WIXLIB

Anemia-2:Overview and Select CasesMarc ZumbergAssociate ProfessorDivision of Hematology/Oncology

Initial Laboratory Complete blood count with indices– MCV-indication of RBC size– RDW-indication of RBC size variation Examination of the peripheral blood smear Reticulocyte count-measurement of newlyproduced young rbc’s Stool guiac

Additional Labs Vitamin levels--FE battery, Vit-b12, folateLDH, bilirubin, haptoglobinCoomb’s testHemoglobin electrophoresisSPEPCreatinineTSHurinalysisConsider bone marrow examination

Anemia:Morphology Classification Microcytic (MCV 80 cu microns)– FE def, thalasemia, chronic disease, sideroblasticanemia, lead poisoning Normocytic (MCV 80-100 cu microns)– acute blood loss, chronic disease, hypersplenism, bonemarrow failure, hemolysis Macrocytic– megaloblastic anemia, hemolysis with reticulocytosis,chemo, hypothyroidism, MDS

Anemia-Case 1 Fe deficiency–––––DiagnosisDifferentialIron studiesTreatmentLength of therapy

Case 2 B-12 deficiency–––––Differential diagnosisPathophysiologyDiagnostic entitiesAssociated conditionsTreatment Options

Case XA 53 year-old female complains of fatigue for 3 months.She falls and breaks her left femur.On reviewing her labs the creatinine is 1.3 mg/dl, calcium10.1 mg/dL. Comprehensive metabolic panel isotherwise normalHematocrit is 25%. White blood count and plateletcounts are mildly depressed at 3.9K/mm3 and 147K/mm3

Case X What is the most likely diagnosis? How do you want to proceed with yourevaluation?– What is the next step?– How would you make the definitive diagnosis?

Case X further evaluation Serum protein electrophoresis (SPEP)– M- spike of 4.2 gm/dl Immunofixation (IFE)– IgG lambda noted in serum. Free lambda light chainsin urine Quantitative immunoglobulins– Moderately suppressed levels of IgM (31 mg/dL) andIgA (32 mg/dL). IgG elevated at 3875 mg/dL Skeletal survey– Multiple lytic lesions throughout the skeleton Bone Marrow aspirate and biopsy– Sheets of malignant appearing plasma cells identified

Serum Protein Electrophoresis An M-protein is usually seen as a discrete band onagarose gel electrophoresis in the γ,β,α2 region ofthe densitometry tracing– Immunoglobulins primarily in γ component, but also inβ and α2 region A polyclonal response produces a broad band or abroad-based peak limited to the γ region

Serum Protein Electrophoresis

α1α2βγ* MYELOMA

AlbuminM-spike ing/dL ofproteinα-2α-1βDensity Scan

When to order a SPEP When you suspect multiple myeloma, Waldenstrom’smacroglobulinemia or amyloidosis With unexplained– Weakness, fatigue, anemia, back pain, fractures, hypercalcemia,renal insufficiency– Recurrent infections– Sensorimotor neuropathy, carpel tunnel syndrome, CHF, syncope

Immunofixation (IFE) Proteins are fractioned on electrophoreticstrips– Each lane overlaid with monospecific antiseraagainst IgG, IgA, IgM, and light chains– Immunoglobulins are precipitated by antisera Wash away nonprecipitated proteins– Precipitated proteins are stained

SPEgammaalphaNORMALmukappalambda

When to order IFE To type the paraprotein (M spike) identified on SPEP Further evaluate an equivocal SPEP To search for a low level paraprotein with a negative SPEP– clinical suspicion of a lymphoplasmacytic disorder is high– unexplained symptoms such as neuropathy, renal failure, etc. When searching for Bence-Jones proteinuria In treated myeloma patients with a negative SPEP

Quantitative Immunoglobulins Useful to quantitate– the amount of monoclonal protein– suppression of uninvolved immunoglobulins in amonoclonal disorder– identify a congenital or acquired deficiency state of anindividual immunoglobulin Serum light chain assays are newer and verysensitive technique for measuring serum lightchains– Adjunct or replacement of urine protein electrophoresis

