Differential Diagnosis for Painless Frank Hematuria and Low Hemoglobin, WBC, and Platelets in a Patient with History of HCC Treated with Durvalumab and Lenvatinib
- Single Most Likely Diagnosis
- Metastatic disease to the urinary tract: Given the patient's history of hepatocellular carcinoma (HCC) and treatment with durvalumab (an immune checkpoint inhibitor) and lenvatinib (a tyrosine kinase inhibitor), the most likely cause of painless frank hematuria could be metastasis to the urinary tract. The low hemoglobin could be due to chronic blood loss, while the low WBC and platelets might be side effects of the treatments or indicative of bone marrow involvement.
- Other Likely Diagnoses
- Hemorrhagic cystitis: This condition, characterized by bleeding from the bladder mucosa, can be a side effect of certain medications, radiation, or infections. Given the patient's treatment regimen, this could be a plausible cause for hematuria.
- Urinary tract infection (UTI) or sepsis: Although less likely given the description of "painless," a UTI could lead to hematuria and affect blood cell counts, especially if it progresses to sepsis.
- Thrombocytopenia or bone marrow suppression: Lenvatinib can cause thrombocytopenia, and both drugs can lead to bone marrow suppression, which might explain the low platelet count and potentially the low WBC count.
- Do Not Miss Diagnoses
- Bleeding disorder: The combination of hematuria and low platelets could suggest a bleeding disorder, either as a side effect of medication or an underlying condition that needs urgent attention.
- Sepsis: Although mentioned earlier, sepsis is a critical condition that can present with nonspecific symptoms, including changes in blood cell counts, and is always a "do not miss" diagnosis due to its high mortality rate if not promptly treated.
- Rare Diagnoses
- Paraneoplastic syndrome: Certain cancers can cause paraneoplastic syndromes that lead to a variety of symptoms, including hematologic abnormalities. While rare, this could be a consideration in a patient with a known malignancy.
- Drug-induced hemolytic anemia: Although rare, some drugs can induce hemolytic anemia, which could explain the low hemoglobin and potentially other cytopenias if there's an immune-mediated response affecting other cell lines.