A previously healthy 14-year-old Caucasian female is seen in the emergency department with complaints of menstrual bleeding and dizziness with standing. The patient reports a history of irregular menses and typically has her period every 3 months, though it has become progressively heavier over the last few cycles. Her last menstrual cycle was the month prior to presentation, lasting 1 week. Her current cycle has lasted 3 days, and she is changing her pad or tampon every hour, which is more frequent than usual.

Vitals: Heart rate 124, blood pressure 122/64, respiratory rate 16, oxygen saturation 98% on room air, temperature 39.2. The exam reveals pallor and scattered bruising to bilateral arms but is otherwise unremarkable.

Labs: White blood cell (WBC) count 2.1 x 103/mcL, hemoglobin 4.7g/dL, platelet count 10 x 103/mcL, absolute neutrophil count 120/mcL, 37% blasts, median cell volume 85.6 fL, 4.5% reticulocytes.

Prothrombin time 19.4 seconds (range 11.3-15.6 seconds), international normalized ratio 1.15, partial thromboplastin time 39.5 seconds (range 24.5-37.5 seconds), and fibrinogen 73 mg/dL.

Electrolytes and liver function panel are within normal limits. Uric acid is 4.5 mg/dL, and LDH 451 unit/L (range 370-645 unit/L).

Based on the clinical presentation and laboratory evaluation, what would you expect to see on the peripheral smear?

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Meagan Vacek, DO, and Erin Guest, MD
Division of Pediatric Hematology Oncology & BMT
Children’s Mercy Hospital
Kansas City, MO

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Categories: Case Quiz