bioguy
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The diagnosis of aplastic anemia is made in cases of pancytopenia with a hypocellular marrow biopsy containing no abnormal cells. Aplastic anemia must be differentiated from other causes of pancytopenia. Myelodysplastic disorders, especially hypocellular forms of myelodysplasia, or acute leukemia may occasionally be confused with aplastic anemia. These are differentiated by the presence of morphologic abnormalities or increased blasts, or by the presence of abnormal cytogenetics in bone marrow cells. Hairy cell leukemia has been misdiagnosed as aplastic anemia and should be recognized by the presence of splenomegaly and by abnormal lymphoid cells on the bone marrow biopsy. Pancytopenia with a normocellular bone marrow may be due to systemic lupus erythematosus, disseminated infection, or hypersplenism. Isolated thrombocytopenia may occur early as aplastic anemia develops and be confused with immune thrombocytopenia.
CMDT08
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| bioguy
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baryar wrote:
@BIOGUY
reticulocyte count was within normal.it was not above normal.
I guess Erythropoietin Deficiency will result in reduced Reticulocyte count
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| bioguy
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Ok,
If the condition is due to Erythropoietin deficiency - serum EPO levels will be low (obviously)
If its aplastic anemia - serum EPO levels will be high
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| bioguy
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What must have caused the 'reduced' leukocyte count, at least of the neutrophils if not the lymphocytes
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| bioguy
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and the platelets too - why are they reduced.
baryar,
according to me, the blood picture you've given fits more into aplastic anemia than primary EPO def.
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| baryar
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@BIOGUY
SIR ,retic count was not raised...not sure wether it was below normal or within normal.....what i m sure of is that it was not above normal.
and yes......platelets are also effected by erythropoetin.
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| new_n_lost
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One more thing Did you see anything else written in the Bone Marrow aspiration cos they wouldnt simply write Hypocellular/hypoplastic. With such counts of platelets every sample would have been rechecked before sending it to the residents.
I like i said earlier you need to go back and look up the reports again and talk to the labs.
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| new_n_lost
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Ok i know all of you are going to go bonkers on my next statement but this is what i feel from the above said discussion. You guys may disagree and discuss this and call me a lot of things.
My feeling is that Baryar here is not looking beyond EPO deficiency and therefore is a lot focused on EPO related examples. Anything else seems to relative to fact of EPO def.
My friend please can you shed some more light on the Labs and Bone marrow results and the complete history of the patient. Cos so far from what you have given us it looks like a Aplastic Anemia. And i dont what makes you so sure that this is EPO def. and how can you find lymphocytosis as normal with neutropenia. Can you elaborate on that fact too.
Maybe i am the one missing the big picture here but really you gotta explain that part to me.
My feeling is that a 50yr old man coming in with 3 months of fatigue and weakness indicating some sort of anemia. We have a Count of 3700/uL of WBC and most of them are Lymphocytes leaving me to 2 options either Aplastic Anemia or SLL ( fits almost the same) but the bone marrow tells me that its hypoplastic and notthing else then i have no other reason to think that this might be drug induced and /or infection related aplastic anemia. But unless i dont get enuf clues all my brainstorming will not get me anywhere cos i m working on a picture which already has 2 forementioned results.
Again my moi 2 cents.
Edited by new_n_lost on 04/07/08 - 06:42 PM
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| baryar
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in PERIPHERAL BLOOD FILM,it was stated that lymphocytes are mature.
BONE MARROW ANALYSIS ...it stated HYPOPLASTIC ( query APLASTIC ?? )...no other information on marrow report
AND U R RIGHT.i posted this question bcaz i wanted to know that can we compare this picture to EPO DEFICIENCY ??
i came across thiss case in a hospital.i went there to meet a friend and just by chance i noticed this case in ward.i thought that how can i say that its not a case of EPO deficiency...may b silly,but i wanted to learn more about it and i posted it here for discussion.To b honest,before that i hadnt come across the term EFFECTS OF DEFICIENCY OF EPO.I thought that may b u fellows will guide me better.
keep smiling
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| hottie99
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i thought aplastic anemia has low retic count so doesnt that mean that the bone marrow isn't functioning properly, so how could epo still be high, could u please explain bioguy, much appreciated!! 
