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Difficulty: HardHematology and Oncology

Review the clinical vignettes describing five different patients presenting with hematologic abnormalities. Based on the provided clinical presentations and laboratory profiles, which peripheral blood smear finding best matches each patient?

  • A 32-year-old woman with systemic lupus erythematosus presents with progressive fatigue and scleral icterus. Laboratory evaluation reveals a hemoglobin of 8.1 g/dL, a reticulocyte count of 7%, and an elevated indirect bilirubin level.Spherocytes and polychromasia
  • A 68-year-old man who underwent a mechanical aortic valve replacement three years ago presents with fatigue and dark urine. Laboratory evaluation reveals a hemoglobin of 9.4 g/dL, a normal platelet count, and normal coagulation studies.Schistocytes and helmet cells
  • A 72-year-old man presents with a 6-month history of progressive fatigue. Laboratory evaluation reveals a hemoglobin of 8.5 g/dL and an MCV of 112 fL. Serum vitamin B12, red blood cell folate, and thyroid-stimulating hormone levels are within normal limits.Hyposegmented, hypogranular neutrophils
  • A 64-year-old man presents with early satiety and a dragging sensation in his left abdomen. Physical examination is notable for massive splenomegaly. Laboratory evaluation reveals a hemoglobin of 9.2 g/dL and a white blood cell count of 12,000/mm³. A bone marrow aspiration yields a "dry tap".Teardrop cells (dacrocytes) and nucleated red blood cells
  • A 45-year-old man with a history of severe alcohol use disorder presents with fatigue, an ataxic gait, and lower extremity paresthesias. Laboratory evaluation reveals a hemoglobin of 9.0 g/dL and an MCV of 116 fL.Hypersegmented neutrophils and macro-ovalocytes

Answer

Patient 1 (SLE, hemolysis) matches with Spherocytes and polychromasia. Patient 2 (Mechanical valve, hemolysis) matches with Schistocytes and helmet cells. Patient 3 (Elderly, macrocytosis, normal vitamins) matches with Hyposegmented, hypogranular neutrophils. Patient 4 (Splenomegaly, dry tap) matches with Teardrop cells (dacrocytes) and nucleated red blood cells. Patient 5 (Alcoholism, neuropathy, macrocytosis) matches with Hypersegmented neutrophils and macro-ovalocytes.
The correct matches pair distinct clinical syndromes with their pathognomonic peripheral blood smear findings. Extravascular hemolysis in autoimmune disease produces spherocytes. Intravascular mechanical shear stress produces schistocytes. Bone marrow dysplasia (MDS) leads to hyposegmented neutrophils. Marrow fibrosis produces teardrop cells. Finally, impaired DNA synthesis from vitamin B12 deficiency leads to hypersegmented neutrophils.

Step-by-Step Solution

1
Analyze the etiology of anemia in the 32-year-old woman with SLE.
The patient has warm autoimmune hemolytic anemia, matching with spherocytes and polychromasia.
SLE predisposes to IgG-mediated hemolysis, causing splenic macrophages to bite off portions of the RBC membrane, forming spherocytes without central pallor.
2
Identify the cause of hemolysis in the 68-year-old man with a mechanical valve.
The patient has macroangiopathic hemolytic anemia, matching with schistocytes.
Mechanical shearing of RBCs by the artificial valve leads to intravascular hemolysis and the formation of schistocytes. Normal platelets differentiate this from microangiopathic processes like TTP.
3
Evaluate the 72-year-old man with macrocytic anemia and normal vitamin levels.
The patient most likely has a myelodysplastic syndrome (MDS), matching with hyposegmented, hypogranular neutrophils.
MDS frequently presents in elderly patients with macrocytic anemia. The smear classically shows dysplastic features such as the pseudo-Pelger-Huet anomaly.
4
Assess the 64-year-old man with massive splenomegaly and a 'dry tap'.
The clinical picture indicates primary myelofibrosis, matching with teardrop cells.
Bone marrow fibrosis results in a dry tap and extramedullary hematopoiesis in the spleen. This process forces RBCs through fibrotic marrow, producing teardrop cells.
5
Diagnose the 45-year-old man with macrocytosis and neurologic deficits.
The patient has a megaloblastic anemia due to vitamin B12 deficiency, matching with hypersegmented neutrophils.
Neurologic symptoms paired with an elevated MCV point to B12 deficiency, which impairs DNA synthesis and produces hypersegmented neutrophils (≥5 lobes) and macro-ovalocytes.

Key Concept

Correlation of distinct anemia etiologies and bone marrow disorders with their characteristic peripheral blood smear morphologies.
Estimated Time:1m 30s
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Topics

Hematology and Oncology

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