CASE STUDIES in HEMATOLOGY.Pptx

3/30/18

CASE STUDIES IN HEMATOLOGY Rita Marie John, EdD, DNP, CPNP, PMHS, FAANP

Disclosures

´ Rita Marie John has no disclosures

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Objectives

´ At the end of this lecture, the learner should be able to: 1. Appropriately interpret the CBC using a stepwise approach 2. To understand the work up for a patient that presents with unexplained bruising or petechiae.

How To Approach the CBC

1. Evaluate the red blood cell (RBC) line ´ Is the child anemic? ´ What kind of anemia does the child have? ´ If microcytic, do Mentzer’s index. 2. Evaluate the White blood cell (WBC) line 1. Look for all 5 cells-Neutrophils (bands) or together granulocytes, lymphocytes, Eosinophils, basophils, Monocytes 3. Evaluate the platelet measurements-both size and amount 4. Look at the smear 1. Blood cell morphology

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Result Normal range

WBC 10,000 4.5-13.5 1. Look first to RBC 3.42 4-5.4 see if the child is Hct 10 12-14 anemic? Hb 30 37-41 MCV 73 78-90 1a. If anemic, what MCH 25.4 27-30 kind of anemia does MCHC 27 31-34 the patient have? RDW 17 9-14 Platelets 190,000 180-327 1b. If microcytic, use Mentzer MPV 9 6-11.3 index to determine if this might by iron deficiency. Differential MCV/RBC Polys (granulocyte) 57 54 If > 13, possible iron deficiency Band 0 If < 13, possible thalassemia

Lymphs 36 36 2. Look at the WBC total count Eos 2 2 • Make sure you count five different cell Mono 3 4 • Do an ANC Basophils 2 1 3. Is platelet count normal? Atypical Lymphs 0 Is the size of platelet normal Smear: Anisocytosis and microcytosis 4. What does the smear look like?

Ordering A CBC

´ When should I order CBC ´ Screening for anemia ´ Suspect hematological disorder ´ Toxic child ´ Caution: well visit, well child with negative history ´ Road to CBC Hell ´ Well child with mild viral illness has transient abnormalities

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The Red Cell Line Is the child anemic What kind of anemia does the child have If microcytic, do Mentzer’s index

The Red Cell Line

´ Number ´ Hemoglobin content ´ RBC ´ MCH: Amount of ´ Hb: Ability of RBC to Hb/RBC carry oxygen ´ MCHC: Portion of ´ HCT: 3 X Hb RBC occupied by Hb ´ Size ´ CHR =Retic-He ´ MCV— ´ Shape ´ Macrocytic ´ RDW ´ Normocytic ´ ´ Microcytic Peripheral Smear

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Red Cell Line: Interpretation

Rule of 3ʼs ´ Measured Hb calculation should be 3 times the RBC count ´ Calculated HCT is 3 times the Hb value ´ The eleven plus point one rule ´ 11 = 0.1 X (age in years) is the lower limit of normal (3rd Percentile) for Hemoglobin concentration

Red Blood Cell Size

´ Normocytic ´ RBC size is normal but there is not enough of them (anemia) ´ Microcytic ´ RBC size is smaller than normal ´ Macrocytic ´ RBC size is larger than normal

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MCV

´ What values help you determine anemia? ´ RDW (Red Blood cell distribution width) ´ MCV (Mean corpuscle volume) ´ What is low of normal? ´ Lower limits of NL for MCV = Age (yrs + 70) ´ Only use once child is 2 years and up to 10 ´ After 10 values for adolescent are the same.

A 5 year old has a Hb of 11.4 with an MCV of 74. How do you interpret this?

A.Likely normal 100% B.Likely abnormal C. Look at the 0% 0% 0% previous

Likely normal values Likely abnormal Let’s start over D.Let’s start over Look at the previous values 5

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Red Cell Shape

´ Red Cell Distribution Width (RDW) ´ Coefficient of variation of the red cell volume histagram distribution, i. e how much does the red cell vary ´ Very helpful in diagnosis of microcytosis ´ RDW Normals ´ In thalassemia minor may be 1 or 2 points over the upper normal ´ In iron deficiency, frequently very elevated ranging from 15-25

Red Cell Shape

´ CHr (Advia) Or Retic-He (Sysmex) ´ This value measure the amounts of of hemoglobin in reticulocyte ´ Normal value is > 28 picogram (pg) ´ This is a measure of iron available for producing new RBC’s ´ Value is reduced in iron deficiency and thalassemia

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Physiological Anemia In Infancy

´ Term Infant: Anemia in the first 2 to 3 months of life ´ Physiologic anemia of infancy ´ Not due to iron deficiency ´ Does not respond to iron therapy. ´ Preterm infants ´ Appears at 1 to 2 months of age and is often more severe.

