Contributed by Siobhan O'Connor, MD and Sandra Kaplan, MD Published on line in June 2005
Contributed by Siobhan O'Connor, MD and Sandra Kaplan, MD
Published on line in June 2005
PATIENT HISTORY:
The patient is a 32 year old male who presented to the emergency department complaining of progressive fatigue and shortness of breath on exertion over a two to three month period. He denied any infection, bleeding or bruising. He reported consumption of one case of beer per day for ten years, but in the last four years had reduced his intake to one six-pack per day. Past medical history is significant for multiple gunshot wounds to the abdomen in the late 90s requiring resection of small bowel and colon, including the terminal ileum and cecum. This was followed by repair of a large ventral hernia in 2001. No outpatient medications and no known drug allergies. Physical exam showed mild scleral icterus, lungs clear to auscultation, heart regular rate and rhythm without murmurs, rubs, or gallops, abdomen with midline scar, liver palpable 2 cm below the left costal margin, and spleen not enlarged.
A bone marrow specimen was sent to pathology accompanied by peripheral blood showing the following:
|
|
Patient Value |
Normal Range (Male) |
|
WBC |
5.2 x 109/L |
3.8 - 10.6 |
|
RBC |
2.61 x 1012/L |
4.13 - 5.57 |
|
Hemoglobin |
9.1 g/dL |
12.9 -16.9 |
|
Hematocrit |
25.7% |
38.0 - 48.8 |
|
MCV |
98.2 fL |
82.6 - 97.4 |
|
MCH |
34.8 pg |
27.8 - 33.4 |
|
MCHC |
35.5 gm/dL |
32.7 - 35.5 |
|
RDW |
14.2% |
11.8 - 15.2 |
|
PLT |
20 x 109/L |
156 - 369 |
|
|
Percentage of Cells |
Absolute Number |
Normal Range for Absolute |
|
POLYS |
68% |
3.54 |
2.24 - 7.68 |
|
LYMPHS |
19% |
0.99 |
0.80 - 3.65 |
|
ATYPICAL LYMPHS |
2% |
0.10 |
|
|
MONOS |
3% |
0.16 |
0.30 - 0.90 |
|
EOS |
5% |
0.26 |
0.00 – 0.40 |
|
BASO |
2% |
0.10 |
0.00 – 0.06 |
|
META |
1% |
|
|
|
nRBC/100WBC |
12 |
|
|
However, Laboratory Values on Admission included the following:
|
|
Patient Value |
Normal Range (Male) |
|
WBC |
2.6 x 109/L |
3.8 - 10.6 |
|
Hemoglobin |
2.7 g/dL |
12.9 -16.9 |
|
Hematocrit |
7.7% |
38.0 - 48.8 |
|
MCV |
129.7 fL |
82.6 - 97.4 |
|
RDW |
46.7% |
11.8 - 15.2 |
|
PLT |
48 x 109/L |
156 – 369 |
|
Reticulocytes |
9.2% |
0.8 – 2.0 |
|
Abs Retic |
0.052 x 1012/L |
0.018 – 0.158 |
|
LDH |
6338 IU/L |
<170 |
|
TBILI |
8.8 mg/dL |
0.3 – 1.5 |
|
DBILI |
<0.1 |
|
|
Iron |
159 µg/dL |
65 – 165 |
|
Saturation |
64% |
25 – 50% |
|
TIBC |
247 µg/dL |
250 – 420 |
|
Ferritin |
135 ng/mL |
10 – 282 |
|
B12 |
63 pg/mL |
211 – 911 |
|
Folate |
13.2 ng/mL |
>5.4 |
|
RBC Folate |
805 ng/mL |
293 – 809 |
Bone Marrow Differential on aspirate smear:
|
Bone Marrow Differential |
Patient Value |
Adult Mean |
Normal Range |
|
Blast |
0.7% |
1.0 |
0.0 - 2.0 |
|
Promyelocyte |
2.0% |
3.0 |
2.0 - 4.0 |
|
Myelocyte |
8.0% |
12.0 |
8.0 - 16.0 |
|
Metamyelocyte |
5.3% |
17.0 |
10.0 - 25.0 |
|
Band |
8.3% |
12.0 |
9.0 - 18.0 |
|
PMN |
10.0% |
9.0 |
7.0 - 14.0 |
|
Eos Myelo/Meta |
1.3% |
2.0 |
1.0 - 4.0 |
|
Eos Band |
0.3% |
1.0 |
0.0 - 3.0 |
|
Eos Seg |
2.3% |
1.0 |
1.0 - 2.0 |
|
Basophil |
0% |
0.0 |
0.0 - 0.2 |
|
Monocytes |
0% |
1.0 |
0.0 - 2.0 |
|
Pronormoblasts |
10.7% |
1.0 |
0.0 - 1.0 |
|
Normoblasts |
45.7% |
24.0 |
16.0 - 32.0 |
|
Lymphocytes |
4.3% |
16.0 |
11.0 - 23.0 |
|
Plasma Cells |
1.0% |
2.0 |
0.0 - 3.0 |
|
Other |
0% |
|
|
|
Myeloid/Erythroid Ratio |
0.7 |
2.4 |
1.5 – 3.3 |
Bacterial and fungal cultures from bone marrow were negative. Parvovirus and HIV were negative.
MICROSCOPIC DESCRIPTION:
Peripheral blood erythrocytes show marked anisocytosis (Image 1), basophilic stippling (Image 2), polychromasia (Image 3), nucleated forms (Image 4), and macroovalocytes (Image 5). Hypersegmented granulocytes are frequent (Images 6 and 7).
FLOW CYTOMETRY:
Normal with heterogeneous cellular populations and CD34 positive blasts comprising less than 1.5% of total events analyzed. Evaluation for evidence of paroxysmal nocturnal hemoglobinuria was negative.
CYTOGENETICS:
Normal, 46 X,Y.
