O/E:

• Concious, oriented.
• Vitals-stable.
• Palllor ++; no icterus/clubbing/cyanosis/lymphadenopathy/edema.
• FUNDUS=B/L multiple dot-blot hemorrhages +; big hemorrhage in left eye;
no neovascularization
• CVS: s1,s2 present; no murmurs/added sounds.
• RS: B/L NVBS
• P/A: soft, no hepatomegaly, no splenomegaly; no masses palpable.
• CNS: NAD.

• D/D::ANEMIA??CAUSE
??ACUTE VIRAL ILLNESS.
CASE::
• 65/M; marble business by occupation came with c/o generlised fatigue for 1
week; low grade fever for 1 day.
• h/o dysnoea on exertion-NYHA II/IV since 2 months.
• h/o travel to hyderabad for a week and returned 1 week prior to day of
admission.

• No h/o myalgia or arthralgia; vomitings and loosestools; hematemesis and

melena; hematuria or other bleeding diathesis.
• No h/o angina/palpitations/syncopal attacks.

• k/c/o T2DM X 12years on metformin, glimepiride and some ayurvedic

medications.
• Hypertensive for past 5 years on telmisartan.
• h/o bilateral diabetic retinopathy for which he had undergone LASER
treatment.

• Occasional alcoholic; takes mixed diet preferably vegetable.

• Non-smoker.
INVESTIGATIONS::
1. CBC🡪 Hb-5.8; pcv-18.6; tc-790(p-32, l-65, E-1,M-2); PLT-21000; MCV=;
MCH=; MCHC=
2. ESR=145
3. FBS=177
4. B.UREA=39mg/dL; sr cr=1.21; Na=135; K=4.3
5. LFT= Bil-T-1.20; D-0.26, SGOT=16;SGPT=13; ALP=36; ALB=4.0;
GLO=2.4; A/G=1.7
6. URE=2-4PC, ALB-NIL; TSH=1.12; FLP-Normal(TG=63); hba1c=9.2

7. ECG=SR,60deg, 77/min,regular, no ST/T changes.

8. CHESTXRAY= WNL

9. EGFR=63.1mL/min/1.73m2 (CKD-EPI)
PANCYTOPENIA EVALUATION
DEFINITION:
• Hemoglobin<9 gm/dL; WBC<4000/cmm; PLATELETS<1,00,000/cmm.

• SEVERE PANCYTOPENIA: ANC< 500/cmm; platelet<20000/cmm;

corrected reticulocyte count<1%

• Symptoms may be attributable to

• ANEMIA🡪 fatigue, breathlesness and cardiac symptoms.
• NEUTROPENIA🡪 febrile illness, increased susceptibility to infection.
• THROMBOCYTOPENIA🡪 mucocutaneous bleeding or bruising.

• Severity of pancytopenia and underlying aetiology determines the

management and prognosis.

• MAIN CAUSES IN OUR COUNTRY: megaloblastic anemia due to

nutritional deficiency; hypersplenism; aplastic anemia; myelodysplastic
syndromes; subleukemic leukemias; miliary tuberculosis; multiple myeloma;
PNH.
AETIOLOGY::
• Can result from

• Failure of production of stem cells

• Infiltration by malignant cells or fibrosis
BONE MARROW • Immune mediated supression
REASONS
• Ineffective erythropoesis and dysplasia

• Peripheral sequestration by overactive

reticulo endothelial system
PERIPHERAL • Immune or nonimmune mediated
destruction of blood cells
• CLASSIFICATION:
MEGALOBLASTIC ANEMIA::
• Predominant cause of pancytopenia in India due to high prevalence of
nutritional deficiencies.
• Pancytopenia is of a hypercellular bone marrow failure.
• Vit B12 def also causes a)SUB ACUTE COMBINED DEGENERATION of
cord; b) megaloblastic madness-psychiatric illness.
• Neurological involvement is inversely proportional to bone marrow
supression.

PERIPHERAL SMEAR: oval macrocytes with anisocytosis and poikilocytosis;

MCV>100fL unless coexisting cause of microcytosis( thalasemia trait or
IDA); hypersegmented neutrophils(>5 nuclear lobes);

• LEUCOPENIA- both granulocytes and lymphocytes(usually >1500/cmm);

platelets are moderately reduced(rarely < 40000/cmm).

