The case.

PRESCRIPTION.
40 ml of liquid acetaminophen (Tylenol) and
10 days of cephalexin (Keflex)
Four days later.
complete blood count,
urinalysis, urine and sputum
cultures, and chemistry
profile
Laboratory
Data
Patient Reference
WBC (x 10
9
/L) 5.9 4.5 - 11
RBC (x 10
12
/L) 1.14 4.3 5.9
Hb (g/dl) 3.8 13.9 16.3
Hct (%) 10 39 - 55
Results.
Platelet count Normal range
PBS Normocytic, normochromic, Few
spherocytes, increase in
neutrophilic bands, few early WBCs,
3 nucleated RBCs
Urinalysis 3+ blood
Urine and sputum cultures negative
chemistry profile elevated levels of total bilirubin,
alkaline phosphatase, lactate
dehydrogenase, and aspartate
aminotransferase
direct antiglobulin test (DAT) positive
indirect antiglobulin test negative
eluate Negative
Guide questions.
Answer.
Guide questions.
Answer.
Guide questions.
Answer.
The hapten or drug adsorption mechanism
The immune complex or innocent
bystander mechanism
Non-immune protein adsorption mechanism
-methyldopa or autoimmune (unknown)
mechanism
Guide questions.
Answer.
Hapten (Drug Adsorption) Mechanism is the most probable cause.

It happens when a hapten,a low molecular weight substance that rarely
stimulates antibody production, is involved in drug induced hemolytic
anemia.

This is caused by drugs such as penicillin (acetaminophen) which was
administered to the patient.

The significantly high values of of total bilirubin,
alkaline phosphatase, lactate dehydrogenase, and
aspartate aminotransferase all indicate a damage to
the liver.
Answer.
Guide questions.
Answer.
Case
Analysis

presented by:
Overview of the Case


A 24-year old woman from Zaire was
brought to the emergency department
because of periodic fever, chills, night
sweats and fatigue. Her laboratory data
revealed the following data:
Laboratory Results

Hematocrit: 0.35 L/L

Reticulocytes: 275 x 10
9
/L

WBC Count: 11 x 10
9
/L

Thin Smear:
slight variation in diameter of RBCs
inclusions noted in the RBCs
diffusely basophilic RBCs

Thick film:
inclusions observed
1. Describe the type of inclusions present on
the blood smear.


Based upon the observations made on
the blood smear, one can conclude that the
patient suffers from parasitism. Because ring
forms of young trophozoites were seen on
the blood smear.
2. Describe the inclusions on the thick
film.
Upon the examination of the thick film,
there are numerous large number of ring
forms in the red blood cells. The infected
cells have highly irregular surface defect.
This may be produced by the intracellular
growth of the parasite or it could represent
the site of parasite entry. This
phenomenon is known to occur in simian
malaria, the pitting of parasites from an
infected cell.
3. Justify the diagnosis.
The diagnosis: the patient have
MALARIA caused by Plasmodium falciparum.
One of the concrete evidence was the presence
of rings forms in the red blood cells in both films.

The erythrocyte in P.falciparum infection is
not enlarged. There is the presence of Mauers
dot and may be a few reddish staining dots. The
presence of extremely numerous rings and no
other stages are seen strongly indicates
P.falciparum case.

Plasmodium
falciparum
Plasmodium falciparum
Plasmodium falciparum
CASE NO. 4
A 55 year old man sought a medical
attention for the onset of chest pain.
Physical examination revealed slight
jaundice and splenomegaly. The past
medical history included gallstones,
and there was a family history of
anemia.
A complete blood count
(CBC) yielded the following
results:
Laboratory
Data
Patient Reference
Range
WBC (x 10
9
/L) 13.4 4.5-11
RBC (x 10
12
/L) 4.28 4.3-5.9
Hemoglobin (g/dL) 11.7 13.9-16.3
Hematocrit (%) 32.5 39-55
MCV (fL) 76 80-100
MCH (pg) 27.3 25.4-34.6
MCHC (g/dL) 36 31-37
RDW (%) 22.9 11.5-13.5
peripheral blood
smear revealed:

slight anisocytosis
slight polychromasia
several dark, round
microspherocytes lacking
central pallor

The platelet count and platelet
distribution on the smear were
normal.
QUESTIONS
Q1
From the data given, what is
your initial diagnostic
assessment of the anemia?
Q1
From the data given, what is
your initial diagnostic
assessment of the anemia?
Hereditary spherocytosis

Q2
What additional laboratory tests
would be of value in establishing
the diagnosis, and what
abnormalities in these tests would
be expected in confirming your
impression?

