“Anemic patient….” Case Conclusion November 7, 2013
Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , trackback
A 54-year-old Hispanic male presents to the ED with the complaints of fatigue and weakness. The weakness is described as generalized, and the symptoms have been present and constant for the last 2 days. The patient denies hematemesis, hematochezia, dark-colored stools, hematuria, or other evidence of bleeding. He also denies chest or abdominal pain, dyspnea, diaphoresis, fever, or chills. The patient has not seen a doctor in the last 15 years and does not think he has any medical conditions. The only medication he has been taking is over-the-counter ibuprofen, which he has been taking daily since he injured his back at work 2 weeks ago. The patient works as a construction laborer and denies past surgeries or allergies. His vital signs are: blood pressure, 110/50 mm Hg; heart rate, 127 beats/min; respirations, 22 breaths/min; and SpO2, 97% on room air. The patient is afebrile. His skin is warm and dry but, despite being dark-skinned, he appears a little pale. On eye examination, the sclerae appear to have a yellow hue. Cardiovascular examination reveals bounding pulses, a hyperdynamic precordium, and a grade II over VI soft, systolic murmur. The remainder of the examination is unremarkable, including a rectal examination, which is negative for occult blood. An ECG shows a sinus tachycardia but is otherwise normal. A basic chemistry panel is within normal limits; however, the CBC reveals a hemoglobin of 5.4 g/dL, hematocrit of 16%, WBC of 8000, and platelet count of 154,000. Based on the presenting symptoms and signs, the patient is likely to need RBC transfusions. An IV catheter is placed, and a normal saline infusion is initiated. A 500-mL bolus of normal saline reduces the heart rate to 105 beats/min.
In this case, the RBC indices were normal (MCV = 86.7 fL, MCH = 27.3 pg, MCHC = 34.5%); however, the RDW was increased at 23.9%. Because the patient had scleral icterus and the RDW was elevated, a peripheral blood smear was ordered, which showed spherocytes. Based on the peripheral blood smear results, you were concerned for a hemolytic anemia and ordered LDH, haptoglobin levels, and a Coombs test. The LDH was elevated at 717 IU/L and the haptoglobin was reduced at 15 mg/dL. The Coombs test was positive, which confirmed the diagnosis of an acute autoimmune hemolytic anemia. Because RBC transfusion was anticipated but the patient had an acute autoimmune hemolytic anemia, you consulted hematology. Prednisone (1.5 mg/kg) was given and transfusion was also recommended with a goal of hemoglobin > 7 to 8 g/dL. The hematologist noted that there would likely be considerable delay in crossmatching blood for the patient. He recommended monitoring the hemoglobin and hematocrit every 3 to 4 hours, and if the patient became more anemic prior to receiving crossmatched blood, type-specific uncrossmatched blood should be transfused. The patient was admitted to the ICU in a stable condition, with a final diagnosis of acute autoimmune hemolytic anemia, likely caused by the ibuprofen.
Congratulations to this month’s winners. They get a free copy of the latest issue of Emergency Medicine Practice on this topic: Anemia In The Emergency Department: Evaluation And Treatment. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!