A minimum of 10 fields were observed by 2 Pathologists and a presence of more than 1 percent schistocytes
were reported as diagnostic.
Automated detection and classification of schistocytes
by a novel red blood cell module using digital imaging/ microscopy.
However, the absence of schistocytes
on the peripheral smear along with the normal haptoglobin pointed away from this diagnosis.
MAHA results from intravascular fragmentation of red blood cells, which produces schistocytes
on peripheral blood smear.
The highest rate of misclassification occurred with dacrocytes and acanthocytes, both of which were predominantly misclassified as schistocytes
Even if no schistocytes
were found on repeated peripheral blood smears, TMA remained our main hypothesis with suspicion of an unusual spleen-localized presentation.
Six of 8 histologic features, including endothelial cell separation, intraluminal schistocytes
, intraluminal fibrin, intraluminal microthrombi, loss of glands, and mucosal denudation, were statistically increased in patients who met all the parameters for hrTA-TMA.
were not appreciated on the peripheral smear.
Regarding the pancytopenia, a peripheral blood smear showed a moderate normocytic anemia with mild hypochromia; a few ovalocytes, burr cells, and schistocytes
; and increased rouleaux formation.
Laboratory studies showed hemoglobin of 5.1 g/dL with schistocytes
and thrombocytopenia on peripheral blood smear (Figure 1), platelet countof 62 K/uL, BUN of 22 mg/dL, and creatinine of 1 mg/dL (baseline 0.6 mg/dL).
The peripheral blood smear showed pancytopenia with RBCs anisocytosis, occasional schistocytes
, and no blasts.
Blood test: platelet = 19 10A9 (was 225 one month ago) Hb =12.4 g/dl, Hct = 36.7, WBC = 13.2, urea = 19.1 mmol/L, Creatinine = 164 umol/L (was normal one month ago), CRP=61.9, blood picture showed schistocytes
= 2 + RBG = 18 mmol/L, reticulocytes = 1.4 %, D-dimer = 19.7 mg/L FEU, total bilirubin = 36.1 umol/L, INR = 1, ALT = 32 U/L, conjugated bilirubin = 11.06 umol/L, lactic acid dehydrogenase = 2495 U/L, urine nitrate=positive, urine WBC 12-45 cells, urine RBC more than 56 cells, urine culture = normal flora, blood culture = no growth, HIV test negative.