Challenges of managing HIV cytomegalovirus co-infection in the presence of pancytopenia

A 60-year-old male patient who presented with generalized weakness and low-grade fever was diagnosed to be human immunodeficiency virus (HIV) positive with a CD4 count of 17. Routine laboratory investigations revealed pancytopenia. Serum cytomegalovirus (CMV) DNA polymerase chain reaction (PCR) was positive and fundoscopy showed CMV retinitis in the right eye. The patient was started on tablet valganciclovir. After 2 weeks, the patient was brought back in an altered sensorium. He was found to have hyponatremia which was corrected. He was started on antiretroviral therapy and tablet valganciclovir was continued. The patient came back again after one and a half months with a urinary tract infection and fissure-in-ano. He was found to have severe neutropenia. Valganciclovir was stopped. He was started on injection granulocyte colony-stimulating factor. The patient clinically improved and his hematological parameters became normal. Patients having HIV and CMV co-infection with pre-existing pancytopenia have to be closely monitored as the medicines used for treatment can exacerbate the existing conditions.

EVALUATION OF PANCYTOPENIA WITH BONE MARROW INTERPRETATION

Background: Pancytopenia is one of the most common clinico-haematological entity observed in our day to day clinical practice. It is a disorder in which all the three major elements of blood (i.e. red blood cells, white blood cells and platelets) are decreased in number. The causes of pancytopenia may be due to decrease in hematopoietic cell production in the marrow resulting from infections, toxins, malignant cell in?ltration, post- chemotherapy or post-radiation. Aims and Objectives: 1) To study the etiology and clinical presentation of pancytopenia in all age groups. 2) To correlate with bone marrow interpretation Materials & Methods: This is a prospective study which was conducted among 50 patients of pancytopenia in the Clinical Pathology, Government General Hospital,Kurnool from January 2021 to October 2022 Bone marrow aspiration was done by using Salah's bone marrow puncture needle. Smears were made from bone marrow aspirate (BMA) and stained by Leishman stain and special stains like Perl`s wherever necessary. The smears were assessed for cellularity, differentiation and maturation of erythroid, myeloid and megakaryocytic lineage, M:E ratio, Plasma cells, Lymphocytes and parasites/ abnormal cells. In the present study the commonest cause of Pancytopenia was Megaloblastic anemia (70%) followed by Results: Dimorphic anemia (20%). The less common conditions were Multiple Myeloma (6%),Chronic Myeloid Leukemia(2%),Acute Leukemia(2%). The present study concludes that complete primary hematological Interpretation and Conclusion: investigations along with bone marrow aspiration in pancytopenic patients are helpful for understanding disease process and to diagnose or to the rule out causes of pancytopenia. These are also helpful in planning for further investigations and management

Analysis of a case of pancytopenia complicated with delayed drug fever induced by vancomycin infusion in a child / 中国药房

OBJECTIVE To accurately identify the rare adverse drug reactions （ADR） of vancomycin-pancytopenia in order to promote its safe use. METHODS Through a case report of a child with suppurative hip arthritis who developed pancytopenia combined with delayed drug fever caused by intravenous infusion of vancomycin，Naranjo score method and related literature were used to summarize the association between the ADR and vancomycin and its possible mechanism， and suggestions for rational use of vancomycin in pediatric patients were put forward. RESULTS & CONCLUSIONS The association of pancytopenia combined with delayed drug fever and vancomycin in this child is “very likely”. In clinical practice， it is difficult to distinguish between pancytopenia combined with delayed drug fever from fever and hematopenia caused by aggravation of infection. Medical staff should increase their awareness of vancomycin rare ADR such as pancytopenia， and pharmacists should assist medical staff in timely screening for ADR. The initial dose of vancomycin infusion for children should start from 60 mg/（kg·d），and the blood concentration should be monitored 48 h after the first infusion and the dose should be adjusted in time to maintain the valley concentration of vancomycin at 5-15 mg/L to prevent the occurrence of ADR caused by excessive blood concentration. For children who have been using vancomycin for more than one week，the blood routine should be rechecked regularly. Once pancytopenia occurs，the drug should be stopped immediately，and symptomatic treatment should be given according to the situation.

