Approach to pancytopenia

1. An approach to Pancytopenia
-Dr Yogeeta Tanty

2. • Pancytopenia is defined as decrease in all three hematologic
cell lines.
• The condition is not a disease in itself but a common pathway
caused by various etiologies .

3. It is characterized (for Adults) by
• Hemoglobin < 12 g/dL in women and
13 g/dL in men,
• Platelets < 150,000 / μL,
• Leukocytes < 4 x 103/ μL or (Absolute neutrophil count < 1.8x
103/μL.)

4. It is characterized (for children) by
• Hemoglobin < 10 g/dL
• Platelets < 100,000 / μL,
• Leukocytes < 4 x 103/ μL or (Absolute neutrophil
count < 1.5x 103/μL.)

5. Reticulocyte production index (RPI)=
Patient’s hematocrit X retic count %
Normal hematocrit reticulocyte mat. Time
RPI is a good indicator of adequacy of the bone marrow response.
If RPI >2 good bone marrow response
RPI < 2 inadequate compensatory bone marrow response

6. Etiology Based on Marrow cellularity
– Hypocellular marrow
• Aplastic anemia
–Congenital
–Acquired
• Marrow necrosis
• Severe sepsis
• Hypoplastic MDS
• Transfusion
associated GVHD
– Cellular marrow
• Primary marrow disease
– Malignancies -Hairy cell, multiple
myeloma
– Myelodysplastic syndrome
– Myelofibrosis
– Hemophagocytic lymphohistiocytosis
– Paroxysmal nocturnal
hemoglobinuria
• Systemic disease
– B12,Folate ,Copper
– Hypersplenism -
– Autoimmune-SLE,RA
– Storage disorders like gaucher’s
disease, Nieman pick’s disease
– Granulomatous Infections like TB,
Fungal.
– Metastasis

7. CONGENITAL Aplastic anemia
• Fanconi's Anemia
• Dyskeratosis congenita
• Congenital amegakaryocytic thrombocytopenia
• GATA2-associated syndromes
• Shwachman-Diamond syndrome
• Diamond- Blackfan anemia

8. ACQUIRED APLASTIC ANEMIA
• Aplastic anemia associated with other disorders – PNH ,MDS , LGL .
• Secondary-
– Ionizing radiation,
– Drugs
• Infections— Hepatitis , EBV infection, parvovirus B19, HIV ,TB
• Immune-mediated
• Miscellaneous— autoimmune disease, transfusion associated GVHD
• Idiopathic aplastic anemia

9. Etiology based on

10. Epidemiology
• Depending upon the cause , the disease presents in a varied
age group.
• Several studies in India by Chandra et al , Gayathri et al etc
showed megaloblastic anemia as the most frequent cause
followed by aplastic anemia.

11. Inherited Aplastic anemia
• Fanconi's Anemia
• Dyskeratosis congenita
• Congenital amegakaryocytic thrombocytopenia
• GATA2-associated syndromes
• Shwachman-Diamond syndrome
• Diamond- Blackfan anemia

12. FANCONI ANEMIA
• Multigenic, autosomal recessive disorder
• Common hereditary marrow failure disease , associated
with chromosomal breaks.

13. • Mutations result in defects in hematopoietic stem cells, and
the cells are ineffective in DNA repair (chromosomal
breakage disorder).
• Premalignant disorder – the long-term risk of progression to
MDS and AML.

14. clinical features of FA are:

15. Fanconi Anemia

16. Hematologic findings
• Presents with cytopenias or pancytopenia
• Anemia is normocytic normochromic.
• Bone marrow is hypocellular with increased fat and
infiltration by lymphocytes and plasma cells.
• Erythroblasts are seen in the same stage of maturation.
• HbF is increased and i antigen expression on the red cells.
• Chromosomal breakage is demonstrable with DEB
(diepoxybutane) and Mitomycin C.

