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What's pancytopenia?
Its combination of anemia , leukopenia and
thrombocytopenia
1.HB < 10 g/dL
2.Leukocyte count < 4000/ul
Absolute Neutrophil count <1500/uL
3.Platelet count < 150,000 uL
What's causes of
pancytopenia?
 Bone marrow failure : aplastic anemia
 Bone marrow infiltration :
Acute leukemia
Myeloma
Lymphoma
Carcinoma
MDS
 Ineffective haematopoiesis
Megaloblastic anaemia
AIDS
 Peripheral pooling / destruction
Hypersplenism: portal hypertension ,
felty's syndrome , malaria , Myelofibrosis
SLE
What's approach to
thrombocytopenia?
 History
 Examination
 CBC & blood film
 BM aspiration & biopsy
 Other specific investigation
History
 Duration of symptom
Long (MDS)
Short (aplastic anemia)
 History of transfusion
 History of hemoglobinurea
 Dietary history
 Exposure to drugs : anti cancer , Abs , anti
thyroid (aplastic anemia)
 Barbiturates , phenytoin ( B12, Folic acid)
 Chemotherapy , radiation ( MDS , AML)
 Weight loss , fever ( Inflammatory or
malignancy)
 Jaundice ( Hepatitis B or C)
 Joint pain (SLE)
 History of blood loss
General examination
 Eye examination: retinal hemorrhage
leukemic infiltrations
 oral examination : oral petechaie
stomatitis / chelitis
gum hyperplasia
oral candidiasis
 Respiratory examination : clubbing
tachypnea
 Abdominal examination : organomegaly
lymphadenopathy
 skin examination : malar rash
purpura
hypo or
hyperpigmentation
 Musculoskelatal system : short stature
synovitis
abnormal thumb
Pancytopenia + Absent thumb
+Child
 Pancytopenia + Back pain +
Hypercalcemia
(multiple myeloma)
 Pancytopenia + Malar rash or GN = SLE
 pancytopenia + HSM = Leukemia
Blood Film
1.RBC morphology ( size & shape)
2.WBC and RBC precursor
3.Platelets count & size
4.Abnormal increase or decrease
granulation in Neutrophil
5. Hypo / hypersegmented Neutrophil
Other evaluating test may be
included
 ESR
 Reticulocyte count
 Serum LFTs
 Hepatic serology
 Serum coagulation profile, bleeding
time, fibrinogen, and D-dimer
 Serum B12 and folate
 HIV test
Anisocytosis--different sized
RBCs
Poikilocytosis--differently
shaped RBCs
Platelets are small, and
reduced in numbers
Aplastic anemia
Macrocytosis
Howel jolly bodies
Basophilic stippling
Hypersegmented Neutrophil
Megaloblastic anemia
Tear drop cells
Hypogranular neutrophils
Pseudo pelger Heut Anomaly
Giant platelets
MDS
 The characteristic peripheral blood
morphologic feature in multiple
myeloma is:
A. Cytotoxic T cells
B. Rouleaux formation
C. Spherocytosis
D. Macrocytosis
True or false?
 In blood film normal platelets count
rules out aplastic anemia
 True
Bone Marrow Examination
Almost always indicated in case
pancytopenia unless cause is apparent.
Both aspiration and biopsy are indicated.
Specifically, bone marrow aspirate permits
examination of:
• Cytology (megaloblastic change,
dysplastic changes, abnormal cell
infiltrates)
• Immunophenotyping : antigen or marker
on cells surfaces e.g ( leukemias,
lymphoproliferative disorders)
• Cytogenetics : structure of chromosome
(myelodysplasia, leukemias,
lymphoproliferative disorders).
True or false?
 Bone marrow examination is required
in diagnosis of Megaloblastic anemia
 False
The differential diagnosis of pancytopenia
are based on cellularity of bone marrow :
Hypocellular: excessive amount of fat
cells
Normocellular: 50-70% hematopoietic
cells & 30-50% fat
Hypercellular: 80-100% cells with little
Hypercellular
Causes of Hypocellular BM
1.Aplastic anemia
2.Hypoblastic MDS
3.Cytotoxic agent & radiotherapy
Causes of Hypercellular BM with
primary marrow disorders
1.Acute leukemia / lymphoma
2. Hairy cell leukemia
3. Myelofibrosis
4.PNH
5.Mutiple myeloma
6. Mylodysblastic leukemia
Causes of Hypercellular BM with
systemic disorders
1.Metastatic solid tumor
2. hypersplenism
3.Megaloblastic anemia
4. Infection (T.B ,kala azar, brucellosis)
5. Overwhelming infections
6. Alcohol
7. Autoimmune disorders- SLE, Sjogren’s
8. Sarcoidosis
9. Storage disease- Gaucher, Niemann-
pick
Pancytopenia +markedly
Hypocellular scattered mature
lymphocytes
aplastic anemia
Pancytopenia + Hypercellular
BM
Infiltration by RS cells HL
Pancytopenia + Hypercellular
B.M + old age
MDS
Pancytopenia + Hypercellular
marrow
Infiltration with malignant cells (Metastasis)
Specific investigations
 Megaloblastic anemia: Vit.B12 , Folate
assay
 Multiple myeloma :
Imunoelectrophoresis
 PNH: Flow cytometry (CD55, CD59)
 Leishmaniasis: blood and bone
marrow culture, serum ELISA
 HIV ,EBV , hepatitis : virology screen
 Fanconi anemia : Chromosomal
breakage study
Pancytopenia

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Pancytopenia

  • 1.
