SHM Converge Scientific Abstract ePoster Gallery-Plasmacytoid Lymphocytes in Pseudo-Thrombotic Microangiopathy- A Case of Diagnostic Dilemma

Pdf Summary

This case report describes a 47-year-old man who presented with one week of weakness, nausea, bloating, dark urine, poor appetite, and weight loss. Initial labs showed severe pancytopenia with hemoglobin 5.0 g/dL, leukopenia, and thrombocytopenia, along with hemolysis markers and peripheral smear findings of schistocytes, teardrop cells, and unusual plasmacytoid lymphocytes. Because the presentation resembled thrombotic thrombocytopenic purpura (TTP) or malignancy, he underwent extensive evaluation, including CT imaging and bone marrow biopsy.<br /><br />Further workup revealed low vitamin B12 (150 pg/mL) with normal folate, and the patient was started on vitamin B12 injections. His clinical course improved rapidly over the next few days, and by two weeks his symptoms and pancytopenia had resolved. Bone marrow biopsy was normal, confirming vitamin B12 deficiency-induced pseudo-thrombotic microangiopathy (pseudo-TMA), likely related to nutritional deficiency from a strict vegetarian diet.<br /><br />The report emphasizes that vitamin B12 deficiency can rarely mimic true thrombotic microangiopathy, causing anemia, thrombocytopenia, and schistocytosis. Recognizing clues such as very high LDH, relatively modest bilirubin elevation, lower reticulocyte response, and a platelet count that is not as severely reduced can help distinguish pseudo-TMA from true TTP. This distinction is important because treatment differs completely and early diagnosis can prevent unnecessary invasive testing.<br /><br />A unique feature of this case was the presence of plasmacytoid lymphocytes on peripheral smear, which had not previously been reported in association with pseudo-TMA. These cells are usually reactive and are more commonly seen in infections or lymphoproliferative disorders, adding to the diagnostic confusion and prompting bone marrow biopsy.

Asset Subtitle

Maria Rose Dominic

Meta Tag

Author List Kristina Tanovic, Lakshmi Priyanka Pappoppula, Maria Rose Dominic, Udit Asija

Category Clinical Vignettes

Concept Vitamin B12 Deficiency

Concept Pseudo-thrombotic Microangiopathy

Concept Thrombotic Microangiopathy

Concept Anemia

Concept Thrombocytopenia

Distinguished Non-Finalist

Presenter Organization The Wright Center for Graduate Medical Education

Presenting Author Maria Rose Dominic

Track Adult

Keywords

vitamin B12 deficiency

pseudo-thrombotic microangiopathy

pancytopenia

thrombotic thrombocytopenic purpura

schistocytes

plasmacytoid lymphocytes

bone marrow biopsy

hemolysis

vegetarian diet

anemia

Vitamin B12 Deficiency

Pseudo-thrombotic Microangiopathy

Thrombotic Microangiopathy

Anemia

Thrombocytopenia