• Severity of all these changes parallels the degree of anemia.

BONE MARROW: hypercellular with accumulation of primitive cells due to
apoptosis of mature forms.

• Erythroblasts: larger than normoblasts , increased in number with eccentric

lobulated nuclei or nuclear fragmants.

• Giant and abnormally shaped metamyelocytes.

• Enlarged hyperpolypoid megakaryocytes.

• Erythroid hyperplasia, sieved nuclear chromatin, asynchronous nuclear

maturation, bluish cytoplasm with blebs.
MEGALOBLASTIC ANEMIA::
• CAUSES OF COBALAMIN DEFICIENCY:
• CAUSES OF FOLATE DEFICIENCY:
HYPERSPLENISM::
• Characterized by
1. SPLENOMEGALY
2. CYTOPENIA
3. NORMAL or HYPERPLASTIC BONE MARROW
4. RESPONSE TO SPLENECTOMY.

• Peripheral pooling and destruction of cells in enlarged spleen.

CAUSES:
1. Congestive splenomegaly: cirrhosis, congestive heart failure.
2. Malaria; hyperreactive malarial splenomegaly.
3. leishmaniasis
4. Thalassemia
5. Hodgkin’s disease
6. Idiopathic(rarely)
INFECTIONS::

1. Advanced stage of HIV🡪 multifactorial: high viral load; ART; acute or

chronic oppurtunistic infections

2. VIRAL HEPATITIS🡪 transcient pancytopenia or may be a/w aplastic

anemia(fatal). HBV, HCV, EBV, CMV; DENGUE VIRUS; HAV.

3. Sepsis and enteric fever🡪 d/t DIC, bone marrow supression, infection ass
hemophagocytic syndrome.

4. Disseminated miliary TB🡪 bacilli load and ATT are attributed.

5. Leishmaniasis; malaria; filaria.

APLASTIC ANEMIA:

• Defined as pancytopenia with hypocellular marrow in absence of abnormal

marrow infiltrate or increased fibrosis.

• Severe aplastic anemia definition:

• Bone marrow cellularity < 25% + ≥2/3(neutrophils < 500/cmm;
platelet < 20000/cmm;
corrected reticulocyte count < 1% or
absolute retic count < 60000cmm).
CAUSES:
1. RADIATION: aplasia is an acute sequelae; dose dependent decline; MDS
and leukemia are late sequelae.

2. CHEMCALS: BENZENE- notorious cause of marrow failure.

3. DRUGS: either as regular effects or idio syncriatic reactions.

4. INFECTIONS: mc-HEPATITIS; rarely EBV; parvo virus B19 may be a/w

transcient aplastic crisis.
5. IMMUNOLOGIC: transfusion ass GVHD- after infusion of nonirradiated
blood products to immunodef pt.; EOSINOPHILIC FASCITIS;
THYMOMA; HYPOIMMUNOGLOBULINEMIA; SLE.

6. PREGNANCY

7. Paroxysmal Nocturnal Hemoglobinuria:

• Acquired mutation in PIG-A gene in hematopoetic stem cell.
• Surface membrane protein deficiency(GPI linked) makes red cell sensitive
to activated complement C 🡪 INTRAVASCULAR HEMOLYSIS.
• Can be a/w pancytopenia.
• Diagnosis: FLOW CYTOMETRY 🡪 Bimodal distribution of cells that are
CD-55 and CD-59 negative.
8. FANCONI ANEMIA:
• Autosomal recessive
• a/w congenital anomaly- short stature, café-au-lait spots, anomalies inv
thumb, radius, genito-urinary tract; pancytopenia; increased r/o
malignancy.
• 16 deficient genes have been identified; MC- type A(FANCA gene defect).

9. DYSKERATOSIS CONGENITA:
• TRIAD-a) mucous membrane leucoplasia
b) dystrophic nails
c) reticular hyperpigmentation.
• a/w aplastic anemia in childhood.
• Defect in genes a/w telomere repair complex.

