APLASTIC

ANEMIA

BY:
Ahmad Fikri Bin Yazit (110100433)
Dhiyanisa Nadhira L (110100167)

Supervisor:
dr. Selvi Nafianti, M.Ked (Ped),
Sp.A (K)
DEFINITION
 Aplastic anemia is a syndrome of bone marrow
failure 
EPIDEMIOLOGY
 Aplastic anemia is thought to be more common in
Asia than in the West.
 The incidence was accurately determined to be 4
cases per million population in Bangkok
 This increased incidence may be related to
environmental factors, such as increased exposure
to toxic chemicals
ETIOLOGY
 Idiopathic factors
 Infectious causes, such as hepatitis viruses, Epstein-
Barr virus (EBV), human immunodeficiency virus
(HIV), parvovirus, and mycobacteria
 Toxic exposure to radiation and chemicals, such as
benzene
 Severe nutritional deficiencies (B12, folate)
 Paroxysmal nocturnal hemoglobinuria (PNH)
 MDS
CLINICAL MANIFESTATION
 Anemia: May manifest as pallor, headache,
palpitations, dyspnea, fatigue, or foot swelling
 Thrombocytopenia: May result in mucosal and
gingival bleeding or petechial rashes
PATHOGENESIS
 Damage of pluripotent stem cells
Disruption of pluripotent stem cells is the main cause
of aplastic anemia. Stem cell disorders failed to
establish or develop into cells of new blood.
Generally this is due to lack of pluripotent stem cells
or decreased function.
PATHOGENESIS
 Damage on microenvironment
It is found on microvascular disorder, humoral factors
(eg erythropoietin) cell growth inhibitors. This
resulted in the failure of bone marrow tissue to grow.
In some patients with aplastic anemia found cell
inhibitors or inhibitors of cell growth. This can be
evidenced by the presence of T lymphocytes which
inhibit the growth of cells in the bone marrow.
DIFFERENTIAL DIAGNOSIS
 Acute Lymphoblastic Leukemia
 ITP
 Non-Hodgkin Lymphoma
 Paroxysmal Nocturnal Hemoglobinuria
 Vitamin B12 deficiency
 Folate deficiency
DIAGNOSIS
 Signs of anemia
 Signs thrombocytopenia
 Bone marrow examination
 Full blood count
 Liver function tests and viral studies
 Vitamin B12 and folate levels
 Radiological investigations
TREATMENT
 Immunosuppressive therapy
 Transfusional support
 Haemopoietic growth factors
 Prevention of infection
PROGNOSIS
 Substantially improved because of improved
supportive care
 10-year survival rate for the typical patient
receiving immunosuppression is 68%, compared
with 73% for hematopoietic cell transplantation
(HCT)
 The major causes of morbidity and mortality from
aplastic anemia include infection and bleeding
CASE REPORT
 Anamnesis
 BS, 8 years and 11 months old was admitted on August, 11 th
2015 with a chief complaint of pale.
 The pale experienced since a month before admission.
 Spontan bleeding (+), bruised on the foot (+), bruised on the eyes
(+), epistaxis (-), gum bleeding (-), black stool (-). History of
spontan bleeding (+), melena (+) ±1 week before entering the
hospital.
 Fever (-), history of fever (+) ± 3 weeks before entering the
hospital.
 Vomitting (-), history of vomitting (-).
 Diarrhea (-), history of diarrhea (+) ±1 10 days before entering
the hospital, the frequency of diarrhea are 4-5 times per day with
consistency water more than stool.
 Urinating system was normal, with yellow clear in the color.
History urine color was like the color of washing meat (-).
 Previous illnes : None
 History of medication : None
 History of family : None
 History of parent’s medication : None
 History of pregnancy : The age of mother during
pregnancy was 34. The gestational was normal, 37
weeks.
 History of birth : Birth was assisted by a
midwife. The patient was born pervaginal and
cried immediately after birth. Body weight at birth
wan 3000 gram, but the body length was unclear.
 History of feeding : 2 years being breast fed
 History of immunization : not at all
 History of growth and development : the
patient’s mother reprted that BS grew normally.
BS had develped talking, crawling, and walking
skills on time.
General status
 Body weight: 19 kg, Body length: 117 cm,
 BW/age: 19/28 x 100% = 67.85%
 BL/age :117/133 x 100% = 87.96%
 BW/BL: 19/21 x 100% = 90.47%

