Investigations of pancytopenia

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Investigations of pancytopenia

  1. 1. PRESENTED BY-DR.BISWAJEETA SAHA(1ST YR PGT) MODERATOR-DR.S.RAMAN,KIMS,BHUBANESWAR
  2. 2. DEFINITION Combination of anemia, leucopenia and thrombocytopenia Hb<9g/dl TLC<4000/cmm TPC<1.5 lacs/cmm
  3. 3. ETIOLOGYHypocellular marrow Cellular marrow with Primary marrow disease def/syst diseases with cellular marrow•Aplastic anemia •Vit B12 and folic acid •Aleukemic leukemia•Hypoplastic MDS deficiency •Hairy cell leukemia•Post chemotherapy •Hypersplenism •MDS•Fanconi’s anemia •Kala azar •Marrow necrosis•Diamond-Shwachman •SLE,sjogrens •Myelofibrosissyndrome syndrome,sarcoidosis •PNH•Transfusion associated •Tuberculosis,brucelosis •HPSGVHD •Metastatic solid tumors•Aplastic crisis in •Alcoholismhemolytic anemia •Storage diseases•Drugs•Infections
  4. 4. Peripheral smear RBC- Normocytic normochromic with few macrocytes,no anisopoikilocytosis,no nRBCs,reticulocytopenia----aplastic anemia Macroovalocytes,howel jolly bodies-megaloblastic anemia Tear drop cells,howel jolly bodies,basophilic stippling--MDS nRBCs,sickle cells-aplastic crisis in sickle cell anemia WBC- Leucopenia,mostly mature lymphocytyes(80-90%)---aplastic anemia Neutrophils present in increased number,with toxic granules,shift to left— infections Basophilic stippling,hypersegmented neutrophils—megaloblastic anemia If blasts present—subleukemic leukemia Hypogranular neutrophils,pseudo pelger heut anomaly--MDS PLATELETS- Normal TPC rules out aplastic anemia Giant platelets—MDS /hypersplenism
  5. 5. History taking Duration of symptoms How many blood transfusions,intervals between transfusions h/o hemoglobinuria Dietary history Socio economic status Exposure to  Drugs, especially antineoplastic, antibiotics (chloramphenicol, sulphonamides),anti epileptics and antithyroid drugs (Aplastic)  barbiturates, phenytoin, and oral contraceptives (B12) Exposure to radiation (Aplastic) Chemical exposure  Benzene & insecticides (Aplastic) Infections  Viruses (viral hepatitis,EBV, parvovirus, and HIV. (Aplastic)
  6. 6.  Weight loss , fever (malignancy, inflammatory) Jaundice (Hep B & C) Evidence of bleeding Infections  TB, Malaria Joint pains  SLE
  7. 7. General physical examination Eye examination Retinal hemorhage Leukemic infiltration Jaundiced sclera(PNH,hepatitis,cirrhosis) Epiphora(dyskeratosis congenita) Oral examination Oral petechaie Stomatitis/chelitis Gingivial hyperplasia Oral candidiasis
  8. 8.  Cardiovascular examination  Musculoskelatal system Tachycardia,edema,CCF Short stature Synovitis Respiratory system Abnormal thumb Clubbing Tachypnoea Abdominal examination Hepatomegaly Lymphadenopathy Splenomegaly Skin examination Malar rash Purpura Reticular pigmentation,dysplastic nails(dyskeratosis congenita) Hypopigmented areas hyperpigmentation
  9. 9. Bone marrow examinationAlmost almost always indicated in cases of pancytopenia unless the cause is apparent. Both aspiration and biopsy required Sample for cytogenetics and immunophenotyping,culture and serological studiesIN THE ASPIRATE: Empty particles,markedly hypocellular,only scattered mature lymphocytes and sometimes plasma cells in excess---aplastic anemia Sometimes pockets of cellularity with widespread hypocellularity—evolving phase of aplastic anemia Hypocellular BM with Blasts(>20%)----hypoplastic leukemia Hypocellular BM with Dysplastic megakaryocytes—hypoplastic MDS Scattered proerythroblasts with large nuclear inclusions in hypocellular BM— parvo virus
  10. 10. In hypercellular BM  Erythroid hyperplasia with megablastosis—megaloblastic anemia  Trilineage dysplasia with ringed sideroblasts on perl stain—MDS  Infiltration by RS cells—HL  Infiltration with malignant cells—metastasis  In PNH and fanconis anemia—early stage will show hypercellular normal appearing marrow
  11. 11. Specific testing pinpoints diagnosis in followingconditions  Fanconis anemia: diepoxybutane (DEB) test for chromosomal breakage in peripheral blood lymphocyte  Lymphoproliferative disorders:immunophenotyping,cytogenetics,lymph node biopsy  PNH:peripheral blood immunophenotyping for deficiency of phosphatidylinositol glycan linked molecules on peripheral blood cells(cd 16,cd 55,cd 59),HAMs test  CMV:serum IgM,IgG  EBV:serum monospot,viral capsid antigen(VCA),Epstein barr nuclear antibody(EBNA)  Leishmaniasis:blood and bone marrow culture,ELISA  Serum PSA:prostatic ca
  12. 12. pancytopenia History,examination,CBC,retic count,serum iron/TIBC Blast,hypo Unexplained No specific HypersegmentedPalpable spleen Sepsis/bleeding PMNs,markedwith increased retic granular splenomegal finding PMNs y/M anisopoikilocytosis protein/meta stasis Trial of B12 and folic acid No response response Acid hemolysis testHypersplenism/malaria/leishmaniasis HIV antibody Bone marrow aspiration and biopsy
  13. 13. CBC AND PS•LFT •PNH and IBMFS •Bone marrow•B12/Folate levels investigations biopsy and•Coagulation aspirateprofile•Viral serology•Autoimmuneprofile Bonemarrow Blood/bm cytogenetics immunophen otyping
  14. 14. THANK YOU

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