The Case of the Well-Known Woman With Unexplained Anemia

Albert Lowenfels, MD

Disclosures

September 09, 2010

The Case

The patient is a 75-year-old woman in reasonably good health but who now complained of weakness and fatigue. Because of anemia (hemoglobin 10 g/dL) her local doctor referred her to a hematologist who diagnosed aplastic anemia on the basis of bone marrow aspiration results. The bone marrow contained 18% myeloblasts. During the next year she required several blood transfusions, often accompanied by chills and fever. Pancytopenia developed for which she was given prednisone.

The patient was rehospitalized 6 months later with vaginal bleeding, and dilation and curettagewas performed. The hemoglobin level had fallen to 8 g/dL. A bone marrow examination revealed hypocellularity and pancytopenia. She received 2 units of blood.

Two years after the initial onset of symptoms, the patient was again hospitalized with a fever of 102°F and a cough of several weeks' duration. Her chest x-ray was clear except for evidence of old scarring, considered to be consistent with previous inactive pulmonary tuberculosis. After 5 days, the patient was discharged on prednisone. She continued to need occasional blood transfusions.

About 6 weeks later the patient was readmitted with persistent fever and blood in the stools. Another bone marrow aspiration was performed and a sample was sent out for culture. The initial bone marrow specimen was negative for tuberculosis. During this final hospitalization her hemoglobin dropped to 3 g/dL. Her temperature increased to 105°F and she appeared to be acutely ill. At her request the patient was sent home where she soon sustained a stroke, became comatose, and died about 30 months after the initial onset of symptoms.

Medical and Personal History

Family and Personal History

The patient's mother died at age 29 of diphtheria. Her father died of complications of alcoholism at age 34. One younger brother also died of alcoholism. Occasionally she smoked cigarettes, but was a non-drinker.

Medical History

The patient suffered from migraine headaches throughout most of her life. In her 30s while travelling in Europe with her husband, severe chest pain developed that was diagnosed as pleurisy. When she was in her 60s her physicians used steroids to treat symptomatic arthritis. At age 62 she fell asleep while driving, leading to a head-on crash that caused minor facial injuries.

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