Haematology Flashcards
What is Virchow’s triad?
Vessel wall, blood, flow
What are the consequences of thromboembolism?
Death
Recurrence
Thrombophlebitic syndrome
Pul HTN
Blood in virchow’s triad
Viscosity: Hct, protein/paraprotein
Platelet count
Coagulation system: triggered by TF, generates thrombin, thrombin converts fibrinogen to fibrin (the clot)
Draw the blood coagulation pathway
How is the blood coagulation pathway regulated by thrombin? (draw)
How is the blood coagulation pathway regulated by Protein C? (draw)
What are the procoagulant factors?
Anticoagulant factors?
What is factor 5 Leidin?
Factor V Leiden thrombophilia[1] is a genetic disorder of blood clotting. Factor V Leiden is a variant (mutated form) of human factor V (one of several substances that helps blood clot) that causes an increase in blood clotting (hypercoagulability). In this disorder, the Leiden variant of factor V cannot be inactivated by the anticoagulant protein activated protein C, so clotting is encouraged. (With this mutation, the protein secreted that helps blood not clot is unable to do so, and therefore clotting is more likely) [2] Factor V Leiden is the most common hereditary hypercoagulability (prone to clotting) disorderamongst ethnic Europeans
What is the most common hereditary cause of hypercoagulability in ethnic Europeans?
FVL
Vessel wall in Virchow’s triad
Expresses anticoagulatn molecules: thrombomodulin, endoethlial protein C R, TF pathway inhibotr, heparans
Does not express TF
Secretes antiplatelet factors: prostacyclin, NO
What happens with vessel wall inflammation/injury?
Makes the wall prothrombotic
Can be caused by infection, malignancy, vasculitis, trauma
Effects: downregulation of anticoagulant factors (TM), upregulation of adhesion molecules, expression of TF, reduced production of prostacycline
What are the implications of thrombosis in Cancer?
l In the 12 months after idiopathic thrombosis, approximately 10% of patients will have cancer diagnosed.
lSimple tests, CXR, FBC, CRP, profile, urine will detect ~50% of these.
lMost malignancies presenting with thrombosis have a poor prognosis.
¨RR is ~7 for patients with active cancer
¨~ 20% of all VTE occur in patients with cancer
¨% incidence of VTE in year after cancer diagnosis
NB there is variation with type of cancer and extent of disease
Which cancer has largest effect on incidence of VTE?
Pancreas
How does stasis promote thrombosis?
Accumulation of activated factors
Promotes platelet adhesion
Promotes leukocyte adhesion and transmigration
Hypoxia produces inflammatory effect on endothelium
What are the causes of blood stasis?
Immobility: Sx, paraparesis, travel
Compression: tumour, pregnancy
Viscosity: polycythaemia, paraprotein
Congenital: vascular abnormalities
When does the risk of PE after air travel start?
3-6h
Greatest >12h
Implications of combined thrombotic risks
Thrombotic factors often combine to produce thrombosis, can have synergistic effect
Have powerful interactions which are unpredictable
e.g.
Pregnancy, increased VIII, fibrinogen, Decreased protein S, Flow
Malignancy: TF on tumour, inflam, flow
Sx: trauma, inflam, flow
What are the principles of managing VTE
ST prevention: during periods of high risk
Immediate treatment: preventing extension and embolisation
LT prevention
Anticoagulants
Anticoagulant therapy:
High dose?
Low dose?
High dose: therapeutic
Low dose: prophylactic
What are the traditional/standard anticoagulants?
Heparin: unfractioneated/LMWH/Direct acting anti-Xa and anti-IIa: IMMEDIATE
Warfarin: DELAYED
Administration of different types of heparin?
What are their actions?
Consequence?
Unfractionated: IV
LMWH: sub cut
Pentasacchadie: sub cut
All act by potentiating antithrombin
Provide immediate effect: e.g. for treatment of thrombosis, long term disadvantages include daily injections and risk of osteoporosis
Monitoring of heparin therapy?
LMWH: reliabl pharmacokinetics so not usually required except in renal failure, extemes of weight or risk, unusual conditions.
Monitor using anti-Xa
Unfractionated heparian: unreliable kinetics
Always moinotr therapeutic levels with APTT or anti-Xa
What are the anti-Xa direct acting anticoagulants?
Rivaroxaban, apixaban, edoxaban
What are the direct acting anti-IIa anticoagulants?
Dabigatran
What are the properties of the direct acting anticoagulants?
Oral
Immediate action peaak within 3-4h
Short t1/2
No monitoring
Limited licensed indications thus far
What is the use of Warfarin?
Action?
Therefore
What is the impact?
Given orally
Indirect effect by preventing Vit K recycling.
Therefore delayed onset of action
Levels of procoagulants falls: II, VII, IX, X
protein C and protien S (anticoagulant factors) also fall
Monitoring of Warfarin?
What are the issues with Warfarin therapy?
Implications in pregnancy?
Always essential through measuring INR. Derived from PT
Difficulty as Warfarin has numerous interactions e.g. dietary K, variable absorption, interaction with other drugs
Teratogenic
Action of heparin vs warfarin vs doac
Cofactor for AT vs Vit K antag vs direct enzyme inhibition
Reversal of heparin
warfarin
DOAC?
Protamine
Factor concentrate, vit K
none atm
Pregnancy: heparin
warfarin
DOAC
Heparin: safe
Warfarin: teratogenic
DOAC: no data- avoid
Who receives thromboprophylaxis?
People at risk: Sx, immobility, pregnancy, general medical inpatients
What is used for thromboprophylaxis?
And the features of each Rx?
LMWH: daily, e.g. tinzaparine 4500u/ Clexane 40mg
Rivaroxaban
TED stocking for Sx or if heparin contraindicated?
Bleeding risk assessment for anticoagulant therapy
Patient factors
Patient: bleeding diathesis, platelt count <100, acute CVA in prevous month (eith categrory)
BP >200 / >120
Severe liver disease
severe renal disease
Active bleeding
anticoagulant or antiplatelet therapy
Bleeding risk assessment for anticoagulant therapy
Procedure features
Neuro, spinal, eye Sx
Other with high bleeding risk
LP, spinal/ epi in previous 4 hours
What is essential for treatment of DVT/PE
What is the approach
Immediate anticoagulation
LMWH (175u/kg) + Warfarin (some NOACS e.g. rivaroxaban now lciensed). Stop LMWH when INR in therapeutic range
Continue for 3-6m
Patients with cancer continue LMWH not Warfarin
Elasticated stocking for 2y to prevent postphlebitic syndrome
Duration of LMWH/Warfarin based on cause
1st VTE, known cause:
3m
Duration of LMWH/Warfarin based on cause
Cancer
LMWH 3-6m
Duration of LMWH/Warfarin based on cause
1st VTE unknown cause
3-6m Warfarin, potentially lifelong
Duration of LMWH/Warfarin based on cause
1st VTE in thrombophilic patient
3m Warfarin
?lifelong
Duration of LMWH/Warfarin based on cause
Recurrent VTE
lifelong Warfarin
What may also be indicated following VTE?
TEDS to prevent postphlebitic syndrome
Use of thrombolysis in VTE
Only for life threatening PE or limb threating DVT
Risk fof ICH ~4%
Reduces subsequent post=phlebitic syndrome
PE/DVT risk of recurrence
Some studies suggest higher risk of recurrence with PE but some not
Generally VTE means increased risk of recurrence
Anticoagulation and recurrence after first VTE with minor precipitant (COCP, flights trauma) length of therapy
Generally 3m adequate
What are the inherited risk factors for VTE?
Antithrombin deficiency
Protein C D
Protein S D
Factor V Leiden, resistance to protein C
Prorthrombin
Lupus anticoagulant
Coag excess:
VIII (10%)
11 (2%),
Fibrinogen
What is the most common coagulant excess in inherited VTE?
Factor VIII (10%)
What are the acquired risk factors for VTE?
Age, obesity
Previous DVT, PE
Immobilisation
Major Sx, esp ortho. >30mins, plaster cast immobilisation
Long distance travel
Malignancy, esp pacnreas NB 10% idiopathic VTE due to Ca
Pregnancy, COCP, HRT
Antiphospholipid syndrome
Polycythaemia
Thrombocythaemia
What is antiphospholipid syndrome?
