Haematology Flashcards
1
Q
Which percentage of hospital deaths are due to pulmonary embolism?
A
- PE is the cause of 5-10% of hospital deaths
- 25000 deaths pa from hospital related VTE
- Difficult to reverse and leads to morbidity
- Preventable
2
Q
What is Virchow’s triad?
A
Blood
Vessel wall
Blood flow
3
Q
What affects the blood part of ‘Virchow’s triad’?
A
- Viscosity
- Haematocrit
- Protein/paraprotein
- Platelet count
- Coagulation system
- Net excess of procoagulant activity
4
Q
Name some familial or genetic conditions which affect blood/hyper coagulation
A
Elevated factor VIII Elevated factor XI Factor V Leiden Protein S deficiency Protein C deficiency Antithrombin deficiency
5
Q
Is the vessel wall normally thrombotic?
A
Yes
6
Q
How does the vessel wall maintain its antithrombotic activities?
A
- Expresses anticoagulant molecules
- Thrombomodulin
- Endothelial protein C receptor
- Tissue factor pathway inhibitor
- Heparans
- Does not express tissue factor
- Secretes antiplatelet factors Prostacyclin
NO
7
Q
Which factors can make the endothelial wall prothrombotic?
A
Inflammation/injury of the vessel wall:
- Infection – including COVID-19
- Malignancy
- Vasculitis
- Trauma
8
Q
How does inflammation/infection make the endothelial wall prothrombotic?
A
- Anticoagulant molecules (eg TM) are down regulated
- TF may be expressed
- Prostacyclin production decreased
- Adhesion molecules upregulated
- Von Willebrand factor release
- Platelet and neutrophil capture
- Neutrophil extracellular traps (NETS) form
9
Q
How does stasis promote thrombosis?
A
- Accumulation of activated factors
- Promotes platelet adhesion
- Promotes leukocyte adhesion and transmigration
- Hypoxia produces inflammatory effect on endothelium
- Adhesion, release of VWF
10
Q
What are some of the causes of stasis?
A
- Immobility: surgery, paraparesis, travel
- Compression: tumour, pregnancy
- Viscosity: polycythaemia, paraprotein
- Congenital: vascular abnormalities
11
Q
What are some immediate and delayed anticoagulant drugs?
A
Immediate
- Heparin
- Unfractionated heparin
- Low molecular weight heparin
- Direct acting anti-Xa and anti-IIa
Delayed
- Vitamin K antagonists
- Warfarin
12
Q
What are the procoagulant factors which lead to fibrin formation?
A
V VIII IX X XI
II Fibrinogen Platelets
13
Q
What are anticoagulant factors which lead to fibrinolysis?
A
TFPI Protein C Protein S Thrombomodulin EPCR Antithrombin
14
Q
Draw out the coagulation cascade and where the anticoagulant factors act on
A
TF/FVIIa
Coagulation Regulation
FVIII FIXa \+ FVIIIa TFPI Protein C & S
FX
FXa
\+
FV
FVa
Prothrombin Thrombin Antithrombin Procoagulant Fibrinogen Fibrin
15
Q
Which conditions target specific factors in the clotting pathway causing clotting disorders?
A
Soluble proteins
◼ Factor VIII > Haemophilia A> bleeding
◼ Protein C > pro-thrombotic
Cellular haematology
◼ Erythrocytes > polycythaemia or anaemia
◼ Leucocytes
Granulocytes > leukaemia(CML) or reactive eosinophilia Lymphocytes > leukaemia(CLL) or Lymphopenia (HIV)
◼ Platelets > essential thrombocythemia or ITP
16
Q
What is meant by a primary disorder of the blood?
A
Primary –> due to the blood and arise from DNA mutations
- germline/inherited - FIX, erythrocyte
- somatic/acquied BM rapid turnover organ - erythrocytes, myeloid, soluble factors
17
Q
What is meant by secondary disorder of the blood?
A
Changes in haematological parameters secondary to non-haematological disease
- erythrocytes (e.g. hypoxia, heart disease)
- factor VIII (inflammatory response, autoantibodies)
18
Q
How may anaemia in malignancy initially present?
A
◼Fe deficiency
◼Leucoerythroblastic anaemia
◼Haemolytic anaemias
19
Q
What would be the blood results in someone with iron-deficiency anaemia?
A
◼ Microcytic hypochromic anaemia
◼ Reduced ferritin, transferrin saturation
◼ Raised TIBC
20
Q
What may be the cause of Fe deficiency in different patients?
A
Fe deficiency is bleeding until proven otherwise
◼ Often menorrhagia in pre menopausal women
◼ Blood loss in men and post menopausal women
21
Q
What are cancers which cause occult blood loss?
A
◼ GI cancers - Gastric, Colonic/rectal
◼ Urinary tract cancers - Renal cell carcinoma, Bladder cancer
22
Q
What is leuco-erythroblastic anaemia?
A
Leukoerythroblastic anemia describes the presence of nucleated erythrocytes and immature white cells of the neutrophilic myeloid series in the peripheral blood
23
Q
What morphological features in the blood film would you see for leuco-erythroblastic anaemia?
A
- Teardrop RBCs (+aniso and poikilocytosis)
- Nucleated RBCs
- Immature myeloid cells
24
Q
What are the causes of leucoerythroblastic anaemia?
A
- Malignant - haemopoietic or non-haemopoietic
- Severe infection - military TB, severe fungal
- Myelofibrosis - massive splenomegaly, dry tap on BM aspirate
25
What are common laboratory features of all haemolytic anaemias?
* Anaemia (though may be compensated)
* Reticulocytosis
* Unconjugated bilirubin raised (pre-hepatic)
* LDH raised
* Haptoglobins reduced
26
What are the two groups haemolytic anaemias?
Inherited (primary): defects of RBC/germline DNA mutation
Acquired (secondary): defects of the environment (systemic disease)
- non-immune: DAT -ve
- immune-mediated: DAT/Coombs +ve
27
What are examples of systemic disease where can get acquired immune haemolysis?
* Malignancy : eg. Lymphoma or CLL
* Auto immune: eg. SLE
* Infection: eg. mycoplasma
* Idiopathic
28
What would you see on the film of someone with immune haemolytic anaemia?
- Spherocytes
| - DAT +ve
29
Give examples of causes of acquired haemolytic anaemia (DAT-negative/non-immune)
Infection - malaria
Micro-angiopathic haemolytic anaemia (MAHA)
◼ Underlying adenocarcinoma
◼ Haemolytic uraemic syndrome
30
What would you see on the film of someone with microangiopathic haemolytic anaemia?
* RBC fragments
| * Thrombocytopenia
31
Describe the stages which occur in micro-angiopathy in malignancy
Adenocarcinomas, low grade DIC
- Platelet activation
- Fibrin deposition and degradation
- Red cell fragmentation (microangiopathy)
- Bleeding (low platelets and coag factor deficiency)
32
Which white blood cells would you expect to see in the bone marrow?
- Blasts (myeloid and lymphoid)
- Promyelocytes
- Myelocytes
33
Which white blood cells would you expect to feel in the peripheral blood?
Phagocytes --> granulocytes (neutrophils, eosinophils, basophils), monocytes
Immunocytes - T lymphocytes, B lymphocytes
34
What does this mean if there are:
- Blasts (myeloid and lymphoid)
- Promyelocytes
- Myelocytes
in the peripheral blood?
In healthy adults these cells never seen in Peripheral blood. If present think leukaemia or metastatic cancer invading bone marrow.
35
What do you observe on the slide of someone with chronic lymphocytic leukaemia?
WBC increased mature cells
36
What do you observe on the slide of someone with acute myeloid leukaemia?
WBC increased immature cells
37
What are the causes of neutrophilia?
- Corticosteroids
- Underlying neoplasia
- Tissue inflammation (e.g. colitis, pancreatitis)
- Myeloproliferative/leukaemic disorders
- Pyogenic infection
38
In neutrophilia, you would suspect either reactive/infection or malignancy as the underlying cause. How would you be able to differentiate between them?
Reactive/Infection: neutrophilia + toxic granulation no immature cells
Malignant: neutrophilia, basophilia, immature cells myelocytes. Suggest a myeloproliferative (CML).
Neutropenia plus myeloblasts suggests acute leukaemia (AML)
39
What are the two underlying causes of eosinophilia?
- Reactive eosinophilia
| - Chronic eosinophilic leukaemia
40
List examples of causes of reactive eosinophilia
- Parasitic infestation
- Allergic diseases e.g. asthma, rheumatoid, polyarteritis, pulmonary eosinophilia.
- Underlying Neoplasms, esp. Hodgkin’s, T-cell NHL (reactive eosinophilia)
- Drugs (reaction erythema multiforme)
41
What are the underlying causes of chronic eosinophilic leukaemia?
- Eosinophils part of the “clone”
| - FIP1L1-PDGFRa fusion gene
42
When would you see monocytosis?
- TB, brucella, typhoid
- Viral; CMV, varicella zoster
- Sarcoidosis
- Chronic myelomonocytic leukaemia (MDS)
43
What are the underlying causes of lymphocytosis?
- EBV, CMV, Toxoplasma
- Infectious hepatitis, rubella, herpes infections
- Autoimmune disorders
- Sarcoidosis
44
What are the underlying causes of lymphopenia?
- Infection HIV
- Auto immune disorders
- Inherited immune deficiency syndromes
- Drugs (chemotherapy)
45
What would you suspect if you saw mature lymphocytes on the slide (PB) and lymphocytosis?
- Reactive/atypical lymphocytes (IM)
| - Small lymphocytes and smear cells (CLL/NHL)
46
What would you suspect if you saw immature lymphocytes on the slide (PB) and lymphocytosis?
lymphoblasts (Acute Lymphoblastic Leukaemia)
47
What technique do we use to determine if the B lymphocyte is monoclonal (malignant) or poly-clonal? What would be the results?
Light chain restriction
Polyclonal: kappa and lambda light chains (60:40)
Monoclonal: kappa only or lambda only (99:1)
48
What are examples of haemato-oncology diagnosis used to assess the morphology of the tumour?
* Architecture of tumour
* Cytology
* Cytochemistry
49
What are examples of haemato-oncology diagnosis used to assess the cytogenetics of the tumour?
* Conventional karyotyping
* Fluorescent in-situ hybridisation
* Interphase FISH
* Metaphase FISH
50
What are examples of haemato-oncology diagnosis used to assess the immunophenotype of the tumour?
- Flow cytometry
| - Immunohistochemistry
51
What are examples of haemato-oncology diagnosis used to assess the molecular genetics of the tumour?
