A 40-yr-old woman presents with fatigue, weight loss, weakness, pallor, and petechiae. She recently had viral pneumonia while traveling in Europe and was treated with Chloromycetin. A CBC was ordered and the results are as follows:

CBC
WBC (x 109/L) 2.00
RBC (x 1012/L) 2.90
HGB (g/dL) 8.3
HCT (%) 25
RBC INDICES
MCV (fl) 86.2
MCH (pg) 28.6
MCHC (g/dL) 33.2
RDW (%) 12.5
PLT (x 109/L) 30

DIFFERENTIAL
WBC identification Relative (%)
segs 14
lymphs 80
monos 6
eos 0
basos 0

Platelet estimate 2/ OIF

QUESTIONS
1. Are the above results within the normal range? If not, indicate those that are outside the reference range.
2. (a) Calculate the absolute counts for each of the white blood cell types – show
all your work.
(b) Are these absolute counts within the normal range? If not, indicate those
that are outside the reference range.
3. How would you describe her red cells morphologically (i.e. normo-, macro-or
microcytic; hypo- or normochromic)?
4. In what conditions would you see similar CBC and differential results? Be specific.
5. Correlate her clinical findings with her CBC/differential results.

A bone marrow aspirate and biopsy were collected. The results are as follows:
less than 5% cellularity, 95% fat; lymphocytosis and plasmacytosis present;
2+ iron stores

6. Why was a bone marrow ordered in this case?
7. Why was the marrow biopsy sample important to acquire in this case?
8. (a) How do you determine iron stores in bone marrow samples?
(b) What is the significance of the 2+ iron stores seen in this patient?
9. Based on the patient’s clinical history, physical exam and test results, what
disorder is the patient most likely suffering from? Justify you answer. Be
specific.
10. What was the most likely cause for her condition?

WEEK 3 Case Study
A 70-yr-old male, who had been getting progressively more tired and lethargic the past few months, sought medical advice. The patient appeared thin with noticeable pallor of the nail beds and mucus membranes. A CBC revealed his H&H to be 9.1 g/dL and 30.0%. He was placed on iron supplementation and told to return for follow-up blood work in six weeks. Six weeks later his hematocrit had dropped to 25.7% (see CBC below). CBC
WBC (x 109/L) 4.0
RBC (x 1012/L) 2.10 HGB (g/dl) 8.5
HCT (%) 25.7 RBC INDICES MCV (fl) 122 MCH (pg) 40
MCHC (g/dl) 33
RDW (%) 21
PLT (x 109/L) 120
RETIC COUNT (%) 0.7

DIFFERENTIAL WBC identification Relative (%) Absolute (x109/L)
segs 40 1.6 lymphs 49 2.0
monos 8 0.3 eos 3 0.1 basos 0 0.0

RBC morphology Moderate poikilocytosis, moderate anisocytosis, several ovalocytes,
occasional Howell-Jolly bodies, neutrophils with 6 lobes noted.
Platelet estimate 7 / OIF

QUESTIONS
1. Are his CBC and differential results within the normal range? If not, indicate those
that are outside the reference range.
2. How would you categorize his red cells morphologically (i.e. normo-, macro-or
microcytic; hypo- or normochromic)?
3. In what conditions would you see similar CBC results? Be specific.

Based on the clinical history and CBC results above, chemistry testing was performed and the following results obtained:
Sodium = 140 mmol/L
Potassium = 4.6 mmolL
Chloride = 99 mmol/L
Bicarbonate = 26 mmol/L
AST = 30 U/L
ALT = 38 U/L
Glucose = 92 mg/dL
Total bilirubin = 0.9 mg/dL
Serum iron= 82 ug/dL
Serum ferritin = 70 ug/L
B12 = 312 pg/ml
Folate = 2.0 ng/ml (serum level– radioassay)

4. Are his chemistry results within the normal range? If not, indicate those that are outside the
reference range.
5. What information do the ALT and AST results provide concerning this patient?
6. What disorder is suggested by the clinical history and test results on this patient? Justify
your answer.
7. Bone marrow
(a) Describe the characteristic appearance of the bone marrow in this disorder.
(b) Discuss the mechanism responsible for these characteristic bone marrow findings.
8. (a) Calculate the absolute reticulocyte count – show all your work. Is it normal or abnormal?
(b) Based on your diagnosis, is this the result you would have expected?
9. Schilling Test
Review the results of the Schilling test below and suggest the most likely diagnosis based on
these findings. Explain your answer.
-Part I, before intrinsic factor = 6.0%
-Part II, after intrinsic factor = 8.0%
10. Why do you think his hematocrit continued to drop after iron supplementation?