Antiphospholipid syndrome orantiphospholipid antibody syndrome (APS or APLS), or often also Hughes syndrome, is an autoimmune,hypercoagulable state caused by antiphospholipid antibodies. APS provokes blood clots (thrombosis) in both arteries andveins as well as pregnancy-related complications such asmiscarriage, stillbirth, preterm delivery, and severepreeclampsia.
Features of Heparin:
MOA
LMWH administration
Unfractionated administration
Antidote
SEs
Potentiates antibthrombin III which inactivates thrombin and factors 9, 10, 11
Given SC daily, does not require monitoring except late pregnancy and reanl failure
IV loading dose then infusion, monitor APTT
Antidote: protamine sulphate
Side effects: heparin induced thrombocytopaenia, osteoporosis (both more common with UFH)
Indications for target INR of 2.5?
1st episode DVT or PE, AF (2-3)
Cardiomyopathy, symptomatic inherited thrombophilia
Mural thrombus
Cardioversion
Indications for target INR 3.5?
Recurrent DVT or PE, mechanical prosthetic valve (2.5-3.5)
Coronary artery graft thrombosis
Antiphospholipid syndrome
Mx of INR 5-8 no bleeding
Withold doses, reduce maintenance, restart when INR <5
Mx of INR 5-8 minor bleeding
Stop warfarin, VIt K slow IV. Restart when INR <5
Mx INR >8 no bleed/minor bleed
Stop Warfarin
Vit K oral/IV
no bleeding/if risk factors for bleeding
Daily INR monitoring
Mx of major bleeding with raised INR including ICH
Stop warfarin
Give prothrombin complex concentrate
If unavailable give FFP
Also give Vit K IV
What is the relationship between Cancer and anaemia?
Give some examples of anaemia as the manifestation of malignancy
NB
Many causes for cancer associated anaemia
Many cases of anaemia are the first presentation of ca:
Fe deficiency
Anaemia of inflammation (chronic disease)
Leucoerythroblastic anaemia
Haemolytic anaemias: autoimmune, microangiopathic
Ca may also cause 2o polycythaemia e.g. RCC and HCC
Fe deficiency and cancer
Cause
Laboratory findings
Occult blood:
GI cancer: gastric, colonic/rectal
Urinary tract cancers: RCC, bladder
Reduced Ferritin, transferrin saturation
Raised TIBC
Fe deficiency is bleeding until proven otherwise
What is leucoerythoblastic anaemia?
Morphological features
Red and white cell precursor anaemia (variable degree of anaemia)
Morphological features: teardrop RBCs (+ aniso and poikilocytosis), Nucleated RBCs, immature myeloid cells
What does this blood film schow?
Leucoerythroblastic film
Tear drop poikilocytes
Nucleated RBC
Myelocyte
Outline the principle causes of a leucoerythroblastic film
What are the features of myelofibrosis?
Massive splenomegaly
Dry tap on BM aspirate
What are the common laboratory features of haemolytic anaemia of any aetiology?
Anaemia (may be compensated)
Reticulocytosis
Raised UNCONJUGATED bilirubin
Raised LDH
Reduced haptoglobins
What are the 2 pathogenci groups of haemolytic anaemia
Inherited: all due to defects of the red cell
Acquired: defects of the environment in which the red cell finds itself (except Paroxysmal Nocturnal Haemolytic anaemia)
What are the three components of of a red cell and how are they affected by iHA
Membrane
Spherocytosis, elliptocytosis
Hb:
Structural (SCD)
Quantitative (thallassaemias)
Enzymes:
G6PD
What are the only two types of acquired HA
What is the one test that distinguishes between them?
Immune
Non-immune
DAT (Coomb’s test)
What are the causes of immune HA?
Auto-immune: allo-immune/blood transfusion.
Spherocytes, DAT +ve
Associated systemic disorder:
Cancer of the immune system: lymphoma
Disease of hte immune system: SLE
Infection: disturbing the immune system
Features of autoimmune haemolysis
Positive DAT means?
Anaemia
Reticuloytosis
Raised LDH
Positive DAT
Either idiopathic or there is an underlying lymphoma/CLL/systemic autoimmune disease e.g. SLE
What are the two main causes of spherocytes
How can they be distinguished between
They are most commonly found in immunologically-mediated hemolytic anemias and in hereditary spherocytosis, but the former would have a positivedirect Coombs test and the latter would not. The misshapen but otherwise healthy red blood cells are mistaken by the spleen for old or damaged red blood cells and it thus constantly breaks them down, causing a cycle whereby the body destroys its own blood supply (auto-hemolysis).
What does this blood film show?
Spherocytes
What are the causes of acquired haemolytic anaemia: Non-Immune
Infection: Malaria
Micro-angiopathic HA
Red cell fragments
Low platelets
DIC/bleeding
Underlying adenocarcinoma
Features on this film
What does it show?
RBC fragments, thrombocytopenia
MAHA
Micro-angiopathy in malignancy (pathogenesis)
Adenocarcinomas, low grade DIC
Platelet consumption
Fibrin deposition and degradation
Red cell fragmentation
Bleeding
Jaundice/Anaemia/Raised LDH
How would you exclude or diagnose?
Lymphoma with liver involvement
Bilirubin conjugated/DAT negative/CT scan liver deposits/BM involved-infiltrated
Jaundice/Anaemia/Raised LDH
How would you exclude or diagnose?
Lymphoma with nodes compressing the bile duct
Bilirubin conjugated/DAT negative/CT scan nodes around porta-hepatis/BM involved-infiltrated
Jaundice/Anaemia/Raised LDH
How would you exclude or diagnose?
Lymphoma with auto immune haemolytic anaemia
Bilirubin Unconjugated/DAT positive/CT scan no liver deposits
What are the causes of true polycythaemia (raised red cell mass)
2o (raised EPO/inappropriate): HCC, bronchial Ca, RCC
Polycythaemia vera: clonal myeloproliferative disorder involving acquired mutaitons in JAK2
What are the types of WBC and where are they normal?
Mature
Phagocytes: granulocytes, monocytes
Immunocytes: lymphocytes
Immature
Normal in BM in an appropriate%, not normal in PB:
Blasts, promyelocytes, myelocytes
What does CLL involve?
WBC increased mature cells
CLL: Increased WBC mature cells
AML: increased immature cells in PB
What are the causes of neutrohilia?
Corticosteroids
Underlying neoplasia
Tissue inflammation e.g. colitis, pancreatitis
Myeloproliferative/leukaemic disorders
Infection
What are the causes of neutrophilia in infection?
Localised and systemic infections, acute bacterial, fungal and certain viral
What is characteristic of infection with brucella, typhoid and most viruses in terms of FBC
Characteristically do not produce a neutrophilia
What are the characteristics of a reactive neutrophilia?
Presence bands
Toxic granulation
Signs of infection/inflammation
What are the characteristics of a malignant neutrophilia
Neutrophilia basophilia plus immature cells and splenomegaly suggests myeloproliferative (CML)
Features of CML
Neutrophilia basophilia plus immature cells myelocytes, and splenomegaly. Suggest a myeloproliferative (CML)
Neutropenia plus myeloblasts=?
AML
Reactive neutrophilia
CML
What are the causes of a reactive eosinophilia?
Parasitic infestation
Allergic disease e.g. asthma, rheumatoid polyarteritis, pulmonary eosinophilia
Underllying neoplasms esp. Hodgkins, T-cell NHL
Drugs: erythema multiforme
What is a malignant cause of eosinophilia
Chronic eosinophilic leukaemia
Eosinophils part of the clone
FIP1L1-PDGFRa Fusion Gene found in?
Chronic eosinophilic leukaemia
Eosinophilia
Causes of monocytosis
Rare, seen in certain chronic infections and primary haematological disorders
Infections: TB, brucella, typhoid, vidal: CMV, VZV
Sarcoid
Chronic myelomonocytic leukaemia
What are the relevant investigations to interpret a lymphocytosis
Clinical: infection or lhymphoma? Lymphadenopathy or splenomegaly?
