14F Anemia and Bicytopenia

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 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT


A 14 yr old female student from Ramanapet has complaints of pulling pain in both legs in the calves and shortness of breath.


HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 5 months back. 

5 months back, she was given the first dose of CORBEVAX vaccine that was freely distributed in her school (Apr. 9th). She had no fever, or muscle pain post vaccination. Approximately 5-7 days, later, she developed SOB after walking and climbing stairs (Grade 2).  

[Advocate mentioned that patient used to walk to school everyday. However, 5-7 days after vaccination, she used to stop in the middle saying she couldn't walk anymore. She used to use an Indian toilet, but started using Western as she was unable to sit down due to her leg pain.]

Patient had similar complaints when family went to a trip in May. She avoided places with stairs. After they returned from a trip, family attended a function, after which the patient complained of extreme fatigue and tiredness, and promptly went to sleep.

All these symptoms were thought to be due to her obesity.

Around the end of May, patient collapsed in a shop. Her parents noticed her pale skin and dry lips and took her for lab tests (CBP). Results showed severely decreased platelets - 33.8 x 10^3/microL (Normal = 150-450 x 10^3/microL)  and Hb of 4.7.

They went to a Pvt. hospital for consultation. The patient underwent blood transfusion. A bone marrow biopsy was performed and they diagnosed the condition as aplastic anemia. She was first prescribed steroids which caused disturbances in her sleep. Later, when no change was seen, she was given cyclosporine, romioplostim, and Danazol.

 All her symptoms decreased. 

But she still had frequent episodes of 'collapsing' and SOB. 

[NOTE: There was no fainting or loss of consciousness. The patient's vision blackened and she collapsed due to weakness in her legs]

Each time, the parents took her for lab tests where her Hb and platelets were found to be low again, and blood transfusions were done. 

They then went to another Pvt. hospital for a second opinion. They gave the same diagnosis of aplastic anemia. She was asked to continue with the same medication. 

10 says ago, the patient got an irradiation transfusion. They have also given a sample for genetic testing.


PAST HISTORY:

No significant past history. 


PERSONAL HISTORY:

Patient used to regularly walk to school, and was overall active. 

Diet: Mixed. More non-veg, and moderate amount of junk food.

Sleep: Disturbed when steroid were give. Now it is normal

Bowel and Bladder movements: Normal


LABS: 

FIRST CBP:



























LAB FINDINGS AND DISCUSSION:
+ results:

- Blood culture (Jun 27) - positive for pseudomonas (sensitive to TMP-SMX, Ceftazidime, Cefepime, Meropenem)

- Vitamin B12 decreased - 178pg/mL (N = 180-814 pg/mL) 

- CBP and bone marrow - severe thrombocytopenia, hypocellular bone marrow with reduced trilineage hematopoiesis. 

- Highly elevated serum iron - 321.2 (N = 39-149) - can be due to blood transfusions

- Blood smear - Anisopoikilocytosis with ovalocytes

-ve results:
Parvovirus not detected (causes aplastic anemia)
PNH diagnosis not supported by labs
Folic acid Normal 
Serum ferritin Normal
Reticulocyte count Normal
LFT Normal (elevated bilirubin might indicate hemolytic anemia)
No hepatosplenomegaly
COOMBs test is negative (can indicate hemolytic anemia/transfusion reactions)
C3, C4 Normal (can indicate AI disorder) 



This document shows that CORBEVAX has been associated with ITP and thrombosis with venous infarct. (2 cases)


"Approximately 50% of ITP-ES patients develop neutropenia and 5% to 10% develop pancytopenia."







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