Case Study

A 78-year-old man was referred to a hematology consult after complications from a total knee operation. After this surgery, the patient experienced bleeding from the operative site that was unexpected. His routine coagulation tests were normal at the time of preoperative review. No organomegaly was noted, and no petechiae were observed. Within 4 weeks, he was readmitted for wound oozing. His CBC and differential on the day of consult are as follows:

WBC 2.3 X 109/L Segmented neutrophils 3% RBC 3.14 X 1012/L Bands 4%

Hgb 10.8 g/dL Metamyelocytes 2%

Hct 31% Myelocytes 3%

MCV 81 fL Lymphocytes 60%

MCH 26 pg Monocytes 7%

MCHC 32 g/dL Eosinophils 3%

Platelets 15.0 X 109/L Blasts 18%

Based upon the patient's age, clinical presentation, CBC, and differential results, what are some of the diagnostic possibilities?

Insights to the Case Study

The CBC on this patient indicates a low platelet count combined with normocytic, normochromic anemia and differential indicating a left shift. The differential showed a fairly large number of blasts but not enough blasts to be called an overt acute leukemia (for acute leukemia, 20% or more blasts). A bone marrow was requested on this patient, but the hematologist was cautious given the low platelet count and decided to delay this procedure until the platelet count normalized. The patient was given platelets to boost his platelet count and was started on prophylactic antibiotics because his white count was depressed. A preliminary diagnosis of refractory anemia with excess blasts was made pending the bone marrow and cytogenetic studies.

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