A 70 year old female presents with generalised weakness and shortness of breath. On examination she has a low grade temperature and is pale looking.
HR 110/min
BP 110/60
Her blood results:
Hb 54 (113-155 g/l)
Platelets 522 (140-400)
WCC 17 (4-11)
Neutrophils 11.5 (4-7.5)
Lymphocytes 4.1 (1-4)
Reticulocytes 27.5 (0.2-2)
Bilirubin 160 (<16 umol/l)
ALP 102 (30-115 U/L)
GGT 27 (<36 U/L)
ALT 43 (<31 U/L)
Na 139 (134-146 mmol/l)
K 4.2 (3.4-5.5 mmol/l)
Urea 8.6 (mmol/l)
Creat 66 (30-100 umol/l)
LDH 1452 (<450 U/L)
Questions:
- Give 3 reasonable differential diagnosis
- Describe 4 important abnormalities and interpret
- What 2 tests would you order to confirm the likely diagnosis and what would you expect?
1. Hemolytic anemia, sickle cell, hemorrhage (unlikely)
2. Low hemoglobin (anemia; can in and of itself be due to multiple reasons), reticulocytosis (indicates increased production of immature RBCs), hyperbilirubinemia (indicates destruction of RBCs in this context), increased LDH (adds to probability of hemolysis).
3. Haptoglobin and direct Coombs test.
My question: does this person benefit from an emergent RBC transfusion absent results of Coombs test? What is the suggested supportive care strategy early in the presentation?
+ Can you look into the commenting system on the page? It is very cumbersome to post comments, especially on mobile (many errors). And the resource is so wonderful but I’m sure it’s a big deterrent to users commenting if they encounter errors. Thanks!
Good answer Jan,
Early consultation with haematology regarding best practice.
Steroids likely to be required early if this is auto immune haemolysis.
Treat complications – high output failure will require diuresis and blood transfusion, treat sepsis, exclude/ treat upper Gi bleed etc
Disposition likely to be high dependancy unit until crises is averted.
Thanks you for the strong interest and will look into comments with admin.