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Aplastic

Anemia

Definition

Pancytopenia resulting from aplasia of


the bone marrow
classified into primary and secondary
types.

Definition
the bone marrow
produces too few
of all three types
of blood cells: red
cells, white cells,
and platelets
(pancytopenia)

Causes
A-Primary:
1- congenital (as Fanconi's anemia).

2- Idiopathic acquired (67% of


cases).

Causes
B-

secondary:

1-chemicals (benzene, toluene, glue sniffing).


2-drugs (chemotherapeutics, antibiotics, gold,
phenytoin).
3-insecticides.
4-ionizing radiation.
5-infections (as hepatitis).
6-paraxysmal nocturnal haemoglobinuria.

Pathophysiology
Reduction in the number of haemopoietic pluripotential
stem cells
-------> fault in the remaining stem cells
OR
Immune reaction against stem cells.
-------> unable to divide and differentiate sufficiently to
produce the blood cells.

Clinical Features
Anemia with malaise, pale, and other
associated symptoms such as palpitations.
Thrombocytopenia (low platelet counts),
leading to increased risk of hemorrhage,
bruising and petechiae.

Clinical Features
Leukopenia (low white blood cell count),
leading to increased risk of infection.
Reticulocytopenia (low reticulocyte counts).
Occurs at any age.

Diagnosis
1- Complete Blood
Picture (CBP): which
shows pancytopenia
and reticulocytes.
2-Bone marrow
aspirate: Markedly
hypocellular marrow,
due to replacement
of hemopoietic
marrow by adipose
tissue (not fibrosis or

To define aplastic anemia there must be at least two of the


following :2
haemoglobin <10 g/dL( i )
platelet count <50 x 10/mm( ii)
(.neutrophil count <1,5 x 10/l( iii)

THERAPY
1-General:
The cause is removed.
Supportive care with blood Transfusion, plts
concentrate.
Prevention of infection.

THERAPY
2. Specific:
A-BONE MARROW
TRANSPLANTATION:
Treatment of choice.
from HLA matched
donor. Usually siblings.
Long term survival
rates: 60-70%.

THERAPY
A-IMMUNOSUPPRESSION: by using drugs
Antithymocyte globulin (ATG)
Antilymphocyte glubulin (ALG)
Cyclosporin
Intensive immunosupression : cyclophosphamide
Corticosteroids.

CASE REPORT
Objective
The objective of this paper is to report a case of a 8
.year old boy with a diagnosis of aplastic anemia

Case
GP, a 8 year old boy, with 15 kg of BW and 112
cm of BH, came to Haji Adam Malik General
Hospital Medan on 11th November 2015 at
.16.00. His chief complaint was pale

: History of disease
GP, a 8 years 6 months old boy, with 15 kg of BW and 112 cm of BH, came
to Haji Adam Malik General Hospital Medan on 11th November 2015 at 16.00
with pale as chief complaint. The patients have been experienced this about
2 days before admitted to hospital.
Petechie (-), hematoma (+) on the arms and legs, black stool (-),
epistaxis (-). History of spontaneous bleeding (+) on the gum found 3
days ago while fever.
Fever has been experienced by patient since 3 days ago and the body
temperature rises and drop, and was decreased by anti-pyretic drug.
Shivering was not found. Seizure was not found.
Patient also experienced malaise since 2 days ago.
Cyanosis (-), vomiting (-) and nausea (-). Defecation and urination is
normal. History of weight loose is not found.

History of
History of
previous
medic- History of
illness:
family:
ation:
He had been
hospitalized in Haji
Adam Malik
hospital on August
and October 2015
for transfusion.

Anti-pyretic drug
PRC transfusion on
August and
October 2015

There is no famiy
history of similar
disease found

History of
pregnanc
y:Patients
mother was 25
years old during
pregnancy. She
regularly goes for
control. No history
of complication
neonate and
maternal problem.
Consumption of
herbal medication
(-)

History
of
parents
medication:
Not found

History of
birth:
Patient was first child.
Gestational age was
aterm (36 weeks).
Body weight was 2800
gram, body length was
not measured. Birth
was assisted by doctor.
Baby was born
normally and cried
spontaneously. Blusih
was not found.

