Haem Flashcards
Anaemia Definition (Hb)
Men <135g/L
Women <115g/L
Causes of microcytic anaemia
FAST Fe-deficiency Anaemia of chronic disease Sideroblastic anaemia Thalassaemia
Causes of macrocytic anaemia
FATRBC(+M) Fetus (pregnancy) Antifolates (phenytoin) Thyroid (Hypothyroidism) B12 or folate deficiency Cirrhosis (++alcohol) Myelodysplastic syndromes
Causes of normocytic anaemia
Acute blood loss Anaemia of chronic disease BM failure Renal failure Hypothyroidism Haemolysis Pregnancy
Fe deficiency anaemia - signs
koilonychia, atrophic glossitis, angular cheilosis
post cricoid webs - Plummer-Vinson Syndrome
Fe deficiency anaemia -blood film
microcytosis, hypochromic
anisytosis/ poikilocytosis
pencil cells
Fe deficiency anaemia - lab results
low Fe
low ferritin
high TIBC
Anaemia of chronic disease - pathophysiology
cytokine driven inhibition of RBC production
IFNs, TNF, Il1 = reduced EPO re3ceptor production (reduced EPO synthesis)
IL6 and LPS = stimulate liver to make hepcidin = decreases iron absorption (inhibits transferrin)
Anaemia of chronic disease - in renal failure
EPO deficiency
Sideroblastic anaemia
in BM - ineffective erythropoiesis - iron loading
causes endocrine/liver/ cardiac damage
Sideroblastic anaemia blood film
Ring sideroblasts
Sideroblastic anaemia - lab results
high Fe
high ferritin
N TIBC
Sideroblastic anaemia - causes
ALCOHOL excess myelodysplastic/ myeloproliferative disorders post-chemo irradiation lead anti-TB drugs
Sideroblastic anaemia - treatment
Pyridoxine - Vit B6 promotes RBC production
Remove cause
Vit B12 deficiency causes
Stomach - Pernicious anaemia (post-gastrectomy)
Terminal ileum - ileal resection (Crohn’s disease, bacteria overgrowth, tropical sprue, tape worms)
Vit B12 deficiency clinical features
glossitis, angular cheilosis
irritabiliy/ depression/ psychosis/ dementia
paraesthesiae, peripheral neuropathy (loss vibration/ proprioception 1st - absent ankle reflex, spastic paraperesis)
Pernicious Anaemia
anti-IF (50%)
anti-parietal cell (90%)
Schilling test
Vit B12 deficiency treatment
IM hydroxocobalamin (B12)
Folate deficiency causes
Diet
Pregnancy
Drugs - alcohol, anti-epileptics (phenytoin), methotrexate, trimethoprim
Hereditary spherocytosis genetics
autosomal dominant
SPECTRIN (or ankyrin) deficiency
Hereditary spherocytosis diagnosis
spherocytes
increase osmotic fragility
DAT +ve
Hereditary spherocytosis features
severe neonatal jaundice
splenomegaly - extravascular haemolysis
haemolytic anaemia complications
Parvovirus B19 susceptibility
- virus infects developing RBC and arrests maturation
if reduced RBC/RBC lifespan - may lead to severe anaemia
self limiting infection - may require transfusion
propensity to gall stones (pigmented)
increased risk of iron overload (increased intestinal absorption)
increased risk osteoporosis (unknown)
Gilbert Syndrome gene
genetic polymorphism
Mutation in UGT 1A1 (extradinucleotide on each allele = TA7/TA7)
Hereditary ellipotcytosis genetics
autosomal dominant - spectrin mutations
Hereditary pyropoikilocytosis (ellipotcytosis) genetics
abnormally snesitive to heat
autosomal recessive
South East Asian Ovalocytosis
recessive - heterozygous +/- malaria protection
G6PD Deifciency genetics
X linked (affect hereo males and homo females)
G6PD = enzyme catalyses first step in pentose phosphate pathway - maintains intracellular gluthianone (GSH)
GSH - protect RBCs against oxidative stress
G6PD Deifciency blood film
Heinz bodies - peripheral inclusions (methylviolet stain)
bite cells
nucleated RBCs, contracted cells
G6PD Deifciency presentation
rapid anaemia/ jaudice precipated by oxidants
drugs (primaquinine, sulfonamides, aspirin), broad/fava beans, acute stressors/infection, moth balls (naptholene0
Pyruvate kinase defiency
autosomal recessive
severe neonatal jaundice, splenomegaly, haemolytic anaemia
Sickle cell mutation