Presens status
 Consciousness: GCS 15 (E4 V5 M6)
 Blood Pressure: 110/70 mmHg
 Heart Rate: 70 x/i
 Respiratory Rate: 23 x/i
 Body Temperature: 37,0 oC.
 Anemic (+). Icteric (-). Cyanosis (-). Edema (-). Dyspnea
(-).
 Local status
Head Eyes: Isochoric pupil . Inferior palpebra conjunctiva pale
(+/+). Icteric sclera (-/-). Light reflex (+/+). Face edema (-).
Inferior and superior palpebraedema (-/-). Bleeding (+/+).
Ears/ nose/ mouth: Within normal limit

Neck Lymph node enlargement (-)

Thorax Symmetricfusiformis. HR: 70x/i, regular. RR: 23x/i, reguler,
ronchi (-). Breath sound: vesicular. Additional sound (-)

Abdomen Soepel, peristaltic (+), liver and spleen unpalpable, Skin pinch
returns quickly
Extremities Pulse 120x/i, regular, adequate pressure and volume, warm,
CRT < 3”. Pitting edema(-)
Differential Diagnosis:
 Aplastic Anemia
 Leukemia

Working Diagnosis:
 Aplastic Anemia

Management:
 IVFD D5% NaCl 0,45% 15gtt/i macro
 PRC transfusion

Diagnostic Planning:
 Serial Complete Blood Test Post Transfusion
 BMP
August, 12th - 15th 2015
S Pale (+), gum bleeding (+)
O Cons: alert, Temp: 37,0oC
Body weight: 19 kg, Body length: 117 cm.
- Head : Eyes : Isochoric pupil . Inferior palpebra conjunctiva pale (+/+). Icteric sclera (-/-). Light
reflex (+/+).
- Ears/nose/mouth : Within normal limit/Within normal limit/Lip pale (+)
- Neck : Lymph node enlargement (-)
- Thorax: Symmetric fusiformis. Chest retraction (+). HR: 90 x/i, regular. RR: 24 x/i, reguler,
ronchi (-).Breath sound: vesicular. Additional sound (-).
- Abdomen: Soepel, peristaltic (+), liver/spleen/kidney unpalpable.
- Extremities: Pulse 90 x/i, regular, adequate pressure and volume, warm, CRT < 3”.
A DD/ Aplastic Anemia
Leukemia
P Management:
- Inj. Ceftriaxone 500 mg/12 hours
- 12-13/08/2015
- PRC transfusion 160cc
- Trombosit transfusion 2 unit
- 14/08/2015
- PRC transfusion 80cc  stop because of fever and itch
- 15-16/08/2015
- PRC transfusion 200cc
- 17/08/2015
- PRC transfusion 90cc

- Diagnostic Planning:
- BMP inf the patient’s condition stabil
- Complete Blood Test Post Transfusion
- Laboratory Finding
- Hb : 10,2 g/dL
- Eritrocyte : 3,45 x /
- Leucocyte : 3,48 x /
- Trombocyte : 139.000/
- Haematocrite : 28,0 %
August, 16 th -18th 2015
S Pale (+), gum bleeding (+), eye bleeding (+)
O Cons: alert, Temp: 37,0oC
Inferior palpebra conjunctiva pale (-/-).
Lip pale (+)
A DD/ Aplastic Anemia + Subconjungtiva bleeding + Hematom palpebra OS
Leukemia
P Management:

- Inj. Ceftriaxone 500 mg

- (BMP if the patient’s condition stabil)
- Consult to ophtalmologist
- Consult answer
- Dx : Subconjungtiva bleeding + Hematom palpebra OS
- P : (kompres hangat 4x15 menit)
Gentamycin ED 4x gtt 1 ODS
Chloramphenicol ED 1xapplic 1 ODS
August, 19th - 22th 2015
S Pale (-),eye bleeding (+)
O Cons: alert, Temp: 37,1oC
Inferior palpebra conjunctiva pale (-/-)
Lip pale (-)
A DD/ Aplastic Anemia + Subconjungtiva bleeding + Hematom palpebra OS
Leukemia
P Management:

