What's pancytopenia?

Its combination of anemia , leukopenia and

thrombocytopenia
1.HB < 10 g/dL
2.Leukocyte count < 4000/ul
Absolute Neutrophil count <1500/uL
3.Platelet count < 150,000 uL
 What's causes of
pancytopenia?
 Bone marrow failure : aplastic anemia
 Bone marrow infiltration :
 Acute leukemia
 Myeloma
 Lymphoma
 Carcinoma
 MDS
 Ineffective haematopoiesis
 Megaloblastic anaemia
 AIDS
 Peripheral pooling / destruction
 Hypersplenism: portal hypertension ,
felty's syndrome , malaria , Myelofibrosis
 SLE
What's approach to
thrombocytopenia?
 History

 Examination

 CBC & blood film

 BM aspiration & biopsy

 Other specific investigation

 History
 Duration of symptom
 Long (MDS)
 Short (aplastic anemia)
 History of transfusion
 History of hemoglobinurea
 Dietary history
 Exposure to drugs : anti cancer , Abs , anti
thyroid (aplastic anemia)
 Barbiturates , phenytoin ( B12, Folic acid)
 Chemotherapy , radiation ( MDS , AML)
 Weight loss , fever ( Inflammatory or
malignancy)
 Jaundice ( Hepatitis B or C)
 Joint pain (SLE)
 History of blood loss
 General examination
 Eye examination: retinal hemorrhage
leukemic infiltrations
 oral examination : oral petechaie
stomatitis / chelitis
gum hyperplasia
oral candidiasis
 Respiratory examination : clubbing
tachypnea
 Abdominal examination : organomegaly
lymphadenopathy
 skin examination : malar rash
purpura
hypo or
hyperpigmentation
 Musculoskelatal system : short stature
synovitis
abnormal thumb
Pancytopenia + Absent thumb
+Child
 Pancytopenia + Back pain +
Hypercalcemia
(multiple myeloma)

 Pancytopenia + Malar rash or GN = SLE

 pancytopenia + HSM = Leukemia

 Blood Film
1.RBC morphology ( size & shape)
2.WBC and RBC precursor
3.Platelets count & size
4.Abnormal increase or decrease
granulation in Neutrophil
5. Hypo / hypersegmented Neutrophil
Other evaluating test may be
included
ESR
 Reticulocyte count
 Serum LFTs
 Hepatic serology
 Serum coagulation profile, bleeding
time, fibrinogen, and D-dimer
 Serum B12 and folate
 HIV test
Anisocytosis--different sized
RBCs
Poikilocytosis--differently
shaped RBCs
Platelets are small, and
reduced in numbers

Aplastic anemia
Macrocytosis

Howel jolly bodies

Basophilic stippling

Hypersegmented Neutrophil

Megaloblastic anemia
Tear drop cells

Hypogranular neutrophils

Pseudo pelger Heut Anomaly

Giant platelets

MDS
 The characteristic peripheral blood
morphologic feature in multiple
myeloma is:

A. Cytotoxic T cells
B. Rouleaux formation
C. Spherocytosis
D. Macrocytosis
True or false?
 In blood film normal platelets count
rules out aplastic anemia

 True
 Bone Marrow Examination
Almost always indicated in case
pancytopenia unless cause is apparent.
Both aspiration and biopsy are indicated.
Specifically, bone marrow aspirate permits
examination of:
• Cytology (megaloblastic change,
dysplastic changes, abnormal cell
infiltrates)
• Immunophenotyping : antigen or marker
on cells surfaces e.g ( leukemias,
lymphoproliferative disorders)
• Cytogenetics : structure of chromosome
(myelodysplasia, leukemias,
lymphoproliferative disorders).
True or false?
 Bone marrow examination is required
in diagnosis of Megaloblastic anemia

 False
The differential diagnosis of pancytopenia
are based on cellularity of bone marrow :

 Hypocellular: excessive amount of fat

cells

 Normocellular: 50-70% hematopoietic

cells & 30-50% fat

 Hypercellular: 80-100% cells with little

Hypercellular
 Causes of Hypocellular BM
1.Aplastic anemia

2.Hypoblastic MDS

3.Cytotoxic agent & radiotherapy

 Causes of Hypercellular BM with
primary marrow disorders
1.Acute leukemia / lymphoma

2. Hairy cell leukemia

3. Myelofibrosis

4.PNH

5.Mutiple myeloma

6. Mylodysblastic leukemia
 Causes of Hypercellular BM with
systemic disorders
1.Metastatic solid tumor
2. hypersplenism
3.Megaloblastic anemia
4. Infection (T.B ,kala azar, brucellosis)
5. Overwhelming infections
6. Alcohol
7. Autoimmune disorders- SLE, Sjogren’s
8. Sarcoidosis
9. Storage disease- Gaucher, Niemann-
pick
 Pancytopenia +markedly
Hypocellular scattered mature
lymphocytes

aplastic anemia
Pancytopenia + Hypercellular
BM

Infiltration by RS cells HL
 Pancytopenia + Hypercellular
B.M + old age

MDS
 Pancytopenia + Hypercellular
marrow

Infiltration with malignant cells (Metastasis)

Specific investigations
Megaloblastic anemia: Vit.B12 , Folate
assay
 Multiple myeloma :
Imunoelectrophoresis
 PNH: Flow cytometry (CD55, CD59)
 Leishmaniasis: blood and bone
marrow culture, serum ELISA
 HIV ,EBV , hepatitis : virology screen
 Fanconi anemia : Chromosomal
breakage study