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Pancytopenia; Study for Clinical Features and Etiological Pattern at Tertiary Care Settings in Abbottabad

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Pancytopenia; Study for Clinical Features and Etiological Pattern at Tertiary Care Settings in Abbottabad The Professional Medical Journal www.theprofesional.com ORIGINAL PROF-2253 PANCYTOPENIA; STUDY FOR CLINICAL FEATURES AND ETIOLOGICAL PATTERN AT TERTIARY CARE SETTINGS IN ABBOTTABAD Dr. Atif Sitwat Hayat1, Dr. Abdul Haque Khan2, Dr. Ghulam Hussian Baloch3, Dr.Naila Shaikh4 1. MBBS, M.D (Medicine) Assistant Professor of Medicine, ABSTRACT... Background: Pancytopenia is an important hematological problem encountered Isra University Hospital, Hala Road in our day-to-day clinical practice. The aim of our study was to evaluate clinical features and Hyderabad, Sind, Pakistan. 2. MBBS, FCPS (Medicine) etiological pattern of pancytopenia at tertiary care settings in Abbottabad. Methods: This Associate Professor of Medicine prospective study was conducted at Northern Institue of Medical Sciences (NIMS) and Ayub Liaquat University of Medical and Health Sciences Jamshoro, Sind, Pakistan. Teaching Hospital Abbottabad from 25th August 2009 to 31st July 2010. A total of 85 patients 3. MBBS, Dip Card, M.D (Medicine) fulfilling the criteria of pancytopenia were randomly selected by time-based sampling. Associate Professor of Medicine Pancytopenia was diagnosed by anemia (hemoglobin ≤ 10.0g/dl), leucopenia (WBC ≤ 4.0×109/L) Liaquat University of Medical and 9 Health Sciences Jamshoro, Sind, Pakistan. and thrombocytopenia (platelets ≤ 150×10 /L). All data has been entered and analyzed by SPSS 4. MBBS, DCP version 10.0. Results: Out of 85 patients, 62(72.94%) were males and 23(27.05%) females with Senior Lecturer, Liaquat University of Medical and M to F ratio of 2.69:1. The mean age (±SD) of males was 30.20±15.42 years, while that of females Health Sciences Jamshoro, Sind, Pakistan. 35.12±16.31 years (p=0.20). Among clinical features, anemia and generalized weakness were the commonest (97.64%), followed by shortness of breath (88.23%). Majority 54(63.52%) had non-malignant disorders responsible for pancytopenia. Overall, the most common cause of Correspondence Address: pancytopenia was aplastic anemia noted in 30(35.29%) cases, followed by megaloblastic anemia Dr. Atif Sitwat Hayat 15(17.64%) and hypersplenism in 13(15.29%). Conclusions: On conclusion, aplastic anemia MBBS, M.D (Medicine) was the most common cause of pancytopenia in our study predominantly affecting young adult Assistant Professor of Medicine, Isra University Hospital, Hala Road males. It was mainly due to use of toxic and ban-drugs by quacks and general practitioners at their Hyderabad, Sind, Pakistan. clinics. [email protected] Key words: Pancytopenia, aplastic anemia, general practitioners, quacks, bone marrow examination. Article received on: 16/04/2013 Accepted for Publication: Article Citation: Hayat AS, Khan AH, Baloch GH, Shaikh N. Pancytopenia; study for clinical 20/10/2013 features and etiological pattern of at tertiary care settings in Abbottabad. Received after proof reading: 26/01/2014 Professional Med J 2014;21(1): 060-065. INTRODUCTION malignant cell infiltration, or antibody-mediated Pancytopenia is an important hematological bone marrow suppression, or ineffective problem encountered in our day-to-day clinical hematopoiesis and dysplasia, and peripheral practice. It is a decrease in all three cellular sequestration of blood cells in overactive reticulo- elements of peripheral blood leading to anemia, endothelial system3. The main causes of leucopenia and thrombocytopenia1. Pancytopenia pancytopenia are aplastic anemia, hyper- usually presents with symptoms of bone marrow splenism, myelodyplastic syndrome4, nutritional failure such as pallor, dyspnea, bleeding, bruising deficiencies leading to megaloblastic anemia5, and increased tendency to infections2. The sub-leukemic (acute) leukemias, multiple laboratory diagnosis of pancytopenia is evident by myeloma, paroxysmal nocturnal hemoglobinuria low values of hemoglobin (≤10.0 g/dl), white and infections such as HIV, miliary tuberculosis, blood cells (≤4.0×109/L) and platelet counts brucellosis, and leishmaniasis. (≤150×109/L). The incidence of various disorders causing pancytopenia varies according to A detailed history, physical examination and geographical distribution and genetic mutations . complete blood counts with reticulocyte count and It can result either from failure of production of peripheral blood smear remain essential for hematopoietic progenitors in bone marrow, or diagnosis. Profound neutropenia and Professional Med J 2014;21(1): 060-065. www.theprofesional.com 060 PANCYTOPENIA 2 thrombocytopenia associated with sepsis and who were less than 13 years, pregnant females, bleeding, most often reflect underlying marrow previously diagnosed cases, received