Haematology
Case 21: A Patient with Macrocytosis and Thrombocytopenia
CASE
A 65‐year‐old publican is seen in haematology outpatients with a macrocytosis and thrombocytopenia. He is feeling well in himself and the abnormal result was picked up incidentally. He has a past history of pancreatitis and hypertension, for which he takes amlodipine. He is a non‐smoker and drinks approximately 20 pints of beer per week. On examination, he was overweight and rather pale. There was no jaundice and his cardiovascular, respiratory and abdominal examination were all normal.
His blood results were as follows:
Hb 12.4 g/dL MCV 108 fL WBC 5.6 × 109/L Platelets 138 × 109/L CRP <8 mg/L Na 136 mmol/L K 4.1 mmol/L Urea 3.6 mmol/L Creatinine 75 µmol/L Bilirubin 12 µmol/L ALT 25 U/L ALP 134 U/L γ‐GT 450 U/L Serum ferritin 250 ng/mL Serum folate 15 nmol/L Serum vitamin B12 350 pmol/L
QUESTION 1
Your score this session: 0 of 0
What is the most likely cause for his raised MCV?
Four years later he is re‐referred to haematology outpatients. He has successfully cut down his alcohol consumption to only 1–2 pints of beer per week after having retired. Over the last 6 months he has been increasingly lethargic and has noticed that he bruises more easily than usual. On examination he was pale. Cardiovascular examination revealed a soft ejection systolic murmur over the aortic area which did not radiate. Respiratory and abdominal examination were normal.
Blood tests results now showed:
Serum ferritin, folate and vitamin B: all normal
Film: dysplastic neutrophils, variation in red cell size and shape