From the Guidelines
The workup for new bicytopenia should begin with a complete blood count with differential and peripheral blood smear, followed by a comprehensive metabolic panel, coagulation studies, reticulocyte count, lactate dehydrogenase, haptoglobin, and direct Coombs test to evaluate for hemolysis, as recommended by the European LeukemiaNet 1. The initial evaluation should aim to distinguish primary myelodysplastic syndromes (MDS) from reactive causes of cytopenia and dysplasia, as well as other clonal stem cell disorders.
- Key laboratory tests include:
- Hematology: WBC count, WBC full differential count, RBC count, hemoglobin, platelet count, RBC indices, reticulocyte count, and RBC, leukocyte, and platelet morphology
- Biochemistry: RBC-folate/serum-folic acid, cobalamin, iron, total iron binding capacity, ferritin, lactate dehydrogenase, bilirubin, and haptoglobin
- Virus: Anti-HIV, anti-parvovirus B19, cytomegalovirus test, hepatitis B antigen, and anti-hepatitis C virus in transfusion-dependent patients
- Morphologic studies of peripheral blood and bone marrow, bone marrow biopsy, and cytogenetics are essential to evaluate abnormalities of peripheral blood cells and hematopoietic precursors, and to identify nonrandom chromosomal abnormalities 1.
- A comprehensive diagnostic approach should be provided at a center with specific hematologic competence, and repeated bone marrow examinations may be required to establish the diagnosis and identify patients with rapid disease progression 1.
- Additional testing, such as vitamin B12, folate, and iron studies, should be performed to rule out nutritional deficiencies, and imaging studies, such as CT scan of chest, abdomen, and pelvis, may be indicated to evaluate for lymphadenopathy, splenomegaly, or occult malignancy.
From the Research
Workup for New Bicytopenia
The workup for new bicytopenia involves a comprehensive approach to identify the underlying cause.
- The initial step includes a complete blood count, reticulocyte count, peripheral smear, serum folate and vitamin B12 level, autoimmune antibody screening, bone marrow smear, and biopsy 2.
- Bone marrow biopsy is an essential diagnostic tool, and its interpretation should be done with knowledge of the clinical history, complete blood count, and findings in the peripheral blood and bone marrow aspirate smears 3.
- The clinico-haematological profile of patients with bicytopenia reveals that it can occur in all ages, with the most common bicytopenia being anaemia with thrombocytopenia, followed by anaemia with leukopenia and leukopenia with thrombocytopenia 4.
- The aetiology of bicytopenia can be non-malignant, infectious, malignant, or drug-induced, with megaloblastic anaemia being the predominant non-malignant aetiology 4.
- The spectrum of hematological malignancies associated with peripheral cytopenia includes acute leukemia, chronic myeloid leukemia, plasma cell neoplasm, myelodysplastic syndrome, Non-Hodgkin lymphoma, and hypereosinophilic syndrome 5.
- A diagnostic algorithm for clinical hematologists approach to pancytopenia, which can be applied to bicytopenia as well, involves a comprehensive evaluation, including genomic profiling and next-generation sequencing 6.
Diagnostic Tests
- Complete blood count
- Reticulocyte count
- Peripheral smear
- Serum folate and vitamin B12 level
- Autoimmune antibody screening
- Bone marrow smear and biopsy
- Genomic profiling and next-generation sequencing
Potential Causes
- Non-malignant conditions (megaloblastic anaemia, immune thrombocytopenic purpura, alcoholic liver disease)
- Infectious diseases (dengue)
- Malignant conditions (acute leukemia, chronic myeloid leukemia, plasma cell neoplasm, myelodysplastic syndrome, Non-Hodgkin lymphoma)
- Drug-induced conditions
- Hemophagocytosis
- Inheritable conditions
Clinical Presentation
- Pallor
- Bleeding
- Hepatomegaly
- Splenomegaly
- Lymphadenopathy
- Fever