Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Aplastic Anemia

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In one line

·The bone marrow factory stops making red cells, white cells, and platelets — usually because the body's own immune cells attack the stem cells or toxic chemicals and drugs destroy them.

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Normal physiology

·Bone marrow is the soft tissue inside your bones—especially your hips, spine, ribs, and the long bones of your arms and legs. It holds hematopoietic stem cells (the master cells that can become any blood cell). These stem cells live in a support neighborhood called the stromal microenvironment—a network of nurturing cells, tiny blood vessels, and chemical signals (growth factors like erythropoietin, G-CSF, and thrombopoietin) that tell stem cells when to divide and what to become. Every day, healthy marrow makes about 200 billion red blood cells (to replace old ones that die after 120 days), 100 billion white blood cells (neutrophils only live 6 to 8 hours, so they need constant replacement), and 100 billion platelets (which last 7 to 10 days). Think of the marrow as a busy factory with three assembly lines running at once, all fed by the same pool of stem cells. Keep that normal picture in your head—every finding in aplastic anemia is a direct result of this factory shutting down.

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What goes wrong

·One broken thing upstream—destruction or failure of the stem cells—explains all the findings you see downstream.

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Hallmark signs

·Fatigue and getting tired quickly during activity
·Pale skin, pale inside of eyelids, and pale nail beds
·Easy bruising and tiny red or purple dots on the skin (petechiae)
·Bleeding gums, nosebleeds, or very heavy menstrual periods
·Getting infections over and over (like skin infections, pneumonia, or mouth sores)
·Fever with no clear cause
·Shortness of breath during activity or even at rest
·Severe bleeding from the stomach, intestines, bladder, or inside the skull

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Red flags · escalate now

·Fever (temperature 100.4°F or 38°C or higher) when your absolute neutrophil count is below 500/µL—this is neutropenic fever and means you could have a life-threatening bloodstream infection (sepsis). You need emergency IV antibiotics right away.
·Platelet count below 10,000/µL—very high risk of bleeding inside your skull (intracranial bleeding (hemorrhage)) or other organs without any warning. You may need an urgent platelet transfusion.
·Sudden severe headache, confusion, slurred speech, one-sided weakness, or vision changes—these can mean bleeding inside your brain from low platelets. This is a medical emergency.
·Blood counts dropping fast over days to weeks—this suggests very severe aplastic anemia or the bone marrow disease is changing into something worse like myelodysplastic syndrome or leukemia. Needs urgent specialist evaluation.
·Chest pain, extreme shortness of breath, or confusion—these mean your heart or brain is starving for oxygen because of severe anemia, and you need immediate care and possibly a blood transfusion.

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Workup

·Complete blood count (CBC) with differential and reticulocyte count
·Peripheral blood smear (looking at blood cells under a microscope)
·Bone marrow biopsy and aspirate (taking a sample from inside the hip bone)
·Flow cytometry for paroxysmal nocturnal hemoglobinuria (PNH) clone (CD55 and CD59 markers)
·Cytogenetic analysis (karyotype) of bone marrow cells
·Viral serologies: hepatitis A, B, C, Epstein-Barr virus (EBV), cytomegalovirus (CMV), HIV, parvovirus B19
·Chromosomal breakage test (diepoxybutane or mitomycin C stress test) and telomere length assay
·Serum vitamin B12 and folate levels

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Treatment

·Allogeneic hematopoietic stem cell transplant from a matched sibling or matched unrelated donor
·Immunosuppressive therapy: horse or rabbit anti-thymocyte globulin (ATG) plus cyclosporine, often with eltrombopag (a pill that signals the marrow to make more platelets)
·Red blood cell transfusions and platelet transfusions, with iron chelation (deferasirox or deferoxamine) if ferritin rises above 1000 ng/mL
·Preventive (Prophylactic) antibiotics (like levofloxacin or ciprofloxacin) and antifungals (like fluconazole or posaconazole) when absolute neutrophil count is below 500 cells/µL
·Granulocyte colony-stimulating factor (G-CSF, like filgrastim) during active severe infection
·Use white blood cell (leukocyte)-reduced, irradiated blood products; avoid platelet or red cell transfusions from family members if transplant is planned
·Eltrombopag (a thrombopoietin receptor agonist) added to immunosuppression or as single agent in refractory disease

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NCLEX trap

·In aplastic anemia, too many platelet transfusions teach the body to attack donor platelets (called alloimmunization — the immune system makes antibodies against the new platelets). This makes a future stem cell transplant fail because the body rejects the donor cells. Only give platelets if the patient is bleeding OR the platelet count is dangerously low (usually below 10,000 per microliter, per current hematology guidelines). Transfuse for safety, not just for the number.
·In aplastic anemia with very low neutrophils (below 500 per microliter — these are the white cells that fight bacteria), even one fever (100.4°F or higher once, or 100°F sustained) is a medical emergency. Start broad-spectrum antibiotics (drugs that kill many kinds of bacteria) within one hour. Do NOT wait for the culture. Infection spreads in minutes when there are no neutrophils to stop it (IDSA neutropenic fever guidelines). Every minute counts.
·In aplastic anemia, a red blood cell transfusion raises oxygen delivery and helps the patient feel less tired RIGHT NOW, but it does NOT fix the root problem — the bone marrow stem cells are failing or being attacked. The real treatment is immunosuppressive therapy (medicines like antithymocyte globulin plus cyclosporine that stop the immune system from killing stem cells) OR an allogeneic stem cell transplant (healthy donor stem cells replace the broken marrow). Transfusions are a bridge, not a cure.
·In aplastic anemia, the spleen usually stays normal size or even shrinks because there are fewer blood cells to filter and trap. If the spleen gets bigger (called an enlarged spleen (splenomegaly) — you can feel it below the rib cage), think of a DIFFERENT disease like myelodysplastic syndrome (MDS — the marrow makes broken cells that pile up), leukemia (cancer cells fill the spleen), or a myeloproliferative disorder (the marrow makes too many cells). A big spleen in aplastic anemia is a red flag to look again.
·In most aplastic anemia cases (60–70%), no drug or clear cause is ever found. The immune system attacks the bone marrow stem cells on its own for reasons we do not fully understand (called with no known cause (idiopathic) — we don't know why). Always ask about drugs (chloramphenicol, carbamazepine, sulfonamides), chemicals (benzene), and viruses (hepatitis, Epstein-Barr) — but most patients will NOT have any of these. Do not blame the patient or assume there is always a trigger.
·In aplastic anemia with severe dangerously low infection-fighting cells (neutropenia) (neutrophil count below 500 per microliter), do NOT give live vaccines (MMR, varicella chickenpox vaccine, intranasal flu spray) because the weakened virus can cause a real infection when the immune system is too weak. BUT inactivated vaccines (injectable flu shot, pneumococcal, COVID-19) are SAFE and important — they prevent life-threatening infections. The patient needs protection even more than a healthy person does (CDC immunocompromised guidelines).

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