4. Case 1
• 35 y old female came to clinic complaining of
fatigue , dizziness.
• She was pale, with history of menorrhagia related
to the use of IUD.
• CBC: HB 6.5 , MCV 56, MCH 19,
Normal PLT, WBC
5. Cont. Case 1
•Next step?
• Urgent packed RBCs transfusion
• Parenteral iron therapy
• Oral iron therapy
• Other
6. Cont. Case 1
• Iron profile was requested
• Ferritin
• Iron
• TIBC
7. Case 2
• 70 year old male presented with anemia (iron
deficiency) , recurrent abdominal pain
• His treating physician prescribed oral iron and
antispasmodics with diagnosis of IBS
• Hb increased from 7 to 9 gm/dl then declined to 8
gm/ dl
• His doctor asked for occult blood in stool
negative so he recommended parenteral iron.
8. Cont. Case 2
• Hb level reached 10 gm/dl then started to decline
to 8.5 and the patient was referred to the
hematologist.
• What’s the next step??
9. Cont. Case 2
• Repeat fecal occult blood
• Repeat iron profile
• Packed RBCs transfusion
• Upper & lower GI endoscopy
• CT enterocolonography
10.
11. Case 3
• 27 year old female patient presented with pallor ,
fatigue
• She did Hb level was 8.5 gm/dl and started to
take oral iron supplement
• One month later, Hb was the same
• So she sought medical advice
14. Case 4
• 16 year old male patient , known to have G6PD
deficiency
• CBC was done as a routine check up
• Hb 12 gm/dl
• RBCs 6.14 x106 /mm
• MCV 68 fl
• MCH 19.7 pg
15. Cont. Case 4
• Ferritin 155 ng/ml
• Iron 53 mcg/dl
• TIBC 256 mcg/dl
• Transferrin saturation 20%
• Hb electrophoresis normal
(HbA 96.77%, HbA2 3.23%)
16. Cont. Case 4
• Alfa , beta thalassemia gene mutation were requested
17. Case 5
• 10 year old child , his father has sickle cell
disease, his mother noticed that he is pale.
• CBC
Hb 9.5 gm/dl
RBCs 3.5 x106 /mm
MCV 72 fl
MCH 23 pg
• Ferritin 8 ng/ml
19. Case 6
• 50 year old female patients presents with bone
pains
• A rheumatologist asked for the following
CBC : Hb 10 gm/ dl normocytic
ESR : more than 100
RF , anti CCP : negative
Sero negative RA MTX for 3 months
20. Cont. Case 6
• Follow up pain not relieved, Hb 8 gm/dl, ESR
still >100
• Referred to heamatologist for correcting anemia
21. Cont. Case 6
CBC film : normocytic anemia , rouleux formation
RFT: creatinine 1.89 mg/dl , uric acid 8.5 mg/dl
Ca : 12 mg/dl
SPEP: M band
SIF: IgG kappa
22. Case 7
• 65 year old female patient presented with pallor,
easy fatigue
• Past history : hypertension 3 months ago, OA,
habitual constipation
• CBC : Hb 9.5gm/dl, MCV 100, MCH normal,
normal PLT, WBC
• Next step?
23. Cont. Case 7
• Thyroid profile was requested
TSH 18
FT4 0.15
L-troxin was initiated
• 8 weeks later
Thyroid profile : normalized
Hb 12 gm/dl
24. Case 8
• 38 year old male patient presented with anemia
• No other symptoms
• CBC was done :
Hb 8.2 g/dl , MCV 91, MCH 29
PLT 75
WBC 4.6 with normal differential
• What’s the next step?
25. Cont. Case 8
• ESR was normal
• Virology (HBsAg, HCV Ab, HIV Ab) : negative
• ANA, Anti dsDNA: negative
• US abdomen: no organomegaly
26. Cont. Case 8
• BMA &biopsy were requested :
Hemodiluted aspirate, biopsy was hypocellular for
age and diminshed hematopoeitic precursors
Aplastic Anemia
27. Case 9
• 39 year old female patient , with history of
bypass bariatric surgery 18 months ago,
presented with pallor and tingling sensation
allover her body.