Autopsy findings of acute erythroid leukemia

ABSTRACT Acute erythroid leukemia (AEL) is an exceedingly uncommon but distinct hematological malignancy that shows neoplastic proliferation of erythroid precursors with maturation arrest and no significant myeloblasts. We describe an autopsy case of this rare entity in a 62-year-old man with co-morbidities. He underwent a bone marrow (BM) examination for pancytopenia during the first outpatient department visit, which revealed an increased number of erythroid precursors with dysmegakaryopoiesis suggesting the possibility of Myelodysplastic syndromes (MDS). Thereafter, his cytopenia got worsened, warranting blood and platelet transfusions. Four weeks later on the second BM examination, AEL was diagnosed based on morphology and immunophenotyping. Targeted resequencing for myeloid mutations revealed TP53 and DNMT3A mutations. He was initially managed along febrile neutropenia with the stepwise escalation of antibiotics. He developed hypoxia attributed to anemic heart failure. Subsequently, he had hypotension and respiratory fatigue pre-terminally and succumbed to his Illness. A complete autopsy showed infiltration of various organs by AEL and leukostasis. Besides, there was extramedullary hematopoiesis, arterionephrosclerosis, diabetic nephropathy (ISN-RPS class II), mixed dust pneumoconiosis, and pulmonary arteriopathy. The histomorphology of AEL was challenging, and the differential diagnoses were many. Thus, this case highlights the autopsy pathology of AEL, an uncommon entity with a strict definition, and its relevant differentials.

Pancytopenia as a presentation of B12 deficiency

We present the case of a 16-year-old boy with hemolytic anemia with investigations showing pancytopenia, which turned out to be due to B12 deficiency. Whenever we see a teenager presenting with pancytopenia, the common causes that we think of are hematologic malignancies, drug-induced cytopenias, hypersplenism, etc. Anemia as a presentation is common in B12 deficiency, yet its occurrence with jaundice is a very uncommon and easily overlooked presentation. The same is the case of B12 presenting as pancytopenia which is a well-described entity, yet omitted initially due to its uncommon nature in this modern developed world.

A confounding case of pancytopenia

Tuberculosis is one of the major health problems in the developing countries like India. Due to its nonspecific presentation, extra pulmonary TB is diagnosed at later stages.It is an important differential diagnosis for pyrexia of unknown origin (PUO). A 54-year-old male came to hospital with complaints of fever, pain abdomen (on and off), easy fatiguability, reduced appetite, weight loss, breathlessness on exertion for 8 months who completely recovered after starting anti-tubercular therapy.

Autoimmune myelofibrosis and systemic lupus erythematosus: a case report

Bone marrow fibrosis is a rare disorder that can be associated with autoimmune diseases such as systemic lupus erythematosus (SLE), and can be confused with the manifestations of that disease. The case is presented on a patient with autoimmune myelofibrosis in the context of SLE.

La fibrosis de la médula ósea es una enfermedad rara que se puede ver asociada con enfermedades autoinmunes como el lupus eritematoso sistémico (LES) y que puede llegar a ser confundida con las manifestaciones propias de la enfermedad. Se presenta el caso de una paciente con mielofibrosis autoinmune en el contexto de LES.

