JCU MB4 Term 2 Week 1 (Anaemia)

1

61yo, fatigue, pale. Which cell is shown?

Blood Film - Neutrophil


  Eosinophil

  Neutrophil

  Lymphocyte

  Monocyte

  Basophil

2

What cell is shown by the arrow?

Blood File - Monocyte


  Eosinophil

  Monocyte

  Neutrophil

  Lymphocyte

  Basophil

3

9yo, fatigue, pale, mild jaundice. Blood film is shown. What is the diagnosis?

Blood Film - Thalassaemia


  Thalassaemia

  Iron deficiency

  Normal smear

  Megaloblastic

  Haemolytic anaemia


Jaundice suggests haemolysis. Note young age, microcytosis and hypochromia - thalassaemia is the most likely cause.

4

24yo African-American, with mild jaundice, splenomegaly. Peripheral blood film shown. What is the possible diagnosis?

Blood Film - Target Cells


  Hb C disease

  Asplenia

  Liver disease (obstructive)

  Thalassaemia

  All of the above


The blood smear shows a large number of target cells, for which all of the above are possible causes (HALT mnemonic). Note that the question does not ask for the most likely diagnosis, which would be Hb C disease given the history and the very large number of target cells (often up to 90%).

5

54yo female on long-term thyroxine therapy, presented with tiredness and repeated injuries of left food. Hb: 90g/L, MCV: 118 fL, reticulocytes: 0.1%, low WCC and platelets. Blood and bone marrow smears are shown. What is she at risk for?

Blood Film - Macrocytosis

Bone Marrow - Normal


  Thyroid cancer

  Gastric cancer

  Myelodysplastic syndrome

  Acute leukaemia

  Aplastic anaemia


The blood smear shows changes consistent with macrocytosis, suggestive of B12 deficiency. This is most likely due to pernicious anaemia - an autoimmune condition whose diagnosis is further supported by the likely history of Hashimoto's disease. Patients with pernicious anaemia have autoantibodies to intrinsic factor, producted by gastric tissue, and is often associated with atrophic gastritis. This places her at heightened risk for gastric cancer. Because of this, pernicious anaemia may be considered a pre-malignant condition.

6

69yo with lung carcinoma on therapy. Weakness and fatigue. Peripheral blood smear shown. What is the likely diagnosis?

Blood Film - Normal


  Iron deficiency

  Normal smear

  Megaloblastic

  Thalassaemia

  Haemolytic anaemia


Chemotherapy may cause bone marrow suppression, but the smear shows normocytic cells with largely normal morphology.

7

54-year-old woman presented with Hb of 20g/L, was pale with tachycardia, a bounding pulse, hepatosplenomegaly. RBC indices: RCC 1.27x10^12^/L, HCT 0.07 L/L, MCV 55.9fL, MCH 15.7pg, MCHC 281g/L and RDW 19%. There were 3 NRBC/100WBC, reticulocyte count was 2%. Peripheral blood smear shown. What is the likely diagnosis?

Blood Film - Iron Deficiency


  Haemolytic anaemia

  Aplastic anaemia

  Iron deficiency anaemia

  Dimorphic anaemia

  Anaemia of chronic disease


No evidence of chronic disease on history. Anaemia is severe, MCV indicates microcytosis. Reticulocyte count appears elevated (normal 0.5-1.5%) but must be adjusted according to the number of RBC's (0.37% in this case) - low and therefore consistent with iron deficiency anaemia.

8

62yo white male, T2DM for 10yrs, poorly controlled. Presents with SOB, pedal oedema, possible CCF. Echocardiogram shows an ejection fraction of 30% and hypokinesis in the anteroinferior wall. Hb 8.9%, ferritin 568mg/L, transferring saturation 18%, creatinine 2.3mg/dL. No response to oral iron. Blood film shows mild microcytic hypochromic RBC's and mild anisopoikilocytosis. No target celss, no pencil cells. Peripheral blood smear shown. What is the likely type of anaemia?

Blood Film - Anaemia of Chronic Disease


  Iron deficiency

  Megaloblastic

  Drug induced haemolytic anaemia

  Autoimmune haemolytic anaemia

  Anaemia of chronic disease


Typical presentation of anaemia of chronic disease: raised ferritin, transferrin saturation low.

