What is the appropriate management for a 73-year-old female patient with leukopenia, anemia, past dengue exposure, and an atheromatous aorta?

Management of 73-Year-Old Female with Leukopenia, Anemia, Past Dengue Exposure, and Atheromatous Aorta

This patient requires comprehensive hematologic evaluation to rule out acute myeloid leukemia (AML) or myelodysplastic syndrome, given her age, cytopenias, and the concerning combination of leukopenia (WBC 3.20) and anemia (Hgb 111 g/L). 1

Immediate Diagnostic Workup

Bone marrow examination is essential and should include:

• Bone marrow aspirate and biopsy with morphological examination, cytochemistry, immunophenotyping, and cytogenetic analysis to definitively rule out AML or myelodysplastic syndrome 1
• Complete blood count with differential to assess absolute lymphocyte count, platelet count, and evaluate for pancytopenia 1
• Peripheral blood smear examination for blast cells or dysplastic features 1

Additional laboratory assessment should include:

• Liver function tests (ALT, AST), renal function (creatinine, eGFR), and coagulation screening 1
• Serum ferritin level, as markedly elevated ferritin (>500 μg/L) combined with cytopenias could indicate hemophagocytic lymphohistiocytosis, a rare but serious post-dengue complication 2, 3
• Inflammatory markers including C-reactive protein and erythrocyte sedimentation rate 1

Risk Stratification

This patient has multiple adverse prognostic factors:

• Age >60 years confers worse prognosis and increased susceptibility to treatment complications if AML is diagnosed 1
• The combination of leukopenia and anemia raises concern for bone marrow failure or infiltrative process 1
• Past dengue exposure (IgG positive) is relevant, as dengue can rarely trigger severe aplastic anemia or hemophagocytic lymphohistiocytosis weeks after acute infection 4, 3

Cardiovascular Management

For the atheromatous aorta finding:

• Target systolic blood pressure <130 mmHg (or 120-129 mmHg if tolerated) to reduce cardiovascular events and potential aortic complications 1, 5
• Initiate statin therapy for plaque stabilization and cardiovascular risk reduction 1, 6
• Consider ACE inhibitor or ARB as these agents provide plaque-stabilizing effects in atherosclerotic disease 6
• Low-dose aspirin (81-100 mg daily) for cardiovascular protection, unless contraindicated by severe thrombocytopenia 1

Important caveat: If platelet count drops below 50 × 10⁹/L, antiplatelet therapy should be withheld due to bleeding risk 1

Monitoring and Follow-Up

Serial complete blood counts every 1-2 weeks initially to:

• Monitor for progression to pancytopenia, which would necessitate urgent bone marrow evaluation 1
• Assess for development of thrombocytopenia, which combined with leukopenia and anemia constitutes pancytopenia 1
• Watch for blast cells in peripheral blood, which would indicate acute leukemia 1

If bone marrow evaluation reveals normal cellularity:

• Consider post-dengue aplastic anemia, which can manifest 4-6 weeks after acute infection 4
• Evaluate for other causes of cytopenias including nutritional deficiencies (B12, folate), medications, or autoimmune processes 1

Critical Decision Points

Proceed to specialized hematology center if:

• Bone marrow shows >20% blasts (diagnostic of AML) or dysplastic features suggesting myelodysplastic syndrome 1
• Progressive worsening of cytopenias despite supportive care 1
• Development of fever, hepatosplenomegaly, or markedly elevated ferritin suggesting hemophagocytic lymphohistiocytosis 2, 3

Common pitfall to avoid: Do not attribute cytopenias solely to past dengue infection without bone marrow evaluation, as elderly patients with new-onset cytopenias require exclusion of hematologic malignancy regardless of infection history 1