A 64-year-old woman presents with lethargy, shortness of breath on exertion and jaundice.
Hb |
64 g/L |
(115-155) |
|
MCV |
102.4 fl |
(80.0-98.0) |
|
Platelets |
114 X 109/L |
(150-400) |
|
White Cell Count |
101 X 109/L |
(4.0-11.0) |
|
Neutrophils |
0.22% |
2.3 X 109/L |
(1.8-7.5) |
Lymphocytes |
97% |
98.7 X109/L |
(1.0-3.5) |
Monocytes |
0.0% |
0.0X109/L |
(0.20-0.80) |
Eosinophils |
0.0% |
0.0X109/L |
(0.02-0.50) |
Basophils |
0.0% |
0.0X109/L |
(0.0-0.10) |
Nucleated RBCs |
3.6 per 100 WBC |
||
Reticulocyte count |
280 X 109/L |
(20-150) |
Polychromasia. Poikilocytosis. Spherocytes. Smudge cells.
i. What is your interpretation of the leucocytosis?
ii. What is your interpretation of the anaemia?
iii. What additional test would you perform to help determine the underlying cause of the anaemia?
i. CLL given lymphocytosis and smudge cells.
ii. Jaundice, presence of spherocytes, and reticulocytosis suggest haemolysis.
Autoimmune haemolytic anaemia associated with warm antibody.
iii. Additional test: Direct Coomb’s test
The real question should read "try to recall the meaning of smudge cells as a blood film abnormality".
That is fairly straightforward. Smudge cells are deformed lymphocytes which are associated with chronic lymphocytic leukaemia. Look, here's a whole bunch of them at the ASH Image Bank.
However, the warm antibody thing is very different. If one were to forget that jaundice formed part of the initial flavour text, one might be tempted to instead jump on the macrocytosis, and ask for B12 and folate studies, or maybe even a bone marrow biopsy.
What do they mean by "warm"? Well, in this instance its a case of an autoimmune haemolytic anaemia with antibodies maximally active at human body temperature. How this spectrum of activity was derived from the clinical history? Probably because cold exposure was never mentioned.According to this article on the topic, the hemolytic anaemia usually associated with leukaemia is indeed a "warm" variety, whereas Waldenstroms and lymphoma tend to cause a "cold" autoimmune haemolytic anaemia.
A good overview of this topic can be found in the American Journal of Haematology.
Their breakdown of the classifications of haemolytic anaemia looks a little like this:
Warm haemolytic anaemia | Cold haemolytic anaemia |
|
|
Additional tests:
Laboratory features common to all haemolytic anaemias
Laboratory features specific to autoimmune causes of haemolytic anaemia
Zeerleder, S. "Autoimmune haemolytic anaemia-a practical guide to cope with a diagnostic and therapeutic challenge." Neth J Med 69.4 (2011): 177-84.
Gehrs, Bradley C., and Richard C. Friedberg. "Autoimmune hemolytic anemia."American journal of hematology 69.4 (2002): 258-271.