Bicytopenia or pancytopenia found on an FBC
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Severity signs: emergency admission
- No tests in the community: refer urgently to the nearest haematology department (or emergency department), with the previous FBCs and the list of medicines.
No severity signs: urgent haematology advice and first tests
Laboratory tests
- Repeat FBC with reticulocyte count and blood film examination
- Vitamin B12
- Folate
- AST
- ALT
- GGT
- Alkaline phosphatase
- Bilirubin
- Serum creatinine with eGFR
- HIV serology
- Hepatitis B serology
- Hepatitis C serology
- LDHif needednon-French guidelineA British review for GPs (2024) and the German recommendation (DGHO, 2024) look for haemolysis: a raised reticulocyte count points to peripheral destruction rather than bone marrow failure [4,5]. The initial work-up of the French PNDS (national protocol for diagnosis and care), centred on aplasia, does not include it [1].
- Haptoglobinif needednon-French guidelineA British review for GPs (2024) and the German recommendation (DGHO, 2024) look for haemolysis: a raised reticulocyte count points to peripheral destruction rather than bone marrow failure [4,5]. The initial work-up of the French PNDS (national protocol for diagnosis and care), centred on aplasia, does not include it [1].
- Direct Coombs testif needednon-French guidelineA British review for GPs (2024) and the German recommendation (DGHO, 2024) look for haemolysis: a raised reticulocyte count points to peripheral destruction rather than bone marrow failure [4,5]. The initial work-up of the French PNDS (national protocol for diagnosis and care), centred on aplasia, does not include it [1].
- Serum copper, caeruloplasmin (if gastric surgery or malabsorption, to look for copper deficiency)if needednon-French guidelineAn American haematologists’ review (2018) and a British review (2024) cite copper deficiency among the nutritional causes, notably after gastric surgery or in malabsorption [4,6]. The French PNDS does not address it [1].
- Do not delay the haematology opinion to wait for results. Enclose with the letter the previous FBCs and the list of medicines and exposures of the last few months.
Also consider
Sources (9)
- Centre de référence des aplasies médullaires acquises et constitutionnelles, filière MaRIH. Protocole national de diagnostic et de soins (PNDS) : Aplasies médullaires acquises et constitutionnelles. Version du 1er mars 2023.
- Centre de référence des aplasies médullaires acquises et constitutionnelles, filière MaRIH. PNDS Aplasies médullaires acquises et constitutionnelles : synthèse destinée aux médecins traitants et pédiatres. Version du 1er mars 2023 (publié sur has-sante.fr ; non validé par la HAS).
- University Hospitals of Leicester NHS Trust. UHL Haematology Referral Guidelines : Pancytopenia (COM3757, version 9, en vigueur à partir de juillet 2026).
- Chew S, Kamangar M. Approach to pancytopenia: From blood tests to the bedside. Clin Med (Lond). 2024;24(5):100235.
- Brümmendorf TH, Burmester PO, Deeg HJ, Göbel U, Höchsmann B, Machherndl-Spandl S, Panse J, Passweg J, Röth A, Schrezenmeier H, Schubert J, Wörmann B. Aplastische Anämie. Leitlinie Onkopedia (DGHO, OeGHO, SGH-SSH, SGMO), Stand September 2024.
- Gnanaraj J, Parnes A, Francis CW, Go RS, Takemoto CM, Hashmi SK. Approach to pancytopenia: Diagnostic algorithm for clinical hematologists. Blood Rev. 2018;32(5):361-367.
- Andrès E, Affenberger S, Zimmer J, Vinzio S, Grosu D, Pistol G, et al. Current hematological findings in cobalamin deficiency. A study of 201 consecutive patients with documented cobalamin deficiency. Clin Lab Haematol. 2006;28(1):50-6.
- Suttorp M, Classen CF. Splenomegaly in Children and Adolescents. Front Pediatr. 2021;9:704635.
- Manchester University NHS Foundation Trust. Haematology GP Pathway Guides, version 4, mars 2026 : Pancytopenia.