Clinical topics conference: Chapter 20, Blood and Lymphoid Tissues I

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  1. 52 year-old male with fatigue
  2. 8 year-old boy with a swollen knee
  3. 30 year-old female with general malaise
  4. 21 year-old male with fatigue and bleeding gums

Clinical vignette 1

A 52 year-old male presents with a chief complaint of fatigue, and you notice marked pallor of the conjunctival membranes on physical examination. You order a complete blood count (CBC).

Laboratory findings - CBC

ComponentValueNormal RangeDifferentialValueNormal Range
WBC8.24-10 thousand/ulNEUT6541-77%
RBC3.74.5-5.9 million/ulBAND30-2%
HGB6.914-17.5 g/dlLYMPH2524-44%
HCT23.342-50%MONO74-12%
MCH18.627.5-33.2 pg/RBC
MCHC29.733.4-35.5 gm/dl
MCV6280-96 fl/RBC
RDW20.611.5-14.5
Platelets518150-400/ul

Discussion topics

  1. Identify the abnormal clinical and laboratory findings.

  2. What other questions would you ask this patient in the review of systems, and what other physical findings would you specifically assess?

  3. Based on the information given, what is the differential diagnosis? What is the most likely diagnosis?

  4. What would you expect to observe when you look at the peripheral blood smear?

  5. What further studies would you do to confirm your diagnosis of this hematologic problem?

  6. Discuss the clinical and hematologic differences between iron deficiency anemia and anemia of chronic disease.

  7. After you characterize the anemia, what else should be done in this clinical setting?
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    Clinical vignette 2

    An 8 year old boy was brought to the emergency room by his mother for a markedly swollen and painful knee. The swelling occured about 2 hours after being hit on the knee by a baseball. The mother reports that he had a history of easy bruising on his arms and legs. Family history was positive for a history of easy bruising in a maternal uncle.

    Physical examination showed marked swelling and erythema of the left knee, and range of motion was markedly decreased. Small resolving ecchymoses were noted on the arms and legs. Aspiration of the knee joint showed bloody fluid.

    Laboratory Findings: hemoglobin 140 g/L (reference range 140-180 g/L), white cells 8 x 109/L (normal 4 .5-11 x 109/L), platelets 250 x 109/L (normal 150-450 x 109/L), prothrombin time 12 sec. (normal 10-13 sec), activated partial thromboplastin time 65 sec. (normal 25 - 35 sec), bleeding time 6 minutes (normal 2-8 minutes), fibrin degradation products <10 mg/L (normal <10 mg/L), Factor VIII 5% (normal 50-150%), Factor IX 88% (normal 50-150%), von Willebrand factor 100 U/L (normal 50-150 U/L).

    Discussion topics

    1. What are the bleeding manifestations in this patient? Do any suggest whether this is a platelet plug defect or a coagulation defect?

    2. What is your interpretation of the lab tests?

    3. Describe the clinical manifestations, prognosis, and treatment of hemophilia A.
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    Clinical vignette 3

    A 30 year-old female presented to her family physician with a one week history of flu - like symptoms, including malaise, headache, and fever. Her past medical history was unremarkable. Physical examination showed petechiae distributed on the palate, conjunctiva, and lower legs.

    Lab studies: hemoglobin 80 g/L (normal 120-160 g/L), white cells 10 x 109/L (normal 4.5-11 x 109/L), platelets 15 x 109/uL (normal 150-450 x 109/L), prothrombin time 13 seconds (normal 10-13 sec.), activated partial thromboplastin time 32 seconds (normal 25-35 sec.), fibrin degradation products <10 mg/L (normal <10 mg/L), bleeding time 15 minutes (normal 2-8 min.), lactate dehydrogenase 264 U/L (normal 38-62 U/L), aerobic and anaerobic blood cultures were negative. Blood smear showed numerous red cell fragments (schistocytes).

    The patient was admitted to the hospital and daily plasmapheresis was performed with fresh frozen plasma as the replacement fluid. Over a period of 10 days the patients symptoms completely resolved, and the platelet count increased to 150 x 109/L and the lactate dehydrogenase levels normalized. Plasmapheresis was discontinued after the tenth procedure.

    Discussion topics

    1. What are the clinical manifestations of thrombotic thrombocytopenic purpura (TTP)?

    2. In addition to clinical manifestations, what laboratory criteria are used to establish the diagnosis?

    3. What are some of the etiologies of TTP?

    4. What are some current theories regarding the pathogenesis of TTP?

    5. What is the treatment for TTP, and what is the prognosis in the absence and presence of treatment?
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    Clinical vignette 4

    A 21 year old male presented with a 2 week history of severe fatigue and gum bleeding after brushing his teeth. He was otherwise athletically active and had an unremarkable past medical history. Physical examination showed pallor of the oral mucosa, petechiae on the abdomen and legs, and a 4 cm ecchymosis on the right thigh. He was afebrile.

    Lab studies: hemoglobin 82 g/L (normal 140-180 g/L), white cells 12 x 109/L (normal 4.5-11 x 109/L), platelets 10 x 109/L (normal 150-450 x 109/L), prothrombin time 20 seconds (normal 10-13 sec.), activated partial thromboplastin time 55 seconds (normal 25-35 sec.), fibrin degradation products >80 mg/L (normal <10 mg/L), bleeding time 20 minutes (normal 2-8 minutes), fibrinogen 0.6 g/L (normal 2.0-4.0 g/L), blood smear showed numerous atypical promyelocytes with folded nuclei and abundant cytoplasm containing numerous large purple granules and Auer rods.

    Discussion topics

    1. What are the different etiologies and underlying pathophysiological mechanisms of disseminated intravascular coagulation (DIC)?

    2. What is the etiology in this patient?

    3. What hemostatic abnormalities are seen in DIC, and which are present in this patient?

    4. How is DIC treated?
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