* Mutation detection
* Direct sequencing
* Pyrosequencing
* PCR analysis
* Gene expression profiling
* Whole genome sequencing
52
What are the examples of lymph-haemopoietic system cancers?
* Bone marrow
* Peripheral blood
* Lymph nodes
* Other sites {skin, gut, brain, eye, testes}
53
Primitive lymphoid blast cells expressing B cell marker. What is your diagnosis?
B cell acute lymphoid leukaemia
54
Mature lymphoid cells expressing T cell antigens and involving skin. What is your diagnosis?
Cutaneous T cell lymphoma
55
Mature erythrocytes with JAK2 mutation. What is your diagnosis?
Polycythaemia vera
56
Describe the stages in normal myeloid differentiation.
Myeloblast --> Myelocyte --> Neutrophil
57
What is the difference between chronic myeloproliferative neoplasm and acute myeloid leukaemia?
Chronic myeloproliferative neoplasm - differentiation of myeloid lineage normal, but the proliferation is increased
Acute myeloid leukaemia - differentiation is blocked and proliferation is increased
58
What types of mutations cause leukaemia and lymphoma?
- Cellular proliferation (type 1) - BCR-ABL1 (CML), JAK2 (MPD)
- Impair/block cellular differentiation (type 2) (PML -RARA in acute promyelocytic leukaemia
- Prolong cell survival (anti-apoptosis) - BCL2 and follicular lymphoma
59
Give 3 examples of lymphoma and which part of B cell development it affects
- B cell Acute lymphoblastic lymphoma
- Mantle cell lymphoma
- Multiple myeloma
60
What would you find after analysing the morphology and immunophenotype in B cell ALL?
TdT +ve
CD19 +ve
Surface Immunoglobulin -ve
61
What would you find after analysing the morphology and immunophenotype in multiple myeloma?
TdT negative
| Surface Immunoglobulin +ve CD138 positive
62
What is the clinical course of these three types of lymphomas?
- Burkitt Lymphoma
- Chronic myeloid leukaemia
- Polycythaemia vera
- Burkitt Lymphoma highly aggressive needs urgent treatment
- Chronic myeloid leukaemia has a chronic phase followed by a blast transformation
- Polycythaemia vera is generally an indolent disorder
63
What are associated problems in leukaemia and lymphoma?
- Lympho-haemopoietic failure
Bone marrow : anaemia, infection (neutrophils) bleeding
(platelets)
Immune system: infection
- Excess of malignant cells
Erythrocytes (polycythemia): impair blood flow >stroke or TIA
Massively enlarged lymph nodes (lymphoma)> compress structures, bowel, vena cava, ureters, bronchus.
- Impair organ function - CNS lymphoma
Skin lymphoma
64
How is leukaemia or lymphoma diagnosed according to the WHO histopathological diagnosis?
Lineage e.g. B or T lymphocyte:
- Stage of maturation (immature or mature)
- Normal cell counterpart
65
What is the use of histopathological diagnosis?
- Predict clinical course (eg aggressive or indolent)
| - Guide need for and choice of therapy
66
How does lymphoma typically present?
- Painless progressive lymphadenopathy - palpable node, extrinsic compression of tubes in body
- Infiltrate/impair organ system
- Recurrent infections
- Constitutional symptoms
- Coincidental e.g. FBC, imaging
67
How does non-Hodgkin lymphoma often present? How would you confirm diagnosis?
Lymphadenopathy - mesenteric, axillae, cervical, spenlomegaly
Biopsy
68
After biopsy lymphoma is confirmed. What would you do to stage?
- CT/PET scans
- BM biopsy
- +/- Lumbar puncture
- Blood tests, HIV, hep B tests
69
What are the main two types of lymphoid malignancies?
Lymphoma/leukaemia - 15%
Non-Hodgkin lymphoma (NHL) - 85%
70
What are characteristic of Hodgkin's lymphoma?
Reed-Sternberg cells
71
What are the types of non-hodgkin lymphomas?
- B cell - precursor (B lymphoblastic leukaemia, B cell neoplasm, follicular NHL, CLL)
- T cell - precursor T lymphoblastic leukaemia or lymphoma, T and NK neoplasm, anapaestic, cutaneous
72
Describe the epidemiology of Hodgkin lymphoma
M>F
| Bimodal age - 20-29, >60
73
What are the typical presentations of Hodgkin lymphoma?
- Painless enlargement of lymph node/nodes
- May cause obstructive symptoms/signs
- Constitutional symptoms - 1) fever, 2) nigh sweats, 3) weight loss
Rarely - pruritus, alcohol induced pain
74
What are the different classifications of Hodgkin lymphoma?
- Nodular sclerosing - 80% - good prognosis
- Mixed cellular - 17% - good prognosis
- Lymphocyte rich - rare - good prognosis
- Lymphocyte-depleted - rare - poor prognosis
- Nodular lymphocyte predominant 5% (disorder of elderly which recurs)
75
How does Hodgkin lymphoma spread?
Lymphatic system
76
How is Hodgkin lymphoma staged?
I: one group of nodes
II: > 1 group of nodes, same side of diaphragm
III: nodes above and below diaphragm
IV: extra nodal spread
A: none of the symptoms in B
B: weight loss>10% in 6m, fever, night sweats
77
Describe the typical presentation of cHL nodular sclerosing subtype of Hodgkin's lymphoma
```
Young women > men
Neck nodes and mediastinal
SVC or trachea
May have B symptoms
Needs tissue diagnosis
```
78
What does ABVD stand for in combination chemotherapy for cHL?
A - adriamycin
B - bleomycin
V - vinblastine
D - DTIC
4-weekly intervals (2-6 cycles)
79
What are the pros and cons of using ABVD combination chemotherapy?
Pros - perseveres fertility
| Cons - long term can cause pulmonary fibrosis, cardiomyopathy
80
How would you treat relapse in Hodgkin's lymphoma?
High dose chemotherapy + autologous PB stem cell transplant as support
81
What are the pros and cons of using radiotherapy for Hodgkin's lymphoma?
Pros - low/negligible risk of relapse in that area
Cons - Ca breast (1:4), leukaemia, lung or skin cancer
Combined chemo + radio = used in greatest risk of second malignancy
82
What is the prognosis for Hodgkin's lymphoma?
Stage I - 90% cured
| Stage IV - 50% cured
83
What is non-Hodgkin's lymphoma?
Neoplastic proliferation of lymphoid cells
84
Describe the epidemiology of non-Hodgkin's lymphoma
- Incidence rising 200/million population/year
- Fastest proliferating malignancy (Burkitt)
- Indolent diseases
- Antibiotic responsive disease
85
When would you do a lumbar puncture in suspected non-Hodgkin lymphoma?
Risk of CNS involvement
86
What are some prognostic markers and important tests in managing non-Hodgkin lymphoma?
- LDH
- Performance status
- HIV serology
- Hep B serology
87
What are the common types of non-Hodgkin lymphoma?
- Follicular
| - Diffuse
88
Which types of lymphoma are aggressive and indolent?
Very aggressive (high grade) - Burkitt, T and B cell lymphoblastic leukaemia
Aggressive (high grade) - diffuse large B cell, mantle cell
Indolent (low grade) - follicular, small lymphocytic/CLL, mucosa associated (MALT)
89
How is diffuse large B cell NHL treated?
Immunotherapy - anti CD20 monoclonal antibodies
50% cure rate
90
How common is follicular NHL and how does it normally arise?
35% of NHL
| Associated with t(14,18) which results in over-expression of bcl2 and anti-apoptosis protein
91
What is the prognosis and treatment of follicular NHL?
Incurable, median survival 12-15 years
May require 2-3 different chemotherapy schedules over the 12-15 year period
May use combination immunotherapy R-COP or R-CHOP
92
What is extra nodal marginal zone lymphoma of stomach (NHL)?
Chronic antigen stimulation - H pylori infection
H-pylori eradication cures 75% of patients
55-60yrs of age
93
What type of NHL are coeliac disease patients at high risk of?
Enteropathy associated T cell lymphoma -- > mature T cells, involves jejunum and ileum, aggressive
Abdo pain, malabsorption, systemic, responds poorly to chemo
94
Describe what is meant by chronic lymphocytic leukaemia
```
Proliferation of mature B cells
Most common leukaemia in western world
Caucasian
72 yrs average
Relative 7x increased risk
```
95
What would be your laboratory findings for someone with CLL?
- Lymphocytosis between 5-200 x109/L
- Smear cells
- Normocytic normochromic anaemia
- Thrombocytopenia
- Bone marrow lymphocytic replacement of normal marrow elements
96
What would you find when immunophenotyping peripheral blood by flow cytometry in normal vs CLL patient?
Normal B cells - CD5-ve, CD19+ve
CLL - CD5+ve, CD19+ve
97
What is the natural history of CLL?
5-10 years of good health until 2-3 years of terminal phase
1/3 never progress
1/3 respond to treatment and die from something other than CLL
1/3 require multiple treatment and die from CLL
98
What is the prognosis of CLL?
Cell-based prognostic factors: IgHV mutation status, CLL FISH cytogenic panel, TP53 mutation status (chromosome 17p del and/or TP53 point mutation)
Clinical staging systems: Binet or Rai (clinical staging), CLL IPI score
99
What would indicate bad prognosis of CLL?
Deletion of 17p (TP53)
100
What are the clinical issues with CLL?
- Increased risk of infection
- Bone marrow failure
- Lymphadenopathy +/- splenomegaly, lymphocytosis
- Transform into high grade lymphoma --> Richter transformation
- Auto-immune complications - immune haemolytic anaemia
101
What supportive care would someone with CLL receive?
- Sino-pulmonary infections: early treatment with antibiotics, recurrent infection + IgG < 5g/L = IVIG replacement therapy
- Vaccinations: pneuomococcal, Covid-19, seasonal flu, avoid live vaccines
102
What are some treatment options in CLL?
- BCR kinase inhibitors - Ibrutinib (BTK), idelalisib (PI3K)
- BCL2 inhibitors - Venetoclax
- Experimental cell-based therapies - chimeric antigen receptor T cells (CAR-T)
103
How does Venetoclax work in treating CLL?
- BCL2 inhibitor - permits apoptosis of CLL cells
- High risk CLL - p53 mutated 85% response and maintained at greater risk than 1 year
- Main risk is tumour lysis syndrome
104
Is CD2 expressed on normal T cells?
Yes
105
What is your diagnosis?
Hb raised
Platelets raised
Haematocrit raised
Polycythaemia
106
How do you differentiate between relative and true polycythaemia?
