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% lymphs –4% monocytes Platelets 676/uL

Retic Index

Adjust Retic % for “Shift” Bone marrow Blood Hct Maturation Time

42 yo CF with chronic diarrhea Hct 34 MCV 118 Retic 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/dLLDH 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 30Retic 4.1% MCV 68Hgb 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/dLMCV 90 fL WBC 3.2Retic 3.4% Plt 132TP 9.2 Creat 3.2Alb 2.8

Case 7 85 yo CF with fatigue, poor appetite, wgt 55kg PMH DM, HTN, Hyperlipidemia Hgb 10.1 g/dLCreat 1.8 WBC 4.5LDH 180 Plt 235 /dLRetic 3.4% MCV 92 fLAlb 4.0

Expected EPO Levels in Uncomplicated Anemia Hct

62 yo AAF with fatigue Hct 30 MCV 104 Retic 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 90 Retic 2.4% RI = 1.1

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

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

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

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

Case 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 37Retic 0.8% Vit B12 740Folate 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 35 MCV 62 Retic 6.8%

Case yo with fatigue, bruising PMH: AIDS, PCP, toxo Meds: zidovudine, pyrimethamine, TMP/sulfa Hct 25Retic 2.3% WBC 1.8 Plt 32

Case yo AAM with fever, rash, arthralgias, pain, DOE PMH: SS dz Hgb 5.2LDH 612 MCV 88Bili 4.5 WBC 5.0 plt 130

Case yo CM presents after “failing” insurance H & P. Hct 36Meds: none WBC 5.6PMH: none Plt 214ROS: feeling good LDH nl Hapto <6

Case yo high school teacher Malaise, fatigue, sore throat

Case yo high school teacher WBC 14 Hgb 13.0 Plt 175

Case yo cheese maker –Hgb 12.1 –Plt 176 –WBC % PMN 56% lymphs 2% eos 0% mono

Case yo in ER with epistaxis, petechia –Hgb 6.2 –Plt <5 –WBC 1.1 –PTT 63 secs –D-dimer elevated FISH for what?

Case 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