A 65-year-old Russian gentleman presents with the following CBC abnormalities. His ferritin is 75 ug/L and his grandparents were from China.
- What is the significant of smudge cells?
- What accounts for the RBC abnormalities?
- What test would help confirm the cause for this patient’s microcytic anemia?
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Diagnosis: Beta thalassemia and CLL
CBC Clues:
(1) Smudge cells – suggestive of CLL, (2) Target cells – suggest thalassemia, (3) Elevated RBC – suggests against iron deficiency
Q1: What is the significant of smudge cells?
Smudge cells are seen in CLL
Q2: What accounts for the RBC abnormalities?
Thalassemia
Q3: What test would help confirm the cause for this patient’s microcytic anemia?
Hemoglobin electrophoresis
Microcytic Anemia Differential
• Thalassemia
• Anemia of chronic inflammation
• Iron deficiency
• Lead poisoning
• Sideroblastic anemia
This is an interesting case of CLL and concurrent beta-thalassemia minor presenting with lymphocytosis and microcytic anemia, respectively. Clues to the diagnosis of CLL include leukocytosis, isolated mostly to lymphocytes, with presence of smudge cells (see Case 12).
CBC Pearls
• Elevated RBC in the presence of microcytic anemia suggests against IDA
• Hemoglobin electrophoresis is diagnostic test of choice for hemoglobinopathies
This patient’s anemia is microcytic in nature, bringing us back to the TAILS differential (see Box). However, the microcytosis is quite severe in context of a normal ferritin level. The Mentzer index is calculated as < 13, suggestive of beta-thalassemia.Similarly, the presence of target cells also supports a hemoglobinopathy diagnosis. Target cells are red blood cells with an increased surface area:volume ratio. This can be seen in thalassemia, hemoglobinopathies, splenectomy, and obstructive liver disease. Hemoglobin electrophoresis confirmed the diagnosis. Given the stable hemoglobin and mild anemia, no further intervention was required.