PHSL2003

Test 1, 2017
Page 1 of 3 pages

BLOOD

PSE (Test 1, 2017)

A 32-year old woman complaining of tiredness and shortness of breath was admitted to a
Johannesburg hospital. Upon examination, her mucosal membranes were noted to be
yellowish and pale and she had yellow sclera.
Blood results from the patient are shown in the table below:

Blood result Patient Normal Values

Haemoglobin (g/dℓ) 6 12.1 - 16.3
Red blood cells (x1012/ℓ ) 2 4.30 - 5.67
Mean Cell Volume (MCV, fℓ) 90 79.1 - 98.9
Haematocrit (%) 18 37 - 49
Reticulocytes (% of total red blood cells) 8 1-2
Unconjugated bilirubin (µmol/ℓ) 200 < 10
Haptoglobin (g/ℓ) undetectable 0.3 - 2
Mean cell haemoglobin (MCH, pg/red 30 27 - 32
blood cell)
Mean corpuscular haemoglobin 33.3 32 - 36
concentration (MCHC, g/dℓ)

The patient was diagnosed with an autoimmune disorder, which causes anaemia and
jaundice.

1. Using data from the table above and giving full physiological reasons for your answers,
decide whether the patient has:

a) an iron deficiency anaemia.

The patient does not have an iron deficiency anaemia. Iron is necessary for
haemoglobin formation. In iron deficiency anaemia there is insufficient iron to
synthesize enough haemoglobin in the red blood cells (1) resulting in a decreased
number and overall concentration of molecules of haemoglobin in each red blood cell
(low MCH/ MCHC) (1) and in a decreased mean cell volume (1). The patient
however has a normal MCV and a normal MCH. The low haemoglobin production
also results in low red blood cell production which would result in a decreased
percentage of reticulocytes in the blood, not increased as in this patient (1). The
patient has neither of those signs and therefore is unlikely to have an iron deficiency
anaemia (1).
Any 3 marks
(3)
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Test 1, 2017
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b) a haemolytic anaemia.

The patient has a normocytic normochromic anaemia.

She also has yellow sclera (1), yellowish mucosal membranes and an increased
concentration of unconjugated bilirubin (1), which points to increased release of
haemoglobin from red blood cells compared to normal (1).
It is also regenerative (increased reticulocytes in the blood) (1).
A regenerative normocytic anaemia with increased unconjugated bilirubin
concentration is compatible with a haemolytic anaemia. (1)
Finally her haptoglobin levels are undetectable: haptoglobin binds free haemoglobin.
In haemolytic anaemias, haptoglobin is very low as its free haemoglobin binding
capacity is saturated (1).
(any 3marks)
(3)

2. Provide a full physiological explanation for the patient’s:

a) unconjugated bilirubin concentration. (3)

Bilirubin is the metabolite / degradation product of haemoglobin (1) when it is released

from the red blood cells and processed by macrophages. In haemolytic anaemias, the
increased destruction of the red blood cells leads to an increased release of haemoglobin
and therefore an increased concentration of bilirubin released in the plasma (1).
Normally, bilirubin is conjugated inside the liver and then secreted in the bile. In this
case, the conjugating capacities of the liver are overwhelmed (1) and therefore there is
an increase in unconjugated bilirubin in the plasma, explaining the jaundice.

b) percentage of reticulocytes. (3)

Reticulocytes are immature forms of red blood cells (last stage of differentiation of the
erythroblast line before the red blood cells) (1). Their increased percentage in the blood
circulation signals a higher level than usual of erythropoiesis (1). In haemolytic
anaemias, the decreased oxygen delivery to tissues leads to increased hypoxic signals
from the tissues, which leads to increased erythropoietin release from the kidney (1)
which leads to increased erythropoiesis and therefore increased presence of reticulocytes
in the blood.
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Test 1, 2017
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3. The patient required a blood transfusion. The agglutination results obtained after adding
the blood-typing anti-sera to the patient’s and a potential donor’s blood are shown in table
2 below:

Table 2: agglutination results for the patient and the potential donor

Patient Potential Donor

Anti-A serum + –

Anti-B serum - –

Anti-D serum + –

(+) agglutination observed when adding the anti-serum

(–) no agglutination observed when adding the anti-serum

Providing a physiological explanation for your answer, decide whether the following
statements are correct or incorrect:

a) The patient’s blood group is Type B negative.

Incorrect. The patient’s blood agglutinated with the anti-A serum indicating that her red
blood cells express the A antigen on their membrane (1) OR the patient’s blood did not
agglutinate with anti-B serum indicating that her red blood cells do not express the B antigen
(1). Similarly, they agglutinated in the presence of the anti-D serum, indicating that the red
blood cells expressed the D antigen on their surface. Therefore the patient is A Rhesus
positive.

(2)

b) The patient is likely to have anti-B antibodies in her blood.

Correct. The patient’s blood does not agglutinate with anti-B serum (1), therefore she does
not express the B antigen (1). This means she produces natural Anti-B antibodies in her their
plasma (1).
(3)

c) It is appropriate to transfuse the potential donor’s blood into the patient.

Correct. The potential donor’s red blood cells do not express the B antigen (1). The patient
has anti-B antibodies which will not react to the donor’s red blood cells (1). So there will not
be agglutination of the donor’s red blood cells when there is a transfusion (1). Also, the
donor’s RBC’s do not express the D antigen therefore the donor’s blood, which is O
negative, is the universal donor and would not cause an agglutination reaction. Therefore it
would be appropriate to transfuse the patient with the potential donor’s blood. (3)
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Test 1, 2017
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