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Symptomatic Pancytopenia

Short summary

74-year-old male has suffered over six months from pancytopenia. The main problem has been the symptomatic anemia, which required blood transfusions. Bone marrow aspiration revealed some myelodysplasia, and immune therapy has been prescribed. The expert suggests possible differential diagnosis of pancytopenia and recommends to establish a definite diagnosis before discussing treatment.

Patient's questions

The patient asks about the differential diagnosis of pancytopenia and the treatment options.

Medical Background
74 year old male gentleman has suffered over the six months from pancytopenia. The main problem has been the symptomatic (weakness ? chest pain ?) anemia (8-9 g/dL), which required blood transfusions (how many units ?).
His past medical history is remarkake for:
  • Vascular surgery (peripheral vascular disease ?)
  • Colon polypectomy
There is also a note in the records that bone marrow aspiration (?) revealed some myelodysplasia, no increased number of blasts and immune therapy has been prescribed.
Also, there is a note about possible GI bleeding.
Medical opinion
The differential diagnosis of pancytopenia in a 74-year old gentleman is broad, but I will mention the more common and more likely possibilities:
  • Myelodysplastic syndrome (MDS): The age, pancytopenia, the high MCV and some myelodysplasia in the marrow – all consistent with this diagnosis.
    However, this should be confirmed by bone marrow analysis by an expert, also with at least cytogenetic analysis.

  • Liver disease with cirrhosis – this should be tested by blood tests (liver function tests, serology) ultrasound and sometimes liver biopsy (if indicated).
  • Immune pancytopenia, whether primary hematological disease, or secondary to connective tissue disease / vasculitis or secondary to lymphatic disease.
  • Other primary bone marrow diseases such as aplastic / hypoplastic anemia, PNH, myeloproliferative disease and others. BM analysis and specific tests can help.
  • Megaloblastic anemia – B12 and / or folic acid deficiency
  • Drug induced or viral induced (B19, EBV, CMV) BM suppression

Missing information / Documents:
  • History – symptoms, clinical picture
  • Routine blood tests – especially chemistry
  • Bone marrow report
  • Anemia work up
  • GI work up
  • Specific tests – see above
Once definite diagnosis is established, treatment can be discussed.
For instance, if MDS is the problem, than several options can be considered:
Supportive treatment (RBC transfusions); Erythropoietin injections; Immune
suppression (Globulins / ATG, cyclosporine); Thalidomide; Lenalidomide;
Chemotherapy; Decitabine; 5-aza-cytabine – just to name a few options.
If the problem is immune – immune suppression can be the preferred approach.
If the liver is the problem, than another approach should be considered.
Final recommendation: An attempt to establish a definite diagnosis.