FBC: degree of lymphocytosis
Microscopy/morpology: mature vs immature
Flow cytometry: lineage- T or B cells. Stage of differentiation
Molecular genetics
Causes of reactive lymphocytosis
Infection: EBV, CMV, Toxoplasma, Infectious hepatitis, rubella, herpes
Autoimmune
Neoplasia
Sarcoid
Lymphocytosis
>3.5x109/l
What could this be?
- EBV viral infection
- early CLL
CLL
ALL
What is the principle of flow cytometry
Throughout B cell development, cells at differential stages express different surface antibodies.
Flow cytometry separates these cells on the basis of Ab expression
What is multiple myeloma?
Neoplastic proliferaiton of bone marrow plasma cells associated with a monoloncal protein in serum and or urine
Production of monoclonal Igs: paraprotein
IgG most common.
Middle-aged to elderly
Afrocarribean’s have increased incidence
CRAB
Clinical features of MM
Calcium high
Renal failure: plus amyloidosis and nephrotic syndrome
Anaemia (and pancytopenia)
Bone pain: osteoporosis, osteolytic lesions, fractures
+ Hyperviscosity syndrome
What are the features of symptomatic plasma cell myeloma
Monoclonal protein in the serum and or urine
Bone marrow clonal plasma cells or plasmacytoma
CRAB
What are the features of asymptomatic/smouldering myeloma
Monoclonal protein in serum at myeloma levels (>30g/l)
10% or more clonal plasma cells in BM
No related organ or tissue impairment
Px of myeloma
3y with conventional CTx
5y with autlogous stem cell transplation (cure)
Epidemiology of MM
M>F
Black>white
Doesn’t occur in children
70y/o median diagnosis
Increased incidence if first degree relative
Ix in MM
Dense narrow band on electrophoreisis
Rouleaux on blood film (RBC stacking)
Bence-Jones protein in urine
Raised ESR (+++)
>10% plasma cells in BM
Bence-Jones protein
MM
Staining in MM
H&E
Immune-peroxidase stain for CD138
Bony features of MM
Multiple sjulll lesions
Plasmacytoma: malignant plasma cell tumour growing within soft tissue
Osteopenia and wedge fractures of hte vertebrae
Serum protein electrophoresis
IgG 52%
IgA 22%
IgM 12
IgE rare
What is the staging system for MM?
Durie Salmon
What are the crtieria for the staging of Duire Salmon
Hb
Serum Ca
Bone disease
IgG
IgA
Urine light-chain M-component
Stages 1-3
International staging system (ISS):
B2-microglobulin
Albumin
Stage 1 MM
>10g/dl
No bone disease
IgG <50
IgA <30
<4mg urine light chain
<3.5B2 microglobulin
>35 albumin
Stage 3 MM
Hb <8.5
Raised Ca
Multiple lytic lesions in bone
>70g/dl IgG
>50g/l IgA
Urine light chain >12g
Raised B2 microgloublin
Hypoalbuminaemia
Multiple myeloma
What is MGUS?
Monoclonal gammaglobinopathy of unkown significance
<10% plasma cells in marrow
<30h/l monoclonal paraprotein
No CRAB
Incidental finding progressing to MM at 1-2%/year
No therapy needed at this stage
Monitor for transformation
What is smoldering MM?
Monoclonal gammaglobinopathy of unkown significance
>10% plasma cells in marrow
>30h/l monoclonal paraprotein
No CRAB
No therapy needed at this stage
Monitor for transformation
What is Waldenstrom’s Macroglobinaemia?
Lymphoplasmacytoid Lymphoma (PLL)
Elderly men
Low grade NHL: lymphoplasmacytoid cells produce monoclonal serum IgM that infiltrates the LNs and BM
Weight loss, fatigues, hyperviscosity syndrome
Treatment: plasmapheresis for hyperviscosity
Chlorambuicl, cyclophosphamide
What are the features of hyperviscosity syndrome?
Visual problems, confusion, CCF, muscle weakeness
What are the criteria for plasma cell leukaemia?
>2x10^9 plasma cells in peripheral blood
or
>20% of the leukocyte differential count
What are the features of systemic amyloidosis?
Ig light chains= paraprotein. Deposition of abn proteniacious substance in tissues
Diagnosed via cong-red: APPLE GREEN BIREFRINGENCE
Presents with macroglossia, carpal tunnel syndrome, peripheral neuropathy, RF
Treatment with CTx or auto-SCT
Cong red: apple green birefringence
Amyloidosis
What is MP?
6-mercaptopurine
What is VAD?
Vincristine
Doxorubicin
Dexamethasone
What is CTD?
Cyclophosphamide
Thalidomide
Dexamethasone
What is MPT?
Melphalan
Prednisolone
Thalidomide
What is the MOA of thalidomide in MM?
Immunomodulatory: alters expression of adhesion molecules, reduces TNF alpha and increases IL-10 leading to increased cell-mediated immunity
Inibits angiogenesis and promotes apoptosis of endothelial cells in established angiogenesis
Advantages: oral, synergistic effects in combination therapy. Used for relapsed myeloma
Toxic, dose-limiting
Side effects
What are the side effects of thalidomide?
Neuropathy
VTE
Somnolence
Consitpation
What is the MOA for Bortezomib
Inactivates Nf-kB by binding to the beta ring of 20S proteosome
Good activity, high and rapid response
Expensive, toxic
What are the toxic effects of Bortezomib?
Neuropathy
Systemic toxicity
What are some new drugs in the treatment of MM?
Thalidomide
Bortezomib
Lenalidomide
What is the therapy of choice in MM
Alkylating agent +/- prednisolone
Maintenance with IFN alpha
ASCT curative
Bisphosphonates reduce #s and bone pain
Treatment of bone disease in MM
Hypercalcaemia: IV fluids, steroids, bisphosphonates
Bone pain: pamidronate, zoledronic acid and clodronate.
What are the transplant options in MM?
Autologous SCT: treatment of choice for most patients. Collect stem cells and give high dose melphalan
Allogenic SCT: decreased deaths due to lower incidence, of infections and interstitial pneumonitis. Consider in patients under 50 with age matched sibling
What are the principle causes of mortality in pregnancy?
Genital tract sepsis
Eclampsia
VTE
Amniotic fluid embolism
Haemorrhage
Ectopic
What are the haematological demands of pregnancy
Iron: 300mg for fetus. 500mg for increased maternal cell mass. RDA30mg. WHO recommends 60mg/d
Folate: increased requirement due to growth and cell division. Additional 200mcg/d. WHO recommends 400mcg/d
RCOG folate recommendations
Before conception and for >12w gestation
400microg/d
What are the risks of Fe deficiency in pregnancy
IUGR
Prematuiry
PPH
What are the blood count changes in pregnancy?
Mild anaemia: dilutional effect, red cell mass rises 120-130%, plasma volume rises 150%
Macrocytosis: may be normal or due to folate or B12 deficicency
Thrombocytopenia (<150): can be physiological
Causes of thrombocytopenia in pregnancy
Physiological (gestational/incidental thrombocytopenia)
Pre-eclampsia
ITP
MAHA
OAll other causes
Increased platelet size
Plt <150 in pregnancy
Gestational most likely
then ITp
then PE
Plt <100 in pregnanc
Gestational most likely cause
then pre-ecl
then ITP
Plt <70 in pregnancy
ITP = Pre-ecl as most likely cause
Then gestational
Features of gestational thrombocytopenia
10% physiological decrease
Mechanism poorly defined
Either dilutional effect or increased consumption
Platelet count rises 2-5d post-partum
What are the plt cut offs for delivery/epidural
Delivery 50
Epidural 80
What are the features of thrombocytopenia in pre-ecl?
50% of pre-eclamptics get therombocytopenia proportional to severity
Due to increased activation and consumption
Associated with coagulation activation. Incipient DIC, normal PT and APTT.
Usually remits following delivery
Features of ITP in pregnancy
5% of thrombocytopenia in pregnancy. Can precede pregnancy and start early in gestation
Treatment of ITP in pregnancy
IV Ig
Steroids
Anti-D in Rhesus negative
Foetal effects of ITP
Unpredictable when <20
Check cord blood daily
What is MAHA?
