haem Flashcards
diagnosis?

thalassaemia trait
- microcytosis and hypochromia with normal Hb
possible diagnoses? (2)
what if B12 and folate were in normal range?
What if there were macro-ovalocytes and hyper-segmented neutrophils?

haemolytic anaemia
megaloblastic anaemia
If normal B12 + folate = haemolysis or acute blood loss i.e. reticulocytosis
if macro-ovalocytes and hyperseg neutrophils = B12/folate deficiency
polychromasia?
macro ovalocytes and hyperseg neutrophils?
reticulocytes
b12/folate deficiency
what parameter on blood count is likely to be raised in patient with spherocytosis?
MCHC because hyperchromic
how can you differentiate between acute blood loss and haemolysis?
spherocytes
spherocytes are marker of membrane damage
will NOT see them in acute blood loss
what blood count parameters would be raised in haemolytic anaemia? (4)
MCHC (spherocytes)
urinary haemosiderin
serum lactate dehydrogenase
DECREASED serum haptoglobin
when to suspect haemolytic anaemia? (3)
anaemia with polychromasia (reticulocytes) - either ACUTE* blood loss or haemolysis
spherocytes - not seen in acute blood loss
haemosiderin/haemoglobin in urine = intravascular
** chronic blood loss associated with microcytic anaemia due to iron deficiency - reticulocytes will not be present
how to confirm autoimmune haemolysis?
DAT test (Coombs)
Dx = autoimmune haemolytic anaemia
Ax autoimmune haemolytic anaemia? (3)
Tx?
infection (CMV, HIV, EBV)
autoimmune disease (lupus)
lymphoma
Tx = steroids 1st line + FOLIC ACID!
blood film shows:
abnormally shaped red cells, neutrohpil segmentation
diagnosis?

myelodysplastic syndrome
i.e. macrocytic anaemia
components of normal haemostatic system? (4)
formation of platelet plug - primary haemostasis
fibrin clot - secondary haemostasis
fibrinolysis
anticoagulant defences - protein C, S, anti-thrombin
when should antiplatelet drugs be stopped prior to surgery?
examples of drugs
approx a week prior to surgery (platelet lifespan 7-10 days)
aspirin, clopidogrel, ticagrelor
steps in primary haemostasis
endothelial damage = expresses VWF
platelets adhere to VWF
aggregation of platelets
failure of primary haemostasis consequences? (4)
spontaneous bruising and purpura (often seen on lower limbs, will blanche)
mucosal bleeding (epistaxes, GI, conjunctiva, menorrhagia)
intracranial haemorrhage
retinal haemorrhage
whats this?

purpura (seen in thrombocytopenia)
causes of primary haemostasis FAILURE? (3)
scurvy, elderly
thrombocytopenia (or reduced platelet function)
VWF defieincy - most common inherited deficiency
secondary haemostasis steps
tissue factor (TF) released from damaged endothelium
TF activates clotting factor VII
VII activates V and X
V and X stimulate prothrombin to become thrombin
thrombin stimulates fibriogen to form fibrin
thrombin also activates clotting factors 8+9
8+9 activate more V and X

causes of FAILURE of secondary haemostasis? (3)
single clotting factor deficiency (usually heridirary e.g. haemophilia)
multiple clotting factor deficiencies (usually acquired e.g. DIC, liver disease, vit K deficiency/Warfarin therapy)
increased fibrinolysis
NB: in multiple clotting factor deficiencies will have prolonged PT and APTT
fibrinolysis process
D-dimer?
TPA converts plasminogen to plasmin
plasmin breaks fibrin into fibrin degredation products (FDPs)
in blood, FDPs show up as D-dimers
consequences of FAILURE of secondary haemostasis?
no characteristic clinical syndrome
bleeding into joints and muscles - haemophilia
DIC - severe bleeding

screening tests for fibrin clot formation
screening test for primary haemostasis?
prothrombin time
activated partial thromboplastin time
primary = platelet count
prolonged PT?
prolonged APTT?
prolonged PT = 7, 5, 10, prothrombin or fibrinogen
prolonged APTT = 8 and 9
e.g. if deficient in factor VII
APTT normal, PT prolonged
clinical approach to bleeding disorders
history - primary or secondary?
purpura, mucosal bleeding = primary
joint bleeds, muscle bleeds = secondary (haemophilia)
duration of bleeding - hereditary will be lifelong
previous surgery/dental extractions + menstrual periods!
drug history - aspirin, anticoagulants, NSAIDs
examination - purpura, mucosal bleed, retinal exam, enlarged spleen (low platelets in circulation)
naturally occuring anticoagulants?
what happens to thrombin?
antithrombin - switches off thrombin
protein C, protein S - switch off factor 5 and 8
thrombin recognises when haemostasis is achieved and binds to thrombomodulin (switches on protein C and S)
thrombophilia?
deficiency of naturally occuring anticoagulants (antithrombin, protein C, protein S)
tendency to develop DVT/PE
markers of normal tissue perfusion?
Blood pressure
consciousness
urine output
lactate
causes of shock?
hypovolaemic (severe dehydration, burns)
cardiogenic (MI!!, cardiomyopathy, valve problems, dysrhythmias)
distributive (massive vasodilation - “hot” shock, sepsis, anaphylaxis, acute liver failure, spinal cord injury)
obstructive (PE, air/fat/amniotic fluid embolism, tamponade, tension pneumothorax)
endocrine (hypothyroid, thyrotoxicosis, addisonian crisis)
there are more but whatever
hypovolaemia classification

monitoring shock patients?
Examination - pale, cold skin, prolonged cap refill
Urine output - sensitive indicator of renal perfusion
Neurological - disturbed consciousness -> cerebral hypoperfusion
Biochemical - acidosis, lactate levels
Blood pressure
Central venous pressure - rarely useful except to assess “fluid responsiveness”
Cardiac output monitoring = gold standard is thermodilution with PA catheter
management shock?
ABCDE
wide bore IV access
Tx underlying cause
target MAP shock?
fluid challenge?
when fluids dont work?
when this fails?
Target for MAP = 65-70 mmHg (normal = 70-100)
fluid challenge = 500ml over 10-20 mins, want to see increased MAP, decreased HR, increased UO
when fluids don’t work = adrenaline (^ HR, contractility), noradrenaline (vasoconstriction), vasopressin
when drugs fail = LVAD, ECMO
2 types of fluids used in shock?
Crystalloids - convenient, cheap, safe
But rapidly lost from circulation - need significantly larger volumes!!
Colloids - cheapish, reduce the volume required
Albumin most common
Can cause anaphylaxis
side effect of resuscitation?
Tx?
fluid overload - oedema, ARDS (wet lung), bowel oedema
young healthy people will just pee it out
elderly = diuretics, dialysis
what is massive haemorrhage?
massive haemorrhage protocol?
One blood volume (5L) in 24 hours OR
50% blood volume in 3 hours OR
blood loss of 150ml/minute
(obstretrics = >1000ml)
ABCDE
call blood bank and state “massive haemorrhage”
send urgent FBC, coag screen, fibrinogen, Xmatch, U+E, calcium
blood bank will issue: 4 units red cells, 4 units FFP, 1 unit platelets
what is FFP?
cryoprecipitate?
transfusion target?
FFP = replaces clotting factors
cryoprecipitate = replaces fibrinogen
aim 2RBC : 1 FFP
in trauma = 1 : 1!!
Mx PPH?
most common cause = uterine atony
uterine massage
uterotonic drugs
cryoprecipitate (fibrinogen much higher in pregnant women)
+ tranexamic acid
trauma haemorrhage Tx?
Variceal bleed?
ruptured AAA?
trauma = tranexamic acid within 3 hours!!
Variceal bleed = terlipressin, FFP very important, band ligation of varices!!
ruptured AAA = blood component support until emergency surgery (EVAR)
what should NOT be used in GI haemorrhage?
tranexamic acid!!
when to suspect DVT?
d-dimer
doppler
WELLS score
types of thrombocytopenia?
hereditary i.e. VWF deficiency (most common)
aquired:
reduced production (marrow problem) - pancytopenia
increased destruction = DIC, ITP, portal hypertension (hypersplenism)
Ax platelet functional deficits (i.e. normal number)?
hereditary
acquired = drugs (aspirin, NSAIDs), renal failure
von willebrand factor deficiency?
most common hereditary bleeding disorder (failure of platelet plug fomration but normal platelet count)
autosomal dominant
commonest cause of primary haemostatic failure?
thrombocytopenia - usually ITP or portal hypertension
clotting factor synthesis?
what is essential for function?
ALL synthsised in hepatocytes (reduced in liver failure)
factor 2, 7, 9 + 10 carboxylated by vitamin K whcih is essential for function
vitamin K absoprtion?
Ax vit K deficiency?
absortped in small bowel, requires bile salts for absorption
Ax deficiency
* poor diet
* malabsorption
* obstructive jaundice (no bile)
* Warfarin
* haemorrhagic disease of the newborn
disseminated intravascular coagulation?
S/s?
blood count will show?
coag screen?
Excessive activation of haemostatic system - primary, secondary and fibrinolysis
S/s = bruising, purpura, generalised bleeding, end organ failure
blood count = thrombocytopenia, reduced clotting factors, lots of D-dimer (FDPs)
coag screen = prolonged PT and APTT

