15. Interactive cases

Question 1

What are the symptoms of anaemia and what do they depend on?

Answer 1

Depends on: age, severity of anaemia, speed of onset of anaemia. Symptoms include: weakness; SOB, lethargy, palpitations, CARDIAC FAILURE (SOBOE, orthopnoea, PND, swollen ankles)

Question 2

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?

Answer 2

Blood film, reticulocyte count, Hb electrophoresis, iron studies

Question 3

What are general signs of anaemia?

Answer 3

Pale mucous membranes, tachycardia, cardiomegaly/CCF

Question 4

What are specific signs of anaemia?

Answer 4

Koilonychia (severe iron deficiency); jaundice (haemolysis); and glossitis (B12 deficiency) NOTE: this is because vitamin B12 is needed for epithelial cell replacement

Question 5

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?

Answer 5

Iron deficiency, thalassemia, anaemia of chronic disease (low or normal)

Question 6

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?

Answer 6

Reticulocytosis is a normal response to anaemia in: haemolysis, haemorrhage, and haematinics (agents that stimulate the production of RBCs).

Question 7

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?

Answer 7

High HbF and HbA2 in thalassemia

Question 8

What are reticulocytes absent in?

Answer 8

Reticulocytes are ABSENT in: inadequate haematinics, bone marrow failure (e.g. infiltration), acute major haemorrhage - reticulocyte response takes at least 6 hours.

Question 9

What does blood film of IDA show?

Answer 9

Pencil cells, anisocytosis, poikilocytosis, hypochromic

Question 10

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?

Answer 10

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)

Question 11

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?

Answer 11

(Blood film); vitamin B12; folate; bone marrow biopsy

Question 12

What are causes of pancytopaenia?

Answer 12

Aplastic anaemia; leukaemia; infiltration (e.g. lymphoma, carcinoma); drugs (e.g. chemotherapy); B12/folate deficiency

Question 13

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?

Answer 13

AML - 80% of acute leukaemia in adults are AML

Question 14

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?

Answer 14

If you see Auer rods, you do NOT need to do cytochemistry or immunophenotyping

Question 15

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?

Answer 15

This is NOT CML because the WBC is NOT raised

Question 16

What are clinical issues in AML?

Answer 16

Anaemia; thrombocytopaenia - easy bruising/bleeding; neutropaenia - increased risk of infection (classically Gram-negative septicaemia)

Question 17

What are the principles of management of AML?

Answer 17

Supportive: red cell transfusions, platelet transfusions, nurse in isolation with prompt use of antibiotics. Disease-related: consider chemotherapy

Question 18

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?

Answer 18

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

Question 19

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?

Answer 19

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)

Question 20

What are the causes of LOW platelets and ABNORMAL clotting?

Answer 20

DIC; alcohol; drugs; leukaemia

Question 21

What are Ix for suspected DIC?

Answer 21

Blood film; D-dimers/FDPs; fibrinogen; blood cultures/CSR/MSU (septic screen); LFTs

Question 22

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?

Answer 22

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.

Question 23

What is the management of DIC?

Answer 23

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