Quantitative Immunoglobulins Albuminα-1 α-2β“M-spike”,“Paraprotein”or “Mcomponent”Note loss of normal “polyclonal”immunoglobulins

Our Patient

Stage III multiple myelomaThe patient is started on systemic chemotherapy and anautologous bone marrow transplant is planned Multiple new and effective agents exist for MM––––Thalidomide or Revlimid and other anti-angiogenic agentsProteosome inhibitors (Velcade)Double autologous transplantMini allogeneic transplant Remains non-curative except possibly for allogeneictransplant

Case 3A woman in her mid thirties has suffered fromepisodes of pleurisy and has been told she may haveSLE.Her prior blood cell counts have been normal. Shenow complains of exertional dyspnea, fatigue andyellowing of her eyes. Physical exam is normalexcept for mild scleral icterus, and moderatesplenomegaly.

Case 3Initial labs reveal:hgb 7.9 gm/dlhct 23.9%wbc 4000 /mm3 with a normal differentialplatelet 138,000 /mm3What other initial labs / values would you liketo see?

Case 3MCV 114 cubic micronsRetic count 14.2% uncorrectedLDH 2343 U/LBilirubin 4.3 mg/dl, .8 direct mg/dlThe peripheral blood smear revealsmacrovalocytes, polychromasia and anoccasional nucleated red blood cell.

Case 3You suspect an autoimmune hemolyticanemia based on her history, PE, labs andsmear.What further tests would you like to order?

Case 3

Case 3Direct Coombs test results are as follows:DAT: Positive 3 IgG: Positive 3 Complement: NegativeWhat type of autoantibody is this?What conditions are typically associated with thistype of antibody?

Case 3You diagnose a warm-antibody hemolytic anemiaand suspect an underlying autoimmune neimmunodeficiencylymphoproliferative drugimmune deficiency

Case 3You decide to avoid blood transfusionbecause of:1.) the difficulties in obtaining cross matchcompatible bloodAND2.) the expected short half life of transfused bloodWhat treatment do you recommend?

Case 3TREATMENT Prednisone Splenectomy Immunosuppressive agents– cytoxan, immuran, cyclosporin Danazol Plasma exchange / immunoadsorption

Case 3You begin her on 60mg Prednisone and shehas a good response. However upon severalattempts at tapering the prednisone she has arelapse with worsening of the hemolyticanemia.As you are concerned about the long term sideeffects of Prednisone you send her for aProcedure.

Case 3She responds well to splenectomy, but stillrequires very low maintenance doses ofPrednisone.Over the years she occasionally requireshigher doses of prednisone when she is ill orhas a lupus flare

Case 4Mrs. P is a previously healthy 32 year-old femalewith no prior medical history. She reports feeling“unwell” for the past month. However in the pastthree days she has experienced fevers, a ‘rash” onher legs, weakness and shortness of breath. She hasbeen to weak to get out of bed the last 24 hours andhas experienced spontaneous nose bleeds.How is this case different from the previous?

Case 4Physical exam reveals an ill appearing female:T 38.6, pulse 122, bp123/54dried blood in the nares, pale conjunctiva,dried mucous membranetachycardia and tachypneapettechia over the lower extremities

Case 4Routine labs include:WBC 1700/mm3Hgb 5.6 gm/dlHct 18.2%Plt 12,000/mm3What important piece of laboratoryinformation is missing from the WBC?

Case 4Differential of the white blood cell countreveals at least 50% of young white cells, thelab thinks are blastsreticulocyte count corrected is 0.4%electrolytes are consistent with dehydrationpotassium and creatinine are slightly elevated

Case 4What would you do next?

Case 4

Case 4

Case 4Hematopathology evaluation revealed AMLsubtype M1 ?Chromosomal studies did not reveal anyabnormalitiesWhat should you do prior to beginningchemotherapy in this patient?

Case 4The patient tolerated induction chemotherapywell and remains in remission 4 months aftercompleting induction and consolidationchemotherapy. Her blood counts have all nownormalized.If she was to relapse what therapy would yourecommend?

Case 5You are referred a pleasant 34 year-oldAfrican American female who has beenknown to have a mild microcytic anemia,which was picked up some years ago on routineblood work. She is entirely asymptomatic. She hasbeen prescribed iron several times over theyears without a response.What data would you like to review?

