Case 17 – update 1

Excellent work on this week’s case.  Almost all of the causes of macrocytosis have been identified:

  • B12/folate deficiency
  • Reticulocytosis
  • Liver disease
  • Alcohol excess
  • Myelodysplastic syndromes
  • Paraproteinaemia
  • Hypothyroidism
  • Pregnancy
  • Cold agglutinins
  • Drugs – DMARDS, chemotherapy, folate antagonists e.g. methotrexate, sulfasalizine, hydrocycarbamide, azathioprine
  • Post chemotherapy
  • Aplastic anaemia

As per the team’s suggestion the patient is forwarded to the medical unit and assessed for care in the ambulatory care unit.  One of the concerns from the team is anaemia with recent NSTEMI.  His alcohol intake is minimal, which is the first question that should be raised with a raised MCV.  On examination there are no signs of pulmonary oedema, but the patient is pale and the medical SHO thinks he may be jaundice.  There is no hepatomegaly but the spleen is just palpated below the ribs.  No obvious lymphadenopathy.  His vital signs are within the normal limits although he is short of breath walking from the car park.  There is no deficit in lying and standing BP.  There are no neurological symptoms. We also feel it important to rule out co-existant iron deficiency, especially given he’s on dual antiplatelet agents after his NSTEMI.  He’s also on lisinopril, atorvastatin and bisoprolol.  He was previously on methotrexate for rheumatoid arthritis but was stopped six months ago.

Some blood tests have returned:

  • B12 – 450ng/L
  • Red cell folate – 300mcg/L
  • ALP – 78 IU/L
  • ALT – 34 IU/L
  • GGT – 40IU/L
  • Albumin – 38g/L
  • Bilirubin – 55micromoles/L
  • Ferritin – 200mcg/L

Questions

  • Do the blood tests help in the differential diagnosis?
  • Was he lying about the alcohol history?

Please reply on Twitter and always include #teamhaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to  evolve over the coming week so keep checking #teamhaem for more information.

Please note – all cases on TeamHaem are entirely fictional to protect patient confidentiality.

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