Download Approach to Cytopenias - Windsor Cancer Research Group

Cancer Education Day
May 13, 2016
Indryas Woldie, MD
No relevant conflict of interest
Approach to Cytopenias
Objectives:
• Discuss general approach to cytopenias
• Discuss common causes of anemia,
neutropenia and thrombocytopenia
• Discuss cytopenia associated conditions that
need urgent referral/management
Case I.
27 years old woman presents with fatigue and
lab showed hemoglobin of 70gm/l, normal
platelets , normal WBC with differential.
Case II.
27 years old woman presents with fatigue and
bruising and lab showed hemoglobin of
70gm/l, platelets of 25K.
• Isolated cytopenias are usually indicative of
less serious diagnosis than bi or pan
cytopenia.
• Questions to ask when seeing someone with
cytopenia:
– Isolated or more than one lineage?
– Severity?
– Duration and change in time?
– Co-morbidity/medications?
– Associated symptoms?
Anemias
• Etiology:
I) Blood loss
II)Increased destruction
-hemolytic anemias
• RBC Indices
– MCV
– MCHC
– MCH
III)Decreased production
I)
-nutritional deficiency
-bone marrow infiltration
-aplastic anemias
-Inflammation (ACI)*
-medications
II)
I)
Normocytic –
normochromic (Normal
MCV and MCH)
Microcytic , hypochromic
(MCV <80, MCHC <32)
Macrocytic (MCV >100)
Case I.
27 years old woman at 32 weeks for gestation
presents with fatigue and lab showed hemoglobin
of 78gm/l.
MCV 65, RDW 25 MCHC 30, platelets 480K
WBC: 7500, with normal differential.
Q: In addition to reviewing her peripheral smear,
what additional lab work will confirm diagnosis?
Q: How will you treat her?
27 years old woman has from Greece has a CBC and
lab showed hemoglobin of 110gm/l.
MCV 65, platelets 250K, WBC: 7500, with normal
differential. She has been on iron pills for the last 2
years with no change in her hemoglobin or MCV, has
constipation and nausea.
Q: What is the most helpful recommendation for the
patient?
Peripheral smear showed (next page)
Q: What is the most likely diagnosis?
Q: How can we confirm the diagnosis?
Case 3: 65 years old man with history of CLL on
conservative follow up comes with worsening
fatigue over the past week.
CBC: Hgb 62 gm/l (was 110 a week ago), MCV 110,
RDW 25, Platelets 129K, WBC 150K ANC 9.5, ALC
138. Attempt to type and crossmatch was
unsuccessful.
Q: What additional labs will you get ?
• Hemolytic work up:
Reticulocyte count
LDH
Haptoglobin
Bilirubin (Indirect)*
Direct coomb’s test (if positive [IgG] , confirms AIHA,
steroid usually effective)
• Coomb’s negative hemolytic anemia (hemolytic
panel positive but negative Coomb’s test).
–
–
–
–
Hemoglobinopathies (SSA, thalassemias..)
Structural abnormalities (spherocytosis)
MAHA (TTP, aHUS, mechanical valve)
PNH
• MAHA/TTP:
– Medical emergency
– No need for traditional pentad as long as patient has
MAHA (schistocytes + HA) and thrombocytopenia.
– Immediate referral for plasma exchange(PE).
– Obtain ADAMSTS13 activity ( result is not needed for
initiation of PE)
– Avoid platelet transfusion
Case: 65 years old man presented with fatigue. He had
history of gastric bypass surgery 8 years ago.
Labs showed:
Hgb 85gm/l, MCV 88, RDW 28, Platelets 75K, LDH 330,
Bilirubin (mildly elevated indirect), low haptoglobin.
WBC 2.4 ANC 1.8
Which lab test/tests will be most relevant?
• Vitamin B12 was low at 120. Folate normal.
• Do we need to send for MMA?
• Patient was treated with B12 supplementation
and repeat labs after 3 months showed:
– Hgb 98, MCV 77, RDW 25, Platelet 480, WBC
normalized.
What next?
• You sent for ferritin and was found to be low at
5, with low iron saturation. He was started on
iron supplement, ferrous sulfate TID.