9

A week after intravenous cephalosporin treatment for pneumonia, a 93yo old male has a haemoglobin of 7.3g/dL [13.8 - 17.2], HCT 22.4% [41 - 50%], normal RBC indices and normal platelet and WCC. His Coombs test is positive at 37°C. Peripheral blood smear with methylene blue supravital stain is shown. What is the likely diagnosis?

Blood Film - Methylene Blue Stain


  Pneumococcal septicaemia

  Malarial complication

  AIHA warm antibody type

  Drug-induced haemolytic anaemia

  Idiopathic thrombocytosis


Note that drug-induced haemolytic anaemia is a type of AIHA (warm). It can be a side-effect of some cephalosporins.

10

21yo male, anaemia since childhood. Occasional jaundice. Now presented with splenomegaly and jaundice. His platelet and WCC are both decreased. Peripheral blood smear shown. What is the type of anaemia?

Blood Film - Spherocytes


  AIHA - cold antibody

  Megaloblastic

  G6PD deficiency

  Autoimmune haemolytic anaemia

  Hereditary spherocytosis


Microspherocytes visible, seen typically with hereditary spherocytosis. Polychromatic cells with Howell-Jolly bodies also visible.

11

21yo male, anaemia since childhood, recurrent jaundice and abdominal pains. Now presented with bone pain and fever. On examination spleen is not palpable. Platelet and WCC counts are increased. Peripheral blood smear shown. What is the type of anaemia?

Blood Film - Sickle Cell


  Hereditary elliptocytosis

  Congenital PK deficiency

  G6PD deficiency

  Sickle cell anaemia

  Hereditary spherocytosis


Some target cells also visible. It is likely that the patient had a splenectomy when younger, which often results in raised platelet and WCC counts.

12

22yo male presented with severe anaemia and bleeding gums. Peripheral blood showed Hb 5g/dL, RBC count of 1 million/cmm, MCV 84fL, MCH 30pg, MCHC 33%. Nil reticulocytes. WCC 1200/cmm, platelets 30,000/cmm. Bone marrow biopsy (iliac crest) shown. What is the diagnosis?

Bone Marrow - Aplastic


  Acute leukaemia

  Subleukaemic leukaemia

  Aplastic anaemia

  Myelofibrosis

  Gelatinous transformation


Note widespread replacement of marrow tissue with fat in marrow with very small haematopoetic areas. Blood results indicate vastly reduced blood cell counts with otherwise normal values.

13

89yo female, nursing home resident presents with SOB, fatigue and CCF. On examination she is pale and yellow. Peripheral blood smear shown. What is the likely diagnosis?

Blood Film - Macrocytosis


  Iron deficiency anaemia

  Normal smear

  Megaloblastic anaemia

  Thalassaemia

  Haemolytic anaemia


Macrocytic cells are observable. Nursing home residents may often be undernourished, raising the possibility of B12 deficiency as a root cause, also supported by the presence of hypersegmented neutrophils. A lack of schistocytes and spherocytes makes autoimmune haemolytic causes less likely.

14

28yo, history of jaundice for three weeks. Recently treated for fever with lymphadenopathy. Peripheral blood smear shown. What is the likely diagnosis?

Blood Film - Haemolysis


  Iron deficiency

  Normal smear

  Haemolytic anaemia

  Megaloblastic

  Thalassaemia


Note presence of polychromatic cells and spherocytes. Probably an infection-associated haemolysis given the history.

15

42yo female, history of hypertension on treatment. Presents pale and jaundiced. Peripheral blood smear shown. What is the likely diagnosis?

Blood Film - Haemolysis


  Iron deficiency

  Normal smear

  Megaloblastic

  Thalassaemia

  Haemolytic anaemia


Likely drug-induced (?ACE/ARBs).

16

12yo, fatigue, pains, pale. What cells are shown in the smear?

Blood Film - Abnormal


  Acanthocytes, spherocytes, echinocytes

  Macrocytes, penic cells, spherocytes

  Stomatocytes, target cells, knizocytes

  Sickle cells, burr cells, polychromasia

  Target cells, sickle cells, polychromasia