17 October 2011 (Monday) - Hypo, Micro...

A blood sample on a chap in his mid-forties was received. No clinical details were provided, and there was no previous history.

GONZALES,SPEEDY  DOB  22/10/1967 Sex M Pat No 654321      Source    GP   Received  10:23 Address   SPAIN        Clinician POPL             17/10/2011 Haemoglobin           10.5           g/dl      (13 to 18) White Blood Cells     7.2            10^9/l    (4 to 11) Platelets             281            10^9/l    (150 to 400) Red Blood Cells       5.38           10^12/l   (4.5 to 6) Haematocrit           0.349          ratio     (0.4 to 0.50) Mean Cell Volume      64.9           fl        (80 to 100) Mean Cell Haemoglobin 19.5           pg        (27 to 32) MCHC                  30.1           g/dl      (32 to 36) Neutrophils            4.4           10^9/l    (2 to 7.5) Lymphocytes            2.1           10^9/l    (1.5 to 4) Monocytes              0.6           10^9/l     (0.2 to 1) Eosinophils            0.1           10^9/l     (0.02 to 0.5) Basophils              0.0           10^9/l     (0 to 0.1) Blood film             ^A blood film has been reviewed

The blood film showed a mild microcytic hypochromic anaemia, target cells, pencil cells and some tear drop cells were seen.

  

GONZALES,SPEEDY  DOB  22/10/1967 Sex M Pat No 654321      Source    GP   Received  10:23 Address   SPAIN        Clinician POPL             17/10/2011 Sodium                     138  mmol/L   (133 to 146) Potassium                  5.3  mmol/L   (3.5 to 5.3) Bicarbonate                24   mmol/L   (22 to 29) Creatinine                 81   umol/L   (64 to 104) GFR (estimated)            >90  units=* Albumin                    42   g/L      (35 to 50) Total Bilirubin            34 umol/L      (0 to 29) Alkaline Phosphatase       55 U/L         (30 to 130) ALT                        13 U/L         (0 to 70) Calcium                    2.3 mmol/L (   (2.2 to 2.6) Albumin-corrected calcium  2.3 mmol/L     (2.2 to 2.6) Phosphate                  1.09 mmol/L    (0.80 to 1.50) Total Cholesterol          4.1 mmol/L     (2.0 to 5.0) Fasting sample HDL Cholesterol            0.9 mmol/L        (0.9 to 1.4) LDL Cholesterol            2.8  mmol/L  T.Chol/HDL Ratio           4.6 Iron                       28.6 umol/L (11 to 28) TSH                        1.5 mIU/L  (0.4 to 5.0) Free T4                    13  pmol/L (9 to 19) Serum Vitamin B12          401 ng/L   (189 to 883) Serum Folate               5.9  ug/L (4.8 to 19.0)

Normally when faced with hypochromia and microcytosis, one thinks of iron deficiency. However the iron levels are fine: if anything a tad high. However serum iron is a transient thing. This should be confirmed by performing a transferring saturation index, or a ferritin assay.

Also the platelet count is not elevated, which often it in with a chronic iron deficiency.

Bearing in mind the elevated red cell count, together with a mildly elevated bilirubin (indicating some increased haemolysis), and the target cells in the blood film, the most likely cause of this blood picture is a thalassaemia trait.

Haemoglobin HPLC should be performed to determine the HbA2 level to distinguish between alpha and beta thalassaemia. Family studies might also be performed.