The differential diagnosis is broad with such little information (we reallyneed that white cell differential don’t we?). It would include:
- Acute sepsis with DIC causing thrombocytopenia (although v anaemic for this alone)
- Acute leukaemia (lymphoblastic or myeloid – we haven’t been told what the white cell differential is)
- B12 or folate deficiency (might expect neutropenia at this point however)
- Acute EBV infection
- Aggressive lymphoma
- Indolent disease such as Hairy Cell Leukaemia (however age and time course don’t fit this)
- Drug-induced cytopenias
- ITP with blood loss causing anaemia – but doesn’t explain clinical sepsis.
- Evans Syndrome – but doesn’t explain clinical sepsis
- Bone marrow failure due to other malignancies
- HIV related cytopenias or malignancies
So we need more information…
The lab calls to say that the white cells look very abnormal and the haematology reg is on their way in to have a look at the film.
Whilst you wait for further information from the haem reg the nurses call you to say his blood presure is now unrecordable and he seems a bit muddled. You re-examine him and find that he is flushed, dyspnoeic and alert but slightly altered, struggling to answer simple questions. He has a cap refill of 2 seconds, HR of 140 and BP on recheck of 65 systolic (no diastolic reading on dynamap). You think he might have a systolic murmur but are not sure. Chest examination reveals creps in the right base but despite warm peripheries his sats on 6l O2 are only 90%. Gastro exam unremarkable. Neuro exam doesn’t suggest any gross abnormality although he is not very cooperative.
How do you manage this patient whilst awaiting more information? Any other information we need?
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