18. DYSKERATOSIS CONGENITA
• X-linked recessive/autosomal dominant/autosomal recessive
disorder.
• Mutations in DKC1 at Xq28, a gene that encodes for dyskerin.
• Mutations in band 3q26 in TERC, a part of telomerase
complex
• Children with dyskeratosis congenita and telomeropathies in
adults - mutations in genes of telomerase complex / shelterin
complex.

19. • Cell lines affected Myeloid mainly, but
Erythroid & Megakaryocytic also affected.
• Monocytopenia is common Blood finding

21. Dyskeratosis Congenita

22. Two congenital clinical types are encountered.
• THROMBOCYTOPENIA WITH ABSENT RADII (TAR)
• CONGENITAL THROMBOCYTOPENIA WITH
MEGAKARYOCYTIC HYPOPLASIA

23. GATA2 DISORDERS
• Autosomal dominant disorders with marrow failure,
MDS or AML.
• Heterozygous mutation in the GATA2 genes
• Bone marrow is hypocellular with multilineage
dysplasia, especially of megakaryocytes.
• Increase reticulin fibrosis occurs in marrow.
• Increased susceptibility to non tuberculous mycobacteria
and viral infections
• Monocytopenia, B and NK cell lymphocytopenia are lab
findings.

24. Shwachman-Diamond syndrome
• AR/AD, Erythroid Cell lines affected
• Pathogenesis- Ribosome biogenesis disruption -
Shwachman –Bodian – Diamond Syndrome (SBDS) gene
• Pancreatic dysfunction, various skeletal deformities,
recurrent infection, myelodysplasia and AML
• Abnormal pancreatic functions- lab findings

25. Case 1
• A 4 year/female presented with generalized weakness and
bleeding gums .
• History of repeated blood transfusions +
• O/E – café-au-lait spots+ , mild deformity of fingers +
• Ps- NORMOCYTIC NORMOCHROMIC ANEMIA WITH
LEUCOPENIA (NEUTROPENIA ) AND THROMBOCYTOPENIA
• Reticulocytopenia

26. • Bone marrow – hypoplastic marrow
• Karyotype 46XX
• Cytogenetics –

27. • Diagnosis ??

28. ACQUIRED APLASTIC ANEMIA
• 1.Aplastic anemia associated with other hematological disorders – PNH
,MDS , LGL
• 2.Secondary-
Ionizing radiation,
Drugs
• Infections— Hepatitis , EBV infection, parvovirus B19,
HIV infection,TB
• Immune-mediated
• Miscellaneous— autoimmune disease, transfusion associated GVHD
• 3.Idiopathic aplastic anemia

30. BONE MARROW ASPIRATE

32. Degree of Severity of Aplastic Anemia
Severe aplastic anemia
bone marrow with < 30% cellularity
and presence of ≥ 2 of the following:
• Absolute neutrophil count < 500/uL (< 0.5 × 10^9/L)
• Transfusion dependance with ,ARC < 60,000/uL (< 60 ×
10^9/L)
• Platelet count < 20,000/uL (< 20 × 10^9/L)
Very severe aplastic anemia
Which fulfill the criteria of severe AA with an absolute
neutrophil count < 200/uL (< 0.2 x10^9/L).

33. Case 2
• 67 year/male previously well
• CBC normal last year
• presented with lethargy and gum bleeding since three weeks
• Hemoglobin 6,
• TLC 3000
• platelet 17000
• Examination
• well built ,pale looking ,no fever
• no significant drug history, no lymph node palpable
• no organomegaly
• iron ,vitamin b12, folate – all within normal range
• viral screening- all negative

34. • Peripheral blood film -Pancytopenia
• ARC reduced
• Bone marrow - hypocellular marrow
NORMAL BONE MARROW HYPOPLASTIC BONE MARROW

