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Patient: Mr. Laxman Kamble | 36 yo Male | Collected: 18-May-2026
Lab Report Summary & Interpretation
CBC Findings
| Parameter | Result | Reference | Interpretation |
|---|---|---|---|
| Haemoglobin | 12.2 g/dL | 13–17 | ↓ Low |
| RBC Count | 3.86 × 10¹²/L | 4.5–5.5 | ↓ Low |
| Haematocrit | 36.7% | 40–50% | ↓ Low |
| MCV | 95 fL | 81–101 | Normal |
| MCH | 31.7 pg | 27–32 | Normal |
| RDW-CV | 21.4% | 11.6–14.0 | ↑↑ Markedly elevated |
| WBC | 5.5 × 10⁹/L | 4.0–10.0 | Normal/Low-normal |
| Platelets | 169 × 10⁹/L | 150–410 | Normal |
| Morphology | Marked Anisocytosis, Normocytic normochromic | Significant |
Widal Test Findings
| Antigen | Result | Significant Threshold |
|---|---|---|
| S. typhi O (TO) | 1:40 | ≥1:80 |
| S. typhi H (TH) | 1:40 | ≥1:80 |
| S. paratyphi AH | 1:20 | ≥1:80 |
| S. paratyphi BH | 1:20 | ≥1:80 |
All Widal titres are below the significant threshold (1:80). Per lab interpretation: titres of 1:20–1:40 indicate absence of significant IgM/IgG antibodies against Salmonella species.
Diagnosis
1. Mild Normocytic Anemia with Marked Anisocytosis (Primary Finding)
The CBC shows normocytic normochromic anemia (Hb 12.2, RBC ↓, HCT ↓) with a markedly elevated RDW-CV of 21.4% and morphology showing marked anisocytosis. This pattern suggests:
- Early or mixed nutritional deficiency (iron + B12/folate) — the most likely cause of marked anisocytosis with a normal MCV (opposing macrocytic and microcytic populations masking each other)
- Haemolytic anemia (less likely without additional clinical features)
- The monocytes are at the upper limit (10%), which can be a reactive response
2. Widal Test — Negative (No Evidence of Active Typhoid)
The Widal titres are sub-significant. This effectively rules out active typhoid fever at this point. Important caveats:
- If collected in the first week of illness, antibodies may not yet have risen — a repeat test in 7–10 days may be warranted if typhoid is clinically suspected
- False negatives occur early in disease or with immunosuppression
- False positives can occur with prior vaccination or old infection
3. Relative Leukopenia / Normal WBC
WBC of 5.5 × 10⁹/L is characteristically low-normal, consistent with the typical hematological pattern in typhoid fever (leukopenia is classic), but also seen in viral illness and nutritional deficiencies. Not diagnostic on its own.
Recommended Management
Immediate Investigations (to clarify anemia)
- Peripheral blood smear — confirm anisocytosis morphology, look for hypersegmented neutrophils, target cells, etc.
- Serum iron, TIBC, ferritin — assess iron stores
- Serum B12 and folate — assess nutritional deficiency
- Reticulocyte count — distinguish productive vs. hypoproliferative anemia
- Blood culture × 2 — if fever is present (blood culture is gold standard for typhoid; Widal is unreliable)
- Malaria RDT / smear — endemic area, can cause anemia + false-positive Widal
If Anemia is Due to Mixed Nutritional Deficiency (most likely):
- Oral iron (ferrous sulfate 200 mg TDS) + Folic acid 5 mg/day
- Vitamin B12 (cyanocobalamin 1000 µg IM weekly × 4 weeks, then monthly if deficiency confirmed)
- Dietary counseling — green leafy vegetables, meat, legumes
- Treat any underlying cause (worm infestation, dietary gaps)
Regarding Typhoid:
- Do NOT start empirical anti-typhoid antibiotics — Widal is negative and below threshold; this would be inappropriate antibiotic use
- If clinically febrile and typhoid suspected: send blood cultures, repeat Widal in 5–7 days
- If blood culture confirms S. Typhi, treat per guidelines (Harrison's 22E):
| Indication | First-Line Agent | Dose | Duration |
|---|---|---|---|
| Empirical (IV) | Ceftriaxone | 2 g/day IV | 10–14 days |
| Susceptible strain | Ciprofloxacin | 500 mg BD PO | 10–14 days |
| Azithromycin (oral) | Azithromycin | 1 g day 1, then 500 mg/day | 5–7 days |
| XDR / resistance | Meropenem or azithromycin | As per susceptibility | 10–14 days |
⚠️ Fluoroquinolones should be used cautiously on the Indian subcontinent due to high prevalence of decreased ciprofloxacin susceptibility (Harrison's 22E, Ch. 171).
Summary
| Issue | Finding | Action |
|---|---|---|
| Anemia | Normocytic, marked anisocytosis, RDW ↑↑ | Investigate iron/B12/folate; treat deficiency |
| Typhoid (Widal) | Negative (sub-threshold titres) | No antibiotic treatment yet; blood culture if febrile |
| WBC | Low-normal (classic in typhoid/viral illness) | Monitor; repeat if clinically deteriorating |
The single most important next step is a blood culture if the patient has fever, combined with an iron/B12/folate panel to characterize the anemia.
— Harrison's Principles of Internal Medicine 22E (2025), Ch. 171; Jawetz Medical Microbiology 28E, Ch. 15
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