Haematology Flashcards
1
Q
What colour bottle is FBC taken in?
A
Purple top (EDTA)
2
Q
What is included in FBC?
A
Haemoglobin (Hb) White Cell Count (WCC) Platelets (Plts) Mean Corpuscular Volume (MCV) Mean Cell Haemoglobin (MCH) Mean Cell Haemoglobin Concentration (MCHC) Red Cell Distribution Width (RDW) Haematocrit (HCT) Neutrophils Lymphocytes Monocytes Eosinophils Basophils
Red Cell Count (RBC)
3
Q
Low Hb?
High Hb?
A
If low: Anaemia
If high: Erythrocytosis
4
Q
Causes of erthrocytosis?
A
- Increase Cell production (Polycythaemia Vera, Haemochromatosis)
- Dehydration
- Elevated EPO levels (Doping, Renal Carcinomas)
- Chronic hypoxia (COPD, High altitude environment)
5
Q
Values for MCV
A
<80fL = Microcytosis
80-100fL = Normocystic
> 100fL = Macrocytosis
6
Q
Values for platelets
A
<150x10^9/L = Thrombocytopaenia
> 400x10^9/L = Thrombocytosis
7
Q
Values for WCC
A
< 4.0x10^9 = Leucopeania
>11.0x10^9 = Leucocytosis
8
Q
Neurtrophils
A
low - neutropenia
high - neutrophilia
- acute immune response to infection and inflammation
- raised in bacterial infection
- chronic infection neutrophils may fall as monocytes proliferate
9
Q
Causes of neutrophilia
A
Infection Vomiting Dehydration Trauma Burns Vasculitis Rheumatoid disease Surgery Labour HAEMATOLOGICAL MALIGNANCIES Drugs (Commonly G-CSF and steroids). Idiopathic
10
Q
What value of neutrophils is considered immune compromised
A
0.5x10^9
11
Q
What is Neutropenic sepsis?
A
Temp > 38.0
Low neutrophils
12
Q
Causes of neutropneia
A
HAEMATOLOGICAL MALIGNANCY
Viral infections (Hepatitis, Influenza, HIV)
Bacterial Sepsis
Hematinic deficiencies (Classically B12)
Splenomegaly
Chemotherapy
Drugs (Phenytoin, Co-trimoxazole, Carbimazole, Gold, Chlorpromazine, Penicillamine)
Autoimmune Neutropenia
Felty’s (RA, Splenomegaly and Neutropenia)
SLE
Congenital
13
Q
Names for high / low lymphocytes
A
Lymphopenia <1.5x10^9
Lymphocytosis >4.5x10^9
14
Q
Patients with chronic severe lymphopneia should be considered for what?
A
Opportunistic infection (fungal) : Candida Pneumocystis jiroveci CMV Herpes Zoster Cryptosporidium Myocplasma Toxoplasmosis Aspergillus
15
Q
What are esinophils?
A
Designed to combat parasitic infections and modulate immune responses to viral infections. - Also associated with allergic reactions and atopy
16
Q
What is haematocrit?
A
measure of red blood cell in a serum sample as a percentage.
17
Q
What is red cell count?
A
Number of red blood cells in sample.
Used to calculate HCT and MCH
18
Q
What is Red cell distribution width
A
Range of size of the Erythrocytes
- Used in conjunction with MCV to assess possible aetiology of Anaemia
- Raised RDW think: Fe; B12; Folate; or haemolysis
- Normal RDW think: Thalassaemia; Chronic disease Renal anaemia; Hereditary Spherocytosis; Aplastic anaemia
19
Q
What is Mean Cell Haemoglobin (MCH)?
A
Measure of the ‘mass’ of haemoglobin in a cell
- Aids in the identification of Haemoglobinopathies
20
Q
What is Mean Cell Haemoglobin Concentration (MCHC)?
A
Measure of the concentration of haemoglobin PER CELL
21
Q
Causes of deranged MCHC
A
Microcytic hypochromic anaemia = low MCHC
Macrocytic normochromic = MCHC normal
Microcytic hyperchromic = High MCHC
22
Q
What is ESR?
A
The measure of sedimentation of RBCs in a column after 1hour.
