HIS Pathology Practical

Question 1

A 25-year old woman was admitted for progressive shortness of breath for 2 weeks. She also complained of heavy menstruation over the past 6 months. Physical examination showed pallor. The liver and the spleen were not palpable. Complete blood count (CBC) showed:
The complete blood count (CBC) showed: White blood cell (WBC) 5 x 109/L (Normal: 3.89-9.93 x 109/L)
Haemoglobin (Hb) 6.1 g/dL (Normal: 11.5-14.8 g/dL) Red blood cell (RBC) count 2.01 x 1012/L (Normal: 4.46-5.71 x 1012) Mean Corpuscular Volume (MCV) 70 fl (Normal: 82.0-95.5 fL) Platelet count 470 x 109/L (Normal: 167-396 x 109/L)
Peripheral blood film review showed absent polychromasia. Red cells were hypochromic and microcytic. Occasional “pencil cells” were observed.
Iron (Fe) profile showed: Iron 3 µmol/L (Normal: 5-28 µmol/L)
Serum total iron-binding capacity (TIBC) 80 µmol/L (Normal: 41-77 µmol/L)
Transferrin (TRF) saturation 10% (Normal: 16 – 45%)

What is the most likely diagnosis?

Answer 1

Iron deficiency anaemia

Low ferritin (storage)
High total iron-binding capacity (TIBC) + high serum transferrin (compensatory response to increase transport)
BUT low transferrin saturation

High RDW -> anisopoikilocytosis

Question 2

25-year old woman was admitted for progressive shortness of breath for 2 weeks. She also complained of heavy menstruation over the past 6 months. Physical examination showed pallor. The liver and the spleen were not palpable. Complete blood count (CBC) showed:
The complete blood count (CBC) showed: White blood cell (WBC) 5 x 109/L (Normal: 3.89-9.93 x 109/L)
Haemoglobin (Hb) 6.1 g/dL (Normal: 11.5-14.8 g/dL) Red blood cell (RBC) count 2.01 x 1012/L (Normal: 4.46-5.71 x 1012) Mean Corpuscular Volume (MCV) 70 fl (Normal: 82.0-95.5 fL) Platelet count 470 x 109/L (Normal: 167-396 x 109/L)
Peripheral blood film review showed absent polychromasia. Red cells were hypochromic and microcytic. Occasional “pencil cells” were observed.
Iron (Fe) profile showed: Iron 3 µmol/L (Normal: 5-28 µmol/L)
Serum total iron-binding capacity (TIBC) 80 µmol/L (Normal: 41-77 µmol/L)
Transferrin (TRF) saturation 10% (Normal: 16 – 45%)

What is the cause of the raised platelet count?

Answer 2

Reactive thrombocytosis (increased megakaryocyte proliferation)

Question 3

An 80-year old woman was admitted for progressive shortness of breath for 3 months The complete blood count (CBC) showed: White blood cell (WBC) 0.9 x 109/L (Normal: 3.89-9.93 x 109/L) Haemoglobin (Hb) 5.5 g/dL (Normal: 11.5-14.8 g/dL) Mean Corpuscular Volume (MCV) 112 fl (Normal: 82.0-95.5 fL) Platelet count 20 x 109/L (Normal: 167-396 x 109/L) Peripheral blood film review showed absent polychromasia, macrocytosis, dysplastic neutrophils and occasional circulating blasts. The serum active vitamin B12 and folate levels were within normal limits.

What is the most likely diagnosis?

Answer 3

Myelodysplastic syndrome (MDS)

Ddx of pancytopenia with significant macrocytosis:
1. MDS
2. Pernicious anaemia
(3. Acute leukaemia)

Hypolobated, hypogranular neutrophils + Pseudo Pelger-Huet anomaly (2 lobes with thin filament)
Ring sideroblasts on iron stain
Micromegakaryocytes

Hypercellular, dysplasic BM

Question 4

List the possible acute
complications that the patient may experience after transfusion.

Answer 4

FEVER: Non-haemolytic febrile transfusion reaction
H: Acute haemolytic transfusion reaction
A: Urticaria, Anaphylactic shock, infective shock
L: transfusion-related acute Lung injury (TRAIL)
O: pulmonary Oedema (old, HF)

Question 5

What are the possible measures to reduce the need for transfusions in MDS?

Answer 5

Erythropoiesis-stimulating agents (ESAs)
Granulocyte-colony stimulating factors (G-CSFs)
TGF-beta targeting (Luspatercept, regulate erythroid differentiation)

Question 6

List the possible
long term complications of recurrent transfusions.

Answer 6

Iron overload
Transfusion-transmitted infections (viral)
Development of Ab to transfused RBCs / WBCs / platelets
Delayed haemolytic transfusion reaction

Question 7

What precautions are necessary before transfusion?

Answer 7

Type (ABO & Rh(D)) & Screen (Ab)
Electronic XM
Full serological XM for Ab screening +ve patients

Question 8

What is the alternative to blood transfusion in this patient with iron deficiency anaemia?

Answer 8

Oral iron supplement