CHAPTER Pancytopenia: Clinical approach

95 Ajai Kumar Garg, AK Agarwal, GD Sharma

INTRODUCTION normal adult marrow produces about 170x109 RBC, Pancytopenia is a common haematological condition often 100x109 neutrophils, and 200x109 daily. Defects encountered in day to day clinical practice. It is defined in the stem cells or in the stroma or microenvironment as a decrease in all the three cell lines of blood viz., red of can lead to bone marrow failure and blood cells, leucocytes, and platelets. Many diseases affect pancytopenia. production of these cells by bone marrow resulting into Pancytopenia is not a disease by itself but a triad of pancytopenia i.e., simultaneous presence of anaemia, haematological finding that can result from a number of leucopenia, and . Pancytopenia is disease processes (Tables 1 & 2). It can be a feature of many defined as haemoglobin of < 9 gm/dl, WBC < 4,000/cmm, serious and life threatening illnesses like drug induced and platelets < 100,000/cmm. Severe pancytopenia is bone marrow hypoplasia, fatal bone marrow aplasia, and defined as absolute neutrophil count < 500/cmm, platelet leukaemias. It can result from failure of production of count < 20,000/cmm, and corrected reticulocyte count < stem cells in bone marrow, infiltration of bone marrow 1%. by malignant cells or fibrosis, immune mediated bone Presenting symptoms of pancytopenia may be attributable marrow suppression, ineffective erythropoiesis and to anaemia, leucopenia, and/or thrombocytopenia. dysplasia, peripheral sequestration of blood cells by Anaemia may present with fatigue, breathlessness, and overactive reticuloendothelial system, and immune or cardiac symptoms. may present with febrile non-immune mediated increased destruction of blood illness due to increased susceptibility to infections. cells. Marrow damage may be caused by infiltration Patients with thrombocytopenia may present with of marrow with tumour or fibrosis that crowds normal mucocutaneous bleed or bruising. Pancytopenia should marrow cells. Tumour or fibrosis that infiltrates the be suspected on clinical grounds in any patient presenting marrow may originate in the marrow as in leukaemia with unexplained anaemia, prolonged and bleeding or myelofibrosis or be secondary to process originating tendency. The severity of pancytopenia and underlying outside marrow as in metastatic cancer or myelophthisis. aetiology determine the management and prognosis. Incidence of various disorders causing pancytopenia Pancytopenia usually presents with the clinical sign varies according to geographical distribution and genetic and symptoms of bone marrow failure such as pallor, mutations. Main causes of pancytopenia in our country easy fatigability, dyspnoea, bleeding or bruising, and are megaloblastic anaemia due to nutritional deficiencies, increased tendency to infection. As platelets have shortest hypersplenism (congestive , malaria, half life, count is first to be affected leading to and ), aplastic anaemia, myelodysplastic thrombocytopenia. Mucocutaneous bleed is typical syndrome, subleukaemic leukaemias, military manifestation of decreased platelet count with petechial tuberculosis, multiple myeloma, paroxysmal nocturnal haemorrhages in the skin and mucous membrane. haemoglobinuria. Epistaxis, haematuria, gastrointestinal