Thread by @UnremarkableLab

1/n Isolated Anemia! To start, a case from 7/14:

45 yo M presents with fatigue and abdominal pain that radiates to lower back.
His CBC is remarkable for WBC 8.9, Hgb 7.4 (L), and Plt 259.9.
His MCV is 86 & RDW is 19.7 (elevated)

#meded #foamed @medrants @uabimres

2/n Which of the following is the next step in evaluation of this patient's anemia?

3/n A high RDW might tempt you into thinking that this is a simple case of Iron Deficiency Anemia, however, we would suggest that you start your eval with a reticulocyte count to help you determine if the marrow's response to anemia is appropriate or not. His Retic % is 8.4

4/n Awesome. Retic % is high. But is it appropriate for his degree of anemia?
To determine appropriateness, calculate a Retic Index (RI) = Retic % x (Hct /Normal Hct) x 0.5

His RI is 2.3. RI >2 =appropriate response

If interested in RI vs ARC check out bit.ly/2Ct4xbr

5/n What's the next step in evaluation?

6/n He hasn't noticed any melena or blood in his stool. But he has noticed he's had yellow eyes... You check a bilirubin (4.1) with undetectable haptoglobin & elevated LDH.

Uh oh. He's hemolyzing. Check a smear, Coombs test, and more hx STAT!

7/n Smear had nucleated RBCs, anisocytosis, and spherocytes. There were no schistocytes.

He has not had any recent medications, travel, or previous history of anemia that he knows of. DAT was (+) for C3 and (-) for IgG antibodies.

Test yourself: What does this mean?

8/n This pattern is consistent with Cold Agglutinin Disease. CAD can be Primary or Secondary: 2nd can be caused by infxns, autoimmune disorders, or lymphoid malignancies

This gentleman was found to have lymphadenopathy which was bx'd and he was found to have. . .

9/9 Diffuse Large B cell Lymphoma. Treatment of cold agglutinin disease, if secondary, is aimed at treating the underlying cause so he was treated for his DLBCL and his hemolysis improved.

If you are interested in reading more about autoimmune hemolytic anemia, check out bit.ly/2CgYYwY for an excellent review article

Podcasts to check out include @CPSolvers: clinicalproblemsolving.com/2019/02/14/epi…
or @thecurbsiders thecurbsiders.com/tag/anemia