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General practice > Haem > Flashcards

Haem Flashcards

1
Q

What is graft versus host disease

A

Occurs when T cells in the donor tissue (the graft) mount an immune response toward recipient (host) cells.

Multi-system complication of allogeneic bone marrow transplantation

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2
Q

Diagnosis criteria for GVHD

A

The transplanted tissue contains immunologically functioning cells

The recipient and donor are immunologically different

The recipient is immunocompromised

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3
Q

Risk factors for graft versus host disease

A

Poorly matched donor and recipient (particularly HLA)

Type of conditioning used prior to transplantation

Gender disparity between donor and recipient

Graft source (bone marrow or peripheral blood source associated with higher risk than umbilical cord blood)

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4
Q

Definition of acute GVHD

A

Is classically defined as onset is classically within 100 days of transplantation

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5
Q

What is chronic GVHD

A

May occur following acute disease, or can arise de novo

Classically occurs after 100 days following transplantation

Has a more varied clinical picture: often lung and eye involvement in addition to skin and GI, although any organ system may be involved

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6
Q

Signs and symptoms of acute GVHD

A

Painful maculopapular rash (often neck, palms and soles), which may progress to erythroderma or a toxic epidermal necrolysis-like syndrome

Jaundice

Watery or bloody diarrhoea

Persistent nausea and vomiting

Can also present as a culture-negative fever

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7
Q

Signs and symptoms of chronic GVHD

A

Skin: Many manifestations including poikiloderma, scleroderma, vitiligo, lichen planus

Eye: Often keratoconjunctivitis sicca, also corneal ulcers, scleritis

GI: Dysphagia, odynophagia, oral ulceration, ileus. Oral lichenous changes are a characteristic early sign

Lung: my present as obstructive or restrictive pattern lung disease

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8
Q

IX for GVHD

A

LFTs may demonstrate cholestatic jaundice. Hepatitis screen/ultrasound may be useful to exclude other causes

Abdominal imaging may reveal air-fluid levels and small bowel thickening (‘ribbon sign’)

Lung function testing

Biopsy of affected tissue may aid in diagnosis if there is uncertainty

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9
Q

Mx of GVHD

A

Intravenous steroids are the mainstay of immunosuppressive treatment in severe cases of acute GVHD.

Extended courses of steroid therapy are often needed in chronic GVHD and dose tapering is vital.

Second-line therapies include anti-TNF, mTOR inhibitors and extracorporeal photopheresis

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10
Q

What is haemochromatosis

A

autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

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11
Q

early presenting features of haemochromatosis

A

early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)

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12
Q

Presentation of haemochromatosis

A

‘bronze’ skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)

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13
Q

Reversible complications of haemochromatosis

A

Cardiomyopathy

Skin pigmentation

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14
Q

Irreversible complications of haemochromatosis

A

Liver cirrhosis**
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy

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15
Q

IX - haemochromatosis

A

general population: transferrin saturation is considered the most useful marker. Ferritin should also be measured but is not usually abnormal in the early stages of iron accumulation

testing family members: genetic testing for HFE mutation

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16
Q

Typical iron study profile in patient with haemochromatosis

A

transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC

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17
Q

Mx of haemochromatosis

A

Venesection is the first-line treatment
monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l

desferrioxamine may be used second-line

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18
Q

What do joint x-rays usually show in haemochromatosis

A

chondrocalcinosis

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19
Q

Classification of blood product transfusion complications

A

immunological: acute haemolytic, non-haemolytic febrile, allergic/anaphylaxis

infective

transfusion-related acute lung injury (TRALI)

transfusion-associated circulatory overload (TACO)

other: hyperkalaemia, iron overload, clotting

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20
Q

What is a non-haemolytic febrile reaction

A

Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage

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21
Q

Features of non-haemolytic febrile reaction and mx

A

Fever, chills

mx - Slow or stop the transfusion

Paracetamol

Monitor

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22
Q

Features of acute haemolytic reaction

A

ABO-incompatible blood e.g. secondary to human error

Fever, abdominal pain, hypotension

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23
Q

Mx of acute haemolytic reaction

A

Stop transfusion
Send blood for direct Coombs test(repeat typing and cross match)
Supportive care(fluids resus)

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24
Q

What is TRALI

A

Transfusion-related acute lung injury (TRALI)

Characterised by the development of hypoxaemia / acute respiratory distress syndrome within 6 hours of transfusion

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25
Q

Features of TRALI

A

hypoxia
pulmonary infiltrates on chest x-ray
fever
hypotension

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26
Q

What causes TRALI

A

Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood

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27
Q

Mx of TRALI

A 
Stop transfusion 
Supportive care(resus)
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28
Q

What is TACO

A

A relatively common reaction due to fluid overload resulting in pulmonary oedema. As well as features of pulmonary oedema the patient may also by hypertensive, a key difference from patients with TRALI.