10. SCHWACHMAN-DIAMOND SYNDROME:

• neutropenia + pancreatic insufficiency + malabsorbtion.
• CAUSES OF APLASTIC ANEMIA:
• DRUGS ASS WITH APLASTIC ANEMIA:
PHYSICAL EXAMINATION:
• Petchiae, ecchymoses, retinal hemorrhages.
• Pallor
• Lymphadenopathy and splenomegaly are highly atypical of aplastic anemia.
• cafe-au-lait spots, shoort stature – s/o fanconi anemia.
• Peculiar nails & leukoplakia – s/o dyskeratosis congenita.
• Early graying of hair – s/o telomerase defects.

PERIPHERAL SMEAR:
• Large erythrocytes qith paucity of granulocytes and platelets.
• MCV-commonly increased; reticulocytes-absent/few; lympho- normal/dec.
• Presence of immature myeloid forms – s/o LEUKEMIA or MDS; nucleated
RBC – S/O MARROW FIBROSIS or TUMOR INVASION; abnormal platelets
– s/o PERIPHERAL DESTRUCTION or MDS.

BONE MARROW:
• Can be readily aspirated but it will be diluted. ( dry tap – s/o fibrosis or
myelophthisis).
• No correlation b/w marrow cellularity and disesase severity.
• Residual hematopoetic cells should have normal morphology.
• APLASTIC ANEMIA pic:
ACUTE LEUKEMIAS:
• AML in all age groups, esp older adults. M>F; incidence-1.7% in <65 yrs,
15.9% in >65 yrs. Mean age=67 yrs.
• ALL is the MC acute leukemia in childhood.

AML-ETIOLOGY:
• High dose radiation, heriditary; chemical and other occupational exposures
• DRUGS: alkylating agents- 4-6 yrs after exposure(5 & 7 chromosomes);
topoisomerase inhibitors-1-3 yrs after exposure(11q); chloramphenicol;
phenylbutazone; less commonly-chloroquine, psoralens.

PHYSICAL FINDINGS:
• Fever; hepato-splenomegaly; lymphadenopathy; sternal tenderness;
evidence of infection & hemorrhage.
• Significant GI bleed, intrapulmonary hemorrhage, ICH
• Bleeding diathesis incl retinal hemorrhages.
• Infiltration of gingivae, skin, soft tissues, meninges with leukemic blasts.
HEMATOLOGIC::
• ANEMIA- of varying degrees irrespective of other hematologic findings,
splenomegaly, or duration.
• NORMOCYTIC NORMOCHROMIC PICTURE.
• Reduced reticulocyte count; RBC survival also decreased by accelerated
destruction.

• LEUKOCYTE: median count-15000/cmm; 25-40% have <5000/cmm; 20%

have >100000/cmm.
• Morphology of malignant cells varies in different subsets.
• Cytoplasm of WBC- contains non-specific granules with fine, lacy chromatin
with one or more nucleoli-s/o IMMATURE CELLS.
• AEUR RODS may be present.

• PLATELETS:: 75%- <100000/cmm; 25%- <25000/cmm; with both

morphologic and functional abnormalities.
• AML TYPES:
• AML EVALUATION:
• AML P SMEAR:
MYELODYSPLASIA:
• Myelodysplastic syndromes are heterogenous group of disorders
characterized by
1. Cytopenias due to bone marrow failure.
2. High risk of development of AML.

• Median age=70 yrs; only 10% below 50 yrs

• Anemia with thrombocytopenia and neutropenia; with abnormally

appearing(dysmorphic) cellular bone marrow🡪 s/0 ineffective RBC
production.

• LOW RISK MDS: marrow failure dominates clinical course.

• HIGH RISK MDS: myeloblasts are present at diagnosis, chromosomal
abnormalities, leukemic progression.
ETIOLOGY::
• environmental-BENZENE; RADIATION.
• SECONDARY MDS: late toxicity of cancer treatment with radiation,
alkylating agents, DNA topoisomerase agents.
• Acquired aplastic anemia, fanconi anemia also can evolve into MDS.

BLOOD::
• Anemia- either alone, or as ass. bicytopenia or pancytopenia; isolated
neutropenia or thrombocytopenia-RARE.
• MACROCYTOSIS is common or may be DIMORPHIC picture.

