Pancytopenia resident survival guide: Difference between revisions

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Treatment of pancytopenia is outlined in the algorithm below.
Treatment of pancytopenia is outlined in the algorithm below.


Abbreviations: LDH- Lactate dehydrogenase, RBC- Red blood cells, G-CSF - Granulocyte colony stimulating factor, CNS- Central nervous system
Abbreviations: LDH- Lactate dehydrogenase, RBC- Red blood cells, G-CSF - Granulocyte colony stimulating factor, CNS- Central nervous system, ATG- Anti thymocyte globulin, HIV- Human Immunodeficiency Virus
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{{familytree | | | | | | | | | A01 | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Pancytopenia diagnosis established''' <br>❑ [[Hemoglobin]] < 10gm/dl <br>❑ [[Leucocyte]] count < 4000/mcL <br>❑ [[Platelet]] count < 150,000/mcL </div>}}
{{familytree | | | | | | | | | A01 | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Pancytopenia diagnosis established''' <br>❑ [[Hemoglobin]] < 10gm/dl <br>❑ [[Leucocyte]] count < 4000/mcL <br>❑ [[Platelet]] count < 150,000/mcL </div>}}
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{{familytree | D01 | | D02 | | D03 | | D04 | | D05|D01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Hypocellular marrow''' <br> Investigate for and treat probable causes such as <br>❑ [[Aplastic anemia]] <br>* [[ATG]] <br>* Drugs such as [[cyclophosphamide]] <br>* Blood transfusions <br>* [[Bone marrow transplant]] is curative <br>❑ [[Paroxysmal nocturnal hemoglobinuria]] <br>* [[Warfarin]] to decrease risk of [[thrombosis]] <br>* [[Blood transfusion]]s when needed <br>* [[Eculizumab]] therapy <br>* [[Meningococcal]] vaccination <br>❑ Congenital aplastic anemia <br>* Hematopoietic [[stem cell]] transplant |D02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''[[Dysplasia|Dysplastic]] cells in bone marrow or infiltration''' <br>❑ [[Leukemia]] <br>* Induction and consolidation [[chemotherapy]] <br>* [[CNS]] prophylaxis <br>* [[Bone marrow transplant]] <br>❑ [[Lymphoma]] <br>* [[Chemotherapy]] <br>* [[rituximab]] <br>* [[stem cell transplantation]] <br>❑ [[Myelodysplasia]] <br>* Supportive care with blood products and [[erythropoietin]] <br>* Eligible candidates may receive [[bone marrow transplant]]ation <br>* [[Chemotherapy]]|D03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Nutritional causes''' <br>❑ [[Vitamin B12]] deficiency <br>* Initially, a single intramuscular dose of cobalamin is sufficient to reverse Vitamin B12 deficiency anemia <br>* Injections of cobalamin are associated with [[allergy|allergic reactions]] which can be circumvented with [[antihistamine]] therapy prior to treatment <br>* Maintenance therapy with a dose of 1000 mcg every week or 6-8 times per month is required <br>❑ [[Folate]] deficiency <br>* Folate deficiency often co-exists with Vitamin B12 deficiency <br>* Oral doses of 1-5 mg daily treats anemia <br>* In patients taking [[methotrexate]], folonic acid is used to prevent folic acid deficiency <br>* Patients must be encouraged to take a diet rich in fresh fruit and vegetables |D04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Infectious causes''' <br>|D05=D05}}
{{familytree | D01 | | D02 | | D03 | | D04 | | D05|D01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Hypocellular marrow''' <br> Investigate for and treat probable causes such as <br>❑ [[Aplastic anemia]] <br>* [[ATG]] <br>* Drugs such as [[cyclophosphamide]] <br>* Blood transfusions <br>* [[Bone marrow transplant]] is curative <br>❑ [[Paroxysmal nocturnal hemoglobinuria]] <br>* [[Warfarin]] to decrease risk of [[thrombosis]] <br>* [[Blood transfusion]]s when needed <br>* [[Eculizumab]] therapy <br>* [[Meningococcal]] vaccination <br>❑ Congenital aplastic anemia <br>* Hematopoietic [[stem cell]] transplant |D02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''[[Dysplasia|Dysplastic]] cells in bone marrow or infiltration''' <br>❑ [[Leukemia]] <br>* Induction and consolidation [[chemotherapy]] <br>* [[CNS]] prophylaxis <br>* [[Bone marrow transplant]] <br>❑ [[Lymphoma]] <br>* [[Chemotherapy]] <br>* [[rituximab]] <br>* [[stem cell transplantation]] <br>❑ [[Myelodysplasia]] <br>* Supportive care with blood products and [[erythropoietin]] <br>* Eligible candidates may receive [[bone marrow transplant]]ation <br>* [[Chemotherapy]]|D03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Nutritional causes''' <br>❑ [[Vitamin B12]] deficiency <br>* Initially, a single intramuscular dose of cobalamin is sufficient to reverse Vitamin B12 deficiency anemia <br>* Injections of cobalamin are associated with [[allergy|allergic reactions]] which can be circumvented with [[antihistamine]] therapy prior to treatment <br>* Maintenance therapy with a dose of 1000 mcg every week or 6-8 times per month is required <br>❑ [[Folate]] deficiency <br>* Folate deficiency often co-exists with Vitamin B12 deficiency <br>* Oral doses of 1-5 mg daily treats anemia <br>* In patients taking [[methotrexate]], folonic acid is used to prevent folic acid deficiency <br>* Patients must be encouraged to take a diet rich in fresh fruit and vegetables |D04=<div style="float: left; text-align: left; width: 5em; padding:1em;">'''Infectious causes''' <br>❑ [[HIV]] infection|D05=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''D05'''}}


