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Myelodysplastic syndrome

Last reviewed: 1 Nov 2023
Last updated: 11 Sep 2023



History and exam

Key diagnostic factors

  • older age
  • fatigue
  • exercise intolerance
  • pallor
  • bruising or bleeding
  • prior chemotherapy and/or radiation therapy
  • congenital disorder
  • bacterial infections
More key diagnostic factors

Other diagnostic factors

  • autoimmune disorders
  • splenomegaly
  • hepatomegaly
  • lymphadenopathy
Other diagnostic factors

Risk factors

  • age >70 years
  • prior chemotherapy
  • prior radiation therapy
  • prior autologous hematopoietic stem cell transplantation
  • congenital disorders
  • tobacco
  • benzene
  • aplastic anemia
  • paroxysmal nocturnal hemoglobinuria (PNH)
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC with differential
  • peripheral blood smear
  • reticulocyte count
  • red blood cell folate
  • serum vitamin B12
  • iron studies
  • bone marrow aspiration with iron stain
  • bone marrow core biopsy
  • genetic testing
More 1st investigations to order

Investigations to consider

  • viral serology
  • serum erythropoietin
  • lactate dehydrogenase
  • HLA typing
  • flow cytometry
More investigations to consider

Treatment algorithm


lower-risk MDS: asymptomatic cytopenia(s)

lower-risk MDS: symptomatic cytopenia(s) without del(5q)

lower-risk MDS: symptomatic cytopenia(s) with del(5q)

higher-risk MDS: transplant candidate

higher-risk MDS: nontransplant candidate



Vijaya Raj Bhatt, ​MBBS, MS

​​Associate Professor

Section Leader, Malignant Hematology

University of Nebraska Medical Center Division of Hematology-Oncology




VRB has participated in a Safety Monitoring Committee for Protagonist Therapeutics. He has received consulting fees from Imugene; research funding (institutional) from Abbvie, Pfizer, Incyte, Jazz, and NMDP; and drug support (institutional) from Chimerix for a trial.

Prajwal Dhakal, MBBS

Clinical Assistant Professor of Internal Medicine-Hematology, Oncology, and Blood and Marrow Transplantation

University of Iowa

Iowa City



PD declares that he has no competing interests.


Dr Vijaya Raj Bhatt and Dr Prajwal Dhakal would like to gratefully acknowledge Professor Apar Kishor Ganti and Associate Professor Alissa Marr, previous contributors to this topic.


AKG has received research support from Amgen, Apexigen, Bristol-Myers Squibb, Janssen, Merck, New Link Genetics, Pfizer, and Takeda Oncology. AKG has been reimbursed for consulting work for AbbVie and Genentech. None of the grants or payments relate to work involving myelodysplastic syndrome. AM declares that she has no competing interests.

Peer reviewers

David P. Steensma, MD, FACP

Associate Professor of Medicine (Hematology) and Oncology

Division of Hematology

Department of Medicine

Mayo Clinic




DPS declares that he has no competing interests.

Adrian C. Newland, BA, MB, BCh, MA, FRCP, FRCPath

Professor of Haematology

Queen Mary University




ACN declares that he has no competing interests.

  • Myelodysplastic syndrome images
  • Differentials

    • Aplastic anemia
    • HIV infection
    • Other viral infections (e.g., parvovirus, CMV, or hepatitis)
    More Differentials
  • Guidelines

    • NCCN clinical practice guidelines in oncology: myelodysplastic syndromes
    • Guidelines for the management of adult myelodysplastic syndromes
    More Guidelines
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