RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE-41
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
NAME OF THE CANDIDATE / NITIN PATILADDRESS / M.sc MLT
DEPT. OF CLINICAL PATHOLOGY.
ST. JOHN’S MEDICAL COLLEGE,
BANGALORE-34.
NAME OF INSTITUTION / ST. JOHN’S MEDICAL COLLEGE, BANGALORE-560034
COURSE OF STUDY / M.sc MLT
SUBJECT / HAEMATOLOGY AND TRANSFUSION MEDICINE
TITLE / LABORATORY EVALUATION OF PANCYTOPENIA
NEED FOR STUDY
The term pancytopenia is used to describe the peripheral blood picture when all three formed elements of the blood are reduced, i.e. the combination of anaemia, leucopenia and thrombocytopenia.
A low level of red blood cells (RBCs) is called anemia; a decreased number of white blood cell (WBCs) is called leucopenia; and an inadequate number of platelets is called thrombocytopenia.
Pancytopenia is a reduction in all the three cellular elements of blood, exists in adult when the hemoglobin level is less than 10 g/dl , total leukocyte count is less than 4x109/Land platelet count is less than 150x109/L
Pancytopenia can be due to decrease in haemopoietic cell producing, ineffective haemopoiesis or peripheral destruction of the cells.The haemopoietic cell production can be influenced in bone marrow by infections,toxins,malignant cell infiltration leading to hypo cellular marrow.
Ineffective hematopoiesis and dysplasia, maturation arrest of all the cells lines and peripheral sequestration of blood cells or peripheral destruction of all blood cells lineage can also be the cause of pancytopenia.Pancytopenia is a common hematological problem with an extensive differential diagnosis, and the optimal diagnostic approach to pancytopenia remains undefined. These disorder may affect bone marrow either primarily or secondarily, resulting in the manifestation of pancytopenia.
In this study the focus is on the laboratory evaluation of pancytopenia in patients reffered in central laboratory of St. John’s Medical College Hospital.
REVIEW OF LITERATURE
The causes of pancytopenia are diverse,and likely causes of pancytopenia differ in children and adults. Particular attention must be paid to patient and family history of significance if any history of previous pancytopenia, Aplastic anemia, inheritedbone marrow failure syndromes (IBMFS), early fetal loss, historyof cancer, metabolic disorder, liver disease or connective tissue disorders. The most common cause of transient pancytopenia in all age groups is cytotoxic chemotherapy and radiotherapy. The symptoms cell lineages affected (RBCs, WBCs and Platelets) mild pancytopenia is often symptomless and detected incidentally when an FBC is performed for another reason. Spontaneous mucosal bleeding (Gums, GI tract) petechiae, and purpura with easy bruising secondary to thrombocytopenia are usually the first symptoms to develop directly related to more severe pancytopenia. This is often followed by symptomatic anemia (fatigue, shortness of breath, dependent edema chest pain in patients with ischemic disease) and bacterial infection secondary to neutropenia. (fever,mucositis, abscesses, rigors)1
CAUSES OF PACYTOPENIA
Viral Hepatitis.
Virus-associated hemophagocytic syndrome.
HIV infection.
Aplastic anemia.
Megaloblastic anemia.
Acute Lymphoblastic leukemia.
Hypersplenism.
Hemophagocyticlymphohistiocytisis..
Vitamin B12 deficiency.
VIRAL HEPATITIS
A Much more severe pancytopenia in the setting of Aplastic anemia occurs as an aftermonth of bouts of viral hepatitis. The presumptive agents is non-A, non-B hepatitis , because serologic testing for other known hepatitis viruses has been negative the marrow disorder is not concomitant with the hepatitis but supervenes weeks to month after the hepatic insult.Usually no relation in severity is found between the proading hepatitis and the subsequent aplasia of the marrow. Because this form of hepatitis-related aplasia carries a poor prognosis with a rapid and high mortality, these patients are candidate for early marrow transplantation when such an option is available. Aplastic anemia accompanies hepatitis in an additional setting. A disproportionate number of liver transplantation patents have developed aplastic anemia after transplantation for non-A ,non-B hepatitis. The mechanisms for the association is not understood, although the hepatitis virus has been demonstrated to be pan tropic and probably involves the marrow element. Several animal and human viruses, such as EBW induce marrow aplasia by direct infection of the marrow.2
VIRUS- ASSOCIATED HEMOPHAGOCYTIC SYNDROME
Pancytopenia in the context of infection may also occur in association with the virus associated hemophagocytic syndrome (VAHS) ( or virus- related hemophaocyticlymphohistocytosis) a “ benign” proliferation of histocyte that is difficult to distinguish from familial erythrophagocyticlymphohistiocytosis or maligned histiocytosis. The disease is characterized by high fevers , failure to thrive or weight loss pancytopenia , hepatosplenomegaly with variable lymphadenopathy , hepatic dysfunction , a disseminated intravascular coagulation (DIC) like bleeding diathesis, marked hyperferritiemia (more than 1000ug/l) and sometimes pulmonary infiltrates and a maculopapular skin rash. The bone marrow feature increased number of “benign” histocyte containing ingested platelets, RBCs and WBCs similar lymphohistocytic infiltrates and hematophagocytosis are also observed in liver , spleen, and lymph node. The patents are very ill with multiorgan signs and symptoms. The disease is more often have a syndrome of EBW- positive T-cell lymphoma affecting particularly the nose , skin and gastrointestinal tract which is considered different than VAHS, although there are many similarities. The syndrome also is characterized by hematophagocytosis and is difficult to distinguish from malignant histocytosis from the reports in the literature. It seems to be more common in foreign countries. Although VAHS is sometime termed a banish histocytosis , it is often progressive and fatal with fatality rates as high as 0% reported VAHS or a very similar syndrome is particularly common in patent’s with chediak-Higashi syndrome , where it has been termed the “accelerated phase” and is usually terminal.3
