hem onco question - yvyhope

[ArchivalUser]

A 72 y/o man with hx of chronic alcoholism and smoking presents to your office with extreme fatigue. Denies any fever or weightloss or nightsweats. Vital signs were normal and physical examination reveals generalized small lymphadenopathy and mild splenomegaly. Laboratory studies reveal CBC with hgb 9.5, wbc 10k with 25% neutrophils, 65% mature lymphocytes and 9% monocytes, platelets 90k. LDH is increased at 600 and reticulocyte count of 8.0% . Haptoglobin level is 22mg% ( N 27 to 160) and urinary hemosiderin level is with in normal limits. Basic metabolic panel, Vitmain B12 and Folic acid levels are within normal limits. Peripheral smear reveals many Smudge cells.

Most likely etiology of this patient’s Anemia is :

A. Microangiopathic Hemolysis

B. Bone marrow infiltration with Chronic Lymphocytic Leukemia

C. Acute Lymphoblastic Leukemia

D. Autoimmune Hemolysis

E. Hypersplenism

[ArchivalUser]

This is a case on CML , so C is off.
Mild splenomegamy, E is off, that is stage 2 CML
Not mention about blood film pict, schistocytes, normal urine hemo sidrin, exclude A.
B or D.

LDH high, lowhaptoglobin...so autoimmune haemolysis. D.

[ArchivalUser]

D;

Thrombocytopenia and anemia is autoimmune in CLL.

[ArchivalUser]

i think is d too but why is urine hemosiderin normal?

[ArchivalUser]

Autoimmune hemolytic anemia is of two types
Intravascular = IgM and Complement mediated
Extravascular = Ig G mediated

Hemosidrin appears in intravascular hemolysis not Extravascular one.

[ArchivalUser]

Anaemia in CLL can be due to 2 reasons: autoimmune or bone marrow infiltration
Here hapto is marginally low and there is no hemosiderin in urine so i'll CHOOSE ANSWER B

[ArchivalUser]

it's not B because corrected reticulo>2% so adequate bone marrow response

[ArchivalUser]

Urine hemosirin is significant for intravascular haemolysis, although it can be seen after haemolysis.

So if no urine haemosidrin can exclude microangiopathic haemolysis.

[ArchivalUser]

D is the answer,Increased reticulocyte count and increased LDH goes with hemolysis. The peripheral smear does not show schistocytes which rules out MAHA.
Smear is here http://usmlegalaxy.files.wordpress.com/2.../cells.jpg
All it shows is smudge cells consistent with CLL. Absence of hemosiderin rules out Intravascular hemolysis. Only thing left is autoimmune hemolysis and this is autoimmune hemolysis by exclusioneven though question does not comment on Direct coomb test.

I think this Q is asked because in CLL, anemia is an indication for treating CLL. And anemia can be of two causes
a) Bone marrow infiltration with CLL
b) Autoimmune hemolysis

We should know the difference b/w the two because if anemia is present in CLL due to BM infiltration, CLL has to be treated with chemotherapy. But if anemia in CLL is because of autoimmune hemolysis, steroids are the treatment not chemotherapy ( Reference : Dr.Red Hematology)

[ArchivalUser]

Anemia in CLL can be because of three causes

A:Bone infiltration
B:Hypesplenism
C:Auto-immune