- Inj. Ceftriaxone 500 mg

- BMP
- Laboratory Finding (21/08/2015)
- LDH : 375 U/L
August, 23th 2015
S Pale (+), eye bleeding (+)
O Cons: alert, Temp: 37,1oC
Inferior palpebra conjunctiva pale (-/-). Subconjungtiva bleeding (+)
A DD/ Aplastic Anemia + Subconjungtiva bleeding + Hematom palpebra OS
Leukemia
P - Inj. Ceftriaxone 500 mg/ 12 hours IV

August, 24th - 27nd 2015

S Pale (+), eye bleeding (+), gum bleeding (+)
O Cons: alert, Temp: 37,2oC
Inferior palpebra conjunctiva pale (-/-). Subconjungtiva bleeding (+)
A DD/ Aplastic Anemia
P - Prednison 3-3-2 tab
- Folic acid 1x1 mg
25/08/2015
- PRC transfusion 200 cc
25/08/2015
- Thrombocyte transfusion 100 cc
- PRC transfusion 175 cc
26/08/2015
- Thrombocyte transfusion 100 cc
 
August, 24th - 27nd 2015
S Pale (+), eye bleeding (+), gum bleeding (+)
O Cons: alert, Temp: 37,2oC
Inferior palpebra conjunctiva pale (-/-). Subconjungtiva bleeding (+)
A DD/ Aplastic Anemia
P - Prednison 3-3-2 tab
- Folic acid 1x1 mg
25/08/2015
- PRC transfusion 200 cc
25/08/2015
- Thrombocyte transfusion 100 cc
- PRC transfusion 175 cc
26/08/2015
- Thrombocyte transfusion 100 cc
 
August, 28th – September, 2nd 2015
S Pale (+), eye bleeding <<
O Cons: alert, Temp: 37,1oC
Inferior palpebra conjunctiva pale (-/-).
A DD/ Aplastic Anemia
P - Prednison 3-3-2 tab
- Folic acid 1x1 mg
31/08/2015
- Thrombocyte transfusion 50 cc
01/09/2015
- PRC transfusion 65 cc
September, 3rd 2015
S Pale (-), eye bleeding (-)
O Cons: alert, Temp: 37,0oC
Inferior palpebra conjunctiva pale (-/-).
A DD/ Aplastic Anemia
P - Prednison 3-3-2 tab
- Folic acid 1x1 mg
Discussion
 This patient was first diagnosed with a suspected diagnosis of apalstic
anemia which was not fixed because of there wasn’t a result from bmp
test. In the history taking, it was found that patient was referred from
Rumah Sakit Umum Daerah Kota Tanjung Balai with a chief complaint
of pale that had occurred in about 1 month. Haematology symptoms
experienced by the patient were in the form of bruised of the foot and the
eyes, as well as the stool colour changed into black.. On 11 August 2015
after referred from Rumah Sakit Umum Daerah Kota Tanjung Balai,
laboratory tests immediately conducted to establish the diagnosis for
more appropriate treatment. After that, the patient was diagnosed with
aplastic anemia after there were decrease of the haematology contents,
which are haemoogloblin, erytrocyte, thrombocyte, and leucocyte.
 Furthermore, test that then carried out to rule out the
differential diagnosis was BML, which was a test to determine
the morphology of the blood components in the bone marrow.
In the laboratory test it was found that LDH is in the normal
range, and there is a hipoplasia in the erythropoiesis,
granulopoiesis, and megacaryocyte. This was also supported
by the patient's medical history before entering the hospital
there was an bleeding of the upper gastriintestinal tract results
in black stool..
 The management of this case was measuring to correct the
symptom of pale and bleeding, which was caused by the
decreased of haemoglobin and the thrombocyte, with
transfusion of packed red cell (PRC) and thrombocyte. Indeed,
the decreased of leucocyte may lead to infection, so antibiotic
prophilaxis is needed for the patients
Summary
 BS, 8 years and11 months old boy was admitted
on August, 11th 2015 with a chief complaint of
pale, and additional symptoms: Spontan bleeding
(+), bruised on the foot (+), bruised on the eyes
(+), epistaxis (-), gum bleeding (-), black stool (-),
was diagnosed with Aplastic Anemia.