Causes of Iron Deficiency Decreased Intake Decreased absorption Achlorhydria Celiac disease Competing metal Fe deficiency Clay starch Increased losses GI GU (menses, hemosidinuria) Lung (pulmonary hemosiderosis) Joints (hemarthroses Factitious Pregnancy Frequent blood donation Newborn exchange transfusion Iatrogenic

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Non Hematologic Assessment Signs of Iron Deficiency ´ Abnormal nails (spooning) Koilonychia ´ Blue sclera ´ Abnormal appearance of tongue ´ Hyperactivity ´ Behavioral difficulties ´ Poor school performance ´ Poor exercise performance ´ Pica ´ Delayed developmental milestone

Indices to distinguish Iron deficiency from Thalassemia

´ Mentzer index (MI) is determined by MCV/RBC. ´ Value greater than 13 suggests iron deficiency – usually around 17 to 20 ´ Less than 13 it suggests thalassemia. ´ Shine and Lal index (S&L) -- (MCV)2 x MCH x 0.01. ´ Less than <1,530, it favors thalassemia but when it is greater than >1,530, it suggests iron deficiency. ´ The Srivastava index (SI) is obtained using the MCH/RBC. ´ When the value is greater than 4.4, it suggests iron deficiency, but when it is less than 4.4 suggests thalassemia trait. ´ Ricerca index (RI) -- RDW/RBC ´ A number less than 3.3 suggests thalassemia ´ Greater than 3.3 suggests iron deficiency. ´ The G&K index -- ([MCV]2 x RDW)/(Hb x 100) ´ number less than 72 suggests thalassemia and greater than 72 suggests iron deficiency

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Causes of Microcytic Anemia ´ Most Common: ´ Iron Deficiency and Thalassemia ´ Less Common: ´ Hemoglobin C disease, Hemoglobin D disease, anemia of inflammation ´ Hereditary pyropoikilocytosis (Lead Poisoning Rare ´ Sideroblastic anemia ´ Copper deficiency ´ Pyridoxine deficiency ´ Severe Hereditary Spherocytosis

Differential Diagnosis of Normocytic Anemia

´ Blood loss—usually GI ´ Fluid overload in hospitalized patients ´ Decreased RBC Production ´ Bone marrow failure ´ Increased RBC Destruction ´ Membranopathies (spherocytosis), ovalocytosis, elliptocytosis), ´ Enzymopathies (G-6-PD, Pyruvate Kinase deficiencies) ´ Hemoglobinopathies (HbSS, HbSC) ´ Microangiopathy (Hemolytic uremic syndrome) ´ Antibody mediated hemolysis ´ Hypersplenism ´ Disseminated intravascular coagulopathy ´ Thrombotic thrombocytopenic purpura (TTP)

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Classifications of Anemias

´ Macrocytic ´ Vitamin B12 deficiency ´ Folate deficiency ´ Liver disease ´ Lots of reticulocytes (due to hemolysis)

WBC • Make sure you identify all five cells • Do an Absolute Neutrophil Count

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Neutrophils

´ First line of defense against bacterial infection ´ Major function: ´ Phagocytosis ´ Killing of microorganisms ´ Enzymatic degradation

Neutrophils ´ At birth, decrease ´ Most abundant type of rapidly after birth within WBC first few days ´ Also known as Polymorphic Nuclear ´ Infancy 20-30% of Leukocyte or circulating WBC granulocyte ´ At age 5 years, equal ´ Can see granules neutrophil and when stained lymphocytes ´ Band is the immature ´ At puberty reaches 70% Neutrophil predominance found in ´ Is an acute phase adult. response

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Factors that Interfere with the Normal WBC

´ AGE ´ MINOR ILLNESS ´ High neutrophil ´ Widely variable count during the first leukocyte count several days of life ´ Neutropenia is not ´ RACE uncommon during a ´ African Americans viral illness have lower WBC ´ MEASUREMENT METHOD ´ Inherent errors

Neutropenia ´ May be: ´ Congenital/Hereditary—Kostmann’s Syndrome ´ Autoimmune antibody ´ Drug Induced ´ Chronic ´ Related to Bone marrow failure ´ Cyclic (often benign) ´ Secondary response to viral infection (i.e. HIV, EBV, Hepatitis Measles, Rubella, Varicella)

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What is neutropenia

´ Add the neutrophils and Bands together and multiply by the total WBC count ´ What is neutrophil count if WBC is 4,500 with 2 Bands, and 10 neutrophils?

