Hematology Organ System Small Group Cases

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Hematology Organ System Small Group Cases
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Case 1

• 32 yr male office worker
• CC fatigue
• ROS negative for abdominal pain, bowel habit
  changes
• Meds frequent ibuprofen, aspirin
• Physical Examination unremarkable

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Case 1 continued

• Laboratory results - current
• Hct 24 mcv 68 fL wbc 7500 plt 550000/mL
• 3 years prior
• Hct 45 wbc 7000 plt 250,000

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Case 1 continues

• Differential diagnosis of microcytic anemia

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Case 1 continued

• Differential diagnosis microcytic anemia
• Iron deficiency
• Anemia of chronic disease/inflammation
• Thalassemia
• Sideroblastic anemia
• Copper deficiency
• Lead poisioning
• unstable hemoglobin - rare

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Iron deficiency laboratory studies

• Serum iron
• TIBC
• Iron saturation
• Ferritin
• FEP
• Reticulocyte count

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Fe deficiency causes

• Ex-premie
• Diet 6-24 months of age/teens
• Milk
• Fast foods
• Blood loss older children/adults

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Iron deficiency anemia

• Poor bioavailability high gastric pH,
  medications
• Chronic bleeding ulcer, gastritis, IBD, GI
  bleeding,
• Rapid period of growth Inadequate intake
• Pulmonary hemosiderosis, TB, inflammation
• Urinary losses
• Abnormal absorption, transferrin, transport
• Prematurity

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Iron Deficiency Anemia

• Poor response to iron therapy
• Noncompliance
• Ongoing blood loss
• Insufficient duration of therapy
• High gastric pH
• absporpion inhibition Pb, Al inflammation,
  neoplasia
• Incorrect diagnosis thalassemia, sideroblastic

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Iron Deficiency Anemia Consequences

• Impaired growth and intellectual development
• Epithelial changes glossitis, stomatitis,
  fingernail spooning
• Exercise intolerance
• Behavioral changes
• Pica

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Iron deficiency Anemia RX

• Oral supplementation
• 3-5 mg/kg/ d elemental
• IM z track
• Parenteral
• Iron dextran, iron gluconate, iron sucrose
• Risk of anaphylaxis
• Duration 3 months after hgb normalizes
• Transfusion rarely indicated

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Case 2

• History
• 45 year old female
• 20 year hx rheumatoid arthritis
• Current exacerbation
• Meds aspirin, nonsteroidals
• ROS heartburn antacids
• PE joint abnormalities

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Case 2 - continued

• Laboratory data
• Hct 30
• Mcv 79 fL
• WBC 8000
• Plt 500,000

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Case 2 continued

• Fe studies
• Stool guiac
• Assessment of total body iron stores
• Bone marrow aspirate/biopsy
• Fe stain
• Gold standard liver biopsy ( chronically
  transfused pts)

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Case 2 continued

• Therapeutic Options
• Observation
• Trial of therapeutic iron
• Re-evaluation of chronic disease

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Case 3 megaloblastic Anemia

• 27 year old male
• ROS dyspnea with exertion
• PMH bullut shot, removal of 5 feet of ileum 5 yr
  prior
• Diet pizza, cheeseburgers
• Exam tatoos, atrophic tongue, slt yellow skin,
  palpable spleen tip

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Case 3 continued

• Laboratory values
• Hgb 3.8 gm/dl
• Hct 12
• Rbc 1.02 x10-6
• Retic 0.4
• Wbc 3500
• Plt 70, 000

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Case 3 continued

• DDX
• B12 deficiency
• Dietary deficiency
• absence of intrinsic factor
• Small bowel malabsorption regional ileitis,
  celiac, lymphoma, sprue, specific B12 absorption
  abnormality
• Inborn errors of metabolism

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Case 3 continued

• Folate Deficiency
• Inadequate intake
• Poverty, malnutrition, goats milk
• Malabsorption celiac, diverticuli, resection,
  blind loops
• Increased requirements growth, hemolysis,
  malignancy
• Impaired folate utilization abx, pyrimethamine,
  sulfonamides, antifolates- methotrexate
• Increased secretion dialysis, biliary, urine
  loss
• Inborn errors of folate

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Case 3 Continued

• Laboratory Evaluation
• CBC, examination of smear
• B12 level
• Folate level
• Schilling Test
• Intrinsic factor

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Schilling Test

• Urinary excretion test
• Patient fasts
• Then given 0.5 micrograms of Co-labelled CNCbl
  combines with IF
• 2 hrs later, sc injection of 1000 micrograms of
  CNCbl given to block uptake of Co-CNCbl, and
  urine excretion is measured nl is 5-35/24 hrs
• Other tests single sample fecal excretion
  testfood schilling test

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Case 3 continued

• Infant B12 deficiency
• Associated with vegan breast feeding mothers
• Early symptoms around 6 months of age
• Increasing developmental delay/loss of milestones
• Associated with permanent neurologic compriomise

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Case 3 Continued

• Treatment
• Administration of B12cautiosly sq
• In pernicious anemia q month injections
• Treat associated hypokalemia

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Fe deficiency lab results

• Fe def Thal minor chronic disease
• Fe nl
• TIBC nl
• Trans sat nl or nl
• Mcv or nl
• Ferritin nl
• FEP nl
• RBC no. inc