Pancytopenia resident survival guide

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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

 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 

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