Haematology

Question 1

Differential DIagnosis of lymphadenopathy

Answer 1

• Lipoma - usually large and soft; may not be in usual lymph node area
• Abscess - tender and erythematous, may be fluctuant
• Sebaceous cyst - intradermal locations
• Thyroid nodule
• Secondary to recent immunisation

Question 2

Causes of ecchymoses

Answer 2

• trauma
• thrombocytonpenia or platelet dysfunction
• coagulation disorders
  
  • Aquired
    
    • Vitamin K Deficient
    • Liver disease
    • Anticoagulants
    • DIC
  • COngenital
    
    • Haemophilia A and B
    • Von Willebrands
• senile ecchymoses due to loss of skin elasticity

Question 3

Felty’s syndrome

Answer 3

• rheumatoid arthritis
• neutropenia
• splenomegaly
• can also be associated with
  
  • thrombocytopenia
  • haemolytic anaemia
  • skin pigmentation
  • leg ulceration

Question 4

Thrombocytopenia causing petechiae

Answer 4

Platelet count <100 x 10^9/L

Increased destruction

• Immunological
  
  • ITP
  • SLE
  • Drugs - quinine, sulfonamide, methyldopa
• Non-immunological
  
  • damage eg prosthetic heart valve
  • consumption eg DIC
  • Loss eg haemorrhage

Reduced productions

• Marrow aplasia
• marrow invasion

Sequestration in hypersplenism

Question 5

Platelet dysfunction causing petechaie

Answer 5

• Congenital or familial
• Aquired
  
  • myeloproliferative disease
  • dysproteinaemia
  • chronic renal failure, chronic liver disease
  • drugs like aspirin

Question 6

Petechiae as a result of small vessel diseaswe

Answer 6

• infection
  
  • infective endocarditis
  • septicaemia eg meningococcal
  • viral exanthemata
• drugs eg steroids
• Scurvy (vitamin c deficiency) - classically perifollicular purpura on the lower limbs
• Cushings syndrome
• Vasculitis
  
  • polyarteritis nodosa
• fat embolism
• dysproteinaemia

Question 7

Causes of localised lymphadenopathy

Answer 7

1. Inguinal nodes
   
   • infection of lower limb
   • sexually transmitted disease
   • abdominal or pelvic malignancy
   • immunisations
2. Axillary nodes
   
   • infections of the upper limb
   • carcinoma of the breast
   • disseminated malignancy
   • immunisations
3. Epitrochlear nodes
   
   • infection of the arm
   • lymphoma
   • sarcoidosis
4. Left supraclavicular nodes
   
   • metastatic malignancy from the chest, abdomen or pelvis
5. Right supraclavicular nodes
   
   • malignancy from the chest or oesophagus

Question 8

Causes of generalised lymphadenopathy

Answer 8

• lymphoma - rubbery and firm
• leukaemia - CLL/ALL
• infections
  
  • viral - CMV, EBV, HIV
  • bacterial - TB, brucellosis, syphilis
  • protozoal - toxoplasmosis
• connective tissue disease - RA, SLE
• infiltration - sarcoid
• drugs - phenytoin

Question 9

Causes of local lymphadenopathy

Answer 9

• local acute or chronic infection
• metastases from carcinoma or other solid tumour
• lymphoma, espcially hodgkins disease

Question 10

Causes of a massive splenomegaly

Answer 10

• Common
  
  • Chronic myeloid leukemia
  • Myelofibrosis
• Rare
  
  • Malaria
  • Kala azar
  • Primary lymphoma of the spleen

Question 11

Causes of a moderate splenomegaly

Answer 11

• Same as for massive
• portal hypertension
• lymphoma
• acute or chronic leukemia
• thalassaemia
• storage diseases

Question 12

Causes of a small splenomegaly

Answer 12

• as for moderate and massive
• polycythaemia rubra vera
• essential thrombocythaemia
• haemolytic anaemia
• megaloblastic anaemia (rare)
• Infection
  
