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MODULE 13 EMQS.
Match each clinical vignette to the most likely diagnosis.
Iron deficiency anaemia
Haemochromatosis
Multiple myeloma
Thalassaemia major
Polycythemia Rubra Vera
Haemolytic uraemic syndrome
Acute lymphoblastic leukaemia
Monoclonal gammopathy of uncertain significance
Acute myeloblastic leukaemia
Thombotic thrombocytopaenic purpura
Iron deficiency anaemia
Haemochromatosis
Multiple myeloma
Thalassaemia major
Polycythemia Rubra Vera
Haemolytic uraemic syndrome
Acute lymphoblastic leukaemia
Monoclonal gammopathy of uncertain significance
Acute myeloblastic leukaemia
Thombotic thrombocytopaenic purpura
EMQ 1.
A 55 year old man presents to the emergency department complaining of itchy skin that is worse when he showers. He previously had a DVT 6 months prior, and has been non compliant with any follow up.
A full blood count is shown below.
HB 195 mg/dL
White cell count 10.7 x109/L
Platelet count 474 x109/L
Haematocrit .61
MCV 85 fL
MCHC 32 g/dL
Neutrophils 8.32 x109/L
Lymphocytes 2.1 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory phones to tell you on review of the film there is a leukoeythroblastic pattern.
Answer: Polycythemia Rubra Vera
Comment: Aquagenic pruritis and thrombosis are two of the more common presentations of polycythemia rubra vera, which is characterised by primarily increased red cell mass. Invasion of the marrow can lead to circulation of immature forms (a leukoerythroblastic smear).
EMQ 2.
A 6 year old boy presents with fevers and lassitude. He has no medical history of note but his mother has noticed that he has had some bleeding from his gums after he brushes his teeth. A full blood count is taken and the results are shown below.
HB 82 mg/dL
White cell count 0.8 x109/L
Platelet count 52 x109/L
Haematocrit .31
MCV 85 fL
MCHC 32 g/dL
Neutrophils 0.32 x109/L
Lymphocytes 2.1 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory has noted that blast cells are visible on the peripheral blood film.
Answer: Acute Lymphoid Leukaemia
Comment: The majority of children with acute leukaemia present with a pan cytopaenia rather than a leukocytosis. ALL is 5 times more common than AML in children.
EMQ 3.
An 88 year old woman presents with weakness and fatigue. She has no medical history of note. Her full blood count is shown below.
HB 69 mg/dL
White cell count 9.3 x109/L
Platelet count 334 x109/L
Haematocrit .29
MCV 70 fL
MCHC 24 g/dL
Neutrophils 7.32 x109/L
Lymphocytes 1.6 x109/L
Monocytes 0.3 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
Her peripheral blood film notes mild poikilocytosis and ansiocytosis. No target cells are seen.
ANSWER: iron deficiency anaemia
COMMENT: the hypochromic microcytic picture in this age group is typical of iron deficiency anaemia. A new diagnosis of thalassaemia is unlikely at this age!
EMQ 4.
A 66 year old woman presents to your emergency department with worsening back and hip pain. Her electrolyte profile shows a calcium of 3.8mmol/L. Her FBC returns and is shown below.
HB 95 mg/dL
White cell count 7.7 x109/L
Platelet count 474 x109/L
Haematocrit .61
MCV 86 fL
MCHC 33 g/dL
Neutrophils 5.32 x109/L
Lymphocytes 1.8 x109/L
Monocytes 0.3 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
Rouleux Formation is seen on peripheral blood smear.
ANSWER: Multiple myeloma
COMMENT: the most common presentations of multiple myeloma are bone pain, hypercalcaemia and anaemia. Other conditions can cause rouleux formation but myeloma is the most common.
EMQ 5.
A 12 year old female presents with acute dyspnoea and weakness. She has a history of a recently treated urinary tract infection with the microscopy showing E.Coli.
Her full blood count is shown below.
HB 75 mg/dL
White cell count 9.9 x109/L
Platelet count 40 x109/L
Haematocrit .28
MCV 85 fL
MCHC 32 g/dL
Neutrophils 7.12 x109/L
Lymphocytes 2.2 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory phones to tell you the peripheral blood film contains 22% schistocytes as well as helmet cells.