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Revision as of 07:23, 24 November 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Synonyms and keywords: Approach to pancytopenia, Approach to anemia

Pancytopenia Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Pancytopenia is described as a decrease in the 3 cell lines which are red blood cells, white blood cells and platelets. Clinically, pancytopenia is defined as hemoglobin< 9gm, white blood cell count< 4,000/cmm and platelets < 100,000/cmm. It can be due to decreased production in the bone marrow or increased destruction of cells in the periphery. Pancytopenia can also be caused due to drugs such as chemotherapy agents. Treatment involves identifying the underlying cause and appropriate therapy.

Causes

Decreased production of cells

Increased peripheral destruction

Other causes

For a full list of pancytopenia causes, click here.

Diagnosis

Diagnosis of pancytopenia is outlined in the algorithm below.

 
 
 
 
 
 
 
Thorough history must be taken including
❑ Symptoms of autoimmune disease such as
* joint pain and swelling
*rash
* lymphadenopathy etc
❑ History of malignancy
❑ History of recent infections
❑ History of usage of drugs which cause marrow suppression such as
* azathioprine and other chemotherapy drugs
* corticosteroids
* linezolid
* chloramphenicol etc
❑ History of chemo or radiotherapy
nutritional status
❑ Family history of anemia or pancytopenia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manifestations of decrease in each cell line
Decrease in RBCs
dyspnea
fatigue
pallor
chest pain
Decrease in WBCs
❑ increased susceptibility to infections
fever
Decrease in platelets
petechiae
easy bruising
bleeding
Other signs to look for are
❑ Signs of liver disease
Splenomegaly
Lymphadenopathy
❑ Signs of eating disorders
❑ Signs of alcoholism
❑ Signs of Vitamin B12 or folate deficiency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First line investigations
Peripheral smear
Look for dysplastic cells such as macrocytes and blasts
Complete blood count with reticulocyte count
Iron studies
Erythrocyte sedimentation rate
C reactive protein
Liver function tests
Lactate dehydrogenase level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Additional investigations
HIV serology
Hepatitis serology
❑ Screening for tuberculosis
Antinuclear antibody level
Coomb's test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bone marrow aspiration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypocellular marrow
 
 
 
 
 
 
 
 
 
Cellular marrow
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Morphology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigate for following conditions
Aplastic anemia
❑ Congenital aplastic anemia such as Diamond blackfan syndrome
❑ Blast cell morphology and CD cell markers
Paroxysmal nocturnal hemoglobinuria
 
 
 
 
 
 
Normal morphology
 
 
 
 
 
Dysplastic cells, marrow fibrosis or infiltration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Systemic causes
 
 
 
 
 
Additional tests to confirm
Leukemia
Lymphoma
Myelodysplastic syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infections such as
HIV serology
Hepatitis serology
❑ PCR for tuberculosis
❑ Smear for malarial parasite
❑ LD body for leishmaniasis
 
Megaloblastic anemia
❑ Vitamin assays
antiparietal cell antibodies
❑ evaluation for malabsorption syndromes
 

Treatment

Treatment of pancytopenia is outlined in the algorithm below.

