Initial Hematology Work Up for Cytopenias

Authors: Rachel Bridwell, MD (EM Attending Physician; Tacoma, WA); Alec Pawlukiewicz, MD (EM Attending Physician; Killeen, TX) // Reviewed by: Brit Long, MD (EM Attending Physician, San Antonio, TX)

Even prior to COVID-19’s strain on emergency departments (ED), boarding has been a longstanding issue. Especially for clinicians working in EDs with limited resources and consultants, the ED workup may not provide comprehensive care, and thoughtful evaluation can improve inpatient care and aid consultants during moving forward.

Case

A 76-year-old male presents with a history of known prostate cancer with known axial metastases not currently on active chemotherapy presents with progressive weakness over approximately 3 months. He was unable to see his primary care physician, so he presents to the ED with generalized weakness, progressive dyspnea on exertion, and decreased exercise tolerance. He denies any melena or hematochezia, chest pain, vomiting, nausea, diarrhea, dysuria, hematuria, weight loss or fevers. Vitals are unremarkable though the patient appears very tired with obvious pallor and noted conjunctival pallor but no hepatosplenomegaly.

Laboratory evaluation reveals a hemoglobin of 2.6 mg/dL with a mean corpuscular volume (MCV) of 86 cubic microns, white blood cell count of 5.1 cells/uL with a normal differential, and platelet count of 14,000 cells/uL You order 2 units of cross matched packed red blood cells and 1 unit of platelets.

You page the hospitalist is paged for admission, but the hospitalist voices concerns that there is no hematologist available for consultation until tomorrow.

What work up can you initiate to best aid your patient, hospitalist, and hematologist?

Anemia

-Peripheral smear

-Type and cross

-If microcytic (MCV < 80 fL), ferritin, total iron binding capacity, serum iron

-Liver function tests

-Reticulocyte count

-Lactate dehydrogenase

-Haptoglobin

-B12

-Folate

-Direct agglutination test

-Basic metabolic panel

-PT, PTT, INR

Leukopenia

-Blood cultures

-Manual differential

-Peripheral smear

-Basic metabolic panel

Thrombocytopenia

-Peripheral smear

-Viral panels (HIV, hepatitis, etc.), if clinically appropriate

-PT, PTT, INR

-Fibrinogen

Case Resolution:

You order the appropriate next step in the laboratory evaluation of this patient’s anemia and thrombocytopenia for review by the hospitalist and hematologist in the morning. His blood products begin transfusing in the emergency department and continue as he is moved to his bed in the hospital.

Take-Home Points:

-Patients with cytopenias are often first diagnosed in emergency departments.

-Thoughtful initiation of the next steps in their work-up may help improve patient’s care and relationships with consultant, especially for patients boarding in emergency departments or with delays in availability of hematology consultation.