• PLATELETS: large without granules(immature); so bleeding manifestations

may be present despite normal numbers.

• NEUTROPHILS: hypogranulated, hyposegmented, ringed or abnormally

segmented nuclei; may contain DOHLE bodies. Functionally inefficient.
 MARROW:
• Normal/hypercellular; 20% cases-hypocellular-confused to be aplasia.>
• No single characteristic feature-s/o MDS.
• Commonly observed🡪
1. Nuclear abnormalities, ringed sideroblasts in erythroid linege.
2. Hypogranulation and hyposegmented granulocyte precursors.
3. Increased myeloblasts.
4. Megakaryocytes- reduced in number with disorganized nuclei.

• Cytogenic analysis, FISH for identifying chromosomal abnormalities.

• MDS classif::
MYELOPHTHISIS::
• Fibrosis of bone marrow usually accompanies by a characteristic blood
smear picture k/a LEUKOERYTHROBLASTOSIS.

1. PRIMARY🡪 myelofibrosis/ myeloid metaplasia.

2. SECONDARY(reactive)🡪 MYELOPHTHISIS.

Fibrosis can be due to

1. invading tumor cells(usually an epithelial cancer of LUNG, BREAST,
PROSTATE, GIT origin or NEUROBLASTOMA).
2. INFECTIONS- mycobateria(tuberculosis & avium); fungi; HIV.
3. Sarcoidosis
4. Gaucher disease🡪 marrow space obliteration by intracellular lipid
deposition.
5. Secondary fibrosis may be due to radiation therapy or consequence of
radiomimetic drugs.
6. Can be a feature of MULTIPLE MYELOMA, CML, LYMPHOMA,
MYELOMA, HAIRY CELL LEUKEMIA.
 PATHOPHYSIOLOGY::
1. Proliferation of fibroblasts in marrow space ( myelofibrosis)
2. Myeloid metapalsia🡪 extension of hematopoesis into long bones and
extramedullary sites(spleen, lymphnode, liver).
3. Ineffective erythropoesis.

INVESTIGATIONS:
• ANEMIA🡪 dominant; normocytic-normochromic
• Leuko-eryhtroblastic smear.
• Leukoerythroblastosis was first described in 1936 byb Vaughan as “AN
ANEMIA CHARACTERIZED BY THE PRESENCE OF IMMATURE RED
CELLS & FEW IMMATURE WHITE CELLS OF MYELOID SERIES in
peripheral smear”
1. Abnormal erythrocyte morphology with circulating nucleated RBC s;
teardrops, shape distortions.
2. WBC- elevated numbers sometimes mimicking leukamoid reaction, with
circulating myelocytes, promyelocytes, myeloblasts.
3. Giant platelets.

• Bone marrow🡪 DRY TAP.

 D/D OF LEUKOERYTHROBLASTOSIS::

1. Chronic myeloproliferative diseases.

2. Acute leukemia.
3. Hairy cell leukemia.
4. Metastatic carcinomas.
5. Malignant lymphoma.
6. Multiple myeloma.
7. Myeloid metaplasia with myelofibrosis.
8. Infections🡪 BACTERIAL incl mycobacteria; FUNGI.
9. Gaucher disease.
10. Bone marrow necrosis.
11. Granulomatous infiltration with sarcoid or the histiocytic type.

DRY TAP D/D:: HAIRY CELL LEUKEMIA; METASTATIC

CARCINOMA, MYELOFIBROSIS; LYMPHOPROLIFERATIVE
DISORDERS.
PICTURE:
MYELOFIBROSIS WITH MYELOID METAPLASIA:
• Also k/a AGNOGENIC MYELOID METAPLASIA.
• Findings of LEUKOERYTHROBLASTOSIS + TEAR DROP CELLS +
SPLENOMEGALY + EXTRAMEDULLARY HEMATOPOESIS.

