The patient is a 5-year-old Caucasian female who is previously healthy and presented to an outside facility after she had syncope at home. For the prior 2 days, she had bloody diarrhea and development of pallor and fatigue. The day prior to presentation, she had one episode of hematemesis and was having epistaxis from both nostrils. She also had decreased oral intake and decreased urine output. Prior to development of these symptoms, she had no medical problems. She eats a regular diet including fruits, vegetables, and meats and no excess of cow’s milk.

Her labs were remarkable for a Hgb of 6 g/dL and platelet count (PLT) of 4x10³/mcL, WBC 13x10³/mcL with a normal differential. Total bili was elevated at 4.4 mg/dL. Her BUN was elevated at 44 mg/dL, and creatinine was elevated at 0.8 mg/dL. DAT was negative. She had an active nosebleed in the ED and hematemesis of 600 mL. She was given a dose of ceftriaxone and transferred to the ICU. Her neurologic exam was within normal limits. There was no indication of seizure activity from the history.

In the ICU, she was given a pRBC transfusion and platelet transfusions, and follow-up CBC showed Hgb improved to 10 g/dL and PLT improved to 67x10³/mcL. LDH was elevated at 4159 U/L. PT was mildly prolonged at 15.9 sec with INR 1.2 and aPTT 30.3 sec. A respiratory PCR panel was positive for RSV.

Based on the clinical presentation and the most likely pathologic process, what would you expect to see on the peripheral smear?

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Sara McElroy, MD; Shabnam Arsiwala, MD
Division of Pediatric Hematology Oncology & BMT
Children’s Mercy Hospital
Kansas City, MO

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