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29
Q

Mx of TACO

A

Slow or stop transfusion

Consider intravenous loop diuretic (e.g. furosemide) and oxygen

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30
Q

Transfusion threshold for patients without ACS

A

70 g/L

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31
Q

Transfusion threshold for patients with ACS

A

80 g/L

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32
Q

Transfusion target for patients without ACS

A

70-90 g/L

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33
Q

Transfusion target for patients with ACS

A

80-100 g/L

34
Q

How quick are RBC units transfused in a non-urgent scenario

A

over 90-120 mins

35
Q

Risk factors Hodgkin’s lymphoma

A

HIV
Epstein-Barr Virus
Autoimmune conditions such as rheumatoid arthritis and sarcoidosis
Family history

36
Q

Presentation of Hodgkin’s lymphoma

A

Lymphadenopathy is the key presenting symptom.

The enlarged lymph node or nodes might be in the neck, axilla (armpit) or inguinal (groin) region.

They are characteristically non-tender and feel “rubbery”.

Some patients will experience pain in the lymph nodes when they drink with alcohol.

37
Q

Symptoms of Hodgkin’s lymphoma

A

Fever
Weight loss
Night sweats

Other symptoms can include:

Fatigue
Itching
Cough
Shortness of breath
Abdominal pain
Recurrent infections
38
Q

IX for Hodgkin’s lymphoma

A

Lactate dehydrogenase (LDH) is a blood test that is often raised in Hodgkin’s lymphoma but is not specific and can be raised in other cancers and many non-cancerous diseases.

Lymph node biopsy is the key diagnostic test.

CT, MRI and PET scans can be used for diagnosing and staging lymphoma and other tumours

39
Q

Lymph node biopsy findings in hodgkin’s lymphoma

A

The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma.

They are abnormally large B cells that have multiple nuclei that have nucleoli inside them.

This can give them the appearance of the face of an owl with large eyes.

40
Q

Staging system used in lymphomas

A

The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma. The system puts importance on whether the affected nodes are above or below the diaphragm.

41
Q

Mx of Hodgkin’s lymphoma

A

The key treatments are chemotherapy and radiotherapy. The aim of treatment is to cure the condition. This is usually successful however there is a risk of relapse, other haematological cancers and side effects of medications.

42
Q

Risks of chemotherapy in Hodgkin’s lymphoma

A

Leukaemia

Infertility

43
Q

Risks of radiotherapy in Hodgkin’s lymphoma

A

Radiotherapy creates a risk of cancer, damage to tissues and hypothyroidism.

44
Q

Examples of non-hodgkin’s lymphoma

A

Burkitt lymphoma
MALT lymphoma
Diffuse large B cell lymphoma

45
Q

What are burkitt lymphomas associated with

A

associated with Epstein-Barr virus, malaria and HIV

46
Q

What is a MALT lymphoma

A

MALT lymphoma affects the mucosa-associated lymphoid tissue, usually around the stomach. It is associated with H. pylori infection.

47
Q

How does a diffuse large B cell lymphoma usually present

A

Diffuse large B cell lymphoma often presents as a rapidly growing painless mass in patients over 65 years.

48
Q

Risk factors for non-hodgkin’s lymphoma

A 
HIV
Epstein-Barr Virus
H. pylori (MALT lymphoma)
Hepatitis B or C infection
Exposure to pesticides and a specific chemical called trichloroethylene used in several industrial processes
Family history
Autoimmune diseases(SLE)
49
Q

Mx of non-hodgkin’s lymphoma

A

Management involves a combination of treatments depending on the type and staging of the lymphoma:

Watchful waiting
Chemotherapy
Monoclonal antibodies such as rituximab
Radiotherapy
Stem cell transplantation
50
Q

What are B symptoms of Hodgkin’s lymphoma and what do they imply

A

‘B’ symptoms imply a poor prognosis

weight loss > 10% in last 6 months
fever > 38ºC
night sweats

51
Q

Mutation associated with burkitt’s lymphoma

A

Burkitt’s lymphoma is associated with the c-myc gene translocation, usually t(8:14).

52
Q

Microscopy findings in burkitt’s lymphoma

A

‘starry sky’ appearance: lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells

53
Q

What might be present in a gastric MALT lymphoma

A

Paraproteinaemia may be present

54
Q

Complications of NHL

A

Bone marrow infiltration causing anaemia, neutropenia or thrombocytopenia
Superior vena cava obstruction
Metastasis
Spinal cord compression
Complications related to treatment e.g. Side effects of chemotherapy

55
Q

What is anisocytosis

A

Anisocytosis refers to a variation in size of the red blood cells. These can be seen in myelodysplasic syndrome as well as some forms of anaemia.

56
Q

What are target cells

A

Target cells have a central pigmented area, surrounded by a pale area, surrounded by a ring of thicker cytoplasm on the outside. This makes it look like a bull’s eye target. These can be seen in iron deficiency anaemia and post-splenectomy.