bleeding, According to a study of 200 cases of pancytopenia menorrhagia, and rarely intracranial bleeding are the conducted by Khunger et al at a large general hospital presenting features of thrombocytopenia. Anaemia in North India, the commonest cause found was develops slowly because RBC has longest half life. Early megaloblastic anaemia seen in 72% cases, followed manifestation of neutropenia is often a sore throat, or chest by aplastic anaemia (14%). The other causes included or soft tissue infection with poor response to . subleukaemic leukaemia (10 cases), myelodysplastic Patients with pancytopenia may develop overwhelming syndrome (4 cases), hypersplenism due to kala azar sepsis without any focal sign of infection, with malaise (4 cases), hypersplenism due to malaria (2 cases), Non- and fever being the only clinical features. Hodgkin’s , myelofibrosis, multiple myeloma AETIOLOGY OF PANCYTOPENIA (2 cases each), Waldenstrom macroglobulinaemia and disseminated tuberculosis (1 case each). In another Normal marrow has tremendous capacity to increase prospective study of 104 pancytopenic patients conducted the output of peripheral blood cells whenever necessary by Gayatri and Rao at a teaching institute in South India for with the help of growth factors and cytokines. All the a period of two years, commonest cause of pancytopenia peripheral cells arise from common progenitor pluripotent was megaloblastosis (74%) followed by aplastic anaemia cells having enormous capacity of self renewal. The (18%). CHAPTER 95 451 2 deficiency deficiency may also cause 12 12 blockers Decreased consumption-vegan diet, Decreased consumption-vegan in cobalamin malabsorption (common elderly) anaemia, atrophic gastritis, Pernicious gastrectomy, gastric bypass, H. pylori infection, Zollinger-Ellison syndrome Chronic pancreatitis, tropical sprue, celiac disease, ileal resection, fish tapeworm infestation, bacterial overgrowth syndrome, HIV infection Metformin, Proton pump inhibitors, H Table 2: Causes of pancytopenia marrow with hypocellular Table Acquired aplastic anaemia) Congenital aplastic anaemia (Fanconi’s Some myelodysplasias leukaemia Acute myeloid Acute lymphoid leukaemia Lymphoma of bone marrow B Vitamin 3: Causes of Table Food Stomach Intestine Drugs subacute subacute combined degeneration of cord and psychiatric illness (megaloblastic madness). marrow The suppression is inversely related to presence and degree of severity bone of neurological dysfunction. The coexistence of significant anaemia and neurological deficit is thought to be rare. subcontinent. subcontinent. Vitamin B Hypersplenism Hypersplenism is cytopenia(s), characterized normal or and by hyperplastic a splenomegaly, bone response there marrow, is to peripheral splenectomy. in pooling enlarged In and spleen destruction resulting hypersplenism of in of pancytopenia. cells hypersplenism hyperreactive Causes malaria, failure), heart congestive (cirrhosis, include congestive malarial splenomegaly splenomegaly, and Hodgkin’s leishmaniasis, disease. Hypersplenism thalassaemia, idiopathic. can rarely be Infections Haematologic abnormalities observed in patients with HIV infection. Pancytopenia is have Aetiology infection. HIV of stage advanced in seen usually been frequently of pancytopenia in advanced HIV stage is multi-factorial

