Pancytopenia resident survival guide

Quick-take

Urgent hematology consult. Send out labs as detailed below. Plan for pt to get bone marrow biopsy.

Visual summary

Differential

Hypercellular bone marrow (1/Y):

Common: MDS (3-4/100K).

Rare: PNH, aleukemic leukemia, severe megaloblastic anemia

Hypocellular bone marrow (1/X):

Aplastic anemia (BM stem cell failure): idiopathic (most common), viruses (ParvoB19, HIV, EBV, HHV6), meds (chloramphenicol, NSAIDs, sulfa), other infection (anaplasma)

Workup

Bone marrow biopsy required for definitive diagnosis.

Treatment

Once identified, treat underlying cause.

Aplastic anemia: Allogeneic stem cell transplant.

Example A/P

Mr. Smith is a 61yo M who was referred from his PCP after presenting with diffuse petechiae. CBC revealed pancytopenia (PLT:11, WBC:1.8, HCT: 24)

#Pancytopenia:

Given patient's age, most likely MDS. Bone marrow biopsy will help narrow differential.

The presence of decreased WBC and HCT makes ITP, TTP less likely.

Dx:

- Hematology consulted, appreciate recs.

- Plan for bone marrow biopsy tomorrow AM. NPO at midnight.

- Peripheral blood smear

- Daily CBC to monitor;

- Peripheral flow cytometry

- SPEP with immunofixation and free light chains

- Anemia labs: Retics, Folate/B12, Iron, TIBC, Direct coombs, Haptoglobin

- Aplastic anemia labs: Hep serologies, HIV, LFTs, Blood parasite smear

- Autoimmune labs: ANA

Tx:

- Type and screen, transfusion consent to be obtained.

- Transfuse for HCT < 21