FURTHER READING
Akkerman JW. Thrombopoietin and platelet function. Seminars in
Thrombosis and Hemostasis2006; 32 : 295–304.
Chong BH, Ho SJ. Autoimmune thrombocytopenia. Journal of
Thrombosis and Haemostasis2005; 3 : 1763–72.
Franchini M. Recombinant factor VIIa: a review on its clinical use.
International Journal of Hematology2006; 83 : 126–38.
Kaushansky K. Lineage-specific hematopoietic growth factors. New
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Limentani SA, Roth DA, Furie BC, Furie B. Recombinant blood clot-
ting proteins for haemophilia therapy. Seminars in Thrombosis and
Hemostasis1993; 19 : 62–7.
McGrath K. Treatment of anaemia caused by iron, vitamin B 12 or folate
deficiency. Medical Journal of Australia1989; 157 : 693–7.
Scott J, Weir D. Folate/vitamin B 12 inter-relationships. Essays in
Biochemistry1994; 28 : 63–72.
Umbreit J. Iron deficiency: a concise review. American Journal of
Hematology2005; 78 : 225–31.396 ANAEMIA AND OTHER HAEMATOLOGICAL DISORDERS
Case history
A 65-year-old woman presents to the medical out-patient
department with a history of fatigue. She has in the last few
months been undergoing adjuvant cytotoxic chemotherapy
for a node-positive resected breast cancer. The patient is
pale, but no other abnormalities are noted. Her full blood
count shows a haemoglobin level of 9.8 g/dL with a mean
corpuscular volume of 86 fL; other haematological indices
and serum transferrin are normal. Her faecal occult blood is
negative. She is started on oral iron sulphate and given
weekly injections of erythropoietin 40 000 U subcutaneously.
Three months later, her haemoglobin level has risen to
13.5 g/dL, but she presents to the Accident and Emergency
Department with acute-onset dysphasia and weakness of
her right arm. Her supine blood pressure is 198/122 mmHg.
Her neurological deficit resolves over 24 hours and her blood
pressure settles to 170/96 mmHg. She has no evidence of car-
diac dyshythmias or of carotid disease on ultrasonic duplex
angiography, and her serum cholesterol concentration was
4.2 mmol/L.
Question
What led to this patient’s acute neurological episode? Does
she require further therapy?
Answer
Her mild normochromic-normocytic anaemia was most likely
related to her cytotoxic cancer therapy. Treatment with iron
and erythropoietin was indicated. She was not iron defi-
cient, and using iron and erythropoietin in combination for
a haemoglobin 10 g/dL is well justified. The most common
dose-limiting side effects of erythropoietic drug administra-
tion are hypertension and thrombosis, which are implicated
in the left middle cerebral transient ischaemic attack (TIA)
she has suffered.
Treatment with erythropoietin and iron should be
stopped, and her blood pressure monitored over 8–12
weeks. If hypertension is solely related to the erythropoi-
etin therapy, her blood pressure should normalize and no
further treatment will be required. In retrospect it may
have been prudent to have more closely monitored her ery-
thropoietic therapy and once her Hb 12 g/dL stopped it as
this may have avoided her neurological event.