• Develops severe constipation, nausea and
occasional vomiting.
• Dose reduced to one tab daily with better
tolerance.
• CBC normalized and iron supplementation
continued.
Any thing else?
Oral iron supplements increase hepcidin and decrease iron absorption
from daily or twice-daily doses in iron-depleted young women. Diego
et.al; Blood Oct. 2015
Continuous line is for first dose
Broken line is for second dose
Thrombocytopenia:
• Thrombocytopenia:
– Mild (80-150K)-no risk of bleeding
– Moderate (20-80K)-minor bleeds
(bruise..) and bleeding with
surgery/trauma
– Severe (<20K)-spontaneous bleeding
possible
Thrombocytopenia: causes
I) Increased destruction:
-Immune (ITP, drug induced)
II) Decreased production
-Nutritional deficiency (B12, folate)
-Bone marrow (leukemia, aplastic anemia)
III) Sequestration
-Splenomegaly (cirrhosis)
Case : 25 y/f has URTI like symptoms, bruises for 2
weeks and CBC showed : WBC 4.5, ANC 3.5, Platelets
3K, Hgb 122gm/l.
Exam showed generalized LAP, few scattered bruises
Peripheral smear was unremarkable except for
thrombocytopenia (no platelet clumping).
Q: What labs do you want to order?
• Hepatitis profile negative (hep B and C)
• ANA 1:32
• HIV: positive ELISA and HIV RNA
You made a diagnosis of HIV associated ITP.
Which of the following is not effective treatment
option for this patient?
A) Platelet transfusion
B) IVIG
C) Steroid (1mg/kg)
D) Treatment of HIV/HAART
• Neutropenia:
Classification
– Mild 1000-1500
– Moderate 500-1000
– Severe <500*
– Profound <100
• Etiology:
–
–
–
–
Infection
Decreased production
Immune
Drugs
Case : 33y/m established new family physician visit
and had a routine CBC that was unremarkable except
for mild neutropenia (ANC 1200).
-on further history he said he was told he has low
neutrophils on several occasions over the past 6 years.
-he denied repeated infections
-family history was positive for low neutrophil count in his
mother.
What is the most likely diagnosis?
Any additional work up?
Case: 55y/m is on chemotherapy for CLL. He was last
treated 10 days ago. He presented to your office c/o chills
and myalgia and LLQ discomfort.
Exam showed T-39 Celsius, BP 109/65 HR 112, LLQ
tenderness.
Stat CBC showed Hgb 110, ANC 50 and Plts 85k
What is the next best step in management?
A) Oral Levofloxacin and follow up in a week.
B) Follow up with his oncologist next day
C) Draw blood culture and send for urgent admission for
IV antibiotics
D) Oral Levofloxacin and daily neupogen
Bi/pancytopenia
Usually serious causes:
–Bone marrow:
Acute leukemia
Aplastic anemia
MDS
Myelofibrosis
–Acute infection
Case: 65 y/m presented with bruises and fever as
well as nose bleeds. He has a routine visit 3 weeks
ago and had normal CBC at that time.
• CBC now shows: Hgb 77, WBC 2.7, ANC 0.7, Few
immature granulocytes reported, Platelets of 25K.
Electrolytes ok.
• PT/INR 1.4, aPTT 36 sec, Fibrinogen 108.
Q: What should be the most important diagnostic
consideration in this patient?
Q: What will you do next?
Overall survival of APL patients treated with ATRA in combination with anthracyclines in
Brazil. (A) Analysis of all patients. (B) Analysis excluding patients who died during induction.
• 63 y/f who was treated with chemotherapy and
radiation for breast cancer 10 years ago was found
to have the following labs on routine CBC.
– Hgb 110, MCV 104, WBC 2.3, ANC 1.2, Platelets 68.
– Vitamin B12 and folate normal.
– Labs 6 months ago showed Hgb 112, MCV 104, WBC
normal, Platelets 88.
You are concerned about long term complications of
chemotherapy (MDS).
The best was to confirm the diagnosis is:
A) PB flow cytometry
B) BM aspiration and biopsy
C) Peripheral smear
Thank you!