Monday, July 19, 2010

When I Look in a Microscope, All I See Are Eyelashes

An 80 year old man with a past medical history significant for depression presents with fatigue. About 5 months ago, his wife passed away from colon cancer, and since then, he has had a dramatic change in diet. He doesn't cook for himself and eats mainly fast food. He has also started drinking more alcohol. His exam, including neurologic and psychiatric exam, is completely normal. Labs show anemia, elevated serum bilirubin, elevated LDH, and a low-to-normal absolute reticulocyte count. WBC and platelets are low. The blood smear is shown below.

Challenge: What's the most likely diagnosis? Second most likely diagnosis?

Image shown under Fair Use.


arif said...

He has macrocytic anemia due to B12 and folate deficiency. Image shows hypeesegmented polymorph

Craig Chen said...

yes! sorry for the late schedules mess everything up
When I Look in a Microscope, All I See Are Eyelashes

The peripheral blood smear shows a hypersegmented neutrophil and macro-ovalocytes, a pattern that highly suggests folate or B12 (cobalamin) deficiency. The time course (4-5 months), relation to diet, and lack of neurologic symptoms make folate deficiency more likely than B12 deficiency.

Source: UpToDate; image originally from Stanley Schrier.