Case 5Summary labs:––––Hcthgbpltwbc31-34%10.6-11.4 gm/dl232-312K/mm36500-8000/mm3 with a normaldifferential– MCV 72-74 cubic microns– RDW NormalWhat is in your differential diagnosis?

Case 5 FE deficiency anemia– noncompliance, inadequate dosing, incorrectformulation Beta-thalassemiaAlpha-thalassemiaAnemia of chronic inflammation/ diseaseSideroblastic anemiaLeadWhat further laboratory tests would you liketo order?

Case 5 Fe studies are normal Chemistries, liver function tests, thyroidstudies are normal No history of lead exposure You ask to see a peripheral blood smear andone other study. What is it?

Case 5

Figure 3. The patient has the Asian variant of alpha thalassemia trait with a deletion in cis ofboth alpha globin genes on one chromosome 16Schrier, S. ASH Image Bank 2002;2002:100327Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Case 5You also request a HemoglobinelectrophoresisHgb A 97.5%Hgb A2 2.1%Hgb F .6%This is normal.What is your diagnosis of exclusion?

Case 5Alpha thalassemia with a double genedeletion.––––No treatment is necessaryAnemia is not progressiveNo other systemic problemsOften mistaken for Fe deficiency and treatedwith Fe or with anemia of chronic disease

Case 6You are asked to see Mrs. J a 43 year oldpreviously healthy female who presented tothe emergency complaining of fevers,weakness, and bleeding from her gums. Heronly significant past history is a recentlyresolved viral syndrome. Her family notesshe has been somewhat confused over the last24 hours.

Case 6The ER attending notes:–––––the patient to be ill appearingtemp 38.3, hr 123, bp 126/76, rr 26dried blood noted in the nares and mouthpettechia on lower extremitiespt. slightly confused, but no focal neurologicfindingsBefore you arrive in the ER she has a seizure

Case 6Labs reveal:Wbc: 5600K/ mm3 with nl diffHct: 16.3%Creatinine 2.4 mg/dLHgb: 5.3gm/dlLDH 3000 U/L (5x nl)Plt: 21,000K/ mm3 Billi 3.2 mg/dl (.2-1.3),mostly indirectPT: 11secReticulocyte count 6.2%PTT: 29 sechaptoglobin 10 mg/dLurine: 2 hemoglobin, negrbc

Case 6

Case 6What is your differential diagnosis based onthe history, physical, labs and blood smearWhat else could give you a similar bloodsmear?

Case 6You diagnosis TTP based on the classicpentad and consistent blood smear:–––––microangiopathic hemolytic anemiathrombocytopeniafeverrenal failureMS changesWhat is the first line treatment of TTP?

Case 6You begin daily plasma exchange proceduresusing FFP as your replacement fluid. Hermental status improves by the next day. Herplatelet count normalizes and LDH decreasesover the next week. Her anemia slowlyimproves as does her renal failure. She isweaned off plasma exchange and has a singlerelapse, which responds to similartherapy.

Pathophysiology Typically an inhibitor against ADAMTS13, a vWF cleaving to protease leading toaccumulation of HMW vWF multimersleading to small vessel thrombosis andmicroangiopathic hemolytic anemia– Plasmapheresis Removes the offending antibody Supplies the deficient vWF cleaving protease

Pathophysiology

Case 7A 36 year-old white male with a history ofprogressive renal failure over the last 4 yearscomes to you for work-up of weakness andprogressive anemia. He has recently begundialysis. His renal failure initially appearedafter an acute febrile illness and the etiologywas never determined.

Case 7Physical exam is only significant for palesclera and an AV shunt in his left armCBC revealed:Wbc 6400/ mm3 MCV 78 / mm3Hgb 7.6gm/dlPlt 242K/ mm3Hct 23.8%What further test would you like to order?

Case 7Prior labs reveal a hematocrit that was normal4 years ago, but has steadily declined as hisrenal function worsened.Reticulocyte count corrected 0.7%FE 26 mcg/dlFe sat 11%TIBC 224 mcg/dlFerritin 145ng/mlWhat is in your original and expandeddifferential?

Case 7