Case 372 -- Chronic Anemia

Contributed by J Manuel Zarandona, MD, and Sandra S Kaplan, MD
Published on line in December 2003


CLINICAL HISTORY:

A caucasian man in his 50s presented to the emergency department with increasing exertional dyspnea, generalized weakness, lethargy, and anemia. The patient underwent orthotopic cardiac transplant approximately six months earlier for ischemic cardiomyopathy secondary to a previous myocardial infarction. The anemia was first noted a few weeks postoperatively.

A bleeding duodenal ulcer was discovered approximately one month after the transplant. Endoscopic repair was performed and the patient received antibiotic treatment for Helicobacter pylori. The anemia did not resolve, although repeat endoscopy one month after the repair demonstrated that the ulcer was healing. The continuing anemia was attributed to an elevated tacrolimus (ProGraf, FK507) level; tacrolimus was subsequently discontinued, and cyclosporin (Neoral) was then used as the patient's primary immunosuppressant. The medication changes were made approximately one month prior to the presentation at the emergency department.

The patient's medications included cyclosporin (Neoral), mycophenolate mofetil (CellCept), valganciclovir (Valcyte), atorvastatin (Lipitor), pantoprazole (Protonix), trimethoprim-sulfamethoxazole, levothyroxine, and prednisone.

PERIPHERAL BLOOD COUNTS AND MORPHOLOGIC FINDINGS:

Rare plasmacytoid lymphocytes were identified; review of the peripheral blood smear was otherwise unremarkable.

BONE MARROW ASPIRATE AND BIOPSY FINDINGS:

Examination of the bone marrow aspirate revealed near absence of erythroid precursors. The rare pronormoblast forms identified were very large and megaloblastic, as shown in Figures A, B, C, D, and E. Myeloid maturation was complete but showed slight to moderate megaloblastoid changes. Some megakaryocytes were dysplastic with separated nuclei.

Examination of the bone marrow biopsy revealed a hypocellular marrow (20%) with very few identifiable erythroid forms, as shown in Figures F and G.

FLOW CYTOMETRY:

Flow cytometric immunophenotyping did not reveal an abnormal cell population. A slight increase in CD3-positive natural killer cells was detected; predominant heterogeneous T-lymphocytes and polyclonal B-lymphocytes were identified.

CYTOGENETICS:

Cytogenetic studies revealed a normal male karyotype (46, XY).

IMMUNOHISTOCHEMICAL STAINS


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