History of
growth
and
History
developm
of
ent:
immuniz
Patients mother
ation:
explained that he
Not complete

grew normally. He
was able to crawl
and sit
appropriately
based on his age.

Physic
al
Exami
nation

Present
status:

Sensorium : CM, body temperature: 37C,


HR: 100 bpm, RR: 22 x/i,
BW: 15 kg, BH: 112 cm, BW/A: Z score < -3 ,
BL/A: Z score < -3, BW/BL: Z score < -3,
anemic (+), icteric (-), dyspnea (-), cyanosis
(-), edema (-)

Localize
d
status:

Head : Face: pale


Eyes : light reflex +/+, isochoric
pupil, pale inferior palpebral
conjunctiva +/+, superior and inferior
palpebra edema-/Ears/Nose/Mouth : within normal
range
Neck : JVP R-2cmH2O lymph node
enlargement (-)
Thorax : Symmetrical fusiform,

Physical
Examinati
on

RR: 22x/i, regular, ronchi (+/+), wheezing (-/-)

Different
ial
Diagnosi
s:
Working
diagnosis
:

Aplastic anemia + ASD

Abdomen: Symmetric, supple, normal peristaltic, liver and


spleen: normal
Extremities : pulse 100 bpm regular, adequate p/v, felt
warm, CRT < 3

Aleukemic leukemia + ASD


Immune Trombositopenia Purpura + ASD
Aplastic anemia+ASD

Therapy:

PRC Transfusion (need 201 cc)

Trombosit Transfusion 2 unit

Diagnosti
c
Planning:

Complete blood analysis

Radiology examination

Echo examination

Laboratory finding
Complete blood analysis (11th November
2015 / 16.00)
Test

Result

Unit

References

Hemoglobin

8.40

%g

11.3-14.1

Erythrocyte

2.50

mm3/106

4.40-4.48

Leucocyte

5.13

mm3/103

6.0-17.5

Thrombocyte

mm3/103

217-497

Hematocrite

24.20

37-41

Eosinophil

1.00

1-6

Basophil

0.500

0-1

Neutrophil

29.80

37-80

Test

Result

Unit

References

Lymphocyte

65.70

20-40

Monocyte

3.30

2-8

Neutrophil absolute

1.53

L/103

1.9-5.4

Lymphocyte absolute

3.37

L/103

3.7-10.7

Monocyte absolute
Eosinophil absolute
Basophil absolute

0.17
0.05
0.01

L/103
L/103
L/103

0.3-0.8
0.20-0.50
0-0.1

MCV

96.80

Fl

81-95

MCH

33.60

Pg

25-29

MCHC

34.70

%g

29-31

Result: Anemia normokrom normositer + Trombositopenia

Radiology examination

:Result
Both of sinus costophrenicus are sharp. Diafragma is smooth, No infiltrate, Cardiomegaly (CTR 75%),
Trachea in middle, Bones and soft tissue normal

Result of Echo examination


Large ASD (19-20mm)
Inadequate right posterior
Risk sided enlargement

12th November 2015


S

(-)Fever(-), cough

Sensorium: CM, Temp: 37C, BW: 15 kg, BH: 112 cm


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-)Thorax : symmetrical fusiform, retraction


(-)HR: 98 bpm, regular, murmur

(-/-)RR : 22x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 98 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

PRC Transfusion 100cc/12jam (201cc)

Answer from Hemato-oncology division


S

(-)Fever(-), cough

, Sensorium: CM, Temp: 37C


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-)Thorax : symmetrical fusiform, retraction


(-)HR: 104bpm, regular, murmur

(-/-)RR : 24x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 104 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

PRC Transfusion II 125cc/12jam (100/202cc)


Trombosit Transfusion 2 unit ->done
Prednisone 2-11/2-2

13th November 2015


S

(-)pale(-), fever(-), nausea

Sensorium: CM, Temp: 36,8C, BW: 15 kg, BH: 112 cm


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-) Thorax : symmetrical fusiform, retraction


(-)HR: 94bpm, regular, murmur

(-/-)RR : 20x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 94 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein

Answer from Hemato-oncology division


S

(-)Pale (-), fever

Sensorium: CM, Temp: 37C


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-)Thorax : symmetrical fusiform, retraction