35. Hypocellular bone marrow ≠ aplastic anaemia
• Hypocellular MDS/AML /T LGL/ partiality treated ALL
• Viral infections parvovirus b19 ,hepatitis ,HIV
• Drug induced bone marrow - antineoplastic agents
,sulphonamides
• Auto immune diseases -SLE/RA
• Aplastic crisis in hemolytic anaemia transfusion associated
GVHD
• Inherited bone marrow failure syndrome eg.Fanconi anemia

36. Case 3
• 45 year/ male comes with a history of generalized weakness ,tingling
sensation
• numbness of hands and feet since 35 days with tinge of yellowish discoloration
• loss of appetite and significant weight loss with history of loose motions since
30 days
• hemoglobin 8g/dl
• TLC 1900 /cumm
• Neutrophil 74
• lymphocyte 29
• Eosinophils 4
• monocyte 3
• platelets 63000
• MCV 119fl
• MCH 28pg RDW 26.2

37. • Reticulocyte count 0.5%
• total bilirubin 30
• Direct 5 , Indirect 15
• Thin ,palor + , jaundice ,poor dental hygiene
• no lymph node palpable ,no organomegaly
• Vitamin B12 = 50 ( 200-1000 )
• Folate level =10 (5-40 )

39. • Diagnosis - Megaloblastic anemia

40. MEGALOBLASTIC ANEMIA
• Megaloblastic anemias are a group of disorders in which
the rate of DNA synthesis is retarded
• RNA synthesis is impaired to a lesser extent, resulting in
imbalanced cell growth.
• Cell populations undergoing rapid proliferation like the
hematopoietic cells manifest the alterations in cell size and
maturation.

41. • Symptoms of lethargy, Weakness, Glossitis, and
Neurological disturbances occur in cobalamin
deficiency.

42. • Bone marrow is markedly hypercellular with erythroid
hyperplasia
• The hallmark in the marrow is the nuclear-cytoplasmic
maturation dissociation, which is best seen in the erythroid
precursors .
• Megaloblasts have open sieve like nuclear chromatin

44. Case 4
39 year old lady with history of generalized weakness , fever since
15 days
• bleeding from gums and nose ,ecchymotic patches since 3 days
• hemoglobin 7.3 g%
• total leukocyte count 1100 /cumm
• neutrophils 00 %
• lymphocyte 30%
• blasts 2%
• promyelocytes 68 %
• platelets 40000
• PT 64 seconds (control 12 sec )
• aPTT 98 seconds (control 30 sec)

45. • Fibrinogen 40 mg/dl
• Bleeding is out of proportion to thrombocytopenia
• Circulating promyelocytes without any mature neutrophils

46. APML (Acute promyelocytic leukemia)

47. Case 5
11 year old female with fever and generalized weakness since 3 months received four
units of blood transfusion since last 6 weeks
examination- toxic look , moderate pallor, no sternal tenderness,
no lymphadenoathy
Hepatosplenomegaly +
• Hemoglobin 4.6
• total leukocyte count 600
• neutrophils 32
• lymphocytes 61
• monocyte 6
• Eosinophils 1
• platelet 36000 ,
• serum ferritin 2000 mg/ml
• serum LDH 1686 IU/l
• serum triglycerides 524mg/dl, serum fibrinogen -60mg/dl

48. Modified HLH diagnostic criteria (2009)

49. HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS
• Life-threatening disorder, presented as pancytopenia.
• It can be either familial or sporadic, caused by various triggers
like infections, malignancies, rheumatologic and
immunodeficiency syndromes.
• It represents a severe hyperinflammatory condition with the cardinal
symptoms of prolonged fever ,cytopenia's ,
hepatosplenomegaly and hemophagocytosis by activated
macrophages.

50. • Initial evaluation should include complete blood count with
differential, coagulation studies, fibrinogen, serum ferritin
(usually>1000 mg/mL), liver function tests and triglycerides.
• Biopsies often reveal red cell ingestion by histiocytes
(hemophagocytosis)
• Treatment is corticosteroids, cyclosporin A, immunoglobulins ,
Etoposide.

