Dr. Kim presented the interesting case of a patient who presented with what sounded like influenza... and was found to be profoundly cytopenic on admission.
How do I approach the Pancytopenic Patient?
Dr. Kim presented a schema for approaching a cytopenic patient. Cytopenias are secondary to either not enough being made or too much getting used up.
Not enough being made includes aplasia (in generally, not enough of a cell is being made) and infiltration (the bone marrow is being invaded, so cells aren't being made). Too much getting used up includes consumptive processes (the cell line is being utilized rapidly), sequestration (the cells are being kept out of the circulation), or destructive processes (something is destroying the cell line after it is made).
There are many causes of pancytopenia... the below image is from Up to Date and includes just the acquired causes.
How do I approach a patient with new pancytopenia?
As always, starting with a good history and physical is essential. Initial workup should include a full CBC with a manual differential, a peripheral blood smear, and a reticulocyte count as well as a type & screen.
When taking the history and reviewing the EMR make sure to think about:
Time course- Is this new in the past week? Or has the patient had this for years?
Severity- Is this subclinical? Has the patient had symptoms? Is the ANC 0?
Symptoms- Ask about fatigue, infectious symptoms, easy bruising/bleeding, constitutional symptoms, etc.
Previous Treatments & Medications
Exposures
Examination can also be helpful in trying to determine the underlying etiology. Specifically, on exam look for rashes (could be secondary to rheumatologic disease, infection, malignancy, or drugs), oral ulcers, candidal infections, lymphadenopathy, splenomegaly, hepatomegaly, or other stigmata of liver disease.
Next, your goal is to determine if there is an emergent situation that requires immediate oncologic consultation in addition to hospitalization. The following are situations that require at the minimum hospitalization and generally require immediate oncology consultation:
ANC <1000 with fever or other evidence of infection
New diagnosis with ANC <1000
Suspected DIC, TTP, HUS or other thrombotic microangiopathy
Suspected acute leukemia or medical emergencies associated with leukemia, such as DIC or tumor lysis syndrome
Suspected HLH
Metabolic emergencies
Therefore, you should order the following in addition to the above labs:
Uric Acid, LDH, Phos and a BMP-- to evaluate for TLS and to check renal function
Coagulation Panel-- to evaluate for DIC & HLH
Blood cultures if concerned for infection
Ferritin & liver function testing-- to rule out HLH
Calcium
References
UpToDate. "Approach to the adult with pancytopenia" by N. Berliner. 2019.
Devitt KA, Lunde JH, Lewis MR. New onset pancytopenia in adults: a review of underlying pathologies and their associated clinical and laboratory findings. Leuk Lymphoma 2014; 55:1099.
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