CASE STUDY

The case….

Elevated temperaturePossible insect biteSmall bite wound

Necrosis was not evidentDiffuse erythematous rash

PRESCRIPTION….

40 ml of liquid acetaminophen (Tylenol) and 10 days of cephalexin (Keflex)

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.

Four days later….

Unable to walkcomplete

blood count, urinalysis, urine and sputum

cultures, and chemistry

profile

Laboratory Data

Patient Reference

WBC (x 109/L) 5.9 4.5 - 11RBC (x 1012/L) 1.14 4.3 – 5.9

Hb (g/dl) 3.8 13.9 – 16.3Hct (%) 10 39 - 55

Results….

Platelet count Normal rangePBS Normocytic, normochromic, Few

spherocytes, increase in neutrophilic bands, few early WBCs, 3 nucleated RBCs

Urinalysis 3+ bloodUrine and sputum cultures negativechemistry profile elevated levels of total bilirubin,

alkaline phosphatase, lactate dehydrogenase, and aspartate aminotransferase

direct antiglobulin test (DAT) positiveindirect antiglobulin test negativeeluate Negative

Guide questions….Is this type of anemia caused by intracorpuscular

or extracorpuscular

defects?

…Answer….

extracorposcular defects

What does a positive result of the DAT imply?

Guide questions….

…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.

What mechanisms can

lead to the development of

drug-related antibodies and drug-induced

immune hemolytic anemia?

Guide questions….

…Answer….•The hapten or drug adsorption mechanism•The immune complex or “innocent bystander” mechanism•Non-immune protein adsorption mechanism•α-methyldopa or autoimmune (unknown) mechanism

Describe the mechanism that is most probable

cause of this patient’s anemia?

Guide questions….

…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.

The significantly high values of of total bilirubin, alkaline phosphatase, lactate dehydrogenase, and aspartate aminotransferase all indicate a damage to the liver.

…Answer….

What is the treatment of

choice?

Guide questions….

…Answer….

Removal of the offending drug ordinarily reverses the hemolytic process

Diagnosis: Drug-Induced Hemolytic Anemia.

CASE ANALYSIS

PRESENTED BY:

MARK MASCARINASMARK JADRIAN PARTOLAN

JOHN PATRICK PINEDA

OVERVIEW OF THE CASE

A 24-year old woman from Zaire was brought to the emergency department because of periodic fever, chills, night sweats and fatigue. Her laboratory data revealed the following data:

LABORATORY RESULTS

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: inclusions observed

1. DESCRIBE THE TYPE OF INCLUSIONS

PRESENT ON THE BLOOD SMEAR.

Based upon the observations made on the blood smear, one can conclude that the patient suffers from parasitism. Because ring forms of young trophozoites were seen on the blood smear.

2. DESCRIBE THE INCLUSIONS ON THE

THICK FILM.

Upon the examination of the thick film, there are numerous large number of ring forms in the red blood cells. The infected cells have highly irregular surface defect. This may be produced by the intracellular growth of the parasite or it could represent the site of parasite entry. This phenomenon is known to occur in simian malaria, the “pitting” of parasites from an infected cell.

3. JUSTIFY THE DIAGNOSIS.

The diagnosis: the patient have MALARIA caused by Plasmodium falciparum. One of the concrete evidence was the presence of rings forms in the red blood cells in both films.

The erythrocyte in P.falciparum infection is not enlarged. There is the presence of Mauer’s dot and may be a few reddish staining dots. The presence of extremely numerous rings and no other stages are seen strongly indicates P.falciparum case.

PLASMODIUM FALCIPARUM

PLASMODIUM FALCIPARUM

PLASMODIUM FALCIPARUM

CASE NO. 4

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.

A complete blood count (CBC) yielded the following results:

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

peripheral blood smear revealed:

slight anisocytosisslight polychromasiaseveral dark, round microspherocytes lacking central pallor

The platelet count and platelet distribution on the smear were normal.

QUESTIONS

Q1

From the data given, what is your initial diagnostic assessment of the anemia?

Q1

From the data given, what is your initial diagnostic assessment of the anemia?

Hereditary spherocytosis

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?

Q2What 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

Q2What additional laboratory tests would be of value in establishing the diagnosis, and what abnormalities in these tests would be expected in confirming 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

Q2What additional laboratory tests would be of value in establishing the diagnosis, and what abnormalities in these tests would be expected in confirming your impression?

Lactate dehydrogenase (LDH) Test – An increased LDH level

Coombs test – A negative Coombs test

Erythorocyte autohemolysis test – An increased autohemolysis test and corrected by the addition of glucose.

Q3

What is the cause of this type of anemia?

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).

This disorder is most common in people of Northern Europe descent, but it has been found in all races.

CASEANALYSIS 1

Presented By:GROUP 4

Garcia, Tiffany VerzilLozano, RossetteNicdao, Jan Kevin

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:

Case Analysis

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

 

Laboratory Diagnosis

  1.Select the confirmatory tests that should be performed and the expected results.

- Confirmatory test should be performed are hemoglobin solubility test and cirtate agar test, hemoglobin C I s separated from hemoglobin A, O, and E as a result of mode of migration; hemoglobin C migrates 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 hemoglobins D and G migrate cathodally.

QUESTIONS

2. Describe the characteristic RBC morphology on the peripheral blood film.

- Characteristically, red blood cell that contain cystallized aggregates of hemoglobin that protrude through the cell membrane are seen. They are irregular shaped cells which appear to contain mis-shapen crystals and increased target cells are seen. 

QUESTIONS

3. Based on the electrophoresis and RBC morphology results, what diagnosis is suggested?

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

QUESTIONS

QUESTIONS4. If this patient were to marry a person of genotype HbAS, what would be the expected frequency of genotypes for each of four children?

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

A S

S AS SS

C AC SC

25% Would be each genotype

Mild, chronic hemolytic anemia associated with variable vaso-occlusive complications.

Splenomegaly

Hgb level usually 11 – 13% g/dLReticulocyte count: 3 – 5%Peripheral smear: few sickle cell, target cells.

And intra – erythrocyte free crystalline structures (may protrude from membrane, HbSC crystals)

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

Diagnosis

Diagnostic Hematology by: Rodak, Bernadette F.

Clinical Hemetolology: Correlations and Principles by: Steininger, Sheryl

REFERENCES: