65 year old man with concerning presentation. Potentially life threatening cause.

Issues –

Resuscitation as indicated with concurrent assessment

Look for acute life threatening causes of syncope – vascular catastrophe (STEMI, A Dissection, PE, AAA rupture, GI bleed), other

The FBC shows a reduction in all three cell lines which indicates a pancytopaenia. The reduction in PCV may indicate acute blood loss. The MCV and MCH  are low normal.

Causes of pancytopaenia:

Decreased bone marrow function

Aplastic anaemia

Acute leukaemia, myelodysplasia, myeloma

Infiltration with lymphoma, solid tumours,

tuberculosis

Megaloblastic anaemia

Paroxysmal nocturnal haemoglobinuria

Myelofibrosis

Haemophagocytic syndrome

Increased peripheral destruction

Splenomegaly

 

Causes of aplastic anaemia:

Primary

Congenital (Fanconi and non-Fanconi types)

Secondary 

Ionizing radiation: Accidental exposure (radiotherapy, radioactive isotopes, nuclear power stations)

Chemicals: Benzene, organophosphates and other organic solvents, DDT and other pesticides, organochlorines, recreational drugs (ecstasy)

Drugs: Those that regularly cause marrow depression (ie. chemotherapy). Those that occasionally or rarely cause marrow depression (e.g. chloramphenicol, sulphonamides, gold, anti-inflammatory, antithyroid, psychotropic, anticonvulsant/antidepressant drugs)

Viruses: Viral hepatitis (non-A, non-B, non-C, in most cases), EBV, HIV, CMV

INVESTIGATIONS

Bed side – ECG, UA, VBG/ABG

Lab

UEC, LFT, Coagulation profile

Reticulocyte count

B12, folate, Fe studies

Auto immune screen

viral serology

Radiology

CXR

CTA, CTPA

Special (in patient)

Erythropoeitin levels

bone marrow aspirate and biopsy

Ham test – paroxysmal nocturnal haemoglobinuria

MRI, PET