hemolytic anemia/hemolysis

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Question 1 / 2

683ba6ed31242d93219d31b9

Hematology

hemolytic anemia

hemolysis

Case History

A 68-year-old woman, originally from the Mediterranean region, presents to her general practitioner's office complaining of progressive fatigue and exertional dyspnea over the past month. She reports feeling increasingly weak, struggling with activities like light gardening, and experiencing occasional episodes of dizziness. She recently recovered from a mild viral illness and mentions taking a non-steroidal anti-inflammatory drug for a few days to manage associated body aches. Her medical history includes a successful prosthetic aortic valve replacement five months ago for severe aortic stenosis. She denies any prior significant anemic episodes. On physical examination, she appears mildly pale, with subtle conjunctival icterus. A soft 2/6 systolic ejection murmur is noted at the right upper sternal border, consistent with her prosthetic valve. Given her clinical picture and laboratory findings, what is the most likely diagnosis and the appropriate initial management strategy?

Lab Parameter	Value	Reference Range
Hemoglobin	88 g/L	120-150 g/L
Mean Corpuscular Volume (MCV)	92 fL	80-100 fL
Reticulocyte Count	5.2 %	0.5-2.5 %
Lactate Dehydrogenase (LDH)	780 U/L	140-280 U/L
Haptoglobin	<0.1 g/L	0.3-2.0 g/L
Total Bilirubin	38 micromol/L	5-21 micromol/L
Direct Bilirubin	5 micromol/L	0-7 micromol/L

A ) Mechanical hemolytic anemia secondary to prosthetic valve; initiate oral iron supplementation and assess valve integrity with echocardiography.

B ) Glucose-6-phosphate dehydrogenase (G6PD) deficiency exacerbated by NSAIDs; advise avoidance of oxidative drugs and perform a G6PD activity assay.

C ) Autoimmune hemolytic anemia; start high-dose corticosteroids and direct antiglobulin test (DAT).

D ) Thrombotic thrombocytopenic purpura (TTP); initiate urgent plasma exchange and check ADAMTS13 activity.

E ) Hereditary spherocytosis; consider splenectomy after confirming with osmotic fragility test.

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Question 2 / 2

683ba6ed31242d93219d31b8

Hematology

hemolytic anemia

hemolysis

Case History

A 70-year-old woman presents to an urgent care clinic with a two-day history of worsening cough, subjective fever, and increasing shortness of breath. She reports attending a community potluck recently. Her medical history includes well-controlled type 2 diabetes, chronic obstructive pulmonary disease, and a recent hospitalization three months prior for significant valvular heart disease, for which she underwent an intervention. Her current medications include an inhaled corticosteroid/bronchodilator combination, oral hypoglycemics, and an anticoagulant for her heart condition. On examination, her temperature is 38.60C (101.50F), blood pressure is 135/88 mmHg, pulse 94/min, and respiratory rate 20/min. Physical examination reveals bilateral inspiratory crackles over the lower lung fields and a grade 3/6 systolic ejection murmur best heard at the right upper sternal border radiating to the carotids. There is also mild conjunctival pallor. A peripheral blood smear is ordered and reveals fragmented erythrocytes. Given the patient's presentation, what is the most likely cause of her hematologic findings and the appropriate next diagnostic step?

Lab Parameter	Value	Reference Range
Sodium (Na+)	139 mmol/L	135-145 mmol/L
Chloride (Cl-)	100 mmol/L	98-106 mmol/L
Potassium (K+)	4.7 mmol/L	3.5-5.0 mmol/L
Bicarbonate (HCO3-)	23 mmol/L	22-29 mmol/L
Urea (BUN)	7.1 mmol/L	2.5-7.1 mmol/L
Glucose	8.05 mmol/L	3.9-6.9 mmol/L
Creatinine	115 µmol/L	53-97 µmol/L
Calcium (Ca2+)	2.52 mmol/L	2.1-2.6 mmol/L
Aspartate Aminotransferase (AST)	11 U/L	10-40 U/L
Alanine Aminotransferase (ALT)	11 U/L	7-56 U/L
Hemoglobin	105 g/L	120-160 g/L
Hematocrit	0.32	0.36-0.48
White Blood Cell Count	16.5 x 10^9/L	4.0-11.0 x 10^9/L
Platelet Count	240 x 10^9/L	150-450 x 10^9/L
International Normalized Ratio (INR)	2.8	0.8-1.2 (therapeutic range for prosthetic valve 2.0-3.0)
Lactate Dehydrogenase (LDH)	550 U/L	140-280 U/L
Haptoglobin	<0.1 g/L	0.3-2.0 g/L
Total Bilirubin	35 µmol/L	5-21 µmol/L

A ) Bacterial pneumonia with associated leukocytosis and initiation of empiric broad-spectrum antibiotics.

B ) Autoimmune hemolytic anemia with positive direct antiglobulin test and treatment with corticosteroids.

C ) Thrombotic thrombocytopenic purpura due to ADAMTS13 deficiency and immediate therapeutic plasma exchange.

D ) Mechanical hemolytic anemia secondary to prosthetic valve dysfunction and echocardiographic evaluation of valve integrity.

E ) Disseminated intravascular coagulation triggered by sepsis and immediate initiation of fresh frozen plasma.

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