(-)HR: 92bpm, regular, murmur

(-/-)RR : 22x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 92 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Complete blood analysis, ferritin

Laboratory finding
Complete blood analysis (13th November 2015
/ 11.08)
Test

Result

Unit

References

Hemoglobin

11.30

%g

11.3-14.1

Erythrocyte

3.56

mm3/106

4.40-4.48

Leucocyte

2.27

mm3/103

6.0-17.5

Thrombocyte

13

mm3/103

217-497

Hematocrite

33.20

37-41

Eosinophil

0.40

1-6

Basophil

0.400

0-1

Neutrophil

69.60

37-80

Lymphocyte

25.60

20-40

Monocyte

4.00

2-8

Test

Result

Unit

References

Neutrophil absolute

1.58

L/103

1.9-5.4

Lymphocyte absolute

0.58

L/103

3.7-10.7

Monocyte absolute

0.09

L/103

0.3-0.8

Eosinophil absolute

0.01

L/103

0.20-0.50

Basophil absolute

0.01

L/103

0-0.1

MCV

93.30

Fl

81-95

MCH

31.70

Pg

25-29

MCHC

34.00

%g

29-31

Ferritin

727.30

ng/ml

Adult: 15-300
Child: 15-240

Result: Leukopenia + Trombositopenia

14th November 2015


S

(+)pale(+), fever(-), nausea

Sensorium: CM, Temp: 36,8C, BW: 15 kg, BH: 112 cm


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-) Thorax : symmetrical fusiform, retraction


(-)HR: 98bpm, regular, murmur

(-/-)RR : 24x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 98 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein

At 22.00
S

(+)Pale (+), fever(-), nausea

Sensorium: CM, Temp: 37C


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-)Thorax : symmetrical fusiform, retraction


(-)HR: 100 bpm, regular, murmur

(-/-)RR : 25x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 100 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein

Laboratory finding
Complete blood analysis (13th November 2015
/ 11.08)
Test

Result

Unit

References

Hemoglobin

11.30

%g

11.3-14.1

Erythrocyte

3.42

mm3/106

4.40-4.48

Leucocyte

3.20

mm3/103

6.0-17.5

Thrombocyte

21

mm3/103

217-497

Hematocrite

32.50

37-41

Eosinophil

1.30

1-6

Basophil

2.800

0-1

Neutrophil

21.20

37-80

Lymphocyte

68.10

20-40

Monocyte

6.60

2-8

Test

Result

Unit

References

Neutrophil absolute

0.68

L/103

1.9-5.4

Lymphocyte absolute

2.18

L/103

3.7-10.7

Monocyte absolute

0.21

L/103

0.3-0.8

Eosinophil absolute

0.04

L/103

0.20-0.50

Basophil absolute

0.09

L/103

0-0.1

MCV

95.00

Fl

81-95

MCH

33.00

Pg

25-29

MCHC

34.80

%g

29-31

Result: Bisitopenia

15th November 2015


S

(+)pale(+), fever(-), nausea

Sensorium: CM, Temp: 36,8C, BW: 15 kg, BH: 112 cm


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-) Thorax : symmetrical fusiform, retraction


(-)HR: 96bpm, regular, murmur

(-/-)RR : 24x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 96 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein

At 21.00
S

(+)Pale (+), fever(-), nausea

Sensorium: CM, Temp: 36,8C


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-)Thorax : symmetrical fusiform, retraction


(-)HR: 96bpm, regular, murmur

(-/-)RR : 24x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 100 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein

16th November 2015


S

(-)Pale(-), fever(-), nausea

Sensorium: CM, Temp: 36,8C, BW: 15 kg, BH: 112 cm


: Head
(-/-)Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric

Ear : within normal range

Nose : within normal range

Mouth : within normal range

(-) Thorax : symmetrical fusiform, retraction


(-)HR: 96bpm, regular, murmur

(-/-)RR : 20x/i, regular, ronchi (-/-), wheezing

Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable

Extremities : pulse 96 bpm, regular, adequate p/v , felt warm, CRT < 3

Aplastic anemia + ASD

Prednisone 2-11/2-2
Diet MB 1200 kkal+ 28 gr protein
PBJ

Done by
- Farzana Khairunisa
- Ananda Putri Tarigan