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1/ Day 3 of #Heme #ConsultTweets -- Smear day!
Called to see a patient with jaundice,
LFTs, fatigue, anemia, and RBC inclusions on an outside smear, no smear yet available here.
Being in MA, I jumped to a concerning likely infection:
Called to see a patient with jaundice,
LFTs, fatigue, anemia, and RBC inclusions on an outside smear, no smear yet available here.Being in MA, I jumped to a concerning likely infection:
2/
Although much more of a summertime dx, the tickborne disease Babesia jumped to my (and others') minds.
Patients generally are febrile, fatigued, with LFT changes and often have hemolytic anemia +/- thrombocytopenia.
I ended up seeing a smear that looked like this:
Although much more of a summertime dx, the tickborne disease Babesia jumped to my (and others') minds.Patients generally are febrile, fatigued, with LFT changes and often have hemolytic anemia +/- thrombocytopenia.I ended up seeing a smear that looked like this:
3/ How does this fit for you into the working diagnosis of babesia?
4/
Depending on where you are, you may not have seen Babesia before. This looks somewhat like the intra-RBC inclusions, but not quite.
The classic appearance is the "Maltese cross" of tetrads of protozoans as below (with example of the forenamed cross). Not quite what is here.
Depending on where you are, you may not have seen Babesia before. This looks somewhat like the intra-RBC inclusions, but not quite.
The classic appearance is the "Maltese cross" of tetrads of protozoans as below (with example of the forenamed cross). Not quite what is here.
5/
It turns out these are actually Pappenheimer bodies: small iron inclusions within mitochondria that can be seen in patients with MDS, hemoglobinopathies, sideroblastic anemia, lead poisoning...and alcohol toxicity.
Everything was explained by alcoholic hepatitis.
It turns out these are actually Pappenheimer bodies: small iron inclusions within mitochondria that can be seen in patients with MDS, hemoglobinopathies, sideroblastic anemia, lead poisoning...and alcohol toxicity.
Everything was explained by alcoholic hepatitis.
6/
In conclusion:
Blood smears are useful, but be sure to review them yourself!
Not all RBC inclusions are parasites
Beware anchoring bias (as I was initially prone to) and be willing to rework dx as more information comes in!
Fin
In conclusion:
Blood smears are useful, but be sure to review them yourself!Not all RBC inclusions are parasitesBeware anchoring bias (as I was initially prone to) and be willing to rework dx as more information comes in!Fin
