Breathless 2

Blood & Lymphoreticular System

Step 1: View Clinicals

A 12 year old girl presents with worsening exertional dyspnea, fatigue, and multiple episodes of fever over the last 3 weeks. She also noticed several bruises over her legs during the last week which could not be attributed to trauma.

She had an episode of glandular fever 2 months ago, with an uneventful recovery. Her medical history is otherwise unremarkable, and there is no family history of hematologic disorders.

She is not on any medications, and consumes a normal diet.

Step 2: Order Relevant Investigations

1. Full Blood Count


WBC: 2,300/mm3 (4,000 - 11,000)

Neutrophils: 15% (50-70)

Lymphocytes: 80% (20-40)

RBC: 2.6 x 10^12/L (4.0-5.4 × 10^12)

Hb: 6.8 g/dL (11.5-13.5)

Plt: 17,000/mm3 (150,000 - 400,000)

Reticulocytes: 0.6% (0.2-2)

2. Blood Picture


There is pancytopenia with macrocytosis, anisopoikilocytosis and small platelets. There are no dysplastic neutrophils, blast cells, or other abnormal cells.

3. Bone Marrow Aspiration, Biopsy and Cytogenetics


The aspirate was insufficient for evaluation.

The bone marrow biopsy was markedly hypocellular (only 20% cellularity) with a profound reduction in haematopoietic cells, with the marrow being largely replaced by fat cells. No malignant infiltration or fibrosis was seen.

Cytogenetic examination revealed a normal karyotype. Flow cytometry with anti-CD55 and anti-CD59 antibodies excludes paroxysmal nocturnal hemoglobinuria clones. PCR failed to detect the Ebstein-Barr virus (EBV) genome in BM nucleated cells.

4. HLA Typing


Identifies a sister with all 8 of 8 HLA matching.

Step 3: Select Appropriate Management

1. Transfuse Irradiated Blood Products


2. Bone Marrow Transplantation


3. Recombinant Erythropoietin


4. Prophylactic Antibiotics