TEXTBOOK DISCUSSION

A. DEFINITION
Pancytopenia
Pancytopenia is a condition in which a person’s body has too few red blood cells, white blood cells, and
platelets. Each of these blood cell types has a different job in the body:
• Red blood cells carry oxygen throughout your body.
• White blood cells are part of your immune system and help fight off infections.
• Platelets allow your blood to form clots.
If pancytopenia occurs, these are the combination of three different blood diseases:
• anemia, or low level of red blood cells
• leukopenia, or low level of white blood cells
• thrombocytopenia, or low platelet levels
Because the body needs all of these blood cells, pancytopenia can be very serious. It can even be life-
threatening if you don’t treat it.
Pancytopenia starts because of a problem with your bone marrow. This spongy tissue inside bones is
where blood cells are produced. Diseases and exposure to certain drugs and chemicals can lead to this
bone marrow damage.
Pancytopenia will more likely to occurs if these following condition is present:
-Cancers that affect the bone marrow, such as:
• leukemia
• multiple myeloma
• Hodgkin’s or non-Hodgkin’s lymphoma
• myelodysplastic syndromes
• megaloblastic anemia, a condition in which your body produces larger-than-normal, immature red
blood cells and you have a low red blood cell count
• aplastic anemia, a condition in which your body stops making enough new blood cells
• paroxysmal nocturnal hemoglobinuria, a rare blood disease that causes red blood cells to be destroyed
• viral infections, such as:
• Epstein-Barr virus, which causes mononucleosis
• cytomegalovirus
• HIV
• hepatitis
• malaria
• sepsis (a blood infection)
• diseases that damage bone marrow, such as Gaucher disease
• damage from chemotherapy or radiation treatments for cancer
• exposure to chemicals in the environment, such as radiation, arsenic, or benzene
• bone marrow disorders that run in families
• vitamin deficiencies, such as lack of vitamin B-12 or folate
• enlargement of your spleen, known as splenomegaly
• liver disease
• excess alcohol use that damages your liver
• autoimmune diseases, such as systemic lupus erythematosus
In about half of all cases, doctors can’t find a cause for pancytopenia. This is called idiopathic
pancytopenia.

Diagnostic Tests:
Complete blood count (CBC). This test measures the amount of red blood cells, white blood cells, and
platelets in the blood. If the CBC is abnormal, the pateint might need a peripheral blood smear. This test
places a drop of your blood on a slide to look at the different types of blood cells it contains.
Bone marrow aspiration and biopsy. In this test, the doctor uses a needle to remove a small amount of
liquid and tissue from inside your bone that can then be tested and examined in a lab.
The doctor might also do separate tests to look for the cause of pancytopenia. These tests can include
blood tests to check for infections or leukemia. CT scan or other imaging test will also be done to look
for cancer or other problems with your organs.

Myelodysplastic Syndrome
Myelodysplastic syndromes are a group of disorders caused by poorly formed blood cells or ones that
don't work properly. Myelodysplastic syndromes result from something amiss in the spongy material
inside your bones where blood cells are made (bone marrow).
Causes:
In a healthy person, bone marrow makes new, immature blood cells that mature over time.
Myelodysplastic syndromes occur when something disrupts this process so that the blood cells don't
mature.
Instead of developing normally, the blood cells die in the bone marrow or just after entering the
bloodstream. Over time, there are more immature, defective cells than healthy ones, leading to
problems such as fatigue caused by anemia, infections caused by leukopenia, and bleeding caused by
thrombocytopenia.
Some myelodysplastic syndromes have no known cause. Others are caused by exposure to cancer
treatments, such as chemotherapy and radiation, or to toxic chemicals, such as tobacco, benzene and
pesticides, or to heavy metals, such as lead.

