A 42-year-old white man presented with jaundice and generalized edema. He had been diagnosed with alcoholic cirrhosis four months prior. Laboratory evaluation is summarized in the Table. Abdominal ultrasound revealed a nodular liver and splenomegaly of 15.6 cm in craniocaudal dimension. Peripheral blood smear (panel A) revealed spur cells (acanthocytes, arrows). Hospital course was complicated by hematemesis and acute kidney injury requiring dialysis.

TestResultReference Range
Hemoglobin 8.8 g/dL 14-17 g/dL 
Mean cell volume 100 fL 81-96 fL 
Platelet count 119 × 109/L 150-425 × 109/L 
White cell count 11.4 × 109/L 4.5-11 × 109/L 
Reticulocytes 5% 0.4-1.9% 
Vitamin B12 > 1,500 pg/mL 225-914 pg/mL 
Folate 12.4 ng/mL ≥ 5.9 ng/mL 
Ferritin 955 ng/mL 22-350 ng/mL 
Creatinine 0.75 mg/dL 0.4-1.3 mg/dL 
Blood urea nitrogen 17 mg/dL 6-26 mg/dL 
Total/direct bilirubin 14.2/5.6 mg/dL 0.2-1.3/0-0.3 mg/dL 
International normalized ration (INR) 3.46 0.9-1.1 
Fibrinogen 69 mg/dL 200-400 mg/dL 
Haptoglobin < 30 mg/dL 44-215 mg/dL 
Direct antiglobulin (Coombs) test Negative Negative 
TestResultReference Range
Hemoglobin 8.8 g/dL 14-17 g/dL 
Mean cell volume 100 fL 81-96 fL 
Platelet count 119 × 109/L 150-425 × 109/L 
White cell count 11.4 × 109/L 4.5-11 × 109/L 
Reticulocytes 5% 0.4-1.9% 
Vitamin B12 > 1,500 pg/mL 225-914 pg/mL 
Folate 12.4 ng/mL ≥ 5.9 ng/mL 
Ferritin 955 ng/mL 22-350 ng/mL 
Creatinine 0.75 mg/dL 0.4-1.3 mg/dL 
Blood urea nitrogen 17 mg/dL 6-26 mg/dL 
Total/direct bilirubin 14.2/5.6 mg/dL 0.2-1.3/0-0.3 mg/dL 
International normalized ration (INR) 3.46 0.9-1.1 
Fibrinogen 69 mg/dL 200-400 mg/dL 
Haptoglobin < 30 mg/dL 44-215 mg/dL 
Direct antiglobulin (Coombs) test Negative Negative 

Peripheral blood smear before treatment (magnification x600)

Peripheral blood smear before treatment (magnification x600)

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