Relative - plasma volume decreased, red cell mass the same
True - red cell mass increases
107
What are the causes of relative/pseudo polycythaemia?
- Alcohol
- Obesity
- Diuretics
108
What are the causes of appropriate true secondary polycythaemia (non-malignant)?
- High altitude
- Hypoxic lung disease
- Cyanotic heart disease
- High affinity haemoglobin
109
What are the causes of inappropriate true secondary polycythaemia (non-malignant)?
- Renal disease (cysts, tumours, inflammation)
- Uterine myoma
- Other tumours (liver, lung)
110
List all the haematological malignancies
```
Myeloid
– Acute myeloid leukaemia (blasts >20%
– Myelodysplasia (blasts 5-19%)
– Myeloproliferative disorders
• Essential thrombocythaemia (megakaryocyte)
• Polycythemia vera (erythroid)
• Primary myeofibrosis
– Chronic myeloid leukaemia
```
Lymphoid
Precursor cell malignancy
• Acute lymphoblastic leukaemia (B & T)
Mature cell malignancy
• Chronic Lymphocytic leukaemia
• Multiple myeloma
• Lymphoma (Hodgkin & Non Hodgkin)
111
Describe normal haematopoiesis for each cell
```
Pre-T --> T cell
Pre-B --> B-cell
BFU-E --> RBCs
Meg-CFC --> megakaryocytic/platelets
GM-CFC --> granulocytes, monocytes
```
112
How is tyrosine kinase activation impaired in malignancy?
Normal: transmit cell growth signals fro surface receptors to nucleus, activated by transferred phosphate groups to self and downstream proteins (JAK2 chime rises-->stat5,mapk,p13k/akt), tightly inactive state and they promote cell growth -- do not block maturation
Activations: more mature cells
RBCs = polycythaemia
Platelets = thrombocytopenia
Granulocytes = CML
113
What's the most common type of mutation associated with polycythaemia vera ~100%?
JAK2
114
How is the diagnosis of MPD Ph negative made?
– Clinical features - symptoms (see next slides), splenomegaly
– FBC +/- Bone marrow biopsy
– Erythropoietin level (epo)
– Mutation testing - phenotype linked to acquired mutation
115
What is the epidemiology of polycythaemia vera?
- More males - 1.2:1
| - Mean age - 60yrs
116
How does polycythaemia vera present?
- Routine FBC
- Symptoms of increased hyper-viscosity: headaches, light-headed, stroke, visual disturbance, fatigue, dyspnoea
- Increased histamine release: aquagenic pruritus, peptic ulcer
- Test for JAK2 V617F mutation
117
What are the treatment options of PCV?
- Aim to reduce HCT <45%
- Venesection
- Cytoreductive therapy hydroxycarbamide
- Reduce risks of thrombosis: control HCT, aspirin, keep platelets below 400x109/L
118
What is essential thrombocythaemia (ET)?
• Chronic MPN mainly involving megakaryocytic lineage
• Sustained thrombocytosis >600x109/L
• Incidence 1.5 per 100000
■ Mean age two peaks 55 years and minor peak 30 years
■ Females:males equal first peak but females predominate second peak
119
What is the typical presentation of essential thrombocytosis?
• Incidental finding on FBC (50% cases)
• Thrombosis: arterial or venous – CVA, gangrene, TIA
– DVT or PE
• Bleeding: mucous membrane and cutaneous
• Headaches, dizziness visual disturbances
• Splenomegaly (modest)
120
What is the treatment of essential thrombocytosis?
* Aspirin: to prevent thrombosis
* Hydroxycarbamide: antimetabolite. Suppression of other cells as well.
* Anagrelide: specific inhibition of platelet formation, side effects include palpitations and flushing
121
What is the prognosis of essential thrombocytopenia?
* Normal life span may not be changed in many patients
* Leukaemic transformation in about 5% after >10 years
* Myelofibrosis
122
What is primary myelofibrosis?
* A clonal myeloproliferative disease associated with reactive bone marrow fibrosis
* Extramedullary haematopoieisis
• Primary presentation:
– Incidence 0.5-1.5 /100000
– Males=females
– 7th decade. Less common in younger patients
• Other MPDs (ET & PV) may transform to PMF
123
What is the typical presentation of primary myelofibrosis?
- Cytopenia: anaemia or thrombocytopenia
- Thrombocytosis
- Splenomegaly: may be massive (Budd-Chiari syndrome)
- Hepatomegaly
- Hypermetabolic state: weight loss, fatigue and dyspnoea, night sweats, hyperuricaemia
124
What would you see on the blood film of someone with primary myelofibrosis?
- Leucoerythroblastic picture
- Tear-drop poikilocytes
- Extramedullary haemopoiesis in spleen and liver
DNA: JAK2 or CALR mutation
125
What would you find when taking a biopsy of someone with primary myelofibrosis?
```
• ‘Dry tap’
• Trephine:
Increased reticulin or collagen fibrosis
Prominent megakaryocyte hyperplasia and clustering with abnormalities
• New bone formation
```
126
What is the prognosis of someone with primary myelofibrosis?
```
• Median 3-5 years but very variable
• Bad prognostic signs:
Severe anaemia <100g/L
Thrombocytopenia <100x109/l Massive splenomegaly
Prognostic scoring system (DIPPS)
Score 0 -- median survival 15years
Score 4-6– median survival 1.3 years
```
127
What is the treatment of someone with primary myelofibrosis?
■ Supportive: RBC and platelet transfusion often ineffective because of splenomegaly
■ Cytoreductive therapy: hydroxycarbamide (for thrombocytosis, may worsen anaemia)
■ Ruxolotinib: JAK2 inhibitor (high prognostic score cases)
■ Allogeneic SCT (potentially curative reserved for high risk eligible cases)
128
What is the typical presentation of chronic myeloid leukaemia (Ph positive)?
Lethargy/ hypermetabolism/ thrombotic event : monocular blindness CVA, bruising bleeding
Massive splenomegaly +/- hepatomegaly
Hb and platelets well preserved or raised
Massive leucocytosis 50-200x109/L
Neutrophils and myelocytes (not blasts if chronic phase), basophilia
129
What are the laboratory features of someone with chronic myeloid leukaemia?
* Leucocytosis between 50 – 500x109/l
* Mature myeloid cells
* Bi-phasic peak Neutrophils and myelocytes
* Basophils
* No excess (<5%) myeloblasts
* Platelet count raised/upper normal (contrast acute leuk)
130
What is meant by the Philadelphia chromosome?
BCR-ABL (BCR from chromosome 22 and ABL from chromosome 9)
Fuse to make gene which expresses 210 KD protein --> oncoprotein with constitutive tyrosine kinase activity--> myeloid proliferation
Use PCR for detection
131
How do you treat CML?
1st line
Imatinib, dasatanib, bosutinib - oral active TKI
Monitor - FBC, cytogenetics, RQ-PCR
2nd line
No response after 1 year - 2Gen or 3G TKI
3rd line
Inadequate response or intolerant of 2G TKIs
Progression to accelerated or blast phase
132
What is multiple myeloma?
Malignancy of bone marrow plasma cells, the terminally differentiated and immunoglobulin (Ig) secreting B cells
133
What are features of myeloma plasma cells?
* home and infiltrate the bone marrow
* form bone expansile or soft tissue tumours: plasmacytomas
* produce a serum monoclonal IgG or IgA: paraprotein or M-spike
* produce excess of monoclonal (κorλ) serum free light chains
* Bence Jones protein: urine monoclonal free light chains
134
What is Waldenstrom’s - Lymphoplacytic lymphoma?
Lymphoplasmacytic lymphoma, also known as Waldenstrom macroglobulinemia, is a low-grade B cell lymphoproliferative neoplasm characterized by small lymphocytes and monoclonal IgM monoclonal gammopathy.
135
What is the median age of myeloma and its prevalence?
Median age 67 years
| The second most common haematological malignancy, 19th in all cancers
136
What is the aetiology of myeloma?
Aetiology is unknown ...
Myeloma is always preceded by a premalignant condition:
Monoclonal Gammopathy of Uncertain Significance (MGUS)
```
Risk factors
• Obesity increases the risk for myeloma
• Age
• Genetics
• Incidence in black population
• Sporadic cases of familiar myeloma
```
137
What is Monoclonal Gammopathy of Uncertain Significance (MGUS)?
Benign M protein levels are higher than normal:
* the most common (known) premalignant condition
* incidence increases with age
138
What is the average risk for progression of Monoclonal Gammopathy of Uncertain Significance (MGUS)?
Average risk for progression: 1% annually
IgG or IgA MGUS → myeloma
IgM → lymphoma
139
What is the diagnostic criteria for Monoclonal Gammopathy of Uncertain Significance (MGUS)?
* Serum M-protein <30g/L
* Bone marrow clonal plasma cells <10%
* No lytic bone lesions
* No myeloma-related organ or tissue impairment
* No evidence of other B-cell proliferative disorder
140
What other risk factors are associated with Monoclonal Gammopathy of Uncertain Significance (MGUS)?
Higher incidence of osteoporosis, thrombosis and bacterial infection compared to general population
141
What are the risk factors for Monoclonal Gammopathy of Uncertain Significance (MGUS)?
* Non-IgG M-spike
* M-spike >15g/L
* Abnormal serum free light chain (FLC) ratio
142
What is the criteria for smouldering myeloma?
Serum monoclonal protein (IgG or IgA) ≥30g/L or urinary monoclonal protein ≥500mg per 24h and/or clinical bone marrow plasma cells 10-60%. Absence of myeloma defining events of amyloidosis.
143
What are the risk factors for smouldering myeloma (2019 IMWG Updated Risk Stratification model)?
* Bone marrow myeloma cells ≥20%
* M-spike ≥20g/L
* Serum FLC ratio ≥20
144
Describe the progression from MGUS to plasma cell leukaemia
MGUS --> smouldering myeloma --> symptomatic myeloma --> remitting relapsing --> refractory --> plasma cell leukaemia
145
What are the primary and secondary genetic events of multiple myeloma?
Primary events
• Hyperdiploidy (60%) - additional odd number Chr
• IGH rearrangements (Chr 14q32) ❑t(11;14) IGH/CCND1
❑t(4;14) IGH/FGFR3
❑t(14;16) IGH/MAF
```
Common secondary events
• KRAS, NRAS
• t(8;14) IGH/MYC
• 1qgain/1pdel
• del 17p (TP53)
• 13- / del 13q
```
146
What is the pathogenesis of multiple myeloma?