4,500 X .12 540 is the ANC

Approach to Neutropenia

´ Clinical guidelines ´ Patient should present with 3 occurrences of neutropenia in a 6 week period along with infections/ fevers to be diagnosed with neutropenia (Boxer, 2012)

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Neutropenia classification

´ In African Americans, 30% may have 1000 as normal ´ Caucasian 8000 to 1500 normal ´ Mild neutropenia: 1500-1000 ´ Moderate neutropenia: 1000-500 ´ Severe neutropenia: < 500 ´ More likely to have life threatening illness

Increased Neutrophils ´ Newborn ´ Physiologic – newborn, stress exercise ´ Acute hemorrhage ´ Acute bacterial infection ´ Metabolic derangement—diabetes, acidosis, anoxia, burn, seizures ´ Drugs-epinephrine, steroids, lithium ´ Connective tissue disease-JIA, Inflammatory Bowel disease ´ Hematological disorders—Cancers, hemolysis splenectomy

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Normal Hemoglobin and Platelet Count with No Recurrent Illnesses

Observe, defer diagnostic work up if well and repeat CBC 1-2 weeks

Neutropenia Persistent Cyclic neutropenia Resolves-viral illness neutropenia benign May be congenital cyclic

If there is a low hemoglobin and/or platelets with a low neutrophil count, refer to Hematology

WBC Evaluation: Neutrophils and Lymphs

´ Shift to the left: ´ Increase in the number of immature neutrophils—bands and metamyelocyte - >5% bands ´ Absolute lymphocytosis ´ Physiologic: 2 months to 4 year ´ Increased in pertussis, TB, mononucleosis, CMV, measles, adenovirus, syphilis ´ Leukemia ´ Lymphopenia <1,000 per mm3 ´ Immunodeficiency disorders, steroids, immunosuppressive agents

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Lymphocytosis

´ Response to acute viral infections ´ Chronic infectious states such as TB, Syphilis ´ Can be seen in pertussis ´ Also seen in ALL, Non Hodgkin's Lymphoma

Monocytes

´ 1- 10 % of Leukocytes ´ Large cells with blue-gray cytoplasm ´ Reniform (kidney) shaped (i.e. folded nuclei) ´ Efficient at digestion of fungi and microbacteria ´ Return of Monocytes precedes return of neutrophils by 1-2 days

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Basophils

´ Less than 1% of Leukocytes ´ Contain large cytoplasmic granules and sulfated acidic proteins ´ Express IgE receptors ´ Release Histamine when stimulated ´ Above 150u/L= Basophilia which is associated with hypersensitivity reactions\ ´ May be associated viral infections such as: ´ Varicella ´ Flu ´ TB

Eosinophils

´ Bilobed nucleus with a red granulocyte filled cytoplasm ´ Fight parasites ´ Control Allergic Reactions ´ Eosinophilia usually seen when Eosinophils make up more than 10% of WBC’s ´ Hypereosinophilia persisting for months can cause tissue damage

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WBC Evaluation: Eosinophilia ´ N – Neoplasm ´ Hodgkin's lymphoma (HL) is commonly associated with eosinophilia. ´ Can also occur with carcinomas, ´ Can be related to the breakdown of tumor cells ´ Neoplastic cells have shown to produce factors that increase eosinophil production. ´ A - Addison's disease ´ Decreased cortisol levels lead to eosinophilia, because normally cortisol sequesters eosinophils back into the lymph nodes. ´ A - Allergy/asthma ´ asthma, allergic rhinitis, and drug reactions. (remember eosinophilic esophagitis, too) ´ C - Collagen vascular (autoimmune) disease ´ Eosinophilia can be associated with rheumatoid arthritis, polyarteritis nodosa, and Churg-Strauss syndrome, among others. ´ P- Parasites Typically associated with parasites that invade tissues, like T. canis and helminthes (worms).

White Cells ´ White blood cells ´ Atypical lymphocytes ´ Predominately an activated T lymphocytes responding to the B-cell infection ´ Metamyelocyte ´ Blasts ´ Dohle Bodies ´ Bluish cytoplasmic inclusions in neutrophils in bacterial infection, burns, myelodysplasia, pregnancy ´ Chediak Higashi syndrome ´ Giant azurophilic granules in lymphocytes

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Platelet line

´ Life span is 8-9 days ´ Pseudothrombocytopenia ´ One third are ´ Artificially low count due sequestered in the spleen to clumping ´ Normal count 150,000 to ´ EDTA-dependent 450,000 antibody against platelets ´ Suspect if the low platelet count and patient is well ´ Clumps of platelets on a blood film from EDTA specimen

