Aplastic Anemia (Crisis)MANAGEMENT

HEMATOLOGIC AND ONCOLOGIC PRESENTATIONS · 12 SECTIONS

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547 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Acute chest syndrome Acute Hemolytic Transfusion Reaction Anticoagulant reversal (warfarin, DOAC, heparin)Aplastic Anemia (Crisis)Autoimmune Hemolytic Anemia CAR-T and cytokine release syndrome Coagulopathy Delayed Hemolytic Transfusion Reaction Disseminated Intravascular Coagulation (DIC)Essential Thrombocythemia Febrile Non-hemolytic Transfusion Reaction Graft Versus Host Disease (Acute)Hemolytic Uremic Syndrome (HUS)Hemophilia A (Bleeding Crisis)Heparin-Induced Thrombocytopenia (HIT)Hyperviscosity syndrome Immune checkpoint inhibitor toxicity Immune Thrombocytopenic Purpura (ITP)Leukemoid Reaction Leukostasis Massive transfusion protocol Myelofibrosis Neutropenic enterocolitis (typhlitis)Paroxysmal Nocturnal Hemoglobinuria Polycythemia Vera (Crisis)Pure Red Cell Aplasia Sickle Cell (Acute Chest Syndrome)Sickle Cell (Splenic Sequestration)Sickle cell crisis (vaso-occlusive)Symptomatic anemia Thrombocytopenia (severe)Thrombotic Thrombocytopenic Purpura (TTP)Transfusion-Associated Circulatory Overload (TACO)Transfusion-Related Acute Lung Injury (TRALI)Tumor lysis syndrome Von Willebrand Disease (Bleeding)