- possible inflammation or ‘acute phase’ response
- Any process which can help overcome the –ve charges of the phospholipid bilayers will increase sedimentation rates
23
Q
ESR vs CRP
A
ESR:
1. Takes 24-48 hours to rise
- Remains elevated for several weeks
- Used in GP with non-specific symptoms
CRP:
1. Can begin to rise within 6 hours of injury and peaks at 36-48hours
- Typically normalizes within 7 days
- Usually used in acute setting
24
Q
What is reticulocyte count?
A
- Assessment of the number of immature blood cells in peripheral blood sample.
- Gives an indication on the rate of erythropoiesis.
- Collected in an EDTA bottle.
25
What is included in haematinics?
```
Ferritin
Transferrin/Total Iron Binding Capacity
Serum Iron Concentration
B12
Folate
```
26
What tube is used for haematinics?
- Gold top
- Turn around is usually 24hours
- Order in the context of assessment of aneamia
27
What is TIBC?
Total Iron Binding Capacity : In Vitro assessment for how much iron could be absorbed by transferrin in the blood.
28
What bottle is used for clotting studies?
Blue top
| - citrate sample
29
What is included in clotting studies?
- Prothrombin time (PT)
- Activated partial thromboplastin time (APTT)
- Thrombin time (TT)
- International normalized ratio (INR)
30
What is the normal prothrombin time?
| what pathway is PT involved in?
11-14 secs
| Extrinsic
31
What can cause prolonged PT?
1. Vitamin K Deficiency
2. Vitamin K Antagonists (Such as Warfarin)
3. DIC
4. Liver Disease
5. Congenital Factor VII deficiency
32
What causes prolonged APTT?
1. Vitamin K Deficiency (though significantly less than PT)
2. Vitamin K Antagonists (Less than PT)
3. DIC
4. Liver Disease
5. *Haemophilia A,B and C*
5. Unfractionated Heparin
6. Factor XII deficiency
33
Causes of prolonged thrombin time?
Unfractionated Heparin
DIC
Thrombolysis
34
What is INR?
A laboratory value calculated to assess anticoagulant effect of Warfarin.
Normal values = 0.8-1.2
35
What is D-dimer?
bi-product of Fibrinolysis
| - used to rule out thrombus
36
Causes of increased d-dimer?
```
PE
DVT
DIC
Thrombosis
Aortic Dissection
Malignancy
Infection
Pregnancy
Inflammation
```
37
What bottle is used for haemoglobinopathies?
EDTA - purple tops
38
What does haemoglobinopathies look at?
screening for sickling or thalassaemia disease
39
What should be sent with haemoglobinopathies?
If it's first time = send ferritin sample to r/o iron deficiencies
- blood transfusion in last 4 months can cause anomalies
40
How long does haemoglobinopathies take?
1. For Sickle cell disease an urgent sample can be complete in <1hr
2. Thalassemia can vary from 4-72 hours dependent on investigation and capability of lab.
41
Normal haemoglobin types
’Normal’/Wild Type
Results:
HbA: 95-98% - Hb with two Alpha and Two Beta complexes
HbA2: <5% - Hb with Two Alpha and Two Delta complexes
HbF: 1-2% - Foetal haemoglobin
42
Sickling disorder haemoglobin types
Sickling Disorders :
1. Sickle cell anaemia: (SS)
- Will identify HbS% (80-99%) with Zero HbA.
- Patient may have elevated HbF around 15-20% especially if on Hydroxycarbamide.
2. S/β+:
- S= sickle cell β+ = minor beta-thalassaemia
- Hb HBS% >50% and HbA% <50
3. Patient’s with Sickle Cell trait (HbAS) will have an HbS% of <50% and HbA >50%
43
Confirmatory test of sickle cell anameia
Hb Electrophoresis or High pressure liquid chromatography
44
Investigations in thalassaemia
𝛂: HPLC will only identify patients with (severe) HbH disease or Hydrops fetalis.
- As such PCR of genotype is normally used is alpha thalassemia is suspected.
β: Can be Major; intermedia or minor.
1. HPLC electrophoresis used to classify major, minor, intermedia
2. Exact Genotyping can be established with PCR
45
What bottles are used for blood films?
