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A Focused Approach to Anemia

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Case Presentation

A 70-year-old woman presented with progressive weakness and fatigue. The symptoms had begun about a month earlier, and she no longer

felt well enough to do her housework or take her daily walk. Although her breathing was normal at rest, she was too short of breath to walk more than two or three blocks.

The results of the complete blood cell count (CBC) performed in her physician's office were hemoglobin, 5.4 gm/dL; mean corpuscular volume (MCV), 103 Ám3; red cell distribution width (RDW), 19.8% (normal, 12%-15%), white blood cell count, 3,900/mm3 (48%
neutrophils, 43% lymphocytes, 8% monocytes, 1% eosinophils); and platelets, 62,000/mm3. Based on these results, the patient was hospitalized.

She had no history of recent bleeding, jaundice, fever, anemia, or heart disease. She had not been exposed to medications (other than occasional vitamins and aspirin) or toxins. She had not abused alcohol and had no previous hospitalizations. Findings on the physical examination were unremarkable except for mild tachycardia at rest (96 bpm), a blood pressure of 146/84 mm Hg recumbent and 142/78 mm Hg standing, pallor, external hemorrhoids, and trace pitting edema of the feet. Neither the liver nor spleen were palpable. The stool was negative for occult blood.

A chest x-ray was normal, and an electrocardiogram showed only sinus tachycardia. The blood urea nitrogen (BUN) level was 15 mg/dL; glucose, 108 mg/dL; and total bilirubin, 1.2 mg/dL (normal, <1.2). Electrolyte levels were normal. A sickle cell preparation was negative.

Orders were written to monitor vital signs, transfuse three units of packed red blood cells during the night, and arrange for a bone marrow aspiration and biopsy in the morning.


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bedo38, Egypt

There is pancytopenia and the indices of RBC are macrocytic so in this setting the first Q is megaloplastic or non megaloplastic? and the answer is easy by see hypersegmented neutrophil in peripheral blood film or bone marrow second Q is if megaloplastic what is the cause folate or B12 deficiency and what is the cause of that? if non megaloplastic we have to rule out autoimmune hemolytic anemia, mylodysplastic syndromes, hypothyroidism.

htun-aye, Myanmar

She has gradual onset of anemic symptoms Her CBC shows macrocytic [MCV.95fl],increased RDW .Platelets counts m/b reduced(<100,000/mm3).No h/o recent bleeding exclude IDA.Jaundice exclude haemolytic .Medication with methotrexate, exclude folic acid B12 deficiency.Alcoholism exclude folic acid def.Hospitalization exclude b12 def in gastric operation.Normal BUN exclude anemia of chronic disease. Dx is probably megaloblastic anemia due to combined f/a and B12 deficiency with underlying hypovitaminosis,antimetabolytes, copper deficiency with zinc excess.Bone marrow will show megaloblasts and hypersegmented neutrophils.

tahayasmin, Saudi Arabia

Diagnosis is must before blood transfusion in this case

tahayasmin, Saudi Arabia

megaloblastic anemia

elsaidelbadrawy, Egypt

mostly pernious anaemia

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