5.
A 61-year-old woman was admitted to this hospital because of epigastric pain,vomiting, diarrhea, anemia, and acute kidney injury.
The patient had been well until approximately 3 weeks before admission, whenvomiting, diarrhea, fevers, arthralgias, and episodes of epigastric pain of increasingfrequency and severity developed, which she attributed to a viral gastroenteritis.
Two weeks before admission, epigastric and midabdominal pain worsened, with
diarrhea and one episode of vomiting.
The next day, she came to the emergency department at this hospital. She rated thepain at 4 on a scale of 0 to 10 (with 10 indicating the most severe pain) and reportedthat it was worse when she was lying flat.
The blood pressure was 150/82 mm Hg, and the pulse 101 beats per minute; other vitalsigns were normal.
The abdomen was soft, and there was mild epigastric tenderness without rebound; theremainder of the examination was normal.
A stool specimen revealed occult blood.
5/24/2018 Anemia Cases
20/35
Laboratory Data.
Bazari H et al. N Engl J Med 2014;370:362-373.
5/24/2018 Anemia Cases
21/35
Pertinent Clinical Details
This 61-year-old woman presented with a 4-week history of epigastric pain, diarrhea,and vomiting.
Arthralgias, fever, anemia, and acute kidney injury developed.
The stool was guaiac-positive and positive for H. pylori antigen, and anesophagogastroduodenoscopy was normal.
In the past, she had had hyperlipidemia and gastroesophageal reflux disease.
On examination, she had mild abdominal tenderness.
Pertinent laboratory values include progressive anemia, an absence of leukocytosis,progressive renal failure, elevated blood levels of aminotransferase and alkalinephosphatase, serum immune electrophoresis with no monoclonal protein detected, anda high serum free light-chain ratio (kappa:lambda ratio, 3.1; normal range, 0.3 to 1.7).
Urinalysis was pathognomonic for an acute glomerulonephritis, with proteinuria andred-cell casts. The rheumatoid factor was weakly positive. Testing for ANA was negative,and blood levels of complement were low (C4, very low; and C3, slightly decreased).Evaluation for anemia was consistent with anemia of chronic disease. A bone marrowbiopsy specimen showed 3% monoclonal B cells, which were CD5 CD10 kappa+.
5/24/2018 Anemia Cases
22/35
Serum free light-chain assays are the most sensitive tests for the detection ofabnormal immunoglobulin-secreting B-cell clones.
Furthermore, flow-cytometric analysis of the bone marrow specimen confirmsthe presence of a small, clonal B-cell population, without an excess of plasmacells.
The patient does not meet the criteria for a diagnosis of overt myeloma orlymphoma. It is possible that she has monoclonal gammopathy ofundetermined significance and a monoclonal B lymphocytosis both ofwhich are relatively frequent findings in older adults which may beunrelated to her current illness.
Other considerations are cryoglobulinemia, immunotactoidglomerulonephritis, and deposition disease with light chains, light and heavychains, or heavy chains
5/24/2018 Anemia Cases
23/35
6.
A 22 month old boy presents to your office with a chief complaint of pallor.
A visiting relative who has not seen the child for 5 months told his mother thatthe boy appears pale.
The mother brings him in for a checkup even though she notices no change inhis coloring (he has always been fair skinned).
On review of symptoms you find that he is an active toddler, with no recentfatigue, exercise intolerance, or increase in sleeping.
He has had no blood in his diapers and no black or tarry stools.
He is a picky eater, taking small amounts of chicken, pork and some
vegetables, but loves milk and drinks six to eight bottles of whole milk per day.
Family history reveals a distant aunt who had anemia when she was pregnantbut which subsequently resolved. There is no history of splenectomy, gallstones at an early age, or other anemia in the family.
5/24/2018 Anemia Cases
24/35
Exam: VS: T 37.5, BP 90/52, P 145, RR 16, Height 85.5 cm (50th %ile), Weight
13.2 kg (75th %ile). General appearance: He is a pale appearing, active toddler,
holding a bottle, tearing and eating paper from your exam table. Eyes: No
scleral icterus. Pale conjunctiva. Mouth: Dental caries. Chest: Clear. Heart:
Mild tachycardia as above, grade II/VI systolic ejection murmur heard best
over the upper left sternal border. Abdomen: No hepatosplenomegaly. Rectal:
Dark brown, soft stool, negative for occult blood.
