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A 68-year-old male presents for further evaluation of fatigue and dyspnea on exertion. Physical examination reveals no hepatosplenomegaly or lymphadenopathy. Laboratory workup reveals leukocyte count of 67,000/.uL. hemoglobin of 6.LJ g/dl, and platelet count of 262.000/ .uL. Flow cytometry of peripheral blood is performed and reveals expression of CDS. CD19. CD20. and CD23. Peripheral slide is shown below.
What is the most likely etiology of anemia in this case?
- Autoimmune hemolytic anemia (AIHA)
- Bone marrow infiltration by CLL
- Pure red blood cell aplasia (PRCA)
- Hypersplenism
- Anemia of chronic disease
Medicine
A. Peripheral blood smear reveals spherocytes and reticulocytosis, suggesting increased bone marrow production of red blood cells (RBC) to compensate for the anemia. This argues against bone marrow infiltration by CLL, PRCA, and anemia of chronic disease, as all of these entities are characterized by suppressed bone marrow function. Hypersplenism is less likely in the absence of sple nomegaly. AIHA appears to be a relatively uncommon feature of the natural history of CLL, occurring in less than 10% of cases throughout their disease course. AIHA does not appear to impact the prog nosis or the outcome of treatment. The distinction between anemia caused by bone marrow infiltra tion by CLL and AIHA is essential for treatment. The management of AIHA associated with CLL follows the usual algorithm for the management of idiopathic AIHA. In cases of refractory AIHA, treatment of underlying CLL is indicated (Blood. 2000;95(9):2786, Br 1 Haematol. 1987;67(2):235, Br 1 Haematol. 2011;154(1):14, Blood. 2010;115(2):187).
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