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 fLRetic 3.8% WBC 12.0/uL –86% PMN –10% lymphs –4% monocytes Platelets 676/uL

4. Retic Index

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

7. 42 yo CF with chronic diarrhea Hct 34 MCV 118 Retic 3.4% RI = 1.7 What test?

8. 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%

10. Macrocytic Anemia Megaloblastic All have in common a problem with DNA Five possibilities –Folate deficiency –B12 deficiency –Drugs/Toxins –Unusual inherited disorders –Erythroleukemia

11. Macrocytic Anemia Non-Megaloblastic Accelerated Erythropoiesis Most Liver Diseases Chronic Alcohol Use Myelodysplastic Syndromes Hypothyroidism Chronic Obstructive Pulmonary Disease

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

13. 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

15. 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

16. 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

18. 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

20. Expected EPO Levels in Uncomplicated Anemia Hct

21. 62 yo AAF with fatigue Hct 30 MCV 104 Retic 5.8% RI = 2.2

22. 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

23. Most likely diagnosis?

24. 43 yo AsF woman with myalgias 2 years after chemo for breast CA Hct 32 MCV 90 Retic 2.4% RI = 1.1

25. 67 yo with CLL Hct 22 MCV 112 Retic 16% RI = 3.2 Best initial treatment?

26. 23 yo with recent URI Hct 32 MCV 154 Retic 8.1% RI = 3.8

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

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

31. 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 37Retic 0.8% Vit B12 740Folate 12

33. 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

34. 22 yo AsM feeling well. Has enlarged spleen. Hct 35 MCV 62 Retic 6.8%

35. Case 17 42 yo with fatigue, bruising PMH: AIDS, PCP, toxo Meds: zidovudine, pyrimethamine, TMP/sulfa Hct 25Retic 2.3% WBC 1.8 Plt 32

38. Case 18 36 yo AAM with fever, rash, arthralgias, pain, DOE PMH: SS dz Hgb 5.2LDH 612 MCV 88Bili 4.5 WBC 5.0 plt 130

40. Case 19 26 yo CM presents after “failing” insurance H & P. Hct 36Meds: none WBC 5.6PMH: none Plt 214ROS: feeling good LDH nl Hapto <6

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

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

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

45. 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?

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

47. 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