Symptoms to Diagnosis

Recurrent anemia in a patient with chronic lymphocytic leukemia

Sassine Ghanem, MD and Jason Gonsky, MD, PhD
Cleveland Clinic Journal of Medicine February 2022, 89 (2) 91-98; DOI: https://doi.org/10.3949/ccjm.89a.21025

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    General approach to finding the mechanism of anemia.

    aBlood loss initially presents with a normal MCV and RDW due to strict whole volume loss. However, with subsequent reticulocytosis, the MCV will increase, thus increasing the RDW. Chronic blood loss leads to iron deficiency, which manifests with anemia that has a low MCV and high RDW.

    G6PD = glucose-6-phosphate dehydrogenase

  • Figure 2
    Figure 2

    Focal bone marrow infiltration by solid nests of tumor cells (arrows) in the patient’s third episode of anemia (hematoxylin and eosin, × 20).

Tables

  • TABLE 1

    The patient’s laboratory values in his second episode of anemia

    StudyPatient’s valueReference range
    Hemoglobin6.5 g/dL14–18 g/dL
    Reticulocyte count13.26 x 109/L
    (0.65%)    		90–130 x 109/L
    (1%–2%)
    Mean corpuscular volume85 fL78–95 fL
    Red cell distribution width14%11.5%–15.1%
    Lactate dehydrogenase162 U/L135–225 U/L
    Direct antiglobulin testNegativeNegative
    Haptoglobin336 mg/dL30–200 mg/dL
    Indirect bilirubin0.2 mg/dL1.0–1.0 mg/dL
    Peripheral smear
     Red blood cellsNormocytic, decreased in number, no schistocytes, no spherocytes
     White blood cellsLymphocytes predominant, no immature white blood cells
     PlateletsNormal in size and granulation
  • TABLE 2

    The patient’s complete blood cell count in the emergency department in his third episode of anemia

    StudyPatient’s valueReference range
    Red blood cell count1.57 x 1012/L4.2–6.1 x 1012/L
    Hemoglobin4.3 g/dL14–18 g/dL
    Hematocrit14.2%42%–52%
    White blood cell count12.15 x 109/L4.5–10.9 x 109/L
     Neutrophils10.58 x 109/L1.5–7.30 x 109/L
     Lymphocytes0.84 x 109/L0.88–5.83 x 109/L
     Monocytes0.61 x 109/L0.09–1.11 x 109/L
     Eosinophils0.00 x 109/L0.00–1.04 x 109/L
     Basophils0.02 x 109/L0.00–1.20 x 109/L
    Platelet count735 x 109/L130–400 x 109/L
  • TABLE 3

    The patient’s basic metabolic panel in the emergency department in his third episode of anemia

    StudyPatient’s valueReference range
    Sodium134 mmol/L136–146 mmol/L
    Potassium5.4 mmol/L3.5–5.0 mmol/L
    Chloride90 mmol/L98–106 mmol/L
    Carbon dioxide13 mmol/L24–31 mmol/L
    Creatinine1.22 mg/dL0.5–0.9 mg/dL
    Urea25 mg/dL8–23 mg/dL
    Calcium0.6 mg/dL9.9–10.2 mg/dL
    Glucose306 mg/dL70–99 mg/dL
  • TABLE 4

    Further laboratory findings in the patient’s third episode of anemia

    StudyPatient’s valueReference range
    Reticulocyte count9.9 x 109/L (0.6%)90–130 x 109/L (1%–2%)
    Mean corpuscular volume90.5 fL78–95 fL
    Red cell distribution width15.9%11.5%–15.1%
    Lactate dehydrogenase231 U/L135–225 U/L
    Direct antiglobulin testNegativeNegative
    Haptoglobin362 mg/dL30–200 mg/dL
    Indirect bilirubin0.7 mg/dL0.0–1.0 mg/dL
    Peripheral smear
     Red blood cellsNormocytic, normochromic, rare schistocytes, no nucleated red blood cells, no teardrop cells
     White blood cellsNo immature white blood cells noted, neutrophil predominance, small mature lymphocytes
     PlateletsIncreased in number, few giant platelets noted
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