Platelets and Bleeding

Ø >100,000 Ø 20,000 to 50,000 Ø Mild cutaneous Ø No bleeding bleeding Ø 50,000 to 100,000 Ø 5,000 to 20,000 Ø Small amount of Ø Moderate cutaneous bleeding may offer and mucosal after trauma bleeding Ø <5,000 Ø Potentially severe CNS bleeding

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Platelet Size: MPV

´ Giant >13 ´ Inherited syndrome

´ Decreased <7 ´ Wiskott-Aldrich Syndrome

´ Increased 10-13 ´ Increased platelet destruction

Thrombocytosis

´ ACUTE PHASE REACTANT ´ Defined as a platelet count >450,000/mm3 ´ Causes: ´ Infection, collagen disease malignancy, stress, post operative, iron deficiency, following marrow recovery or splenectomy or in myeloproliferative disease (rare) ´ Manage by treating the underlying disease and/or benign neglect unless over 1 million repeatedly

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Peripheral Smear - RBC Morphology

´ Poikilocytosis (difference in shapes) ´ Spherocytes ´ Artifactual, immune mediated ´ Anisocytosis (difference in size) hemolytic anemia, spherocytosis ´ Hypochromia (pale cells) ´ Nucleated erythrocytes-hemolytic ´ Microcytosis (small cells) disease ´ Schistocytes and helmet cells ´ Membranopathies (spherocytosis, (microangiopathic hemolytic ovalocytosis, elliptocytosis) anemia) ´ Basophillic stippling ´ Speculated erythrocytes and acanthoctyes (spur cells) in ´ Aggregated ribosomal DNA and pyruvate kinase deficiency mitochondrial fragments ´ Bite or blister cells in Glucose-6- phosphate deficiency ´ Lead poisoning and thalassemia ´ Target cells in iron deficiency, liver disease hemoglobinopathies, postsplenoectomy ´ Howell jolly bodies splenic hypofunction

Case 1: 2.5 Year Old Male

´ Well visit. ´ History is significant for 32 ounces of milk a day and 16 ounces of juice. ´ The mother reports a poor appetite for solid food. ´ Physical exam is normal except for mild pallor. A CBC follows.

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Case 2

Test Result Range Unit WBC 9.5 6.0-17.5 10*9/l RBC 3.12 3.5-5.0 10*12/l Hgb 9.3 11.5-15.5 g/dl Hct 27.9 35-45 % MCV 64 75-81 ﬂ MCH 21.9 24-30 pg MCHC 30.5 31-37 g/dl RDW 18 11.5-14.5 % Plt 475 150-400 10*9/l MPV 10 9.0-12.95 ﬂ NRBC 0.0 0 /100 WBC Abs Neut Count 1.5-8.5 10*9/l Neutrophils 9 33 % % Lymphocytes 85 59 % % Monocytes 3 3-7 % % Basophils 0 0-1 % % Eosinophils 2 1-3 % Smear shows Anisocytosis, microcytosis, hypochromasia

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What kind of anemia does the paent have in case 1? A. Microcyc anemia 100% B. Normocyc anemia C. Macrocyc anemia. D. No anemia

0% 0% 0%

No anemia

Microcytic anemiaNormocytic anemiaMacrocytic anemia. 5

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Test Result Range Unit WBC 9.5 6.0-17.5 10*9/l RBC 3.12 3.5-5.0 10*12/l Hgb 9.3 11.5-15.5 g/dl Hct 27.9 35-45 % MCV 64 75-81 ﬂ MCH 21.9 24-30 pg MCHC 30.5 31-37 g/dl RDW 18 11.5-14.5 % Plt 475 150-400 10*9/l MPV 10 9.0-12.95 ﬂ NRBC 0.0 0 /100 WBC Abs Neut Count 1.5-8.5 10*9/l %Neutrophils 9 33 % % Lymphocytes 85 59 % % Monocytes 3 3-7 % % Basophils 0 0-1 % % Eosinophils 2 1-3 %

What is the ANC?

A. 191 25% 25% 25% 25% B. 855 C. 238 D. 1200

191 855 238 1200 :5

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Normal Transient Viral Changes

´ Anemia of inflammation—mild normocytic anemia usually; can be microcytic ´ WBC alteration ´ Leukopenia ´ Neutropenia ´ Leukocytosis ´ Neutropenia ´ lymphocytosis

Let’s look at how the indices do

´ Mentzer index (MI) is determined by RBC/MCV [20.5] yes ´ Shine and Lal index (S&L) -- (MCV)2 x MCH x 0.01. [897.02] No ´ The Srivastava index (SI) is obtained using the MCH/RBC. [7.019] yes ´ Ricerca index (RI) -- RDW/RBC [5.76] Yes ´ The G&K index -- ([MCV]2 x RDW)/(Hb x 100) [79.27] yes

