1. PRESENTED BY-DR.BISWAJEETA SAHA(1ST YR PGT)
MODERATOR-DR.S.RAMAN,KIMS,BHUBANESWAR

2. DEFINITION
 Combination of anemia, leucopenia and thrombocytopenia
 Hb<9g/dl
 TLC<4000/cmm
 TPC<1.5 lacs/cmm

3. ETIOLOGY
Hypocellular marrow Cellular marrow with Primary marrow disease
def/syst diseases with cellular marrow
•Aplastic anemia •Vit B12 and folic acid •Aleukemic leukemia
•Hypoplastic MDS deficiency •Hairy cell leukemia
•Post chemotherapy •Hypersplenism •MDS
•Fanconi’s anemia •Kala azar •Marrow necrosis
•Diamond-Shwachman •SLE,sjogrens •Myelofibrosis
syndrome syndrome,sarcoidosis •PNH
•Transfusion associated •Tuberculosis,brucelosis •HPS
GVHD •Metastatic solid tumors
•Aplastic crisis in •Alcoholism
hemolytic anemia •Storage diseases
•Drugs
•Infections

4. Peripheral smear
 RBC-
 Normocytic normochromic with few macrocytes,no anisopoikilocytosis,no
nRBCs,reticulocytopenia----aplastic anemia
 Macroovalocytes,howel jolly bodies-megaloblastic anemia
 Tear drop cells,howel jolly bodies,basophilic stippling--MDS
 nRBCs,sickle cells-aplastic crisis in sickle cell anemia
 WBC-
 Leucopenia,mostly mature lymphocytyes(80-90%)---aplastic anemia
 Neutrophils present in increased number,with toxic granules,shift to left—
infections
 Basophilic stippling,hypersegmented neutrophils—megaloblastic anemia
 If blasts present—subleukemic leukemia
 Hypogranular neutrophils,pseudo pelger heut anomaly--MDS
 PLATELETS-
 Normal TPC rules out aplastic anemia
 Giant platelets—MDS /hypersplenism

5. History taking
 Duration of symptoms
 How many blood transfusions,intervals between transfusions
 h/o hemoglobinuria
 Dietary history
 Socio economic status
 Exposure to
 Drugs, especially antineoplastic, antibiotics (chloramphenicol,
sulphonamides),anti epileptics and antithyroid drugs (Aplastic)
 barbiturates, phenytoin, and oral contraceptives (B12)
 Exposure to radiation (Aplastic)
 Chemical exposure
 Benzene & insecticides (Aplastic)
 Infections
 Viruses (viral hepatitis,EBV, parvovirus, and HIV. (Aplastic)

6.  Weight loss , fever (malignancy, inflammatory)
 Jaundice (Hep B & C)
 Evidence of bleeding
 Infections
 TB, Malaria
 Joint pains
 SLE

7. General physical examination
 Eye examination
 Retinal hemorhage
 Leukemic infiltration
 Jaundiced sclera(PNH,hepatitis,cirrhosis)
 Epiphora(dyskeratosis congenita)
 Oral examination
 Oral petechaie
 Stomatitis/chelitis
 Gingivial hyperplasia
 Oral candidiasis

8.  Cardiovascular examination
 Musculoskelatal system
 Tachycardia,edema,CCF Short stature
Synovitis
 Respiratory system Abnormal thumb
 Clubbing
 Tachypnoea
 Abdominal examination
 Hepatomegaly
 Lymphadenopathy
 Splenomegaly
 Skin examination
 Malar rash
 Purpura
 Reticular pigmentation,dysplastic
nails(dyskeratosis congenita)
 Hypopigmented areas
 hyperpigmentation

9. Bone marrow examination
Almost almost always indicated in cases of pancytopenia unless the cause is
apparent.
 Both aspiration and biopsy required
 Sample for cytogenetics and immunophenotyping,culture and serological
studies
IN THE ASPIRATE:
 Empty particles,markedly hypocellular,only scattered mature lymphocytes and
sometimes plasma cells in excess---aplastic anemia
 Sometimes pockets of cellularity with widespread hypocellularity—evolving
phase of aplastic anemia
 Hypocellular BM with Blasts(>20%)----hypoplastic leukemia
 Hypocellular BM with Dysplastic megakaryocytes—hypoplastic MDS
 Scattered proerythroblasts with large nuclear inclusions in hypocellular BM—
parvo virus

10. In hypercellular BM
 Erythroid hyperplasia with megablastosis—megaloblastic anemia
 Trilineage dysplasia with ringed sideroblasts on perl stain—MDS
 Infiltration by RS cells—HL
 Infiltration with malignant cells—metastasis
 In PNH and fanconis anemia—early stage will show hypercellular normal
appearing marrow

11. Specific testing pinpoints diagnosis in following
conditions
 Fanconis anemia: diepoxybutane (DEB) test for chromosomal breakage in
peripheral blood lymphocyte
 Lymphoproliferative disorders:immunophenotyping,cytogenetics,lymph node
biopsy
 PNH:peripheral blood immunophenotyping for deficiency of
phosphatidylinositol glycan linked molecules on peripheral blood cells(cd 16,cd
55,cd 59),HAMs test
 CMV:serum IgM,IgG
 EBV:serum monospot,viral capsid antigen(VCA),Epstein barr nuclear
antibody(EBNA)
 Leishmaniasis:blood and bone marrow culture,ELISA
 Serum PSA:prostatic ca

12. pancytopenia
History,examination,CBC,retic
count,serum iron/TIBC
Blast,hypo Unexplained No specific Hypersegmented
Palpable spleen Sepsis/bleeding PMNs,marked
with increased retic granular splenomegal finding
PMNs y/M anisopoikilocytosis
protein/meta
stasis
Trial of B12 and folic acid
No response response
Acid hemolysis test
Hypersplenism/m
alaria/leishmanias
is
HIV antibody
Bone marrow aspiration and biopsy

13. CBC AND PS
•LFT •PNH and IBMFS •Bone marrow
•B12/Folate levels investigations biopsy and
•Coagulation aspirate
profile
•Viral serology
•Autoimmune
profile
Bonemarrow Blood/bm
cytogenetics immunophen
otyping

14. THANK YOU