Ax DIC?
Tx?
basically anything that leads to massive tissue damage and so excess haemostatic activity = sepsis, obstetric emergencies, malignancy, hypovolemic shock
Tx = treat underlying cause, platelets, FFP, cryoprecipitate
haemophillia?
inheritance?
Types?
severity?
Hereditary single clotting factor deficiency
X-linked
Hemophilia A (factor VIII deficiency) - 5 x more common than hemophilia B
Hemophilia B (factor IX deficiency)
3 types: mild, moderate, severe (severe is most common)
features haemophilia?
No abnormality of primary hemostasis
Depending on if hemophilia A or B, will only have deficiency of factor VIII or IX
So prothrombin time will be normal
APTT will be prolonged
clinical features of severe haemophilia?
complication?
Recurrent hemarthrosis
Recurrent soft tissue bleeds
Bruising in toddlers
Prolonged bleeding after dental extractions, surgery and invasive procedures
comp: recurrent bleeds within the joint can lead to significant joint damage (can see loss of joint space + fusion)

isolated prolonged APTT?
suspect haemophillia
categories thrombosis?
Arterial = coronary, cerebral, peripheral
Venous = deep venous thrombosis, pulmonary embolism
arterial thrombosis Ax?
thrombus?
Tx?
Ax = atherosclerosis
platelet rich thrombus
Tx = aspirin and other antiplatelet drugs
modify risk factors for atherosclerosis - smoking, weight
venous thrombosis Ax?
thrombus?
Ax = Virchow’s triad
* stasis + endothelial damage + hypercoagulability
platelets not activated so fibrin-rich clot
Tx = anticoagulants e.g. heparin, wafarin, DOACs
risk factors VTE?
elderly
obesity
pregnancy + puerperium
HRT, COCP
previous DVT/PE
trauma, surgery
malignancy
thrombophillia
thrombophillia?
commonest thrombophillia?
Deficiency of anticoagulant defences (protein S, C, antithrombin)
commonest thombophilia = facotr V Leiden
* change in factor V protein, cannot be switched off by proten C or S
Hereditary thrombophilias?
Factor V Leiden
Prothrombin 20210 mutation
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
when to suspect hereditary thrombophillia?
Tx?
Venous thrombosis <45 years old
Recurrent venous thrombosis
Unusual venous thrombosis
Family history of venous thrombosis
Family history of thrombophilia
Tx = avoid COCP
short term prophylaxis to prevent thrombotic events during period of known risk
short term anticoagulation to treat thrombotic events
long term anticoagulation if recurrent thrombotic events
acquired thrombophillia?
S/s?
features?
Dx?
Antiphosphilipid antibody syndrome
s/s = recurrent thrombosis (arterial i.e. TIAs, venous), recurrent foetal loss, mild thrombocytopenia
Dx = aCL + LA
will see prolonged APTT (confusing but just know this)
conditions associated with APS?
Tx?
Autoimmune disorders
Lymphoprilifative disorders
Viral infections
Drugs
Primary - most common
Tx = aspirin + Warfarin
(remember different in pregnancy - LMWH)
indications for anticoagulant drugs?
Examples?
Venous thrombosis
Atrial fibrillation
anticoagulants = heparin + LMWH, Warfarin, DOACs
heparin mechanism?
benefit?
2 types?
mechanisms of types?
heparin = increases antithrombin effect
benefit = immediate effect
2 forms = unfractioned + LMWH
LMWH = antithrombin-Xa reaction
unfractioned = antithrombin-thrombin reaction
herpatin complications?
reversal?
Bleeding
Heparin induced thrombocytopenia (with thrombosis) HITT - so if patient on heparin and platelet count DROPS they are actually at risk of thrombosis
Osteoporosis with long term use
Heparin - reversal
* stop herparin (short half-life)
* in emergency = protamine sulphate
mechanism of action Warfarin?
what do you have to give warfarin with initially?
why?
inhibition of vit K
warfarin must be given with herparin initially as inhibits protein C and protein S for a while
Warfarin therapy cons?
Benefits?
requires INR monitoring (every few weeks)
risk of haemorrhage
drug interactions - aspirin, antibiotics, NSAIDs, spinach, kale, cranberry juice
cant take in pregnancy
benefits = reversible with vitamin K (or in emergency = clotting factors, as vit K takes a few hours)
DOACs?
benefits?
cons?
new anticoagulants
oral Xa inhibitors = edoxaban, rivaroxiban, apixiban
direct thrombin inhibitors = dabigatran
benefits = no monitoring
cons = not reversible + cannot be used in renal disease (Warfarin can)
DOACs used for?
DVT/PE
stroke prevention in AF patients

PSIS

immunophenotyping

ESRD and erythropoetin
haemopoesis?
types?
production of RBCs, WBCs + platelets
erythropoiesis = RBC
Thrombopoesis = platelets
Lymphopoiesis = WBC
granulopoiesis/myelopoiesis = production of granulocytes
lifespan of blood cells?
therefore?
RBC = 120 days
neutrophils = 7-8 hours
platelets = 7-10 days
So if haemopoiesis switched off, would expect neutrophils to fall, then platelets then red cells
ancestry of blood cells?
RBC
Pro-normoblast → late normoblast → reticulocyte → erythrocyte
Neutrophil
Myeloblast → promyelocyte → myelocyte → metamyelocyte → band neutrophil → mature neutrophil
Platelet = megakaryocyte
where do precursors (erythroblasts, myeloblasts) come from?
haemopoetic proginitor cells, which come from haemopoetic stem cells

myelocytes?
nucleated precursor between myeloblasts and neutrophils
myeloid terminology?

haemopoetic stem cells originate from?
sites of haemopoesis?
originate in mesoderm
yolk sac is first site of haemopoeisis
week 6 = liver
week 16 = bone marrow
in adults, haemopoesis restricted to axial skeleton, pelvis, and proximal long bones
in children, haemopoesis occurs in all bones
bone marrow cellularity?
subtract age from 100
so 20 year old has 80% cellularity
where to collect bone marrow biopsy?
adults = PSIS
children = anterior tibia
red vs yellow marrow?
myeloid:erythroid ratio?
normal ratio?
when will it change?
Red (haemopietically active) vs yellow (fatty inactive) marrow: increase in yellow marrow with age results in reduction in marrow cellularity in older individuals
myeloid:erythroid ratio = proprtion of neutrophils/precursors to proportion of nucleated red cell precursors
Normal = 1.5:1 to 3.3:1
ratio reverses in haemolysis as compensation
neutrophil precursor maturation regulated by?
platelets?
erythropoeisis?
neutrophil precursor maturation regulated by G-CSF (granulocyte colony stimulating factor)
thrombopoetin regulates development of magakaryocytes
erythropoesis = erythropoetin, iron (haem), folate, globin synthesis

Ix haemopoesis?
Routinely undertaken = FBC, cell indices, morphology (blood films)
Less common (specialist) - bone marrow examination

investigations for non-lymphoid cells vs lymphoid?
For non-lymphoid = blood count/morphological assessment often sufficient
lymphoid cells = immunophenotyping
how to harvest stem cells?
G-CSF injections stimulate mobilisation of stem cells form bone marrow into blood
ancestry lymphoid cells?

lymphoid system?
Central (primary) lymphoid tissues = bone marrow + thymus
Peripheral (secondary) lymphoid tissues = lymph nodes, spleen, tonsils (waldeyer’s ring), epithelio-lymphoid tissues
lymph node anatomy?
afferent channels drain lymph into peripheral sinus where it is filtered
efferent vessel exits hilum, drains to:
cisterna chyli/thoracic duct
or left subclabian vein
into venous system :)
arterial and venous supply to nodes enter/exit via hilum
lymphoid system function?
immune function
prevents oedema
cell populations in lymph nodes?
Lymphocytes
- B cells
- Associated with follicles and germinal centres
- Interfollicular
- Plasma cells - mainly in medulla
- T cells
- T helper cells + cytotoxic
- Natural killer cells
Macrophages, antigen presenting cells, and dendritic cells
Endothelial cells
lymphadenopathy Ax?
(INDAM = infectious/inflammatory, neoplastic, drugs, autoimmune, metabolic)
Local inflammation
- Infection (some have typical features e.g. TB, toxoplasma)
- Others e.g. vaccination, dermatopathic
Systemic inflammation
- Infection e.g. viral infections
- autoimmune/CT disorders
Malignancy
- Haematological e.g. lymphoma/leukemia
- Metastatic
Others
- E.g. sarcoidosis, Castleman’s disease, IgG4 related disease
red lines extending from inflamed node?
lymphangitis

generalised lymphadenopathy suggests?
systemic infection
lymphoma/leukemia - must check FBC
autoimmune
lymph node response to autoimmune? tumour? viral infection?

spleen palpable?
surfaces?
vascular supply?
rupture?
spleen not palpable unless substantially enlarged
2 key surfaces: diaphragmatic + visceral (left kidney, gastric fundus, tail of pancreas, splenic flexure of colon)
supplied by splenic artery (branch of coelic)
- drained by splenic vein (forms portal vein alongside SMV)
rupture is a surgical emergency
structure of spleen?
function?
red pulp + white pulp
- red pulp = sinusoids + cords
- sinusoids = fenestrated
- cords = contain macrophages
- white pulp = contains CD4+ cells + PALS
functions as a filter = eliminates unwanted material, facilitates immune response to blood-borne antigens

how does spleen facilitate immune repsonse?
APCs in white pulp present antigen to immune cells
When stimulated by antigen, T and B cell responses may occur

splenomegaly symptoms?
Traid of hypersplenism?
Dragging sensation in LUQ
Discomfort with eating
Pain if infarction
Triad of hypersplenism = splenomegaly + fall in one or more cellular components of blood + correction of cytopenias by splenectomy
causes of splenomegaly?
infection = EBV, malaria, TB, typhoid, brucellosis, lesihamniasis, trypanosomiasis
congestion = portal hypertension, cirrhosis, splenic vein thrombosis, cardiac failure
haemotological diseases = lymphoma/leukemia, haemolytic anaemia, ITP, myeloproliferative disorders
inflammatory conditions = RA, SLE
storage diseases = Gaucher’s, Neimmann-Pick disease
miscellaneous = amyloid, tumours, cysts
Ax hypersplenism vs hyposplenism?
hypersplenism
- conditions associated with splenomegaly
hyposplenism
- most commonly from splenectomy (need immunopsuppression)
- other causes = coeliac disease, sickle cell, sarcoidosis, iatrogenic
features of hyposplenism?
Howell-Jolly bodies
also some immune deficiency

basophilia seen in?
polycythaemia rubra vera
chronic myeloid leukaemia
monocytosis seen in?
chronic bacterial infections
malignancy (chromic myelomonocytic leukaemia)
connective tissue disease (SLE + RA)
are monocytes raised in smoking?
No - will see mild neutrophilia tho
features of monocytes?
precursor?
large monolobular cells
same precursor as granulocytes but unlike granulocytes do not have prominent granules

functions monocytes?
phagocytosis + antigen presenting
lymphocyte origins and development?
lymphocytosis?
arise in bone marrow + develop in primary lymphoid organs (bone marrow + thymus)
lymphocytosis in response to infection or malignancy
can also be seen after removal of spleen
EBV mononucleosis characteristic appearance?
T cells blue cytoplasm wraps around neighbouring cells
(can also be seen in HIV, CMV, viral hepatitis + toxoplasma)

stable plaques can cause?
unstable plaques?
stable plaques = stable angina (coronary artery) + PVD claudication
unstable plaques = MI, stroke
risk factors arterial thrombosis?
Hypertension
Smoking
High cholesterol
Diabetes
platelets bind to?
platelet aggregation chemicals?
platelets bind to VWF (released by damaged vessel wall)
ADP, thromboxane A2
e.g. antiplatelet drugs?
Aspirin - inhibits cyclooxygenase which is necessary to produce thromboxane A2 (prevents platelet aggregation i.e. stops them sticking together)
Clopidogrel, prasugrel - ADP receptor antagonists
Dipyridamole - hosphodiesterase inhibitor, reduced production of cAMP which is “second messenger” in platelet activation
abciximab - GP II2b/IIIa inhibitor (surface proteins platelets use to bind to each other)
side effects aspirin?
Bleeding
Blocks production of prostaglandins
- GI ulceration
- Bronchospasm (contraindicated in asthma)
which drug is contraindicated in asthma?
aspirin!!!
side effects antiplatelet drugs?
Tx?
bleeding!
will affect platelets for 7-10 day lifespan so stop antiplatelets approx a week before surgery
in emergency = can reverse with platelet transfusion

A - acute leukemia

D - chronic lymphocytic leukemia

???
how are proginitor/stem cells identified?
immunophenotyping
acute leukaemia pathophys?
Blood count?
bone marrow?
Proliferation of abnormal progenitors PLUS
Lack of differentiation/maturation of RBCs, platelets, and granulocytes
high white cell count + low RBC, platelets, granulocytes
tons of abnormal cells in bone marrow

chronic myeloproliferative disorders pathophys?
e.g.?
blood count?
why?
in contrast to acute leukemia = proliferation of abnormal proginitors but no differentiation/maturation failure
e.g. chronic myeloid leukemia
so blood count = very high white cells (due to neutrophils), low RBC, low/high platelets
the platelets and red cells may be low because all the neutrophils will take up space in bone marrow - there is no problem with maturation!!!
main cell type that differentiates CML and AML?
neutrophils!!
In AML = low
in CML = high
haematological malignancy divided into?
myeloid or lymphoid
developmental stage i.e. lymphoblastic vs lymphocytic vs myeloma
anatomical site
- blood = leukemia
- lymph node = lymphoma

myeloma?
malignancy of plasma cell in marrow
differences in histology/progression of haematological malignancies?
Acute leukaemias and high grade lymphomas are more aggressive (histologically and clinically) than chronic leukaemias and low grade lymphomas
in acute leukemias + high grade lymphomas more likely to see: high nuclear:cytoplasmic ratio, prominent nucleoli, rapid proliferation
what do all leukemias present with?
All Leukaemias present (more commonly than chronic leukaemia) with significant bone marrow failure
malignant haemopoesis
myeloid vs lymphoid?
myeloid malignancies tend to involve more primitive progenitor cells
lymphoid malignancies can turn malignant at various stages

acute leukemia features?
Types?
Rapidly progressive malignancy of bone marrow + blood
With maturation defects
Defined as excess of “blasts” >20% in blood or bone marrow
Loss of normal blood cell production (RBC, platelets, neutrophils, basophils + eosinophils)
Types
- Acute myeloid leukaemia (AML)
- Acute Lymphoblastic leukemia (ALL)
acute lymphoblastic leukemia?
clinical presentation?
Malignant disease of primitive lymphoid cells (lymphoblasts)
(most common childhood cancer!)
clinical presentation
- bleeding (nosebleeds), bruising, anaemia + infections (due to marrow failure)
- fever
- fatigue, weakness
- weight loss
- bone pain
commonest childhood cancer?
acute lymphoblastic leukemia
acute myeloid leukemia epidemiology?
S/s?
elderly >60 y/o
presentation same as ALL (marrow failure)
some have characteristic presentation
- DIC in acute promyelocytic leukemia
- gum infiltration
Ix acute leukemia?
Blood count (increase in WBC - reduction in Hb, neutrophils, platelets)
Blood film (will see “blasts”, large size, huge nucleus, prominent nucleolus)
Coagulation screen (d-dimers and fibrinogen for DIC)
Bone marrow aspirate (same as blood film)
Cytogenetic analysis
Auer rods?
AML!!!

how to differentiate between AML and ALL?
why is this important?
bone marrow aspirate sub-optimal?
Immunphenotyping used to differentiate between AML and ALL even if there are Auer rods in the blasts
important because treatment of AML is different from ALL
Trephine (piece of bone) - enables better assessment of cellularity and helpful when aspirate sub-optimal
so definitive diagnosis of acute leukemia?
immunophenotyping!!
(only definitive way to distinguish between AML and ALL)
Tx acute leukaemia?
ALL - can last up to 2-3 years
- chemo
AML - between 2-4 cycles of chemotherapy (5-10 days of chemo followed by 2-4 weeks recovery)
- Prolonged hospitalisation
- Often need long-term central venous access
CVC placement for AML?
tip should sit at junction of SVC and right atrium
acute leukaemia (marrow failure) complications?
Tx?
Anaemia
Neutropenia
- Gram NEGATIVE infections can be life-threatening
- Therefore if neutropenic patient develops fever, broad spectrum antibiotics are initiated IMMEDIATELY
- DO NOT WAIT FOR CULTURE RESULTS (but do take blood culture before administering antibiotics)
- In patients with neutropenic fever that does not resolve with antibiotics, assume fungal infection
thrombocytopenia
- bleeding, purpura, petechiae
- prophylactic platelet infusions even if no evidence of bleeding

chemo side effects
late effects?
Nausea and vomiting
Hair loss
Liver + renal dysfunction
Tumour lysis syndrome (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia)
Infection
- Bacterial - empirical treatment with broad spectrum antibiotics (esp covering gram neg) as soon as neutropenic fever (IMPORTANT)
- Fungal (if prolonged neutropenia and persisting fever unresponsive to anti-bacterial agents) - IMPORTANT
- Protozoal e.g. PJP (more relevant in ALL therapy)
- So patients with ALL often offered prophylaxis against pneumocystis (co-trimox?)
Late effects e.g. loss of fertility, cardiomyopathy with anthracyclines

D - urgent biopsy followed by steroids

B - excision biopsy of lymph gland
I THINK
symptoms of lymphoma?
when to suspect Hodgkins?
lump
B symptoms - fever, night sweats, weight loss (10% over a 6 month period)
itch without rash + alcohol-induced pain = suspect Hodgkin’s lymphoma
lymphadenopathy features

Ix lymphadenopathy?
FBC - chronic lymphocytic leukaemia (CLL) is one disease where FBC is diagnostic = lymphocytosis
- then do immunophenotyping (do not need biopsy in CLL)
Biochemical profile - hypercalcaemia
General investigations for INDAM
Biopsy “the only way” for diagnosis and treatment
Imaging - extent of lymphadenopathy and/or associated pathology
diagnostic approach lymphadenopathy?

imaging for lymphoma?
CANNOT be diagnosed by CT
but still useful
Dx = biopsy!!
Dx lymphoma
Dx = incision biopsy!!!!
(FNA + core biopsy not acceptable)

…
immunohistochemistry lymphoma?
antibodies against proteins in biopsy
brown = positive

reed sternberg cells?
Hodgkins lymphoma
genetics analysis of lymphoma biopsy?
Fluorescence in situ hybridisation (FISH) or PCR for specific abnormalities:
- t(14;18) in follicular lymphoma
- t(8;14) in Burkitt’s lymphoma
- Myc rearrangements in high-grade B cell lymphoma
types of B cell lymphoma?
Hodgkins
non-hodgkins:
Burkitt’s
diffuse large cell B cell lymphoma
Mantle cell lymphoma
Follicular lymphoma
classifications of lymphoma?

risk factors lymphoma?
In many patients there is no identifiable risk factor
Immunosuppression (e.g. HIV, inherited immunodeficiency states)
Autoimmune disorders (e.g. Sjogren’s, coeliac)
Infections (EBV, H.pylori, HHV-8, HTLV-1)
Genetic predisposition
Environment
staging of lymphoma using?
system?
CT + PET
Ann Arbor staging system:
- stage 1 = only one lymph node or one extra-nodal area
- stage 2 = 2 or more lymph nodes on one side of diaphragm
- stage 3 = 2 or more lymph nodes on both sides of diaphragm
- stage 4 = disseminated, or multiple extra-nodal areas
prognosis lymphoma?
lactate dehydrogenase (LDH) = prognostic
hodgkin’s lymphoma associated with?
spread?
hallmark?
Tx?
prognosis?
link with EBV infection
spread to lymph node groups is orderly
hallmark = reed-Sternberg cell (variant “lacunar” cell)
Tx = multi-agent chemotherapy +/- radiotherapy
- Immunotherapy/stem cell transplant is an option for patients not responding to chemo
prognosis:
- good cure rates - particularly in younger patients
complication chemo?
Bleomycin can cause pneumonitis
Long term toxicity including secondary cancers, cardiovascular disease, infertility
non-Hodgkin’s subtype associated with high-grade lesions?
Extranodal disease?
Tx?
prognosis?
diffuse large B cell lymphoma = common high-grade NHL
Extranodal disease = T cell NHL, Burkitt lymphoma
Tx
- multi-agent chemo +/- radiotherapy
- Monoclonal antibody therapy
- Ritixumab in B cell NHL
- Brentuximab in T cell NHL
- stem cell transplant when unresponsive to therapy
High grade NHL = usually curable
Low-grade is incurable but many patients may not need treatment (unless rapidly progressive lymphadenopathy, B symptoms etc)
burkitt’s lymphoma?
Ax?
disease sites?
genes?
complication?
Fastest growing human tumour!
Ax = EBV, HIV, sporadic
Disease sites = jaw or abdominal tumour, bone marrow, CNS, kidney or testis
genes = c-myc!!
comp = tumour lysis (usually following treatment)
- hyperkalaemia, hypocalcaemia, hyperphosphataemia, hyperuricaemia, renal failure
steroid use lymphoma?
used in emergency management of suspected lymphoma i.e. in compression symptoms (SVC, spinal cord, respiratory tract)
- Always try to avoid steroids before biopsy
- Can cause cell necrosis making it hard for pathologist
Dx?

pancytopenia - not a diagnosis on its own (must find cause)
pancytopenia?
rules?
Pancytopenia = deficiency of blood cells of ALL lineages (but generally excludes lymphocytes)
so anaemia + neutropenia + thrombocytopenia
- Pancytopenia is NOT a diagnosis
- It does NOT always mean bone marrow failure or malignancy
erythrocyte precursor?

pancytopenia Ax?
reduced production or increased destruction
- reduced production = acquired or inherited
- increased destruction = hypersplenism
triad inherited bone marrow syndromes?
congenital anomalies + impaired haemopoeisis (pancytopenia) + cancer predisposition
Ax reduced production pancytopenia?
inherited bone marrow syndromes e.g. Fanconi’s anaemia
acquired causes:
- primary bone marrow failure
- idiopathic aplastic anaemia - autoimmune attack against haemopoetic stem cells
- myelodysplastic sysndromes (MDS)
- acute leukaemia
- secondary bone marrow failure
- drug-induced (chemo, alcohol, azathiprine, methotrexate, chloramphenicol) = aplasia
- B12/folate deficiency (nuclear maturation can affect all lineages)
- infiltrative - metastasis, lymphoma
- viral
- storage diseases
Fanconi’s anaemia S/s?
Ax?
S/s = short stature, hypogenitalia, GI defects, cardio disease, renal disease
haematological abnormalities!
- marrow failure by 20 years old
- macrocytosis, thrombycytopenia, neutropenia
Ax = unable to fix DNA damage
idiopathic aplastic anaemia?
Ax?
features?
cause of primary pancytopenia
Ax = auto-reactive T cells to HSC
will have no RBCs, neurophils or platelets
(different to B12/folate deficiency + MDS when u see hypercellular marrow)

myelodysplastic syndromes?
feature?
why do you get pancytopenia?
compliation MDS?
Dysplasia!! - cause of primary pancytopenia
Hypercellular marrow (despite low cellularity in blood)
Increased apoptosis of progenitor and mature cells (ineffective haemopoeisis)
complication = evolution into AML
why can acute leukaemia cause pancytopenia?

secondary bone marrow failure?
Ax?
cause of pancytopenia
- Drug-induced (e.g. chemotherapy, alcohol, azathioprine, methotrexate, chloramphenicol) - causes aplasia
- B12/folate deficiency (nuclear maturation can affect all lineages) - marrow is hypercellular
- Infiltrative - metastatic malignancy, lymphoma
- Misc - viral (HIV), storage diseases
increased destruction pancytopenia?
S/s?
Ax?
HYPERSPLENISM
s/s = splenomegaly
Ax:
- splenic congestion - portal hypertension
- systemic diseases - rheumatoid arthritis
- haematological = splenic lymphoma
summary pancytopenia

s/s pancytopenia?
Anaemia
- Fatigue
- SOB
Neutropenia = infections
Thrombocytopenia
- Bleeding
- Purpura
- Petechiae
- “Wet” bleeds i.e. visceral bleeds
Ix cause of pancytopenia?
History
Clinical findings - skeletal abnormalities (Fanconi)
FBC, blood film
B12/folate, LFTs, virology, autoantibody tests
Bone marrow examination (hyper vs hypocellular)
Specialised tests guided by above (cytogenetics, e.g. chromosome fragility testing in Fanconi’s syndrome, NGS, WES)
marrow cellularity in pancytopenia?
Hypocellular in aplastic anaemia
Hypercellular in:
- Myelodysplastic syndromes
- B12/folate deficiency
- Hypersplenism
Tx pancytopenia?
supportive
- Red cell transfusions, platelet transfusions
- for neutrophils tranfusions are not routine - instead = antibiotic prophylaxis
- TREAT NEUTROPENIC SEPSIS IMMEDIATELY
specific = related to cause
-
primary bone marrow disorders
- malignancy = chemo
- congenital = bone marrow transplant
- idiopathic aplastic anaemia = immunosuppression
-
secondary bone marrow disorder
- drug reaction = stop
- viral = treat HIV
- replace B12/folate
- hypersplenism = treat cause (e.g. portal hypertension) or splenectomy
immediate cytotoxic drug side effects?
long term?
Tx?
immediate (affects rapidly dividing organs)
- Bone marrow suppression, gut mucosal damage, hair loss (alopecia)
- Vinca alkaloids = neuropathy
- Anthracyclines = cardiotoxicity
- Cis-platinum = nephrotoxicity
long term
- Alkylating agents = infertility, secondary malignancy
- Anthracyclines = cardiomyopathy
Tx for immunosuppression = haemopoetic growth factors! + combine suppressive vs non-suppressive drugs
what is used to monitor response to therapy in Hodgkin’s lymphoma?
PET scan
haematological uses of biologics?
e.g.?
multiple myeloma!!
e.g. thalidomide, lenalidomide (revlimid)
Tx CML?
tyrosine kinase inhibitors
myeloproliferative disorders (neoplasms)?
what do they result in?
Myelo = bone marrow (granulocytes, red cells and platelets)
Proliferative = rapid multiplication
MPNs result in overproduction of mature, differentiated cells as opposed to primitive blast cells seen in AML (acute leukaemia)
myeloproliferative neoplasm types?
BCR-ABL1 negative
- Primary myelofibrosis
- Polycythaemia vera (overproduction of red cells)
- Essential thrombocytopenia (overproduction of platelets)
BCR-ABL1 positive = CML
- CML = overproduction of granulocytes
- Philadelphia chromosome!!! (chromosome 22)
when to consider MPN?
High granulocyte count
High red cell count/Hb
High platelet count
Eosinophilia/basophilia
Splenomegaly
Thrombosis in an unusual place (i.e. toe)
NO REACTIVE EXPLANATION

suspect MPN - polycythaemia vera?
- raised Hb
- raised eosinophils + basophils
- significantly raised haematocrit
this patient has severe COPD

this is NOT myeloproliferative disorder as there is a reactive cause for the symptoms
- significantly raised Hb + haematocrit
- neutrophilia
so Dx is secondary polycythaemia due to hypoxia from COPD
chronic myeloid leukaemia?
clinical features?
Proliferation of myeloid cells
- Granulocytes and their precursors
- Other lineages (platelets)
S/s = asymptomatic, splenomegaly, hypermetabolic symptoms (weight loss, sweats), gout, problems related to hyperleukocytosis e.g. priapism
lab features CML?
Blood count changes
- normal/decreased Hb
- Leukocytosis with neutrophilia and myeloid precursors (myelocytes)
- eosinophilia, basophilia
- thrombocytosis
Bone marrow biopsy
- Increased cellularity
- Increased granulocytes

early satiety + weight loss

Dx = CML
- weight loss
- moderate anaemia
- very high WCC (neutrophillia, eosinophillia + basophilia)
- raised platelets
empyema

Dx = reactive picture seconary to empyema
- moderate anaemia
- high WCC (neutrophilia)
- thrombocytosis
hallmark of CML?
philadelphia chromosome
(chromosome 9 + 22 translocation)
BCR-ABL1 positive!!
pathophys CLM?
thus Tx?
Philadelphia chromosome results in new gene: BCR-ABL1
Gene product is a tyrosine kinase which causes haematological changes
Tx = tyrosine kinase inhibitors (e.g. imatinib)
BCR-ABL1 negative MPN?
symptoms?
Polycythaemia vera
Essential thrombocythemia
Primary myelofibrosis (very rare)
symptoms common to MPN = can be asymptomatic
- gout, fatigue
- weight loss, sweats
- marrow failure (anaemia)
- thrombosis (arterial or venous including TIA, MI, abdominal vessels, claudication)
- erethromelalgia - pain and redness in hands and feet
polycythaemia vera features?
must distinguish from?
High haemoglobin + haematocrit!
Erythrocytosis (true increase in red cell mass)
Rest of blood count probably normal
MUST DISTINGUISH FROM secondary polycythaemia
- Chronic hypoxia
- Smoking
- Erythropoietin-secreting tumour
AND pseudopolycythaemia
- Dehydration
- Diuretics
- Obesity
pseudopolycythaemia?
actually a normal amount of red blood cells - however haematocrit high due to decreased volume of blood

clinical features polycythaemia vera?
Clinical features common to MPN (see before)
Plus
- Headache, fatigue (remember blood viscosity raised NOT plasma viscosity)
- Itch (aquagenic pruritus) - i.e. itch in response to warm water
Ix polycythaemia vera?
History (e.g. history suggestive of secondary polycythaemia?)
Examination e.g splenomegaly + investigation of secondary/pseudo causes e.g. CXR, SaO2
FBC, film
JAK2 mutation status (IMPORTANT)
JAK2 mutation?
Present in >95% of patients with PV
NOT present in patients with secondary or pseudopolycythaemia
Tx polycythaemia vera?
Venesect to haematocrit <0.45
Aspirin (thrombosis risk)
Cytotoxic oral chemotherapy e.g. hydroxycarbamide (also used in sickle)
essential thrombocythaemia?
overproduction of platalets + abnormally large platelets
i.e. uncontrolled production of abnormal platelets

- clinical features ET?
platelet function abnormal so thrombosis + at high levels can result in bleeding due to acquired Von Willebrands disease
- can be asmptomatic
- clinical features common to MPN (particularly thrombosis)
- bleeding

does high platelet count = essential thrombocytopenia?
example
High platelet count DOES NOT equal essential thrombocythemia
on left = high platelet, normal Hb + WBC = ET
on right = low Hb, neutrophillia = reactive thrombocytosis secondary to major surgery (AAA repair)

ET diagnosis?
Exclude reactive thrombocytosis - IMPORTANT (blood loss, inflammation, malignancy, iron deficiency)
Exclude CML - can present with high platelet count
Genetics (about 50% have JAK2)
ET Tx?
Antiplatelets = aspirin
Cytotoxic = hydroxycarbamide, anagrelide, interferon alpha
myelofibrosis?
Ax?
rare cause of BCR-ABL1 negative MPN
Ax
- primary = idiopathic
- secondary = post-polycythaemia vera or post-ET
idiopathic myelofibrosis clincal features?
Marrow failure (variable degrees)
Bone marrow fibrosis (no alternative cause)
Extramedullary haemopoesis (liver and spleen)
Leukoerythroblastic film appearances - IMPORTANT
Teardrop-shaped RBCs in peripheral blood
myelofibrosis symptoms?
Clinical features common to MPN
Marrow failure = nnaemia, bleeding infection
Splenomegaly (LUQ pain) + hepatomegaly
- complications e.g. portal hypertension
Night sweats
Unexplained weight loss

myelofibrosis Dx?
Typical blood film (teardrop RBC and leukoerythroblastic)
Trephine (unable to aspirate bone marrow due to underlying fibrosis)
- Fibrosis on trephine biopsy
JAK2, CALR, MPL mutations (majority JAK2)

leukoerythroblastic blood film?
Ax?
neutrophil precursors (myelocytes) + red cell precursors (erythroblasts) in peripheral blood
Ax
- reactive - sepsis
- marrow infilration
- myelofibrosis

fibrosis in bone marrow trephines?
Dx = myelofibrosis
myelofibrosis Tx?
Different from ET and PV
- Supportive care (blood transfusion, platelets, antibiotics)
- Allogeneic stem cell transplantation in young, fit patients (only potentially curative option but extremely high morbidity)
- JAK2 inhibitors (improve spleen size, symptoms) - ruxolitinib

….

