Oncology Case Challenge: A Daily Beer Drinker With Bruises, Back Pain, and Bleeding

Arun Gupta, MD, DNB


July 28, 2022

Physical Examination and Workup

Upon physical examination, the patient is an alert, middle-aged woman in no apparent distress. She has an oral temperature of 98°F (36.7°C), pulse rate of 92 beats/min, blood pressure of 110/68 mm Hg, respiratory rate of 12 breaths/min, and an oxygen saturation of 97% on room air. Examination of the head and neck reveals pale sclerae but no evidence of jaundice. Chest examination demonstrates lungs clear to auscultation with normal S1 and S2 heart sounds. The abdomen is soft and nontender with no palpable organomegaly. No evidence suggests cervical, axillary, or inguinal lymphadenopathy. Rectal examination shows normal sphincter tone with no evidence of blood. Examination of the skin over the buttocks, thighs, and shoulders shows a few ecchymotic patches ranging from 2 to 4 cm in diameter. A few tiny petechial spots are also visible on the skin in the scapular and abdominal regions.

Laboratory investigations reveal moderate normocytic normochromic anemia, with a hemoglobin level of 6.7 g/dL (reference range, 12.1-15.1 g/dL), and thrombocytopenia, with a platelet count of 22 × 109/L (reference range, 150-400 × 109/L). The white blood cell count is within the normal range. A blood film examination demonstrates a leukoerythroblastic picture with many band neutrophils, occasional metamyelocytes, and nucleated red blood cells. A few plasmacytoid lymphocytes can also be appreciated. The erythrocyte sedimentation rate (ESR) is 42 mm/hr (reference range, < 20 mm/hr). Her coagulation profile is normal. Direct antiglobulin test results are negative, and a 24-hour urine sample is negative for protein. Her serum chemistry panel demonstrates normal kidney function and electrolyte levels. The liver function tests are normal, except for her lactate dehydrogenase (LDH), which is elevated at 1341 IU/L (reference range, 105-333 IU/L), and a mildly raised alkaline phosphatase level at 161 IU/L (reference range, 20-140 IU/L).

The patient's serum beta-2 microglobulin level is elevated at 3.5 µg/mL (reference range, 0.7-1.80 µg/mL). Serum iron, transferrin saturation, ferritin, B12, folic acid, and red cell folate levels are all normal. Serum haptoglobin levels are also within normal limits. Serum immunoglobulin levels are normal, and serum protein electrophoresis does not demonstrate an M-protein spike. A skeletal survey with a radiograph of the skull is ordered (Figure).

Figure 1.


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