51. Case 6
• 70 year old male with history of symptomatic anemia requiring
repeated blood transfusions since 3 months , pallor + , otherwise
unremarkable
• hemoglobin 5
• TLC 2700
• neutrophils 60
• lymphocytes 36
• Eosinophils 1
• monocytes 3
• Platelets 89000 MCV 127 fl MCH 28 pg, RDW 21.4
• retic count 1.5%
• bone marrow shows hypercellular bone marrow with trilineage
dysplasia with blasts

52. • Diagnosis
• Myelodysplastic syndrome

53. Myelodysplastic syndrome
• Myelodysplastic syndrome is a clonal stem cell disorder
characterized by dysplastic bone marrow.
• It usually affects elderly with a male predominance
• Peripheral blood findings are pancytopenia, bicytopenia, or
isolated cytopenias with reticulocytopenia.
• A macrocytic anemia is common, hypogranulated
neutrophils also seen in the smear.
• Morphologic evidence of dysplasia in the peripheral smear.

54. • Bone marrow aspirate shows normocellular or
hypercellular with various degrees of qualitative
abnormalities of one or more cell lineages.
• Flow cytometry and immunophenotyping helps in
differentiating MDS from other cytopenias in post cancer
therapy patients.

57. Case 7
• 75 year/male chronic alcoholic, fever, septic looking, acute
kidney injury ,pancytopenia
• hemoglobin 9 ,TLC 4 ,platelet 20000
• blood cultures taken
• started antibiotics

58. • peripheral blood smear -Anaemia ,thrombocytopenia ,shift to
lift ,leukoerythroblastic picture
• Neutrophils with toxic granulations and vaculations presence
of inclusion bodies ? bacilli within
neutrophil cytoplasm
• blood culture - listeria monocytogenes

59. • Diagnosis
• Pancytopenia due to severe sepsis

61. Case 8
• 48 year/ female having constitutional symptoms for 3 months
presented with pancytopenia 1 month ago hemoglobin 9g%
• TLC 1800
• Platelet 68000
• ANA > 1: 1280 homogenous
• Anti dsDNA 1 : 1280

62. • peripheral blood film - reactive lymphocytes, normocytic
normochromic anemia , no blasts
• Further examination
• malar rash ,alopecia ,cutaneous lupus
• small oral ulcer of upper palate

63. • Diagnosis
• Systemic lupus erythematosus (autoimmune causes)

64. Case 9
• 45 year / female presented with fatigue, abdominal
discomfort ,massive splenomegaly
• Pancytopenic picture

65. • Myelofibrosis
• no clinically relevant mutations were detected in JAK2, CALR
and MPL genes on this patient
• serum SSA /RO antibodies = 81.07 ( < 20)

66. Other causes of Myelofibrosis
• Primary autoimmune Myelofibrosis
• disseminated tuberculosis or histoplasmosis
• metastatic carcinoma (esp breast, prostate etc)
• other Myeloproliferative neoplasm in fibrotic phase
• Hairy cell leukemia
• renal osteodystrophy
• SLE/ scleroderma
• radiation exposure
• osteoporosis
• mastocytosis

67. PRIMARY MYELOFIBROSIS
• Primary myelofibrosis is one of the chronic
myeloproliferative neoplasms (MPN)
• Characterized by clonal proliferation of abnormal
megakaryocytes.
• Usually present with pancytopenia, extreme fatigue and an
enlarged spleen and liver .
• The peripheral smear shows leukoerythroblastic reaction
(myelophthisic smear), tear drop cells, left-shifted
(immature) white blood cells and nucleated RBCs

68. • Circulating CD34+ cells can help in distinguishing
this entity from other forms of myeloproliferative
disorders.
• Bone marrow aspiration usually is difficult, yielding
a dry tap, and bone marrow biopsy is necessary for
demonstrating reticulin fibrosis.