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| bioguy
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baryar wrote:
@BIOGUY
and yes......platelets are also effected by erythropoetin.
Reference please? Where did you read that platelets are 'affected' by erythropoietin? And what do you exactly mean by 'affected' in the context of our discussion here? did you mean to say that given the condition that everything is normal except for EPO deficiency - there will be thrombocytopenia, then I DISAGREE!!!!
Thrombopoiesis is primarily regulated by Thrombopoietin (TPO). TPO and EPO share significant homology in protein structure. (Ref: Williams Hematology) THATS ALL. No functional significance of homology in our discussion. Its possible that in the absence of TPO, EPO may act redundantly to induce thrombopoiesis - and THIS IS A WILD GUESS, i have no reference for this. I am basing this entirely on protein homology. Ok, forget it, my emphasis here is EPO has no role in Thrombopoiesis. So in primary EPO deficiency, enough TPO is there to drive megakaryocyte generation.
I welcome you to counter-argue, and I am open to healthy criticism
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| bioguy
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hottie99 wrote:i thought aplastic anemia has low retic count so doesnt that mean that the bone marrow isn't functioning properly, so how could epo still be high, could u please explain bioguy, much appreciated!!
You are right. Aplastic anemia has low reticulocyte count and thats because bone marrow is not functioning properly - to be exact the progenitor cells are sparse in the marrow and are not sufficient to sustain the turnover required to maintain the normal cell count in blood. So in peripheral blood there will be less blood cells, and for our discussion - less RBC - and less oxygen carrying capacity - hypoxia - stimulates the kidney to make EPO - but this high EPO has no effect on the marrow (and we are back to square one)
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| bioguy
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I totally agree with nnl. I feel Baryar may be biased.
Baryar, its ok to stick to your idea, since i am also sticking to my idea (maybe stronger than you to yours) and everyone else is sticking to their own ideas. Well, thats a good thing, isn't it. Then we can discuss our ideas, present arguments and counterarguments and clear any misconceptions instead of just taking a hammer and banging on the other person's head to make him accept your idea.
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| bioguy
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bioguy wrote:
Rare cases of parvovirus B19 may lead to neutropenia and apparent lymphocytosis.
Koch WC, Massey G, Russell CE, Adler SP. Manifestations and treatment of human parvovirus B19 infection in immunocompromised patients. J Pediatr. 1990;116:355-359.
Sorry, couldn't get hold of the actual article.
I take this back. This might be too esoteric.
Generally, Parvo virus causes Pure Red Cell aplasia, while EBV causes more of a wider aplastic anemia
Ref: Williams
Edited by bioguy on 04/07/08 - 11:09 PM
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| bioguy
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I think this discussion is turning futile. (maybe because its time to go to sleep.)
Baryar, lets be realistic.
If you think its EPO deficiency, get serum EPO levels and that will solve this case.
And if it turns out to be really EPO def. then find its cause. Kidney disease???? I think so, because this person is 50y old, and genetic EPO def. would have been detected earlier. So the kidney is damaged enough to cause EPO def. then there must be symptoms of kidney failure too, don't you think???
Thats it. I am done.
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| 1.ammara
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EPO affects BFU-E ( Blood forming unit- Erythroid) and then CFU-E and then, erythropoiesis continues, so it basically affects the committed stem cells for RBCs. so, when there is a deficiency of EPO, only RBCs will be affected and anemia, bla bla bla but there is no alteration in the other counts at all due to EPO deficiency, thats so simple and logical! here, i must mention that Baryar wrote Erythroid or myeloid series in one of the posts which apparently means that he is taking it as the same and thats why insisting on the first mentioned clinical scenario as a case of EPO defficiency. but actually, myeloid series (myeloid stem cells) includes CFU-Eo, CFU-GM, CFU-MEGAK, CFU-E, CFU-Baso and all these cells are termed as myeloid series including erythrocytes. but, taking erythroid and myeloid as the same thing is ridiculous.