GAG -> GTG (Glu-> Val)
codon 6 on beta chain
HbA-> HbS
Sickle-haemaglobin C disease
HbSC
HbS from one parent
HbC from other parent (defective b chain)
Sickle beta thalassaemia
HbS/Beta
HbS from one parent
beta thalassaemia trait from other parent
SCD vaso-oclusion/ infarction SICKLED
Stroke Infection Crises (splenic, sequestration, chest pain) Kidney Liver - gallstones Eyes - retinopaty Dactilitis
Mesenteric ischaemia
Priapism
SCD Haemolyis features
anaemia 60-80 splenomegaly folate deficiency gallstones aplastic crisis
SCD presentation
usually at 3-6 months (decrease HbF)
reduced O2 = HbS polymerisation = sickling
child - strokes, splenomegaly, splenic crisis, dactylitis
teens - impaired growth, gallstones, psych, priapism
adult - hyposplenism, CKD, retinopathy, pumonary HT
Beta thalassaemia
reduced beat chain synthesis
thalassaemia scull x ray
skull bossing
maxillary hypertrophy
hair-on-end
Beta thalassaemia treatment
blood transfusions + desferrioxamine (prevents iron overload)
Warm Autoimmune Haemolyitc Anaemia
37C IgG DAT +ve Spherocytes Idiopathic, lymphoma, CLL, SLE, methyldopa
Cold Agglutinin Disease
<37C IgM DAT +ve Raynauds Idiopathic, lymphoma, infections: EBV, mycoplasma
Warm Autoimmune Haemolyitc Anaemia Tx
steroids
splenectomy
immunosuppression
Cold Agglutinin Disease Tx
treat underlying condition
avoid cold
chlorambucil (chemo)
Paroxysmal Cold Haemoglobinuria
Hb in urine
Viral infection - measles, syphillis, VZV
Donath-Landsteiner Ab - stick to RBCs ub cold - complement mediated haemolysis in rewarming
(self limiting - IgG dissociate at higher temp than IgM)
Paroxysmal nocturnal haemoglobniuria
acquired loss of GPI surface markers (protective)
Complement mediated lysis
Chronic intravascular haemolysis (NIGHT)
morning haemoglobinuria, thrombosis(+ Budd Chiari Syndrome)
Immunophenotyping or Ham’s Test
Paroxysmal nocturnal haemoglobinuria treatment
iorn/folate supplement
Prophylactic vaccine, Ab
Eculizimab (expensive) - prevents complement binding
TTP Ab
anti-ADMTS13
TTP
- MAHA
- fever
- renal impairment
- focal neurology
- thombocytopenia
TTP pentad
- MAHA
- fever
- renal impairment
- focal neurology
- thombocytopenia
HUS pathophysiology
E.coli toxin damages endothelial cells = fibrin mesh and RBC destruction
HUS features
MAHA, diarrhoea, renal failure
Children/ elderly
Acute Leukaemia feautres
rapid onset
death in w-m if untreated
immature cells (blasts)
BM failure - anaemia, neutropenia, thrombocytopenia
Acute Pro Myelocytic Leukaemia mutation
t(15;17) translocation = PML-RARA fusion gene
AML Chromosomal translocations
t(15;17) = promyelocytic leukaemia (M3)
t(5;8)
inv(16)/ t(16;16) = good prognosis
AML Chromosomal duplications
+ chr 8
+ chr 21 (i.e. Trisomy 21) - increased risk AML and ALL
Chromosomal Loss/ deletion
5/5q - parital loss of chr 5
7/7q - total loss of chr 7
AML molecular abnormalities
point mutations
NPM1 = good prognosis
CEBPA = good prognosis (both alleles)
partial duplication FLT3 = bad prognosis event
Multiple hit hypothesis
AML requires at least 2 interacting molecular defects - synergise to give leukaemic phenotype
Type 1 abnormality - promote proliferation and survival
Type 2 abnormalities - block differentiation
(CML - single mutation may be sufficient to cause disease)
Acute Pro Myelocytic Leukaemia clinical features
excess abnormal promyelocytes a/w DIC (due to hyperactive fibrinolysis)
must be diagnosed early to prevent death from haemorrhage
Acute Pro Myelocytic Leukaemia blood film
blasts (no present in aleukaemic leukaemia)
multiple auer rods
hypergranular
Multiple hit hypothesis - in acute pro myelocytic leukaemia
Type 1 abnormality - FLT3-ITD
Type 2 abnormalities - t(15;17) PML-RARA
Multiple hit hypothesis - Core Binding factor (CBF) Leukaemias
Type 1 abnormality - KIT mutation
Type 2 abnormalities - CBF function mutation
inv(16)/ t(16;16)
good prognosis