Deposition of plt in small BVs.
Thrombocytopenia
Fragmentation and destruction within the vasculature, results in organ damage: Kidney, CNS (placenta)
Blood film in MAHA
Fragments
Low plt
Polychromasia (increased RBCs)
TTP and HUS in pregnancy
More common
Not helped by delivery
Usually earlier than HELLP, usually in 2nd trimester
What is the net effect of coagulation changes in pregnancy?
Procoagulant state:
Increased thrombin generation
Increased fibrin cleavage
Reduced fibrinolysis and interaction with other maternal factors leading to
Increased rate of thrombus
PE in pregnanc
Risk highest in 40-46w gestation/post-partum then 0-13w
Risks in pregnancy for VTE
BMI
FH
Bed rest
Pre-ecl
Operative delivery
Previous VTE
Thrombophilia
Age
Parity
Multiple pregnancy
Other medical problems
Hyperemesis gravidarum/dehdration.
OHSS
Unreltaed surgery
D-dimer in pregnancy
Already elevated
Useless
Complications of thrombophilia in pregnancy
Associated with impaired placental circulation
Results in:
IUGR, recurrent miscarriage, late foetal loss, placental abruption, severe Pre-ecl
Which thrombophilias are associated with pregnancy complications?
Antiphospholipid syndrome: recurrent miscarriage and persistent lupus anticoagulant/anticardiolipin Abs
AT PC and PS deficiency
FVL
High protthombin
Treatment of APLS
Aspirin
Heparin
What is the normal blood loss in
SVD
C-sec
300-500mL
900-1100mL
Def: PPH
>500mL after SVD
>1100mL after C-sec
DIC syndromes in pregnancy
DIC precipitated by amniotic fluid embolism
Placental abruption
Retained dead foetus
Pre-eclampsia
Sepsis
Why does DIC occur in amniotic fluid embolism?
Due to tissue factor in te amniotic fluid
Why is Hbopathy screening performed in pregnancy?
To avoid birthds of children with alpha0 thalassamie which die in utero or from hydrops fetalis
How is thalassaemia screening stratified?
Based on pregnant women FBC indices
FBC indices:
MCH <27: possible thalassameia trait
<25 requires DNA analyiss
Ethnic origin
Options if hbopathy identified in pregnancy?
Proceed
Prenatal Dx at 10-12 CVS
Amniocentesis
Foetal blood sampling
USS
Features of SCA and pregnancy
Painful crises become more frequent, anaemia is exaggerated and transfusions are often required
Also associated with:
Increased risks of hospital admission
Post-partum infection
IU foetal death
IUGR
Prematurity
Perinatal mortality
Pyelonephritis
Low birth weight
PROM
Pre term labour
Pre-ecl
What immune disorders are significant in pregnancy?
HDN Haemolytic disease of newborn
NAITP
What is NAITP?
Neonatal alloimmune thrombocytopenia: gaining of Abs to platelets from the mother’s circulation
Genetic differences lead to Ag expression on the foetal platelets.
Signs and symptoms of anaemia
Weakness
Pale
Tired
Cardiac failure
SOB
Orthopnea
PND
Swollen ankles
Lethargic
Decreased exercise times
Syncope
Palpitations
Tachycarida
Koilonychia (Fe def.)
Glossitis (B12 def)
Jaundice (haemolysis)
Pale mucous membranes
Cardiomegaly
CCF
Koilonychia in anaemia
Fe deficiency
Glossitis in anaemia
B12 deficiency
Jaundice in anaemia
Haemolysis
Causes of microcytic anaemia
Fe deficiency
Anaemia of chronic disease
Thalassaemia
Features of reticulotcytosis
Normal resposne to anaemia- haemolysis, haemorrhage and haematinics
Absent reticulocytosis if inadequate or bone barrow failure or after acute haemorrhage as takes 6 hours.
Pushes MCV up
What does reticulocytosis do to MCV?
Pushes t up
Features of Fe deficiency
Blood film: pencil cells, anisocytosis, poikilocytosis, hypochromic
Low ferritin, low transferrin saturation
Establish source of blood
Blood film: pencil cells, anisocytosis, poikilocytosis, hypochromic
Fe deficiency
Causes of pancytopenia
BM failure
Lymphoma/leukaemia
Aplastic anaemia
RTx, CTx
Myelofibrosis
B12/Folate deficiency
Ix of pancytopenia
Bone marrow aspirate
Blood film
B12 and folate levels
Ix of low platelets
Coagulation screen
Blood film
BM aspirate
ANA/RAPA/Antiplatelet Ab/HIV test
D-dimer
Fibrinogen
Blood cultures/CSF/MSU
LFTs
DIC=
Anaemia and thrombocytopenia
Mx of DIC
Antibiotics
Blood products; RBCs, platelets, croprecipitate, FFP
Regular bloods to assess response to products
Auer rod=
Accumulation of granules in myeloid cells
AML
How is testing of blood performed?
Use known anti-A, anti-B and anti-D reagents to test for ABO and RhD group
Positive test causes agglutination. If the RBCs have agglutinated they are seen at the top of the column
What are the methods for testing blood type?
Column agglutination
Abbreviated testing
Automated blood grouping
Ab screening
Abbreviated blood group testing
Blood added to card or tube and reacts with rapid reagents
Automated blood grouping
Bar coded samples with image analysis, quicker to interpret with no manual steps
What is the purpose of the antibody screen?
Need to identify clinically significant antibodies and transfuse Abs negative for that antigen.
Thisis to prevent delyed haemolytic transfusion reactions.
Can be done using the indirect antiglobulin technique. Test the pateint’s plasma with 2 or 3 RBCs that contain all the important antigens. Screen by incubating pateint’s plasma with screening cells
Cross-matching
Blood label: donor RBCs labelled with ABO + D type. And other Rh Ags and K
Select blood.
What is the IAT?
Patient plasma incubated with donor red cells at 37deg for 30-40mins
This will pick up antibody antigen reactions that could cause extravascular haemolysis. Need to add antiglobulin reagenet
Immediate spin cross matching
Saline, room T, incubate patients plasmawith donor cells for 5 minutes and spin. This will detect ABO incompatibility. IgM anti-A and or IgM anti-B will bind to RBCs, fix complement and cause cell lysis
What is electronic crossmatch
LIMS automatically determines compataibility without serological testing of donor cells against patient plasma
What is MSBOS
Negotiations between surgeons and transufion lab for predictable blood loss from surgery
Group and Save or Group and Crossmatch
Pt details
Indication for transfusion and urgency
Number of RBCs to crossmatch or group and save
Previous transfusions and date
Special requirements: irradiation, CMV negative
Location of patient
Handwrite on blood sample taken.
Methods of autologous blood transfusion
Pre-operative autologous deposit of blood, shelf life 5w, taken at weekly intervals with Fe supplementation.
Cell salvage: use a machine to suck up blood during surgery. Can’t do this if there is malignant or bacterial contaminant. Used in obstetric and vascular/bloody surgery
What is HDN
Person may form red cell Ab through blood transufion or if fetal cells enter woman’s circulation during pregnancy or delivery. Some Ags are more likely to form Abs than other
If maternal Ab level is high, it can destroy fetal red cells if they have corresponding red cell Ag. Leads to HDN (fetal anaemia and jaundice)
Only IgG can cross the placenta.
Anti-D often most responsible.
Other Ab= anti-C, anti-K, IgG ABO
Rhesus D isoimmunisation
1st preg: Rhesus +ve fetus: RhD positive foetal celss cross the placenta causing anti-D Abs to form
2nd pregnancy: Rhesus +ve foetus: moether is sensitised. Maternal anti-D crosses the placenta and coats foetal RhD +ve cells. Leads to their destruction in spleen and liver
What are the clinical features of rhesus disease in foetus
Foetal anaemia and HDFN: anaemia and high bilirubin.