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Causes of Anemia and Lab Values Iron deficiency Β Thalassemia Chronic Lead Poisoning Sickle Disease trait inflammation

Reticulocyte Low to normal Low Normal low Count RDW é ê Normal ê Ferritin ê Normal to é Normal ê to Normal

FEP é Normal é é é Serum Iron ê Normal ê ê to normal TIBC é Normal ê Electrophoresis Normal é Normal Normal HbSS HbA2 or F ESR Normal Normal é Normal Low Smear Hypochromic, Normochromic, Varies Basophilic Sickle cells target cells microcytic Stippling

From Gilbert- Barness, E & Barness, L. Clinical Use of Pediatric Diagnostic Tests, p. 344.

Case 2: A routine CBC

´ This was a routine CBC which was sent at the one year visit. ´ The child is an African American female. ´ Her medical, family, and social history is unremarkable.

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Test Result Range Unit WBC 7.5 4.5-13 10*9/l RBC 5.40 4-5.20 10*12/l Hgb 9.8 11.5-15.5 g/dl Hct 29.8 35-45 % MCV 55 77-95 ﬂ MCH 22 25-33 pg MCHC 32 32-36 g/dl RDW 14.5 11.5-15 % Plt 180 150-450 10*9/l MPV 7 6.5-10 ﬂ NRBC 0 0 /100 WBC Abs Neut Count 3450 1.5-8.5 10*9/l % Neutrophils 46 33-61 % % Bands 2 0-11 % % Lymphocytes 44 28-48 % % Monocytes 5 3-6 % % Basophils 1 0-1 % % Eosinophils 2 0-3 %

What is the next step?

1. Start on iron 2. Do a hemoglobin electrophoresis 3. Do a hemoglobin electrophoresis with a ferritin 4. Do a hemoglobin electrophoresis, ferritin, and CBC with diff

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Case 3 ´ HR, a 6-year-old previously healthy girl with no significant past medical history, developed a sore throat, fever of 103 with non-productive cough two weeks ago. During that time, she had one episode of bright red blood per rectum. Her mother brought her to an urgent care center where she was noted to have tachycardia and was diagnosed with a viral illness. ´ For 5 days, the mother reports that child has been increasing tired and weak, slept more than usual, and did not play. ´ Two days ago, she developed intermittent abdominal pain which resolved without treatment. She was not seen for the abdominal pain. HR has been without fevers, nausea, vomiting, diarrhea, constipation, joint pain, muscle pain, bruising, or bleeding. All other items on review of systems were negative. She is a vegetarian, has a high intake of milk (3-4 16 ounce glasses per day). ´ She does not take regular or alternative medications but does take one Flintstone chewable without iron. Her immunizations are up to date. Family history is noncontributory. ´ AR’s height and weight are on the 50th and 51st percentiles, respectively. Her vital signs are: T 101.2, AR 154 bpm, and 29 breaths per minute. She has a widened pulse pressure with a blood pressure of 107/45. Her oxygen saturation is normal at 100%. The physical exam is remarkable for 1 cm spleen. A CBC was done stat.

Lab Value Reference Status WBC 218.1 4.5-13.0 x 10(3)/uL HIGH RBC 1.02 3.8-5.2 x 10(6)/uL LOW Hgb 2.9 11.5-16.0 g/dL LOW Hct 8.6 35.0-47.0 % LOW Platelets 21 150-450 x 10(3)/uL LOW MCV 83.8 77.0-95.0 fL MCH 27.9 25.0-35.0 pg MCHC 33.3 31.0-37.0 g/dL RDW 16.4 11.5-14.5 % High MPV 6.4 8.0-12.0 fL Low Reticulocytes 1.32 0.5-2.17 % RI .13 0.5% and 2.5% Low Lymphocytes 3 20-50% Low

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Reticulocyte count

´ Reasons for ordering this test ´ Normocytic anemia ´ Acute blood loss ( usually doubling of reticulocyte count in first 24 hours) ´ Problems with bone marrow ´ Response to anemia therapy ´ Infections ´ Parvovirus causes aplasia of bone marrow since there is no new RBC production for 7 days ´ Drugs causing hemolysis or bone marrow aplasia

Reticulocyte production index (RPI)

´ Raw reticulocyte count: misleading in anemic patients. ´ Reticulocyte count is a percentage ´ Number of reticulocytes as a percentage of the number of red blood cells. Normally they mature in one day. ´ If severe anemia, more reticulocytes are produced and they say longer so the reticulocyte count may be spuriously high. ´ In anemia, the patient's red blood cells are depleted, creating an erroneously elevated reticulocyte count.

