15. Interactive cases Flashcards
What are the symptoms of anaemia and what do they depend on?
Depends on: age, severity of anaemia, speed of onset of anaemia. Symptoms include: weakness; SOB, lethargy, palpitations, CARDIAC FAILURE (SOBOE, orthopnoea, PND, swollen ankles)
Case 1: A&E, 36 y/o F, 2 years SOBOES, Hb 32 g/l, WBC 7x10^9/L, platelets 452x10^9/L, MCV 54fl. What further investigations could be done?
Blood film, reticulocyte count, Hb electrophoresis, iron studies
What are general signs of anaemia?
Pale mucous membranes, tachycardia, cardiomegaly/CCF
What are specific signs of anaemia?
Koilonychia (severe iron deficiency); jaundice (haemolysis); and glossitis (B12 deficiency) NOTE: this is because vitamin B12 is needed for epithelial cell replacement
Case 1: A&E, 36 y/o F, 2 years SOBOES, Hb 32 g/l, WBC 7x10^9/L, platelets 452x10^9/L, MCV 54fl. What are causes of anaemia with a low MCV?
Iron deficiency, thalassemia, anaemia of chronic disease (low or normal)
Case 1: A&E, 36 y/o F, 2 years SOBOES, Hb 32 g/l, WBC 7x10^9/L, platelets 452x10^9/L, MCV 54fl. Why measure reticulocyte count?
Reticulocytosis is a normal response to anaemia in: haemolysis, haemorrhage, and haematinics (agents that stimulate the production of RBCs).
Case 1: A&E, 36 y/o F, 2 years SOBOES, Hb 32 g/l, WBC 7x10^9/L, platelets 452x10^9/L, MCV 54fl. Why do haemoglobin electrophoresis?
High HbF and HbA2 in thalassemia
What are reticulocytes absent in?
Reticulocytes are ABSENT in: inadequate haematinics, bone marrow failure (e.g. infiltration), acute major haemorrhage - reticulocyte response takes at least 6 hours.
What does blood film of IDA show?
Pencil cells, anisocytosis, poikilocytosis, hypochromic
Case 1: A&E, 36 y/o F, 2 years SOBOES, Hb 32 g/l, WBC 7x10^9/L, platelets 452x10^9/L, MCV 54fl. Reticulocytes high, Hb electrophoresis normal, blood film shows anisocytosis, poikilocytosis, pencil cells and very pale cells (hypochromic). Iron studies - low ferritin, low transferrin saturation. What is the diagnosis? And what to do next?
Iron deficiency anaemia. Once iron deficiency is diagnosed, identify the source of bleeding. This tends to be either: uterine (e.g. menstruation/pregnancies), gastrointestinal.
(This patient was found to have previously had a pedunculated uterine fibroid which led to blood loss)
Case 2: haematology clinic, 68 y/o male, 6 wks nosebleeds and fatigue. Hb 60 g/dl, WBC 1x10^9/L, platelets 4x10^9/L. The blood film demonstrated presence of abnormal circulating cells. What investigations could be done?
(Blood film); vitamin B12; folate; bone marrow biopsy
What are causes of pancytopaenia?
Aplastic anaemia; leukaemia; infiltration (e.g. lymphoma, carcinoma); drugs (e.g. chemotherapy); B12/folate deficiency
Case 2: haematology clinic, 68 y/o male, 6 wks nosebleeds and fatigue. Hb 60 g/dl, WBC 1x10^9/L, platelets 4x10^9/L. The blood film demonstrated presence of abnormal circulating cells. Blood film shows myeloid blast cells which are granular with Auer rods. What is the diagnosis?
AML - 80% of acute leukaemia in adults are AML
Case 2: haematology clinic, 68 y/o male, 6 wks nosebleeds and fatigue. Hb 60 g/dl, WBC 1x10^9/L, platelets 4x10^9/L. The blood film demonstrated presence of abnormal circulating cells. Blood film shows myeloid blast cells which are granular with Auer rods. Do we need to do cytochemistry or immunophenotyping?
If you see Auer rods, you do NOT need to do cytochemistry or immunophenotyping
Case 2: haematology clinic, 68 y/o male, 6 wks nosebleeds and fatigue. Hb 60 g/dl, WBC 1x10^9/L, platelets 4x10^9/L. The blood film demonstrated presence of abnormal circulating cells. Blood film shows myeloid blast cells which are granular with Auer rods. Why is it not CML?
This is NOT CML because the WBC is NOT raised
What are clinical issues in AML?
Anaemia; thrombocytopaenia - easy bruising/bleeding; neutropaenia - increased risk of infection (classically Gram-negative septicaemia)
What are the principles of management of AML?
Supportive: red cell transfusions, platelet transfusions, nurse in isolation with prompt use of antibiotics. Disease-related: consider chemotherapy
Case 3: Surgical in-patient, 40 y/o M, admitted 4/7 ago with 35% burns, now bleeding nose/venepuncture sites. Hb 120g/L, WBC 10x10^9/L, platelets 28x10^9/L. Coagulation screen APTT 54 seconds (Control 40s). What are causes of thrombocytopania?
Defect in platelet production: drugs (e.g. chemotherapy, thiazides); bone marrow disorders (e.g. leukaemia, aplastic anaemia, myelodysplasia, myeloma, infiltration with carcinoma). Increased destruction of platelets: ITP; DIC; heparin-induced thrombocytopaenia
Case 3: Surgical in-patient, 40 y/o M, admitted 4/7 ago with 35% burns, now bleeding nose/venepuncture sites. Hb 120g/L, WBC 10x10^9/L, platelets 28x10^9/L. Coagulation screen APTT 54 seconds (Control 40s). What investigations to do next?
Coagulation screen; blood film; bone marrow aspirate/trephine biopsy; ANA/RAPA/anti-platelet antibodies (check for rheumatoid arthritis or SLE); HIV (NOTE: worldwide, HIV is a common cause of isolated platelet destruction)
What are the causes of LOW platelets and ABNORMAL clotting?
DIC; alcohol; drugs; leukaemia
What are Ix for suspected DIC?
Blood film; D-dimers/FDPs; fibrinogen; blood cultures/CSR/MSU (septic screen); LFTs
Case 3: Surgical in-patient, 40 y/o M, admitted 4/7 ago with 35% burns, now bleeding nose/venepuncture sites. Hb 120g/L, WBC 10x10^9/L, platelets 28x10^9/L. Coagulation screen APTT 54 seconds (Control 40s). This patient has DIC. What is the cause?
In his case, it is likely that he has developed DIC due to widespread tissue damage from the 35% burns which releases a lot of tissue debris into the circulation and inappropriately activates the coagulation cascade.
What is the management of DIC?
Liaise with the haematology team and the haematology lab; antibiotics; blood products (red cells, platelets, cryoprecipitate, FFP); regular blood tests to assess response to products