  • 2. What's pancytopenia? Its combination of anemia , leukopenia and thrombocytopenia 1.HB < 10 g/dL 2.Leukocyte count < 4000/ul Absolute Neutrophil count <1500/uL 3.Platelet count < 150,000 uL
  • 3. What's causes of pancytopenia?  Bone marrow failure : aplastic anemia  Bone marrow infiltration : Acute leukemia Myeloma Lymphoma Carcinoma MDS
  • 4.  Ineffective haematopoiesis Megaloblastic anaemia AIDS  Peripheral pooling / destruction Hypersplenism: portal hypertension , felty's syndrome , malaria , Myelofibrosis SLE
  • 5. What's approach to thrombocytopenia?  History  Examination  CBC & blood film  BM aspiration & biopsy  Other specific investigation
  • 6. History  Duration of symptom Long (MDS) Short (aplastic anemia)  History of transfusion  History of hemoglobinurea  Dietary history  Exposure to drugs : anti cancer , Abs , anti thyroid (aplastic anemia)  Barbiturates , phenytoin ( B12, Folic acid)  Chemotherapy , radiation ( MDS , AML)
  • 7.  Weight loss , fever ( Inflammatory or malignancy)  Jaundice ( Hepatitis B or C)  Joint pain (SLE)  History of blood loss
  • 8. General examination  Eye examination: retinal hemorrhage leukemic infiltrations  oral examination : oral petechaie stomatitis / chelitis gum hyperplasia oral candidiasis  Respiratory examination : clubbing tachypnea
  • 9.  Abdominal examination : organomegaly lymphadenopathy  skin examination : malar rash purpura hypo or hyperpigmentation  Musculoskelatal system : short stature synovitis abnormal thumb
  • 10. Pancytopenia + Absent thumb +Child
  • 11.  Pancytopenia + Back pain + Hypercalcemia (multiple myeloma)  Pancytopenia + Malar rash or GN = SLE  pancytopenia + HSM = Leukemia
  • 12. Blood Film 1.RBC morphology ( size & shape) 2.WBC and RBC precursor 3.Platelets count & size 4.Abnormal increase or decrease granulation in Neutrophil 5. Hypo / hypersegmented Neutrophil
  • 13. Other evaluating test may be included  ESR  Reticulocyte count  Serum LFTs  Hepatic serology  Serum coagulation profile, bleeding time, fibrinogen, and D-dimer  Serum B12 and folate  HIV test
  • 15. Macrocytosis Howel jolly bodies Basophilic stippling Hypersegmented Neutrophil Megaloblastic anemia
  • 16. Tear drop cells Hypogranular neutrophils Pseudo pelger Heut Anomaly Giant platelets MDS
  • 17.  The characteristic peripheral blood morphologic feature in multiple myeloma is: A. Cytotoxic T cells B. Rouleaux formation C. Spherocytosis D. Macrocytosis
  • 18.
  • 19. True or false?  In blood film normal platelets count rules out aplastic anemia  True
  • 20. Bone Marrow Examination Almost always indicated in case pancytopenia unless cause is apparent. Both aspiration and biopsy are indicated. Specifically, bone marrow aspirate permits examination of: • Cytology (megaloblastic change, dysplastic changes, abnormal cell infiltrates) • Immunophenotyping : antigen or marker on cells surfaces e.g ( leukemias, lymphoproliferative disorders) • Cytogenetics : structure of chromosome (myelodysplasia, leukemias, lymphoproliferative disorders).
  • 21. True or false?  Bone marrow examination is required in diagnosis of Megaloblastic anemia  False
  • 22. The differential diagnosis of pancytopenia are based on cellularity of bone marrow : Hypocellular: excessive amount of fat cells Normocellular: 50-70% hematopoietic cells & 30-50% fat Hypercellular: 80-100% cells with little
  • 23.
  • 25. Causes of Hypocellular BM 1.Aplastic anemia 2.Hypoblastic MDS 3.Cytotoxic agent & radiotherapy
  • 26. Causes of Hypercellular BM with primary marrow disorders 1.Acute leukemia / lymphoma 2. Hairy cell leukemia 3. Myelofibrosis 4.PNH 5.Mutiple myeloma 6. Mylodysblastic leukemia
  • 27. Causes of Hypercellular BM with systemic disorders 1.Metastatic solid tumor 2. hypersplenism 3.Megaloblastic anemia 4. Infection (T.B ,kala azar, brucellosis) 5. Overwhelming infections 6. Alcohol 7. Autoimmune disorders- SLE, Sjogren’s 8. Sarcoidosis 9. Storage disease- Gaucher, Niemann- pick
  • 28. Pancytopenia +markedly Hypocellular scattered mature lymphocytes aplastic anemia
  • 31. Pancytopenia + Hypercellular marrow Infiltration with malignant cells (Metastasis)
  • 32. Specific investigations  Megaloblastic anemia: Vit.B12 , Folate assay  Multiple myeloma : Imunoelectrophoresis  PNH: Flow cytometry (CD55, CD59)  Leishmaniasis: blood and bone marrow culture, serum ELISA  HIV ,EBV , hepatitis : virology screen  Fanconi anemia : Chromosomal breakage study