A Prospective and Retrospective Study of Bone Marrow in Patients with Pancytopenia– A Study of 150 Cases

BACKGROUND : The bone marrow is widely distributed organ and is the principle site for blood cells forma?on. The broad spectrum of disorders affects the marrow primarily or secondarily with presenta?on of peripheral pancytopenia. Hence, bone marrow examina?on is extremely helpful in evalua?on of pancytopenia. This study emphasizes the different causes of pancytopenia and bone marrow morphology in cases of pancytopenia. MATERIALS & METHODS: The present study is a retrospec?ve and prospec?ve study done in the department of Pathology, for a period of two years. All the relevant history, clinical details, radiological details, and biochemistry parameters were considered. RESULTS: Out of 150 cases,96 were males and 54 were females. Majority of the pa?ents were in the age group of 41-60 years (54%) amongst whom Megaloblas?c anaemia was the most important cause of pancytopenia. CONCLUSION: Bone marrow aspira?on is rela?vely a very safe invasive procedure and primarily permits cytological assessment since the underlying pathology determines the management and prognosis of the pa?ents.

Malaria cerebral con pancitopenia por plasmodium vivax en la amazonía peruana: reporte de caso / Plasmodium vivax cerebral malaria with pancytopenia in the peruvian amazon: case report

RESUMEN Plasmodium vivax es la especie más común en la Amazonía peruana y ocasiona el 81% del total de casos de malaria. Presentamos el caso de un paciente adulto varón con malaria cerebral por Plasmodium vivax, que inicia con malestar general y fiebre, luego presenta convulsiones más de dos veces al día con pérdida de consciencia y limitación funcional motora. Se le realiza gota gruesa donde se observa trofozoítos de Plasmodium vivax y depresión de las tres series sanguíneas. Se inicia tratamiento con artesunato y clindamicina por cinco días, se le transfunde un paquete globular, y continua con primaquina por siete días. El paciente muestra mejoría clínica con secuela neurológica en extremidad inferior izquierda.

ABSTRACT Plasmodium vivax causes 81% of all malaria cases and is the most common species in the Peruvian Amazon. We present the case of a male patient with cerebral malaria caused by Plasmodium vivax, who had general malaise and fever, and then presented seizures more than twice a day with loss of consciousness and motor functional limitation. Plasmodium vivax trophozoites were detected by thick blood smear, besides, we also observed low counts of all three blood cell types. Treatment began with artesunate and clindamycin for five days, then one unit of packed red blood cells was transfused; treatment continued with primaquine for seven days. The patient showed clinical improvement with neurological sequelae in one lower limb.

Anemia megaloblástica. A propósito de un caso / Megaloblastic anemia

La OMS reporta anemia en 24,8% de la población con predominio en países en desarrollo. La anemia megaloblástica, es una causa frecuente en la población adulta mayor. Se caracteriza por alteración en la síntesis de ácido desoxirribonucleico por deficiencia de vitamina B12 y/o folatos. Presentamos el caso de una mujer con manifestaciones clínicas y alteraciones de laboratorio características. Recibió tratamiento combinado con cianocobalamina y ácido fólico. Paulatinamente presentó reversión clínica y laboratorial. A pesar del nombre, la anemia megaloblástica, suele cursar con anemia, bicitopenia o ancitopenia y alteraciones sistémicas. Es obligatorio buscar la causa desencadenante para instaurar el tratamiento completo.

The WHO reports anemia in 24.8% of the population mainly in developing countries. Megaloblastic anemia is a frequent cause in the elderly population and it is due to an impaired synthesis of deoxyribonucleic acid. A deficiency of vitamin B12 and / or folic acid are the main causes. We present the case of a woman with characteristic clinical manifestations and laboratory abnormalities. She was treated with cyanocobalamin and folic acid. She improved and her laboratory tests got to normal gradually. Despite the name, megaloblastic anemia usually presents anemia, bicytopenia or pancytopenia and systemic manifestations. It is mandatory to search for the etiologic cause to make a complete treatment.