….
neutrophil maturation?
myeloblast > promyelocyte > myelocyte > neutrophil
RBC maturation?
earliest site of entry to bloodstream?
pronormoblast > normoblast > reticulocyte > eryethrocyte
earliest site of entry to blood = reticulocyte (also first nucleus free cell)
granulocytes?
Eosinophils
Basophils
Neutrophils
neutrophil features?
function?
Segmented nucleus (polymorph)
function = phagocytose invaders, kill with granule contents, attract other cells

eosinophil features?
function?
Bi-lobed + bright orange/red granules
Function = fight parasitic infections, allergic reactions

basophil features?
function?
Large deep purple granules obscuring nucleus
Function
- Basically circulating version of tissue mast cell
- Mediates hypersensitivity reactions
- FcE Receptors bind IgE
- Granules contain histamine

monocytes features?
function?
Large single (mono) nucleus, often vacuolated
Function
- Enter tissues to become macrophages
- Phagocytose invaders
- Kill them and present antigen to lymphocytes
Much longer lived than neutrophils

lymphocytes mature vs atypical?
Mature
- Small with condensed nucleus
Activated (atypical) - seen in glandular fever!!
- Large with plentiful blue cytoplasm
Atypical shown here:

structure of RBCs
full of Hb to carry oxygen
No nucleus - can’t divide, can’t replace damaged proteins
No mitochondria either - limited to glycolysis for energy generation (no Kreb’s cycle)
High surface area/volume ratio to allow for gas exchange
Flexible to squeeze through capillaries
oxidation RBC?
Oxidation (Fe3+) is BAD for RBCs!!
Hb structure?
2 alpha + 2 beta chains
haeme group is Fe2+ in flat porphyrin ring
one haem per subgroup (4)
one oxygen molecule binds to one Fe2+
(oxygen does NOT bind to Fe3+)
red cell production regulated by?
Red cell production regulated by erythropoietin
- Hypoxia sensed by kidney
Erythropoietin produced
Stimulates RBC production
red cell destruction?
aged cells taken up by macrophages in spleen + liver
red cell contents recycled (amino acids + iron)
- haem broken down to iron + bilirubin
- globin chains broken down to amino acids
bilirubin then taken to liver and conjugated
then excreted in bile (colours faeces and urine)
redistribution of blood cells?
Low cell count
- Chronic liver disease -> portal hypertension -> splenomegaly
High cell count
- Steroids - neutrophils will leave tissues and enter circulation instead
- Splenic trauma

…
erythroid hyperplasia?
hypoxia results in increased erythropoetin production
result is erythroid hyperplasia

…
glycolysis pathway

free radicals?
what protects body?
what is needed to regenerate?
problem?
Superoxide and hydrogen peroxide are free radicals - damages DNA structure
glutathione - protects us from hydrogen peroxide by reacting with it to form water and an oxidised glutathione product (GSSG)
Glutathione eplenished by NADPH (which is generated by hexose monophosphate shunt)
Rate limiting enzyme is glucose-6-phosphate dehydrogenase!
can get GPD6 deficiency resulting in oxidative damage to RBCs

G6PD deficiency?
X-linked male disorder
- oxidative damage to RBCs, thus ANAEMIA
CO2 transport?
Only 10% dissolved in solution
Around 30% bound directly to Hb as carbamino-Hb
60% as bicarbonate - RBC very important for generating that bicarbonate

foetal Hb?
2 alpha, 2 gamma
allosteric effect?
Oxygen binding to Hb = allosteric effect
When one oxygen binds to subunit, the Hb shape changes
This makes it easier for next O2 to bind to different subunit
Cooperative binding
oxygen dissociation curve?
Dissociation curve for haemoglobin is sigmoidal!

curve shifted right by?
results in?
significance?
Curve shifted right by 2,3-BPG, H+ and CO2
this results in more O2 delivered to tissues - think, when H+ and CO2 are high, its good to have more O2 in tissues
significance = 2,3-BPG (sometimes called DPG) is increased in chronic anaemia
what shifts curve to the left?
increased pH (low H+), low DPG, low temperature
when are Hb/hct not a good marker of anaemia?
rapid haemorrhage
or when fluids are given

polychromasia?
reticulocytes!!

classifying anaemia?
Decreased production (low reticulocyte count)
- Hypoproliferative - reduced AMOUNT of erythropoiesis
- Maturation abnormality - erythropoiesis present but INEFFECTIVE
- Cytoplasmic defects - imapired hemoglobinization
- Nuclear defects - imapired cell division
Increased loss or destruction of red cells (high reticulocyte count)
- Bleeding
- Haemolysis
Mean cell volume
- If MCV low (microcytic) consider problems with haemoglobinization
- If MCV high (macrocytic) consider problems with maturation
haemoglobin synthesis
occurs in cytoplasm
porphyrin made in mitochondria

hypochromic microcytic anaemias?
Causes of hypochromic microcytic anaemia (TAILS)
Haem deficiency:
- lack of iron
- Iron deficiency (low body iron)
- Anaemia of chronic disease (normal body iron but lack of available iron) - most anaemia of chronic disease normocytic
- Problems with porphyrin synthesis
- Lead poisoning
- Congenital sideroblastic anaemias
Globin deficiency
- Thalassemia
iron states?
Can exist in Fe2+ (ferrous) or Fe3+ (ferric) state
iron stored as?
transported by? - where?
Iron stored as ferritin in liver
Iron transported by transferrin
- transported to bone marrow, where macrophages “feed it” to red cell precursors
tests to assess iron?
Functional iron = haemoglobin
Transported iron = serum iron + transferrin
Storage iron = serum ferritin
% saturation transferrin?
%saturation of transferrin with iron measures iron supply
- Reduced in iron deficiency
- Reduced in anemia of chronic disease
- Increased in haemochromatosis
ferritin stores?
measures?
low?
Stores up to 4000 ferric ions (fe3+)
Serum ferritin = measure of storage iron
Low ferritin means iron deficiency!!
iron deficiency Dx?
reduced Hb + reduced ferritin
iron deficiency consequences?
Microcytic anaemia!!
Epithelial changes
- Skin
- Koilonychia
- Angular chelitis
causes of iron deficiency?
- not enough dietary iron (pregnant women + growing children)
- chronic blood loss: menorrhagia, GI (tumours, ulcers, NSAIDs), haematuria
- malabsoprtion = coeliac disease, achlorhydria
(remember iron absorbed in duodenum)
where is iron absorbed?
duodenum

B12 deficiency (macrocytic)

life-style
causes of macrocytosis?
Macrocytosis can be genuine (true) or spurious (false)
- Genuine - true increase in volume of red cells
- Megaloblastic
- non-megaloblastic
- Spurious - red cell volume normal but laboratory analyser measures MCV as high
what is a megaloblast?
Megaloblast - an abnormally large nucleated red cell precursor with an immature nucleus
megaloblastic anaemia occurs due to?
explain process
Due to prominent defects in DNA synthesis!!
- Cytoplasmic development and haemoglobin accumulation occur normally and so precursor cell is bigger with immature nucleus e.g. megaloblast
- division is reduced and apoptosis increases
- Once Hb level optimal, nucleus is extruded, leaving behind bigger than normal red cell e.g. macrocyte
Overall, there are still fewer macrocytes hence ANAEMIA
causes of megaloblastic anaemia?
B12 deficiency or folate deficiency (essential DNA synthesis and nuclear maturation)
how B12 absorbed?
Acid in stomach liberates B12 which then binds to rapid binder proteins
Intrinsic factor secreted from gastric parietal cells
B12 released from rapid binder proteins and binds to intrinsic factor protein
B12-intrinsic factor complex travels to distal small bowel (ileum) and is absorbed
Enters bloodstream and binds to transcobalamin
causes of B12 deficiency?
(thus megaloblastic anaemia)
Diet (vegans)
Stomach
- Pernicious anaemia
- Atrophic gastritis
- PPIs
- gastrectomy/bypass
Chronic pancreatitis
Small bowel
- basterial overgrowth
- coeliacs
- crohns
Inherited deficiency
- Cubilin receptors (where B12 binds before being absorbed into bloodstream)
what is pernicious anaemia?
asociated with?
Autoimmune condition associated with destruction of gastric parietal cells
Results in intrinsic factor deficiency with B12 malabsorption and deficiency (megaloblastic anaemia)
Associated with atrophic gastritis and history of other autoimmune disorders (e.g. hypothyroidism, vitiligo, Addison’s)
folate absorbed?
causes of folate deficiency?
Absorbed in jejunum
Causes of folate deficiency - much lesser stores than B12
- ALCOHOLICS
- Malabsorption
- Coeliacs, crohns
- Excess utilization
- Haemolysis
- Exfoliating dermatitis
- Pregnancy
- Malignancy
- Drugs = anticonvulsants
B12 + folate sources, stores, abdorbed, daily req

