Approaching Pancytopenia

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1 Approaching Pancytopenia Lisa Sproat MD, MSW American College of Osteopathic Internists Annual Convention MFMER slide-1

2 Objectives Understand work up of Pancytopenia Present differential diagnosis of Pancytopenia Recognize Not Miss causes of Pancytopenia 2012 MFMER slide-2

3 2012 MFMER slide-3

4 Most common indication for bone marrow biopsy 2012 MFMER slide-4

5 H&P Fever URI symptoms LAD Hepato or splenomegaly B symptoms Travel history Prescribed, non-prescribed and herbal medications ETOH Environmental and chemical exposure history Sexual history 2012 MFMER slide-5

6 Most Common Cause Chemotherapy 2012 MFMER slide-6

7 Congenital Bone Marrow Failure Syndromes Fanconi Anemia (Mitomycin C or Diepoxybutane test) Dyskeratosis Congenita (genetic testing) Shwachman-Diamond Syndrome (genetic testing, sweat chloride test normal) Congenital Amegakaryocytic Thrombocytopenia (genetic testing, elevated thrombopoietin level) Hemophagocytic Lymphohistiocytosis (hemophagocytosis, hypertriglyceridemia, hypofibrinogenemia, low/absent NK cell activity, elevated serum ferritin, soluble CD25>2,400 U/ml 2012 MFMER slide-7

8 Paroxysmal Nocturnal Hemoglobinuria Hemolysis Pancytopenia Venous Thrombosis Flow Cytometry for PNH: CD CD55 and MFMER slide-8

9 Peripheral Destruction of Hematopoietic Cells Hemophagocytosis Prosthetic valves Splenomegaly Drugs Infection 2012 MFMER slide-9

10 Sequestration Splenomegaly 2012 MFMER slide-10

11 Acquired Bone Marrow Failure Syndromes Most often what is seen in adult population 2012 MFMER slide-11

12 Chemotherapy 2012 MFMER slide-12

13 Radiation 2012 MFMER slide-13

14 Autoimmune Disorders Aplastic Anemia Idiopathic (if not caused by drugs, chemicals,radiation,virus, anorexia, pregnancy) Distinguish from hypoplastic MDS (cytogenetics and FISH) 2012 MFMER slide-14

15 The Differential Diagnosis and Bone Marrow Evaluation of New-Onset Pancytopenia Elizabeth P. Weinzierl, MD, PhD and Daniel A. Arber, MD American Journal of Clinical Pathology, 2013; 139, MFMER slide-15

16 Autoimmune Disorders Systemic Lupus Erythematosus Any other autoimmune disorder (or the treatment for it) 2012 MFMER slide-16

17 Marrow Space Occupying Lesions Heme malignancy MDS/MPD Leukemia Lymphoma Multiple Myeloma Metastatic malignancy Granulomatous disease 2012 MFMER slide-17

18 Infection Viral Fungal Bacterial 2012 MFMER slide-18

19 The Differential Diagnosis and Bone Marrow Evaluation of New-Onset Pancytopenia Elizabeth P. Weinzierl, MD, PhD and Daniel A. Arber, MD American Journal of Clinical Pathology, 2013; 139, MFMER slide-19

20 Hemophagocytosis Must have 5 of the following Fever Splenomegaly Cytopenia involving 2 or more cell lines Hypertriglyceridemia or hypofibrinogenemia Hepatitis Low or absent NK cell activity Histiocyte activation 2012 MFMER slide-20

21 Ineffective Marrow Production Drugs ETOH Infiltration Deficiencies 2012 MFMER slide-21

22 Malignancy Any Lung and Breast most common non heme malignancy 2012 MFMER slide-22

23 Drugs Most common cause for aplastic anemia 2012 MFMER slide-23

24 The Differential Diagnosis and Bone Marrow Evaluation of New-Onset Pancytopenia Elizabeth P. Weinzierl, MD, PhD and Daniel A. Arber, MD American Journal of Clinical Pathology, 2013; 139, Shimamura A, Guinan E. Acquired and inherited aplastic anemia syndromes. In: Greer J, Foerster J, Lukens Jet al. Wintrobe s Clinical Hematology. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; MFMER slide-24

25 Nutritional Deficiencies Copper Folate B12 Anorexia Nervosa 2012 MFMER slide-25

26 The Differential Diagnosis and Bone Marrow Evaluation of New-Onset Pancytopenia Elizabeth P. Weinzierl, MD, PhD and Daniel A. Arber, MD American Journal of Clinical Pathology, 2013; 139, MFMER slide-26

27 The Differential Diagnosis and Bone Marrow Evaluation of New-Onset Pancytopenia Elizabeth P. Weinzierl, MD, PhD and Daniel A. Arber, MD American Journal of Clinical Pathology, 2013; 139, MFMER slide-27

28 Work up H&P Fever URI symptoms LAD Hepato or splenomegaly B symptoms Travel history Prescribed, non-prescribed and herbal medications ETOH Environmental and chemical exposure history Sexual history CBC Diff MCV Review of peripheral smear blasts Bone Marrow Biopsy Aspirate and Core Flow Cytometry Cytogenetics FISH PCR *Talk to your pathologist 2012 MFMER slide-28

29 Not Miss MDS Distinguish from AA Leukemia Early treatment has better outcomes for the non elderly population HIV I have been fooled! ETOH I have been fooled! 2012 MFMER slide-29

30 Take Home Points H and P will lead you Listen to your patients but check for HIV and watch for ETOH withdrawal Don t miss Leukemia (AML or ALL) Bone Marrow Biopsy Talk to the pathologist 2012 MFMER slide-30

31 Thank You!!!! Lisa Sproat MD, MSW 2012 MFMER slide-31

Introduction. About 10,500 new cases of acute myelogenous leukemia are diagnosed each

Introduction. About 10,500 new cases of acute myelogenous leukemia are diagnosed each Introduction 1.1 Introduction: About 10,500 new cases of acute myelogenous leukemia are diagnosed each year in the United States (Hope et al., 2003). Acute myelogenous leukemia has several names, including