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A 50-year-old woman was referred to a hematologist for recurring pancytopenia. At present, her WBC was 2.5 X 109/L; RBC, 3.0 X 1012/L; Hct, 30%; platelet count, 40 X 109/L; MCV, 68 fL; MCH, 26 pg; and MCHC, 36.5%. In addition to pancytopenia, she has been experiencing shortness of breath and fatigue for the past 3 weeks, and lately these symptoms had gotten worse. Her family history was unremarkable, but she explained that she has had excessive menstrual bleeding for the past 4 months. A CBC and differential were ordered, as well as a bone marrow examination. What is the likely cause for this patient's pancytopenia?

Insights to the Case Study

This patient has a microcytic, hypochromic anemia characterized by small cells lacking Hgb. The MCV and MCHC are both outside of the normal range and are decreased. Additional studies such as serum iron, total iron binding capacity, and serum ferritin need to be initiated to determine the cause of her anemia, but with a history of menorrhagia for approximately 3 weeks, iron deficiency anemia is the most likely diagnosis. Other diagnostic possibilities include hereditary hemochromatosis, thalassemia minor, or the anemia of inflammation, all of which present with hypochromic microcytic indices. Additionally, the patient's bone marrow showed 60% myeloid elements and 20% erythroid elements. A normal level of megakaryocytes was noted. The M:E ratio was designated as 3:1. No atypical cellular formations or abnormal changes to the bone marrow architecture were noted. No specific diagnostic cause for the pancytopenia was determined, and the patient will be followed with a CBC every 3 months.

Review Questions

1. What are the organs of hematopoiesis in fetal life?

a. Bone marrow b. Thymus and thyroid gland c. Spleen and liver d. Pancreas and kidneys

2. How does the bone marrow respond to anemic stress?

a. Production is expanded, and red cells are released to the circulation prematurely.

b. Production is expanded, and platelets are rushed into circulation.

c. Production is diminished, and the M:E ratio is increased.

d. Production is diminished, and the M:E ratio is unaffected.

3. Which chemical substances are responsible for differentiation and replication of the pluripotent stem cell?

a. Cytokines b. Insulin c. Thyroxin d. Oxygen

4. A hormone released from the kidney that is unique for the erythroid regeneration is a. estrogen.

b. erythropoietin.

c. progestin.

d. testosterone.

5. In the adult, the usual location for obtaining a bone marrow aspirate is the a. sternum.

b. iliac crest.

c. long bones.

d. lower lumbar spine.

6. What is the most stable parameter of the complete blood count?

a. White blood cell count b. Mean corpuscular volume c. Red cell distribution width d. Platelet count

7. Which one of the red cell indices reflects the amount of hemoglobin per individual red cell?

c. MCHC

8. Given the formulas below, which formula indicates the correlation check between hemoglobin and hematocrit?

9. Which of the following CBC parameters may provide an indication of anemia before the MCV indicates an overt size change?

d. MCHC

10. Which of the following tests is the most effective means of assessing red cell generation in response to anemia?

b. Reticulocyte count c. Platelet count d. CBC

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