EFA/ Haematology Tutorial Flashcards
What is this? What causes this?
Nutmeg liver
HF: pressure increases in central vein
Pattern of blood going from middle of the lobule to the 6 corners
A 67M presents to A+E disoriented. He is unkempt + smells of alcohol. OE he is jaundiced, has an enlarged abdomen + spier naevi on his chest. He demonstrates a liver flap.
What is the most likely cause of his condition?
A. Hypercalcaemia
B. Hyperammonaemia
C. Hyperkalaemia
D. Hyponatraemia
B. Hyperammonaemia
High level of ammonia poisons you, causing encephalopathy + liver flap
Hb 80
MCV 102
Reticulocyte count 257 (50-100)
BR 33 (<17)
ALT 50 (5-42)
ALP 178 (100-300)
LDH 657 (200-450)
Creatinine 72 (60-125)
Hb 80
MCV 102
What is the most likely explanation for these lab results?
A. Acquired haemolytic anaemia
B. Transfusion associated GvHD
C. Obstrutive jaundice caused by pigment Gallstones
D. Transfusion transmitted Hepatitis E
E. Pernicious anaemia
A. Acquired haemolytic anaemia
LDH + BR are high
Incorrect options because:
B: severely immunocompromised state- pancytopenia
C. BR would be conjugated
D. Hepatic jaundice picture: raised transaminases + BR
E. MCV would be much higher
Summarise pre-hepatic jaundice
Excessive red cell breakdown- overwhelms Liver’s ability to conjugate BR
Unconjugated hyperbilirubinaemia
Any BR that is conjugated will be excreted normally
Give 2 differential diagnoses for pre-hepatic jaundice
Haemolytic anaemia
Summarise hepatic jaundice
Dysfunction of hepatic cells
Lose ability to conjugate BR/ cirrhotic liver compresses biliary tree causing obstruction
Unconjugated + conjugated BR in blood
Give 6 differential diagnoses for hepatic jaundice
Alcoholic liver disease
Viral hepatitis
Iatrogenic e.g. drugs
AI hepatitis
PSC/ PBC
Hepatocellular carcinoma
Summarise post hepatic jaundice
Obstruction of biliary drainage.
Conjugated hyperbilirubinaemia
Give 3 types of differential diagnosis for post hepatic jaundice
Intra-luminal: Gallstones
Mural: cholangiocarcinoma, strictures, drug induced cholestasis
Extra-mural: pancreatic cancer/ abdo masses e.g. lymphoma
In which disease states do you see coca cola dark urine?
Conjugated hyperbilirubinaemia
Mixed hyperbilirubinaemia
(as conjugated hyperbilirubinaemia is water soluble + can be excreted in urine)
In which disease states do you see pale stools? Why is this?
Post hepatic, Obstructive jaundice
Reduced levels of stercobilin entering the GIT (which usually gives colour to stool)
In a peripheral film spherocytes are seen in which scenario? What causes this?
A. Microangiopathic haemolytic anaemia
B. Folate deficiency anaemia
C. DAT positive hereditary spherocytosis
D. G6PD associated acute haemolysis
E. DAT positive AI haemolytic anaemia
E. DAT positive AI haemolytic anaemia
Immunoglobulin bind RBC as passes through spleen, spleen recognises Ig bound to antigen- damages RBC membrane
RBC seals itself again, but with loss of membrane for same intracellular vol constricting it into a small spherocytic shape
What is the mechanism causing spherocyte formation in hereditary spherocytosis?
Mutation in one of the proteins involved in red cell membrane construction: Ankyrin, Spectrin
NO immune mediated damage
What does the DAT test determine?
Whether normal RBCs (with no Ig bound to them)
OR
Whether RBCs are bound to by immunoglobulin in patients producing antibodies against the red cell membrane
In which condition are ghost cells seen?
G6PD associated acute haemolysis
What is seen on the blood film in a patient with folate deficiency anaemia?
Oval macrocytes
In a 25F who is symptomatic from AI haemolytic anaemia which is the most appropriate first line treatment?
