Hematology Case Studies

5/21/2018 Hematology Case Studies

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CASE STUDY


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The case.

Elevated temperature

Possible insect bite

Small bite wound

Necrosis was not evident

Diffuse erythematous rash


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PRESCRIPTION.

40 ml of liquid acetaminophen Tylenol) and

10 days of cephalexin Keflex)


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A secretion from the lesion was

subjected to culture, but there was no

growth after 72 hours. Blood was drawn

for cultures, which were reported as

negative after 5 days.


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Four days later.

Unable to walk

complete blood count,

urinalysis, urine and sputum

cultures, and chemistry

profile


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Laboratory

Data

Patient Reference

WBC (x 109/L) 5.9 4.5 - 11

RBC (x 1012/L) 1.14 4.35.9

Hb (g/dl) 3.8 13.916.3

Hct (%) 10 39 - 55

Results.


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Platelet count Normal range

PBS Normocytic, normochromic, Few

spherocytes, increase inneutrophilic bands, few early WBCs,

3 nucleated RBCs

Urinalysis 3+ blood

Urine and sputum cultures negative

chemistry profile elevated levels of total bilirubin,

alkaline phosphatase, lactate

dehydrogenase, and aspartate

aminotransferase

direct antiglobulin test (DAT) positiveindirect antiglobulin test negative

eluate Negative


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Guide questions.

Is this type of anemia caused by

intracorpuscular or

extracorpuscular defects?


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Answer.

extracorposcular defects


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What does a positive result of the

DAT imply?

Guide questions.


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Answer.

A positive DAT or Direct Antiglobulin

Test which is a confirmatory of an immune

hemolytic anemia implies that the patient

has antibodies, a complement or both are

present on the RBC surface.


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What mechanisms can lead to the

development of drug-related

antibodies and drug-induced

immune hemolytic anemia?

Guide questions.


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Answer.

The hapten or drug adsorption mechanism

The immune complex or innocent

bystander mechanism

Non-immune protein adsorption mechanism

-methyldopa or autoimmune unknown)

mechanism


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Describe the mechanism that is

most probable cause of this

patients anemia

Guide questions.


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Answer.

Hapten Drug Adsorption) Mechanism is the most probable cause.

It happens when a hapten,a low molecular weight substance that rarely

stimulates antibody production, is involved in drug induced hemolytic

anemia.

This is caused by drugs such as penicillin acetaminophen) which was

administered to the patient.


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The significantly high values of of total bilirubin,

alkaline phosphatase, lactate dehydrogenase, and

aspartate aminotransferase all indicate a damage to

the liver.

Answer.


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What is the treatment of choice?

Guide questions.


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Answer.

Removal of the offending drug

ordinarily reverses the hemolytic

process


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Diagnosis: Drug Induced

Hemolytic Anemia.


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A 24-year old woman from Zaire

was brought to the emergencydepartment because of periodic fever,

chills, night sweats and fatigue. Her

laboratory data revealed the following

data:


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Hematocrit: 0.35 L/L

Reticulocytes: 275 x 109/L

WBC Count: 11 x 109/L

Thin Smear:

slight variation in diameter of RBCs

inclusions noted in the RBCs

diffusely basophilic RBCs

Thick film:


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Based upon the observations made on

the blood smear, one can conclude that thepatient suffers from parasitism. Becauseringforms of young trophozoiteswere seen on

the blood smear.


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Upon the examination of the thick film,there are numerous large number of ringforms in the red blood cells. The infectedcells have highly irregular surface defect.This may be produced by the intracellular

growth of the parasite or it could representthe site of parasite entry. This

phenomenon is known to occur in simianmalaria, the pitting of parasites from aninfected cell.


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The diagnosis: the patient haveM L RI caused by lasmodium falciparum .

One of the concrete evidence was the presenceof rings forms in the red blood cells in both films.

The erythrocyte in P.falciparum infection isnot enlarged. There is the presence of uersdot and may be a few reddish staining dots. Thepresence of extremely numerous rings and no

other stages are seen strongly indicatesP.falciparum case.


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CASE NO. 4


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A 55 year old man sought a medical

attention for the onset of chest

pain. Physical examination revealed

slight jaundice and splenomegaly. The

past medical history included

gallstones, and there was a family

history of anemia.