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp44

Immediate priorities

›Life threats in aplastic crisis

›Overwhelming infection from neutropenia

›ANC < 0.5 x 10^9/l severe risk

›ANC < 0.2 x 10^9/l very severe risk

›Hemorrhage from thrombocytopenia

›Platelets < 10 x 10^9/l spontaneous bleeding risk

›Intracranial or GI hemorrhage threat

›Symptomatic anemia

›High output cardiac failure

›Demand ischemia with Hb < 70 g/l

›Time critical actions

›Febrile neutropenia is an oncologic emergency

›Temperature >= 38.3 C with ANC < 0.5 x 10^9/l

›If febrile neutropenia, broad spectrum antibiotics within 1 hour

›Active uncontrolled bleeding

›Platelet transfusion for platelets < 10 x 10^9/l or active bleeding

›If intracranial hemorrhage suspected, emergent CT head

›Hemodynamic instability

›If septic shock, fluid resuscitation and early vasopressors

›Massive transfusion planning for hemorrhagic shock

Monitoring and targets

›Monitoring bundle

›Continuous cardiac and pulse oximetry

›SpO2 target >= 92%

›Tachycardia trend from anemia

›Frequent vital sign cadence

›Temperature surveillance for occult infection

02History/hx53

Presentation pattern

›Core syndrome

›Progressive fatigue

›Exertional dyspnea

›Pallor over weeks to months

›Bleeding symptoms

›Gingival bleeding and epistaxis

›Petechiae and easy bruising

›Menorrhagia

›Infection symptoms

›Recurrent fevers

›Sore throat and oral ulcers

›Crisis features

›Febrile neutropenia

›Temperature >= 38.3 C

›Rigors and sepsis symptoms

›Major hemorrhage

›Melena or hematuria

›Headache suggesting intracranial bleed

Triggers and exposures

›Preceding events

›Viral illness 2 to 3 months prior

›Non-A non-B non-C hepatitis association

›Parvovirus B19 or EBV or CMV

›New medication exposure

›Recent antibiotic or antiepileptic start

›Checkpoint inhibitor therapy

›Chemical or toxin exposure

03Physical Exam/exam48

Vitals and general

›Stability snapshot

›Temperature

›Fever as infection marker

›Hypothermia as severe sepsis marker

›Hemodynamics

›Tachycardia from anemia or sepsis

›Hypotension from hemorrhage or sepsis

›General appearance

›Pallor and ill appearance

›Tachypnea

›Anemia signs

›Conjunctival and nail bed pallor

›Flow murmur on auscultation

›High output failure signs

›Functional limitation

›Exertional dyspnea

›Lightheadedness

Bleeding and infection exam

›Mucocutaneous bleeding

›Skin findings

›Petechiae and purpura

›Ecchymoses

›Mucosal findings

›Gingival bleeding

›Epistaxis

›Fundoscopy

›Retinal hemorrhages

04Differential Diagnosis/ddx37

Life threats and primary mimics

›Hematologic malignancy

›Acute leukemia

›Blasts on peripheral smear

›Bone pain and organomegaly

›ICD-10 C95.90

›Myelodysplastic syndrome

›Dysplasia and cytogenetic abnormalities

›Most important mimic

›ICD-10 D46.9

›Hairy cell leukemia

›Splenomegaly with pancytopenia

›Fried egg cells on smear

›Clonal and reversible causes

›Paroxysmal nocturnal hemoglobinuria

›Hemolysis and thrombosis

›Overlaps with aplastic anemia

›ICD-10 D59.5

›Megaloblastic anemia

›Macrocytosis with hypersegmented neutrophils

›Reversible with B12 or folate

›Copper deficiency

›Post gastric bypass

›Excess zinc supplementation

Infiltrative and infectious mimics

›Marrow infiltration

›Myelofibrosis

›Dry tap on aspirate

05Laboratory Tests/lt64

Core hematology

›Complete blood count with differential

›Pancytopenia

›Low hemoglobin

›Low white cell count

›Low platelets

›Absolute neutrophil count

›< 0.5 x 10^9/l severe

›< 0.2 x 10^9/l very severe

›Reticulocyte count

›Depressed reticulocytes

›Reticulocyte production index < 2

›Hallmark of production failure

›Corrected count interpretation

›Distinguishes hypoproliferative state

›Excludes hemolysis as cause

›Peripheral blood smear

›Normocytic or macrocytic red cells

›No blasts

›No dysplasia

›Exclusion findings

›No schistocytes

›No leukoerythroblastic features

Etiology and overlap workup

›Hemolysis and overlap panel

›LDH and haptoglobin and indirect bilirubin

›Rule out hemolysis

›Screen for PNH overlap

06Diagnostic Tests/dt59

Scoring Systems

›Modified Camitta severity criteria

›Severe aplastic anemia

›Marrow cellularity < 25 percent

›Plus at least 2 of three cytopenia criteria

›Cytopenia criteria

›ANC < 0.5 x 10^9/l

›Platelets < 20 x 10^9/l

›Reticulocytes < 60 x 10^9/l

›Very severe aplastic anemia

›Same as severe

›ANC < 0.2 x 10^9/l

›Risk and prognosis tools

›MELD or hepatic scores

›If hepatitis associated disease

›Guides hepatology involvement

›Severity drives urgency

›Determines transplant versus IST

›Determines admission level

MRI

›MRI role

›Limited diagnostic utility

›Diagnosis requires marrow biopsy

›Not first line in crisis

›Problem solving indications

›Marrow fat fraction assessment

›Suspected marrow infiltration

›Brain MRI

07Disposition/dispo34

Level of care selection

›Admission indications