A. Prednisolone
B. Transfusion of Group O RhD -ve blood
C. Folic acid supplements
D. Cyclosporin A
E. Ecluzimab (anti-complement) monoclonal antibody
A. Prednisolone
Fast acting, will suppress immune response + allow reduction of haemolysis
NO transfusion- even universal cells will be subject to same pathogenic mechanism
Cyclosporin A could be option longer term but is not rapidly acting
DAT positive acquired haemolytic anaemia may be seen in association with which other haematological disorders?
A. CML
B. Polycythaemia Vera
C. Hereditary spherocytosis
D. CLL
E. Hereditary spherocytosis
D. CLL
Prone to forming autoantibodies to RBCs
CML + PV: myeloid disorders, no a/w immune mediated haemolysis
In a 29M with bilateral cervical lymphadenopathy which disorder would NOT be in the differential diagnosis list?
A. Acute EBV infection
B. Follicular non-Hodgkin lymphoma
C. Multiple myeloma
D. Acute HIV infection
E. TB
C. Multiple myeloma
NEVER has lymphadenopathy
MM is a disease of BM with abnormal protein affecting kidneys, + with proliferation of BM itself affecting bones + spinal cord
In a 29M with bilateral cervical lymphadenopathy which disorder would NOT be in the differential diagnosis list?
A. Acute EBV infection
B. Follicular non-Hodgkin lymphoma
C. Multiple myeloma
D. Acute HIV infection
E. TB
C. Multiple myeloma
NEVER has lymphadenopathy
MM is a disease of BM with abnormal protein affecting kidneys, + with proliferation of BM itself affecting bones + spinal cord
Which of the following conditions is NOT associated with a widened mediastinum?
A. Teratoma
B. Thymoma
C. Hodgkin lymphoma
D. B cell ALL
E. B cell non-hodgkin lymphoma
D. B cell acute ALL
Lymphoblasts fill BM, eventually spill into peripheral blood
Become severely unwell, without tx, die of sepsis/ bleeding
Don’t survive long enough to build up a bulky lymphoid infiltration in the LN, Spleen or LN in mediastinum
What phrase can be used to remember the causes of a large mediastinal mass?
3 Ts: Teratoma, Thymoma + Terrible lymphomas
(Hodgkins, T cell lymphoblastic, T cell lymphomas involving thymus, B cell non-hodgkin)
In a 28F with classical hodgkin lymphoma, nodular sclerosing subtype, ann arbor stage 1A with disease confined to the left cervical nodes which of the following statements is true:
A. Does not require treatment
B. Chemotherapy and radiotherapy will achieve a cure rate >80%
C. Treatment will make her infertile
D. PET CT scan is not required after beginning treatment
E. Chemotherapy only will achieve a cure rate >80%
Chemotherapy only will achieve a cure rate >80%
(limited disease)
Standard tx will not affect fertility
PET CT is required to determine whether complete remission or whether radiotherapy required
Which lymphomas DON’T require urgent treatment?
Indolent lymphomas e.g. Follicular lymphoma or even CLL
Which therapy is no longer used first line in patients with hodgkins lymphoma?
Radiotherapy
Although combo has higher remission rates, there are higher rates of secondary cancers due to receivign 2 DNA damaging therapies
In a 40F splenomegaly + generalised lymphadenopathy which is the most likely haematological dx?
FBC:
WBC: 120.3 x 10^9
Hb: 120 g/l.
Platelets: 130 x 10^9
A. B cell non-hodgkin lymphoma
B. Acute lymphoblastic leukaemia
C. Chronic myeloid leukaemia
D. Chronic lymphocytic leukaemia
E. Hodkins lymphoma
D. Chronic lymphocytic leukaemia
WCC 120 much more likely leukaemia than lymphoma
A: involves nodes, but not usually BM + blood
B: Present acutely- die or get tx- don’t survive long enough to build up splenomegaly + gen lymphadennopathy
C. Myeloid- hepatomegaly + splenomegaly. NO lymphadenopathy
E. disease of LN, rarely involves blood
Massive hepatosplernomegaly
Lymphadeopathy
Abnormal blood count: v high WCC, smear cells
Over years Hb and platelets start to fall
What is the likely diagnosis?
Chronic lymphocytic leukaemia
Massive hepatosplenomegaly
Abnormal blood count
Hb + platelets preserved
V high WCC: neutrophils, myelocytes, basophils
No lymphadenopathy
What is the likely diagnosis?
Chronic myeloid leukaemia