Q2
What additional laboratory tests would be of value in establishing the
diagnosis, and what abnormalities in these tests would be expected in
confirming your impression?

Mearuement of bilirubin An increased
bilirubin level would be expected

Reticulocyte count An increased
reticulocyte count

Measurement of haptoglobin A decreased
or absence of haptoglobin

Q2
What additional laboratory tests would be of value in establishing the
diagnosis, and what abnormalities in these tests would be expected in
confirming your impression?

Osmotic fragility test
An increased Osmotic
fragility test

Chromium labelled RBC
test Abnormal (15 days)

Fecal urobilinogen
Presence of urobilinogen
because of destruction of
ertythrocytes

Q2
What additional laboratory tests would be of value in establishing the
diagnosis, and what abnormalities in these tests would be expected in
confirming your impression?

Lactate dehydrogenase
(LDH) Test An increased
LDH level

Coombs test A negative
Coombs test

Erythorocyte
autohemolysis test An
increased autohemolysis
test and corrected by the
addition of glucose.

Q3
What is the cause of this type
of anemia?

Q3
What is the cause of this type of anemia?

Hereditary spherocytosis is due to the
presence of an autosomal dominant mutation.
This mutation caused an abnormal red blood
cell membrane (abnormal or lack of spectrin).



This disorder is
most common in
people of Northern
Europe descent,
but it has been
found in all
races.

CASE
ANALYSIS 1


Presented By:
GROUP 4
Garcia, Tiffany Verzil
Lozano, Rossette
Nicdao, Jan Kevin
An 18-year old African American woman was
seen in the emergency department for fever and
abdominal pain. The following results were
obtained on a blood count:

Case Analysis
WBC count: 11.9 x 109/L - increased
RBC count: 3,67 x 1012/L - decreased
Hgb: 10.9 g/dL decreased
Hct: 32.5% (0.325L/L) decreased

Platelet count : 410 x 109/L - normal
RDW : 19.5% - increased
Segmented neutrophils : 75% - normal
Lymphocytes : 18% - normal
Monocytes : 3% - normal
Eosinophils : 3% - normal
Basophils : 1% - normal
Reticulocyte count: 3.1% - increased



Laboratory Diagnosis
1.Select the confirmatory tests that should be performed and
the expected results.

- Confirmatory test should be performed are hemoglobin
solubility test and cirtate agar test, hemoglobin C I s separated
from hemoglobin A, O, and E as a result of mode of migration;
hemoglobin C migrates more toward the anode, whereas
hemoglobins A, O, and E migrate toward the cathode. Likewise,
hemoglobin S migrate toward the cathode. Likewise,
hemoglobin S migrates anodally, wheraes hemoglobins D and G
migrate cathodally.
QUESTIONS
2. Describe the characteristic RBC morphology on the
peripheral blood film.

- Characteristically, red blood cell that contain cystallized
aggregates of hemoglobin that protrude through the cell
membrane are seen. They are irregular shaped cells which
appear to contain mis-shapen crystals and increased target
cells are seen.



QUESTIONS
3. Based on the electrophoresis and RBC
morphology results, what diagnosis is suggested?

- On the basis of the ectrophoretic pattern, the
daignosis of presence of hemoglobin SC can be
made

QUESTIONS
QUESTIONS
4. If this patient were to marry a person of genotype HbAS,
what would be the expected frequency of genotypes for
each of four children?

- According to Mendelian law, the genotype can be
depicted by the following chart:
A S
S AS SS
C AC SC
25% Would be each genotype
Mild, chronic hemolytic anemia associated with
variable vaso-occlusive complications.
Splenomegaly

Hgb level usually 11 13% g/dL
Reticulocyte count: 3 5%
Peripheral smear: few sickle cell, target cells. And
intra erythrocyte free crystalline structures
(may protrude from membrane, HbSC crystals)
Citrate agar: C migrates, separation from S, E, O
Diagnosis
Diagnostic Hematology by: Rodak, Bernadette
F.
Clinical Hemetolology: Correlations and
Principles by: Steininger, Sheryl

REFERENCES: