Case 128 – Update 2!

Thank you for everyone’s ongoing contributions!

We now have the outstanding results to help diagnose our patients bi-cytopenias (and old results for reference) and some additional history as requested:

Her bloods from this morning are as follows:

  • Hb 71 (several transfusions required throughout this admission)
  • Plts 20 (plt count was within normal range upto 3 days ago)
  • PT 19, APTT 40, Clauss fib 5.2
  • DAT negative. LDH 326
  • Stage 2 AKI, bilirubin 84 (ULN 21), ALT 250 (0-40), Alk phos normal

 

Outstanding results now in:

  • Blood film: Normocytic normochromic anaemia with unremarkable red cell morphology including NO red cell fragments or features of haemolysis. Thrombocytopenia appears genuine with no plt clumps. Plts morphologically normal. left shifted neutrophils with toxic granulation.
  • Retics: upper level of normal.
  • HIT assay: negative (and intermediate 4Ts score)
  • B12 / folate: normal
  • Autoimmune screen: negative
  • HIV / hep B / C: negative
  • Serum electropheresis: no paraprotein.
  • The patient has received 10 units packed red cells over the past 2 weeks for support several surgeries but has also been given appropriate associated FFP / platelet support.
  • (NB: an ADAMST13 has not been requested given the above findings and plasma exchange had not been initiated.)

Questions:

  1. What are the most likely differentials now?
  2. Any others related to the transfusion history and how could you investigate?
  3. Can you give a definitive diagnosis for cause of anaemia / thrombocytopenia?

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