Definition & approach of pancytopenia

2. What's pancytopenia?
Its combination of anemia , leukopenia and
thrombocytopenia
1.HB < 10 g/dL
2.Leukocyte count < 4000/ul
Absolute Neutrophil count <1500/uL
3.Platelet count < 150,000 uL

3. What's causes of
pancytopenia?
 Bone marrow failure : aplastic anemia
 Bone marrow infiltration :
Acute leukemia
Myeloma
Lymphoma
Carcinoma
MDS

4.  Ineffective haematopoiesis
Megaloblastic anaemia
AIDS
 Peripheral pooling / destruction
Hypersplenism: portal hypertension ,
felty's syndrome , malaria , Myelofibrosis
SLE

5. What's approach to
thrombocytopenia?
 History
 Examination
 CBC & blood film
 BM aspiration & biopsy
 Other specific investigation

6. History
 Duration of symptom
Long (MDS)
Short (aplastic anemia)
 History of transfusion
 History of hemoglobinurea
 Dietary history
 Exposure to drugs : anti cancer , Abs , anti
thyroid (aplastic anemia)
 Barbiturates , phenytoin ( B12, Folic acid)
 Chemotherapy , radiation ( MDS , AML)

7.  Weight loss , fever ( Inflammatory or
malignancy)
 Jaundice ( Hepatitis B or C)
 Joint pain (SLE)
 History of blood loss

8. General examination
 Eye examination: retinal hemorrhage
leukemic infiltrations
 oral examination : oral petechaie
stomatitis / chelitis
gum hyperplasia
oral candidiasis
 Respiratory examination : clubbing
tachypnea

9.  Abdominal examination : organomegaly
lymphadenopathy
 skin examination : malar rash
purpura
hypo or
hyperpigmentation
 Musculoskelatal system : short stature
synovitis
abnormal thumb

10. Pancytopenia + Absent thumb
+Child

11.  Pancytopenia + Back pain +
Hypercalcemia
(multiple myeloma)
 Pancytopenia + Malar rash or GN = SLE
 pancytopenia + HSM = Leukemia

12. Blood Film
1.RBC morphology ( size & shape)
2.WBC and RBC precursor
3.Platelets count & size
4.Abnormal increase or decrease
granulation in Neutrophil
5. Hypo / hypersegmented Neutrophil

13. Other evaluating test may be
included
 ESR
 Reticulocyte count
 Serum LFTs
 Hepatic serology
 Serum coagulation profile, bleeding
time, fibrinogen, and D-dimer
 Serum B12 and folate
 HIV test

14. Anisocytosis--different sized
RBCs
Poikilocytosis--differently
shaped RBCs
Platelets are small, and
reduced in numbers
Aplastic anemia

15. Macrocytosis
Howel jolly bodies
Basophilic stippling
Hypersegmented Neutrophil
Megaloblastic anemia

16. Tear drop cells
Hypogranular neutrophils
Pseudo pelger Heut Anomaly
Giant platelets
MDS

17.  The characteristic peripheral blood
morphologic feature in multiple
myeloma is:
A. Cytotoxic T cells
B. Rouleaux formation
C. Spherocytosis
D. Macrocytosis

19. True or false?
 In blood film normal platelets count
rules out aplastic anemia
 True

20. Bone Marrow Examination
Almost always indicated in case
pancytopenia unless cause is apparent.
Both aspiration and biopsy are indicated.
Specifically, bone marrow aspirate permits
examination of:
• Cytology (megaloblastic change,
dysplastic changes, abnormal cell
infiltrates)
• Immunophenotyping : antigen or marker
on cells surfaces e.g ( leukemias,
lymphoproliferative disorders)
• Cytogenetics : structure of chromosome
(myelodysplasia, leukemias,
lymphoproliferative disorders).

21. True or false?
 Bone marrow examination is required
in diagnosis of Megaloblastic anemia
 False

22. The differential diagnosis of pancytopenia
are based on cellularity of bone marrow :
Hypocellular: excessive amount of fat
cells
Normocellular: 50-70% hematopoietic
cells & 30-50% fat
Hypercellular: 80-100% cells with little

24. Hypercellular

25. Causes of Hypocellular BM
1.Aplastic anemia
2.Hypoblastic MDS
3.Cytotoxic agent & radiotherapy

26. Causes of Hypercellular BM with
primary marrow disorders
1.Acute leukemia / lymphoma
2. Hairy cell leukemia
3. Myelofibrosis
4.PNH
5.Mutiple myeloma
6. Mylodysblastic leukemia

27. Causes of Hypercellular BM with
systemic disorders
1.Metastatic solid tumor
2. hypersplenism
3.Megaloblastic anemia
4. Infection (T.B ,kala azar, brucellosis)
5. Overwhelming infections
6. Alcohol
7. Autoimmune disorders- SLE, Sjogren’s
8. Sarcoidosis
9. Storage disease- Gaucher, Niemann-
pick

28. Pancytopenia +markedly
Hypocellular scattered mature
lymphocytes
aplastic anemia

29. Pancytopenia + Hypercellular
BM
Infiltration by RS cells HL

30. Pancytopenia + Hypercellular
B.M + old age
MDS

31. Pancytopenia + Hypercellular
marrow
Infiltration with malignant cells (Metastasis)

32. Specific investigations
 Megaloblastic anemia: Vit.B12 , Folate
assay
 Multiple myeloma :
Imunoelectrophoresis
 PNH: Flow cytometry (CD55, CD59)
 Leishmaniasis: blood and bone
marrow culture, serum ELISA
 HIV ,EBV , hepatitis : virology screen
 Fanconi anemia : Chromosomal
breakage study