A diabetic patient presented with atypical retinopathy, likely resulting from the combination of idiopathic aplastic anemia and concomitant diabetes. Reduced Hb levels in this patient made accurate HbA1c analysis impossible, but an error message that arose in testing pointed to an underlying etiology of the patient’s symptoms.
A 72-year-old male with type two diabetes came to my office for a dilated retinal examination. He reported that his diabetes arose 10 years ago and that his HbA1c was “good” but he felt unusually tired the last several months and was having trouble catching his breath. His previous eye exam from one year earlier, showed no diabetic retinopathy and mild nuclear sclerosis in each eye with best-corrected visual acuities of 20/20+.
His current medications included losartan, feonfibrate, and metformin and he noted a an internal medicine doctor’s diagnosis of diabetic peripheral neuropathy but no evidence of kidney dysfunction. Corrected acuities were again better than 20/20, with minimal refractive change. Both lenses showed early nuclear sclerosis and the irides were normal. Intraocular pressure measured 19/18 by applanation. A dilated fundus exam showed dot and blot hemorrhages in the posterior pole, which appeared far more numerous in the mid-peripheral retina with BIO exam. I did not detect retinal thickening with a fundus lens.
Montage ultrawide-field retinal imaging confirmed predominantly peripheral retinopathy, right eye more than left (see Figure 1). Closer inspection of the images showed a few intra-retinal hemorrhages with a white center. Spectral domain optical coherence tomography was performed to rule out subclinical macular edema, and was ‘normal’ and unchanged compared to SD-OCT captured a year earlier. I performed in-office glycosylated hemoglobin (HbA1c, A1cNOW, PTS Diagnostics) which gave the following error reading “the blood sample may have too little hemoglobin (Hb) for the test to work properly.” A spot glucose reading was performed and measured 161 mg/dl.
Given the fundus appearance and clinical history, moderate, non-proliferative, diabetic retinopathy as well as predominantly peripheral, diabetic retinopathy lesions (PPL), both risk factors for sight-threatening diabetic retinopathy, seemed probable. The white-centered hemorrhages, though, were less typical of diabetic retinopathy and careful review of previous fundus imaging showed no retinopathy whatsoever. Moreover, the HbA1c error message and self reported malaise/dypsnea made me suspect a hematologic disorder. I sent a report to the patient’s internist and asked him to return in eight weeks.
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