Anemia and Severe Erythrocytic Morphologic Abnormalities in Two Young Patients

Abstract

Possible Answers: 1. Patient #1. Markedly decreased hemoglobin (Hb) and hematocrit; low MCV and MCH; decreased WBC count with decreased neutrophils and increased lymphocytes; markedly increased nucleated RBCs with marked reticulocytosis; markedly abnormal RBC morphology, including the presence of target cells; decreased RBC osmotic fragility [T1] and [I1]; and, hypergammaglobulinemia. Patient #2. Markedly decreased hemoglobin and hematocrit; low-normal MCV and MCH; increased WBC count with decreased neutrophils, increased bands; a few nucleated RBCs with marked reticulocytosis; and markedly abnormal RBC findings, including the presence of sickle cells [T2] and [I2]. 2. Microcytic-hypochromic anemia (Patient #1; low hemoglobin, hematocrit, MCV, and MCH) and normocyticnormochromic anemia (Patient #2; low hemoglobin and hematocrit with low-normal MCV and MCH). Moreover, both patients demonstrated pallor and parasternal systolic murmurs, findings consistent with anemia. Nucleated red blood cells (RBCs) were observed on the peripheral blood smear from both of these patients. Circulating nucleated RBCs are abnormal except in the neonatal period and often enter the circulation during periods of bone marrow stress caused by severe hemolysis. Both patients had an elevated reticulocyte count (reticulocytosis), which is a reliable indicator of accelerated erythropoiesis, especially when hemolysis is severe enough to produce anemia. White blood cell abnormalities: Patient # 1 had leukopenia and neutropenia. Common causes of non-neoplastic neutropenia include therapeutic drugs, such as analgesics and antibiotics, certain infections (our patient had a clinically undefined febrile illness), and autoimmune disease. Patient #2 had increased neutrophilic bands in the context of an increased WBC count. This is probably a non-specific finding, but it could be an indication of an early left-shift as seen Principal Laboratory Findings: Patient #1