Myeloma cells interact with bone marrow microenvironment:
- Bone destruction
- Angiogenesis
- Anaemia
- Immunosuppression and infections
147
What is the diagnostic criteria of multiple myeloma?
≥10% plasma cells in bone marrow or plasmacytoma + ≥1 CRAB or MDE
CRAB
C: Hypercalcaemia
calcium >2.75mmol/L
R: Renal disease
creatinine >177μmol/L or eGFR <40ml/min
A: Anaemia
Hb <100g/L or drop by 20g/L
B: Bone disease
One or more bone lytic lesions in imaging
2014 Myeloma Defining Events (MDE)
• Bone marrow plasma cells ≥60%
• Involved : uninvolved FLC ratio >100
• > 1 focal lesion in MRI (>5mm)
148
What is the most common clinical presentation of bone disease?
80% of myeloma patients present with bone disease
* Proximal skeleton
* Back (spine), chest wall and pelvic pain
* Osteolytic lesions, never osteoblastic
* Osteopenia
* Pathological fractures
* Hypercalcaemia
149
What are the different imaging options for myeloma bone disease?
Plain XR films (skeletal surveys): are now obsolete – low sensitivity, require >30% bone mass loss
Whole-body diffusion-weighted MRI - bone marrow cellularity, active vs treated disease
150
What are some emergencies in myeloma?
- Cord compression
| - Hypercalcaemia
151
What is cord compression?
Spinal cord compression occurs when a mass places pressure on the cord. A mass can include a tumor or bone fragment. Symptoms include pain, numbness, stiffness, cramping, trouble with hand coordination.
152
What is the management of cord compression?
* Diagnosis & treatment within 24hrs
* MRI scan
* Ig and FLC studies +/- biopsy
* Dexamethasone
* Radiotherapy
* Neurosurgery: rarely required
* Stabilise unstable spine
* MDT meeting
153
What are some symptoms of hypercalcaemia?
* Presents with drowsiness, constipation, fatigue, muscle weakness, AKI
* Fluids, steroids, zolendronic acid
154
What is the definition of myeloma kidney disease?
– Serum creatinine >177μmol/L (>2mg/dL ) or eGFR <40ml/min (CDK-EPI)
– Acute kidney injury and result of myeloma
* 20-50% acute kidney injury at diagnosis
* 2-4% of newly diagnosed patients will require dialysis
* 25% develop renal insufficiency at relapse
155
What is the cause of myeloma kidney disease?
Cast nephropathy is caused by high serum free light chains (FLC) levels and Bence Jone proteinuria
Hypercalcaemia, loop diuretics, infection, dehydration, nephrotoxics
156
What is cast nephropathy in myeloma kidney disease?
The formation of plugs (urinary casts) in the kidney proximal tubule from free immunoglobulin light chains leading to kidney failure in the context of multiple myeloma. It is the most common cause of kidney injury in myeloma.
157
What is the prognosis of those with kidney disease and myeloma?
Patients with severe kidney disease (eGFR <30ml/min) have a much worse outcome.
Early mortality in severe kidney disease is an area on unmet clinical need:
• 12% early death (<2 months)
• Prolonged hospital stay, lethal infections
• Nephrotoxic or renal excreted myeloma drugs: eg zoledronic acid, lenalidomide
158
What is the cornerstone treatment of kidney disease in myeloma?
Bortezomib-based therapy
159
What are the causes of complex humeral and cellular immunodeficiency in myeloma?
Immunoparesis: low serum normal Igs
Myeloid, T cells and NK cells impairment
Chemotherapy impairs immune response
Myeloma immune evasion
160
What is the myeloma diagnostic workup?
1) Immunoglobulin studies: serum protein electrophoresis, serum free light chain levels, 24hr Bence Jones proteins
2) Bone marrow aspirate and biopsy: IHC for CD138
3) FISH analysis
4) Flow cytometry immunophenotyping: diagnosis, MRD
161
How is myeloma staged and risk stratified?
1) International staging system: I, II, III (stage I: <3.5 mg/L beta-2-microglobulin, >3.5 g/dL serum albumin, stage II: serum beta-2-microglobuli >5.5 mg/L)
2) Revised international staging system: I, II, III (using cytogenic abnormalities, iFISH, LDH)
162
What is amyloidosis?
* Misfolded free light chains aggregate into amyloid fibrils in target organs
* The amyloidogenic potential of light chains is more important than their amount
* Amyloid fibrils stain with Congo Red, are solid, non- branching and randomly arranged with a diameter of 7 – 12 nm
163
What are the chains commonly found in amyloidosis?
Lambda light chain is involved in 60%
- IGLV6-57 in kidney
- IGLV1-44 in cardiac
164
What is the clinical presentation of amyloidosis?
• Nephrotic syndrome (70%)
– Proteinuria, peripheral oedema
• Unexplained heart failure → determinant of prognosis
– Raised NT-proBNP
– Abnormal echocardiography and cardiac MRI
* Sensory neuropathy
* Abnormal liver function tests
* Macroglossia
165
What is Monoclonal Gammopathy of Renal Significance (MGRS)?
MGRS applies specifically to any B-cell clonal lymphoproliferation where there are: one or more kidney lesions caused by mechanisms related to the produced monoclonal immunoglobulin (Ig) and the underlying B cell clone does not cause tumor complications or meet current hematological criteria for immediate specific therapy
166
What is the pathology of Monoclonal Gammopathy of Renal Significance (MGRS)?
* Rare disease, several subtypes
* Demonstration of the involved monoclonal Ig or light chain is possible in most cases
* Work up similar to myeloma
* Many patients will require myeloma-type treatment aiming to renal survival
167
What are examples of alkylators and steroids used in the treatment of myeloma therapy?
1) Melphalan - nitrogen mustard derivate, high-dose melphalan 200 mg/m2 still in use in Autologous SCT
2) Cyclophosphamide - used in combination with steroids, immunomodulation and microenvironment
3) Dexamethasone and prednisolone - induce apoptosis in myeloma, strong synergy in all combinations
168
Which combination of thalidomide with other drugs can be used in the treatment of myeloma?
* Thalidomide in combination with cyclophosphamide and dexamethasone was established in the treatment of relapsed myeloma
* It was later replaced older therapies as a front line treatment prior to autologous SCT
169
What are different immunomodulatory drugs (IMiD) used in myeloma?
* Lenalidomide - 2005: more potent, different toxicity profile, better tolerated
* Pomalidomide – 2013 : even more potent than Lenalidomide
* Iberdomide–awaits approval
170
How do proteasome inhibitors in myeloma work?
Myeloma cells are protein production factories
Proteasome is crucial in removing misfolded protein
Accumulation of misfolded protein→endoplasmic reticulum stress and unfolded protein response → apoptosis
Alteration of NF-κB pathway
171
What are proteasome inhibitors in myeloma?
1) Bortezomib - neuropathy is main toxicity, first line or relapse
2) Carfilzomib - more potent, only approved in relapse, thrombocytopenia, cardiotoxicity
3) Ixazomib - approved in relapse
172
How do therapeutic moAbs in multiple myeloma
| anti-CD38: Daratumumab and Isatuximab work?
Therapeutic moAbs in multiple myeloma:
1) Anti-CD38: Daratumumab and Isatuximab
2) Daratumumab is the first therapeutic moAb approved for multiple myeloma (2015)
3) CD38 is strongly expressed in normal and malignant plasma cells
Not a lineage specific marker
173
What is the treatment algorithm in new diagnosis myeloma?
Transplant-eligible patients - fit and typically <65 years old
If fit: induction and then transplant - consolidation, the maintenance
If not fit: different combination therapies
174
What is BiTE and CAR-BCMA in the context of myeloma treatment?
BiTE - Bispecific antibodies: CD3-BCMA and CD3-FcRL5 BiTE under development
BCMA: B cell maturing antigen, specific for plasma cells (normal and malignant)
175
What is the definition of lymphoma?
The term ‘lymphoma’ means a neoplastic (malignant) tumour of lymphoid cells.
176
Where are lymphomas normally found in?
Lymph nodes, bone marrow and/or blood (the lymphatic system
Lymphoid organs; spleen or the gut-associated lymphoid tissue
Skin (often T cell disease)
Rarely “anywhere” (breast kidney) {*Immune privilege sites CNS, occular, testes}
177
List the different types of lymphoid malignancies
1) Precursor malignancies - B or T cell lineage
2) Mature B cell malignancies - Non-Hodgkin's, Hodgkin's lymphoma
3) Mature T cell malignancies - T cell or NK cell Non-Hodgkin's lymphoma
178
Where does B cell acute lymphoblastic leukaemia affect in B cell ontogeny?
B-precursor lymphoblastic leukaemia
179
Where does mantle cell lymphoma affect on B cell ontogeny?
Large non-cleaved cell in mantle zone
180
Where does multiple myeloma affect on B cell ontogeny?
Plasma cells
181
How does DNA instability lead to malignancy?
Lymphocyte: DNA molecules are 1) cut and recombined 2) subjected to deliberate DNA mutagenesis (somatic hypermutation)
- Generates immunoglobulin and T cell receptor diversity and Ig class switching
- Potential for recombination errors and new point mutations
Rapid cell proliferation in the germinal centre
- Allows rapid response to infection
- Rapid cell division = increased risk of DNA replication errors
Dependent on apoptosis (90% of normal lymphocytes die in the Germinal centre!)
Exquisite antibody specificity & eliminates self reactive clones
Apoptosis is “switched off” in germinal centre
Consequences of mutation ins in apoptosis regulating genes
182
What is the molecular basis of adaptive immune response?
VDJ recombination
Occurs in BM
Key enzymes: RAG1+2
TdT
Class switch recombination
Somatic hypermutation
Key enzyme: Adenosine induced
Deaminase
183
What are some immune genes recombination errors and lymphoma-linked translocations?
Chr 14 --> instead of Ig heavy chain you can get C-MYC oncogene t(8;14)
Lymphoma/recombination associated translocations
Involves the Ig Locus (IgH, K or l loci)
Ig promoter highly active in B cells
Bring intact oncogenes close to the Ig promoter
Oncogenes may be anti apoptotic, proliferative.
bcl2
bcl6
Myc
cyclinD1
184
What are the three main mechanisms of Non-Hodgkin's lymphoma?
1) Constant antigenic stimulation
Bacteria infection (chronic)
Auto immune disorders
2) Viral Infection (direct viral integration of lymphocytes)
3) Loss of T cell function and EBV infection (EBV driven B cell lymphomas)
Loss of T cells (HIV)
Iatrogenic immunosuppression
185
What are two examples of Non-Hodgkin's lymphoma which have bacterial or autoimmune antigenic drive?
