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LMED28002 Haematopathology Case study 1 Sample

A 20 year old pregnant woman from Mumbai went to her GP complaining of lethargy, and shortness of breath. As she was pregnant she was admitted to an obstetrics hospital for investigation. Clinical symptoms showed pale conjunctiva, tachycardia and mild spooning of nails. She reported unusual dietary cravings.

The results of an initial Full Blood Count from a Sysmex XN-1000 analyser are shown below:

A Wright’s stained peripheral blood smear showed this morphology:


Further testing was requested, and the results and methods are shown below:

As described the following methods were used to achieve these results, details of each method are included in subsequent pages.

Full Blood Count

Blood collection was by a standard venepuncture technique of the antecubital vein with the blood collected into a Vacutainer® tube containing K2EDTA.
Analysis was completed within 30 minutes of collection, the Haemoglobin and cell counts were performed using the Sysmex XN-1000 analyser and the smear was prepared using the manual wedge technique.

Smears were stained manually using Wright’s stain.

Biochemistry

Blood collection was by a standard venepuncture technique of the antecubital vein with the blood collected into a Vacutainer® Serum Spearation Tube (SST™).
The blood was mixed by inverting the tube 5 times and allowed to stand for 30 minutes prior to centrifugation for 10 minutes at 1,200 g.
Analysis was completed within 30 minutes of centrifugation, the Iron Studies including Iron, Ferritin, Transferrin and UIBC were performed using the Beckman Coulter AU680 analyser.

The Soluble Transferrin Receptor assay was performed using the Beckman Coulter Access II analyser.

Electrophoresis

The Haemoglobin Electrophoresis was performed using the Perkin Elmer RESOLVE™ Hemoglobin Kit on the blood used for the Full Blood Count.

Solution

Abstract

A pregnant woman in her 20s from Mumbai presented with unusual dietary cravings, lethargy, and shortness of breath. She had mild nail spooning, pale conjunctiva, and tachycardia. Her full blood count revealed microcytic hypochromic red cells, low hemoglobin (60 g/L), low hematocrit (21 L/L), and an increased red cell distribution width. Studies on iron revealed low levels of iron, ferritin, and transferrin, all of which are indicative of iron deficiency anemia. Electrophoresis of hemoglobin was normal. She was treated with iron supplements and regular visits to obstetricians to monitor fetal growth. This case for the assignment help demonstrates how crucial it is for pregnant women to be diagnosed and treated for iron deficiency anemia as soon as possible.

Introduction

A 20-year-old pregnant lady from Mumbai was introduced to her GP with dormancy and windedness, prompting admission to an obstetrics emergency clinic for additional examination. The patient reported unusual dietary cravings, pale conjunctiva, tachycardia, and mild nail spooning on clinical examination (Yeoh, and Chiew, 2022). A Sysmex XN-1000 analyzer's Full Blood Count (FBC) revealed anemia with a high red cell distribution width and low hemoglobin, hematocrit, and mean cell volume. The elevated count of reticulocytes points to a possible compensatory response. White cell and platelet counts were within acceptable ranges. The Beckman Coulter AU680 analyzer was utilized for the iron investigations, which included ferritin, transferrin, and unsaturated iron-restricting limit (UIBC). The soluble transferrin receptor assay was performed with the Beckman Coulter Access II analyzer. On the blood that was used for the FBC, the Perkin Elmer RESOLVETM Hemoglobin Pack was used to perform hemoglobin electrophoresis. A clinical examination revealed anemia with a wide red cell distribution and low hemoglobin, hematocrit, and mean cell volume. The unsaturated iron-binding capacity and soluble transferrin receptor assay, as well as the iron, ferritin, and transferrin studies, were carried out. The hemoglobin electrophoresis was carried out. The number of reticulocytes was up, which could be a response to compensate. These findings point to an underlying possibility of iron deficiency anemia during pregnancy, which calls for additional investigation and appropriate treatment.

Materials and methods

Standard venipuncture was used to collect blood from the antecubital vein for the Full Blood Count and Iron Studies. The blood was collected using a Vacutainer® tube containing K2EDTA for FBC and a Vacutainer® Serum Separation Tube (SSTTM) for Iron Studies. The FBC analysis was performed with the Sysmex XN-1000 analyzer. The smear was stained manually with Wright's stain and prepared using the manual wedge method. For the Iron Studies, which included iron, ferritin, transferrin, and UIBC, a Beckman Coulter AU680 analyzer was utilized. The Soluble Transferrin Receptor assay was performed with the Beckman Coulter Access II analyzer. The Perkin Elmer RESOLVETM Hemoglobin Kit was used to conduct the hemoglobin electrophoresis on the same blood sample that was used for the Full Blood Count. All tests were analyzed within 30 minutes of collection or centrifugation.

Results

Haemoglobin (Hb) and Haemoglobin (Hb) and hematocrit (Hct) levels are significantly lower in the FBC results, indicating anemia. Both the mean cell hemoglobin concentration (MCHC) and the low mean cell volume (MCV) point to microcytic anemia. The elevated red cell distribution width (RDW) indicates that the size of red blood cells (RBCs) varies. The reticulocyte count is slightly higher, indicating that the bone marrow is producing new RBCs in response. The white blood cell count (WBC) is slightly elevated, with a predominant neutrophil population, but the platelet count is within the normal reference range.

