Haematology Flashcards
What type of transfusion is TRALI most common
FFP
What is normal central venous pressure
0-6
What is platelet target for before invasive procedure
50
What is platelet target for before surgery or invasive procedure at critical site
100
Pathophysiology of factor V leiden
Resistance of activated protein C due to conformational change in factor V
What is the reversal agent for dabigatran
Idarucizumab
Pentad for TTP
Fever
Neuro signs
Renal failure
Haemolytic anaemia
Thrombocytopenia
What is point of irradiating blood products for immunosuppressed patient
Prevent graft versus host disease
What are bite and blister cells alongside heinz bodies seen in
G6PD
What is a sequestration crisis
When blood pools in an organ due to sickling
How identify a sickling episode on bloodwork
Reticulocytes
Where do sequestration crises occur
Spleen
Lungs
What is management of PCV
Aspirin long term to prevent thrombotic events
Venesection
Chemo- hydroxycarbamide
What are risks of PCV
Thrombotic events
Progression to myelofibrosis or AML
Presentation of acute GVHD
Painful maculopapular rash
Jaundice
Diarrhoea
Presenation of chronic GVHD
Skin- scleroderma, vitiligo, lichen planus
Eyes- keratoconjunctivitis, scleritis
Restrictive lung disease
GI- dysphagia, odonyphagia
Difference between toxoplasmosis and CNS lymphoma on HIV CT scan
Toxoplasmosis
- multiple lesions
- ring enhancing
- thallium SPECT negative
CNS lymphoma
- single lesion
- homogenous
- thallium SPECT positive
What causes CNS lymphoma in HIV
EBV
Most common cause of cerebral lesion in HIV patient
Toxoplasmosis- 50%
Lymphoma- 30%
Management of toxoplasmosis lesions in brain
Sulfazadine
Pyrimethamine
Management of CNS lymphoma in HIV
Steroids
Chemo- methotrexate
Radiotherapy
What is post operative anaemia
Where lose blood intraoperatively and then end up with anaemia as a result in following days
What are mirror image nuclei
Reed steenberg cells
In a non-urgent scenario, how long are transfusions given over
90-120 mins
What is the RBC threshold for requiring transfusions
70- no ACS
80- ACS present
What causes urethritis in a male that is negative for gram-neg diplococci
Cant be chlamydia or gonorrhoea so most likely is mycoplasma genitalum
Main constituent of cryoprecipitate
Factor 8
What is in cryoprecipitate
Factor VIII
Fibrinogen
Can be VWB and factor 13
Blood findings of anaemia of chronic disease
Normocytic anaemia
High ferritin
Low TIBC
What is mangement of TLS
Hyperhydrate
IV allopurinol or rasburicase
What would cause a stable CLL patient to become severely unwell suddenly with B symptoms
Richter transformation to high grade lymphoma
TRALI vs TACO
TRALI
- hypotension
TACO
- hypertension
- raised JVP
What is use of hydroxyurea in SCD
Chronic use to prevent further relapses if there are consistent relapses
When are platelet transfusions CI
Chronic bone marrow failure
ITP
Heparin induced thrombocytopenia
TTP
What is threshold for needing a platelet transfusion if actively bleeding
Below 30
What is threshold for needing platelet transfusion when not bleeding
Below 10
Provided not CI from
- Chronic bone marrow failure
- ITP
- Heparin induced thrombocytopenia
- TTP
What is rain drop skull seen in
Multiple myeloma
How is multiple myeloma initially investigated
Serum protein electrophoresis and urinalysis for bence jones protein
How is multiple myeloma confirmed
Bone marrow aspiration showing increased plasma cells
What imaging is used for multiple myeloma
Whole body MRI
Hodgkins lymphoma presentation
Bimodal presentation -20s and then 60-80
B symptoms
- weight loss
- night sweats
- fever
Pruritus
Pain on drinking
Lymphadenopathy most commonly in neck and supraclavicular
Reversal agent for rivaroxaban and apixaban
Andexanet alpha
Management of sickle cell crisis
Opiates
Fluids
Oxygen
What is t(9;22) translocation seen in
CML mainly
Also ALL
What is post thrombotic syndrome
A complication long term of DVT where can get chronic venous HTN. Post thrombotic syndrome incorporates
- painful heavy calves
- itching
- swelling
- varicose veins
- venous ulceration
Management of post thrombotic syndrome
Compression stockings
Causes of B12 defic
Vegan diet
Post gastrectomy
Coeliac
Pernicious anaemia
Crohns
How long are VTEs treated for in cancer
6 months as treat like unprovoked as ongoing risk factor
What is first line for DVT
Apixaban or rivaroxaban
What is anticoagulant choice for people with cancer
DOAC
What do if renal impairment and needs anticoagulant
LMWH
How long treat a provoked VTE for
3 months
How long treat an unprovoked VTE for
6 months
How does wells score influence investigations for DVT
1= DVT unlikely therefore do D-dimer within 4 hours
2 or more= DVT likely so do USS
What do if wells score 2 or more
Do USS within 4 hours
If not able to measure D-dimer and give interim anticoagulation
What do if wells score 1
Do D-dimer within 4 hours
If not possible then give interim anticoagulation
How interpret D-dimer when wells score is 1
If positive then do USS within 4 hours, if can’t give interim anticoagulation
If negative consider other diagnoses
What do if USS is negative after wells score=2 or more
Do d-dimer
What do if USS negative but D-dimer positive
Stop anticoagulation
Repeat USS in a week
Definitive diagnosis of SCD
Haemoglobin electrophoresis
What happens to bleeding time and APTT in VWB
Both prolonged
What use to treat acute intermittent porphyria