  • viral - EBV, hepatitis
  • bacterial - infective endocarditis
  • protozoal - malaria
• connective tissue disorders
  
  • rheumatoid arthritis
  • Systemic lupus erythematosus
  • polyarteritis nodosa
• Infiltrations - amyloid, sarcoid

Question 13

Signs of severe anaemia

Answer 13

• pallor
• tachycardia
• wide pulse pressure
• systolic ejection murmurs due to a compensatory rise in cardiac output
• cardiac failure if myocardial reserve is reduced

Question 14

Causes of a pancytopenia

Answer 14

• Aplastic anaemia : severe hypoplasia of the erythroid, myeloid and platelet precursor cell lines in the bone marrow
• Marrow infiltration by leukemia, lymphoma, carcinoma, myeloma, myelofibrosis, granulomata
• other: subleukemic phase of acute leukemia, pernicious anaemia, hypersplenism, SLE, folate deficieny, paroxysmal nocturnal haemoglobinuria

Question 15

Causes of a microcytic anaemia

Answer 15

• iron deficieny - chronic bleeding, malabsorption, hookworm, pregnancy
• thalassaemia minor
• sideroblastic anaemia
• long standing anaemia of chronic disease

Question 16

Causes of a macrocytic anaemia

Answer 16

Megaloblastic bone marrow (oval macrocytes)

• B12 deficiency due to pernicious anaemia, gastrectomy, tropical sprue or bacterial overgrowth, ileal disease, poor diet
• Folate deficiency due to dietary deficiency (alcoholics), malabsorption (coeliac disease), increased cell turnover (pregnancy, leukemia, chronic haemolysis or inflammation), anti-folate drugs (phenytooin,methotrexate, sulfasalazine)

Non-megaloblastic bone marrow (round macrocytes)

• alcohol
• cirhhosis
• reticulocytosis
• hypothyrodism
• marrow infiltration
• myelodysplastic syndrome
• myeloproliferatice disease

Question 17

Causes of a normocytic anaemia

Answer 17

Bone marrow failure

• Aplastic anaemia - drugs, SLE,radiation, viral hepatitis, pregnancy, Fanconi syndrome
• ineffective haematopoeisis - myelodysplastic syndrome, paroxysmal nocturnal haemoglobinuria
• infiltration

Anaemia of chronic disorders

• chronic inflammation
• malignancy
• endocrine deficiency’s
• liver disease
• chronic renal failure
• malnutriton

Haemolytic anaemia

• intracorpuscular defects - hereditary spherocytosis, elliptosis, haemoglobinopathis
• extracorpuscular defects - immune -autoimmune incompatible blood transfusion, hypersplenism, trauma, microangiopathic, malaria

Question 18

Signs of polycythemia rubra Vera

Answer 18

-plethoric appearance including engorged conjunctival and retinal vessels -scratch marks from prutitis -splenomegaly -bleeding tendency -peripheral vascular and ischemic heart disease -gout -mild hypertension

Question 19

Causes of polycythemia

Answer 19

Absolute polycythemia (increased red cell mass) -idiopathic polycythemia rubra vera -secondary polycythemia -increased erythropoietin (renal disease, HCC, uterine fibroma, virile sing syndromes, cushing’s, phaechromocytome) -hypoxia states ( erythropoietin secondarily increased in chronic lung disease, sleep apnoea, living at high altitude, cyanosis congenital heart disease, abnormal haemoglobins, CO poisoning)

Question 20

Ann Arbor Staging

Answer 20

STAGE I Disease confined to a single lymph node region or a single extra-lymphatic site. (IE) STAGE II Disease confined to 2 or more lymph node regions on one side of the diaphragm STAGE III Disease confined to lymph nodes on both sides of the diaphragm with or without localized involvement of the spleen (IIIS) other extra lymphatic organ or site (IIIE) or both (IIIES) STAGE IV Diffuse disease with one of more extra lymphatic organs (with or without lymph node disease) For any stage a= no symptoms B= fever, weight loss greater than 10% in 6 months, night sweats E involves direct invasion from lymph node into surrounding tissue