Case Study # 1
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition Iron-Deficiency Anemia
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on stopping his activity. He has no history of heart or lung disease. His physical examination was normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.156
Red blood cell (RBC) count, p.396 2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume(MCV) 72 mm3 (normal: 80–95 mm3)
Mean corpuscular hemoglobin (MCH) 22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin concentration (MCHC) 21 pg (normal: 27–31 pg)
Red blood cell distribution width (RDW) 9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p. 466 7800/mm3 (normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte count), p. 362
Within normal limits (WNL) (normal: 150,000–400,000/mm3)
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+ Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity (TIBC) 500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis.
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal examination indicated that his stool was positive for occult blood. Colonoscopy indicated a rightside colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for the answer
4. What other questions would you ask to this patient and what would be your rationale for them?
Case Study # 2
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
AIDS (Acquired Immunodeficiency Syndrome)
The patient, a 30-year-old homosexual man, complained of unexplained weight loss, chronic diarrhea, and respiratory congestion during the past 6 months. Physical examination revealed right-sided pneumonitis. The following studies were performed:
Studies Results
Complete blood cell count (CBC), p. 156
Hemoglobin (Hgb), p. 251 12 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 36% (normal: 42%–52%)
Chest x-ray, p. 956 Right-sided consolidation affecting the posterior lower lung
Bronchoscopy, p. 526 No tumor seen
Lung biopsy, p. 688 Pneumocystis jiroveci pneumonia (PCP)
Stool culture, p. 797 Cryptosporidium muris
Acquired immunodeficiency syndrome
(AIDS) serology, p. 265
p24 antigen Positive
Enzyme-linked immunosorbent assay
(ELISA)
Positive
Western blot Positive
Lymphocyte immunophenotyping, p. 274
Total CD4 280 (normal: 600–1500 cells/L)
CD4% 18% (normal: 60%–75%)
CD4/CD8 ratio 0.58 (normal: >1.0)
Human immune deficiency virus (HIV)
viral load, p. 265
75,000 copies/mL
Diagnostic Analysis
The detection of Pneumocystis jiroveci pneumonia (PCP) supports the diagnosis of AIDS. PCP is
an opportunistic infection occurring only in immunocompromised patients and is the most
common infection in persons with AIDS. The patient’s diarrhea was caused by Cryptosporidium
muris, an enteric pathogen, which occurs frequently with AIDS and can be identified on a stool
culture. The AIDS serology tests made the diagnoses. His viral load is significant, and his
prognosis is poor.
The patient was hospitalized for a short time for treatment of PCP. Several months after he was discharged, he developed Kaposi sarcoma. He developed psychoneurologic problems eventually and died 18 months after the AIDS diagnosis.
Critical Thinking Questions
1. What is the relationship between levels of CD4 lymphocytes and the likelihood of clinical complications from AIDS?
2. Why does the United States Public Health Service recommend monitoring CD4 counts every 3–6 months in patients infected with HIV?
3. This is patient seems to be unaware of his diagnosis of HIV/AIDS. How would you approach to your patient to inform about his diagnosis?
4. Is this a reportable disease in Florida? If yes. What is your responsibility as a provider?