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Agency for Toxic Substances and Disease Registry
Case Studies in Environmental Medicine (CSEM)
Benzene Toxicity
Case Study
A 50-year-old man is prompted to visit your office because of a nosebleed that has been recurring for 2 days. He says that this is the third episode of nosebleeds in the last 6 months. He expresses concern that he becomes easily fatigued at work, and 2 months ago he began noticing bruises on his arms and legs, although he does not recall the causes. He has lost more than 12 pounds in the last 2 years, which he attributes to loss of appetite.
History of previous illness includes a fractured arm in childhood. In the past 2 years he has had three bad colds that lasted for more than a week and included coughing and breathing difficulty. The patient occasionally drinks beer; he quit smoking cigarettes 4 years ago. He does not have allergies and is taking no medications at this time. Review of systems: patient admits to fatigue, headache, dizziness, nausea and loss of appetite, loss of weight, and weakness.
On examination, blood pressure is 138/84; heart rate is 94 and regular; respiratory rate is 20, temperature 98.9°; skin exam reveals pale and dry skin. A head, ear, nose, and throat exam shows a hyperemic inflamed pharynx, bleeding gums, and pale conjunctivae. The lung exam is clear to auscultation and the cardiovascular exam shows a regular rate and rhythm. The abdominal exam indicates no hepatosplenomegaly; the genitourinary exam is unremarkable; and the neurologic exam shows a normal gait, Glasgow coma scale 15. The extremity exam finds numerous ecchymoses and petechiae in variable stages of healing on the upper and lower extremities, although the extremities have good range of movement. The lymph node exam reveals prominent, palpable cervical nodes, and the rectal exam stool guaiac is negative.
On further questioning, you learn that the patient is a diesel mechanic and has worked on trucks for the same employer for the previous 12 years. He and his wife divorced 8 years ago; his wife became nervous and withdrawn after two miscarriages. There was marital stress. He has lived in his home for the past 16 years. He has a daughter, age 16, who lives with his ex-wife.
Laboratory studies reveal the following: glucose, blood urea nitrogen, and bilirubin within normal limits; hemoglobin (Hgb) 10.2 grams/deciliter (normal 14.0-18.0); hematocrit (Hct) 32.6% (44.8-52.0); red blood cell count 3.32 million per millimeter cubed (mm3) (4.3-6.0); mean corpuscular volume (MCV) 98 femtoliters (80-100); mean corpuscular hemoglobin (MCH) 31 picograms (26-31); mean corpuscular hemoglobin concentration (MCHC) 31% (31-36); white blood cell count 1,500/mm3 (5,000-10,000); segmented cells 60% (40-60); bands 1% (0-5); lymphocytes 31% (20-40); monocytes 8% (4-8); platelets 50,000/mm3 (150,000-400,000). A chest radiograph is remarkable for hyperlucency. There are no infiltrates, effusions, or other abnormalities noted; electrocardiogram is within normal limits. Urine was negative for blood.
- What is the problem list for this patient? What is the differential diagnosis?
- What additional testing would you recommend?
- What measures would you take to manage the case and treat this patient?
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