Clinical Case
Mr. Simmons, a 69-year-old engineer, presents to your clinic with pallor and fatigue. He is recently retired, and now enjoys relaxing around the house. He lives far away from the city and has not been to the doctor in over 20 years. He does not reveal much about his past medical history, but does report that his grandmother died of cancer at an old age, though he does not recall which type. He has always felt generally healthy, despite being a smoker (20 pack-years), but now feels a little tired when he climbs up the stairs. His wife has also been telling him that he looks a little bit pale. His diet typically includes morning coffee, a ham and cheese sandwich for lunch, and usually steak for dinner. You decide to draw some blood. His lab results are listed below:
| Hemoglobin | 5 gm/dL |
| Hematocrit | 29% |
| Fe | Low |
| TIBC | High |
| Ferritin | Low |
| MCV | Low |
| MHCH | Low |
- What is the diagnosis?
- Fe-deficiency anemia
- What would be expected on a peripheral blood smear?
- Microcytosis and hypochromasia
- Given the clinical picture, what do you consider to be the most likely etiology of his iron deficiency?
- GI bleed
- A colonoscopy reveals multiple colonic polyps, which are biopsied. The biopsy results support carcinoma of the colon. Where should you be most concerned about metastatic spread?
- Liver
- If this patient develops infectious endocarditis, which organism would you expect?
- Strep. Bovis
Several years later, after many cycles of chemotherapy and radiation therapy, Mr. Simmons returns to your clinic complaining of fever of 2-weeks duration and frequent epistaxis. His bloodwork reveals anemia, lymphocytopenia, neutropenia, and increased MCV. You suspect myelodysplastic syndrome secondary to the patient's cancer treatment, and order a bone marrow biopsy.
- Which of the following results are you most expecting to see?
- Hyper-cellular bone marrow with >20% blasts
- What is the underlying pathophysiology of MDS?
- MDS: Myelodysplastic syndrome is a condition in which there is dysplasia of the bone marrow. This typically arises from previous exposure to alkylating agents (like chemotherapy drugs) or radiation. Patients with MDS typically present with cytopenias (low cell counts in the blood), a hypercellular bone marrow (revealing increased cellular proliferation to compensate for the cytopenias), and increased blasts in the bone marrow (immature BM cells resulting from irregularly high cell proliferation). Because the highly proliferating cells are abnormal, they apoptose before reaching the circulation, resulting in cytopenias. These patients typically present with symptoms of anemia (due to low red cell counts), infection (due to low white counts), and/or bleeding (low platelets).
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