clinical features B12/folate deficiency?
Common to both B12 and folate
- Symptoms/signs of anemia
- Weight loss, diarrhoea, infertility
- Sore tongue (glossitis), jaundice
- Developmental problems
Specific to B12
Neurological problems!!! - damages myelin sheath
- dorsal column abnormalities (sensation)
- Neuropathy
- Dementia
- Psychiatric manifestations
Dx B12 + folate deficiency?
Macrocytic anaemia (RBC count low) - pancytopenia in some patients
Blood film = macro ovalocytes and hypersegmented neutrophils (normally 3-5 nuclear segments)
autoantibodies
- anti-gastric parietal cell (GPC) - sensitive but not specific
- anti-intrinsic factor - specific but not sensitive

problems with B12 + folate interpretation?
Tx megaloblastic anaemia?
Treat cause!!
Vitamin B12 injections for life in pernicious anaemia (IM)
Folic acid tablets 5mg per day orally
Blood transfusion only if life-threatening anaemia
non-megaloblastic macrocytic anaemia Ax?

spurious macrocytosis Dx?
Ax?
Volume of red cell is NORMAL but MCV is measures as high
Ax
-
Reticulocytosis
- Increase in reticulocyte numbers in response to acute blood loss or red cell breakdown (haemolysis)
- Blood film will show polychromasia
-
Cold-agglutinins
- Produced in certain types of cancer
- Clumps of “agglutinated” red cells registered as 1 giant cell
approach to macrocytic anaemia

what chemicals are released from dead red cells?
Haemoglobin and lactate dehydrogenase (LDH)
earliets part of haem ring synthesised where?
Earliest part of haem ring synthesised in mitochondria
pernicious anaemia Tx?
lifelong B12 IM injections
Tx alcoholic with macrocytic anaemia?
folic acid 5mg/day
haemglobinopathies e.g.?
Alpha thalassemia
Beta thalassemia
Sickle cell anaemia
forms of haemoglobin?
HbA (2 alpha chains and 2 beta chains)
HBA2 (2 alpha chains and 2 delta)
HbF (2 alpha 2 gamma)
genetics globin chains
Alpha genes on chromosome 16
- 2 alpha genes per chromosome (4 per cell)
Beta genes on chromosome 11
- One beta gene per chromosome (2 per cell)
when do Beta chain problems manifest?
6-12 months of age
haemaglobinopathies inheritance?
categories?
Autosomal RECESSIVE
2 main groups
- Thalassaemias - decreased rate of globin chain synthesis
- Structural haemoglobin variants - normal production of ABNORMAL globin chain (variant haemoglobin i.e. HbS, sickle)
types thalassemias?
consequences?
Alpha thalassemia - not making enough alpha chains
Beta chains - not making enough beta chains
Consequences:
- Microcytic hypochromic anaemia! (TAILS)
- If severe
- Unbalanced accumulation of globin chains (i.e. too many beta chains) which are toxic to cells!!!
- Ineffective erythropoiesis
- Haemolysis - jaundice
alpha thalassaemia affects?
types?
Alpha chains present in HbA, HbA2 and HbF so all are affected
- Unaffected = 4 normal alpha genes (aa/aa)
- Alpha thalassaemia trait = one or 2 alpha genes missing, asymptomatic carrier state, microcytic hypochromic red cells but ferritin normal
- HbH disease = only one alpha gene left (–/-a), moderate to severe anaemia
- Hb Barts hydrops fetalis = no functional alpha genes, incompatible with life
beta thalassemia affects?
types?
Only B chains and hence only HbA (a2B2) affected
- B thalassaemia trait (B1/B or B0/B) = asymptomatic, no/mild anaemia, low MCV/MCH, raised HbA2 diagnostic!!!
- B thalassaemia intermedia (B+/B- or B0/B+) = moderate severity requiring occasional transfusion (similar phenotype to HbH disease)
- B thalassaemia major = severe, lifelong transfusion dependency
Tx alpha thalassemia trait?
important to?
Asymptomatic carrier state, no Tx needed
Important to distinguish from iron deficiency (ferritin will be normal)
HbH disease clinical features?
S/s?
HbH disease = more severe form of alpha thalassemia
clinical features:
- Anaemia with very low MCV and MCH
- excess B chains form tetramers called HbH
- golf ball cells!!
s/s
- jaundice
- splenomegaly
- anaemia

Tx HbH disease?
may req transfusions
Hb Barts Hydrops Foetalis syndrome?
pathophys
clinical features?
Dx?
Severest form of alpha thalassaemia
No alpha genes inherited from EITHER parent (–/–)
- no alpha chain production -> HbF and HbA cant be made
- so tetramers produced - Hb Barts (y4) and HbH (B4)
Clinical features
- Profound anaemia
- Growth retardation
- Severe hepatosplenomegaly
- Skeletal and cardiac abnormalities
- Almost all die in utero
Dx = nucleated, pale red cells on blood film

beta thalassemia major presents?
S/s?
Hb content?
blood film?
presnets 6-24 months (as HbF falls)
s/s
- pallor + failure to thrive
- hepatosplenomegaly
- skeletal changes (frontal bossing)
Hb = mainly HbF (no HbA)
Blood film = very distorted mishapen red cells

Tx B thal major?
complication?
Regular transfusion programme to maintain Hb at 95-105g/l
complication = iron overload from transfusion
consequecnes of iron overload from transfusion?
Tx?
Endocrine dysfunction
- Impaired growth and pubertal development
- Diabetes
- Osteoporosis
Cardiac disease = cardiomyopathy + arrhythmias
Liver disease = cirrhosis + hepatocellular carcinoma
Tx = iron chelating drugs (e.g. desferrioxamine)
(venesection not feasible as already anaemic)
sickle cell trait?
s/s?
HPLC?
One normal, one abnormal B gene (B/BS)
Asymptomatic carrier state
Few clinical features as HbS level very very low
- may sickle in severe hypoxia e.g. high altitude, under anesthesia
- Blood film NORMAL
HPLC = mainly HbA, HbS <50%
sickle cell anaemia?
s/s?
it is a haemolytic anaemia
2 abnormal B genes (BS/BS)
S/s
- Episodes of tissue infarction due to vascular occlusion - sickle crisis!! - extreme pain
- Chronic haemolysis - distorted red cells get stuck
- Hyposplenism due to repeated splenic infarcts
precipitants of sickle crisis?
Tx?
Precipitants of sickle crisis = hypoxia, dehydration, infection, cold exposure, stress/fatigue
Treatment of sickle crisis
- Opiate analgesia
- Hydration
- Rest
- Oxygen
- Antibiotics if evidence of infection
- Red cell exchange transfusion in severe crisis e.g. lung crisis or brain (stroke)
long term management of sickle cell anaemia?
Hyposplenism - reduce risk of infection
- Prophylactic penicillin
- Vaccination
Folic acid supplementation (increase RBC turnover to increased demand)
Hydroxycarbamide can reduce severity of disease by inducing HbF production
Regular transfusion to prevent stroke in selected cases
Dx haemoglobinopathies (alpha, beta, sickle)?
Simple things first:
- FBC, Hb
- Blood film
- Ethnic origin
High performance liquid chromaopgraphy (HPLC) or electrophoresis to quantify haemoglobins
- Identifies abnormal haemoglobins e.g. HbS
- Raised HbA2 diagnostic of beta thal trait
raised HbA2?
diagostic of beta thal trait
when to suspect thalassemia?
microcytic anaemia with normal ferritin
IAT?
use IAT to determine patient’s blood type
clinical use blood transfusion?
Symptomatic anemia Hb <70g/L (80g/L if cardiac disease)
Major bleeding
(Transfuse single unit then reassess patient)
indications for platelet transfusion?
Prophylaxis in patients with bone marrow failure and very low platelet counts
Treatment of bleeding in thrombocytopenic patient
Prophylaxis prior to surgery/procedure (e.g. biopsy) in thrombocytopenic patient
(again 1 unit usual dose)
indications for FFP transfusion?
Treatment of bleeding in patient with coagulopathy (PT ratio >1.5)
Prophylaxis prior to surgery or procedure in patient with coagulopathy
Management of massive haemorrhage
Transfuse early in trauma (1:1 within 4 hours)
(NOT used in absence of bleeding/planned procedure - even if abnormal coagulation screen)
observations blood transfusion?
Observations before blood is commenced
Observations at 15 minutes
Observations within 60 minutes of completion
- Acute transfusion reactions
next steps?
Tx given likely diagnosis?