69. Case 10
• 55 year/ male alcoholic , anxiety disorder, no comorbidities
• fatigue since 3 months
• hemoglobin 8
• TLC 6500
• platelets 130000
• PS -marocytic RBCs
• LDH , b12 - normal
• bone marrow shows dysplasia in all three lineages

70. • Diagnosed as MDS
• tranfused 3 PRBCs , as routine- given B12 and folic acid
• asked to follow up with cytogenetics and biopsy report

71. • 15 days later
• appetite greatly improved
• general condition improved
• hemoglobin 10
• TLC 8500
• platelets 180000

72. Dysplastic changes in bone marrow
• megaloblastic anaemia
• heavy metal toxicity
• alcohol abuse
• HIV , parvovirus
• anti-tubercular therapy
• drugs- chemotherapy , valproate
• chronic liver disease
• if all the above our ruled out- myelodysplastic syndrome

73. Case 11
• 45 year /male
• in ICU ,alcoholic
• pneumonia with sepsis
• pancytopenia -worsening rapidly

74. • Bone marrow aspiration- dilute
• Bone marrow biopsy shows necrosis

75. Bone marrow necrosis
• tumors- ALL , MPN , HL , solid tumors
• infections- sepsis, tuberculosis
• drugs -chemotherapy , interferons
• sickle cell disease
• DIC , HUS , APLA
• SLE
• radiation exposure

76. Other causes

77. Storage disorders
• Gaucher disease - inherited lysosomal storage disease -
autosomal recessive defect of the gene encoding β-
glucocerebrosidase,
• The lipid-laden cells are called Gaucher cells and are
predominantly found in the spleen, liver, bone marrow
and rarely lung.
• Clinical presentation- hepatosplenomegaly, pancytopenia,
bone complications

79. HYPERSPLENISM
• Hypersplenism is characterized by anemia , leukopenia
and/or thrombocytopenia.
• It causes pancytopenia by splenic sequestration
• Causes - Cirrhosis, congestive heart failure, malignancies
like leukemia/lymphoma and infections like TB, typhoid
fever , malaria , leishmaniasis etc
• Patients can present with pain or fullness in the left upper
quadrant, abdominal distension or referred pain to the
shoulder.

80. Paroxysmal nocturnal
hemoglobinuria
• PNH is an acquired mutation in the PIGA gene ( X Linked
chromosome) resulting in defective cell membrane leading
to hemolysis, pancytopenia and thrombosis.
• Defect in glycosylphosphatidylinositol (GPI linked proteins )
– CD 55 and CD 59 (membrane associated complement
regulatory proteins.)

81. • Anemia symptoms – jaundice , morning cola colored urine
Hematologic findings-normocytic normochromic, increased reticulocyte
count.
• Cases with marrow failure, display leucopenia, thrombocytopenia and low
reticulocyte counts.

82. • Bone marrow- cellular, erythroid hyperplasia. In later stages aplasia
supervenes and may be difficult to differentiate fromAplastic Anemia.
• Iron stores are usually nil in PNH, while they are increased in AA.
• Diagnosis- Flow cytometry detects CD16/CD66b in granulocytes &
CD55,CD59 in RBCs.
• Flow cytometric analysis (FLAER) of granulocytes and red cells for CD56
and CD59 is useful in distinguishing AA from PNH overlap syndrome.

83. • Large granular Lymphocyte (LGL) leukemia is a clonal disorder
affecting the large granular lymphocytes which can cause marrow
infiltration leading to cytopenia.
• The diagnosis is based on immunophenotypic analysis of the
peripheral smear but bone marrow biopsy/aspirate may be
required in some cases
• HCL typically presents with massive splenomegaly and
pancytopenia.
• Granulomatous diseases like miliary TB and sarcoidosis and
metabolic disorders like Gaucher disease can also cause
pancytopenia by causing intense marrow infiltration.