HIV INFECTION
Human immunodeficiency virus (HIV) is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS), a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive. HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages, and dendritic cells. HIV infection leads to low levels of CD4+T cells through three main mechanisms: First, direct viral killing of infected cells; second, increased rates of apoptosis in infected cells; and third, killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected cells. When CD4+ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infection.
APLASTIC ANEMIA
Aplastic anemia (AA) is a disease characterized by pancytopenia and hypocellular (or Fatty) marrow. It is a rather rare disorder , with an annual incidence of about 2-6 per million population. In about 50% of these cases, the etiology is unknown (Idiopathic Aplastic Anemia). The second leading cause of AA is drug and chemical use. Based upon the severity of disease, AA can be considered as a severe or moderate disease.Severe AA is characterized by two of the following blood criteria along with the presence of either marrow criteria.
Blood criteria:
Neutrophil <500/mm3,
Platelets <20,000/mm3
Corrected Reticulocytes <1%.
Marrow criteria:
Severe hypocellularity (<25%)
Moderate cellularity (50%) with less than 30% of hematopoietic cells.
Pancytopenia is a relatively common hematological entity. It is a striking feature of many serious and life-threatening illnesses, ranging from simple drug-induced bone marrow hypoplasia, megaloblastic anemia to fatal bone marrow aplasias and leukemia’s. The severity of pancytopenia and the underlying pathology determine the management and prognosis. Thus, identification of the correct cause will help in implementing appropriate therapy.
ACUTE LYMPHOBLASTIC LEUKEMIA
Brucellosis is a disease involving the lymphoproliferative system, which may lead to changes in the hematological parameters; however, pancytopenia is a rare finding. However, malignant diseases in association with brucellosis are rarely the cause of pancytopenia. Herein, two cases with fever and pancytopenia, diagnosed as simultaneous acute lymphoblastic leukemia and brucellosis are presented. Anti-leukemic therapy and brucellosis treatment were administered simultaneously, and normal blood parameters obtained. The first patient is in complete remission; the other recovered from the brucellosis, but later died due to a leukemic relapse.5
HYPERSPLENISM
Splenomegaly is an enlargement of the spleen. The spleen usually lies in the left upper quadrant (LUQ) of the human abdomen. It is one of the four cardinal signs of hypersplenism, some reduction in the number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination; a compensatory proliferative response in the bone marrow; and the potential for correction of these abnormalities by spleenectomy. Splenomegaly is usually associated with increased workload (such as in hemolytic anemias), which suggests that it is a response to hyper function. It is therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red blood cells being destroyed in the spleen. Other common causes include congestion due to portal hypertension and infiltration by leukemias and lymphomas. Thus, the finding of an enlarged spleen; along with caput medusa; is an important sign of portal hypertension.6
HEMOPHAGOCYTIC LYMPHOHISTIOCYTISIS
Hemophagocytic lymphohistiocytosis (HLH), also known as hemophagocytic syndrome. is an uncommon hematologic disorder that, typically, clinically manifests as fever, hepatosplenomegaly, lymphadenopathy, jaundice and rash, with laboratory findings of histiocytosis, and the pathologic finding of hemophagocytosis. Pancytopenia (anemia, neutropenia, and thrombocytopenia), markedly elevated serum ferritin levels, and abnormal liver enzymes are frequently present.7
VITAMIN B12 DEFICIENCY
Vitamin B12 deficiency or hypocobalaminemia is a low blood level of vitamin B12. It can cause permanent damage to nervous tissue if left untreated long enough. Vitamin B12 itself was discovered through investigation of pernicious anemia, which is an autoimmune disease that destroys parietal cells in the stomach that secrete intrinsic factor. Pernicious anemia, if left untreated, is usually fatal within three years. Once identified,
however, the condition can be treated successfully and with relative ease, although it cannot be cured and ongoing treatment is required. Intrinsic factor is critical for the normal absorption of B12 in amounts that occur in foods; and thus, a lack of intrinsic factor, as occurs with pernicious anemia, causes a vitamin B12 deficiency. Other more subtle types of vitamin B12 deficiency have been elucidated, including the biochemical effects, over the course of time in significant numbers. The results of the Framingham Offspring Study indicate that B12 deficiency may be more common than was previously believed. Deficiency is most significantly linked to improper absorption rather than low consumption, as many who consume high amounts of B12 may still experience deficiency.8
AIMS AND OBJECTIVES
§ To evaluate the causes of pancytopenia.
§ To study complete haemogram, peripheral smear and Bone marrow examination Finding in patients with pancytopenia.
DESIGN OF STUDY
Data of collection from Hematology laboratory at St. John’s Medical College, Hospital.
DURATION
One Year two Month.
MATERIALS AND METHOD
SOURCE OF DATA: Department of Clinical Pathology and medical records.
Subject with a Finding of pancytopenia will be selected for the study.
The Hemogram, peripheral blood smear finding and findings on the bone marrow aspirate and biopsy will be correlated to evaluate the cause of pancytopenia.
CLARIFICATION: This study involves only laboratory evaluation of pancytopenia a does not involve subjects.
SAMPLE SIZE: - 200
INCLUSION CRITERIA
Hemoglobin< 10 g/dl.
Total leucocytes count <4x109/l.
Platelet count <150x109/l.
EXCLUSION CRITERIA
Hemoglobin> 10 g/dl.
Total leukocytes count >4x109/l.
Platelet count >150x109/l
METHOD USED
Complete Hemogram.
Hemoglobin.
Reticulocyte count.
Reticulocyte index.
Red Cell Indices
Mean corpuscular volume.(MCV)
Mean corpuscular Hemoglobin.(MCH)
Mean corpuscular Hemoglobin concentration.(MCHC)
RDW.
Total WBC count.
Differential WBC count.
Platelet count.
Erythrocyte sedimentation rate (ESR)
Leishman stained peripheral smear.
Other cytochemical stain wherever relevant.
Peripheral smear of those sample will do to verify the above result and note any morphological abnormalities.
Bone marrow aspiration & biopsy.
Leishman stain (morphology)
Perl’s Prussian blue reaction.
BIOCHEMICAL FINDING.
Serum iron level.
Serum ferritin.
Total iron binding capacity and % saturation.
Vitamin B12 & Folic acid deficiency.
LDH ( lactate dehydrogenase)
REFERENCES
1. Kara M, Ghost A. pancytopenia. Indian jnof clinical medicine. 2002;3: 29- 34.
2. Maxwell M.Wintrobe,Richard G .Lee Thomas C,Bitheel.The approach to the patient with pancytopenia..Wintrobesclinical Hematology: 10th edition;1993:p-1449.
3.Knodke K, Marwah S, Buxi G, Vadav RB, Chaturvedi NK. Bone marrow examination in cases of pancytopenia.J Academy Clin Med:2001;2:55–9.
4. Keisu M, Ost A. Diagnosis in patients with severe pancytopenia suspected of having aplastic anemia. Europian J Haematol:1990;45: 11-40.
5. Tilak V, Jain R. Pancytopenia-A clinical- hematologic analysis of 77 cases. Indian journal of pathology:1999;42:399-404.
6. Andrews NC. Richard GL, BithelTC John F, John WA and John NL: Iron deficiency and related disorders: Wintrobes clinical hematology. 11th edition: 2003;p-998-999.
7.Handin lax stossel : principal and practice of Hematology : edition II, chapter-8th page-209,1980-1982.
8.Gupta V, Tripathi S, Tilak V, Bhatia BD. A study of clinico-hematological profiles of pancytopenia in children. Tropical Doct: 2008;38:241–3.
SIGNATURE OF THE CANDIDATENAME AND DESIGNATION OF GUIDE / Dr. SITA LAKSHMI.S
DCP, DNB, PhD
PROFESSOR AND HEAD,
DEPT. OF CLINICAL PATHOLOGY,
ST.JOHN’S MEDICAL COLLEGE HOSPITAL,
BANGLORE – 560034
SIGNATURE OF THE GUIDE
HEAD OF THE DEPARTMENT / Dr. SITA LAKSHMI
DCP, DNB, PhD
PROFESSOR AND HEAD,
DEPT. OF CLINICAL PATHOLOGY,
ST.JOHN’S MEDICAL COLLEGE HOSPITAL,
BANGLORE – 560034.
SIGNATURE OF THE HEAD OF THE DEPARTMENT