Case 22 – update 1

You have been asked to see a pancytopenic patient on the liver ward. Without knowing any more you have been working on a differential diagnosis as you climb the stairs to the ward.

Suggestions from the team so far have included:

  • Splenomegaly
  • Alcohol (direct marrow toxity)
  • Malignant marrow infiltration
  • Medication (immunosupressant) side effect
  • Sickle crisis
  • coeliac disease
  • B12/folate deficiency

The patient is a 55 year old man who required a liver transplant for a paracetamol overdose 9 months ago. He is not, and has not been a heavy drinker and has no significant past medical history. He was readmitted from out-patient clinic 3 days ago as his full blood count, which had been drifting down, reached the reported levels. The notes also say he’s complaining of being ‘generally not well’.

Now that we know this is a man we can exclude HELLP (!) and alcohol has been ruled out. Coeliac disease leads to hyposplenism and thrombocytosis so is less likely in this case. A sickle crisis, particularly splenic sequestration, can cause a precipitous drop in Hb but shouldn’t cause pancytopenia.

So, that leaves us with B12/folate deficiency, medication, splenomegaly and malignant infiltration.

Further reading of the notes tells us that his tacrolimus levels have always been within the desired range and b12/folate levels are within the normal range. For the haematologists, the blood film confirms pancytopenia, a few reactive lymphocytes but does not show leucoerythroblastic features or tear drop cells.

What aspects of the history and examination are important? What other tests might be important in this patient?

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