›Severe or very severe disease

›ANC < 0.5 x 10^9/l

›Platelets < 20 x 10^9/l

›Acute decompensation

›Febrile neutropenia

›Active hemorrhage

›New diagnosis

›Urgent marrow biopsy needed

›Initiation of therapy

›ICU indications

›Septic shock

›Vasopressor requirement

›Rising lactate despite resuscitation

›Catastrophic hemorrhage

›Intracranial hemorrhage

›Massive GI or pulmonary bleed

›Respiratory failure

›Pneumonia with hypoxemia

›Need for ventilatory support

Service and follow up

›Specialist disposition

›Hematology or oncology service

›All severe cases

›Coordination of definitive therapy

›Consult network

›Transplant team for eligible patients

08Treatment/t83

Initial stabilization

›Resuscitation measures

›ABCs and IV access

›Continuous monitoring

›Two large bore lines for hemorrhage

›Oxygen for symptomatic anemia

›Titrate to SpO2 >= 92%

›Reduce myocardial demand

›Transfusion support

›pRBC transfusion

›Symptomatic anemia or Hb < 70 g/l

›Irradiated leukoreduced CMV safe products

›Platelet transfusion

›Active bleeding or platelets < 10 x 10^9/l

›Higher threshold with fever or sepsis

›Alloimmunization prevention

›Avoid unnecessary transfusions

›Minimize donor exposures if transplant candidate

Febrile neutropenia and prophylaxis

›Empiric antibiotics

›Antipseudomonal beta lactam within 1 hour

›Piperacillin-tazobactam 4.5 g IV every 6 hours

›Cefepime 2 g IV every 8 hours

›Carbapenem alternative

›Meropenem 1 g IV every 8 hours

›For severe sepsis or resistance risk

›Escalation

›If beta lactam allergy, aztreonam plus vancomycin

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Rare association with aplastic anemia

›May present or worsen in pregnancy

›May remit postpartum

›Treatment modifications

›Cyclosporine can be continued

›Avoid ATG and eltrombopag if possible

›Transfusion strategy

›Maintain platelets > 20 x 10^9/l

›Higher platelet target for delivery

›Imaging approach

›Shield abdomen for chest imaging

›Limit CT to essential indications

Geriatric

›Older adult features

›Second incidence peak

›Patients over 60 years

›Worse prognosis

›Treatment selection

›IST preferred over transplant

›Reduced intensity approaches

›Comorbidity impact

›Higher infection mortality

›Cardiac risk from anemia

›MDS overlap

›Higher pretest probability of MDS

›Cytogenetics essential

10Background/b50

Epidemiology

›Incidence and distribution

›Rare disorder

›Roughly 2 per million per year in Western countries

›2 to 3 times higher in East Asia

›Bimodal age distribution

›Young adults 15 to 25 years

›Older adults over 60 years

›Outcome burden

›Mortality without treatment

›2 year mortality approaches 80 percent in severe disease

›Infection and hemorrhage are leading causes

›Long term complications

›Clonal evolution to MDS or AML in 10 to 15 percent

›Relapse after IST in 30 to 40 percent

Pathophysiology

›Mechanism of marrow failure

›Immune mediated destruction

›Cytotoxic T cell attack on stem cells

›Interferon gamma and TNF mediated suppression

›Marrow hypocellularity

›Cellularity < 25 percent

›Fat replacement without fibrosis

›Triggers and clonal biology

›Inciting triggers

›Viral antigens

›Drug haptens and toxins

›Clonal hematopoiesis

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Aplastic anemia home care

›Take all medications exactly as prescribed

›Keep all blood count and hematology appointments

›Strict hand hygiene and avoid sick contacts

›Avoid crowds during low blood counts

›Bleeding precautions

›No aspirin or anti-inflammatory medicines

›Use a soft toothbrush and electric razor

›Avoid contact sports and bleeding risk activities

›No intramuscular injections

›Infection precautions

›Avoid raw meats and unpasteurized dairy

›Wash all raw fruits and vegetables

›Report any fever immediately and do not take fever medicine first

›Warning signs to return to ER

›Fever of 38 C or higher

›New or worsening bleeding from gums nose or bowels

›Severe headache or confusion

›Dizziness fainting or chest pain

›Shortness of breath or new cough

›Follow up

›Hematology follow up as scheduled

›Frequent blood count checks

›Bring updated medication list to every visit

12References/r12

Guidelines and key sources

›Society guidelines

›American Society of Hematology 2026 severe aplastic anemia guideline

›British Society for Haematology aplastic anaemia guideline

›NCCN myelodysplastic syndromes guideline for overlap

›Landmark evidence

›Eltrombopag added to immunosuppression in severe aplastic anemia NEJM 2022

›Pathophysiology of acquired aplastic anemia NEJM review

›Haploidentical BMT for relapsed or refractory severe aplastic anemia BMT CTN 1502

›Coding standards

›ICD-10 D61.9 aplastic anemia unspecified

›ICD-10 D61.1 drug-induced aplastic anemia

›SNOMED CT aplastic anemia disorder concept

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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