Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 28-year-old woman with progressive dyspnea and fatigue

mksap
Conditions
December 12, 2015
3 Shares
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 28-year-old woman is evaluated for a 1-week history of progressive dyspnea and fatigue. She was diagnosed with Hodgkin lymphoma 2 months ago and is receiving chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). She takes no other medications.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 134/82 mm Hg, pulse rate is 105/min, and respiration rate is 16/min. Oxygen saturation is 98% breathing ambient air. Conjunctival pallor is noted but no scleral icterus. The lungs are clear to auscultation, and the cardiac examination is normal. The remainder of the examination is unremarkable.

Laboratory studies:

Hemoglobin 6.8 g/dL (68 g/L)
Leukocyte count 1300/µL (1.3 × 109/L)
Platelet count 83,000/µL (83 × 109/L)
Cytomegalovirus IgG antibody Positive

A peripheral blood smear shows pancytopenia but is otherwise unremarkable.

Which of the following is the most appropriate erythrocyte transfusion product for this patient?

A: Leukoreduced
B: Leukoreduced, cytomegalovirus-negative
C: Leukoreduced, irradiated
D: Leukoreduced, washed

MKSAP Answer and Critique

The correct answer is C: Leukoreduced, irradiated.

The patient should receive leukoreduced, irradiated erythrocytes. She has pancytopenia with symptomatic anemia likely because of her chemotherapy. Her bone marrow erythrocyte production cannot be efficiently increased because of her cancer treatment, so an erythrocyte transfusion is clinically indicated. However, immunocompromised patients (those with severe, inherited T-cell immunodeficiency syndromes or Hodgkin lymphoma or recipients of allogeneic or autologous hematopoietic stem cell transplantation, purine analog–based chemotherapy [fludarabine, cladribine, deoxycoformycin], alemtuzumab, or rabbit antithymocyte globulin therapy) are at increased risk of developing transfusion-associated graft-versus-host disease (ta-GVHD). ta-GVHD occurs when the recipient’s immune system is unable to eradicate contaminating donor lymphocytes in the transfused erythrocyte or platelet product; the transfused lymphocytes mount an immune response toward the recipient that may result in a maculopapular skin rash, gastrointestinal symptoms, cough and dyspnea, and pancytopenia due to marrow aplasia. Irradiation of the cellular product inactivates contaminating lymphocytes and prevents this complication. ta-GVHD may also occur when partial HLA matching occurs, in which the recipient is heterozygous for an HLA haplotype for which the donor is homozygous. In such a situation, the recipient’s immune system will not recognize the donor lymphocytes as foreign and will fail to mount an immune response. As such, all HLA-matched products require irradiation (that is, HLA-matched platelets for patients with platelet transfusion refractoriness owing to alloimmunization), regardless of the competency of the recipient’s immune system.

The patient would benefit from leukoreduced erythrocytes, thus minimizing the risk of febrile nonhemolytic transfusion reactions, as well as HLA alloimmunization and subsequent platelet transfusion refractoriness. Although leukoreduction alone likely reduces the risk of ta-GVHD, it does not eliminate the risk of this complication.

This patient has a positive cytomegalovirus (CMV) IgG antibody and thus has already been exposed to this infectious agent. Therefore, a CMV-negative product is not required. Furthermore, the current generation of prestorage leukocyte filters has significantly decreased the risk of CMV transmission as a result of erythrocyte and platelet transfusion. As such, not all transfusion centers use CMV-negative products for recipients who are CMV seronegative.

Washed erythrocytes are considered for patients with a history of severe allergic reactions to transfusions, which this patient does not have.

Key Point

  • Leukoreduced and irradiated erythrocytes should be used when transfusing select patients who are immunocompromised to reduce the risk of transfusion-associated graft-versus-host disease and febrile nonhemolytic transfusion reaction.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Fragmentation is behind health care's biggest problems

December 11, 2015 Kevin 27
…
Next

We should radically change the way we play football

December 12, 2015 Kevin 9
…

Tagged as: Hematology

Post navigation

< Previous Post
Fragmentation is behind health care's biggest problems
Next Post >
We should radically change the way we play football

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • What does it mean to be a progressive doctor?

    Surafel Tsega, MD
  • 3 ways we’ve failed woman who breastfeed

    Joanna Buscemi, PhD
  • How one woman prevented a pharmaceutical disaster

    James Essinger and Sandra Koutzenko

More in Conditions

  • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

    Angel Garcia Otano, MD
  • Family support is pivotal in the treatment of schizophrenia

    Frank Chen, MD
  • Exploring disfigurement and self-worth

    Kathleen Watt
  • Are we doing enough to help chronic pain sufferers?

    Adam Strohl, MD
  • Lessons taught by Bell’s palsy

    Alexander Rakowsky, MD
  • Unthinkable choices in childbirth emergencies

    Kim M. Puterbaugh, MD
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Unveiling excessive medical billing and greed

      Amol Saxena, DPM, MPH | Policy
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Dying is a selfish business

      Nancie Wiseman Attwater | Conditions
    • Navigating medical decision-making: Embracing limits and growth

      Benjamin Wade Frush, MD | Physician
    • Empathy and compassion in palliative care [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Bitcoin’s role in diversified portfolios [PODCAST]

      The Podcast by KevinMD | Podcast
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • The pros and cons of whole life insurance for high-income earners

      Shane Tenny, CFP | Finance
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
    • Is emergency medicine your calling? [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Reduced Mortality Seen in Cancer Survivors Who Meet Exercise Guidelines
  • CDC Advisors Endorse Maternal RSV Vax to Protect Newborns
  • Amoxicillin Alone for Acute Sinusitis Holds Up Against Broad-Spectrum Cousin
  • Despite Taboo, Med Students, Doctors Use Substances Too
  • White House Opens Gun Violence Prevention Office

Meeting Coverage

  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • ERS Roundup: Cell Transplant Boosts Lung Function in COPD Patients
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Unveiling excessive medical billing and greed

      Amol Saxena, DPM, MPH | Policy
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Dying is a selfish business

      Nancie Wiseman Attwater | Conditions
    • Navigating medical decision-making: Embracing limits and growth

      Benjamin Wade Frush, MD | Physician
    • Empathy and compassion in palliative care [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Bitcoin’s role in diversified portfolios [PODCAST]

      The Podcast by KevinMD | Podcast
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • The pros and cons of whole life insurance for high-income earners

      Shane Tenny, CFP | Finance
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
    • Is emergency medicine your calling? [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...