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Severe Symptomatic Anemia in a 30-Year-Old Man

Severe Symptomatic Anemia in a 30-Year-Old Man

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A 30-year-old man is admitted for profound, symptomatic anemia. He has become weaker and more tired and fatigued in recent weeks. In the days before admission, dyspnea with minimal effort developed as well. He denies hemoptysis, melena, hematochezia, or other bleeding. He also denies fever and signs of bleeding, such as petechiae, purpura, or ecchymoses.

HISTORY

The patient had been reasonably healthy until several months before this admission. Since then he has lost more than 11 kg (about 25 lb), and he now weighs 54.5 kg (120 lb). Although his appetite has been diminished, he has had no specific GI symptoms, such as abdominal pain or changes in bowel habits. He went to the public health clinic, where a battery of blood tests was ordered, but he has not returned to find out the results.

He is currently unemployed and lives in an apartment with his brother. He has a history of intravenous use of both heroin and cocaine.

PHYSICAL EXAMINATION

This thin man looks older than his stated age. Heart rate at rest is 110 beats per minute. Temperature and blood pressure are normal. Mucosae are very pale. Diffuse 1-cm lymph nodes are palpable bilaterally in the anterior cervical areas. Lungs are clear. Abdomen is soft, without masses or hepatosplenomegaly. No rashes are evident, and results of a neurological examination are normal.

LABORATORY EVALUATION

Hemoglobin level is 3.9 g/dL; hematocrit, 15 mL/dL; and mean corpuscular volume, 104 fL. Platelet count is 151,000/µL. White blood cell count is 3500/µL, with 89% segmented neutrophils, 4% monocytes, and 7% lymphocytes. Smear reveals moderate anisocytosis but is otherwise morphologically normal. Results of routine chemistry and biochemical panels are normal.

Which of the following represents optimal management for this patient?
A. Abnormal hemoglobin electrophoresis results demonstrating hemoglobin S.
B. A high titer of IgM neutralizing antibody to parvovirus B19.
C. A need for IV immune globulin therapy acutely—and perhaps chronically—to control his anemia.
D. A CD4+ cell count in excess of 400/µL.

(answer on next page)

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