1) B cell Non Hodgkin Lymphoma Marginal zone sub type (MZL)
| 2) Enteropathy associated T-Cell Non Hodgkin lymphoma (EATL)
186
What are the causes of B cell Non Hodgkin Lymphoma Marginal zone sub type (MZL)?
H.Pylori: Gastric MALT (mucosa associated lymphoid tissue) (MZL of stomach)
Sjogren syndrome: MZL (Low-grade marginal zone lymphomas) which causes joint pain, swelling and stiffness
Hashimoto’s: MZL of thyroid
187
What is the main potential cause of enteropathy associated T-Cell Non Hodgkin lymphoma (EATL)?
Coeliac disease/Gluten: small intestine EATL
188
What is the cause of direct viral integration and lymphomagenesis?
Direct Viral Integration
- HTLV1 retrovirus infects T cells by vertical transmission
- Caribbean, Japan (and world wide) endemic infection
- Risk of Adult T cell leukaemia lymphoma is 2.5% at 70 years
- ATLL is a subtype of T cell Non Hodgkin Lymphoma
189
How can the following cause Non-Hodgkin's lymphoma?
- EBV
- Loss of T cell function
- Loss of cytotoxic T cell function can cause failure to eliminate EBW driven proliferation of B cells
1) EBV infection
EBV infects B lymphocytes, healthy carrier state post glandular fever.
EBV driven proliferation of B cells is associated with surface expression of EBV antigens. Proliferating B cells targeted and killed by EBV specific cytotoxic T cell response
2) Loss of T cell function
HIV (in uncontrolled infection there is x60 increased incidence of B NHL )
Iatrogenic (transplant immunosuppression)
PTLD (post transplant lympho-proliferative disorder)
3) Loss of cytotoxic T cell function can cause failure to eliminate EBV driven proliferation of B cells
190
What would be the histological findings for classical Hodgkin's lymphoma?
Reed Sternberg cells
191
What are the B symptoms in Hodgkin's lymphoma?
Fever
Night sweats
Weight loss
192
What is the classification of Hodgkin's lymphoma?
Nodular sclerosing 80%
Mixed cellularity 17% Good prognosis
Lymphocyte rich (rare) Good prognosis
Lymphocyte depleted (rare) Poor Prognosis
193
What are the two most significant blood subtypes in blood transfusion?
ABO and Rh systems
194
What are the ABO blood groups determined by?
1. By the antigens (sugars) on the red cell membrane.
| 2. The naturally-occurring antibodies (IgM) in the plasma.
195
What would happen if you give an ABO incompatible blood transfusion?
If you give an ABO incompatible blood
| transfusion it will cause massive INTRAVASCULR haemolysis and this is potentially fatal
196
Describe RhD+/- blood type
RhD positive (85% of population)
• Carry the RhD antigen
• Patients can receive RhD negative or RhD positive red cells
RhD negative (15% of population)
• Lack the RhD antigen
• Patients can make immune anti-D if exposed to RhD positive red cells
197
A RhD- individual is exposed to RhD+ blood. What happens next?
Immune anti-D antibodies
• Are IgG (so cross the placenta)
• Do not cause direct agglutination of RBCs
• Cause delayed haemolytic transfusion reaction
There are some other Rh antigens e.g., C, c, E and e
198
A RhD+ baby is exposed to RhD- blood from the mother which also has anti-RhD antibodies. What could be a complication of this?
Rh D negative women exposed to Rh D positive blood can produce immune anti D, which can cause haemolytic disease of the newborn or severe foetal anaemia and heart-failure (hydrops fetalis) in pregnancy.
199
How is blood group tested for?
Column Agglutination Technology
• Automated
• Manual
• Room temp
Positive Agglutination (clumping)
Negative
Red cells stay suspended
200
What is meant by group and screen when testing for blood type?
Use 2 or 3 reagent red cells containing all the important red cell antigens between them
Indirect anti-globulin technique: (bridges red cells coated by IgG, which can’t themselves bridge 2 red cells – to form a visible clump. Takes 30 mins’ incubation at 37°C)
201
What is electronic crossmatch in blood group testing?
Electronic issue (EI) is the selection and issue of red cell units where compatibility is determined by IT system, without physical testing of donor cells against patient plasma
202
What is serological crossmatching for blood groups?
FULL CROSSMATCH
INDIRECT ANTIGLOBULIN TECHNIQUE
Patient plasma incubated with donor red cells at 370C for 30-40 mins, will pick up antibody antigen reaction that could destroy the red cells and cause extravascular haemolysis
ADD ANTIGLOBULIN REAGENT (AHG)
```
IMMEDIATE SPIN (SALINE, ROOM TEMPERATURE)
Incubate patient plasma and donor red cells for 5 minutes only and spin, will detect ABO incompatibility only
```
IgG antibodies can AGGLUTINATION (OR bind to RBC antigens HAEMOLYSIS) = but do not crosslink so AHG reagent is INCOMPATIBLE added IgM anti-A and/or anti-B bind to RBCs, fix complement and lyse the cell
203
How are blood bags labelled in the hospital?
Donor RBCs are labelled with:
1. ABO & D TYPE
2. Kell
3. OTHER Rh ANTIGENS
Select the correct ABO and D type from stock fridge.
Select antigen negative blood if RBC antibody detected in antibody screen and ID panel
Select K negative blood for females of childbearing potential
All units have a traceability tag – 100% traceability is a legal requirement
204
What are the pillars of patient blood management?
1) Optimise haemopoiesis
2) Minimise blood loss and bleeding
3) Harness and optimise physiological tolerance of anaemia
205
How are red cells stored prior transfusion?
Stored at 40 C for 35 days.
Must be transfused within 4 hours of leaving fridge
Transfuse 1 unit RBC over 2-3 hours
206
How are platelets stored and given in transfusion?
If group O given to A, B or AB patients select ‘high-titre’ negative (anti-A/B antibodies)
Stored at 20C for 7 days
Transfuse 1 unit of platelets over 20-30 minutes
207
How is fresh frozen plasma stored and then transfused?
Once thawed can be kept at 4 0C for 24 hours
| Transfuse 1 unit over 20-30 minutes
208
How is cryoprecipitate stored and then transfused?
Once thawed has to kept at room temperature and use within 4 hours
Transfuse 1 unit over 20-30 minutes
209
What is Maximum Surgical Blood Ordering Schedule (MSBOS)?
MSBOS is based agreement between surgeons and transfusion lab about predictable blood loss for ‘routine’ planned surgery
210
What are some transfusion indications?
Major Blood Loss - if >30% Blood volume lost
Peri-Op, Critical Care - Hb <70g/L vs 80g/L
Post Chemo - Hb <80g/L
211
What are the platelet transfusion indicators?
```
Massive transfusion - Aim Plts >75 x109/L
Prevent bleeding (post chemo) - If < 10 x109/L (<20 if sepsis)
Prevent bleeding (surgery) - <50 x109/L (<100 if critical site: eye, CNS, polytrauma)
```
Platelet dysfunction or immune cause – only if active bleeding
212
What are the indications of fresh frozen plasma and the dosage?
- Replacement of single coagulation factor deficiency
- DIC in the presence of bleeding and abnormal coagulation results
- Thrombotic thrombocytopenic
Dosage: 15-20ml/kg
213
What is cryoprecipitate?
```
Fibrinogen
Factor VIII, vWF
Fibronectin
fXIII
Platelet microparticles
IgA
Albumin
```
214
What is the difference between cryoprecipitate and FFP?
FFP contains coagulation factors at the same concentration present in plasma. Cryoprecipitate is a highly concentrated source of fibrinogen.
215
What are the different autologous blood transfusion options?
Pre-operative autologous deposit - donate own blood before surgery
Intra-operative cell salvage - collect blood lost during surgery: centrifuge, filter, wash & re-infuse it - most UK surgical and obstetric units can do this
Post-operative cell salvage - collect blood lost post-op into wound drain – filter & re-infuse - mainly orthopaedic (knee surgery)
216
What are some special requirements which must be undertaken in immunocompromised or pregnant individuals who need a transfusion?
* CMV negative blood - only required for intra-uterine /neonatal transfusions and for elective transfusion in pregnant women (baby in-utero is exposed to maternal transfusion)
* Irradiated blood - required for highly immunosuppressed patients, who cannot destroy incoming donor lymphocytes: which can cause (fatal) transfusion associated graft versus host disease (TA-GvHD)
* Washed - red cells and platelets are only given to patients who have severe allergic reactions to some donors’ plasma proteins
217
What is the most common blood type?
O+
218
What is the acute reaction to blood transfusion in the case of mismatch?
```
<24hrs
1. Acute haemolytic (ABO incompatible)
2. Allergic/anaphylaxis
3. Infection (bacterial)
4. Febrile non-haemolytic
5. Respiratory
• Transfusion associated circulatory overload (TACO)
• Acute lung injury (TRALI)
```
219
What is the delayed reaction to blood transfusion in the case of mismatch?
>24hrs
1. Delayed haemolytic transfusion reaction (antibodies)
2. Infection - viral, malaria, vCJD
3. TA-GvHD
4. Post transfusion purpura
5. Iron overload
220
Describe the features of the febrile non-haemolytic transfusion reaction
‘MILD/ MODERATE’
During / soon after transfusion (blood or platelets), rise in temperature of 10C, chills, rigors
Common before blood was leucodepleted, now rarer Have to stop or slow transfusion; may need to treat with
paracetamol
Cause: White cells can release cytokines during storage
221
Describe the features of incorrect blood transfusion
‘Severe or fatal’
Symptoms and signs of acute intravascular haemolysis- IgM
• Restless, chest/ loin pain, fever, vomiting, flushing, haemoglobinuria (later);
• ↓BP & ↑HR (shock), ↑Temp
Stop transfusion – check patient / component
Take samples for FBC, biochemistry, coagulation
Repeat x-match and Direct Antiglobulin Test (DAT)
Discuss with haematology doctor ASAP
221
Describe the features of allergic transfusion reactions
‘MILD/ MODERATE’
Common especially with plasma
Mild urticarial or itchy rash sometimes with a wheeze
During or after transfusion
Usually have to stop or slow transfusion
IV antihistamines to treat (and prevent in future if recurrent)
Cause:
Allergy to a plasma protein in donor so may not recur again, depending on how common the allergen is
Commoner in recipients with other allergies and atopy
222
Describe the features of bacterial contamination after blood transfusion
Restless, fever, vomiting, flushing, ↓BP & ↑HR (shock), ↑Temp, collapse, ‘severe or fatal’
•Bacterial growth can cause endotoxin production which causes immediate collapse
•From the donor (low grade GI, dental, skin infection) •Introduced during processing (environmental or skin) •Platelets >red cells > frozen components (storage temp)
223
Why do platelet transfusions have a higher risk of bacterial contamination as oppose to red blood cell transfusion?