CBC: WBC 6,100, Hgb 6.2 g/dl, Hct 19.8%, Plt 589,000, MCV 54 fL, RDW 17%.
Reticulocyte count is 1.8%. The lab reports microcytosis, hypochromia, mild
anisocytosis and polychromasia. There is no basophilic stippling.
You correctly diagnose iron deficiency anemia, start oral iron and limit his milk
intake. You see him in 3 days to assure compliance and his RDW is 27% and his
reticulocyte count 17%. When you see him back in two weeks his mother is
amazed at his new interest in table foods. His Hgb is now 8.5 g/dl, and his MCV
64 fL. Two months later his hemoglobin has completely normalized, and you
continue iron therapy for three more months.
5/24/2018 Anemia Cases
25/35
7.
ML is a 64-year old male who has not had any primary care for several
years. When he tried to give blood last week, he was told that he was
anemic. He presents to your clinic for evaluation.
What would you do??
5/24/2018 Anemia Cases
26/35
HPI: Ive been a little more tired than usual, but Ive been busy at work.
Im getting close to retirement. Nothing else is unusual. I avoid doctors if I
can
PMH: Inguinal hernia repair 20 yrs ago FH: F & MGF-heart attack(age 80), brother-alcoholism
SH: Married x44yr, smokes 1ppd, a couple beers/night
MEDS: daily multivitamin
ALLERGIES: none
ROS:+fatigue, +urine seems a little darker lately
Only a CBC w/ diff was obtained:
WBC: 8.2, HCT 32.2, MCV 79, Platelets 221, differential - normal
5/24/2018 Anemia Cases
27/35
Initial Thoughts?
Blood loss?
Age places him at risk for colon CA
Decreased Production?
Alcohol use, Iron deficiency
Increased Destruction?
Darker urine lately
Peripheral Blood Smear Reticulocyte count Iron Studies
Ferritin
TIBC % Saturation
Urinalysis Colonoscopy referal
5/24/2018 Anemia Cases
28/35
More Results
Smear reveals microcytic, microchromic RBCs
Retic count is interpreted as low
Urinalysis negative for hemoglobin
Iron Studies
Ferritin: 10
TIBC: 350
% Sat: 15
5/24/2018 Anemia Cases
29/35
Diagnosis
Colonoscopy revealed smallsuspicious lesion in sigmoidcolon, pathology revealingadenocarcinoma.Excisedsurgically, no mets.
Routine labs, one year later,reveal an HCT of 40%. He feelsbetter than ever!
5/24/2018 Anemia Cases
30/35
8.
42 yo admitted with anemia
Hemoglobin 8.8 g/dl
MCV 80 fL Retic 5.8%
WBC 12.0/uL
86% PMN
10% lymphs
4% monocytes
Platelets 676/uL
?
5/24/2018 Anemia Cases
31/35
9.
80 yo CM admitted for diarrhea, anorexia, fall
PMH EtOH, hemicolectomy for CA
Hgb 9.4 g/dL LDH 600 U/L
MCV 124 fL WBC 3.4
Plt 144
Retic 1.4%
?
5/24/2018 Anemia Cases
32/35
10.
26 yo CM.
Hct 36 Meds: none
WBC 5.6 PMH: none
Plt 214
LDH nl Hapto
5/24/2018 Anemia Cases
33/35
11.
36 yo AAM with fever, rash, arthralgias, pain
PMH: SS dz
Hgb 5.2 LDH 612
MCV 88 Bili 4.5
WBC 5.0 plt 130
5/24/2018 Anemia Cases
34/35
12.
51 YO female presents with fatigue, occasional tingling of her hand and
feet. She reports decrease in concentration and memory
PSHx: cholecystectomy, gastric bypass
Social Hx: negative for drug, tobacco and alcohol
LABS:WBC 1.7
HGB 8.9 G/DL
PLATELETS 109,000
MCV 109
SEGS 52%
LYMPHS 40%
MONO 5%
EOS 2%
METAMYELOCYTES 1%
5/24/2018 Anemia Cases
35/35
13.
47 YO African American Female presents with fatigue, heavy menstrualbleeding, body aches.
FHx: anemia of unknown etiology
Social Hx, PMHx is unremarkable
WBC 5K, HGB 9.8 g, PLT 166,000, MCV 56
How do you approach this case?
Serum Ferritin 15
Iron saturation 9%
TIBC 470
B12 and folate are normal
Retic 2.6%
Bone marrow biopsy ?