Types of myelodysplastic syndromes:

The World Health Organization divides myelodysplastic syndromes into subtypes based on the type of
blood cells — red cells, white cells and platelets — involved.
Myelodysplastic syndrome subtypes include:
Myelodysplastic syndrome with unilineage dysplasia. One blood cell type —white blood cells, red blood
cells or platelets — is low in number and appears abnormal under the microscope.
Myelodysplastic syndrome with multilineage dysplasia. In this syndrome, two or three blood cell types
are abnormal.
Myelodysplastic syndrome with ring sideroblasts. This type, which has two subtypes, involves a low
number of one or more blood cell types. A characteristic feature is that existing red blood cells in the
bone marrow contain a ring of excess iron called ring sideroblasts.
Myelodysplastic syndrome associated with isolated del chromosome abnormality. People with this
syndrome have low numbers of red blood cells, and the cells have a specific mutation in their DNA.
Myelodysplastic syndrome with excess blasts — types 1 and 2. In both these syndromes, any of the
three types of blood cells — red blood cells, white blood cells or platelets — might be low and appear
abnormal under a microscope. Very immature blood cells (blasts) are found in the blood and bone
marrow.
Myelodysplastic syndrome, unclassifiable. In this uncommon syndrome, there are reduced numbers of
one of the three types of mature blood cells, and either the white blood cells or platelets look abnormal
under a microscope.

Diagnostic Tests:
A physical exam, medical history and tests might be used by the doctor to diagnose myelodysplastic
syndrome.
Tests might include:
Blood tests. Your doctor might order a number of blood tests to determine the number of red cells,
white cells and platelets and look for unusual changes in the size, shape and appearance of various
blood cells.
Removing bone marrow for testing. During a bone marrow biopsy and aspiration, a thin needle is used
to withdraw (aspirate) a small amount of liquid bone marrow, usually from a spot on the back of your
hipbone. Then a small piece of bone with its marrow is removed (biopsy). The samples are examined in a
laboratory to look for abnormalities.

Aplastic Anemia
Aplastic anemia is a condition that occurs when your body stops producing enough new blood cells.
Aplastic anemia leaves you feeling fatigued and with a higher risk of infections and uncontrolled
bleeding.
A rare and serious condition, aplastic anemia can develop at any age. Aplastic anemia may occur
suddenly, or it can occur slowly and get worse over a long period of time. Treatment for aplastic anemia
may include medications, blood transfusions or a stem cell transplant, also known as a bone marrow
transplant.
Aplastic anemia develops when damage occurs to your bone marrow, slowing or shutting down the
production of new blood cells. Bone marrow is a red, spongy material inside your bones that produces
stem cells, which give rise to other cells. Stem cells in the bone marrow produce blood cells — red cells,
white cells and platelets. In aplastic anemia, the bone marrow is described in medical terms as aplastic
or hypoplastic — meaning that it's empty (aplastic) or contains very few blood cells (hypoplastic).
Factors that can temporarily or permanently injure bone marrow and affect blood cell production
include:
Radiation and chemotherapy treatments. While these cancer-fighting therapies kill cancer cells, they can
also damage healthy cells, including stem cells in bone marrow. Aplastic anemia can be a temporary side
effect of these treatments.
Exposure to toxic chemicals. Exposure to toxic chemicals, such as some used in pesticides and
insecticides, may cause aplastic anemia. Exposure to benzene — an ingredient in gasoline — also has
been linked to aplastic anemia. This type of anemia may get better on its own if you avoid repeated
exposure to the chemicals that caused your initial illness.
Use of certain drugs. Some medications, such as those used to treat rheumatoid arthritis and some
antibiotics, can cause aplastic anemia.
Autoimmune disorders. An autoimmune disorder, in which your immune system begins attacking
healthy cells, may involve stem cells in your bone marrow.
A viral infection. Viral infections that affect bone marrow may play a role in the development of aplastic
anemia in some people. Viruses that have been linked to the development of aplastic anemia include
hepatitis, Epstein-Barr, cytomegalovirus, parvovirus B19 and HIV.
Pregnancy. Aplastic anemia that occurs in pregnancy may be related to an autoimmune problem — your
immune system may attack your bone marrow during pregnancy.
Unknown factors. In many cases, doctors aren't able to identify the cause of aplastic anemia. This is
called idiopathic aplastic anemia.