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A complete blood count

(CBC) yielded the following

results:


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Laboratory

Data

Patient Reference

Range

WBC (x 109/L) 13.4 4.5-11

RBC (x 1012/L) 4.28 4.3-5.9

Hemoglobin (g/dL) 11.7 13.9-16.3

Hematocrit (%) 32.5 39-55

MCV (fL) 76 80-100

MCH (pg) 27.3 25.4-34.6

MCHC (g/dL) 36 31-37

RDW (%) 22.9 11.5-13.5


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peripheral blood smear

revealed:


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slight anisocytosisslight polychromasia

several dark, round

microspherocytes lackingcentral pallor


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The platelet count andplatelet distribution on the

smear were normal.


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QUESTIONS


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Q1

From the data given, what is

your initial diagnostic

assessment of the anemia?


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Q1

From the data given, what is

your initial diagnostic

assessment of the anemia?

Hereditary spherocytosis


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Q2

What additional laboratory testswould be of value in establishing

the diagnosis, and what

abnormalities in these tests would

be expected in confirming yourimpression?


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Q2

What additional laboratory tests would be of value in establishing the

diagnosis, and what abnormalities in these tests would be expected in

confirming your impression?

Mearuement of bilirubin An increased

bilirubin level would be expected

Reticulocyte count An increased

reticulocyte count

Measurement of haptoglobin A decreased

or absence of haptoglobin


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Q2What additional laboratory tests would be of value in establishing the

diagnosis, and what abnormalities in these tests would be expected inconfirming your impression?

Osmotic fragility test An increased

Osmotic fragility test

Chromium labelled RBC test Abnormal (15

days)

Fecal urobilinogen Presence of

urobilinogen because of destruction of

ertythrocytes


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Q2What additional laboratory tests would be of value in establishing the

diagnosis, and what abnormalities in these tests would be expected inconfirming your impression?

Lactate dehydrogenase (LDH) Test An

increased LDH level

Coombs test A negative Coombs test

Erythorocyte autohemolysis test An

increased autohemolysis test andcorrected by the addition of glucose.


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Q3

What is the cause of this typeof anemia?


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Q3

What is the cause of this type of anemia?

Hereditary spherocytosis is due to the

presence of an autosomal dominant mutation.

This mutation caused an abnormal red blood

cell membrane (abnormal or lack of spectrin).


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This disorder is most common in

people of Northern Europe

descent, but it has been foundin all races.


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An 18-year old African American woman was

seen in the emergency department for fever and

abdominal pain. The following results were

obtained on a blood count:


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WBC count: 11.9 x 109/L - increased

RBC count: 3,67 x 1012/L - decreased

Hgb: 10.9 g/dL decreased

Hct: 32.5% (0.325L/L) decreased

Platelet count : 410 x 109/L - normal RDW : 19.5% - increased

Segmented neutrophils : 75% - normal

Lymphocytes : 18% - normal

Monocytes : 3% - normal Eosinophils : 3% - normal

Basophils : 1% - normal

Reticulocyte count: 3.1% - increased


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1.Select the confirmatory tests that should be

performed and the expected results.

- Confirmatory test should be performed arehemoglobin solubility test and cirtate agar test,

hemoglobin C I s separated from hemoglobin A, O, andE as a result of mode of migration; hemoglobin Cmigrates more toward the anode, whereas hemoglobins

A, O, and E migrate toward the cathode. Likewise,

hemoglobin S migrate toward the cathode. Likewise,hemoglobin S migrates anodally, wheraes hemoglobinsD and G migrate cathodally.


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2. Describe the characteristic RBC morphologyon the peripheral blood film.

- Characteristically, red blood cell that containcystallized aggregates of hemoglobin thatprotrude through the cell membrane are seen. Theyare irregular shaped cells which appear to contain

mis-shapen crystals and increased target cells areseen.


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3. Based on the electrophoresis and RBCmorphology results, what diagnosis issuggested?

- On the basis of the ectrophoretic pattern,the daignosis of presence of hemoglobin SC

can be made


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4. If this patient were to marry a person of genotypeHbAS, what would be the expected frequency ofgenotypes for each of four children?

- According to Mendelian law, the genotype can bedepicted by the following chart:

A S

S AS SS

C AC SC

25% Would be each genotype


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Mild, chronic hemolytic anemia associated withvariable vaso-occlusive complications.

Splenomegaly

Hgb level usually 1113% g/dL

Reticulocyte count: 3 5%

Peripheral smear: few sickle cell, target cells. And intra

erythrocyte free crystalline structures (may protrudefrom membrane, HbSC crystals)

Citrate agar: C migrates, separation from S, E, O


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Diagnostic Hematology by: Rodak, Bernadette F. Clinical Hemetolology: Correlations and Principles by:

Steininger, Sheryl

Date post:	12-Oct-2015
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Hematology Case Studies

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