Figure 1: Full Blood Count from a “Sysmex XN-1000” analyser
(Source: Provided)

Any abnormal variants of hemoglobin that may be present can be identified with the aid of the hemoglobin electrophoresis test. The iron studies will provide information on iron stores, transferrin saturation, and iron binding capacity in terms of biochemistry, which can assist in determining the cause of the anemia. The soluble transferrin receptor assay can also give you more information about how much iron is in your body. By and large, the FBC and resulting tests recommend a finding of iron-lack weakness. The strange dietary desires revealed by the patient may likewise uphold this analysis. The GP ought to give fitting iron supplementation and screen the patient's reaction to treatment. The obstetric group ought to likewise intently screen the patient's pregnancy and guarantee ideal consideration.

Discussion

The pregnant lady has extreme pallor, as per the FBC results. Her mean cell volume (MCV) is low at 55 fL, indicating that she has microcytic anemia, and her hemoglobin (Hb) level is 60 g/L, which is significantly lower than the reference range of 115-165 g/L. Her red cell count (RCC) is also significantly lower than the reference range, at 3.82 x 1012/L, and her hematocrit (Hct) is significantly lower, at 21 L/L (Obeid et al., 2019). Low concentrations of MCHC and mean cell hemoglobin (MCH) point to hypothermia. A high degree of anisocytosis is indicated by a 19.1% rise in the red cell distribution width (RDW). The reticulocyte count (Retics), which is within the reference range at 1.7%, indicates that the bone marrow's response to the anemia is normal. Neutrophils (N) are slightly elevated on the differential white cell count (Diff) at 4.8 x 109/L, while lymphocytes (L), monocytes (M), eosinophils (E), and basophils (B) fall within the normal range. The white cell count (WCC) and platelet count (Plts) are both within the reference range. At 569 x 109/L, the platelet count is slightly elevated.

Iron deficiency anemia, the most common cause of anemia during pregnancy, appears to be the diagnosis made by the FBC results for the pregnant woman (Samarron et al., 2020). Iron is required for the production of hemoglobin, and since maternal red cell mass and fetal requirements increase during pregnancy, iron requirements rise as well. Iron deficiency anemia is suggested by the low Hb, RCC, and Hct is values. Because this is a characteristic morphological feature of iron deficiency anemia, the high RDW of microcytic, hypochromic red cells also suggests iron deficiency. The bone marrow is effectively counteracting the anemia, as evidenced by the normal reticulocyte count.

As thrombopoietin, a hormone produced by the liver and kidney is stimulated in response to anemia, leading to an increase in platelet production, the elevated platelet count is likely the result of the compensatory response to the anemia. The normal Diff and WCC results indicate that the anemia is not caused by an underlying infection or inflammation.

Serum iron, ferritin, transferrin, and unsaturated iron-binding capacity (UIBC) studies would be the next step in the investigation of this woman's anemia (Wu et al., 2021). The results of these tests will assist in confirming the diagnosis of iron deficiency anemia and determining its severity. Additionally, the soluble transferrin receptor assay (sTfR) can be used to distinguish between microcytic anemia caused by other conditions like thalassemia and iron deficiency anemia.

The clinical signs of sluggishness, shortness of breath, and unusual food cravings support the diagnosis of iron deficiency anemia (Hall, 2020). Fatigue, weakness, shortness of breath, and pica—a craving for things other than food like ice or dirt—are all symptoms of iron deficiency.

Inadequate iron intake from food is the most common cause of iron deficiency anemia, but it can also be caused by excessive blood loss or poor iron absorption in the gastrointestinal tract. In this instance, the patient said that she had unusual food cravings, which could mean that she didn't have enough iron or other nutrients. Additionally, her shortness of breath and lethargy are indicative of anemia. The full blood count reveals a significant drop in hemoglobin, hematocrit, and mean cell volume, all of which point to a smaller red blood cell mass. Hypochromia is indicated by a decrease in the mean cell hemoglobin concentration. A high red cell distribution width and these findings suggest that the anemia is microcytic and likely caused by iron deficiency (Carville, 2021). The reticulocyte count is marginally raised, showing a reaction to pallor, and the platelet count is raised, which can be a compensatory system for diminished oxygen conveyance to tissues. The fact that the differential and white cell count are within normal ranges suggests that the anemia is not caused by an infection or a hematologic malignancy. Hemoglobin electrophoresis and iron studies can be used to confirm the diagnosis and identify the underlying cause of the anemia.

In conclusion, the findings of the FBC suggest that the Mumbai-based pregnant woman, who is 20 years old, suffers from severe iron deficiency anemia. The most common cause of anemia during pregnancy is iron deficiency, which can have significant negative effects on both the mother and the fetus. Iron tests would be the next step in the investigation to confirm the diagnosis and determine the severity of the iron deficiency. Corrective treatment requires iron supplementation. 

References


 

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