ANSWER: Haemolytic uraemic syndrome.
COMMENT: the picture of a microangiopathic haemolytic anaemia in the context of a recent E.Coli infection (likely shigatoxin producing) suggests haemolytic uraemic syndrome. TTP is rare in children.
A 55 year old man presents to the emergency department complaining of itchy skin that is worse when he showers. He previously had a DVT 6 months prior, and has been non compliant with any follow up.
A full blood count is shown below.
HB 195 mg/dL
White cell count 10.7 x109/L
Platelet count 474 x109/L
Haematocrit .61
MCV 85 fL
MCHC 32 g/dL
Neutrophils 8.32 x109/L
Lymphocytes 2.1 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory phones to tell you on review of the film there is a leukoeythroblastic pattern.
Answer: Polycythemia Rubra Vera
Comment: Aquagenic pruritis and thrombosis are two of the more common presentations of polycythemia rubra vera, which is characterised by primarily increased red cell mass. Invasion of the marrow can lead to circulation of immature forms (a leukoerythroblastic smear).
EMQ 2.
A 6 year old boy presents with fevers and lassitude. He has no medical history of note but his mother has noticed that he has had some bleeding from his gums after he brushes his teeth. A full blood count is taken and the results are shown below.
HB 82 mg/dL
White cell count 0.8 x109/L
Platelet count 52 x109/L
Haematocrit .31
MCV 85 fL
MCHC 32 g/dL
Neutrophils 0.32 x109/L
Lymphocytes 2.1 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory has noted that blast cells are visible on the peripheral blood film.
Answer: Acute Lymphoid Leukaemia
Comment: The majority of children with acute leukaemia present with a pan cytopaenia rather than a leukocytosis. ALL is 5 times more common than AML in children.
EMQ 3.
An 88 year old woman presents with weakness and fatigue. She has no medical history of note. Her full blood count is shown below.
HB 69 mg/dL
White cell count 9.3 x109/L
Platelet count 334 x109/L
Haematocrit .29
MCV 70 fL
MCHC 24 g/dL
Neutrophils 7.32 x109/L
Lymphocytes 1.6 x109/L
Monocytes 0.3 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
Her peripheral blood film notes mild poikilocytosis and ansiocytosis. No target cells are seen.
ANSWER: iron deficiency anaemia
COMMENT: the hypochromic microcytic picture in this age group is typical of iron deficiency anaemia. A new diagnosis of thalassaemia is unlikely at this age!
EMQ 4.
A 66 year old woman presents to your emergency department with worsening back and hip pain. Her electrolyte profile shows a calcium of 3.8mmol/L. Her FBC returns and is shown below.
HB 95 mg/dL
White cell count 7.7 x109/L
Platelet count 474 x109/L
Haematocrit .61
MCV 86 fL
MCHC 33 g/dL
Neutrophils 5.32 x109/L
Lymphocytes 1.8 x109/L
Monocytes 0.3 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
Rouleux Formation is seen on peripheral blood smear.
ANSWER: Multiple myeloma
COMMENT: the most common presentations of multiple myeloma are bone pain, hypercalcaemia and anaemia. Other conditions can cause rouleux formation but myeloma is the most common.
EMQ 5.
A 12 year old female presents with acute dyspnoea and weakness. She has a history of a recently treated urinary tract infection with the microscopy showing E.Coli.
Her full blood count is shown below.
HB 75 mg/dL
White cell count 9.9 x109/L
Platelet count 40 x109/L
Haematocrit .28
MCV 85 fL
MCHC 32 g/dL
Neutrophils 7.12 x109/L
Lymphocytes 2.2 x109/L
Monocytes 0.4 x109/L
Basophils 0.02 x109/L
Eosinophils 0.02 x109/L
The laboratory phones to tell you the peripheral blood film contains 22% schistocytes as well as helmet cells.
ANSWER: Haemolytic uraemic syndrome.
COMMENT: the picture of a microangiopathic haemolytic anaemia in the context of a recent E.Coli infection (likely shigatoxin producing) suggests haemolytic uraemic syndrome. TTP is rare in children.