Hematology Case Study 4
Rachael, a 13-year old female, was admitted to the hospital with complaints of
progressive weakness and shortness of breath with minimal physical effort. She has
experienced recurrent fevers reaching 1020 F. Physical examination reveals a welldeveloped adolescent with good nutritional status and in no acute distress. There is no
lymphadenopathy or organomegaly. Many petechial hemorrhages cover her chest and
legs. Several bruises are found on her legs and thighs. Laboratory tests were ordered on
admission.
1.
What laboratory tests would be appropriate for screening for aplastic anemia?
A CBC
2.
Justify your selection of tests based on Rachael’s clinical signs and symptoms.
A CBC is an important screening test for all anemias. It is important to know
the patient’s hemoglobin and hematocrit, as anemia may be one cause of
weakness and shortness of breath. A low platlet count may explain the
presence of petechiae and bruises.
Rachael is a 13-year old female.
3.
If aplastic anemia is present, would you expect her to have an idiopathic or
secondary form? Explain your answer.
It is difficult to estimate the cause without a more complete history.
Idiopathic forms are more common in this age group.
For the past 3 months, Rachael’s family physician has been following her recovery from
viral hepatitis. Her recovery was uneventful, with her liver enzyme levels returning to
normal within two months. She has no other past medical history. There is no family
history of hematologic disorders.
4.
What aspect of this patient’s history may be associated with the occurrence of
aplastic anemia?
There is data suggesting an association with aplastic anemia and certain viral
infections
5.
Is it likely that Rachael has a congenital form of aplastic anemia?
It is unlikely because it would have been detected at a younger age than
Rachael currently is.
Rachael has complaints of progressive weakness and shortness of breath with minimal
physical effort. She has experienced recurrent fevers reaching 1020 F. Many petechial
hemorrhages cover her chest and legs, and several bruises are found on her legs and
thighs.
6.
Correlate these clinical findings with her laboratory screening test results,
which follow:
Admission laboratory data for patient:
RBC:
2.42 x 1012/L
HGB:
7.1 gd/L
HCT:
24%
PLT:
8.0 x 109/L
WBC:
1.2 x 109/L
Differential:
Segmented neutrophils:
Lymphocytes:
Monocytes:
Uncorrected reticulocyte count:
2%
94%
4%
0.7%
The patient’s weakness and shortness of breath are due to the anemia. The
petechiae and bruising are due to low platlets. The recurrent infections are
suggestive of infection. She is neutropenic and, therefore, at high risk for
infection.
7.
Evaluate each of he patient’s laboratory results by comparing them to
reference ranges.
All CBC parameters are low
8.
Which of the patient’s routine laboratory results are consistent with those
expected for aplastic anemia?
All are consistent with those expected for aplastic anemia
9.
Classify the morphologic type of anemia.
Normocytic, hypochromic
10.
Calculate the absolute lymphocyte count. Are her lymphocytes truly elevated
as suggested by the relative lymphocyte count?
The absolute lymphocyte count is 1.1 x 109/L which is slightly decreased.
The relative lymphocytosis is high due to the severe neutropenia
11.
Correct the reticulocyte count. Why is this step important?
The corrected reticulocyte count is 0.4%, which is below the reference range.
All reticulocyte counts need to be corrected when anemia is present in order to
assess the bone marrow’s degree of compensation for anemia.
12.
Calculate the absolute reticulocyte count.
The absolute reticulocyte count is 16.9x109/L and this is consistent with a
diagnosis of aplastic anemia
Rachael was referred to a hematologist who ordered a bone marrow examination. The
aspirate obtained was inadequate for evaluation due to lack of marrow. Only a single site
could be aspirated. Preps made from the aspirate showed a markedly hypocellular
marrow with very few hematopoietic cells. Cells present consisted of lymphocytes,
plasma cells, and stromal cells. There were no malignant cells present.
13.
Compare these results with those expected with a person with aplastic anemia.
A markedly hypoplastic bone marrow is consistent with a diagnosis of aplastic
anemia.
14.
Interpret the significance of the lack of malignant cells and hematopoietic
blasts.
If malignant cells were present, a diagnosis of metastatic disease or lymphoma
would have been likely. Bone marrows of patients with leukemia or
myelodysplastic syndromes typically are hyperplastic with increased numbers
of hematopoietic blasts present.
15.
Appraise the prognosis for Rachael.
The prognosis is poor unless a compatible bone marrow donor is found.
16.
Predict a treatment regime.
Treatment would be supportive therapy using blood components. Platlets
should be administered immediately and a bone marrow donor should be
searched for.
17.
What other hematologic conditions needed to be ruled out for this patient?
Myelodysplastic syndromes and megaloblastic anemia (both lead to
pancytopenia)
18.
What laboratory test would be most beneficial in differentiating aplastic
anemia from these other disorders? Compare the results for aplastic anemia
with those of the other disorders.
B12 and folic acid levels could be used to rule out anemia due to a deficiency
in either of these. However, a bone marrow was necessary to make a
definitive diagnosis. If the anemia were a megaloblastic anemia or a
myelodysplastic syndrome, it would be hyperplastic.