PANCYTOPENIA

Pan = all
Cyto = cell
Penia = decrease

Normal Hb level

○ 13 - 18 G/di in male

○ 11.5 - 16.5 G/di in female

Normal total WBC count

○ 4-11 x 109 / L

Normal platelet count

○ 150-400 × 109 / L

DEFINITION
• Peripheral blood picture showing simultaneous (+)ce of anemia, leucopenia, &
thrombocytopenia i.e. Hb level
< 13.5 G/dI in male,
< 11.5 G/dI in female
total WBC count
<4 × 109 / L
platelet count
< 150 × 10° / L

Causes
(AS DR MD SP)

A Aplastic anaemia
S Subleukaemic acute leukaemia
D Cytotoxic Drugs
R Radiotherapy
M Bone Marrow infiltration or replacement

○ Hodgkin's & Non-Hodgkin's lymphoma,

○ Multiple myeloma
○ Metastatic carcinoma of BM, Myelofibrosis

Megaloblastic macrocytic anaemia

Myelodysplastic disorder
D Disseminated TB
S SLE
Hypersplenism
P PNH

CLASSIFICATION:
I. Hypocellular bone marrow
II. Cellular bone marrow with primary marrow disorders
Ill. Cellular bone marrow with systemic disorders

I. Hypocellular bone marrow

○ Aplastic anaemia
○ Hypoplastic myelodysplastic syndrome
○ Acute leukaemia in hypoplastic bone marrow (rare)
○ Lymphoma in hypoplastic bone marrow
○ Cytotoxic agents and radiotherapy

II. Cellular bone marrow with primary marrow disorders

○ Acute leukaemias
○ Lymphomas
○ Hairy cell leukaemia
○ Myelofibrosis
○ Myelodysplastic leukaemia
○ Paroxysmal nocturnal haemoglobinuria
○ Multiple myeloma
○ Bone marrow metastasis

Ill. Cellular bone marrow with systemic disorders

○ Hypersplenism
○ Deficiency of vitamin B12 and folic acid
○ Infection such as tuberculosis, kala - azar, brucellosis
○ Overwhelming infections
○ Alcohol
○ Autoimmune disorders like systemic lupus erythematosus

Clinical features
○ Anaemia - Signs & symptoms of anaemia
(Tiredness, Lassitude, Weakness, Dyspnoea on exertion, Palpitation, Pallor)
○ Infection due to neutropenia
○ Bleeding manifestations due to thrombocytopenia
DIAGNOSIS
1. CLINICAL FEATURES (history & physical examination)
2. PERIPHERAL BLOOD EXAMINATION
3. BONE MARROW ASPIRATION AND TREPHINE
4. FURTHER INVESTIGATIONS WHERE APPROPRIATE

1. CLINICAL FEATURES
History

○ Age, Sex, Occupation, diet

○ Exposure to chemicals, drugs, or radiation
○ Bone pain
○ Fever, night sweats, malaise, weight loss, pruritus
○ Symptoms of disorders causing major splenic enlargement

Physical Examination

○ Lymph node enlargement

○ Splenomegaly
○ Bone tenderness, deformity, or tumour
○ Hepatomegaly
○ Gum hypertrophy
○ Signs of disorders causing hypersplenism especially portal hypertension
○ Evidence of primary malignancy often associated with metastasis to bone,
○ especially breast, prostate and lung

2. PERIPHERAL BLOOD EXAMINATION

A. Anisopoikilocytosis

○ common in acute leukaemia & less marked in aplastic anaemia, multiple myeloma,
bone marrow infiltration by lymphoma
○ Marked poikilocytosis in myelofibrosis (pear- and tear-shaped
poikilocytes)

B. White and red cell precursors

○ Present in myelofibrosis, subleukemic leukaemia, metastatic carcinoma in bone

(leuco-erythroblastic picture)
○ Not typical of aplastic anaemia
○ Blast cells in subleukaemic leukemia and acute myelofibrosis
○ Immature lymphoid cells in lymphoma
○ Immature plasmacytic cells in multiple myeloma

C. Abnormal granulation in neutrophils

 ○ toxic granulation in aplastic anaemia (independent of infection)
○ Hypogranular in MDS and acute myeloid leukaemia (AML)

D. Hypo or hypersegmentation in neutrophils

○ Pelger-Huet-like cells in MDS and some leukaemias

○ Hypersegmentation in megaloblastosis (Vitamin By & folic acid deficiency)

E. Erythrocyte rouleaux formation in multiple myeloma and

macroglobulinaemia

F. Platelets - Giant platelets in leukaemia and

MDS
Platelet size is normal in aplastic anaemia

G. ESR

○ Increased in aplastic anaemia +++

○ Very high in multiple myeloma and macroglobulinaemia (may exceed
150 mm/hr)

3. BONE MARROW ASPIRATION AND TREPHINE

○ A 'dry' or 'blood tap'.

○ Bone marrow aspiration is diagnostic in subleukaemic leukaemia, multiple myeloma
and aplastic anaemia);
○ often diagnostic in marrow involvement by metastatic carcinoma and MDS
○ can be helpful in Non-Hodgkin's lymphoma & macroglobulinaemia.
○ Trephine biopsy is necessary in aplastic anaemia, myelofibrosis or involvement by
Hodgkin's disease.
○ Not specific in hypersplenism
○ Ziehl Nielsen stain & culture for mycobacteria in disseminated tuberculosis.

4. FURTHER INVESTIGATIONS WHERE APPROPRIATE

○ Bone X-ray (multiple myeloma, metastatic carcinoma, lymphomas)

○ Chest X-ray (lymphoma, carcinoma lung, TB)
○ Serum alkaline and acid phosphatase (metastatic carcinoma)
○ Serum protein electrophoresis (multiple myeloma, macroglobulinaemia)
○ DNA antibody, LE cell test (SLE)
○ Urinary Bence-Jones protein (multiple myeloma )
○ Needle biopsy of liver (hypersplenism, lymphomas, disseminated TB)