Bilirubin accumulates after birth as it is no longer removed by the placenta
Hydrops foetalis
Kernicterus can result
Features of hydrops fetalis
Accumulation of oedema in at least two foetal compartments, can cause spontaneous abortion and heart failure
Kernicterus=
Bilirubin induced brain dysfunction
What are the methods to prevent rhesus disease
Prevent sensitisation in the first place
Anti-D antiglobuline
RAADP
Prevention of rhesus sensitisation
Transfuse RhD negative childbearing females with RhD negative blood.
Give IM injections of anti-D Ig at times when the mother is at risk of fetomaternal bleed
What is the timelit for anti-D to be given
72h
Doesn’t work if previous sensitisation
What are the different doses of anti-D used
<20/40: 250IU
>20/40: 500iU, larger doses are needed for larger bleeds to a FMH/Kleihauer test is conducted to determine the size of the bleed
Kleihauer-Betke test
Blood test used to measure the fetal Hb transferred from fetus to maternal blood stream and determine severity of bleed.
Acid bath removes adult Hb but not fetal Hb. Staining using Shephard’s method appear rose-pink while adult RBC seen as ghosts.
Percentage of fetal to maternal cells calculated
Kleihauer test, showing fetal red blood cells in rose-pink color, while adult red blood cells are only seen as “ghosts”.
Dosing for FMH
125iU/mL
RAADP
Routine antenatal anti-D prophylaxis for women who are rehsus D negative.
1% of pregnancies have no obvious sensitising event.
Routine anti-D prophylaxis is given in 3rd trimester
500iU at 28 and 34w
or 1500iU at 30w.
Routine management of Abs in pregnancy
Women undergo screen at 11 and 28w to check for RBC Abs
If Abs are present, quantify, check and monitor levels.
High or rising= more likely to affect the foetus
Monitor for HDFN through MCA Doppler USS
Deliver baby early as HDN gets worse in last few weeks fo gestation
in utero Mx of HDFN
Monitor using doppler USS
Deliver early
Intrauterine transfusions can be given
Monitor babies Hb and bilirubin at delivery and for several days after.
Transfuse to decrease bilirubin and increase Hb
Phototherapy
Subsequent pregnancies are usually worse
What other antibodies are implicated in HDN?
Anti-C: less severe.
Anti-kell: causes reticulocytopenia in foetus as well as haemolysis
IgG Anti-A and Anti-B Abs from group O mothers can cause mild HDN but not severe and can be treated with phototherapy
What is the difference between forawrd and reverse grouping?
Øuse known anti-A and anti-B and anti-D reagents against patient’s RBCs = FORWARD GROUP
Øand A and B reagent RBCs against patient’s plasma (contains IgM antibodies) = REVERSE GROUP
Indications for use of platelet as transfusion
Massive transfusion
Prevent bleeding post chemo
Prevent bleeding post surgery
Platelet dysfunction or immune cause
What is an adult treatment dose?
One unit of platelets
Raises platelet count by 30-40
When is a platelet transfusion contraindicated?
Heparin induced TP and TTP
Indications for FFP transfusion
Massive transfusion
DIC with bleeding
Liver disease + Risk
Not used to reverse warfarin
Draw causes of low plt count
Draw ABO blood groups
Draw anti-D doses
What is SHOT?
Serious hazards of transfusion
TRALI=
Transfusion related acute lung injury
TACO=
Transfusion associated circulatory overload
TAD=
Transfusion associated dyspnoea
PTP=
Post-transfusion purpura
How can adverse blood transfusion related events be prevented?
Bedside check
Use a giving set with a filter in the line
Don’t add drugs to blood
Don’t keep blood out of fridge for >30m without transfusion
Do routine obs during hte transfusion
Immediate clinical action in SHOT
Preventative action
ABC
Treat symptoms
Check blood components
Inform transfusion department
Take laboratory sampes
Contact local member of tranfusion team
Complete incident form
Take witness statements
Report to SHOT
Root cause analysis
Features of acute transfusion reaction
May start as rise in temp, pulse or fall in BP
Fever, rigors, flushing, vomiting, dyspnoea, pain at transfusion site, loin and chest pain, urticaria, itching, headache, collapse
Treatment of acute transfusion reaction
Severe: 2222. Take down components
Replace tranfusion with saline to keep the vein open, ABC, haem input
Mild: medical assistance, administer antihistamine or paracetamol (diuretics if fluid overload). Observe patient.
Features of FNHTR
During or soon after hte transfusion, rise in temp of 1 degree, chills and rigors
Slow/stop transfusion
Paracetamol
Caused by Abs against WBCs, less common with leukodepletion
Features of allergic reaction to blood transfusion
Common esp with plasma
Mild urticarial or itchy rash, sometimes with a wheeze. During or after transfusion. Stop or slow transfusion
Antihistamines
Cause: allergen is the donor plasma, so may not recurr dependant on the IgE specificity in the recipient. More common in recipients with hx of atopy
What are the most common reactions with RBCs?
Febrile
Allergy
Unclassified
Mixed allergic and febrile
Hypotensive
Anaphylactic
What are the most common ATR with platelets?
Allergic
Febrile
Anaphylactic
Mixed
Unclassified
Hypotensive
What are the most common ATRs with plasma?
Allergic
Anaphylactic
Febrile
Hypotnesive
Mixed febrile and hypotensive
What are the most common ATRs with mixed components?
Anaphylactic=allergic
Febrile=hypotensive
Then mixed allergic and febrile
Features of Wrong ABO ATR
Sings and symptoms of acute intravascular haemolysis: restlessness, chest/loin pain, fever, vomiting, flushing, collapse, Hburia.
Take samples for FBC, biochemistry, coagulation, repeat cross match and DAT.
Causes: failure of bedside check, wrongly labelled x-match sample, lab error
Features of anaphylaxis ATR
Severe life threatening reaction soon after hte start of the transfusion
Patient will be in hypotensive shock, breathless with wheeze and have laryngeal and facial oedema
Mech: IgE cross linking with mast cells leading to degranulation.
Caused by: previous exposure to Ag and development of an IgE antibodiy. Classically IgA deficiency or IgE Ab is passively transferred by the transfusion
What is the differnce between an anaphylactic and an anaphylactoid reaction?
Anaphylactic is IgE mediated
Features of IgA deficiency
Partial or total deficiency where anti-IgA Abs are more likely to develop.
Can be part of CVID and more commonly associated with infection and autoimmunity. Abs develop in response to sensitising event.
At greater risk of allergic transfusion reactions
Endogenous infection of blood products
Exogenous infection of blood products
Yersinia enterocolitica
Salmonella
E coli
Strep
Staphy
Pseudomonas
Serratia
Prevention of bacetial contamination of blood products
R/v blood product
Donor questioning
Screening of platelets occurs within 36h of donation and are held for further 6h nefore release
What is TRALI
Transfusion associated lung injury.
Acute dyspnoea with hypoxia and bilateral pulmonary infiltrates during or within 6h of tranfusion
Mechanism of TRALI
Donor anti-leucoyte Abs interact with patients WBC Ags which aggregate and stick in pulmonary capillaries
Results in release of neutrophil proteolytic enzymes and toxic oxygen metabolites which cause lung damage
Prevention is through using male donor plasm and avoiding plasma usage e.g. Warfarin reversal is using vit K.
What is TACO
Transfusion associated circulatory overload
Occuring within 6h of tranfusion:
Acute resp distress
Tachycardia
Raised BP
Acute or worsening pulmonary oedema
Evidence of positive fluid balance
Causes of TACO
Lack of attention to fluid balance.
Can be due to cardiac/renal failure or hypoabluminaemia.
Over transfusion
What is the impact of 1 unit of RBCs on recipient Hb?
Increases by 1g/dL
Check Hb after every 2 units
What is TAD?
Tranfusion associated dyspnoea
Respiratory distress within 24h of transfusion that does not meet the criteria of TRALI or TACO or allergic reaction.
What are the Cxs of massive blood transfusions
e.g. one blood volume in one day?
Hypothermia
Hyperkalaemia (as stored RBCs leak K)
Hypocalacaemia (as anticoagulant in each bag binds to Ca)
Air embolism
What are the features of delayed haemolytic transfusion reactions?
Lysis of red cells= raised bilirubin, decreased Hb, increased reticulocytes, Hburia over next few days.