84. Pancytopenia may present with the following emergencies
• Febrile Neutropenia
• Metabolic emergencies (e.g., symptomatic hyperkalemia,
hypercalcemia, tumor lysis syndrome)
• Disseminated intravascular coagulation
• Hemophagocytic lymphohistiocytosis
• Abnormal peripheral blood smear (e.g., microangiopathy, blasts)
• Severe aplastic anemia
• Symptomatic anemia (e.g., cardiac ischemia, hemodynamic
instability, worsening congestive heart failure)
• Thrombocytopenia (platelets <10,000/microL, or <50,000/microL
associated with bleeding)

85. when to say pancytopenia urgent?
• Absolute neutrophil count <1000/ ul with fever or other
evidence of infection
• or <500/ul
• symptomatic anemia
• thrombocytopenia
• platelets < 10,000 /uL or platelets < 50,000 / uL with clinical
significant bleeding
When is a referral less urgent?
• Asymptomatic
• Blood counts stable

86. Pancytopenia associated with

87. History Taking
• Severity and durations of symptoms
• Constitutional symptoms - fever , night sweats , weight loss , fatigue
• Age
• Mucosal Bleeding
• Jaundice
• Joint pain
• Diet history
• Infections
• Previous treatment history
• Drug history
• Alcohol consumption history
• Family history

88. PHYSICAL Examination
• Icterus
• Gum hypertrophy
• Hyperpigmented knuckles , Bald tongue
• Naildystrophy
• Sternal tenderness
• Petechiae, purpura
• Rashes- malar , purpural
• Skeletal anomalies (tenderness , deformity or tumor)
• Lymphadenopathy
• Organomegaly

89. – CBC with Peripheral smear and Reticulocyte count
– Vitamin B12 and folate assays
– LFT
– Serum iron profile
– Serology – HIV, HBsAg and HCV

90. What to look in the Peripheral Blood Smear?
• Red Cells – Macrocytes, Ovalocytes, Tear drop forms,
Nucleated RBCs
– Inclusions – Cabot rings, basophilic stippling, siderocytes
• WBC – Hypersegmented neutrophils, Hyposegmented-
hypogranular neutrophils, hairy cells, Large granular
lymphocytes, Abnormal promyelocytes, Blasts, Shift to left
• Platelets – Giant or small sized
• Hemoparasites

92. • Further Work-up
• Bone marrow Morphology
• Serological testing for viruses, auto-immune disorders
• Cultures
– Ancillary testing
• Flow cytometry / Immunophenotyping

93. Bone Marrow Evaluation
• Not required – if Vitamin B12 or folate
assays are low, consistent with
Megaloblastosis
• Yes for all Pancytopenias
– When levels of Vitamin B12 and / or folate assays
cannot explain the degree of severity of
Pancytopenia

96. Management of some common cause

97. Summary
• Pancytopenia is a decrease in all three blood cell lines with a
wide list of possible causes.
• Most common causes include megaloblastic anemia, aplastic
anemia myelodysplastic syndrome and acute leukemia
• Hypersplenism ,infections and drugs .
• Urgency of evaluation depends primarily on the severity and
duration of symptoms.
• Management focuses primarily on stabilizing clinical status
followed by thorough investigation to identify the cause.

98. Reference
• Singh T. Atlas and Text of Hematology: 4th edition. New
Delhi: Avichal Publication Company; 2018
• Mckenzie SB, Williams JL. Clinical Laboratory
Hematology: 4th edition. Boston: Pearson; 2016
• Greer PJ et al. Wintrobe’s Clinical Hematology: 14th
edition. Philadelphia: Wolters Kluwer; 2019
• Kumar V, Abbas AK, Aster JC. Robbins & Cotran
Pathologic Basis of Disease. 10th ed. Vol I. New York:
Elsevier; 2021.