Unexpected Cause of Anemia in a 45-Year-Old Patient With Acute Lymphoblastic Leukemia

Abstract

Patient: A 45-year-old Caucasian female Chief Complaint: The patient reports feeling light-headed, fatigued, and short of breath with exertion. History of Present Illness: The patient was recently diagnosed with precursor B-cell acute lymphoblastic leukemia (ALL) and is now 4 weeks status post induction chemotherapy. Her original therapeutic course included prednisone, asparaginase, vincristine, and daunorubicin. She returned for a bone marrow evaluation prior to consolidation therapy. Prior to discharge the patient was prescribed Dapsone for Pneumocystis carinii pneumonia (PCP) prophylaxis, as previously documented intolerance prevented trimethoprim-sulfamethoxazole therapy. Her glucose-6-phosphate dehydrogenase (G6PD) level prior to chemotherapy initiation was normal. Several days prior to this scheduled visit, the patient felt light-headed, fatigued, and noted progressive shortness of breath with exertion. Subsequently, a complete blood count at her primary physician’s office showed a hemoglobin (HGB) of 8.5g/dL (normal: 12–16g/dL), and she was transfused 2 units of compatible RBCs. She denies fevers, chills, and night sweats. Past Medical History: As above, otherwise not contributory. Family History: Not contributory. Vital signs: Temperature 37.7°C; blood pressure 103/68 mm Hg; heart rate 106 bpm. The patient did not have scleral icterus or other evidence of jaundice. No rashes, ecchymosis, or petechiae were identified. The patient did not have cervical, supraclavicular, or axillary lymphadenopathy. Her abdomen was soft, non-tender, non-distended, with no evidence of hepatosplenomegaly or palpable masses. Additional Laboratory Tests: Peripheral blood smear (Image 1). Principle Laboratory Findings : Table 1. 1. What are the patient’s most striking clinical and laboratory findings? 2. What are the most likely causes of this patient’s laboratory findings and underlying pathophysiology of this patient’s condition? 3. What additional diagnostic procedure may help clarify these findings? 4. What is the patient’s most likely diagnosis? 5. How should this patient be treated? 1. Clinically, the most striking finding in this patient with a recent diagnosis of precursor …