12 deficiency, folate 12 Dietary deficiency chronic Infancy and childhood, pregnancy, malignancy, chronic haemolytic anaemia, (tuberculosis, rheumatoid dermatitis, chronic inflammatory disorders exfoliative homocystinuria disease, haemodialysis, arthritis, Crohn’s disease), CHF, chronic enteropathy Tropical and non-tropical sprue, gluten sensitive Antiepileptic drugs, methotrexate, pyrimethamine, alcohol Abnormalities of folate metabolism deficiency Hypersplenism Alcoholism Sepsis, enteric fever HIV infection, hepatitis B, hepatitis C, Ebstein-Barr virus, cytomegalovirus Malaria, leishmaniasis, filariasis erythematosus, Systemic sarcoidosis Secondary to systemic disease systemic to Secondary B Vitamin Paroxysmal nocturnal Paroxysmal haemoglobinuria Myelophthisis Myelofibrosis Subleukaemic leukaemia Bone marrow lymphoma Hairy cell leukaemia Table 4: Causes of 4: Causes of folate Table Nutritional deficiency Increased requirements Malabsorption Drugs Congenital Table 1: Causes of pancytopenia with cellular bone marrow Table marrow bone Primary disease Myelodysplasia OVERVIEW OF COMMON CAUSES OF PANCYTOPENIA OF CAUSES COMMON OF OVERVIEW (cobalamin) and folate. These nutrients have important role in synthesis of DNA. predominant Megaloblastic anaemia cause is of a pancytopenia of in high India prevalence because of nutritional anaemia in Indian Megaloblastic anaemia (Tables 3 & 4) Megaloblastic anaemia (Tables Megaloblastic haematopoiesis bone marrow failure due is to deficiency of vitamin a B hypercellular In another prospective study of 250 cases of pancytopenia pancytopenia of cases 250 of study prospective another In conducted by Jain and infections Naniwadekar (29.2%), hypersplenism at Maharashtra in hospital a tertiary care (25.6%), myelosuppression (13.2%), and (16.8%), hypoplastic/aplastic anaemia (4.8%) megaloblastosis found to were be the common causes of pancytopenia. In female this to male observed, was preponderance male a study ratio being 2.6:1 and majority of cases were encountered in third and fourth decade of life. In an analysis cases of of pancytopenia 166 conducted by Kumar et al at two receiving patients where centers care tertiary myelotoxic chemotherapy or those with leukaemic cells in peripheral blood smears study, it were was observed that excluded aplastic anaemia from (49 was cases) the most common anaemia cause (37cases), aleukaemic followed leukaemia or lymphoma by (30 cases), megaloblastic and hypersplenism (19 cases). Megaloblastosis not commonest cause of pancytopenia in these series was probably because many cases of megaloblastic anaemia need not be referred to a tertiary care centre and easily be treated at general hospitals. could 452 in nature and includes high viral load, use of antiretroviral Acute leukaemias therapy, and presence of acute or chronic opportunistic Acute myeloid leukaemia occurs in all age group but infection. Viral hepatitis has been known to cause predominantly in older adults. Acute lymphoblastic transient pancytopenia during the course of illness and leukaemia is the most common acute leukaemia in has also been associated with aplastic anaemia. Hepatitis childhood. Clinical history and symptoms usually indicate associated with pancytopenia and aplastic anaemia is bone marrow failure. These include fatigue, dyspnoea, usually fatal. Whereas hepatitis B and hepatitis C are dizziness, bleeding, easy bruising, and recurrent common causes; Epstein-Barr virus, cytomegalovirus, infections. Cytogenetic abnormalities are prognostically and rarely hepatitis A and dengue virus can also cause important and affect patient management. In all cases pancytopenia. Mild blood count depression is common in of severe pancytopenia (symptomatic anaemia, WBC < course of many viral and bacterial infections but resolves 500/mcL, and platelets < 20,000/mcL) investigations are with the resolution of infection. Sepsis and enteric mandatory within first 24-48 hrs. Supportive therapy fever continue to be important public health problems with RBC, platelets, and broad spectrum antibiotics may in India and have been associated with pancytopenia be initiated before underlying cause has been ascertained. which has been attributed to , disseminated intravascular coagulation, and infection HAEMATOLOGY associated haemophagocytic syndrome. Tuberculosis Myelodysplastic syndromes (MDS) are the common is a common disease in India. Disseminated miliary haematological diseases characterized by cytopenias tuberculosis is known to cause pancytopenia. Although associated with abnormal appearing cellular marrow pancytopenia is a rare presentation of tuberculosis, it producing ineffective red blood cells. The incidence of should always be considered in patients presenting with MDS increases with advancing age. Median age at disease pancytopenia, unexplained pyrexia and weight loss. onset is 70 years with only about 