Question

Case 11

A 64-year-old obese man who is a heavy smoker complains of worsening shortness of breath, fatigue, swollen ankles, and a sore swollen left calf.

      

WBC       6.3               Band neutrophils       5

RBC       6.00               Seg neutrophils    55

Hgb       19.0                Lymphs       31

Hct       60.0               Monos         9

MCV 100.0               Eos

MCH    31.6               Basos

MCHC   31.7               Metamyelocytes   

RDW    12.9               Myelocytes        

PLT       230.9               Promyelocytes

                       Red cell morphology: normal

Baseline coagulation prior to start of heparin and Coumadin for blood clot in the lower leg:

PT:       14.6 sec

APTT:    44.5 sec

Describe the peripheral blood findings.

    High in PT and APTT, Hgb and Hct are high too.

What additional tests should be performed to evaluate the red cell parameters?   

      

The results of the proposed additional studies were as follows:

O₂ saturation:       Decreased

EPO:            Increased

Red cell mass:       WNL

Based on the results of the CBC and the additional studies, what condition is most likely related to the blood counts?

      

What additional tests should be performed to evaluate the coagulation results?

.

Evaluate the results of the following additional studies:

Repeat coagulation tests (performed on a sample with reduced anticoagulant):

PT:       12.9 sec

APTT:    27.9 sec

Based on all the data provided, what coagulation condition is most likely?

   

   

What information is most diagnostic?

Answer 1

Let us consider the normal range in order to describe peripheral blood count.

WBC is 6.3 which is normal ( normal range 3.5- 10.5), RBC is 6 which is slightly elevated ( 4.32- 5.72), Hgb of patient is 19 which is elevated (13.5- 17.5), Hct is 60 which is elevated (38.8- 50), MCV is 100 which is normal (80-100), MCH is 31.6 which is normal (27- 32) , MCHC is 31.7 which is normal (32- 36), RDW is 12.9 which is normal (11.5- 14.5) , platelet count PLT is 230 which is normal (150-450), band neutrophil 5 is normal (3-5), seg neutrophil 55 is normal (20-60) , lymphocyte 31 is normal (20-40), monocyte 9 is little elevated (2-8) , both PT 14.6 sec and APTT 44.5 sec are elevated ( PT : 11-13.5 sec; APTT : 30- 40 sec).

If we consider the above evaluation then there is elevation in Hemoglobin(Hgb), Hematocrit(Hct), Prothrombin time (PT) and Activated partial thromboplastin time (APTT).

Red cell parameters can be evaluated by two more tests :

Fibrinogen tests : The test is done to check patient's ability to blood clot. The test can be done when PT and APTT levels are abnormal which is in the above case.

Clotting factor tests : It can be done to check the presence of bleeding disorder.

Increased EPO or erythropoietin rate is increased and oxygen saturation is decreased whereas red cell mass is within normal limit. The findings suggests the condition of polycythemia vera due to pulmonary dysfunction. The condition occurs when there is abnormal red cell production within the bone marrow. Polycythemia can be considered when hematocrit is greater than 52% and hemoglobin is greater than 18.5 g/dL in men which can be seen in our previous findings for the patient. Abnormal red cell production is regulated by erythropietin hormone and the hormone is up- regulated in response to hypoxia or low oxygen levels in blood. Hypoxia can be from lung disease or smoking. Polycythemia may leads to several carcinoma including liver, lung carcinoma.

Thrombin time or TT can be performed to check blood clotting function.

The previous elevation can be due to liver disease or due to disseminated intravascular coagulation and that is the reason for prolonged clotting time; later on when APTT reduced significatly to 27.9 that denotes carcinogenic condition.