blood aplasia or leukemia, while glossitis, diarrhea and transfusions recently and on cytotoxic drug paresthesias are associated with megaloblastic therapy, excluded from this study. Pancytopenia anemia. Blast cells are seen on blood film of most has been diagnosed by the presence of anemia patients having acute leukemias, whereas hypo- (hemoglobin ≤ 10.0g/dl), leucopenia (WBC ≤ granulated and segmented neutrophils often 4.0×109/L) and thrombocytopenia (platelets ≤ indicate myelodyplastic syndrome. In addition, 150×109/L). All patients fulfilling the criteria of hyper-segmentation of neutrophils in pancyto- pancytopenia were randomly selected for this penic patients or abnormalities of erythrocyte study by using technique of time-based sampling. morphology with low serum vitamin B12 and folate levels confirm megaloblastic anemia. Bone A pre-designed proforma was developed to record marrow examination is essential to determine the history, examination details and investigation cause of pancytopenia, as it plays a major role in reports. All patients were thoroughly evaluated hematological malignancies, unexplained with special emphasis on history of prior drugs cytopenias and storage disorders3. Trephine intake, exposure to chemical agents and radiation biopsy is mainly undertaken when hypoplasia or either by occupational, accidental or by medical aplasia of bone marrow being suspected on treatment. History of recent viral infections, fever, aspiration6. weight loss, bleeding (e.g. gums, nose, mouth, vagina) were noted. Dietary history with special This study is important in Abbottabad context as focus on animal products (e.g. meat, milk, eggs), majority of our patients visit quacks and general any episodes of abdominal pain, diarrhea/ bulky practitioners for their problems, who injudiciously stools. Also any history of worm expulsion in stool prescribe toxic and ban-drugs from clinics (like and blood transfusions were noted. All patients chloramphenicol, cotrimoxazole, phenylbuta- have undergone for general and systemic zone, metamizole etc) due to low costs. In- examinations to note anemia, jaundice, pedal addition, due to poverty peoples could not take edema, mouth ulcers, bone pain, splengomegaly, meat, fruits and green leafy vegetables, which are hepatomegaly and lymphadenopathy. The the main sources of vitamin B12 and folate. laboratory analyses include complete blood count Furthermore, this study provides a new forum for (CBC) with absolute values and reticulocyte approaching the patients with pancytopenia. counts which were conducted on an automated There are only few studies in Pakistani literature on blood analyzer (Sysmex). Peripheral blood smear clinical spectrum of pancytopenia. The present was examined manually after being stained with study was undertaken to evaluate clinical features giemsa’s stain and looked for malarial parasite and etiological pattern of pancytopenia at tertiary (MP). Differential leukocyte count and red cell care settings in Abbottabad. morphology were also measured manually. Hepatitis A serology, chest radiograph and PATIENTS AND METHODS abdominal ultrasound examinations have been This prospective, descriptive, hospital-based performed in selected cases. All patients have study has been conducted at Northern Institute of undergone for bone marrow aspiration and Medical Sciences (NIMS) and Ayub Teaching wherever required, a trephine biopsy was also Hospital Abbottabad from 25th August 2009 to 31st taken. July 2010. The local Ethical Committees of the Institutes approved the study protocol and all All data has been entered and analyzed by SPSS patients gave written and informed consent. A total version 10.0. The age was described as mean 85 patients of either sex having pancytopenia, (±SD), while discrete variables like gender, clinical from indoor and outdoor medical departments of features and causes of pancytopenia were above mentioned hospitals, were studied. Those presented in percentages. Professional Med J 2014;21(1): 060-065. www.theprofesional.com 061 PANCYTOPENIA 3 infections and exposure to chemicals. Out of RESULTS 15(17.64%) patients of megaloblastic anemia, Eighty five patients were enrolled during eleven 12(80%) had vitamin B12 deficiency and 3(20%) months of study for analysis of clinical features were folate deficient. There were 12(80%) males and various causes of pancytopenia in relation to and 3(20%) females with M to F ratio 4:1. Mean age age and gender. There were 62(72.94%) males of males was 34.21 years, while that of females and 23(27.05%) females, with M to F ratio 2.69:1. 42.1 years. Amongst the patients with B12 The age of our patients ranged from 13-70 years. deficiency, 10(83.33%) had history of nutritional The mean age of males was 30.20±15.42 years deficiency (i.e. lack of animal products in diet), (mean ±SD), while of females 35.12±16.31 years. 01(8.33%) had history of ileal
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