Red cells are stored at 4°C
Platelets are stored at room temperature – more likely to get bacterial growth
224
What are some methods of bacterial contamination prevention?
Donor questioning
Arm cleaning
Diversion of first 20mL into a pouch (used for testing)
Look for abnormalities e.g. clumps of discoloured debris; brown plasma etc.
225
How does anaphylaxis present after blood transfusion?
```
Immediate and fatal reaction
• ↓BP & ↑HR (shock),
• very breathless with wheeze,
• often laryngeal &/or facial oedema
Mechanism:
IgE antibodies in patient cause mast cell release of granules & vasoactive substances Most allergic reactions are not severe, but few are e.g. in IgA deficiency
```
226
In which patients is anaphylaxis more common in after blood transfusion?
IgA deficiency
• 1:300 - 1:700 (common); where in 25%, anti-IgA antibodies develop in response to exposure to IgA (transfusion – especially with plasma);
• But only minority ever have transfusion reactions- frequency is 1:20,000 - 1:47,000
227
What are the respiratory complications of blood transfusion?
Transfusion Associated Circulatory Overload (TACO) Transfusion Related Acute Lung Injury (TRALI) Transfusion Associated Dyspnoea (TAD)
228
Which is the most common pulmonary complication of blood transfusion?
TACO is the most common pulmonary complication
Majority present within 6 hours of transfusion
229
What are the clinical features of transfusion associated circulatory overload (TACO)?
Often lack of attention to fluid balance, especially in cardiac failure, renal impairment, hypo-albuminaemia, those on fluid replacement, very young, very small and very old.
Clinical features: SOB, ↓SAO2 , ↑HR, ↑BP
CXR: fluid overload / cardiac failure
230
What is transfusion related acute lung injury?
Acute lung injury/ARDS
* SOB, ↓O2, ↑HR, ↑BP; (similar to TACO)
* CXR: bilateral pulmonary infiltrates during/within 6 hr of transfusion
Mechanism
• Anti-wbc antibodies (HLA or neutrophil Abs) in donor
• Interact with corresponding ag on patient’s WBCs
• Aggregates of WBCs get stuck in pulmonary capillaries → release neutrophil proteolytic enzymes & toxic O2 metabolites → lung damage
• Prevention - male donors for plasma & platelets (no pregnancy or transfusion, so no HLA/HNA antibodies)
231
What are some infections which occur post-blood transfusion?
```
CMV
Very immunosuppressed (stem cell transplant) patients can get fatal CMV disease, but leucodepletion removes CMV (in wbc’s) Only give CMV- now for pregnant women (foetus) & neonates.
```
Parvovirus
Causes temporary red cell aplasia - affects foetuses and patients with haemolytic anaemias e.g. sickle cell; hereditary spherocytosis
232
What is the delayed haemolytic transfusion reaction?
1-3% of all patients transfused develop an ‘immune’ antibody to a RBC antigen they lack ALLOMMUNISATION
If the patient has another transfusion with RBCs expressing the same antigen, antibodies cause RBC destruction EXTRAVASCULAR HAEMOLYSIS (as IgG) so
takes 5-10 days
233
What are the test results for someone with delayed haemolytic transfusion reaction?
```
Haemolysis screen:
High: bilirubin, LDH, retics
DAT positive
Haemoglobinuria over a few days
Test U&Es – as can cause renal failure
```
234
What is the transfusion associated graft-versus-host disease (TaGVHD)?
* Donor’s blood contains some lymphocytes (able to divide)
* In ‘susceptible’ patients (e.g... very IS) - lymphocytes not destroyed
* Lymphocytes recognise patient’s tissue HLA antigens as ‘foreign’ – so attack patient’s gut, liver, skin and bone marrow
Prevent: irradiate blood components for very immunosuppressed; or patients having HLA matched components
Clinical features - severe diarrhoea, liver failure, skin desquamation, bone marrow failure
235
Describe the features of post transfusion purpura
Purpura appears 7-10 days after transfusion of blood or platelets and usually resolves in 1-4 weeks but can cause life threatening bleeding
Affects HPA -1a negative patients - previously immunised by pregnancy or transfusion (anti-HPA-1a antibody)
?exact mechanism of own platelet destruction, as HPA-1a negative!
?innocent bystander mechanism
236
How is post-transfusion purpura treated?
Infusion of IVIG
237
What is immune-modulation?
Possible
• Increased rate of infections post-op
• Increased recurrence of cancers in patients who have blood transfusion
238
What is iron overload?
If lots of transfusion (e.g. >50) over time accumulate iron (not excreted); 200-250mg of iron per unit of blood
• Can cause organ damage - liver, heart, endocrine etc
• Prevent by iron chelation (Exjade) with transfusions once ferritin >1000 e.g. used in Thalassaemia / Sickle cell disease - regular transfusions
239
What are the clinical features of haemolytic disease of the newborn?
Only IgG antibodies can cross the placenta
If mother has high levels of IgG antibody - it can destroy foetal red cells
Fetal anaemia (haemolytic)
Haemolytic disease of newborn (anaemia plus high bilirubin)
240
How does prophylactic anti-D immunoglobulin work?
To be effective - must give anti-D injection within 72 hours of the ‘sensitising event’
It does not work if the mother has already been sensitised (developed anti-D) in the past
241
What are sensitising events?
1. Give anti-D at delivery if baby is RhD positive
2. Give anti-D Ig for ‘sensitising events’ during pregnancy, where FMH is likely to occur
- spontaneous miscarriages if surgical evacuation needed and therapeutic terminations
- amniocentesis and chorionic villous sampling
- abdominal trauma (falls and car accidents) - external cephalic version (turning the fetus)
- stillbirth or intrauterine death
242
What are the doses of anti-D?
- At least 250 iu - for events before 20 weeks of pregnancy
| - At least 500 iu - for events any time after 20 weeks of pregnancy (including delivery)
243
What are other antibodies which can cause sensitisation reaction?
Anti-c and anti-Kell can cause severe HDN
- usually less severe than anti-D
- Kell causes reticulocytopenia in fetus as well as haemolysis
IgG anti-A and anti-B antibodies from Group O mothers can cause mild HDN
- usually not severe (phototherapy)
244
What is non-invasive fatal genotyping for mother with antibodies?
* A rapid, non-invasive, convenient and reliable service for prediction of fetal D, C, c, E and K status, using cell-free fetal DNA in maternal blood for women who have allo- antibodies.
* Upon identification, mothers can then be informed and prepared for further careful monitoring during their pregnancy.
* Also identifies pregnant women who have antigen-negative fetuses and who therefore are not at danger from HDFN
245
What can predict the Rh D status of the foetus? how can this be managed?
The ffDNA technique can predict Rh D status of fetus from 11+2 weeks gestation.
• At 16 weeks women can be consented for sample for ffDNA testing
• Results available in 10 days
• If baby Rh D negative – no anti D needed
Currently anti-D (1500 IU) is administered at 28 weeks gestation as RADDP regime.
At birth: further dose of 1500 IU
246
Which HLA molecules are relevant in transplant and which cells are they found on?
HLA-A, -B, -C, (class I), present peptide to CD8+ (cytotoxic T-cells)
HLA-DP,-DQ and -DR (class II), present peptide to CD4+ (helper T-cells)
Function – present foreign peptides to T cells
Routinely, HLA-A, -B and DR are typed for compatibility purposes
247
Describe the stages involved in autologous transplantation
1) Grown factor given
2) Collect stem cells and freeze
3) Thaw and reinfuse
4) High dose chemotherapy
248
What are autologous transplantations suitable for?
```
Acute leukaemia
Solid tumours
Autoimmune disease
Myeloma
Lymphoma
Chronic lymphocytic leukaemia
```
249
What is allogeneic transplantation?
Bone marrow or peripheral stem cells given by donor
250
When is allogeneic transplantation suitable?
```
Suitable for
Acute leukaemia
Chronic leukaemia
Myeloma
Lymphoma
BM failure
Congenital immune deficiencies
```
251
How many human stem cells are needed for transplantation?
Need 2x106/kg CD34+ cells
252
What is graft versus host disease (GvHD)?
An immune response when donor cells recognise the patient as ‘foreign’
Acute GvHD affects skin, gastrointestinal tract and liver. Chronic GvHD affects skin, mucosal membranes, lungs, liver, eyes, joints.
253
What are risk factors for acute GvHD?
```
Degree of HLA disparity
Recipient age
Conditioning regimen
R/D gender combination
Stem cell source
Disease phase
Viral infections
```
254
What is the treatment for acute GvHD?
```
Corticosteroids
Calcineurin inhibitors: cyclosporin A, tacrolimus, sirolimus
Mycophenylate mofetil
Monoclonal antibodies
Photopheresis
Total lymphoid irradiation
Mesenchymal stromal cells
```
255
How can GvHD be prevented?
Methotrexate
Corticosteroids
Calcineurin inhibitors: cyclosporin A, tacrolimus, sirolimus
CsA plus MTX
T-cell depletion
Post-transplant cyclophosphamide
256
When does GvHD occur?
Diagnosis within 6 months of transplant, lasts 2-5 years
85% of survivors can discontinue treatment at that time
5-year survival is 70–80%, in persons with low risk cGVHD and those responding to corticosteroids.
Five-year survival is 30–40% for those with high-risk disease +/- failure of steroids
257
What are the consequences of chronic GvHD?
Immune dysregulation
Immune deficiency,
Impaired end-organ function
Decreased survival.
258
What are risk factors for chronic GvHD?
Affects 50% of patients who survive >1 year from transplant
```
Prior acute GvHD
Increased degree of HLA disparity
Male recipient: female donor
Stem cell source (PB>BM>UCB)
T-cell replete
Older donor age
Use of DLI
```
259
What are the main sources of infection in neutropenic patients?
Gram positive - vascular access
| Gram negative - gastrointestinal tract
260
In how many neutropenic patients is the causative organism identified?
1/3
261
What is the most common causative bacterial infection in neutropenic patients?
Gram positive e.g. staph epidermidis
262
What is the most common bacterial infection which causes the most deaths due to sepsis in neutropenic patients?
Gram negative organisms eg e.coli, pseudomonas aeruginosa
263
How can bacterial infections be reduced in neutropenic patients?