some maturation to abnormal eosinophil precursor - giant purple granules
AML bloodfilm
Auer rods (fusion of primary granules in crystal) Granular cells
AML cytochemistry (less used nowadays)
Positive staining for myeloperoxidase non-specific esterase sudan black B - these stains are negative in ALL
Immunopheonotyping ALL
Pre-B cell: CD19, Cd20, CD10, TdT
B cell: CD19, CD20, surface Ig
T cell: CD2, CD3, CD4, CD8, TdT
Immunopheonotyping AML
MPO
CD13, CD33, CD14, CD15
Glycophorin E
Platelet Antigens
Immunopheonotyping ALL and AML
CD34
CD45
HLA-DR
DIC in leukaemia
DIC presents as vascular obstuction (even gangrene) and due to sepsis (BM failure)
In pro-myelocytic - due to hyperactive fibrinolysis (substances secreted from leukaemic cells)
Clinical features of AML - eyes
retinal haemorrhages/ retinal exudates
due to hyperviscosity if WCC is +++ also due to thrombocytopenia
Clinical features of ALL
BM failure (anaemia, thrombocytopenia, neutropenia) Lymphadenopathy ++ Thymic enlargment - T cell HSM Testes, CNS, other site Painful bones in children
ALL mutations good prognosis
Hyperdiploidy = t(12;21), t(1;19)
t(9;22) - Ph+ Chr - prev poor prognosis - now GOOD with TK inhibitors - IMATINIB
ALL mutations poor prognosis
Hypodiploidy = t(4;11)
ALL B and T cell percentages
T-lineage = 15% B-lineage = 85%
ALL Treatment - specific therapy
CNS directed therapy - propensity to cross BBB and migrate into CSF - drugs directly injected or high dose to cross BBB
(+ systemic chemo)
PV gene mutation
JAK2 V617F mutation (100%)
ET gene mutaiton
JAK2 - 60%
Calreticulin - 30%
MPL - 5%
PMF gene mutaiton
JAK2 - 60%
Calreticulin - 30%
PV Treatment
Venesection
Hydroxycarbamide
target HCT <45%
ET Treatment
Aspirin - prevent thrombosis
Hydroxycarbamide - anti metabolite
Anagrelide - specifically inhibits platelet formation (SE - palpitations, flushing)
MF investigations
Tear drop poikilocytes (dacrocyte)
Leukoerythroblasts (primitive cells)
BM dry tap
Poor prognosis in MF
Severe anaemia <100g/L
Thrombocytopenia <100x10^19
Massive splenomegaly
Prognostic scoring system DIPPS
Score 0 - median survival 15y
Score 4-6 - median survival 1.3y
MF treatment
Hydroxycarbamide, thalidomide
Supportive
Allogenic SCT
Ruxolotinib - high prognostic score cases
MF cell signal inhibitor
Ruxolitinib (JAK2 inhibitor)
ALL TK inhibitor
IMATINIB (PH+ ALL)
Hodgkin Lymphoma staining
CD15
CD30
Hodgkin Lymphoma tissue diagnosis - characteristic cell
Reed-Sternberg Cells (owl eye)
Bi/multi-nucleate
Hodgkin Lymphoma Staging
Ann-Arbor
S1 One LN region
S2 Two or more LN regions on same side of diaphragm
S3 Two or more LN regions on opposite side of diaphragm
S4 extranodal sites (liver, BM)
A - no constitutional symptoms
B - constitutional symptoms (‘B’ symptoms)
Hodgkin Lymphoma Treatment
- Combination chemo (ABVD)
adriamycin, bleomycin, vinblastine, decarbgazine - Radiotherapy (high risk breast cancer)
- Intensive Chemo and Autologous SCT
NHL - H. Pylori
Gastric MALT (mucosa associated lymphoid tissue) Marginal Zone NHL of stomach
NHL - Sjogrens
Marginal Zone NHL of Parotid lymphoma
NHL - Coeliac disease
Small bowel T cell lymphoma
EATL (enteropathy associated T-Cell Non Hodgkin lymphoma)
NHL - HTLV
HTLV1 infects T cells by vertical transmission
Carribean and Japan carriers
May develop Adult T cell leukaemia lymphoma (2.5% at 70 years) – very aggressive
NHL - EBV
EBV infects B lymphocytes
Healthy Carrier state maintained by cytotoxic T cells - kill EBV antigen expressing B cells
Loss of T cells function give risk of EBV driven lymphomas
HIV
60 fold increase in lymphoma in HIV (high grade B-NHL)
Iatrogenic (renal heart pancreas transplant imunosuppression)
PTLD (post transplant lymphoproliferative disorder) – prednisolone or cyclosporin
NHL Prognosis
LDH, B2 microglobulin – raised in rapidly dividing tumours
Albumen – low in sick patients
Kidney/BM function – is it obstructing?