57
Q

What are Heinz bodies

A

Heinz Bodies are individual blobs seen inside red blood cells caused by denatured globin. They can be seen in G6PD and alpha-thalassaemia.

58
Q

What are Howell-jolly bodies

A

Howell-Jolly bodies are individual blobs of DNA material seen inside red blood cells. Normally this DNA material is removed by the spleen during circulation of red blood cells.

They can be seen in post-splenectomy and in patients with severe anaemia where the body is regenerating red blood cells quickly.

59
Q

What are reticulocytes

A

Reticulocytes are immature red blood cells that are slightly larger than standard erythrocytes (RBCs) and still have RNA material in them. The RNA has a reticular (“mesh like”) appearance inside the cell.

It is normal to have about 1% of red blood cells as reticulocytes. This percentage goes up where there is rapid turnover of red blood cells, such as haemolytic anaemia. They demonstrate that the bone marrow is active in replacing lost cells.

60
Q

What are schistocytes

A

Schistocytes are fragments of red blood cells. They indicate the red blood cells are being physically damaged by trauma during their journey through the blood vessels.

61
Q

What might the presence of schistocytes indicate

A

They may indicate networks of clots in small blood vessels caused by haemolytic uraemic syndrome, disseminated intravascular coagulation (DIC) or thrombotic thrombocytopenia purpura. They can also be present in replacement metallic heart valves and haemolytic anaemia.

62
Q

What are sideroblasts

A

Sideroblasts are immature red blood cells that contain blobs of iron. They occur when the bone marrow is unable to incorporate iron into the haemoglobin molecules. They can indicate a myelodysplasic syndrome.

63
Q

What are smudge cells

A

Smudge cells are ruptured white blood cells that occur during the process of preparing the blood film due to aged or fragile white blood cells. They can indicate chronic lymphocytic leukaemia.

64
Q

What are spherocytes

A

Spherocytes are spherical red blood cells without the normal bi-concave disk space. They can indicated autoimmune haemolytic anaemia or hereditary spherocytosis.

65
Q

Main types of myeloproliferative disorders

A

Primary myelofibrosis
Polycythaemia vera
Essential thrombocythaemia
Chronic myeloid leukaemia

66
Q

What can all myeloproliferative disorders transform into

A

Acute myeloid leukaemia

67
Q

Genetic mutation associated with CML

A

t(9:22) BCR-ABL

68
Q

Genetic mutation associated with PV, PMF and ET

A

v617F mutation –> activation of JAK2 kinase

69
Q

What does activation of JAK 2 kinase result in

A

Stimulates erythropoietin and thrombopoietin receptors, but not GM-CSF receptors leading to a huge increase in RBCs and platelets but not WBCs

EPO and TPO levels decrease due to negative feedback from overestimation of TPO and EPO receptors

70
Q

What is primary myelofibrosis

A

result of proliferation of the hematopoietic stem cells.

71
Q

What is PV

A

Polycythaemia vera is the result of proliferation of the erythroid cell line

72
Q

What is myelofibrosis

A

proliferation of the cell line leads to fibrosis of the bone marrow. The bone marrow is replaced by scar tissue. This is in response to cytokines that are released from the proliferating cells(fibroblast growth factor)

73
Q

Presentation of myelproliferative disorders

A

Systemic sx(fatigue, weight loss, fever)

Anaemia

Splenomegaly

Portal HTN

Low platelets

Raised RBCs

Low WBCs

74
Q

Key signs of PV on examination

A

Conjunctival plethora (excessive redness to the conjunctiva in the eyes)
A “ruddy” complexion
Splenomegaly

75
Q

FBC findings - PV

A

Raised Hb (more than 185g/l in men or 165g/l in women)

76
Q

FBC findings in primary thrombocythaemia

A

Raised platelet count (more than 600 x 109/l)

77
Q

FBC findings in myelofibrosis

A

due to primary MF or secondary to PV or ET can give variable findings:

Anaemia
Leukocytosis or leukopenia (high or low white cell counts)
Thrombocytosis or thrombocytopenia (high or low platelet counts)

78
Q

What might a blood film show in myelofibrosis

A

teardrop-shaped RBCs, varying sizes of red blood cells (poikilocytosis) and immature red and white cells (blasts).

79
Q

Diagnosis of myeloproliferative disorders

A

Bone marrow aspiration is usually “dry” as the bone marrow has turned to scar tissue.

Testing for the JAK2, MPL and CALR genes can help guide management.

80
Q

Mx of primary myelofibrosis

A

Mild disease - monitor

Allogeneic stem cell transplantation

Chemotherapy

Supportive management

81
Q

Mx of polycythaemia vera

A

Venesection 1st line

Aspirin to reduce thrombus formation risk

Chemotherapy to control disease(hydroyurea)

82
Q

Mx of essential thrombocythaemia

A

Aspirin

Chemotherapy

General practice (26 decks)

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