ANEMIA (Case Studies)

JOACHIM B. DOMOSIE
CASE 1
A 10-month-old child was referred to the laboratory for testing after being seen by a pediatrician.
The phlebotomist noted that the child was very pale and listless. The following tests were
ordered: complete blood count (FBC), reticulocyte count, total serum bilirubin, total serum iron
and TIBC, and a stool examination for occult blood, ova, and parasites. The results were as follows:
■ Laboratory Data
• Hemoglobin 5.6 g/dL (10 – 14)g/dl
• Hct 24% (30- 38)%
• RBC 3.5 X 10^12/L (3.88 – 5.13)
• WBC 10.5 X 10^9/L 5.13 – 13.6)
• The RBC indices were as follows:
• MCV 68.6 fL (70 – 83)
• MCH 16 pg (23 – 29)
• MCHC 23 g/dL (32 – 35)
The peripheral blood smear revealed significant anisocytosis, microcytosis, hypochromia, and poikilocytosis.
A normal distribution of platelets was present. Additional laboratory findings were as follows:
• Platelet count 200 X 10^9/L (205 – 553)
• Reticulocyte count 0.5% (>2.5%)
• Total serum bilirubin 0.9 mg/dL
• Serum iron 40 mg/dL (50 – 170)mg/dl
• TIBC 465 mg/dL (250 – 450)mg/dl
• Percent saturation of transferrin 8.6% (20 – 50)%
A stool examination was negative for occult blood, ova, and parasites.
■ Questions
1. What category of anemia is suggested by the morphology of the RBCs on the peripheral blood smear?
2. What laboratory assays would be of additional value in establishing the diagnosis?
3. What is the most probable cause of the patient’s anemia?
CASE 2
• A 75-year-old woman started feeling a bit weak. The patient reported limited red meat
intake. A cholecystectomy was performed at age 60 and some bowel was removed. The
patient has occasional diarrhea but considers this a minor inconvenience. The patient has
experienced some bilateral loss of sensation in the feet and a tingling that was getting
worse and more frequent over the past few months. She takes over-the-counter
medications and her husband’s pills for indigestion. The patient complained of arthritis;
she has been taking nonsteroidal anti-infl ammatory drugs for 5 years, and she has started
low-dose methotrexate for arthritis flare-ups. The physician is certain that she is anemic
and requests a CBC and differential, iron, TIBC, and % Sat/ferritin. No malignancies or GI
bleeding is noted. Blood loss from the GI tract has been ruled out. Profound atrophic
gastritis with patches of inflammation is noted, as is H. pylori at stomach biopsy study.
■ Questions
• 1. Is ferritin a reliable laboratory indicator of iron stores?
CASE 3
• A 35-year-old woman with type I diabetes was admitted to the hospital with severe anemia, vomiting,
and fever. She had not felt well for the past several months. She had lost more than 11 kg without
dieting. Physical examination revealed a pale and slightly obese female with a distended abdomen. She
was the mother of two young children, ages 3 and 5. Her menstrual periods were regular. A FBC, blood
glucose, urinalysis, and pregnancy test were ordered.
■ Laboratory Data
• Hemoglobin 11.40 g/dL (12 – 16)
• RBC 4.06 ´ 1012/L (4.0 – 6.40)
• Hematocrit 35.5% (39.8 – 52.0)
• MCV 87 fL (80 – 100)
• MCH 28.1 (26 – 34)
• MCHC 32 g/dL (32 – 36)
• RDW 16% (11.5 – 15)
• WBC 22.1 ´ 109/L (4 – 10)
• Her peripheral blood smear showed abnormal erythrocyte morphology,
anisocytosis, poikilocytosis, and some teardrop (dacryocytes) cells. Her serum blood
glucose was elevated. Her urinalysis was normal, except for an elevated blood
glucose. The result of her pregnancy test was negative. A follow-up ultrasound of
the abdomen revealed a 20-cm extrauterine mass. Subsequent surgical excision of
the mass revealed a malignant epithelial tumor of the left ovary with metastases to
the pelvic lymph nodes, opposite ovary, and right lung.
• ■ Questions
• 1. Does this patient have AOI?
• 2. Which hematopoietic cells are involved in an inflammatory response?
• 3. What are the characteristic iron and iron storage results in anemia of chronic
inflammation?
CASE 4
• A 23-year-old woman is noted to be suffering from mild anemia in a preemployment
physical examination. The patient denied any significant illness in the past. She has no
history of joint or abdominal pain and she was not sickly as a child. She had been told on
several occasions that she has anemia and was given medications containing iron. She
has not noted any unusual bleeding. Her menstrual periods are regular at monthly
intervals and they last for about 3 days. She has never been pregnant. She has no history
of excessive alcohol intake. Physical examination revealed an enlarged spleen. She has no
icterus, purpura, or lymphadenopathy. Her liver is not enlarged.
■ Laboratory Data
• Hemoglobin 11.0 g/dL
• Hematocrit 35%
• RBC 5.0 × 1012/L
• WBC 9.5 × 109/L
The peripheral blood smear shows target cells, an occasional sickle-shaped cell,
microcytes, and slight hypochromia. The reticulocyte count is 7.2%.
■ Questions
1. What is the differential diagnosis?
2. What test will aid in the differential diagnosis?
3. What is the probable diagnosis if HbA2 was present on Hb Electrophoresis?
4. How do you account for this patient’s benign course?
5. Why does the patient have disease, compared to AS individuals who are
asymptomatic?
6. What complications might arise in the future?
Case 5
• A 50-year-old white woman had seen her physician and reported having
no energy and feeling tired all the time. She also reported experiencing
mild pain in the abdominal region. The physician ordered a routine CBC.
• Laboratory Data
The results of the blood count were as follows:
Hemoglobin 6.2 g/dL
Hct 22%
RBC 1.7 × 10 /L 12

