Pancytopenia approch

13 yrs old girl brought to hospital with complaints of fever with vomiting and loose motions since 2 days.that was subsided with medication after 2 days .on examination DAY 1- pt has severe anemia (5.9gm),LFT raised (TB4.7),wbc 4200.,ESR 50,CRP positive,malara negative. Widal 1:160,Hbsag negative,Usg- splenomegaly (14.5cm), Peripheral smear -macrocytic picture, reticulocyte count normal.(splenomegaly+) DAY-2, patient got one spike of fever so transfusion delayed CBP-4.2gm,LFT- normal, platelet count one lakh,wbc count- 2400,iron profile normal and vit B12 levels raised Day3 - no fever CBP 4.8gm,WBC 2200(lymphocyte predominant),platlets 1.48 Due to the patient finacial issues other hemolytic and auto immune investigation not done. pt has no previous similar history and no bleeding manifestation,no family history,no other symptoms. APPROACH. AND TREATMENT?

(Edited)

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widal should have been done after 7 days of fever . in the first week blood c/s IgM typhidot becomes the investigation of choice . however splenomegaly leucopenia thrombocytopenia even anemia can present in enteric fever . even lft can become deranged too . now u have already r/o hemolytic anemia n megaloblastic anemia as well . give blood transfusion . inj montaz 1 gm twice daily . tab azithromycin at a dose of 20 mg/kg/day . u will get the results . if possible bone marrow aspiration cytology .

Thank you doctor
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? PANCYTOPENIA.. ? HEMOLYTIC ANEMIA.. WITH..ASSOCIATED..HYPERBILLIRUBINEMIA..WIDAL POSITIVE.. SPLEENOMEGALY.. NEED'S.. ANEMIA PROFILE.. TYPHIDOT..MP.. DENGUE TEST.. MEANWHILE TREAT SYMPTOMATICALLY.. BT .. IV..FLUIDS.. MVI .. HEMATINIC'S.. LIVER TONICS.. ANTIBIOTICS WITH.. ANTIPYRETIC..PCM..AS PER REQUIREMENT..

Tnx Saurabh Burkul
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There is Spenomegaly . It means peripheral cytopenia. S - Bilirubin on day 1 was 4.7 . How did it become normal on second day? , High Bilirubin , with splenomegaly could denote hemolysis if reticulocytes r high ( Usually) . But here it is normal . Spenomegaly may denote Portal hypertension but Hbsag and LFT was normal . S LDH may required also . Usually in Liver disease Pancytopenia with macrocytosis ( MCV >100 fl) occurs due to vit B12 deficiency and Folate deficiency or deposition of cholesterol on RBC . But here Vit B12 is high . Rule out Myelodysplastic syndrome May require bone marrow biopsy. Aslo rule out Leptospirosis.

Yes sir due to patient financial issues I couldn't investigate further.peripheral smear shows macrocytes with no abnormal cells and reticulocyte count normal only.now im planning to tranfuse blood along with rule out megaloblastic anemia..need to be rule out hemolytic ,autoimmune and bone marrow pathology..
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RDW and peripheral smear for basophillic stippling and hypersegmented neutrophils or any abnormal cells should atleast be done. Pancytopenia and raised s.bilirubin are a feature of megaloblastic anaemia. Should increase vit 12 dose gradually over a week if it is megaloblastic anaemia

Peripheral smear macrocytes with pencil cells only no abnormal cells,Vit B12 HIGH (>1500),iron profile normal.Repeated LFT normal.
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For pancytopenia,the next approach after GBP c RC is Bone marrow examination.as the pt poor we can only help conservatively.inj cyanocal 1.6 units im OD,inj iron surose 100 ml iv for 5 days and tab albendazole 100 mg stat

Thank you doctor
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R/O Dengue/Covid-19/RBC indices (Megaloblastic Anemia)/Typhidot- Meanwhile Repeat Hemogram, observe Vitals, Symptomatic Rx

Thank you doctor
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Do a blood culture to rule out enteric fever/septicemia. Hyperspleenism may be causing pancytopenia. Liver disease to rule out as a cause of high Vit B12.

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This case looks like- Megaloblastic anemia with normal reticulocyte count with raised vit b12 with derranged LFT(nw normalised)associated with enteric fever- Points towards myelodysplasia or other bone marrow failure syndromes... But since bone marrow biopsy is not affordable here-go for blood transfusion and symptomtic treatment... Regular follow up..serial CBC,LFT to be done..

Thank you doctor
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