Bone Marrow Aspiration Findings in Hematological Disorders in Children

Background: Primary objective was to study bone marrow aspiration(BMA) findings in hematological disorders in children with secondary objective to find correlation between peripheral blood film (PBF) findings with BMA.Material & Methods:It was observational and cross-sectional study conducted on 65 children in age group of 1-18 yrs admitted to Pediatrics Department of Government Medical College, Patiala over period of 1 yr. Inclusion criteria was based on clinical and laboratory parameters. Children were of anaemia, leucopenia and pancytopenia. Complete hemogram, reticulocyte count, PBF smear and bone marrow aspiration were done. The data was analyzed using IBM Statistical Packages for Social Sciences SPSS software version 22.Results:The mean age of study population was 10.39�29yrs. 93.8% children presented with pallor followed by fever in 84.6% and lethargy in 66.2%. 62 children were severely anaemic, 33 had bicytopenia, 23 children had pancytopenia. Bone marrow was hypercellular in 59 (90.8%) children. 40 (61.5%) children had megaloblastic anaemia on BMA followed by dimorphic anaemia in 8, Idiopathic thrombocytopenic purpura in 6 children. 4 children each had Megaloblastic anaemia with gelatinous transformation and micronormoblastic anaemia. 2 children had acute lymphatic leukemia and one had aplastic anaemia. The predominant PBF was dimorphic in 30 children, out of whom 22 had megaloblastic anaemia and 8 had dimorphic anaemia on BMA. Conclusions:Bone marrow was megaloblastic in majority (61.5%) of children. There was no significant association found between PBF findings and bone marrow diagnosis.

A rare case of pancytopenia due to leishmaniasis - A case report

Visceral Leishmaniasis (VL) or Kala Azar is a chronic protozoal infectious disease caused by the Leishmania donovani complex which causes a variety of hematologic manifestations. It is manifested by fever, hepatosplenomegaly, weight loss, pancytopenia and hypergammaglobinemia. In India it is mainly seen in the states of Bihar and West Bengal. Patients with VL can present to the hematologist for variety of hematological presentation even before the diagnosis of VL is made. Anemia is the most common hematological manifestation of VL. VL may also be associated with leucopenia, thrombocytopenia, pancytopenia, hemophagocytosis and disseminated intravascular coagulation. Hematological improvement is noted with the treatment for VL. Relapses are rare. In this case report, we present a rare case of leishmaniasis with pancytopenia, which is rare in Hyderabad, Telangana, India

The muddled pancytopenia

Pancytopenia always remains a challenge for its detailed diagnostics evaluation, ranging from megaloblastic anemia to marrow aplasia and leukemia. Here, we report the case scenario of a 70-year-old male who presented with pancytopenia and his elaborated diagnostics approach, concluding the diagnosis of myelofibrosis with positive W515L. This case illustrates the uniqueness of establishing the diagnosis of myelofibrosis.

Aetiology of pancytopenia: Experience of a South African tertiary academic centre

Background: Pancytopenia is a manifestation of numerous disease entities. The causes of pancytopenia differ with geographic region, socio-economic factors and HIV prevalence. Awareness of the common causes of pancytopenia may aid timely diagnosis. Objective: This study aimed to determine the aetiology of pancytopenia in a South African population.Methods: A retrospective observational study of adult patients presenting with pancytopenia at Tygerberg Academic Hospital, South Africa, from January 2016 to December 2017 was performed. Data on pancytopenia cases were obtained from the laboratory information system and utilised to determine the causes of pancytopenia. Results: A total of 673 cases of pancytopenia were identified. The most common causes of pancytopenia were chemoradiation therapy (25%), sepsis (18%), haematological malignancy (9%), advanced HIV (7%), and megaloblastic anaemia (6%). The diagnostic yield of bone marrow examinations (BME) was 57% (n = 52/91). The aetiology of pancytopenia differed according to age, with malignancy being a more common cause of pancytopenia among the elderly. Conclusion: Several easily recognisable and treatable conditions can manifest as pancytopenia. Prompt management of such conditions, notably sepsis and megaloblastic anaemia, can result in the resolution of the cytopenias and negate the need for a BME. However, haematological malignancy and unexplained pancytopenia strongly rely on a BME to establish a diagnosis. Pancytopenia investigations, when guided by appropriate clinic-laboratory findings, can promptly identify the underlying aetiology, while also identifying cases where an expedited BME is required. This is valuable in resource-conscious medicine

