A 63-year old woman presented to her GP complaining of tiredness and indigestion. When questioned about her general health, she said she had never had any problems, she had always been fit and healthy, but that she had been suffering fatigue for the last 6-12 months. She was eating a good, well-balanced diet and did not appear emaciated.
On examination her skin looked pale, there were signs of mild jaundice, and the lips and tongue appeared normal. There was mild hepatomegaly, but the spleen was not palpable. Her pulse rate was 95 bpm.
The GP ordered some blood tests, results of which are recorded below with reference ranges.
Parameter Result Normal range
RBC 0.9 x 1012/L 4.0 – 5.4 x 1012/L
Hb 65 g/L 115 – 155 g/L
PCV 0.29 0.36 – 0.48
MCV 126 fL 77 – 95 fL
MCH 38 pg 26 – 33 pg
Reticulocytes 12 x 109/L 30 – 100 x 109/L
WBC 3.2 x 109/L 4.0 – 11 x 109/L
Platelets 90 x 109/L 180 – 400 x 109/L
Serum iron 45 µM 10 – 30 µM
Transferrin saturation 46% 13 – 35%
Serum transferrin 0.9 g/L 2.0 – 3.0 g/L
Serum vitamin B12 45 ng/L 160 – 925 ng/L
Serum folate 8 µg/L 3.0 – 15.0 µg/L
Red cell folate 85 µg/L 160 – 640 µg/L
AST 32 IU/L 11 – 47 IU/L
ALT 29 IU/L 7 – 43 IU/L
Alkaline phophatase 87 IU/L 38 – 126 IU/L
Total bilirubin 60 µg/L 2 – 13 µg/L
Conjugated bilirubin 5 µg/ml 0 – 2 µg/ml
LDH > 1000 IU/L 0 – 200 IU/L
The blood film showed a macrocytosis with occasional tear-drop cells. Many cells had Howell-Jolly bodies, and there were a number of hypersegmented neutrophils.
At a later referral a bone marrow aspirate was taken. The marrow was hypercellular with erythroblasts the predominant cells. The late erythroblasts were vastly enlarged with abnormally large nuclei and clumped, speckled chromatin. Howell-Jolly bodies were in evidence.
The Biomedical Scientist in the laboratory looks at a peripheral blood film on this patient and comments on the presence of hypersegmented neutrophils. Explain why the presence of hypersegmented neutrophils is significant in this case. (50-100 words)
Would a packed red blood cell transfusion be appropriate for this patient? Justify your answer with reference to peer-reviewed scientific sources. What alternatives are available for this patient? (200-300 words)
What is the likely diagnosis for this patient? Justify your answer by explaining how this is supported by the clinical and laboratory findings (100-150 words)