Authors: Thomas Mac Mahon / Editor: Turlough Bolger / Reviewer: Thomas Mac Mahon / Codes: HC7, HP1, HP2, SLO5 / Published: 18/03/2022
A 14-year-old boy presents with a one week history of lethargy, shortness of breath on minimal exertion such as climbing stairs, palpitations, recurrent spontaneous epistaxis lasting 10-15 minutes and easy bruising. He has no bone pain, abdominal discomfort or distension. He has not lost weight.
He has had no recent illnesses, is usually fit and extremely healthy, and is a keen basketball player. He has no past medical history, no medications or allergies, and is fully vaccinated. Born in Lithuania and living in Ireland since infancy, he has not travelled recently.
His temperature, blood pressure, pulse rate, oxygen saturation and respiratory rate are all within normal limits.
When you see him, he looks pale, with pale sclerae. His ENT, cardiovascular, respiratory, abdominal and neurological examinations are all normal. He has no regional lymphadenopathy. He has several recent spontaneous bruises on his arms and legs.
An urgent full blood count shows a macrocytic anaemia (haemoglobin low at 6.0g/dl; MCV elevated at 98.3fl). His platelet count is markedly decreased at 14×109/l. He is leukopaenic (white cell count 2.4×109/l) and neutropaenic (0.5×109/l). His reticulocyte count is decreased. A blood film shows polychromasia but no blast cells.
His infectious mononucleosis screen is negative. His renal, liver and bone profiles are normal. His CRP, LDH, vitamin B12, folate and ferritin levels are all normal. His iron studies, prothrombin time, APTT and fibrinogen levels are also normal.
Chest x-ray, ECG and urinalysis are all normal.
33 responses
A good case with systematic approach
Good case
Useful learning, thanks
excellent case,thanks
Interesting case study
excellent case
Nicely covered case. good explanation as to reasons for answers and what tests would be positive and negative. Seen not too infrequently as walk ins.
A good overview of likely cause of pancytopenia/bleeding disorder
Provides an useful to approach to assessment, investigation and management of a child with bleeding disorder.
Useful module
excellent
Interesting clinical case
good learning case, thank you
great thanks
It’s good to assume that ED clinicians shall remember all that needs to be done once you have found an abnormality and acted on the immediate aspects of the same but practically it’s unlikely that we’ll remember or stay up to date with treatments that we don’t do everyday
Helpful case for learning, thanks!
good case
Helpful
Good learning
good case
Interesting case
Good recap
Good recap of haematological emergencies
Well pitched case, thanks.
Good case
Very important paediatric case. Would help me in my practice
Good case
Very good haematology case.
Very informative.
Nice case – very helpful
interesting case, thank you
good case
thank you