CASE:
A 55 year old male presenting with 1 week history of dizziness and easy
fatigability. He was noted to be pale and claims to have tea colored urine.
Persistence of symptoms prompted consult.
PMH: (-) DM (-) HPN
PSH: non smoker and occasional alcoholic beverage drinker
FH: unremarkable
On Physical Examination:
BP; 110/80 CR: 110/min RR: 24 Temp: 37.5 C
HEENT: (+) Pale palpebral conjunctivae, slightly icteric sclerae,
Lymphnodes: no cervical and axillary and inguinal lymphadenopathy
Chest: symmetrical chest expansion,cxlear breath sounds
Heart: Adynamic precordium, tachycardic with regular rhythm, (-) Murmurs
Abdomen: Flat, soft, non tender, (+) palpable mass 4cm below the left costal
margin
Extremities: full and equal pulses, (-) edema
Primary Clinical Impression
Chronic Liver Disease with Hypersplenism
Basis for Clinical Impression
1) (+) dizziness
2) (+) pallor
3) (+) tea colored urine
4.) (+) pale palpebral conjunctivae
5.) (+) icteric sclerae
6.) (+) palpable mass – 4cm below the left costal margin
Differential Dx
1.) Hemolytic Anemia
2.) Iron Deficiency Anemia
3.) Aplastic Anemia
II. Diagnostic Approach:
Diagnostic tests and rationale
1.) CBC with platelet count: to check for cytopenias;
2.) Reticulocyte count
3). PT,PTT: to check for coagulopathy
4.) urinalysis,
5.) Peripheral blood smear to identify the morphology of red cells,
leukocytes and platelets
6.) LDH
7.) Total Bilirubin (Direct and Indirect)
8.) Coombs Test (Direct and Indirect)
9.) Ultrasound of whole abdomen
Interpretation of Diagnostic tests results:
(show available lab results)
1) CBC – see attached sheet
2.) Reticulocyte count: 3% - elevated
3.) PT and PTT: normal
4.) U/A: RBC: 10-20 PC: 0-1
5.) Peripheral blood smear – see attached sheet
6.) LDH- elevated
7.) Total Bilirubin – elevated; Indirect Bilirubin:- elevated; Direct
bilirubin – normal
8. Direct Coombs Test – Positive ; Indirect Coombs Test - Negative
III. Final complete Diagnosis
Autoimmune Hemolytic Anemia
IV. Therapeutic Plans and rationale
Important to differentiate primary autoimmune hemolytic anemia from
secondary autoimmune hemolytic anemias such as malignancies, immune
diseases, or drugs. Since they may be treated in a way similar to primary
autoimmune hemolytic anemias and treatment of underlying disease.
1) First line therapy: Glucocorticoid - 1mg/kg/day prednisone orally or
methyprednisolone IV ( initial dose administered until a hematocrit of
greater than 30% or a hemoglobin greater than 10g/dL) Once treatment
goal is achieved the dose of PDN is reduced to 20-30mg/day within a few
weeks. Thereafter the PDN dose is tapered slowly under careful
monitoring of hemoglobin and reticulocyte count. .
2) Second line therapy- if treatment goal is not achieve within 3 weeks
Splenectomy ,Immunosuppressants, Rituximab
V. Follow-up Problems (provide actual or hypothetical scenario)
Plans:
1) Refractory or recurrent disease after splenectomy or rituximab
a) Refractory or recurrence after splenectomy: retreatment with steroids or
directly treat with Rituximab
b) Refractory or recurrence after immunosuppressants or rituximab
treatment – Splenectomy