10% of the patients below Both tuberculous bacilli and anti-tuberculous therapy 50 years. MDS are diseases of haematopoietic stem cells. have been implicated in pathogenesis of pancytopenia. They are characterized by disturbance of differentiation Wuchereria bancrofti is an endemic filarial nematode spread and maturation, and by changes in the bone marrow by a mosquito vector. The clinical manifestations vary stroma. MDS are accompanied not only by reducing from asymptomatic microfilaraemeia to lymphoedema. blood cell counts but also with an increased risk (20-25%) Cases of microfilaria in bone marrow aspirate presenting of developing acute myeloid leukaemia. The disease as pancytopenia in peripheral blood have been reported. course varies greatly from patient to patient, with median Though, aetiopathological correlation of pancytopenia survival time from few months to years. with microfilaria infection is not clear. Systemic lupus erythematosus (SLE) Aplastic anaemia Haematologic abnormalities such as anaemia, leucopenia, Aplastic anaemia is defined as pancytopenia with and thrombocytopenia secondary to peripheral destruction hypocellular marrow in absence of abnormal infiltrate are commonly seen in SLE. Most frequent haematologic or increased fibrosis. It is a normocytic normochromic manifestation of SLE is normocytic and normochromic anaemia that results from a loss of blood cell precursors, anaemia. is also common and almost always causing hypoplasia of bone marrow leading to consists of lymphopenia and not granulocytopenia. pancytopenia. Severe aplastic anaemia is defined as a bone Thrombocytopenia may be a recurring problem in SLE. marrow cellularity < 25% with at least two of the three Cytopenias from autoimmune myelofibrosis are also criteria i.e., neutrophils < 500/mcL, platelets < 20,000/mcL, uncommonly seen in SLE. and reticulocyte count < 20,000/mcL. It is a potentially life Idiopathic cytopenia of undetermined significance threatening failure of bone marrow. Most cases of aplastic Idiopathic cytopenia of undetermined significance anaemia are acquired and T-cell mediated autoimmune (ICUS) is a recently proposed provisional diagnosis disease. Triggering factors may include drugs, viruses, that recognizes patients who present with cytopenias and toxins but most cases are idiopathic. In some cases of undetermined aetiology. Diagnostic criteria for ICUS radiation, drugs, toxic chemicals and viruses induce include: i) persistent cytopenia for 6 months (Hb < 11mg/ depletion of haematopoietic stem cells by direct toxicity. dl, neutrophil < 1.5x109 /L, and platelets < 100x109/L); ii) Paroxysmal nocturnal haemoglobinuria (PNH) No morphologic feature of myelodysplasia; iii) normal PNH is an acquired chronic haemolytic anaemia chromosome analysis; and iv) A detailed clinical history characterized by persistent intravascular haemolysis with and investigation that excludes other secondary causes recurrent exacerbations due to activation of complement of cytopenias. The diagnosis of ICUS should only be C. In addition to haemolysis, there is often pancytopenia established when all possible differential diagnosis have and a risk of venous thrombosis. Haemolysis in PNH been excluded. The term Idiopathic fatal pancytopenia is due to an intrinsic abnormality of the red cell, which has been suggested for ICUS because it is a fatal disease makes it sensitive to activated complement C. Diagnostic with no definite cause. gold standard of PNH is flow cytometry which can be Drug Induced pancytopenia (Table 5) carried out on granulocytes as well as on RBC. A bimodal Drugs are the common cause of pancytopenia. Drug distribution of cells with a discrete population that is induced pancytopenia can be dose dependent or immune CD59 and CD55 negative is diagnostic of PNH. CHAPTER 95 453 and/or folate 12 or folate). In 12 , folate levels, HIV 12 ABSOLUTE RETICULOCYTEABSOLUTE COUNT serology, serology, antinuclear antibodies (ANA) should be done. Serum ferritin levels should also be assessed. Low levels of serum ferritin along with low serum B megaloblastic anaemia bone marrow shows megaloblastic shows marrow bone anaemia megaloblastic erythroid hyperplasia, asynchronous nuclear maturation, bluish cytoplasm with sieved forms band and metamyelocytes Giant blebs. cytoplasmic nuclear are chromatin, predominant in granulocyte in series. aplastic anaemia is Bone hypocellular with marrow suppression of with megakaryopoiesis and myelopoiesis, erythropoiesis, relative lymphoplasmacytosis. In acute leukaemias, bone marrow is hypercellular are cells of majority with and series megakaryocytic reduced erythroid and or lymphoblast. Bone marrow aspiration in AML shows rods. Auer with myeloblast levels may indicate mixed anaemia/pancytopenia. mixed anaemia/pancytopenia. may indicate levels Peripheral blood smear provides important information in pancytopenia and it to should always transfusion be done of polychromasia—red prior cells blood. that are Blood normal slightly larger and smear than greyish may reticulocytes blue that have been reveal in prematurely released colour. from the bone These marrow. These cells may cells appear in circulation are due to architectural damage of the bone marrow caused cell infiltration. by fibrosis or malignant is almost in always cases of indicated pancytopenia unless the cause apparent is otherwise (e.g., hypertension, chronic deficiency of vitamin liver B disease with portal An accurate reticulocyte evaluation count of pancytopenia. Normally, is reticulocytes are the the red key cells that to have been recently initial bone released from marrow. the Normal reticulocyte count 1-2% and ranges reflects the daily from replacement of 0.8-1% of the circulating RBC population. Reticulocyte count provides a reliable measure of RBC production. Reticulocyte count and absolute reticulocyte count (ARC) should be on done day one along with CBC in related order to changes avoid in therapy reticulocyte count is (ARC) count reticulocyte Absolute particularly anaemia. nutritional with reticulocyte of product the from derived index calculated a 4.32-5.72 Male: (Normal; count RBC and percentage count million/cmm, Female: 3.90-5.03 million/cmm). ARC is a marker of red cell production by bone marrow. It plays important role in establishing the cause of pancytopenia and helps in distinguishing between and hypoproliferative hyperproliferative anaemias. absolute reticulocyte Normal count is cases 50,000-100,000/cmm. range All of pancytopenia of with cmm) very should low be examined ARC by (< bone marrow 25,000/ for All aplastic cases anaemia. of pancytopenia with aspiration high ARC (> 100,000/cmm) should also be evaluated by bone marrow aspiration unless there is a history suggestive of sepsis or malaria. Pancytopenia with ARC 25,000-50,000/ megaloblastic megaloblastic anaemia. test, In viral markers addition fibrinogen, for liver hepatitis, D-dimer, coagulation function serum profile, B café (CBC) is required as a part of initial evaluation By bone marrow suppression: Cytotoxic drugs Cytotoxic suppression: marrow By bone effect: By dose dependent reaction mediated idiosyncratic By immune NSAIDS, phenothiazines, chloremphenicol, thiazides, anti-epileptics, anti-thyroid anti-diabetic azathioprine drugs, sulphonamide, drugs, , A thorough physical examination is of paramount b. c. Table 5: Common drugs causing 5: Common pancytopenia Table a. APPROACH TO A CASE OF PANCYTOPENIA CASE OF A TO APPROACH CONGENITAL CAUSES OF PANCYTOPENIA OF CAUSES CONGENITAL of pancytopenia. CBC should include red peripheral blood cell film, indices, reticulocytes count and absolute reticulocyte count. A very high MCV (>110fl) indicates Evaluation Evaluation of pancytopenia requires a and physical careful examination. history The causes of are pancytopenia diverse. Attention must patient and be paidthe family. Nutritional history, drug history to historyand of the history of alcohol intake should always be assessed. History suggestive of previous anaemia, pancytopenia, aplastic inherited bone repeated early foetal loss, cancer, liver disease, metabolic marrow failure disorders, syndrome, or connective tissue Cytotoxic chemotherapy and radiotherapy are disorder important is important. cause of transient loss and pancytopenia. anorexia may suggest History underlying infection malignancy. Recurrent or of oral ulcers and chronic diarrhoea weight may point towards HIV infection. Recurrent oral ulcers, and pain Bone SLE. suggest may pain joint and rash malar loss of height indicate multiple myeloma. importance in evaluation of include pancytopenia. assessment It of should lymphadenopathy jaundice, clubbing of and infection, infectious mononucelosis, fingers, lymphoproliferative splenomegaly disorder, and malignancy), loss of height (suggestive of (underlying oral haemorrhage, retinal rash, malar myeloma), multiple petechiae, gingival hyperplasia, stomatitis oropharyngeal or candidiasis, RUQ cheilitis, abdominal tenderness, disease. signs of chronic liver Laboratory evaluation: count A routine complete blood au lait spots, and anomalies involving and thumb, radius, genitourinary characterized tract. Dyskeratosis by dystrophic congenita mucous nails, is childhood. of aplastic anaemia during development membrane reticular hyperpigmentation, leukoplakia, and Fanconi’s anaemia is an autosomal and recessive manifests disorder as congenital progressive developmental pancytopenia, anomaly, and malignancy. an Patients typically increased have short risk stature, of mediated (idiosyncratic). Chloramphenicol pancytopenia can by cause both the an mechanisms. Azathioprine, various diseases, used usually causes for leucopenia and pancytopenia. treatment rarely of Flow diagram for evalua tion of pancytopenia