Reduced incidence of infection using isolation measures and broad spectrum oral antibiotics
264
How is neutropenic sepsis treated?
Assess patient: temperature, pulse, oxygen saturation and blood pressure. History and examination for evidence of source
Blood cultures, MSU, CXR
Initiate empirical broad spectrum antibiotics and supportive care
265
Define neutropenic sepsis
Defined as temperature >38 sustained for one hour, or single fever >39, in a patient with neutrophils <1.0 x 109/L
266
How can fungal infections occur post-transplant?
Yeasts from translocation from the intestinal mucosa, or indwelling catheters
Moulds: inhalation, chronic sinusitis, skin, mucosa
267
How can CMV be reactivated in immunosuppressed individuals and manifest?
Pneumonitis
Retinitis
Gastritis – colitis
Encephalitis
268
How can CMV be treated in transplant patients?
Twice weekly quantitative monitoring of peripheral blood viraemia to day 100
Thresholds for treatment together with evidence of increasing viral load
Ganciclovir/valganciclovir: oral and IV preparations.
Minimum of 2/52 treatment with clear evidence of reduction in viral load
269
Apart from CMV, what are other viral complications of post-transplant?
EBV: acute infection, PTLD
Respiratory viruses: influenza, parainfluenza, respiratory syncytial virus, rhino, metapneumovirus, COVID-19
PAPOVA viruses: BK and haemorrhagic cystitis
Adenovirus
270
Which factors can affect the outcome of the transplant?
- Age
- Disease phase
- Gender
- Time to BMT
- Donor
271
Why are conditions like iron and folic acid deficiency more common in children?
The rapid growth of the child can predispose to deficiency of vitamins or minerals
272
How are the neonatal blood ranges different to an adult's?
A higher Hb
A lower WBC
Smaller red blood cells
The same percentage of haemoglobin F
Enzyme levels in red cell also differ, e.g. glucose-6-phosphate dehydrogenase (G6PD) concentration is about 50% higher than in adults
273
What can polycythaemia in the foetus or neonate be caused by?
Twin-to-twin transfusion
Intrauterine hypoxia
Placental insufficiency
274
What are the causes of anaemia in a foetus or neonate?
Twin-to-twin transfusion
Fetal-to-maternal transfusion
Parvovirus infection (virus not cleared by immature immune system)
Haemorrhage from the cord or placenta
275
What happens if a lactating woman eats fava beans and breastfeeds her baby who is G6PD-deficient?
Haemolysis
276
In which cases can congenital leukaemia occur?
Congenital leukaemia is particularly common in Down syndrome
This specific type of neonatal leukaemia (also sometimes called transient abnormal myelopoiesis or TAM) differs greatly from leukaemia in older infants or children
Can relapse after 1-2 years in 25% of cases
277
What are the three normal forms of haemoglobin in the foetus, infant, child and adult?
A - 2 alpha, 2 beta - late foetus, infant, child and adult
A2 - 2 alpha, 2 delta - infant, child and adult
F - 2 alpha, 2 gamma - foetus and infant
278
How does vascular obstruction in sickle cell anaemia occur?
Red cells elongate to pass through capillary bed to post-capillary venules
Red cells adhere to endothelium
Sickle cells obstruct venues and retrograde capillary obstruction occurs
279
Why is sickle cell anaemia different in infants compared to adults?
The distribution of red bone marrow (susceptible to infarction) differs
The infant still has a functioning spleen—splenic sequestration can occur
The infant has an immature immune system and has not developed immunity to pneumococcus or parvovirus
280
How do crises of sickle cell manifest in children and adults?
Infancy --> childhood --> adulthood manifestations in order
1) The hand/foot syndrome
2) Acute chest syndrome
3) Painful crisis
4) Stroke/cumulative incidence
281
What is spenlic sequestration?
Splenic sequestration is the acute pooling of a large percentage of circulating red cells in the spleen
The spleen enlarges acutely
The Hb falls acutely and death can occur
This doesn’t happen in older children and adults because recurrent infarction has left the spleen small and fibrotic
282
Why do infants with sickle cell have higher folic acid requirements?
Hyperplastic erythropoiesis requires folic acid
Growth spurts require folic acid
Red cell life span is shorter so anaemia can rapidly worsen
283
How can sickle cell be managed in infants?
Accurate diagnosis
Educate parents
Vaccinate
Prescribe folic acid and penicillin
284
Define beta-thalassaemia
Beta thalassaemia is a condition resulting from reduced synthesis of beta globin chain and therefore haemoglobin A. Manifests in the first 3-6 months.
285
What are the clinical effects of poorly treated thalassaemia major?
Anaemia - heart failure, growth retardation
Erythropoietic drive - bone expansion, hepatomegaly, splenomegaly
Iron overload - heart failure, gonadal failure
286
What are the two types of haemolytic anaemia?
Inherited
| Acquired
287
What can inherited haemolytic anaemias be caused by?
Red cell membrane
Haemoglobin molecule
Red cell enzymes—glycolytic pathway
Red cell enzymes—pentose shunt
288
What are the haemolytic anaemias according to which part of erythrocyte synthesis they affect?
Red cell membrane defects
Hereditary spherocytosis
Hereditary elliptocytosis
Haemoglobin defects
Sickle cell anaemia
Glycolytic pathway defects
Pyruvate kinase deficiency
Pentose shunt defects
G6PD deficiency
289
What are the two acquired haemolytic anaemias in children?
Autoimmune haemolytic anaemia
| Haemolytic uraemic syndrome
290
What is autoimmune haemolytic anaemia characterised by on blood film?
Spherocytosis
| Positive direct antiglobulin test (Coombs’ test)
291
What is microangiopathic haemolytic anaemia?
The red cells are damaged in capillaries and are fragmented by the process. Small angular fragments and microspherocytes are formed.
292
What is the typical presentation of haemophilia A and B?
Bleeding following circumcision
Haemarthroses when starting to walk
Bruises
Post-traumatic bleeding
293
What is the typical presentation of von Willebrand disease?
Mucosal bleeding
Bruises
Post-traumatic bleeding
294
What is the mode of inheritance of VWD?
Mostly autosomal dominant
295
Prolonged aPTT but all other variables normal. Joint bleeding was first presentation. What is your diagnosis?
Haemophilia A
296
What is the typical presentation of autoimmune thrombocytopenia purpura?
Petechiae
Bruises
Blood blisters in mouth
297
How is autoimmune thrombocytopenia purpura treated?
Observation
Corticosteroids
High dose intravenous immunoglobulin
Intravenous anti-Rh D (if Rh positive)
298
What are some chromosomal abnormalities which can occur in AML?
Duplication (usually trisomy)
Loss
Translocation t(15;17), t(5;8)
Inversion (16)
Deletion - loss of 5/5q & 7/7q, tumour suppression gene loss
Altered DNA sequence - creation of new fusion genes, abnormal regulation of genes
299
What are some risk factors of AML?
Familial or constitutional predisposition
Irradiation
Anticancer drugs
Cigarette smoking
300
What are the two types of abnormalities which occur in leukaemogenesis in AML?
Type 1 abnormalities - promote proliferation & survival
Type 2 abnormalities - block differentiation (which would normally be followed by apoptosis)
301
What is an example of a chromosome with fusion gene in a core binding factor AML?
t(8;21)
RUNX1 gene chromosome 21: red probe
RUNX1T1 gene chromosome 8: green probe
302
What is core binding factor in the context of haematopoeisis?
- Dimeric transcription factor
| - Master controller of haematopoiesis
303
What is acute promyelocytic leukaemia caused by and the clinical manifestations?
t(15;17)
An excess of abnormal promyelocytes
Disseminated intravascular coagulation (DIC)
Two morphological variants but the same disease (classical and variant)
The great majority of patients can now be cured
304
How can you differentiate between AML and ALL?
Cytological features
Cytochemistry
Immunophenotyping
305
What are the three types of immunophenotyping?
Flow cytometry
Immunocytochemistry - binds to monoclonal antibody
Immunohistochemistry
306
What are the clinical features of AML?
Bone marrow failure
Anaemia
Neutropenia - infection e.g. necrotising fasciitis
Thrombocytopenia - bleeding, DIC (also promyelocytic)
```
Local infiltration
Splenomegaly
Hepatomegaly
Gum infiltration (if monocytic)
Lymphadenopathy (only occasionally)
Skin, CNS or other sites
Retinal haemorrhages/exudates
```
307
How is AML diagnosed?
```
Blood film
Usually diagnostic: circulating blasts
Auer rods (proves myeloid)
ALL versus AML -Immunophenotyping
“Aleukaemic” leukaemia If there are no leukaemic cells in in the blood you need a bone marrow aspirate
```
308
What can be used to determine prognosis of AML?
Cytogenic studies
| Molecular studies and FISH
309
How can AML be treated?
Supportive care
Red cells
Platelets
Fresh frozen plasma/ cryoprecipitate if DIC
Antibiotics
Long line
Allopurinol, fluid and electrolyte balance
Chemotherapy
4-5 courses - 6 months each
x2 remission, x2-3 consolidation
Targeted molecular therapy
Transplantation
310
Give some examples of molecularly targeted therapy in AML
All-trans-retinoic acid (ATRA) and A2O3 for acute promyelocytic leukaemia
Tyrosine kinase inhibitors for the rare Ph-positive cases
Drugs targeting the products of other mutated genes
Antibody treatment, e.g. gemtuzumab ozogamicin, a cytotoxic antibiotic linked to an anti-CD33 antibody
311
Name some clinical features of ALL
Bone marrow failure
Anaemia
Neutropenia
Thrombocytopenia
```
Local infiltration
Lymphadenopathy (± thymic enlargement)
Splenomegaly
Hepatomegaly
Testes, CNS, kidneys or other sites
Bone (causing pain)
```
312
What are the pathological features of ALL?
```
Peripheral blood
Anaemia
Neutropenia
Thrombocytopenia
Usually lymphoblasts
```
Bone marrow and other tissues
Lymphoblast infiltration
Lymphoblasts may be B-lineage or T-lineage
313
What changes could result in photo-oncogene dysregulation?
- Fusion genes
- Wrong gene promoter
- Dysregulation by proximity to T-cell receptor (TCR) or immunoglobulin heavy chain loci
314
What is the Philadelphia chromosome?
t(9;22)(q34;q11.2)
Predisposes to CML and ALL
315
Why does immunophenotype matter for ALL and AML?
AML and ALL are treated very differently
| T-lineage (15%) and B-lineage (85%) ALL may be treated differently
316
How are Philadelphia positive ALL patients treated?