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Reticulocyte Production index (RPI)

´ Corrects the reticulocyte count for the degree of anemia ´ Evaluates whether the bone marrowʼs response is appropriate. ´ Reticulocyte production should increase in response to any loss of red blood cells ´ RPI = reticulocyte count X the patientʼs hemoglobin/ normal hemoglobin X .5 ´ Increase within 2–3 days of a hemorrhage ´ Will peak in 6–10

Reticulocyte Index

´ Normal 0.5% and 2.5% ´ RI < 2% with anemia indicates loss of red blood cells, but decreased production of reticulocytes ´ Lymphoproliferative disorders ´ Ineffective erythropoiesis (megaloblastic anemia) ´ RI > 3% with anemia indicates loss of red blood cells with an increased compensatory production of reticulocytes to replace the lost red blood cells ´ Hemolytic anemia ´ Recent hemorrhage ´ Marrow response to therapy

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CBC Case 2

´ High white count exceeds 100,000 classifying it as hyperleukocytosis (Jain, Bansal, & Marwaha, 2012).

´ most commonly caused by an acute leukemia (Chiaretti, Zini, & Bassan, 2014). ´ Extreme increase in white blood cells increases the viscosity of the blood

´ Increased risk for stasis, also known as leukostasis (Jain et al., 2012). ´ High count of peripheral blasts, of which any presence at all is almost always abnormal and usually indicative of bone marrow dysfunction from malignancy (Lanzkowsky, 2011).

CBC Case 2

´ Severe normocytic anemia secondary to hyperleukocytosis, likely the cause of her lethargy and pallor. ´ Due to bone marrow disruption resulting in pallor, fatigue, tachycardia, and dyspnea (Lanzkowsky, 2011). ´ Although her reticulocytes are normal based on the range, her bone marrow should be producing more reticulocytes in attempts to adjust for her degree of anemia. Therefore, with the other lab values in consideration, she has an inadequate reticulocytosis (Orkin, et al., 2009) ´ Functional neutropenia due to bone marrow dysfunction, likely contributing to her fever and recent infection.

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Children with leukemia can have a normal WBC and a slight normocytic normochromic anemia? A. True B. False

Case 4

´ This 4 year old presented to the ED with a history of bleeding per rectum. The mother who was 18 seemed young to the ED attending. He planned on sending her home as he felt she had anal fissures and the mother was exaggerating. ´ An initial CBC is seen in the next slide.

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Test Result Range Unit WBC 9.1 4.5-13.5 10*9/l (HL) RBC 3.9 4.00-5.20 10*12/l Hgb 11.0 11.5-15.5 g/dl Hct 33 35-45 % MCV 85 77-95 ﬂ MCH 28.3 25-33 pg MCHC 38 32-36 g/dl RDW 14 11.5-15 % Plt 195 150-450 10*9/l MPV 10 6.5-10 ﬂ %Neutrophils 54 33-61 % %Lymphocytes 39 28-48 % %Monocytes 4 3-6 % %Basophils 1 0-1 % %Eosinophil 2 0-3 %

What kind of anemia does the paent have? A. Microcyc anemia 25% 25% 25% 25% B. Normocyc anemia C. Macrocyc anemia D. Paent is not anemic

Microcytic anemiaNormocytic anemiaMacrocytic anemia Patient is not anemic 5

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Denouement

´ A comparison CBC done 7 months ago showed a hgb of 12 and a hct of 36. ´ The child rushed to the BR while I was in the ED ´ Passed a polyp that looked like a normal mushroom about 1.5 cm. ´ The follow-up hgb was 7.9 and hct. Of 24, with a reticulocyte count of 8.

Case 5

´ This 9 year old child presented with petechiae on the ankle. The history was benign and the physical exam was normal. ´ A routine CBC was helpful.

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Test Result Range Unit WBC 9.1 4.5-13.5 10*9/l (HL)

RBC 4.93 4.29-5.6 10*12/l Hgb 12.5 11.5-13.5 g/dl

Hct 38.5 34.5-44 % MCV 85 80-95 fl MCH 28.3 26.-32 pg MCHC 37 32-36 g/dl RDW 14.3 11.5-14.5 %

Plt 55 150-350 10*9/l MPV 10 6-9.50 fl Neutrophils 54 1.5-8.6 %

Lymphocytes 38 0-10 %

Monocytes 4 15-45 %

Eosinophils 2 0-5 %

Case 6

´ JA. is a 16 year old Hispanic female with a history of iron deficiency anemia (not currently taking iron supplementation) presents with heavy menstrual bleeding and cramps for the past 12 days and passing large clots. ´ LMP 12 days ago ´ Patient missed 3 days of school last week due to menstrual bleeding and pain. ´ Patient has been taking OCP (Ortho Tri Cyclen ) due a history of heavy vaginal bleeding lasting 9 days. Long history of an irregular cycle with heavy bleeding and severe cramps. ´ Since starting OCPs the bleeding is much better until this past month. Denies cramps. ´ Taking OCP QD at the same time every day ´ Patient denies coitarche or any other sexual activity. Denies sexual abuse or trauma. Denies gum bleeding, easy bruising. Denies syncope, nausea, vomiting. No signs of hyperandrogenism including acne, obesity, hirsutism.