Can occur to Kidd antigens, anti-D, K, Jk
Can cause renal failure
May require further transfusions
Do DAT
What are the intravascular symptoms of haemolytic transfusion reactions?
Extravascular?
Red/brown plasma and urine
Fall in Hb and jaundice
What are some other causes of haemolysis following transfusion?
Bacterial contamination
Mechanical damage
Addition of drugs incompatibile with IV fluids
What viruses are tested for in donor blood?
HBV, HCV, HIV, HTLV but NB window period for infeciton
Syphillis
CMV (removed through leiukodepletion)
Parvovrisu: can affect foetus and patients with haemolytic anaemia
What are the features of TA-GvHD
Rare but alway fatal.
Donor’s blood contains viable lymphocytes that are not recognised by host immune system in susceptible patients.
Donor lymphocytes recognise the Ags on patients gut, liver, skin, bone marrow and mount an immunological response
Causes severe diarrhoea, liver failure, skin desquamation, bone marrow failure
Who is susceptible to TA-GvHD?
Very immunosuppressed: SCT patients, CTx durgs e.g. fludarabine, Hodgkin’s foetus. Donor needs to be HLA matched for intrauterine transfusion. (HLA homozygosity)
Prevention of TA-GvHD
Identify at risk recipients
Irradiate donor blood to leukodeplete
Features of PTP
Purpura= pin prick red/purple blood spots due to very low platelets or vasculitis
Appears 7-10d post transfusion and can cause life-threatening bleeding.
Affects HPA-1a negative patients
Usually resolves in 1-4w
Sped by IV Ig
Need to be given HPA-1a negative platelets
Features of Fe overload in transfusions?
Lots of transfusions (>50) over time can lead to an accumulation of Fe.
This can cause organ damage, to hte liver, heart and endocrine system
Prevented through the use of Fe chelators e.g. desferioxamine once Fe >1000g.
Used in thalassaemia where patients have monthly transfusions
Draw SHOT: immediate and delayed
Draw symptoms of ATR
Draw fever vs allergic ATR
Def: lymphoma
Neoplastic tumour of lymphod tissue
Often found in LNs and BM. May spill into blood
Sometimes found in other lymphoid tssues e.g. spleen, MALT
Rarely found in skin (T-cell), CNS, testes, breast
Risk factors for lymphoma
No identifiable risk factor in majority of cases
Constant antigenic stimulation, infection and immunosuppression are known to contribute
H. pylori and lymphoma
Gastric MALT
Lymphoma
Sjogren’s and lyomha
Parotid lymphoma
Coeliac and lymphoma
small bowel T cell lymhoma
EATL (enteropathy associated T-cell lymphoma)
Viral causes of lyphoma
HTLV1
EBV
HIV
HTLV1 and lyphoma
Infects T cells by vertical/sexual transmission. May develop adults T-cell leukaemia lymphoma
EBV and lymphoma
EBV infects B lymphocytes. Carrier state regulated by healthy T cells.
Iatrogenic suppression of T cells e.g. transplantation regimens, leads to increased risk
HIV coinfection may also lead to deregulation of EBV infected B cells
Why are lymphocytes at risk of malignancy
Prolferative rate
Rely on apoptosis: 90% of lymphocytes die, apoptotsis switched off in germinal centre
Mutations: DNA undergoes deliberate mutations to generate Ig and TcR diversity.
Mutations and Ig in lymphoma
Ig promoter is highly active in B cells, if an intact oncogene is brought close to the Ig promoter, lymphoma may result.
NHL mutations: majority are translocations
What is the generative tissue in the lymphoreticular system
BM and thymus
What is the reactive LR tissue
LNs and spleen: develops immune reaction
What is the acquired LR tissue?
Extranodal lymphoid tissue e.g. skin, stomach, lung, to develop local immune reaction
LN features
Peripherally B cells
Centrally, T cells
Function of the B cell area in the LN
Forms a lymphoid follicle.
In the mantle zone there are naive unstimulated B lymphocytes
In the germinal centre, B cells mix with APC to select them and activate them
Diagnosis of lymphoma:
Morphology
Cytology
Histology
Diagnosis of lymphoma:
Immunophenotyping
T: CD3 and CD5
B: CD20
Examines cell distribution, loss of surface proteins, abnormal expression of proteins and clonality of B cell
Diagnosis of lymphoma:
Molecular pattern
FISH: for translocations
PCR
Diagnostic
Prognostic
Features of NHL
Most common 80-85%
All lymphomas but Hodgkins
>40 subtypes
NHL
presentation
Varies from subtype to subtype:
Painless lymphadenopathy often multilocular
Compression symptoms
B symptoms
No pain after ETOH
No pain after ETOH
NHL
How can NHL e classified
Mature vs immature
Histologically: high grade vs low grade
Lineage: B or T cell
Dx of NHL
Staging
Tissue biopsy, WHO subtype
CT scan, PET scan (in aggressive lymphomas)
BM biopsy
LP if risk of CNS
What are the prognostic markers in NHL
LDH and performance status
What are the high grade aggressive NHLs?
Burkitt’s
T or B cell lymphoblastic leukaemia/lymphoma
Diffuse large B-cell, mantle cell
Treated on acute leukaemia protocols
What are the low grade indolent lymphomas?
Follicular
marginal zone
Small lymphocytic
MALT
Features of Follicular lymphoma
B cell
Indolent
Mostly incurable: median survival 12-15y
t14:18 resulting in overexpression of anti-apoptosis protein Bcl-2
“Follicular pattern” “Nodular appearance”
t14:18 resulting in overexpression of anti-apoptosis protein Bcl-2
Follicular lymphoma
“Follicular pattern” “Nodular appearance”
Follicular lymphoma
Px in follicular lymphoma
Indolent but can transform to a high grade lymphoma
Mx of follicular lymphoma
Watch and wait
Rixucimab CVP
CVP
Cyclophosphamide
Vincristine
Prednisolone
Features of small lymphocytic lymphoma/CLL
Middle aged and elderly found in nodes or blood.
Small lymphocytes, naive or post-germinal centre memory B cells.
CD5 or 23
Indolent but can transform to high grade lymphoma
Featurs of mantle cell lymphoma
Middle-aged, M>F
Aggressive
Disseminated at presentation
Median survival 3-5y
t11:14 translocation.
Cyclin D1 deregulation
Angular nuclei
t11:14 translocation.
Cyclin D1 deregulation
Mantle cell lymphoma
Angular nuclei
Mantle cell lymphoma
Presentation of MALT
May present with dyspepsia or epigastric pain, B symptoms are uncommon
Treatment of MALT
Microbial dependent: remove antigen with tirple therapy. Can lead to remission in 75%
Microbial independent: CTx
Features of MALT
Marginal zone NHL found in middle aged.
Chronic antigen syimtulation:
H pylori-> gastric MALT
Djogrens-> Parotid lymphoma
What are the types of Burkitt’s
Endemic
Sporadic
Immunodeficiency
What is the histology in Burkitt’s
Starry sky
Features of Burkitt’s
Very aggressive
Fast growing
t8:14
c-myc overexpression, rapidly responsive to Rx
Rx in Brukitt’s
CTx: Rituximab + leukaemia protocol or SCT
Features of endemic Burkitt’s
Most common in equatorial Africa
EBV associated
Characteristic jaw involvement and abdominal masses
Features of sporadic Burkitts
Found outside Africa
EBV-associated
Jaw less commonly involved
Features of immunodeficiency Burkitts
Non-EBV associated
HIV/post-transplant patients
Features of Diffuse Large B cell lymphoma
Middle aged and elderly
Aggressive
Richter’s transformation
Other lymphomas occur secondary to DLBCL
“sheets of large lymphoid cells, germinal centre or post germinal centre B cells”
Germinal centre phenotype is a good prognostic factor
“sheets of large lymphoid cells, germinal centre or post germinal centre B cells”
DLBC
What are the components of the international prognostic indec for lymphoma?
Age >60
Serum LDH >normal
Performance status 2-4
Stage III-IV
More than one extranodal site
Rx of DLBC
Rituximab-CHOP
Auto-SCT for relapse
R-CHOP?
