PART 1

A 55-year-old woman presented at the cardiology clinic with acute dyspnea on exertion with generalized edema for 1 week. She was afebrile. Her blood pressure was 180/100 mmHg. Echocardiogram result showed suspicious evidence of acute myocarditis. 

Laboratory results:  

• CBC Hct 26% (baseline 35%), MCV 80, WBC 8,000, N 75%, L 20%, platelet 67,000 (baseline 250,000) 
• Cr 1.69 (baseline 1.0) 

Peripheral blood smear was as shown above. 

Question 1 

1. Please describe and interpret the peripheral blood smear

2. What could be the causes of abnormal CBC result in this patient? 

PART 2

Additional information: 

• The patient had polyarthritis with stiffness of hand joints for 1 year 
• Physical examination was as follows:  CLICK
• Other physical examination showed decreased skin wrinkles with skin tightening of face, decreased interdental space, poikeloderma of skin at upper chest wall and extremities, tendon friction rub and pitting edema 1+ at both legs. 

Question 2

3. What is the provisional diagnosis of the patient's condition?

4. Please give plan for specific management

โดย น.ท.หญิง อินทิรา  อุไรเลิศ อาจารย์หน่วยอายุรศาสตร์โรคข้อและรูมาติสซั่ม

ร.ท.หญิง เพ็ญพิชชา  ลิ้มประเสริฐ อาจารย์หน่วยอายุรศาสตร์โรคเลือด

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ANSWERs

1. Please describe and interpret the peripheral blood smear

• Normochromic normocytic RBC, anisocytosis 1+, poikilocytosis 1+, schistocyte 1+, polychromasia few, microspherocyte few platelet 5-10/HPF
• Compatible with microangiopathic hemolytic anemia (MAHA blood picture) 

2. What could be the causes of abnormal CBC result in this patient? 

• MAHA blood picture could be due to multiple causes, for example 
  • Disseminated intravascular coagulation (DIC) 
  • Thrombotic thrombocytopenic purpura (TTP)
  • Hemolytic uremic syndrome (HUS)
  • Malignant hypertension 
  • Scleroderma renal crisis (SRC)
  • Malfuntioned heart valves  
  • Eclampsia, HELLP syndrome
• Therefore, more information from the patient's clinical presentation should be obtained. 

3. What is the provisional diagnosis of the patient's condition?

• The patient presented with chronic polyarthritis, sclerodactyly with digital tuft resorption and digital pitting scars on the finger tips, as shown in the picture, also with multiple distinctive clinical presentations of Systemic sclerosis. 
• The cause of hypertension, hemolytic anemia with thrombocytopenia with MAHA blood picture, and acute kidney injury was due to Scleroderma Renal Crisis (SRC). 
• Echocardiogram result was suspicious of acute myocarditis from systemic sclerosis. 

4. Please give plan for specific management

• Treatment of SRC:  ACE inhibitor 
• Treatment of acute myocarditis in systemic sclerosis:  Corticosteroids. However, dose should be adjusted according to severity of myocarditis, risk of SRC or worsening of concurrent SRC, infections, and other side effects of corticosteroids. 

Reference:  

Luc Mouthon, Guillaume Bussone, Alice Berezné, Laure-Hélène Noël and Loïc Guillevin. The Journal of Rheumatology June 2014, 41 (6) 1040-1048

โดย น.ท.หญิง อินทิรา  อุไรเลิศ อาจารย์หน่วยอายุรศาสตร์โรคข้อและรูมาติสซั่ม

ร.ท.หญิง เพ็ญพิชชา  ลิ้มประเสริฐ อาจารย์หน่วยอายุรศาสตร์โรคเลือด

กองอายุรกรรม โรงพยาบาลภูมิพลอดุลยเดช พอ.