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Case 6 Value Reference Status WBC 7.7 4.8-10.8 Normal RBC 2.25 3.38-5.08 Low Hgb 8.96 12.0-16.0 low Hct (%) 27.2 37-47 low MCV 89.8 80.4-95.9 Normal MCH 29.7 27-31 Normal MCHC 33.1 32-36 Normal RDW (%) 13.4 12-15 Normal Platelets 288 150-400 Normal

MPV 8.2 7.4-10.4 Normal Reticulocytes 4.42 .5 to 1.5 High

PT Value Reference Status 11.5 9.1-11.9 sec. Normal PTT Value Reference Status 66.0 25.1-36.5 High

von Willebrandt Reference Status Factor Value (%) 44 (%) 70-200 (Adult, Normal non O blood type)

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Screening tests for von Willebrand’s Disease (vWD)

´ Done in Primary care setting ´ Prothrombin time (PT) ´ partial thromboplastin time (PTT) ´ Ordered by hematology ´ Next-generation sequencing may done and can Identify causative vWF defects ´ Factor VIII coagulant activity ´ Ristocetin cofactor (RCoF) activity ´ Concentration of vWF antigen (vWF:Ag)

Differential Diagnosis of Bleeding Disorder Cues to diagnosis

Quantitative Platelet Disorder Bleeding, bruising, petechial or purpura (ITP, TTP, malignancy, virus) Functional platelet disorders Lifelong history of bleeding with negative lab work up. Glycoprotein disorders—storage pool disease, Bernard Soulier syndrome, vWD Hemophilia A or B Joint or soft tissue bleeding, family history of bleeding in men Factor inhibitors Similar of hemophilia but sudden onset without family history Hereditary Hemorrhagic Telangiectasia over lips, tongue, nasal cavity and skin telangiectasia with epistaxis Vasculitis or cryoglobulinemia Neuropathy, pulmonary renal involvement and purpura Leukemia Abnormalities of CBC/peripheral blood smear Vitamin K deficiency Malabsorption, IBD, short gut, poor diet use of drugs that bind to vitamin K (Questran)

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Differential Diagnosis of Bruising

Disorder Findings or Cues to Diagnosis Alcohol abuse Social history Child abuse Atypical pattern of bruising or bleeding, bruises in nonmobile child, inconsistent history Cushing’s disease Facial plethora, hirsutism, hyperglycemia, hypertension, poor wound healing and striae Marfan syndrome Enlarged aortic root, eye involvement, MVP, Scoliosis, pectus excavatum, stretch marks, tall and slim with long limbs and digits Vitamin C deficiency Dietary history Ehler Danlos syndrome or Atrophic scarring, hypermobile joints, skin another connective tissue hyperextensibility disorder

Evaluation of Bleeding Disorders Prothrombin time (PT) Partial Thromboplastin Further evaluation Next Step time (PTT)

Normal Normal Platelet function Is there prolonged analyzer-100 aggregation time with both m

Normal Abnormal Partial thromboplastin If it corrects with APTT time mixing study (APTT) study, Factor VII, IX, and • Determines if XI assay prolonged PT or PTT is If factor VII low, work up due to a factor for von Willibrand’s deficiency or due to Disease the presence of No: Screen for inhibitors inhibitor. (lupus anticoagulant and factor VIII inhibitor) Abnormal Normal Is patient malnourished or Does PT correct with Vitamin K deficiency Vitamin K administration Abnormal Abnormal DIC Consider factor assays for Verify no heparin or factor deficiencies warfarin use No liver disease

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Prothrombin Time (PT)

´ PT measures the factors of the extrinsic pathways ´ Deficiencies of extrinsic factors prolong the PT ´ Vitamin K needed for the synthesis of the critical factors of these pathways so if a patients has vitamin K deficiency=prolonged PT (Ballas & Kraut, 2008) ´ In our patient’s PT was normal and extrinsic factor deficiencies were ruled out.

