Aplastic Anemia

1. Noon Conference
Kristen Beck
08/13/2018

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Objectives
Aplastic Anemia
• Review differential diagnosis of aplastic
anemia
• Discuss clinical presentation
• Discuss diagnostic tests
• Discuss treatment

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A practical approach to anemia
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Low H&H
Reticulocyte
Count
Inappropriate
bone marrow
response
Appropriate bone marrow
response
Categorize by
MCV
• Microcytic
• Normocytic
• Macrocytic
Biopsy

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Causes of bone marrow suppression
• Inherited syndromes
• Fanconi anemia
• Acquired Causes
• Drugs, radiation
• Viral infection, immune disorder
• Myelodysplastic syndrome
• Paroxysmal nocturnal hemoglobinuria
• LGL leukemia
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Bone Marrow Biopsy
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Bone Marrow Biopsy
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Parvovirus B-19
• Erythrovirus discovered in
1975
• Destroys erythrocyte
progenitor cells
• Transient reticulocytopenia
• Aplastic crisis in
immunocompromised pts
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Hematologic course
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right lung nodules and infiltrates
Course of parvovirus B19 infection

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Clinical manifestations of
Parvovirus B19
• Erythema infectiosum (5th disease)
• Arthropathy
• Transient aplastic crisis
• Fetal infection
• Pure red cell aplasia
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Question #1
What percentage of immunocompetent
individuals infected with Parvovirus
B19 are asymptomatic?
1. 10%
2. 25%
3. 33%
4. 75%
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Clinical presentations
Immunocompetent Immunocompromised/
hematologic d/o
Pregnant women
Asymptomatic 25%
Flu-like syndrome 50%
Malar rash (slapped
cheek rash) 25%
Arthralgias 25%
Transient aplastic crisis:
(pallor, weakness,
lethargy)
Undetectable retic count
Anemia
Usually no rash or
arthralgias
Miscarriage
Intrauterine fetal death –
1st/2nd trimester
Non-immune hydrops
fetalis
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PVB19 in transplant recipients
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• Review of 98 cases at Mayo Clinic over 16 year period
• Median onset to disease 7 weeks after transplantation
• Anemia 98.8%, leukopenia 37.5%, thrombocytopenia
21%
• Most were asymptomatic; 25% with flu-like symptoms,
13% rash, 6% arthralgias
• Also myocarditis, pneumonitis, hepatitis

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Diagnostic tests
• IgG and IgM serologies
 Parvovirus B-19 IgG and IgM Ab negative
• PCR via blood and/or BM biopsy
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Question #2
A 28-year-old woman is evaluated for a 1-week history of pain and morning
stiffness in her hands. Three weeks ago, she had muscle aches, malaise,
fevers, and coryza, all of which have resolved. She is an elementary school
teacher; prior to her initial illness, several children in her class had similar
symptoms accompanied by an erythematous rash on the cheeks. She does
not have other pertinent personal or family history, and she takes no
medications.
On physical examination, temperature is 37.3 °C (99.2 °F), blood pressure is
120/78 mm Hg, pulse rate is 66/min, and respiration rate is 13/min. BMI is
22. Symmetric wrist, metacarpophalangeal, and proximal interphalangeal
joint tenderness and pain with motion are noted without significant joint
swelling. The remainder of the examination is normal.
What is the most appropriate initial treatment?
1. Azithromycin
2. Interferon alfa
3. Ibuprofen
4. Prednisone
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Treatment
• Supportive care
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Epilogue
• Readmitted about 3 weeks later with
recurrent severe anemia
• PVB19 PCR >10 million
• Started on IVIG
• Final diagnosis?
• Chronic Parvovirus B19
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