Wider treatment options in younger patients
Classical Hodgkin Lymphomas
Nodular sclerosing 80% Good prognosis (causes the peak incidence in young women)
Mixed cellularity 17% Good prognosis
Lymphocyte rich (rare) Good prognosis
Lymphocyte depleted (rare) Poor Prognosis
Nodular Lymphocyte predominant HL
5% - disorder of the elderly multiple recurrences
Hodgkin Lymphomas Treatment
ABVD Adriamycin Bleomycin Vinblastine DTIC
ABVD, is given at 4-weekly intervals.
Effective treatment Preserves fertility (unlike MOPP the original chemo) Can cause (long term) Pulmonary fibrosis cardiomyopathy
LN B Cell area
Lymphoid follicle
Mantle zone - naïve unstimulated B cells
Germinal center - B cells, Antigen presenting cells
This is where B cells which bind antigen epitopes are selected and activated
LN T Cell area
T cells
Antigen presenting cells
High endothelial vessels (T cells interact with APCs)
This is where T cells which bind antigen epitopes are selected and activated
Immunophenotyping - T and B cell markers
CD 20 = B cell marker
CD 3, CD 5 = T cell marker
Protein expressed in B cells of Mantel Cell Lymphoma
Cyclin D1
B cell clonality and malignancy
Light chain expression
Malignant B cells = monoclonal (kappa or lamda)
Normal B cells = poly clonal kappa and lamba light chain expression
FISH: Mantle cell lymphoma
t (11;14)
FISH: Follicular lymphoma
t (14;18)
FISH: anaplastic large cell lymphoma
t (2;5) a/w better prognosis in anaplastic large cell lymphoma
Immunophenotyping in CLL (poor prognosis)
CD38 staining
Follicular Lymphoma
Lymphadenopathy middle aged/elderly
Follicular pattern - whole node is replaced with neoplastic follicles
Germinal centre cell origin = CD10, bcl-6+ positive staining
May transform to high grade
Small lymphocytic lymphoma/CLL
Middle Aged/elderly; lymphadenopathy or high blood code
CD5, CD23 +
Multiple genetic abnormalities
Indolent, but can transform to high grade lymphoma (Richter transformation)
Mantle cell lymphoma
MA male predominence Lymph nodes, GI tract Disseminated disease at presentation Aberrant CD5, cyclin D1 expression 11;14 translocation Cyclin D1 over expression Median SR 3-5 yrs
Burkitt’s lymphoma
Jaw or abdominal mass children/young adults
Endemic, Sporadic, Immunodeficiency
EBV associated
Germinal center cell origin
“starry-sky” appearance
C-myc translocation (8:14, 2:8, 8;22) – removes break on cell cycle
Aggressive disease
Diffuse large B cell lymphoma
MA/elderly
Germinal center or post-germinal center B cell
Germinal centre phenotype - CD10+ = better prognosis
Sheets of large lymphoid cells
Germinal center phenotype = good prognosis
p53 positive, high proliferation fraction = poor prognosis
Diffuse large B cell lymphoma prognosis
CD10+ = better prognosis
p53 positive, high proliferation fraction = poor prognosis
Hodgkin vs Non Hodgkin
Hodgkin
More often localised to a single nodal site
Spreads contiguously
Non-Hodgkin
More often involves multiple lymph node sites
Spreads discontinuously
Classical Hodgkin Lymphoma
Young and MA (double peak)
Often involves just single lymph node group
Though to be germinal center/post germinal center B cell origin
EBV associated
Sclerosis, mixed cell population in which scattered Reed-Sternberg and Hodgkin cells with eosinophils
Moderately aggressive
CD 30 and CD 15 = diagnostic markers for HL
Nodular LP (Non Classical) Hodgkin Lymphoma
Isolated lymphadenopathy
Germinal centre B cell (positive for some germinal centre B cell markers)
No association with EBV
B cell rich nodules with scattered L&H cells
Indolent
Can transform to high grade B cell lymphoma (i.e. transforms to Non-Hodgkin Lymphoma)