MALIGNANT LYMPHOMA::
• Pancytopenia + leukoerythroblastosis + monoclonal gammopathy.
• Smear may contain occasional cleaved lymphocytes.
• The small cell lymphocytic lymphomas(waldenstorm macroglobulinemia,
well diff lymphocytic lymphoma) have diffuse lymphadenopathy with
marrow involvement.
Waldenstorm macroglobulinemia:
• male; lymphadenopathy; hepatosplenomegaly; severe anemia; raised ESR.
• Hyperviscosity syndrome- presenting as retinal hemorrhages, epistaxis,
neurologic manifestations, cardiac dysfunction in 30%.
IDIOPATHIC CYTOPENIA OF UNDETERMINED SIGNIFICANCE:

• It is a provisional diagnosis in patients presenting with cytopenias of

undetermined aetiology.

DIAGNOSTIC CRITERIA:
1. Persistent cytopenia for 6 months.( Hb<11mg/dL; neutrophil <1500/dl;
platelet<100000/dl)
2. No morphological features of myelodysplasia.
3. Normal chromosomal analysis
4. Detailed clinical h/o and examination excluding secondary causes of
pancytopenia.
HAIRY CELL LEUKEMIA::
• Uncommon form of adult chronic B-cell leukemia.
• M:F=4:1; mean age= 55 years.

LAB::
• Pancytopenia; withb most patient having monocytopenia.
• Morphologic evidence of HAIRY CELLS on blood films characterized by pale
blue or grey cytoplasm with serrated/ruffled border.
• TRAP positive hairy cells in olden days; now with immunohistochemical
stains.
• Flow cytometry-definitive diagnosis.

MARROW::
• Severely hypocellular marrow.
• Fried egg appearance of cells- characteristic mononuclear cells with
nonoverlapping cllular borders.
• IHC with anti CD-20.
DRUGS::::
• Cytotoxic drugs: marrow supression.
• Chloramphenicol: dose dependent effects.
• Idiosyncriatic reactions: NSAIDS, chloramphenicol, sulphonamide,
phenothiazines, thiazides, anti-thyroid drugs, anti-epileptics, anti-diabetic
drugs, colchicine, azathioprine.
APPROACH TO PANCYTOPENIA:
Detailed h/o and careful examination.

Nutritional h/o, drug h/o, alcohol h/o; family h/o.

Previous h/o of pancytopenia, aplastic anemia, inherited bone marrow

failure syndroems, repeated early foetal loss, cancer, liver disease, metabolic
disorders, connective tissue disorders.

Cytotoxic chemotherapy or drugs.

Recurrent oral ulcers and chronic diarrhea may point towards HIV.

Recurrent oral ulcers and malar rash or joint pains- SLE.

Bone pains and loss of height- MULTIPLE MYELOMA.

PHYSICAL EXAM::
• Jaundice, clubbing, lymphadenopathy
• splenomegaly, loss of height, malar rash, retinal hemorrhages, oral
petechiae, gingival hyperplasia, stomatitis or cheilitis, oropharyngeal
candidiasis, RUQ abdominal tenderness, signs of CLD.

LABORATORY::
• CBC with red cell indices, peripheral smear, reticulocyte count and absolute
retic count.
• LFT, viral markers for hepatitis, coagulation profile, fibrinogen, D-dimer,
serum B12, FOLIC ACID, ANA, serum ferritin.

BONE MARROW:
• Almost always indicated unless the cause is otherwise apparent.
ABSOLUTE RETIC COUNT::

• Normal retic count=1-2%(reflects the daily replacement of 0.8-1% of

circulating RBC).
• It is a marker of red cell production by marrow.
• ARC= RETICULOCYTE COUNT PERCENTAGE X RBC count.
• Normal range of ARC=50,000-1,00,000/cmm.
• ARC<25000/cmm🡪 evaluate with bone marrow aspiration for aplastic
anemia.
• ARC>100000/cmm🡪 evaluate with bone marrow unless history s/o
sepsis/malaria.
• pancytopenia+ARC 25000-50000/CMM🡪 initially evaluate withB12,
FOLATE, FERRITIN.
M:E RATIO::

• Ratio of maturing myeloid cells to erythroid cells in the bone marrow.

• 3-4:1-normal.

• Decreased M;E ratio🡪 HEMOLYTIC & MEGALOBLASTIC anemia.

• Increased M:E ratio🡪 CML, LEUKAMOID reactions.