EDTA - purple top
46
2 ways protein electrophoresis can be carried out
Serum
| Urine
47
What bottle is used to collect blood serum for electrophoresis?
Red/brown top
48
When is urinary protein electrophoresis indicated?
1. Urinary electrophoresis its typically performed in the assessment of worsening kidney disease which could be due to DM; auto immune conditions or malignancy .
2. Haematology = Bence Jones proteins which are not always detectable in serum.
49
When is protein electrophoresis indicated?
1. Assessing + monitoring paraproteinaemia
- e.g. myeloma
2. Pt with persisting bony pain + > 60
3. Pt with elevated ESR with no obvious clinical cause
4. Hypercalcaemia with normal parathyroid hormone
50
What do you look for in protein electrophororesis?
Monoclonal spikes in the gammaglobulin region.
Raised IgM, M band present
51
Causes of raised IgM on protein electrophoresis
Multiple Myeloma
Lymphoma
CLL
Amyloidosis
MGUS
Waldenstroms Macroglobulinaemia
```
Gammopathy may also be caused by:
Rhuematoid arthritis
SLE
Liver cirrhosis
Chronic infections
```
52
Next steps after M-band found on protein electrophoresis
1. Detailed History and examination to identify possible symptoms
2. Definition of the immunoglobulin class
3. FBC; serum Immunoglobulin levels; U/E; Bone profile
M-Protein in the presence of signs above or a level of 30g/L should be referred under 2WW to Haematology
Refer patients with:
1. Urinary BJP >500mg/L
2. IgD or E M-protein bands regardless of concentration
3. IgG greater >15g/L
4. IgA and IgM >10g/L
53
What is Direct antibody testing?
AKA: Direct Coombs test
1. Used to test for immunoglobulins which are targeting erythrocytes
2. investigate for autoimmune haemolytic aneamia
3. Investigating acute haemolytic transfusion reaction.
54
What bottle is used for Direct antibody testing?
Pink top - EDTA sample
| - Turn around time 24-48 hrs
55
What is Bone Marrow Aspiration and Trephine (BMAT)?
First aspirate is spread onto slides:
1. Review by Haematology Consultant
- Can given an idea of appearance and quantity of cell lineages and often is the quickest results to get.
- Helps identify malignancies quickly so that patient can begin workup for chemotherapy
2. Then send for : immunophenotyping, cytogenetics, trephine
56
What is immunophenotyping?
- Identifies the cell linages involved in malignancy.
| - Useful to diagnosis, classification, prognostication and monitoring of response to treatment
57
What is cytogenetics?
- Chromosomal sequencing of regions associated with mutations in haematological disease (These can be advantages or disadvantageous)
- Useful in prognostication, monitoring of response to treatment and guiding treatment based on mutations.
58
What is trephine?
The ‘coring’ biopsy. Gives a ‘topographical’ detail of the bone marrow and helps identify degrees of infiltration of malignancy
59
What is tumour lysis syndrome?
1. Metabolic abnormalities which are caused by rapid cell death often occurring in the treatment of haematological disease.
2. When cells are lysed by chemotherapy their contents are released, as haematological malignancies are in the blood stream it means that they are directly released into blood stream.
3. Patients with a high (>50x10^9) WCC can also develop a tumour lysis syndrome spontaneously
60
Biochemical findings of tumour lysis syndrome
- Hyperkalemia
- Hyperuricaemia
- Hyperphosphatesmia
- Hypocalcemia
- AKI (Raise creatinine and Urea)
61
Managing tumour lysis syndrome
Prevention is better than treatment:
1. Bidaily monitoring of: Weight; Urine output; Renal function; Bone profile; LDH and Uric acid levels
- ECG to monitor arrhythmias
2. Commence Allopurinol 300-600mg in patients with normal renal function
3. IV hydration aiming for patients to produce >3L urine/day
4. IV furosemide for hyperkaleamia if patients well hydrated but be aware it can increase Ca++ and Uric acid levels
62
MCV high + High reticulocyte --> Next steps?
Possible haemolyisis:
check billirubin
- normal billirubin = ? bleed
- High billirubin = carry out blood film, LDH, DAT --> refer to haematology
63
Leukaemia blood findings
- Neutrophilia
| - esonophilia
64
Lymphoma blood findings
- esinophilia
65
When is blood film indicated?
