Question

INTERNAL MEDICINE

1. A 72 year-old-female was admitted to the hospital with a complaint of fatigue persisting during the last one year. Her blood tests go as follows: (8 points)

WBC: 5200/µL

Neu: 4000/µL

Hb: 10.0 g/Dl

Hct: 30%

MCV: 105 fL

PLT: 254,000/µL,

lactate dehydrogenase within normal ranges.

There is no reticulocytosis.

a) How would you classify her anemia?

b) What are your possible diagnoses? Why?

c) Which tests would you order to confirm your possible diagnoses?

d) What are the treatment options for your possible diagnoses?

2. On peripheral blood smear: (7 points)

a) Schistocytes can be seen in which diseases? (Please write at least three causes.)

b) Tear-drop shaped cells (Please write at least one causes)

c) Spherocytes (Please write at least two causes)

d) Macro-ovalocytes (Please write at least one cause)

3. What are the causes of activated partial thromboplastin time? (At least 5 causes) (10 points)

Answer 1

1(a)Anemia can also be classified based on the size of the red blood cells and amount of hemoglobin in each cell. If the cells are small, it is called microcytic anemia; if they are large, it is called macrocytic anemia; and if they are normal sized, it is called normocytic anemia.

(b) aplastic anemia

(c)

· Blood tests. Normally, red blood cell, white blood cell and platelet levels stay within certain ranges. In aplastic anemia all three of these blood cell levels are low.

· Bone marrow biopsy. A doctor uses a needle to remove a small sample of bone marrow from a large bone in your body, such as your hipbone. The sample is examined under a microscope to rule out other blood-related diseases. In aplastic anemia, bone marrow contains fewer blood cells than normal. Confirming a diagnosis of aplastic anemia requires a bone marrow biopsy.

(d)

Treatments for aplastic anemia, which will depend on the severity of your condition and your age, might include observation, blood transfusions, medications, or bone marrow transplantation. Severe aplastic anemia, in which your blood cell counts are extremely low, is life-threatening and requires immediate hospitalization.

Blood transfusions

Although not a cure for aplastic anemia, blood transfusions can control bleeding and relieve symptoms by providing blood cells your bone marrow isn't producing. You might receive:

· Red blood cells. These raise red blood cell counts and help relieve anemia and fatigue.

· Platelets. These help prevent excessive bleeding.

While there's generally no limit to the number of blood transfusions you can have, complications can sometimes arise with multiple transfusions. Transfused red blood cells contain iron that can accumulate in your body and can damage vital organs if an iron overload isn't treated. Medications can help rid your body of excess iron.

Over time your body can develop antibodies to transfused blood cells, making them less effective at relieving symptoms. The use of immunosuppressant medication makes this complication less likely.

Stem cell transplant

A stem cell transplant to rebuild the bone marrow with stem cells from a donor might be the only successful treatment option for people with severe aplastic anemia. A stem cell transplant, also called a bone marrow transplant, is generally the treatment of choice for people who are younger and have a matching donor — most often a sibling.

If a donor is found, your diseased bone marrow is first depleted with radiation or chemotherapy. Healthy stem cells from the donor are filtered from the blood. The healthy stem cells are injected intravenously into your bloodstream, where they migrate to the bone marrow cavities and begin creating new blood cells.

The procedure requires a lengthy hospital stay. After the transplant, you'll receive drugs to help prevent rejection of the donated stem cells.

A stem cell transplant carries risks. Your body may reject the transplant, leading to life-threatening complications. In addition, not everyone is a candidate for transplantation or can find a suitable donor.

Immunosuppressants

For people who can't undergo a bone marrow transplant or for those whose aplastic anemia is due to an autoimmune disorder, treatment can involve drugs that alter or suppress the immune system (immunosuppressants).

Drugs such as cyclosporine (Gengraf, Neoral, Sandimmune) and anti-thymocyte globulin suppress the activity of immune cells that are damaging your bone marrow. This helps your bone marrow recover and generate new blood cells. Cyclosporine and anti-thymocyte globulin are often used together.

Corticosteroids, such as methylprednisolone (Medrol, Solu-Medrol), are often used with these drugs.

Although effective, these drugs further weaken your immune system. It's also possible for anemia to return after you stop these drugs.

Bone marrow stimulants

Certain drugs — including colony-stimulating factors, such as sargramostim (Leukine), filgrastim (Neupogen) and pegfilgrastim (Neulasta), epoetin alfa (Epogen/Procrit), and eltrombopag (Promacta) — help stimulate the bone marrow to produce new blood cells. Growth factors are often used with immune-suppressing drugs.

Antibiotics, antivirals

Having aplastic anemia weakens your immune system, which leaves you more prone to infections.

If you have aplastic anemia, see your doctor at the first sign of infection, such as a fever. You don't want the infection to get worse, because it could prove life-threatening. If you have severe aplastic anemia, your doctor might prescribe antibiotics or antiviral medications to help prevent infections.

Other treatments

Aplastic anemia caused by radiation and chemotherapy treatments for cancer usually improves after those treatments stop. The same is true for most other drugs that induce aplastic anemia.

Pregnant women with aplastic anemia are treated with blood transfusions. For many women, pregnancy-related aplastic anemia improves once the pregnancy ends. If that doesn't happen, treatment is still necessary.

2.(a) hemolytic anemia.

other causes are

red blood cell membrane defects, thalassemia, megaloblastic anemia, primary myelofibrosis, and thermal injury.

(b) bone marrow fibrosis

(c) causes of spherocytosis include thermal injury, clostridial septicemia with exotoxemia, and Wilson disease

(d) megaloblastic, macrocytic anemia are deficiency or defective utilization of vitamin B12 or folate

3.

A prolonged PTT result may be due to:

• reproductive conditions, such as recent pregnancy, current pregnancy, or recent miscarriage
• hemophilia A or B
• deficiency of blood clotting factors
• von Willebrand disease (a disorder that causes abnormal blood clotting)
• disseminated intravascular coagulation (a disease in which the proteins responsible for blood clotting are abnormally active)
• hypofibrinogenemia (deficiency of the blood clotting factor fibrinogen)
• certain medications, such as the blood thinners heparin and warfarin
• nutritional issues, such as vitamin K deficiency and malabsorption
• antibodies, including cardiolipin antibodies
• lupus anticoagulants
• leukemia
• liver disease