R- Rituximab: anti CD20 monoclonal antibody anti-B cell
Cyclophosphamide
Adriamycin
Vincristine
Prednisolone
MOA Rituximab
Anti CD20: anti B cell
Features of peripheral T-cell lymphoma
Middle aged and elderly
Aggressive
Large T cells with associated reactive cell population, especially eosinophils
Large T cells with associated reactive cell population, especially eosinophils
Peripheral T cell lymphoma
Features of adult T cell leukaemia/lymphoma
Carribean and Japan
Associated with HTLV-1 infection
Features of EATL
Associated with longstanding coeliac
Features of cutaenous T cell lymphoma
Associated with mycosis fungoides
Features of anaplastic large cell lymhpoma
Children and young adults
Aggressive
Large epitheloid lymphocytes
t2:5
Alk-1 protein expression (+ve= better Px)
Large epitheloid lymphocytes
Anaplastic large cell lymphoma
t2:5
Alk-1 protein expression (+ve= better Px)
Anaplastic large cell lymphoma
Reed-sternberg cell=
Hodgkins
binucleate/multinucleate owl-eyed cell on background of lyphomcytes and reactive cells=
Reed-Sternberg= HL
Reed-Sternberg cell
Clinical presentation of HL
Asymmetrical painless lymphadenopathy +/- obstructive/mass effect symptoms
Mediastinal mass, cough, respiratory infectoin, SVCO, dysphagia
Constitutional symptoms (incl pruritus)
Alcohol induced pain (rarely)
HL
Pel-Ebstein fever
Cyclical 1-2 weekly fever seen in HL
Epidemiology of HL
M>F
Bimodal age incidence: 20-29 and >60
Most common type of HL?
Nodular sclerosing, good Px causing peak incidence in young women
Ix in HL
CT/PET
Tissue dx: LN or BM biopsy, cell stain with CD15 and CD30
Reed-sternberg cell on a background of lymphocytes and reactive cells
Features of classical HL
Young and middle aged, often involving single LN and supradiaphragmatic
Thought to be germinal/post-germinal centre in origin
EBV and HLA DPB1 associated
Reed-Sternberg and Hodgkins cells
Richter’s transformation
Richter’s syndrome (RS), also known as Richter’s transformation, is a transformation which occurs in about 5-10% of B cell chronic lymphocytic leukemia (CLL)[1] and hairy cell leukemia into a fast-growing diffuse large B cell lymphoma, a variety of non-Hodgkin lymphoma which is refractory to treatment and carries a bad prognosis.[2]There is also a less common variant in which the CLL changes into a Hodgkin’s lymphoma. Rarely, transformations to a form of myeloid leukemia have been observed. These extraordinarily rare transformations carry a very poor prognosis. [3]Richter’s transformation affects about 5% of CLL patients at some point during their lives.[4]
EBV associated and HLA DPB1
Classical HL
Features of nodular lymphocyte predominant HL (NLPDHL)
Isolated lymphadenopathy
Germinal centre B cell
No EBV association
B cell richnodules with scattered L and H cells.
Can transform to high grade B cell lymhpoma
Staging of HL
1: one LN region (including spleen)
2: >2 LN regions on the same side of the diagram
3: >2 LN regions on different side of the diagram
4: Extranodal sites: BM, liver
A: no constitutional symptoms
B: constitutional symptoms
Mx of Hodgkins
Combination CTx used in most cases
RTx often used alongside CTx in large areas.
Intensive CTx and autologous SCT: relapsed patients
ABVD
Used in HL
Adriamycin
Bleomycin
Vinblastine
Decarbazine
Given at 4 weekly intervals
What are the issues for treating HL
Combination CTx and RTx increases the risk of secondary C
Features of Autologous SCT
Patients own SCs
Enbales high dose CTx and RTx to eradicate malignant cells
Frozen SCs then reintroduced into ptient
Used in MM and lymhpoma more than leukaemia
No risk of GvHD
Features of allogenic SCT
HLA-matched donor SCs are harvested
Patients own BM completely eradicated
Donors SCs are introducted
Used more in leukaemia
GvHD, risk of opprotunistic infections, infertility and secondary malignancies
Lymphoma tree
Draw NHL and the LN
Draw normal haematopoeisis
Draw the hierarchy of haematological malignancies
What are the myeloid malignancies?
AML (>20%)
Acute promyelocytic (like AML but more mature cells)
Myelodysplasia
Myeloproliferative
CML (mature cells)
What are the lymphoid malignancies?
Precursor cell: ALL
Mature cell:
CLL
MM
NHL and HL
What are type 1 mutations in haematological malignancies
Involved in cellular proliferation e.g. RtK
Activation of TK leads to expression in mature cells
RBCs: PCV
Platelets: thrombocytopenia
Granulocytes: CML
What is the BCR-ABL mutation seen in?
What type of mutation
CML
Type 1
What are type 2 mutations?
Prevent differentiation
Translocations create fusion genes
What is AML-ETO seen in?
What type of mutation?A
AML
Type 2
What is PML-RARA seen in?
What type of mutation?
APML
Type 2
What is t9:22
Philadelphia chromosome
Seen in CML
What is BCR-ABL
Fusion gene created in CML. Philadelphia chromosome
What is the philadelphia chromosome?
Mutation affecting GM-CSF causing proliferation of the granulocytes
Caused by activating tyrosine kinase mutation
Large numbers of differentiated neutrophils are present in the peripheral blood
Large numbers of differentiated neutrophils in peripheral blood with an increase in myelocytes and increased platelets
CML
Epidemiology of CML
M:F 1.4:1
40-60y/o
Symptoms of CML
Weight loss, lethargy, night sweats, splenomegaly, anaemia, bursing, bleeding and gout
Splenomegaly due to infiltration of cords and red pulp by granulocytes, if massive, infarction may occur
What are the phases of CML?
Bi or triphasic
Chronic phase: 5-6y stabilisation. 80% diagnosed here. <5% of cells in blood are blast cells.
Leucocytosis 500-5000 myeloid cells. Neutrophils and myelocytes no excess of myeloblasts
Bone marrow very hypercellular due to increased numbers of neutrophils and their precurorors
Accelerated phase: 6-12m. 10-19% of peripheral cells are blast cells
Blast crisis: 3-6m surivival. >20% blast cells.
Leucocytosis with mature myeloid cells
CML
Monitoring of CML
FBC and leucocyte count
Cytogenetics: philadelphia chromosome. RT-PCR of the ABL-BCR fusion transcript.
Haematological resposne: complete CHR WBC <10
Cytogenetic response: 0% philadelphia positive
Molecular: reduction in BCR-ABL transcripts.
Molecular most sensitive
Treament of CML
Need to target activated RtK: ABL kinase inhibitor
First line Rx in CML
RtK: Imatinib
93% survival at 60m
Second line Rx in CML
RtKI: dasatanib and nilotinib
Management of failure in CML
Monitor BCR-ABL transcripts, if rising some may respond to 2nd gen.
Failure of TKIs consider allogenic SCT (good survival in CP, extremely poor in blast crisis)
Pathogenesis of AML
Two hit model
T8:21 mutation resulting in AML-ETO fusion protein.
This is a tumour suprresor known as p14ARF
T8:21 mutation
AML
Management of AML
Supportive:red cell transfusions, platelet transfusions. Nurse in isolation, prompt antiboitcs.
Dx of AML
Morphology
Immunophenotyping: lineage and stage of differentation. Examine expression of antigens on cell surface.
Cytogenetics: chromosomal translocations
Molecular genetics: detection of fusion mRNA
Def: Acute Leukaemia
A neoplastic condition characterised by rapid onset, early death if untreated, immature blast cells and BM failure
What lineage of cells is affected in AML
Pluripotenet HSC or granulocyte/monocyte precursor
What lineage of cells is affected in CML
Pluripotent HSC
What lineage of cells is affected in B-ALL
B cell
What lineage of cells is affected in T-ALL
T cells
What lineage of cells is affected in CLL
Terminal B cell
Haematological definition of acute leukaemia
Immature blasts >20% BM cells
What are the clinical features of acute leukaemia
BM function failure: anaemia, thrombocytopenia, neutropenia
Organ infiltration: hepatomegaly, splenomegaly, lymphadenopathy, bone pain, CNS, skin, gum hypertrophy
Aetiology of acute leukaemia
Uinknown
Ionising radiotherapy
Cytotoxic drugs
Benzene
Pre-leukaemic disordres: myelodsplastic syndrome
DS: AML++
Neonates: often develop transient abnormal myelopoeisis
Which population group is affected by ALL?