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PTT versus aPTT

´ PTT and aPTT are used to test for the same functions; ´ In an aPTT, an activator is added that speeds up the clotting time and results in a narrower reference range. ´ The aPTT is considered a more sensitive version of the PTT and is considered a mixing study ´ If PT and PTT are both prolonged and mixing study shows correction, then most likely there is deficiency of factor in the common pathway. ´ A mixing study or an aPTT will help you in determining the diagnosis.

Overview of Initial Workup for Bleeding/Bruising

´ PTT is mildly prolonged in approximately 50% of patients with vWD ´ PT will be normal ´ Bleeding time is not accurate and should not be done ´ Prolongation of both may indicate vWF or a two bleeding disorders

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Overview of Initial Workup for Bleeding/Bruising ´ vWF varies with blood type. ´ Individuals with type O blood approximately 50-75% of the vWF levels ´ Need to compare vWF levels with ABO blood group ´ Levels of vWF vary ´ physiologic stress ´ plasma levels increase with estrogens, vasopressin, growth hormone, and adrenergic stimuli. ´ vWF levels ´ Can be normal in patients with vWD ´ Measurements should be repeated to confirm abnormal results.

Case 7

´ A 15-year-old Caucasian male developed a large bruise on his left upper arm without known injury. He reports that 2-3 weeks ago, there was a similar bruise on his right lower arm, which is almost gone. ´ Today, there is a 10 cm area of ecchymosis on the left upper arm with a smaller area of resolving ecchymosis on the right lower arm that is 1-2 cm in diameter. ´ No other areas of ecchymosis or petechiae are present on the face, chest, back, or legs. There are also no signs or history of epistaxis, bleeding gums, petechiae of the mouth or any other physical bleeding symptoms. ´ The child had a circumcision without bleeding. ´ The rest of the physical exam is normal. The child is following his growth curves.

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Value Reference Normal WBC 10.34 3.58 – 11.23 K/mcL RBC 5.24 4.21 – 5.55 M/mcL Hgb 15.5 11.6 – 15.3 g/dL High Hct 44.4 35.2 – 45.3% MCV 84.7 73.8 – 92.2 fL MCH 29.6 24.3 – 31.4 pg MCHC 34.9 31.6 – 35.3 g/dL RDW 12.9 12.4 – 15.4% MPV 10.1 8.6 – 11.9 fL Poly% 51.3 28.0 – 72.0% Lymph% 39.7 17.7 – 57.9% Mon% 6.3 4.6 – 12.1% Eos% 2.3 0.4 – 6.7% Bas% 0.3 0.1 – 0.9% Immature granulocytes 0.1 0.0-0.3%

Value Reference Status

PT 11.5 9.1-11.9 sec. INR 1.07 2.00-3.00 Low

Value Reference Status PTT 85.1 23.6-31.6 sec High

Note: abnormal coagulation test confirmed by repeat analysis.

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Overview of partial thromboplastin time (PTT) ´ Deficiencies of these factors prolong the PTT ´ Factor VIII (hemophilia A) ´ Factor IX (hemophilia B) will prolong the PTT. ´ Other factors of the intrinsic pathway include PK, HMWK, factors XII, XI (hemophilia C), X, V, II, and fibrinogen (Taylor, 2003). ´ Inhibitors, and autoantibodies attaching to a factor will render it useless for clot formation ´ Most common inhibitors are the factor VIII inhibitors and the lupus anticoagulant. ´ Factor VIII levels can be low in patients with von Willebrand's disease (Ballas & Kraut, 2008).

Overview of Factor XI Deficiency ´ Bleeding is not predictable within a patient or family ´ Contrast to Hemophilia A and Hemophilia B ´ Bleeding manifestations in hemophilia C do not correlate with the FXI level. ´ Some children with severe FXI deficiency (e.g. levels <20 IU/dL), have no excessive bleeding ´ Other individuals with levels only moderately below the normal range bleed after surgery. (Gomez & Bolton-Maggs, 2008) ´ Most common bleeding complains 1. Epistaxis 2. Bruising 3. Abnormal bleeding during surgery in only 6% (Acosta et al., 2005). ´ Little morbidity is associated with FXI deficiency, except after surgery or trauma. ´ 65% were asymptomatic. ´ For 35%, bleeding after surgery and after trauma (Mumford et al., 2014)

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Overview of Factor XI Deficiency

´ If only the PTT is abnormal ´ Consider factor deficiencies (Barik, 2015). ´ If the patient has a bleeding, a prolonged PTT contrasting with a normal PT suggests of FXI deficiency, provided that hemophilia A and B are ruled out. ´ Lupus anticoagulant, and FXII deficiency may alternatively explain a prolonged PTT if there is no bleeding problem ´ An aPTT or a mixing study can be helpful