January 22, 2010

A 23 years Old Malay Female with Pancytopenia

A 23 years old Malay female presented with history of difficulty in swelling for three weeks duration and fever with lethargy for 2 weeks duration. On examination, she looks pale with mild dehydration. Full blood counts show pancytopenia with hypochromic microcytic anemia. There is no history of blood loss, heavy menses or hematuria. Below is the picture of her mouth.

a) What is your finding?

b) Give differential diagnosis for hypochromic microcytic anemia

c) What condition can cause pancytopenia?

c) What is your next step in managing this patient?


  1. Hi, any answers for this? Thanks.

  2. a) tonsillitis?
    b)Iron deficient from diet, of malabsorption ex. coeliac or crohn's.
    Blood loss.
    Sickle cell anaemia.
    c)Pancytopenia: bone marrow infiltration of chronic leukaemia.
    d)Admit. If symptomatic: blood transfusion, or iron tablet. IV fluid. Do blood film,bone marrow biopsy? may need GCSF?Antibiotic, blood culture as she is feverish. Platelet if less than 10 may need PCC?

    Can you please check my answers?
    Thank you!

  3. or is that glossitis?

  4. a) The picture actually shows a mass extending from the hard palate which is well defined margin, rounded, single, red in color with estimated sixe aroud 3X3 cm. non pedunculated and no associated gum swelling. Oral hygiene is fair and there is no oral thrust. no vascularization.

    hypochromic microcytic anemia. you got it but never forget about thallasemia or chronic blood loss.

    3) apart from bone marrow infiltration, it can also arise in pt with hypersplenism or portal hypertension with spleenomegally.

    to treat this patient, you need to identify the problem first. and generally, the step in managing pt is recognizing of the presenting problem and aetiology, establishing diagnosis and differential, investigation and finally pharmacotherapy,any surgical intervention or diagnosis specific management.

    1) pallor indicate anemia. i agree. but sometime, in poorly dehydrated pt and inadequate perfusion, you may confuse yourself as well. in real practice, ask yourself, is it symptomatic anemia. Possible because pt is lethargic (even so, it could be attributed to the poor oral intake as well) but i definetely agree that she require admission and blood transfusion. Packed cell is adequate and platelet is rarely required unless <10 or <20 if you want to perform procedure.
    2) pancytopenia for investigation.
    3) fever.is it infective vs oncology problem..

    Well, i could not remember exactly the diagnosis for this patient.. but when this kind of patient presented to you, this swelling could be incidental finding or part of the illness. the mass can be due to infection or tumor.. although rare, it can be also metastasis tumor. a further test is required to establish the diagnosis.


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