Case Study

Mrs. C., a 79-year-old woman, presented to the emergency department barely able to walk. She said that she had gotten progressively weaker in the past couple of weeks and that she has noticed that her appetite was failing. She had seen some yellow color to her eyes and skin, and that worried her. She had no desire to eat but she did crave ice. Mrs. C. was thin, emaciated, and pale, and she had difficulty walking and seemed generally confused. A CBC and peripheral smear were ordered, with more tests pending the initial results. The initial results are WBC of 4.5 X 106/L, RBC 2.12 X 109/L, Hgb 7.5 g/dL, Hct 22%, MCV 103 fL, MCH 35.3 pg, MCHC 34.9, and platelet count 105 X 106/L. The peripheral smear showed a mixture of microcytes and macrocytes, with target cells, schistocytes, few oval microcytes, rare hyperseg-mented neutrophils, and occasional hypochromic macrocytes. Because of mixed blood picture, an iron profile was ordered as well as serum folate and serum B12. Which conditions show hypersegmented neutrophils?

Insights to the Case Study

This case study presents a confusing morphological picture because no one red cell morphology leads to any single clinical conclusion. The follow-up blood work showed serum iron of 25 pg/dL (reference range, 40 to 150), TIBC 500 pg/ dL (200 to 400), red cell folate 100 ng/mL (130 to 268), and serum B12 200 pg/dL (100 to 700). Clearly, there are multiple nutritional deficiencies at work here. Mrs. C. is in a vulnerable age range, prone to poor dietary habits and noncompliance to health or food suggestions. Yet as can be seen from her laboratory values, she is iron and folic acid deficient. Folic acid deficiency is one of the most common vitamin deficiencies in the United States and easy to develop because folic acid stores are moderate and the folic acid daily requirement is high. Add to this her iron deficiency, and you have a set of symptoms and a blood smear picture that represents a mixture of morphologies. She clearly showed a pancytopenia, but she did not show the blatantly elevated MCV Her elevated MCH could have been a clue to the megaloblastic process because in the megaloblastic anemias, the MCV and MCH are usually high. Her peripheral smear shows micro-cytes and macrocytes, with a few target cells and an occasional hypersegmented neutrophil. She was immediately started on oral iron and oral B12 supplementation, and her physical symptoms began to diminish. Once her mental capacity was cleared, she began nutritional counseling, and she began to receive visits from Meals on Wheels, to ensure that she had a balanced and varied diet.

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