A Pancytopenic Patient’s PlightDr Suzanne Bullock – FY2 , Dr Micayla Telfer – Consultant

Macclesfield District General Hospital

Introduction

Myelodysplasia is a cause of pancytopenia.Pancytopenia is defined as a ‘reduction in all the major cell lines: red cells, white cells and platelets’1.

We present a case of pancytopenia leading to a delayed diagnosis of appendicitis.

Case Report

A 78 year old male with recently diagnosed myelodysplasia presented with pyrexia and rigors two days post blood transfusion. No focal symptoms were elicited on the initial clerking history, examination, or post-take ward round.

The admission bloods revealed a pancytopenia with haemoglobin 90, white cell count 0.8, neutrophils 0.17, platelets 37 and CRP 20.

A diagnosis of neutropenic sepsis was made and intravenous antibiotics were prescribed, as per the neutropenic sepsis pathway.

Further detailed assessment by the Acute Medicine team revealed that the patient had commented to the on-call team over the previous two days that he had some lower right-sided pain but that this had not been pursued. On examination the patient had a positive Dunphy’s sign but no peritonism. Our suspicions were aroused.

Dunphy’s sign - Increased pain in the right lower quadrant on coughing2,3.

Abdominal ultrasound revealed a blind-ended non-compressible structure suggestive of an inflamed appendix. An inflamed appendix was removed during a laparoscopic appendicetomy and the patient was discharged post surgery.

Discussion

The patient was unable to mount an adequate inflammatory response due to pancytopenia, hence the subtle and slowly progressive signs of appendicitis.

This case demonstrates the need for careful and sometimes repeated history, examination and vigilance in this complex group of patients.

It is important to consider the differential diagnoses in neutropenic sepsis and be prepared to deviate from clinical pathways especially when something appears to be amiss.

Remember Osler’s words …

‘Listen to your patient, he is telling you the diagnosis’, ‘the value of experience is not in seeing much, but in seeing wisely.’4

References1. Longmore M, Wilkinson IB, Baldwin A, Wallin E. Oxford Handbook of Clinical Medicine. Ninth Ed. Oxford University Press; 2014, Chapter 8, 358 p.2. McLatchie G, Borley N, Chikwe J. Oxford Handbook of Clinical Surgery. Fourth E Oxford University Press; 2013, Chapter 7, 298 p.3. Hardin DM Jr. Acute appendicitis: review and update. Am Fam Physician. 1999;60:2027–34.4. Silverman ME, Murray TJ, Bryan CS. The Quotable Osler. McNaughton and Gunn; 2008. 285 p, 287 p, 613 p.