A Medical Mystery — A 71-Year-Old Man with Pancytopenia

Abstract

images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 359;18 www.nejm.org october 30, 2008 1941A 71-year-old-man presented to the emergency department with dizziness, progressive lethargy, and confusion, which he reported having had for the past 10 days. A complete blood count showed pancytopenia. A peripheral-blood smear (Panel A) and bone marrow aspirate (Panel B) are shown. What is the diagnosis?Editor's note: We invite our readers to submit their answers at www.nejm.org/ mystery. We will publish the diagnosis in the Correspondence section of the December 25, 2008, issue and e-mail it to everyone who submits an answer. All answers must be

Hematological parameters and prevalence of anemia in white and British Indian vegetarians and nonvegetarians in the UK Biobank

“…On the other hand, a low white blood cell count may also be an indication of an impaired immune system or abnormal bone marrow pathology (57). Vitamin B-12 deficiency is a reversible cause of bone marrow failure (58), and some case reports have suggested a link between vitamin B-12 deficiency (more likely in vegetarians and vegans) and pancytopenia (low counts of red blood cells, white blood cells, and platelets) (59, 60). Differences in intake of other nutrients between the diet groups might also explain the differences in white blood cell count.…”

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“…Also, there are numerous infections like infections caused by herpes virus family specially cytomegalovirus [8], tuberculosis or kala-azar can cause pancytopenia either by direct toxic effect on bone marrow stem cell or by inducing anomalous immune responses. Finally, the most common cause of secondary pancytopenia in clinical practice is peripheral sequestration by hypersplenism secondary to liver disease and inefficient erythropoiesis by vitamin B12 deficiency (megaloblastic anemia) [9,10]. The use of low-molecular-weight heparins (LMWHs) have become popular in the past 2 decades.…”

What should I know before ordering a bone marrow aspiration/biopsy in patients with vitamin B12deficiency?

“…However, many patients still undergo this procedure, especially when presenting with severe pancytopenia 2. Unfortunately this may complicate the initial assessment and result in patient misdiagnosis, leading to further unnecessary and costly testing.…”