Case of Anemia and Thrombocytopenia

Describe the CBC

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Normocytic anemia, thrombocytopenia and anisocytosis

Describe the white blood cell differential

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Lymphopenia and eosinopenia

Name conditions associated with concomitant anemia and thrombocytopenia

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See graphic on next slide

Graphic showing the differential diagnosis of anemia and thrombocytopenia, with special focus on overlapping conditions.

There are some conditions missing from the list of extracorpuscular hemolysis. What are they?

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Valve hemolysis (and footstrike hemolysis)
Clostridial sepsis
Thermal injury

We will come to the peripheral smear shortly, but which of the following labs would be most helpful (choose the one most appropriate answer):

Ferritin

Vitamin B12 level

Reticulocytes

ALT

Blood culture

The reticulocyte count was elevated (140 x 10⁹/L). This is an appropriate response to anemia and suggests that the patient has hyperproliferative anemia.

What two general processes would you consider based on the reticulocyte count?

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Bleeding
Hemolysis

What blood tests would you order to determine whether there is hemolysis?

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Haptoglobin
LDH
AST
Bilirubin (indirect)

Here are the results of the tests you considered in the last question:

True or false: these results are consistent with hemolysis.

True

False

Here are the results of the tests you considered in the last question:

Which of the above tests is/are not associated with hemolysis?

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Albumin
ALT
ALK

This is the same graphic that was shown several slides earlier, only now the list of differential diagnoses for hemolytic anemia are shaded, as is the list of overlap conditions that would explain concomitant hemolysis and thrombocytopenia.

So having “reverse engineered” the case, we are now ready for a history!

60 yo F with asplenia (past gastrectomy/splenectomy for gastric spindle cell tumor) presented to ED with:

This is the actual peripheral smear (thin smear) from the patient (100x). It shows red blood cells with ring forms, classic for babesiosis.

The patient had a diagnosis of babesiosis with 10.3% parasitemia on her thin smear. She was treated with atovaquone and azithromycin x 6 weeks. Because of her history of splenectomy and the high % parasitemia, she received red cell exchange x 6 rounds. The level of parasitemia on thin smears trended down and eventually became negative 9 days after admission.

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