microcytic anaemia with normal ferritin so thinking thalassemia
nex steps = HPLC
Tx for B thal major = regulat transfusions to maintain minimum Hb (beware iron overload)
spherocytes seen in?
hereditary spherocytosis + autoimmune haemolytic anaemia
sickle cell microcytic?
NO you will NOT be microcytic in sickle cell
in other haemoglobinopathies i.e. thalassemias you will be
consequences of haemolysis?
Erythroid hyperplasia (increased bone marrow red cell production)
Excess red cell breakdown products e.g. bilirubin

…
classification haemolysis?
Extravascular
- Red cells taken up by spleen and liver
Intravascular
- Red cells destroyed within circulation
They have different breakdown products = useful in determining cause of haemolysis
extravascular haemolysis s/s?
breakdown products?
S/s = splenomegaly + hepatomegaly, jaundice, gallstones
breakdown products:
- Unconjugated bilirubin (jaundice, gallstones)
- Urobilinogenuria
(they are normal products but found in EXCESS)
intravascular haemolysis breakdown products?
Haemoglobinaemia (free Hb in circulation)
Methaemalbuminaemia
Haemoglobinuria - pink urine, turns black if left for a while
Hemosiderinuria
(abnormal products unlike extravascular = life-threatening)
Ax intravscular haemolysis?
extravascular?
Intravascular Ax
- ABO incompatible blood transfusion (immediate, IgM)
- G6PD deficiency
- Severe falciparum malaria (blackwater fever)
- Rarer still - PNH, PCH
extravascular Ax = all other causes
Ix haemolysis?
Confirm haemolytic state
- FBC + blood film
- Reticulocyte count
- Serum unconjugated bilirubin
- Serum haptoglobins
- Urinary urobilinogen
Identify cause
- History + examination - FHx, organomegaly
- Blood film - membrane damage (spherocytes)
- Mechanical damage (red cell fragments)
- Oxidative damage (Heinz bodies)
- Others e.g. HbS (sickle cells)
- Specialist investigations e.g. direct Coomb’s (ATR)
acquired causes of haemolysis?
Immune
- Autoimmune haemolysis
- Alloimmune haemolysis (from blood transfusion)
Mechanical
Abnormal cell membrane
Abnormal red cell metabolism
Abnormal haemoglobin
autoimmue haemolysis Ax
Warm or cold autoantibody
- Warm (IgG)
- Idiopathic - commonest
- Autoimmune disorders (SLE)
- Lymphoproliferative disorders - CLL
- Drugs (penicillins)
- Infections
- Cold (IgM)
- Idiopathic
- Infections (EBV, mycoplasma)
- Lymphoproliferative disorders
alloimmune haemolysis Ax?
Dx?
Haemolytic transfusion reaction
- Immediate (IgM) - intravascular
- Delayed (IgG) - extravascular
Passive transfer of antibody
- Haemolytic disease of the newborn!!
- RhD, ABO incompatibility, others e.g. anti-Kell
Dx = DAT Coombs???
mechanical haemolysis Ax?
DIC
Haemolytic uraemic syndrome (E.coli 0157)
thrombotic thrombocytopenic purpura (TTP)
Leaking heart valve
Infections e.g. malaria

abnormal cell membrane haemolysis Ax?
Liver disease (Zieve’s syndrome)
Vitamin E deficiency
Paroxysmal nocturnal haemoglobinuria
red cell membrane haemolysis Ax?
heriditary spherocytosis
abnormal red cell metabolism haemolysis Ax?
Dx?
G6PD deficiency = makes RBCs more prone to oxidative damage
thus haemolysis
Dx = Heinz bodies
ABO incompatible vs delayed haemolysis
Delayed haemolysis - extravascular
ABO incompatible would be intravascular and immediate
iron absoprtion enhanced by?
Inhibited by?
Enhanced by
- Ascorbic acid (reduces iron to Fe2+ form)
- Alcohol
Inhibited by
- Tannins e.g. tea
- Phytates e.g. cereals, bran, nuts and seeds
- Calcium e.g. dairy produce
process of iron absoprtion at duodenum
Duodenal cytochrome B
- Found in luminal surface
- Reduces ferric iron to ferrous form
DMT (divalent metal transporter)-1
- Transports ferrous iron into duodenal enterocyte
Ferroportin
- Facilitates iron export from enterocyte
- Passes on to transferrin
how is iron absorbtion regulated?
Hepcidin!!!
- Major negative regulator of iron uptake
- Produced in liver in response to
- Increased iron level
- Inflammation
- Binds to ferroportin and causes its degradation
Hepcidin levels decrease when iron deficient
raised ferritin?
rises when iron levels high BUT ALSO in infection + malignancy (acts as an acute phase protein)

GI blood loss iron deficiency?
GI blood loss of 8-10ml per day (4-5mg iron) can occur without any symptoms or signs of bleeding
iron malutilisation?
anaemia of chronic disease
(due to increased hepcidin - remember ferritin may be high too due to inflammation)
hereditary heamochromatosis Ax?
pathophys
S/s?
mutation in HFE gene
Decreased synthesis of hepcidin so increased iron absorption
Clinical features
- weakness/fatigue
- Joint pains
- Impotence
- Arthritis
- Cirrhosis
- Diabetes (bronze diabetic)
- Cardiomyopathy
Dx haemochromatosis?
Tx?
HFE gene (C282Y mutation)
transferrin sat >50%
raised serum ferritin
Tx
- weekly venesection
acute transfusion reactions?
s/s?
happen early in transfusion (within 1st hour)
Symptoms
- Chills, rigors, rash, flushing
- Feeling of impending doom
- Collapse
- Loin pain
- Respiratory distress
Signs
- Fever
- Tachycardia
- Hypotension
- Tachyopnoia
EMERGENCY Tx!!
Tx ATR?
Treatment for ALL transfusion reactions
- 1 - STOP the transfusion
- 2 - ABCDE
- 3 - re-check compatibility tag against patient details
- 4 - document event in medical notes
acute haemolytic transfusion reaction:
- same as above
- FBC, coag screen, renal function, haemolysis products, blood cultures (to rule out infection)
pathophys AHTR?
Binding of IgM anti-A or B antibodies to transfused cells (intravascular haemolysis)
Release of inflammatory cytokines
- Shock, DIC, renal failure!!
- Often fatal
trasnfusion associated circulatory overload (TACO) clinical features?
Risk factors?
Tx?
Clinical features
- respiratory distress within 6 hours of transfusion
- Raised blood pressure
- Raised JVP
- oedema
Risk factors = elderly patients, cardiac failure, low albumin, renal impairment
Tx of TACO
- Oxygen + supportive care
- Diuretics
(consider slowing the rate of future transfusions + diuretic)
Mild transfusion reactions?
tx?
Isolated temp rise >38 or rash only
Management
- Continue transfusion - consider slowing rate
- Close monitoring of patient in case condition worsens
- Consider paracetamol/antihistamine
delayed haemolytic transfusion reactions?
Dx?
Extravascular haemolysis 5-10 days post transfusion
Dx = positive DAT (alloantibody)
if see reticulocytosis on blood film?
look for red cell breakdown products
if none = bleeding rather than haemolysis
normochromic normocytic anaemia?
Marrow failure - drug induced, aplastic anaemia (can be macrocytic)
Hypometabolic (can be macrocytic)
Marrow infiltration (metastatic malignancy, fibrosis)
Renal impairment (failure of erythropoetin)
Chronic disease (infective, inflammatory, malignant)
commonest causes of anaemia?
how to distinguish?
iron deficiency + anaemia of chronic disease
in anaemia of chronic disease ferritin will be normal

could be iron deficient or thalassemia
need ferritin to find out
oral vs IV iron?
oral iron 1st line in most patients
IV only used in certain circumstances
- 3rd trimester of pregnancy
- imminent surgery
- malasbsorption
- chronic renal failure or heart failure?