Pancytopenia

Question 1

Describe what is meant by pancytopaenia

Answer 1

Pancytopaenia refers to a decrease in all peripheral blood cell lines.:
- red blood cells (RBCs)
- white blood cells (WBCs)
- platelets.

Question 2

What exact values determine that pancytopaenia is present [3]

Answer 2

Haemoglobin:
- < 115 g/L (women), < 130 g/L (men)

Leucocytes:
- < 4.0 x109/L
OR

Neutrophils:
- < 1.5 x 109/L

Platelets:
- < 150 x109/L

Question 3

Pancytopaenia may be caused by which three broad mechanisms? [3]

Answer 3

Bone marrow suppression:
- the process of haematopoiesis is reduced preventing blood cell production.

Bone marrow infiltration:
- the bone marrow is infiltrated (e.g. malignant cells, microorganisms) impairing its ability to conduct haematopoiesis.

Blood cell destruction:
- there is an increased turnover of blood cells in the peripheral circulation due to destruction or sequestration in organs (e.g. spleen).

Question 4

Name causes for the different categories of pancytopaenia:

Haemotological [4]
Metatstatic [3]
Infections [4]

Answer 4

Haemotological:
- Leukaemia
- Lymphoma
- Multiple myeloma
- Myelodysplastic syndromes

Metatstatic:
- Lung cancer
- Breast cancer
- Prostate carcinoma

Infections
- TB
- Fungal
- HiV
- Parvovirus B19

Question 5

Name causes for the different categories of pancytopaenia:

Nutrional deficiencies [3]
Medications and toxins [4]
Autoimmune disorders [3]

Answer 5

Nutrional deficiencies:
- Vitamin B12
- Folate
- Anorexia nervosa

Medications and toxins:
- Alcohol
- chemotherapy
- azathioprine
- methotrexate,
- carbamazepine

Autoimmune disorders:
- aplastic anaemia
- rheumatoid
- SLE

Question 6

Name causes for the different categories of pancytopaenia:

Peripheral destruction [1]
Peripheral sequestration [1]
Congenital [2]

Answer 6

Peripheral destruction
- Disseminated intravascular coagulation

Peripheral sequestration
- portal hypertension

Congenital:
- Wiskott Aldrich syndrome,
- Fanconi anemia

Question 7

What are the common characteristic features of pancytopaenia? [3]

Answer 7

Lethargy (anaemia)
Weakness (anaemia)
Pallor
Bruising (low platetlets)
Bleeding
Recurrent infections (leucopaenia)

Question 8

What examination findings should you look for in a patient with suspected pancytopaenia? [7]

Answer 8

• Lymphadenopathy
• Organomegaly (e.g. splenomegaly, hepatomegaly)
• Scleral findings: pale, jaundiced
• Oral findings: ulcers, thrush (e.g. as immunocompromised)
• Features of cardiac failure (e.g tachypnoea, raised JVP, crackles on auscultation, peripheral oedema): due to symptomatic anaemia
• Skin findings: pale, jaundiced, bruising, petechiae, purpura
• Other: joint pain or swelling, sarcopenia, active bleeding

Question 9

What peripheral blood film results would indicate pancytopaenia? [6]

Which pathologies would these indicate? [6]

Answer 9

Circulating blasts (i.e. immature white blood cells): suggestive of leukaemia

Abnormal / dysplastic white cells: suggestive of myelodysplastic syndrome

Immature white blood cells: suggestive of myeloproliferative disorder

Hypersegmented neutrophils: suggestive of megaloblastic anaemia (e.g. B12 deficiency)

Schistocytes (fragmented red blood cells): suggestive of peripheral destruction

Question 10

What follow up testing would you investigate with after a peripheral blood film for suspected pancytopaenia? [4]

Answer 10

• bone marrow aspirate
• biopsy
• flow cytometry
• cytogenetic testing
• molecular studies.

A bone marrow biopsy is particularly important in patients with a suspected primary haematological disorder.

Question 11

Which further specialist tests would you use to investigate pancytopaenia? [5]

Answer 11

• Autoimmune / vasculitis screen
• Malaria screen
• Viral screen (e.g. HIV, hepatitis B/C)
• Serological tests for infections
• Bone marrow biopsy
• Lymph node biopsy
• CT-PET