Q90) A 57 year old hispanic woman is admitted to the hospital with right leg cellulitis. The patient is started on intravenos antibiotics. She is afebrile. Physical examination reveals erythema and tenderness in right lower extremity. Venos Doppler is negative for DVT. Her past medical history is significant for chronic alcoholism and liver cirrhosis. Laboratory investigations reveal a WBC count of 1700/µl with absolute neutrophil count of 800, Hemoglobin of 10.2gm% and Platelet count of 52,000/µl. Peripheral smear reveal reduced platelets and no evidence of any abnormal cells. B12 and folic acid level as well as Iron studies are with in normal limits. Blood cultures are negative at Day 1. HIV serology, Hepatitis B and Hepatitis C are negative. Antinuclear antibodies are negative. Reticulocyte count is 4% and Lactic Dehydrogenase is 170 *( normal). Haptoglobin is 220( normal). A hematology evaluation is obtained and a bone marrow biopsy performed to evaluate her pancytopenia. BM biopsy reveals hypercellualar bone marrow with no dysplatic features. The most important next step in evaluating this patient’s pancytopenia?
A) CT scan of the abdomen
B) Parvo virus B19 Antibodies
C) CT scan of the chest to rule out Thymoma
D) Methyl malonic acid level
E) Flow cytometry for CD58 and CD59
Q91) Most likely cause of this patient’s Pancytopenia?
A) Hypersplenism
B) Parvovirus B19
C) Aplastic Anemia
D) Sub clinical Vitamin B12 deficiency
E) Acute Leukemia
F) Paroxysmal Nocturnal Hemoglobinuria
Archer USMLE Step 3 Blog 
B
B
b/b
a/a
Increased retic: hemolysis +nt
Normal haptoglobin: extravascular hemolysis
hyperspleenism causes extravascular hemolysis
Its not B/B(parvovirus related) bcoz: The dramatic decrease or absence of measurable reticulocytes is a hallmark laboratory finding in persons with B19 infection. A bone marrow biopsy is usually remarkable for severe aplasia.
In this case retic is 4% and BM is hypercellular
AA. Hypersplenism is more likely because: 1)Pt has cirrhosis and thus, most likely has splenomegaly bc of portal hypertension (although hypersplenism and splenomegaly are different entities); 2) Reticulocyte count is HIGH in hypersplenism and LOW in Parvovirus 19 infection.
A/A
A. A.( Hypersplenism: in this patient: cirrhosis, hyper cellular BM, high Rt count, no hemolysis ). Decrease of 1 or more cell lines due to an overreactive spleen that removes cells from your body too fast and too early.
A,A