Children
Children get it ALL
Which population group is affected by AML
Adulthood: risk increases with age
Infants <2
What are the clinical features of ALL
As for leukaemia but
Lymphadenopathy ++++
CNS involvement ++++
Testicular enlargement
Thymic enlargement
What are the clinical features of AML
As for leukaemia but
Lymphadenopathy less common.
What is acute promyelocytic anaemia?
Medical emergency
Prone to DIC
Ix in ALL
High WCC
Lymphocytes/precursors +++
Ix in AML
High WCC
Auer rods and granules
Myeloperoxidase and Sudan Black B stains
Auer rods
AML
T15:17 associated with
Acute promyelocytic leukaemia. Increased risk of DIC
What is classical AML
T15:17
Clinical features of Acute Monocytic leukaemia
CNS disease, skin infiltration, gum infiltration, organomegaly.
What is an issue with very high WCC?
Hyperviscosity.
What has a good prognosis in AML?
T15:!7
T 8:21
Intermediate and poor risk have normal/complex karyotypes and other chromosomal abnormalities
Treatment of AML
Supportive: RBC, platelest, FFP if DIC, antibiotics, long line. Allopurinol, U&Es monitoinrg
CTx:
Danorubicin and cytarabine. Combination therapy, non-overlapping toxicity with synergistic effect. 4-5 courses. remission induced in 2 courses and consolidated in 2-3 courses.
Allo-SCT in young or if poor prognosis.
CTx in AML
Daunorubicin and cytarabine
4-5 courses
Remission induction in first 2
Consolidation in 2-3 courses
When is the Px of ALL worse?
With increasing age
What are the features of B lineage ALL
Starts in bonw marrow, very strong association between genetics and prognosis
Poor prognosis associated with philadelphia chromosome
What are the features of T cells lineage ALL
Starts in thymus which amy become enlarged.
Treatment of ALL
(Ph +ve need imatinib)
Systemic chemotherapy and CNS directed therapy
Lasts 2-3 yeasr
Remission induction cycle
Consolidation and CNS therapy: intrathecal Ctx to treat occult CNS disease for 6-8 treatments. If lymphoblasts in CSF then more frequent and intesnive therapy required.
Intensification
Maintenance therapy
Consider allogenic SCT
Supportive:
Blood products, Abx, allopurinol, fluids, electrolytes (to prevent tumour lysis syndrome).
May require leukapharesis if extreme leukocytosis
CTx treatment of ALL
Systemic CTx and CNS directed therapy lasting 2-3 yeasrs with intrathecal CTx to treat occult CNS disease for 6-8 treatments.
Case 1: 5 yr boy. WCC 180 x 109/L, Hb 93 g/L, platelet 43 x 109/L. Thymic mass
WCC : diagnosis of leukaemia most likely.
o Low Hb and platelet – bone marrow infiltration.
Thymic mass: infiltration by T lymphoblasts.
Pathophysiology of Megaloblastic anaemia
DNA cannot be produced fast enought to allow cell division at the right time resulting in larger RBCs e.g. folate and B12 deficiency.
Associated with bone marrow features like meagloblasts, ovalocytes in the peripheral blood and hypersegmented neutrophils
Megaloblastic anaemia
What results in the production of codocytes/target cells?
Pathologies of the liber spleen which result in increased red cell membrane
What are the mechanisms of macrocytic anaemia
Megaloblastic anaemia
Red cell membrane disorders
Alcohol
Rapid cell turnover and reticulocytosis
Features of macrocytic anaemia caused by rapid red celll turnober and reticulocytosis
Diseases in which there is a high red cell production causes a greater proportion of reticulocytes (which are larger) e.g. COPD: low O2 levels induces production, traumatic loss, rapid haemolysis (G6PDD)
Normal RBC lifespan
120d
What is haemolysis?
Shortened red cell survival
Draw the classiciation of haemolytic anaemias
Causes of intravascular haemolysis
Malaria
G6PD
Mismatch
Cold Ab haemolytic syndromes
Drugs
MAHA: HUS, TTP, PNH
What are the MAHAs?
HUS, TTP, PNH
What are the extravascular causes of HA?
Autoimmune, alloimmune, hereditary and spherocytosis
What are the inherited causes of HA?
Membrane: cytoskeletal proteins, cation permeability
Red cell metabolism
Hb: thalassaemia, SCD, unstable Hb variants
What are the consequences of HA?
Anaemia
Erythroid hyperplasia with increased rate of RBC production and reticulocytes
Increased folate demand
Susceptibility to Parvovirus B19
Cholelithiasis: increased risk if inherited with Gilbert
Increased risk of Fe overload and osteoporosis
Fe overload can lead to hepatic siderosis
What is hepatic siderosis
Hemosiderosis (AmE) or haemosiderosis(BrE) is a form of iron overload disorderresulting in the accumulation ofhemosiderin.
Types include:
Transfusion hemosiderosis[1]
Idiopathic pulmonary hemosiderosis
Transfusional diabetes[2][3]
Hemosiderin deposition in the lungs is often seen after diffuse alveolar hemorrhage, which occurs in diseases such asGoodpasture’s syndrome, granulomatosis with polyangiitis, and idiopathic pulmonary hemosiderosis. Mitral stenosis can also lead to pulmonary hemosiderosis. Hemosiderin collects throughout the body inhemochromatosis. Hemosiderin deposition in the liver is a common feature of hemochromatosis and is the cause of liver failure in the disease. Selective iron deposition in the beta cells of pancreatic islets leads to diabetes[1] [2] due to distribution of transferrin receptor on the beta cells of islets [3] and in the skin leads to hyperpigmentation. Hemosiderin deposition in the brain is seen after bleeds from any source, including chronic subdural hemorrhage, Cerebral arteriovenous malformations,cavernous hemangiomata. Hemosiderin collects in the skin and is slowly removed after bruising; hemosiderin may remain in some conditions such as stasis dermatitis. Hemosiderin in the kidneys has been associated with marked hemolysis and a rare blood disorder called paroxysmal nocturnal hemoglobinuria.
Hemosiderin may deposit in diseases associated with iron overload. These diseases are typically diseases in which chronic blood loss requires frequent blood transfusions, such as sickle cell anemia and thalassemia, though beta thalassemia minor has been associated with hemosiderin deposits in the liver in those with non-alcoholic fatty liver disease independent of any transfusions.[4][5]
Consequences of all haemolytic anaemias
Rasised (unconjugated) bilirubin
Raised urobilinogen
Raised LDH
Reticuylocytosis (raised MCV and polychromasia)
May have gallstone
Hereditary spherocytosis
Hereditary elliptocytosis
Hereditary pyropoikilocytosis
SEA Ovalocytosis
In severely affected patients, a widening of the diploic space (medulla) with a thinning of the tables (cortices) occurs, frequently with complete obliteration of the outer table. New bone forms in response to marrow proliferation beneath the periosteum. These bony spicules may be seen radiographically and result in a classic “hair-on-end” appearance. Because it lacks hematopoietic marrow, the occipital bone usually is not involved. (See the image below.)
CLL
Smear cell are cells that are damaged due to peripheral blood smear
Due to reduced strength of abnormal white cells in CLL
Pelger-Huet Anomaly
Abnormality in neutrophils seen in MDS
Ringed sideroblasts
Seen in refractory anaemia
Prussian blue stain of bone marrow shows blue staind haemosiderin deposits in the mitochondria of erythroid precurors forming an apparent ring around the nucleus
Auer rod
AML
Myelokathexis
Bone marrow smear from a patient with neutropenia due to myelokathexis
Fanconi anaemia
Dyskeratosis congenita
Draw the process of haemostasis
Draw the coagulation cascade
Draw the process of platelet adhesion and aggregation
Draw the process of arachidonic acid metabolism
