It gives me great pleasure in introducing this unique newsletter which will highlight the recent advances in the field of haemato-oncology and also we will discuss interesting cases which will help us all to understand this subject better.
Aims and objectives:
- To create awareness about Haematology and Oncology.
- Continuing Medical Education (CME).
- To update the medical community about latest developments in diagnostic haematology.
Case history: Mrs RK, 55 year old lady referred for anaemia. She had typical symptoms of anaemia. No history of blood loss and she was a vegetarian with good balanced diet. She had lost 4 kg in last 3 months. Except pallor, nothing significant on examination.
Hb: 6.4, wbc: normal. Platelet count: normal. MCV: normal. Reticulocyte count: 1%.
VitB12, Iron studies, TSH, creatinine, ESR: normal. LDH: marginally raised.
Next investigation of choice?Bone marrow examination. It was indicated as she had no obvious cause for her anaemia.
Result of bone marrow: metastatic carcinoma.
Primary tumour: Breast.
Take home message:
- Anaemia in elderly patients has to be taken very seriously and always think beyond routine causes like iron and Vit B12 deficiency.
- If not sure of anaemia, please investigate according to the financial status of the concerned patient.
- Thorough examination of whole body absolute necessary.
- If proper protocol for any anaemia is followed, then we will diagnose almost 90% of the underlying cause.
- Never use steroids unknowingly in any case of anaemia.
Referred by: Dr S S Kawade, Gynaecologist, Nashik.
Mrs NS, 28 year old married female. 2 first trimester abortions.Chronic anaemia. She was 4 weeks pregnant when referred for anaemia and repeated abortions.
Past history: she has thalassaemia intermedia and underwent splenectomy for same in 1991. She was not on regular transfusion. She also had gall stones. She always had mild jaundice.
She had cerebellar infarct in 2008 for which she was on anticonvulsants.
On first consultation: Hb: 7.6, MCV and MCH: very low. Wbc and platelets: Normal. S. Bil: 3.4, Indirect: 2.3. S.LDH: 635 (Normal upto 240).
Further investigations: Lupus anticoagulant and anti-cardiolipin antibody: negative. ANA: negative.
Above investigations were done in view of repeated abortions.
What was going in my mind??
How can I correlate thalassaemia intermedia (which is a haemolytic anaemia with severity much less than thalassaemia major and these patients donot need regular transfusion, but they always have splenomegaly and gall stones), repeated abortions and can I fit her cerebellar infarct in above scenario?
Answer was YES.
Thalassaemia intermedia itself increases thromboembolic risk due to endothelial activation. Splenectomy was an accepted treatment option in past, but today we know that it actually increases the risk of thromboembolism.
So this patient had significantly increased risk of thromboembolism and that explained her repeated abortions and I think was the cause of her cerebellar infarct as well.
We started her on daily aspirin 75 mg OD (till 34 weeks) and low molecular weight heparin (40mg SC OD) till 36 weeks. She needed blood transfusion in last trimester once.
Outcome: she delivered a healthy baby girl at 37 weeks by caesarean section.
Further course: she developed deep vein thrombosis 2 days post partum. She was started on heparin and then on warfarin for 3 months.
Last follow up medication: her baby just celebrated her first birthday. The patient is currently on Tab. Ecosprin 75 mg OD (for life)
Take home messages:
- Detailed history and clinical correlation necessary in complicated cases.
- Young stroke should be meticulously investigated.
- Splenectomy should be avoided until absolutely necessary.
I would like to thank Dr SS Kawade, Dr Shodhan Gondkar and their team for the positive outcome in this patient.