A 75-year-old man presents with a 3-month history of increasing tiredness and breathlessness on mild exertion. On examination he has pallor of the mucous membranes. His spleen is not palpable. His blood count shows a haemoglobin of 87 g/L with an MCV of 105fl and his serum bilirubin is normal.
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(a) What are the most likely causes of these symptoms and findings?
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Correct answer:
The most likely causes of macrocytic anaemia of this severity at this age are:
(a) Myelodysplasia
(b) Megaloblastic anaemia
(c) Haemolytic anaemia
(d) Myeloma
(e) Liver disease
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(b) What will the blood film show?
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Correct answer:
The blood film may show hypogranular neutrophils, Pelger like cells and thrombocytopenia; these would all indicate myelodysplasia. Megaloblastic anaemia would be indicated by the presence of hypersegmented neutrophils, oval macrocytes and thrombocytopenia. Auto-immune haemolytic anaemia would be associated with micro-spherocytes; microangiopathic haemolytic anaemia would give rise to fragmented red cells; Rouleaux might indicate myeloma; and acanthocytes and thrombocytopenia would indicate liver disease.
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(c) What further information can you obtain from the blood count?
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Correct answer:
A full blood count and reticulocyte count are needed. The reticulocyte count is raised in haemolytic anaemia. The white cell count and platelets may be subnormal in myelodysplasia, megaloblastic anaemia and liver disease.
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(d) The patient’s blood film shows neutropenia, hyposegmented neutrophils and a reduced platelet count. What further tests are needed?
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Correct answer:
Bone marrow examination. This is performed as myelodysplasia is suspected. It may reveal abnormalities in red cell, neutrophil and platelet precursors. Iron staining is done for presence of ringed sideroblasts. Chromosome analysis is needed to confirm the diagnosis and assess prognosis.
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(e) What is the most likely cause of the anaemia and how should it be treated?
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Correct answer:
Anaemia in myelodysplasia is due to ineffective red cell production. If causing symptoms, blood transfusions may be needed. Erythropoietin injections may help in some cases of refractory anaemia. If there are excess blasts in the marrow chemotherapy is needed (see Chapter 25).