Imatinib
317
How is ALL treated?
Tyrosine kinase inhibitors for Ph-positive cases e.g. imantinib
Rituximab – monoclonal antibody directed at CD20 (applicable to CD20-positive cases)
318
What is the most common cause of osteomyelitis?
Staphylococcus aureus
319
What is the pentad of clinical features of thrombotic thrombocytopenic purpura?
```
Microangiopathic haemolytic anaemia
Thrombocytopenia
Fever
Neurological abnormalities
Renal impairment
```
320
What is microangiopathic haemolytic anaemia?
Microangiopathic haemolytic anaemia is a term that is used to describe the anaemia that results from physical damage to the red cells following the occlusion of arterioles and capillaries as a result of fibrin deposition or platelet aggregation
321
What is the pathophysiology of anaemia of chronic disease?
Reduction in red cell lifespan
Cytokine release
IFNg, IL1 and TNF
Reduced proliferation of erythroid precursors
Suppression of endogenous erythropoietin production
Impaired iron utilisation
322
What are some of the associations of Hodgkin lymphoma?
Increased risk in families of affected patients
Association with HLA DPB1
Epstein‒Barr virus found in >79% of over 50s
323
What can be used to predict prognosis and monitor Hodgkin patients?
ESR
324
How can you distinguish between anaemia of chronic disease (inflammation) or Fe deficiency?
Low ferritin confirms Fe deficiency
Normal or high ferritin can be ACD {or Fe deficiency in a case with inflammation and iron deficiency}
The iron transporting protein transferrin is the key
Low/normal >> ACD
High>> Fe deficiency
325
Why are iron stores sequestered in inflammation?
Hepcidin is master regulator of Iron - elevated hepcidin inhibits GI absorption of Iron and sequesters Fe in macrophage and Kupffer cells
Hepcidin is an anti bacterial/ inflammatory response protein. Removing available iron from the blood circulation deprives invading bacteria of iron required for rapid bacterial proliferation
326
What would you see on the blood film of someone with chronic myeloid leukaemia?
Neutrophils and myelocytes (not blasts if chronic phase)
| Basophilia
327
What are the different treatment options in CLL?
BCR Kinase Inhibitors: Ibrutinib (BTK), Idelalisib (PI3K
BCL2 inhibitors: Venetoclax
Experimental Cell Based Therapies: Chimaeric Antigen Receptor T cells (CAR-T)
328
What does CRAB stand for in multiple myeloma?
Calcium elevation
Renal dysfunction
Anemia
Bone disease
329
What happens to the FBC in pregnancy?
```
Mild anaemia
Red cell mass rises (120 -130%)
Plasma volume rises (150%)
Macrocytosis
Normal
Folate or B12 deficiency
Neutrophilia
Thrombocytopenia
increased platelet size
```
330
What are the nutritional demands of pregnancy?
Iron requirement
300mg for fetus
500mg for maternal increased red cell mass
RDA 30mg;
Increase in daily iron absorption:1-2mg to 6mg
Folate requirements increase
Growth and cell division
Additional 200mcg/day required
331
What are the causes of thrombocytopenia in pregnancy?
Physiological: ‘gestational’/incidental thrombocytopenia
Pre-eclampsia - associated with coagulation activation
Immune thrombocytopenia (ITP)
Microangiopathic syndromes
All other causes: bone marrow failure, leukaemia, hypersplenism, DIC etc.
332
How may ITP be treated for delivery or in PPH?
IV immunoglobulin
| Steroids etc.
333
Describe the coagulation changes in pregnancy
Increase in: factor VIII, vWF, fibrinogen, factor VII
Decrease in: protein S
PAI-1 and PAI-2 increase
- Increased thrombin generation
- Increased fibrin cleavage
- Reduced fibrinolysis
- Interact with other maternal factors
334
What are some risk factors of VTE during and following pregnancy?
- BMI > 25
- Personal/family Hx
- Air travel
- Hyperemesis gravidarum
- OHSS
- Unrelated surgery
- Age
335
What are some issues with using Warfarin in the first trimester?
Chondrodysplasia Punctata:
```
Abnormal cartilage and bone formation
Early fusion of epiphyses
Nasal hypoplasia
Short stature
Asplenia
Deafness
Seizures
```
336
What is the typical triad in antiphospholipid syndrome?
Antiphospholipid Syndrome (APLS): Recurrent miscarriage + persistent Lupus anticoagulant (LA) and/or antiphospholipid antibodies
Adverse pregnancy outcome: three or more consecutive miscarriages before 10 weeks of gestation
337
Define what is meant by postpartum haemorrhage
> 500 mL blood loss
5% of pregnancies have blood loss >1 litre at delivery
338
What is disseminated intravascular coagulation (DIC)?
```
Amniotic fluid embolism
Abruptio placentae
Retained dead fetus
Preeclampsia (severe)
Sepsis
```
339
What is myelodysplasia?
Disorder of the elderly.
Symptoms/signs are those of general marrow failure
Develops over weeks & months
340
List the different myelodysplasia disorders
Pelger-Huet anomaly (bilobed neutrophils)
Dysganulopoieses of
neutrophils
Dyserythropoiesis of red cells
Dysplastic megakaryocytes – e.g. micro-megakaryocytes
Increased proportion of blast cells in marrow (normal < 5%)
341
What are some of the driver mutations in myelodysplasia?
TP53, EZH2, ETV6, RUNX1, ASXL1
Others: SF3B1, TET2, DNMT3A
342
What is the prognosis of myelodysplasia?
1. Deterioration of blood counts
• Worsening consequences of marrow failure
2. Development of AML
– Develops in 5-50%< 1 year (depends on subtype)
– Some cases of MDS are much slower to evolve
– AML from MDS has an extremely poor prognosis and is usually not curable
3. As a rule of thumb
• 1/3 die from infection
• 1/3 die from bleeding
• 1/3 die from acute leukaemia
343
What are the two treatment options of myelodysplasia?
1. Allogeneic stem cell transplantation (SCT)
| 2. Intensive chemotherapy
344
What are all the treatment options of myelodysplasia?
1) Supportive care
Blood product support
Antimicrobial therapy
Growth factors (Epo, G-CSF, TPO-Receptor Agonist)
2) Biological Modifiers Immunosuppressive therapy Azacytidine, Decitabine, Lenalidomide (del5q variant)
3) Chemotherapy - Hydroxyurea
4) Low dose chemotherapy SC low dose cytarabine
5) Intensive Chemotherapy/SCT (for high risk MDS) AML type regimens
Allo/VUD standard/ reduced intensity
345
What are some primary and secondary disorders of bone marrow failure?
1. PRIMARY
1. Congenital: Fanconi’s anaemia (multipotent stem cell)
2. Diamond-Blackfan anaemia (red cell progenitors)
3. Kostmann’s syndrome (neutrophil progenitors)
4. Acquired: Idiopathic aplastic anaemia (multipotent stem cell)
2. SECONDARY
1. Marrow infiltration:
2. Haematological (leukaemia, lymphoma, myelofibrosis) 3. Non-haematological (Solid tumours)
4. Radiation
5. Drugs
6. Chemicals (benzene)
7. Autoimmune
8. Infection (Parvovirus, Viral hepatitis)
346
Which drugs can cause bone marrow failure?
1. PREDICTABLE (dose-dependent, common)
1. Cytotoxic drugs
2. IDIOSYNCRATIC (NOT dose-dependent, rare)
1. Phenylbutazone
2. Gold salts
3. ANTIBIOTICS
1. Chloramphenicol
2. Sulphonamide
4. DIURETICS
1. Thiazides
5. ANTITHYROID DRUGS
1. Carbimazole
347
What are the different types of aplastic anaemia?
- Idiopathic
- Inherited - Dyskeratosis congenita, Fanconi anaemia, Shwachman-Diamond
- Secondary - drugs (chloramphenicol, NSAIDs), viruses, immune
- Miscellaneous (thymoma, paroxysmal nocturnal haemoglobinuria)
348
What is the pathophysiology of aplastic anaemia?
Failure of BM to produce blood cells
“Stem cell” problem (CD34, LTC-IC) [Long-Term Culture-Initiating Cells]
Immune attack:
Humoral or cellular (T cell) attack against multipotent haematopoietic stem cell
349
What is the triad of bone marrow failure?
1) Anaemia - fatigue, breathlessness
2) Leucopenia - infections
3) Platelets - easy bruising/bleeding
350
What are the two types of aplastic anaemia?
1. Severe aplastic anaemia (SAA)
| 2. Non-severe aplastic anaemia (NSAA)
351
What is the Camitta criteria for severe aplastic anaemia?
2 out of 3 features:
1. Reticulocytes < 1% (<20 x 109/L)
2. Neutrophils (< 0.5 x 109/L)
3. Platelets (< 20 x 109/L)
Bone marrow <25% cellularity
352
How can bone marrow failure be managed?
1. Seek and remove a cause (detailed drug & occupational exposure history)
2. Supportive: Blood/platelet transfusions (leucodepleted, CMV neg, irradiated) Antibiotics
Iron Chelation Therapy
3. Immunosuppressive therapy (anti-thymocyte globulin, steroids, eltrombopag, cyclosporine A)
4. Drugs to promote marrow recovery - Oxymethone, TPO receptor agonists (eltrombopag)
5. Stem cell transplantation
6. Other treatments in refractory cases – e.g. alemtuzumab (anti-CD52, high dose cyclophosphamide)
353
What is the treatment of aplastic anaemia?
Blood products
Leucodepleted (CMV negative)
(Irradiated)
Antimicrobials
Iron Chelation Therapy (when ferritin > 1000 μg/L)
354
What is Fanconi anaemia?
1. The most common form of inherited aplastic anaemia
2. Autosomal recessive or X-linked inheritance
3. Heterozygote frequency may be 1:300
4. Multiple mutated genes are responsible
5. When these genes become mutated, this results in:
• Abnormalities in DNA repair
• Chromosomal fragility (breakage in the presence of in-vitro mitomycin or diepoxybutane)
Congenital malformations may occur in 60-70% of children with FA
355
What is dyskeratosis congenita characterised by?
Marrow failure
Cancer predisposition
Somatic abnormalities
Classical Triad:
1) Skin pigmentation
2) Nail dystrophy
3) Leukoplakia
356
What are the different inheritance patterns of dyskeratosis congenita?
X-linked recessive trait — the most common inherited pattern (mutated DKC1 gene - defective telomerase function)
Autosomal dominant trait — (mutated TERC gene - encodes the RNA component of telomerase)
Autosomal recessive trait — The gene for this form of DC has not yet been identified