• CBC: Hb 8.5g/dl, MCV 98cmm, MCH 22 pg,
PLT 110, WBC 3.2
• CBC film: Dimorphic RBCs, hyposegmented
neutrophils
29. Case 9
• 23 year old female patient presented with acute
onset of anemia , jaudice
• CBC: Hb 7g/dl, MCV110, MCH 28, PLT normal ,
WBC normal
• Bilirubin Total 5.7mg/dl, indirect 4.8mg/dl, direct
0.9mg/dl
30. Cont. Case 9
• Reticulocyte 8%
• LDH 596
• ESR 110
• Virology negative
• US abdomen normal
31. Cont. Case 9
• Cross matching can’t be done
• Coomb’s test ( direct & indirect): positive
AIHA
32. Cont. Case 9
• ANA : 1/320
• Anti dsDNA: 150
SLE with secondary AIHA
33. Case 10
• 58 year old male patient no past medical history
presented with clinical manifestations of anemia,
jaundice
• No palapable lymphadenopathy/ organomegaly
• CBC : Hb 7.5g/dl, MCV 108, PLT 280, WBC
28.000 of which 90% mature lymphocytes
• Bilirubin Total 4.6 , indirect 3.6
34. Cont. Case 10
• Retic: elevated
• LDH: elevated
• Coomb’s test (direct, indirect): positive
• Immunophenotyping chronic pannel :CLL
CLL with secondary AIHA
35. Case 11
• 52 years old male patient known to have thalassemia trait
with a baseline Hb 10g/dl presented with sudden fall Hb
to 4g/dl , deep jaundice bilirubin 6.5mg/dl mainly
indirect.
• PLT 27, WBC 6.000 with normal differential
• What’s the next step?
36. Cont. Case 11
• Retic :
• Coomb’s test : positive
• US abdomen : mild splenomegaly 13 cm
• Virology: negative
• BMA & biopsy: no infiltration, increased erythropoeisis
and megakaryocytes
Evan’s Syndrome
37. Case 12
• 27 year old male patient complained with easy
fatigue, dizziness, recurrent abdominal pain
mainly Lt hypochondrium relieved by analgesics
and antispasmodics.
• On examination splenomegaly (5 fingers below
costal margin)
40. Case 13
• 60 year old female patient presented with fatigue,
exertional dyspnea, anemia, one attack of
epistaxis and recurrent abdominal pain
• PMH : uterine prolapse
• Admitted to Damanhour fever hospital
• CBC Hb 5g/dl MCV 70, MCH 20, PLT 158,
WBC25.000 with absolute lymphocytosis
41. Cont. Case 13
• US abdomen :liver cirrhosis, portal vein not
dilated, huge splenomegaly~25cm
• Normal renal and liver functions
• HBsAg negative, HCV Ab positive, HCV RNA
positive
• Upper GI endoscopy : antral gastritis only !!!
42. Cont. Case 13
• Anemia ?
• Cause of bleeding ?
• Splenomegaly?
• Lymphocytosis?
43. Cont. Case 13
• CBC film :rouleux formation
• SPEP : M band
• Ig M : markedly elevated
• Flowcytomery peripheral blood + BMB :
Lymphoplasmacytic lymphoma
44. Case 14
• 38 year old female patient presented with alleged
convulsions, no prior history, went to ER in
general hospital and diagnosed as being
hysterical and discharged
• In the following day, she had a syncopal attack,
so she went to a private clinic.
45. Cont. Case 14
• She was pale, ecchymotic patches on body side ,
vitally stable except for being febrile (37.9)
without any obvious source of infection
• DD??
46. Cont. Case 14
• CBC with film : Hb7 g/dl, PLT 10, WBC 13.000
neutropilia with toxic granulations, schistocytes
TTP