454 Pancytopenia

Peripheral blood smear and reticulocyte count

Bone marrow aspiration, Liver function test, coagulation profile Trephine biopsy Vitamin B12, folate levels

Viral serology (HIV, HBV, HCV, EBV, CMV)

Autoimmune profile Bone marrow cytogenetics and immunophenotyping HAEMATOLOGY

Specific investigations

Fig. 1: Flow diagram for Evaluation of Pancytopenia

cmm should initially be evaluated with serum B12, folate REFERENCES and ferritin assays and if any one of these is found to be 1. Madhuchanda Kar, Alokendu Ghosh. Pancytopenia. J Ind low, bone marrow aspiration is not needed. Acad of Clinical Medicine 2002; 3:29-34. 2. BN Gayatri, Kadam Satyanarayan Rao. Pancytopenia: SPECIFIC EVALUATION A Clinico Haematological Study. Journal of Laboratory Lymphoproliferative disorders: immunophenotyping, Physicians 2011; 3:15-20. cytogenetics, biopsy 3. Kumar R, Kalra SP, Kumar H, Anand AC, Madan H. J Assoc Multiple myeloma: serum electrophoresis, bone marrow Physician India 2001; 49:1078-81. aspiration 4. Arvind Jain, Manjari Naniwadekar. An etiological reappraisal of pancytopenia-largest series reported to date Paroxysmal nocturnal haemoblobinuria: flow cytometry from a tertiary care teaching hospital. BMChematology. (CD55, CD59) biomedcentral.com/articles/10.1186/2052-1839-13-10. Cytomegalovirus infection: serology for CMV (IgG, IgM) 5. Jitendra Mohan Khunger, S. Arulselvi, Uma Sharma et al. Pancytopenia- A Clinico Haematological study of 200 cases. Epstein-Barr virus: Serum monospot, viral capsid antigen, Indian journal of Pathology and Microbiology 2002; 45:375-79. EB nuclear antibody 6. Poorana Priya P, Subhashree AR. Role of absolute Leishmaniasis: Blood and bone marrow culture, LD reticulocyte count in evaluation of Pancytopenia: A bodies Hospital based study. Journal of Clinical and Diagnostic Research 2014;8: FC01-03. Carcinoma prostate: Serum PSA 7. Eduardo J, Santiago Rodriguez, Angel M mayer et al. Fanconi’s anaemia: diepoxybutane test for chromosomal Profile of HIV infected Hispanics with Pancytopenia. Int J breakage in peripheral blood lymphocyte Environ Res Public Health 2016; 13:38 8. Martinez Faci C, Ros Arnal I, Martines de Zabarte CONCLUSION (FIGURE 1) Fernandes JM et al. Azathioprine induced pancytopenia: Pancytopenia is not a disease itself. It is a haematological case series. Arch Argent Pediatr 2016; 114:e252-5. feature of varying aetiology with slight male 9. Jain M, Shukla A, Kumar A et al. Wuchereria bancrofti: preponderance. Megaloblastic anaemia along with mixed Unusaual presentation as Pancytopenia. Journal of Clinical nutritional anaemia is leading cause of pancytopenia in and Diagnostic Research 2016; 10:ED05-6. India followed by hypersplenism and aplastic anaemia 10. Ungprasert P, Chowdhary VR, Davis M, Makol A. being second and third common causes respectively. Autoimmunefibrosis with pancytopenia as a presenting Absolute reticulocyte count is an important indicator for manifestation of SLE responsive to mycophenolate mofetil. determining the cause of pancytopenia and should be Lupus 2016; 25:427-30 done along with peripheral smear in the very beginning. 11. Mohammad Arphan Azad, Yongping Le, Quirong Zhang,

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