Abbreviations: LDH- Lactate dehydrogenase, RBC- Red blood cells, G-CSF - Granulocyte colony stimulating factor, CNS- Central nervous system, ATG- Anti thymocyte globulin, HIV- Human Immunodeficiency Virus

 
 
 
 
 
 
 
 
Pancytopenia diagnosis established
Hemoglobin < 10gm/dl
Leucocyte count < 4000/mcL
Platelet count < 150,000/mcL
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial investigations
Peripheral blood smear
❑ Coagulation profile
❑ Serum LDH level
Complete blood count with reticulocyte level
Bilirubin level
Coomb's test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute bleeding
Prompt treatment with
❑ Insert two large bore IVs
❑ Type and match blood
❑ IV fluids to correct hypovolemia
❑ Packed RBCs
Fresh frozen plasma
Platelet transfusion for platelet count < 10,000/mcL to prevent intracranial bleeding
❑ Monitor vital signs and laboratory parameters at frequent intervals
 
 
 
 
 
 
 
Neutropenic fever
❑ Send two sets of blood cultures
❑ Empirical intravenous antibiotic therapy should be started with an antipseudomonal beta lactam such as cefepime/ a carbepenem or piperacillin-tazobactam
❑ Modify antibiotics once culture and sensitivity results come back
❑ If MRSA is suspected, vancomycin/daptomycin or linezolid may be started
❑ Empirical treatment with antifungals is not recommended
❑ Periodic assessment of response to therapy
❑ Monitor vitals regularly
G-CSF therapy is recommended in patients undergoing chemotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypocellular marrow
Investigate for and treat probable causes such as
Aplastic anemia
* ATG
* Drugs such as cyclophosphamide
* Blood transfusions
* Bone marrow transplant is curative
Paroxysmal nocturnal hemoglobinuria
* Warfarin to decrease risk of thrombosis
* Blood transfusions when needed
* Eculizumab therapy
* Meningococcal vaccination
❑ Congenital aplastic anemia
* Hematopoietic stem cell transplant
 
Dysplastic cells in bone marrow or infiltration
Leukemia
* Induction and consolidation chemotherapy
* CNS prophylaxis
* Bone marrow transplant
Lymphoma
* Chemotherapy
* rituximab
* stem cell transplantation
Myelodysplasia
* Supportive care with blood products and erythropoietin
* Eligible candidates may receive bone marrow transplantation
* Chemotherapy
 
Nutritional causes
Vitamin B12 deficiency
* Initially, a single intramuscular dose of cobalamin is sufficient to reverse Vitamin B12 deficiency anemia
* Injections of cobalamin are associated with allergic reactions which can be circumvented with antihistamine therapy prior to treatment
* Maintenance therapy with a dose of 1000 mcg every week or 6-8 times per month is required
Folate deficiency
* Folate deficiency often co-exists with Vitamin B12 deficiency
* Oral doses of 1-5 mg daily treats anemia
* In patients taking methotrexate, folonic acid is used to prevent folic acid deficiency
* Patients must be encouraged to take a diet rich in fresh fruit and vegetables
 
Infectious causes
HIV infection
 
D05

Do's

Dont's

  • Don't prescribe Aspirin or NSAIDs, or any other drugs that may precipitate bleeding in patients with pancytopenia.
  • Don't wait for culture and sensitivity reports in case of neutropenic fever or sepsis in pancytopenic patients. Prompt treatment with broad spectrum antibiotics is key.
  • Don't progress to treatment without correcting underlying nutritional deficiencies such as Vitamin B12 or folate deficiency.

References