Two cases of brucellosis complicated with liver abscess or pancytopenia / 中华全科医师杂志

Two brucellosis patients with rare complications are presented in this report. In case 1, abdominal CT showed two liver abscesses with the maximum diameter>5.0 cm, no puncture and drainage were given. After treatment with anti brucellosis drugs, the abscess lesions disappeared completely. Case 2 had pancytopenia, the platelet count was reduced to 14×10 9/L. After anti brucellosis drug treatment the peripheral blood routine returned to normal. These two cases of rare complications of brucellosis suggests that early identification, diagnosis and treatment can improve the clinical outcomes of the patients.

Pancytopenia caused by intrathecal injections of chemotherapeutic agents in central nervous system leukemia: report of 1 case and review of literature / 白血病·淋巴瘤

Methods:The clinical data of a CNSL patient with pancytopenia caused by intrathecal injections of chemotherapeutic agents in the First Affiliated Hospital of Zhengzhou University in January 2017 were retrospectively analyzed, and the related literature was reviewed.Results:The patient was a 71-year-old man who was diagnosed with acute myeloid leukemia. During regular chemotherapy, he suffered from extramedullary relapse, and leukemic cells invaded the superior sagittal sinus of brain. Lumbar puncture and intrathecal injections of chemotherapeutic agents were given intermittently. During this period, the complete blood count of patient progressively declined, and oral mucositis appeared. After calcium folinate rescue and intermittent blood transfusion, the complete blood count recovered. Eventually, the patient developed bone marrow relapse and died of infection.Conclusions:On the one hand, the invasion of leukemia cells into the central nervous system leads to increased intracranial pressure and accelerated absorption of cerebrospinal fluid; on the other hand, it induces the structural damage of the superior sagittal sinus or increased permeability, and therefore chemotherapy agents continue to enter the blood with cerebrospinal fluid, which may be the cause of pancytopenia.

Co-occurrence of myeloid neoplasm and plasma cell neoplasm

ABSTRACT Co-occurrence of myelodysplastic syndrome (MDS) and plasma cell neoplasm in patients with no history of chemo and/or radiotherapy is rarely reported. Herein, we report a case of a female in her seventieth decade of life who was referred to the hospital for pancytopenia. The patient was asymptomatic and was doing well overall. Serum protein electrophoresis was remarkable for a lambda-restricted monoclonal protein (IgG) estimated at 1.8g/dL. Immunoglobulin G serum level was also elevated, and serum Kappa/Lambda free light chain ratio was decreased. At that time, a bone marrow biopsy showed myelodysplastic syndrome with excess blasts-2 (MDS-EB2) and a monoclonal plasma cell proliferation. Some studies have shown that patients with plasma cell neoplasm could be associated with an increased risk of developing MDS compared to the general population. Based on reviewing the literature, to our knowledge, the pathological mechanism of the co-occurrence of both diseases is not yet clear.

Hipoplasia de medula óssea: manifestação atípica do hipertireoidismo / Bone marrow hypoplasia: atypical manifestation of hyperthyroidism / Hipoplasia de la médula ósea: manifestación atípica del hipertiroidismo

Alterações hematológicas, como anemia ou pancitopenia, podem ser manifestações atípicas do hipertireoidismo. Embora a maioria dos casos de pancitopenia na doença de Graves seja decorrente do uso de drogas antitireoidianas ­ tionamidas ­, ela também pode estar associada ao quadro de hipertireoidismo não tratado e, assim, se manifestar como uma complicação grave. Este estudo tem como objetivo relatar o caso de uma paciente portadora de hipertireoidismo que evoluiu durante o internamento por pancitopenia secundária à doença primária. As informações foram obtidas por meio da revisão do prontuário, entrevista com a paciente e revisão da literatura. Trata-se de uma paciente do sexo feminino, de 39 anos, internada em um hospital de Salvador por apresentar um quadro de edema em membros inferiores que evoluiu progressivamente para anasarca por 45 dias. Associados ao quadro, a paciente apresentava perda ponderal, dispneia paroxística noturna, taquicardia, sudorese e calafrios, além dos exames laboratoriais terem apresentado pancitopenia. O caso relatado demonstra uma manifestação atípica e rara do hipertireoidismo, que melhorou após o início do tratamento e do estado de eutireoidismo.