- FBC with differential, performed with an automated blood cell counter, shows the presence of abnormal or immature cells.
- suspecting a deficiency, disease or disorder that is affecting blood cell production, such as an anaemia, decreased or abnormal production of cells in the bone marrow, or increased cell destruction
66
What pathway is APTT involved in?
Intrinsic pathway
67
Investigations for haemophilia
1. Prolonged aPTT
2. decreased or absent factor VIII or IX levels
Other:
- FBC
- PT
- Bleeding time
- VWF studies
- AST + ALT
68
Investigations for thrombophilia
1. FBC:
- anaemia
- high WBC
- abnormal platelet count
2. Peripheral blood smear
- presence of red cell fragmentation
- spherocytes,
- thrombocytopenia
- pancytopenia, or macrocytes
- Sickle cell: Howell-Jolly bodies
3. Prolonged or reduced aPTT
4. Elevated fibrinogen
5. Prolonge PT = indicate DIC
6. Normal or elevated d-dimer
7. Factor V leiden positive
69
Signs & symptoms of transfusion reaction
Chills
flushing
SOB
fever
OTHER:
headache
N+V
anxiety
70
Investigations for transfusion reaction
1. direct antiglobulin test
- postive haemolytic transfusion reaction
2. visual inspection of post-transfusion blood sample
3. repeat ABO testing on post-transfusion blood sample
- incompatibility
4. post-transfusion urinalysis
- free Hb
71
indications for ESR
- Polymyalgia rheumatica
| - Temporal arteritis
72
What does presence os bence-jones protein in urine indicate?
Multiple myeloma
```
Other:
amyloidosis
lymphoma
leukaemia
chronic renal failure
```
73
Increased reticulocyte indicate ....
Bleeding
Haemolytic anaemia
Haemolytic disease of the newborn
74
Decreased reticulocyte indicate ....
Iron deficiency anaemia
Pernicious anaemia or folic acid deficiency
Aplastic anaemia
Radiation therapy
Bone marrow failure caused by infection or cancer
75
Explain bone marrow biopsy aspirate
1. The bone marrow biopsy procedure itself is in two parts that are undertaken concurrently by the specialist Doctor or Nurse.
2. A local anaesthetic is given around the back of the hipbone when you are lying on your side - after giving this time to numb the area, the procedure will begin.
3. The bone marrow aspirate will take a sample of fluid extracted via a syringe and needle - this is spread on glass slides (to examine under the microscope) and placed in sample bottles that will be sent to the specialist laboratory.
4. There will also be a core of the bone marrow taken with a larger bore needle. This is called a trephine biopsy and is examined by microscopy.
5. Both the aspirate and trephine are important for diagnosis and assessment of disease response.
76
Investigation for ALL
Bone marrow test
| Lymph node biopsy
77
Investigation for AML
1. Bone marrow biopsy
| 2. Cytogenetic
78
Investigation for CLL
1. FBC
2. Bone marrow biopsy
3. Lymph node biopsy
4. CT
79
Investigation for CML
1. Bloods
2. PCR
3. Bone marrow biopsy
80
Investigation for Hodgkin lymphoma
Biopsy
| CT /MRI/PET
81
Investigation for Non- Hodgkin lymphoma
Biospy
| Staging = CT/MRI/PET
82
Investigation for myeloma
```
FBC
skeletal survey
X-ray
urine test
bone marrow biopsy
```
83
Investigations for Thrombotic Thrombocytopenia Purpura (TTP)
Blood test
| blood film
84
Investigations for thalassaemia
blood test
| antenatal screening
85
CA 27.29 - indicates which cancer?
breast
86
CEA - indicates which cancer?
Colorectal cancer
87
CA 19-9 - indicates which cancer?
Pancreatic and biliary tract cancers
88
AFP - indicates which cancer?
Hepatocellular carcinoma, nonseminomatous germ cell tumours.
89
Beta-hCG - indicates which cancer?
Nonseminomatous germ cell tumours, gestational trophoblastic disease.
90
CA 125 - indicates which cancer?
Ovarian cancer
91
PSA- indicates which cancer?
Prostate cancer
