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Hematology Cases

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  1. Hematology Cases Mark Juckett MD April 28, 2004

  2. 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

  3. Retic Index

  4. Hct Blood Bone marrow 3.5 1.0 45 35 3.0 1.5 25 2.5 2.0 15 1.5 2.5 Adjust Retic % for “Shift” Maturation Time

  5. 42 yo CF with chronic diarrhea What test? Hct 34 MCV 118 Retic 3.4% RI = 1.7

  6. 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%

  7. All have in common a problem with DNA Five possibilities Folate deficiency B12 deficiency Drugs/Toxins Unusual inherited disorders Erythroleukemia Macrocytic AnemiaMegaloblastic

  8. Macrocytic AnemiaNon-Megaloblastic • Accelerated Erythropoiesis • Most Liver Diseases • Chronic Alcohol Use • Myelodysplastic Syndromes • Hypothyroidism • Chronic Obstructive Pulmonary Disease

  9. 32 yo AAM admitted for SZ Hgb 8.0g/dL MCV 98 fL WBC 15.0 Plt 4/uL Case 4 Next Step?

  10. 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

  11. 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

  12. 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

  13. 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

  14. Expected EPO Levels in Uncomplicated Anemia Hct

  15. 62 yo AAF with fatigue Hct 30 MCV 104 Retic 5.8% RI = 2.2

  16. 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 Case 9

  17. Most likely diagnosis?

  18. 43 yo AsF woman with myalgias 2 years after chemo for breast CA Hct 32 MCV 90 Retic 2.4% RI = 1.1

  19. 67 yo with CLL Best initial treatment? Hct 22 MCV 112 Retic 16% RI = 3.2

  20. 23 yo with recent URI Hct 32 MCV 154 Retic 8.1% RI = 3.8

  21. 21 yo police officer with fatigue Hct 42 Plt 142 WBC 133.4 MCV 87 INR 1.2 Case 13 Best initial treatment?

  22. Case 14 • 48 yo factory worker with fatigue • PMH: hyperlipidemia, HTN • SH: heavy EtOH, smoking • Hct 28 • WBC 4.5 • Plt 390 • MCV 79

  23. 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

  24. 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 Myelodysplasia - Prognosis

  25. 22 yo AsM feeling well. Has enlarged spleen. Hct 35 MCV 62 Retic 6.8%

  26. 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

  27. 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

  28. 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

  29. Case 20 • 24 yo high school teacher • Malaise, fatigue, sore throat

  30. Case 21 • 42 yo high school teacher • WBC 14 • Hgb 13.0 • Plt 175

  31. Case 22 • 47 yo cheese maker • Hgb 12.1 • Plt 176 • WBC 2.6 • 43% PMN • 56% lymphs • 2% eos • 0% mono

  32. 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?

  33. Case 24 • 62 yo with recent dx of RA • Hgb 8.1 • WBC 2.1 • Plt 28 What Tests?

  34. Iron deficiency Folate deficiency B12 deficiency TTP  thal trait Myeloma Renal insufficiency MDS P. vera with fibrosis Metastatic breast cancer Autoimmune hemolysis Cold agglutinin CML Sideroblastic anemia MDS Hbg E G6PD Parvovirus HS Mono CLL Hairy Cell APL LGL leukemia Index