Hematological changes such as anemia or pancytopenia can occur as atypical manifestations of hyperthyroidism. Although most cases of pancytopenia in Graves' disease are due to the use of antithyroid drugs (thionamides), it can also be associated with untreated hyperthyroidism, thus manifesting as a serious complication. This study aims to report the case of a 39-year-old hyperthyroid female patient who developed pancytopenia during hospitalization. Data were collected by means of the medical record, an interview conducted with the patient, and literature review. The patient was admitted to a hospital in Salvador presenting lower extremity edema that progressively evolved to anasarca within 45 days prior to the interview. She also presented weight loss, paroxysmal nocturnal dyspnea, tachycardia, sweating, chills, and laboratory test results for pancytopenia. The case reported here demonstrates an atypical and rare manifestation of hyperthyroidism that improved after the beginning of the treatment, reaching the euthyroid state.

Los cambios hematológicos como anemia o pancitopenia pueden ocurrir como manifestaciones atípicas de hipertiroidismo. Aunque la mayoría de los casos de pancitopenia en la enfermedad de Graves se deben al uso de fármacos antitiroideos (tionamidas), también se puede asociar a um hipertiroidismo no tratado y, por tanto, puede manifestarse como una complicación grave. Este estudio tiene como objetivo reportar el caso de una paciente con hipertiroidismo que desarrolló durante la hospitalización pancitopenia secundaria a la enfermedad primaria. La información se obtuvo revisando la historia clínica, entrevistando a la paciente y revisando la literatura. Se trata de una paciente de 39 años ingresada en un hospital de Salvador por presentar edema en miembros inferiores, evolucionando progresivamente a anasarca durante 45 días. Asociado a la afección, presentaba pérdida de peso, disnea paroxística nocturna, taquicardia, sudoración, escalofríos y análisis de laboratorio que mostraban pancitopenia. El caso aquí reportado demuestra una manifestación atípica y rara de hipertiroidismo, que evolucionó luego del inicio del tratamiento y del estado de eutiroidismo.

Lithium Toxicity Associated with Pancytopenia And Megaloblastic Anaemia.

A 29-year-old male was treated for Bipolar Affective Disorder since 5 months with Lithium 400 mg per day which was gradually up titrated to 800 mg in 10 days of start of treatment in view of minimal improvement in symptoms. After 2 months of treatment patient started experiencing weakness and fatiguability. During third month of treatment patent had complaints of 3 episodes of vomiting associated with nausea, mild abdominal pain, diarrhea, dyspnea on exertion, restlessness, tremors, dry mouth and decreased sleep. Patient was brought to emergency department and all baseline investigations were done which were suggestive of Pancytopenia. Hematology reference was done, and lithium toxicity was considered as contributing factor for above symptoms and results. Short-term lithium administration may be life-threatening and should thus be prescribed cautiously in hematological disorders as in other conditions

Pharmaceutical care for a patient with pancytopenia and liver injury induced by methimazole / 药学实践杂志

Objective To explore the treatment of pancytopenia and liver injury induced by methimazole and provide medication therapy reference for clinical pharmacists in clinical practice. Methods The clinical pharmacists provided clinical interventions by the evaluation of adverse drug reactions, assessment of the therapeutic effects, adjustment of therapeutic regime based on the patient′s disease condition. Results The physician adopted the recommendations from the clinical pharmacists. The patient with pancytopenia and liver injury induced by methimazole gradually recovered with biochemical indices back to normal levels. Conclusion The therapeutic outcome was improved with clinical pharmacist’s knowledge on medication, optimization of therapeutic regime and implement of pharmaceutical care.