WBC 4.0 × 10 /L 9

Her RBC indices were as follows:

MCV 129.4 fL
MCH 36.5 pg
MCHC 28 g/dL
• The peripheral blood smear demonstrated abnormalities of erythrocytes
and leukocytes. On receipt of the laboratory data, the physician ordered
the following additional tests: vitamin B and folate assays, reticulocyte
12

count, serum iron and TIBC, serum bilirubin, and serum LDH. A fecal
examination for occult blood was additionally ordered.
• The results of the tests were as follows:
Vitamin B : 121 pmol/L (decreased)
12

Serum folate level: normal

Reticulocyte count: 0.4%
Serum iron and TIBC: normal
Serum bilirubin: 1.8 mg/dL (slightly increased)
Serum LDH: >3,000 units (significantly increased)
• ■ Questions

1. What category of anemia is suggested by the

hematological findings in this case?
2. What specific kind of anemia can be diagnosed based
on the laboratory findings?
3. What is the etiology and physiological process in this
anemia?
CASE 6
• A 21-year-old Driver’s mate was admitted to the hospital
for the repair of an abdominal hernia. His physician was concerned
that strangulation of the hernia could occur. The patient
was in extremely good physical condition. He did not remember
having any unusual illnesses. His family history did include
minor bleeding problems among some of his relatives.
Laboratory Data
On admission, the hemoglobin and hematocrit were
15.0 g/L and 44%, respectively. The PT was 13 seconds
( normal, 10 to 15 seconds), and the aPTT was 55 seconds
(normal, 28 to 35 seconds).
• Because of the results obtained on the original and a
repeat specimen of the aPTT in conjunction with a vague
family history of bleeding, this patient’s surgery was
postponed until a bleeding disorder could be ruled out.

Questions
1. What coagulation deficiencies might be present in this
patient?
2. What supplementary laboratory assays would be
appropriate?
• Further testing was performed. The results were as
follows: bleeding time increased, platelet aggregation
decreased, factor VIII decreased, and factor VIII/vWF
decreased.
3. How could this be distinguished from other similar
disorders?