Approach to the adult with unexplained pancytopenia
- Nancy Berliner, MD
Nancy Berliner, MD
- Professor of Medicine
- Harvard Medical School
- Chief, Division of Hematology
- Brigham and Women's Hospital
- John M Gansner, MD, PhD
John M Gansner, MD, PhD
- Instructor in Medicine
- Harvard Medical School
- Associate Physician, Division of Hematology
- Brigham and Women's Hospital
Pancytopenia refers to decreases in all peripheral blood lineages and is considered to be present when all three cell lines are below the normal reference range.
Pancytopenia can be associated with a multitude of disease states, some of which are life threatening. A thoughtful history and physical examination along with focused laboratory studies are required to establish a diagnosis and select proper management. In most cases of pancytopenia, referral to a hematologist will be important for purposes of diagnosis and/or management.
The diagnostic approach to an adult patient with pancytopenia will be discussed here. The evaluation of isolated neutropenia, anemia, and thrombocytopenia are presented separately. (See "Approach to the adult with unexplained neutropenia" and "Approach to the adult patient with anemia" and "Approach to the adult with unexplained thrombocytopenia".)
DEFINITION OF PANCYTOPENIA
Pancytopenia refers to decreases in all peripheral blood lineages. Many disorders that cause pancytopenia can also cause bicytopenia (ie, decreases in only two cell lines); thus, in most cases the evaluation of bicytopenia is similar to that presented here.
Individual laboratories typically establish their own reference ranges for hemoglobin/hematocrit, white blood cell count, and platelet count. These institutional cutoff values supersede published reference standards such as those published by the World Health Organization :
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- DEFINITION OF PANCYTOPENIA
- MECHANISMS OF PANCYTOPENIA
- CAUSES OF PANCYTOPENIA
- INITIAL EVALUATION
- History and physical examination
- Physical findings
- Laboratory studies
- Hematology referral
- SUBSEQUENT EVALUATION
- Bone marrow and other specialized evaluation
- Specific clinical scenarios
- - Coagulopathy
- - Abnormal cells on blood smear
- Malignant disorders
- Non-malignant cells
- - Hypoproliferative conditions
- - Splenomegaly and/or liver disease
- - Lymphadenopathy
- - Autoimmune conditions
- - Constitutional symptoms
- - Metabolic abnormalities
- - Suspected medications
- - Multifactorial causes
- - Other patient scenarios
- SUMMARY AND RECOMMENDATIONS