Diagnostic Tests:
To diagnose aplastic anemia, the doctor may recommend:

Blood tests. Normally, red blood cell, white blood cell and platelet levels stay within a certain range.
There will be a suspected aplastic anemia when all three of these blood cell levels are very low.
Bone marrow biopsy. To confirm a diagnosis, there will be a need to undergo a bone marrow biopsy. In
this procedure, a doctor uses a needle to remove a small sample of bone marrow from a large bone in
your body, such as your hipbone. The bone marrow sample is examined under a microscope to rule out
other blood-related diseases. In aplastic anemia, bone marrow contains fewer blood cells than normal.

Pneumonia in Immunocompromised Host

Pneumonia in the immunocompromised host is a complex infection and inflammation of the lower
respiratory tract, complicated by widespread multi-drug antibiotic resistance, and aided by medical
advances such as improvements in diagnostic measures and immunosuppressive agents. Though overall
patient survival has increased, pneumonia is both the most common invasive infection in
immunocompromised patients and continues to carry a high mortality and morbidity rate.
The major immunocompromised host groups are those with:
• HIV/AIDS
• Solid organ and hematopoietic cell transplants
• Malignancy on chemotherapy or radiation therapy
• Primary immunodeficiencies and autoimmune diseases
• Acquired immunodeficiencies: asplenia, long-term steroid use

Diagnostic Tests:
Laboratory studies that should be obtained includes:
• Complete blood count (CBC) with differential
• basic metabolic panel
• arterial blood gas (ABG)
• lactate dehydrogenase (LDH) level
• erythrocyte sedimentation rate (ESR)
• C reactive protein (CRP)
Chest Radiography
Chest radiography is usually the initial imaging modality.The timing, progression, and distribution of
findings are helpful in identifying correlations. The most typical findings on chest radiography include
infiltrates with consolidation, peribronchovascular lesions, and nodular space-occupying lesions. Other
findings include atelectasis, cavitation, pleural effusions, lymphadenopathy, and cardiomegaly.
Some findings are correlated with certain etiologies of pulmonary infection; however, the pattern of
radiographic findings is often unreliable in immunocompromised patients given the decreased
inflammatory response.

B. SIGNS AND SYMPOTOMS

a. Pancytopenia
Signs and symptoms according to textbook
Signs and symptoms manifested by the patient
Weakness
(+) 02/10/19
Fatigue
(+) 02/10/19
rashes
(-)
easy bruising
(-)
Pale skin
(-)
Rapid heart rate
(-)
Shortness of breath
(+)
Bleeding problems, such as bleeding gums, nosebleeds or internal bleeding
(-)
Infections
(-)
b. Myelodysplastic Syndrome
Signs and symptoms according to textbook
Signs and symptoms manifested by the patient
Fatigue
(+) 02/10/19
Shortness of breath
(+)
Unusual paleness
(-)
Easy or unusual bleeding
(-)
Pinpoint red spots beneath the skin
(-)
Frequent infecttions
(-)

c. Aplastic Anemia
Signs and symptoms according to textbook
Signs and symptoms manifested by the patient
Fatigue
(+) 02/10/19
Shortness of breath
(+)
Rapid or irregular heart rate
(-)
Pale skin
(-)
Frequent or prolonged infections
(-)
Easy bruising
(-)
Nose bleed or gum bleeding
(-)
Skin rash
(-)
Dizziness
(-)
Headache
(-)
d. Pneumonia in Immunocompromised Host
Signs and symptoms according to textbook
Signs and symptoms manifested by the patient
malaise

chills
(+) 02/10/19
fever
(+) 02/10/19
rigor
(-)
cough
(+) 03/04/19
dyspnea

chest pain

Source:
https://www.healthline.com/health/pancytopenia#diagnosis
https://www.mayoclinic.org/diseases-conditions/myelodysplastic-syndrome/diagnosis-treatment/drc-
20366980
https://www.mayoclinic.org/diseases-conditions/aplastic-anemia/symptoms-causes/syc-20355015
https://www.mayoclinic.org/diseases-conditions/aplastic-anemia/diagnosis-treatment/drc-20355020
https://emedicine.medscape.com/article/807846-overview