so, if there is EPO deficiency, thats is going to affect the erythroid series series only, but not the rest of the myeloid series cells. but if the case is of aplastic anemia, that affects the common stem cells basically, then, all the cells of myeloid series i.e neutrophils, platelets, RBCs( these 3 are more imp), eosinophils and basophils are affected of course! like the lab reports he has mentioned. here, arises an issue that lymphoid cells are not showing the decline in the report even though the common stem cells are being affected in aplastic anemia... the probable explanation is that although the common stem cells are a source of common lymphoid stem cells and hence, the lymphoctes but once, the naive lymphocytes are formed, they migrate to the thymus (T cells) for further processing and maturation or in case of B cells,reside the bone marrow for pre-processing but later goes to the lymhpoid organs like lymph nodes, etc for further processing and maturation. after that, the lymphocytes maily reside in the lymphoid organs and not the bone marrow. so, when the bone marrow is affected in aplastic anemia, little does it affect the lymphocytes. somebody else mentioned that lymphocytosis may be due EBV, which sounds reasonable here. aint it?? i guess the explanation well justifies the clinical picture and lab reports of the case under discussion as APLASTIC ANEMIA !
suggestions are welcome!
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| macintosh
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Can you guys believe I missed the whole show . Now may any one of you please summarise the whole discussion  
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| bioguy
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excellent, excellent post, ammara!!!! that settles it!
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| bioguy
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Guys, believe me, this is the first time i ever saw a normal bone marrow next to any pathological marrow. everywhere i find only pathological marrows and always search for a normal marrow for comparison. so here it is ... from Williams
Left - normal
Right - aplastic, with few scattered lymphocytes
Attached Files:
marrow.jpg (95 KB, 2 downloads)
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| bioguy
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Blood Findings in Aplastic Anemia: (Ref: Williams)
Patients with aplastic anemia have varying degrees of pancytopenia. Anemia is associated with a low reticulocyte index. The reticulocyte count usually is less than 1.0 percent and may be zero despite the high levels of erythropoietin. Macrocytes may be present. The total leukocyte count and platelet counts are low. The differential white cell count reveals a decrease in neutrophils and monocytes. An absolute neutrophil count less than 500 x 106/liter and a platelet count less than 20,000 x 106/liter are indicative of severe disease. A neutrophil count less than 200 x 106/liter indicates very severe disease. Lymphocyte production is thought to be normal, but patients may have mild lymphopenia. Platelets are reduced but function normally. Significant qualitative changes of red cell, leukocyte, or platelet morphology are not features of classic acquired aplastic anemia. On occasion, only one cell line is depressed initially, which may lead to an early diagnosis of red cell aplasia or amegakaryocytic thrombocytopenia. In such patients, other cell lines fail shortly thereafter (days to weeks) and permit a definitive diagnosis.
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| GoodGirl
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Yes, could someone summarize it for us, please ?
macintosh wrote:Can you guys believe I missed the whole show . Now may any one of you please summarise the whole discussion
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| bioguy
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Summary:
Above clinical findings (1st post)
Is it Aplastic Anemia or EPO deficiency?
Every finding fits aplastic anemia - reduced RBC, Hb, Hct, Thrombocytopenia, neutropenia etc.
WBC count - 3700 (divided opinion if this is low are low normal)
differential count is definitely abnormal
lymphocyte % = some 80 or so
question was why are lymphocytes relatively high???
Why is it not EPO def.?
because EPO effects only RBC. that won't explain the low leukocytes and platelets.
End of the story
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| bioguy
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If someone is thorough in Aplastic anemia - you may save time avoiding this post.
This was more of a time-pass fight rather than an intense discussion of a tough case. i didn't know much about aplastic anemia, so i jumped in. now i know something.
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| hottie99
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oh poor bioguy, what r u doing still attempting this post, it is useless, thus i quit after u pm!!! hahaa.. i stopped and asked what i needed to know, i find it hard to believe they will ask anything like this.. u are rite, this was for certain ppl who want to just prove god knows what (ahem, hehee) so spend time more effectively going over goljan and his aplastic anemia, he's got it covered.. best o luc!!
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| silver
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actually no one wants to prove anything here except have a productive discussion and walk away learning something. in fact this is the most "effective" way of spending time--having a group discussion. really not sure what you're trying to prove.
@NNL: buddy, you nailed it as usual......way to go!! honestly, i think you're ready to nail the exam now!
@bioguy: thanks for turning this thread into something worthwhile
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