Labs

The following is the complete blood count (CBC) when you first see the patient:

What’s what: WBC, white blood cell count; Hb, hemoglobin; MCV, mean cell volume; MCHC, mean cellular hemoglobin concentration; RDW-SD, red cell distribution width-standard deviation; platelets, PLT; Normal values: WBC 5-10 x 10⁹/L, RBC 4-6 x 10¹²/L, Hb 12-16 g/dL, Hct 35-47%, MCV 80-100 fL, MCHC 32-36 g/dL, RDW-SD < 45 fL, platelets (PLT) 150-450 x 10⁹/L

How would you describe the CBC?

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Normocytic, normochromic anemia with anisocytosis and thrombocytopenia

The patient’s white cell count was normal. Does that mean the white cell differential must be normal?

The following is a white cell differential from the patient:

Is this differential from the complete blood count shown on the first slide?

The following is a white cell differential from the patient:

This differential is from the next day. Note that despite the normal total white cell count, there is a left shift (this is indicated by the increase in the number of immature granulocytes) and he has lymphocytopenia.

The learning point here is that you should NOT assume a normal differential when the white cell count is normal.

Are you surprised the mean cell volume (MCV) was not increased?

If you were told that the patient’s baseline mean cell volume (MCV) – before his admission to hospital – is high, what would be your explanation for the normal MCV when you see him?

What is one explanation?

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Replacement of patient cells with donor cells from repeated transfusions

We will get to the anemia in a moment (that is why you were asked to see the patient), but let’s consider the low platelet count.

Are you surprised by the thrombocytopenia?

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You shouldn’t be! Thrombocytopenia occurs in 77%-85% of patients with cirrhosis

Thrombocytopenia is the most common cytopenia in patients with cirrhosis and hypersplenism. Consider the following results in a cohort of 213 subjects with compensated cirrhosis without esophageal varices:

Note: other studies report that up to 70% of cirrhotic patients have anemia.

The patient has been in hospital for almost a full month, so it is certainly possible that there are other factors contributing to his thrombocytopenia, for example infection or medication. But there were no signs of active infection and he was not taking any new medications. Moreover, A review of his old records reveals a chronically low platelet account of 80-100 x 10⁹/L. Thus, his thrombocytopenia is likely secondary to his cirrhosis and portal hypertension.

Here is the time course of the patient’s hemoglobin for the 2 weeks prior to you seeing him (day 0) and the transfusions he received.

As seen in the table, the patient has required multiple red cell transfusions to maintain Hb > 7 g/dL. A similar pattern was observed in the first 2 weeks of his admission. He has had a total of 12 units packed red cells over the past month.

His reticulocyte counts are as follows:

The absolute reticulocyte count is right at the cusp for what we would consider an appropriate bone marrow response (>120 x 10⁹/L).

There is no evidence of blood loss:

1. The patient does not have hematemesis or melena.
2. Upper endoscopy early in his admission showed non-bleeding varices, and these were banded.
3. His vital signs are stable – there is no hypotension or postural changes in blood pressure.

The following was the patient’s prothrombin time (PT) and activated partial thromboplastin time (aPTT) the day you saw him:

Do these results make it more likely that the patient is bleeding?

So now you are wondering about hemolysis. Which of the following hemolytic markers are also seen in patients who have cirrhosis without hemolysis?

Here are the test results for markers of hemolysis and cirrhosis:

Because of the overlap in hemolytic markers between hemolysis and cirrhosis, they cannot be reliably used to diagnose hemolysis in a patient with cirrhosis. But there is another test that will help. And it is one that should really come before biochemistry in the workflow – especially for hematologists.

What is the test?

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Peripheral blood smear

Before looking at the peripheral smear, what are you now considering in the differential diagnosis?

The following is the peripheral smear from this patient:

What is the principle finding?

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The presence of a large number of acanthocytes (spur cells)