• Normal M:E ratio🡪 both series equally affected. Seen in aplastic anemia,
myelophthisis, chloramphenicol toxicity.
SPECIFIC EVALUATION:
• Lymphoprolferative disorders🡪 immunophenotyping, cytogenetics, LN bx.

• Multiple myeloma🡪 serum electrophoresis, bone marrow aspiration

• PNH🡪 flow cytometry(CD-55, CD-59)

• CMV serology(IgG, IgM)

• EBV: serum monospot, viral capsid antigen, EB nuclear antibody.

• Leishmaniasis🡪 blood and bone marrow cultures, LD bodies.

• Serum PSA to r/o ca.prostate.

• Fanconi anemia🡪 diepoxy butane test to check for chromosomal breakage

in peripheral blood lymphocyte.
• PANCYTOPENIA EVALUATION::
What have we done in our case??
• ORDERED FOR
1) Peripheral smear🡪 RBC-macrocytic, anisocytosis; WBC Count reduced;
platelet count-reduced; marked pancytopenia.

2) LDH=136.3; RETIC COUNT=1.1; direct coombs test=negative;

FERRITIN=430.8; PT=11.8; INR=1.07; APTT=22.5; corrected calcium=9.1
mg%

3) STOOL OB=+VE; repeat sample=+ve; urine hemoglobin=neg;

MP CARD=NEGATIVE.

4) WIDAl, dengue serology=not done.

5) USG ABDOMEN= mild fatty liver; mild prostatomegaly with significantg

PVUR;; serum PSA=1.35.

6) Serology for HIV, HBSAG,HCV=NEGATIVE.

7. ANA=negative; B12=420pg/ml(211-911); folic acid=2.77 ng/ml(>5.38).

8. Serum electrophoresis= no M band seen; normal globulin fractions.

PROBABLE DIAGNOSIS:
1) PANCYTOPENIA due to FOLATE DEFICIENCY.
2)??DRUG INDUCED
3)APLASTIC ANEMIA.
4)MYELODYSPLASTIC SYNDROME.

OPHTHALMOLOGY consultation done for fundus changes; advised

LASER treatment.

GASTROENTEROLOGY consultation done to r/o GI pathologies for

malabsorbtion🡪 advised OGD and COLONOSCOPY if bone-marrow is not
diagnostic.

Patient is started on FOLATE supplementations.

• BONE MARROW ASPIRATION AND BIOPSY done under local anaesthesia.

BONE MARROW ASPIRATION REPORT🡪

• Cellularity🡪 increased.
• M:E ratio=1:3
• Erythropoesis🡪 erythroid hyperplasia with normoblastic and megaloblastic
maturation are seen.
• Megakaryocytes🡪 normal
• Myelopoesis🡪 maturing myeloid forms are seen.
• Lymphoid cells🡪 normal
• Plasma cells🡪 6%; no atypical cells or blasts seen.

• Conclusion:: erythroid hyperplasia with megaloblastic maturation.

Consistent with megaloblastic anemia.
•
• BONE MARROW SLIDE::
DAY HB PCV TC P L E M PLT

1 5.8 18.2 790 32 65 1 2 21000

2 6.1 18.6 1260 23000

3 5.3 1410 24 73 1 2

4 5.4 1730 20 75 2 3 21000

5 5.5 1540 21000

6 5.9 1580 19 79 1 1 22000

7 5.8 1820 25000

8 5.8 1680 19 79 1 1 27000

9 5.9 1780 20 77 2 1 29000

FINAL DIAGNOSIS::

1)PANCYTOPENIA-probably due to folate deficiency.

2)B/L severe non proliferative diabetic retinopathy.
3) T2DM
4) SYSTEMIC HYPERTENSION.
TREATMENT🡪
• Oral dose of 5-25 mg of folic acid is satisfactory.

• Customary to continue therapy for atleast 4 moths, when all folate deficient
will have been eleimated and replaced with folate replenished red cells.

• Cobalamin deficiency must be excluded before starting therapy.

• Long term folate replacement is required in patients when underlying cause

may not be corrected like chronic hemodialysis or hemolytic anemias.

• Dietery advice should be done.

• In patients on long term folate therapy, serum cobalamin should be

measured atleast anually to avoid coincidental cobalamin deficiency.