EMQs in Clinical Medicine.pdf - Peshawar Medical College

The peripheral blood film – answers 63
22 The peripheral blood film
Answers: E G A J B
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Presence of Burr cells in a patient being treated in the ICU with
multiple organ failure.
Burr cells indicate uraemia.
Howell–Jolly bodies in a patient with coeliac disease.
Howell–Jolly bodies are found in hyposplenism.
Neutrophil hypersegmentation in a patient with paraesthesia in the
fingers and toes.
Vitamin B 12 deficiency is a recognized cause of megaloblastic anaemia
and, if left untreated, can lead to a polyneuropathy affecting the peripheral
nerves. There is early loss of vibration sense and proprioception
because the posterior columns are affected first.
Other changes in megaloblastic anaemia include chromatin deficiency,
premature haemoglobinization and the presence of giant metamyelocytes.
Microcytic hypochromic film in a 24-year-old woman presenting with
lethargy.
Target cells are a feature of iron deficiency anaemia. Koilonychia (brittle
spoon-shaped nails) are found in severe disease. Other rare signs include
angular cheilosis and oesophageal web. The presence of an iron deficiency
anaemia plus oesophageal web is known as the
Plummer–Vinson/Paterson–Brown–Kelly syndrome.
Film of a 3-month-old baby boy shows a hypochromic microcytic
anaemia with target cells and nucleated red blood cells. There are
markedly high HbF levels.
In -thalassaemia there is defective synthesis of chains with a severity
that depends on the inheritance of the defect. A patient with thalassaemia
minor is an asymptomatic heterozygous carrier. The thalassaemia
major patient is homozygous and usually presents in the first year of life
with a severe anaemia and failure to thrive. The symptoms of anaemia
start at this point because this is the period when chain production is
switched off and chains fail to form in adequate numbers.
Blood transfusions are required to keep the Hb 9–10 g/dl. Iron
chelators are required to protect the major organs from transfusionmediated
iron overload. Ascorbic acid (vitamin C) can also be used to
increase urinary excretion of iron. The patient requires long-term folic
acid supplements caused by the extreme demand associated with bone
marrow hyperplasia.