Case 135 – Update 1

Thanks for your help so far…

We have now established that our 81 year old lady with AIHA has been feeling tired for several months and has noted some exertional dyspnoea. She has noted recently that she has lost some weight (around 3kg) and has found her trousers feel tight despite this. She is also most troubled by drenching night sweats that have been present for several months.

On examination you find a palpable spleen protruding 3cm from costal margin. She has no other lymphadenopathy.

On review of her blood counts she has a mild lymphocytosis of 5×10^9 and there is a comment of “atypical lymphocytes’ alongside the description of spherocytes.

She went on to have a CT scan that confirms a 19.5 cm spleen but no other findings. You decide that you should proceed with a bone marrow biopsy before starting steroids. The results are awaited.

On balance, you felt you should be cautious given her age and gave 60mg Prednisolone with a PPI. She also started folic acid, VTE prophylaxis and Calcium/Vitamin D to manage her haemolysis.

She is discharged home with a Hb 98, Retics 50 (Normal), LDH 380 (prev 490) to return to the haematology day unit a few days later.

What is the differential diagnosis for the splenomegaly and AIHA?

How likely is she to respond to steroid therapy for AIHA?

How long would you leave the patient on high dose steroids before weaning if she responds?

Would you send the patient home on VTE prophylaxis at this stage?

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