Reactive population = lymphocytes (eosinophils and macrophages not seen – unlike classical HL)
Express CD 20 strongly and diffusely (Negative for CD 30 and 15)
CLL vs Small lymphocytic lymphoma (SLL)
CLL - primarily seen in BM
SLL - primarily seen in LN
Evan’s syndrome
CLL a/w autoimmunity - AIHA, ITP
CLL diagnosis
Lymphocytosis >5 (high % of WCC = small, mature lymphocytes)
Low serum Ig
SMEAR CELLS
CLL prognostic factors - poor
Raised LDH
CD38+
11q23 deletion
CLL prognostic factors - good
Hypermutated Ig Gene
Low ZAP-70 expression
13q14 deletion
CLL Staging
Binet Staging
A = high WBC, <3 enlarged LN (no treatment)
B = >3 enlarged LN
C = anaemia or thrombocytopenia
CLL treatment
watchful wairting if asymptomatic
Supportive
p53 +ve - first line = ALEMTUZUMAB
Multiple Myeloma Features
CRAB
Calcium = high
Renal failure (+amyloidosis, nephrotic syndrome)
Anaemia (+pancytopenia)
Bones (pain, osteoporosis, osteolytic lesions, fractures)
(+hyperviscosity)
MONOCLONAL Ig (paraprotein) - Bence Jones protein in urine
MM staging
Durie-Salmon Staging
MM Investigations
Narrow band on electrophoresis Rouleaux on blood film Bence-Jones protien in urine ESR +++ >10% plasma cells in BM
MM vs MGUS vs smouldering MM
MGUS
Monoclonal serum protein <30g/L
<10% clonal plasma cells
No CRAB
Smouldering MM
Monoclonal serum protein >30g/L
<10% clonal plasma cells
No CRAB
MM
Monoclonal serum protein >30g/L
Any population of clonal plasma cells
CRAB (>1)
MM Bone Aspirate Morphology
Mature plasmacytic myeloma cells - clumped chromatin, low nuclear-cytoplasmic ratio, abundant cytoplasm, rare nucleoli
Immature plasmacytic myeloma cells - reticular chromatin, less abundant cytoplasm, prominent nucleoli
= WORSE PROGNOSIS
MM Immunophenotyping
Stain positive for CD138
Stain negative for CD20 (unlike other B cell lymphomas)
Cytoplasmic Ig stain (other B cells stain for surface Ig)
Kappa/lamda = monoclona
Myeloma nephropathy
Paraprotein light chain fragments crystalise in kidney - blockage
Proximal tubule necrosis
Fanconi syndrome (renal tubule acidosis)
Cast nephropathy
MM treatment options
Steroids Chemotherapy (e.g. mephalan - high dose tx before SCT) IMIDS (e.g. thalidomide) Proteosome inhibtors (e.g. bortezomib)
MM treatment (path guide)
Supportive + bisphosphonates
First line - Bortezomib (proteosome inhibitor)
Auto CT curative in young pt
Not suitable SCT - daratumumab
MM treatment proteosome inhibitors
Build up of misfolded proteins
Fatal ER stress
E.g. bortezomib, carfilzomib
MM treatment IMIDS
IMIDS (e.g. thalidomide)
TF inihibtors
Myelodysplastic syndrome morphological feautres
WBC - Pelger-Huet anomaly (bilobed neutrophils) - Hypogranulation - Micro megakaryocytes RBC - ring sideroblasts
> 5% blast cells in BM
Myelodysplastic syndrome prognosis
1/3 die from infection
1/3 die from bleeding
1/3 die from acute leukaemia
(IPSS-R = prognosis)
Fanconi Anaemia
Inherited AA - opanytopenia
Autosomal recessive
Skeletal abnormalities, renal malformations, microopthalmia, short stature, skin pigmentation
Dyskeratosis Congenital
X linked most commonly
DKC1 gene - defective telomerase function
Autosomal dominant - mutated TERC gene
encodes telomerase RNA
Dyskeratosis Congenital
- Skin pigmentaiton
- Nail dystrophy
- Oral leukoplaskia
(+ BM failure)
Blood transfusions acute adverse reactions <24h
Acute haemolytic (ABO incompatibility) Anaphylaxis/ allergy Infection (bacterial) Febrile non-haemolytic TACO TRALI
Blood transfusions delayed adverse reactions >24h
Delayed haemolytic (ABO incompatibility) Infection (viral, malaria, VCJD) TA-GVHD Post transfusion purpura Iron overload