IV haem arginate
What is a reduced leukocyte ALP seen in
CML
What is given long term to prevent acute sickle cell crises
Hydroxycarbamide (hydroxyurea) as it increases HbF
What blood transfusion complication does IgA deficiency put you at risk of
Anaphylaxis
Folate deficiency presentation
Anaemia
Glossitis
Blood film findings of megaloblastic anaemia
Hypersegmented neutrophils
Megaloblasts
Metamyelocytes
What is used to treat neutropenia in chemotherapy
Filgastrim- GCS-F
Which medications increase risk of VTE
HRT
3rd gen COCP
Tamoxifen
Antipsychotics
Which electrolyte abnormality are most likely to see after a transfusion
Hyperkalaemia
Causes of sideroblastic anaemia
MDS
TB medications
Alcoholism
Lead poisoning
What is sideroblastic anaemia
where fail to fully form heam leading to a ring of iron around the RBC
Blood findings of sideroblastic anaemia
High iron
High ferritin
High transferrin saturations
Blood film will show basophilic stippling
What is basophilic stippling seen in
Sideroblastic anaemia
Management of ITP
Oral prednisolone
If needs be can use IVIG
If give more than 1 unit of RBC what need to give in between
Furosemide
What can be used to treat VWB disease
If mild- tranexamic acid
If more severe then desmopressin or factor VIII concentrates
Differentiating IDA from ACD
IDA
- very low iron ie less than 8
- high TIBC
- low ferritin
- low transferrin sats
ACD
- low iron ie less than 15
- low TIBC
- high ferritin
- low transferrin sats
What are howell jolly bodies and pappenheimer bodies seen in
Post splenectomy
What are indications for exchange transfusion in SCD
Stroke
Splenic sequestration
Acute chest syndrome
Sickle crises
Which hodgkins lymphoma has best and worst prognosis
Best= lymphocyte predominant
Worst= lymphocyte depleted
Management of acute haemolytic anaemia
Stop transfusion
IV fluids
Haem review
If are deficient in folate and B12, how administer
B12 injections first as folate can precipitate subacute degeneration of spinal chord
Then once levels are normal can give folate
Alphabetical- B->F
Management of TRALI
Stop tranfusion
Fluids
Titrate oxygen
Abdo pain, fever and hypotension after transfusion
Acute haemolytic reaction
Management of allergic reaction to transfusion
Temporarily stop the transfusion
Give an antihistamine
Causes of cold AIHA
Mycoplasma
EBV
Lymphoma
Presentation of cold AIHA
Raynauds
Fatigue
MOA of dabigatran
Direct thrombin inhibitor
MOA of apixaban and rivaroxaban
Direct factor Xa inhibitor
What is a raised HbA2 seen in
Beta thalassaemia trait
Presentation of acute chest syndrome
SOB
Chest pain
Pulmonary infiltrates
Universal donor for FFP
AB rhd negative
Pancytopenia a few years post chemo/radiation
MDS
How can differentiate MDS and myelofibrosis on presentation
Myelofibrosis more likely to have B symptoms on top of pancytopenia
Presentation of lead poisoning
Abdominal pain
Motor peripheral neuropathy
Neuropsychiatric features
Constipation
Blue lines on gum margin
What are blue lines on gum margin seen in
Lead poisoning
Management of lead poisoning
Chelating agents
- DMSA
- penicillamine
B12 deficiency presentation
Anaemia
Glossitis
Subacute degeneration of the spinal chord
What do anisocytosis, macrocytosis and hyposegmentation of the neutrophils suggest
MDS
Presentation of AIP
abdominal: abdominal pain, vomiting
neurological: motor neuropathy
psychiatric: e.g. depression
hypertension and tachycardia common
Autoimmune haemolytic anaemia treatmetn
Steroids
Rituximab too
Who is benign familial neutropenia seen in
black African and Afro-Caribbean ethnicity
Which drugs cause aplastic anaemia
Phenytoin
Chloramphenicol
Sulphonamides
What give for VTE if allergic to DOAC
Warfarin
What are siderocytes seen in
Hyposplenism
When and how confirm diagnose of G6PD
Enzyme assay 3 months after
Mangement of TACO
Slow or stop
IV furosemide
Sickle cell lung presentation with infiltrates in the lung
Acute chest crisis
How manage IDA before surgery
Depends on time to surgery
Oral iron takes 2-4 weeks to work
If less than this or oral not tolerated then give IV
Management of INR 5-8 if on warfarin but no bleeding
Withhold 1-2 doses and reduce subsequent dose when restart
Management of INR 5-8 if on warfarin but minor bleeding
Stop warfarin
IV vitamin K
Restart when INR under 5
Management of INR>8 if on warfarin but no bleeding
Stop warfarin
Oral vitamin K
Remeasure in 24 hours and restart once INR under 5 if not regive IV vitamin K
Management of INR>8 if on warfarin but minor bleeding
Stop warfarin
IV vitamin K
Repeat INR in 24 hours and regive if INR over 5
Restart when under 5
Management of major bleeding if on warfarin
Stop warfarin
IV vitamin K
Give prothrombin complex concentrate
What is alternative prothrombin concentrate if bleeding on vitamin K
FFP
As a rule of thumb when do you restart warfarin when restarting after bleeding/high INR
Under 5
What counts as major bleeding on warfarin
Intracranial
Variceal
GI
What is target INR for surgery if on warfarin
Less than 1.5
When stop warfarin pre surgery
5 days
What is management if on INR drops below 2 on warfarin
Increase dose and start LMWH
What is lower INR threshold to be concerned by when on warfrain
If drops below 2 then be concerned and start LMWH
IDA on examination
Glossitis
Angular cheilitis
Soft ejection systolic murmur which doesnt radiate
Pallor
Potassium of 7.6 in context of AKI, what need to consider
Dialysis
What can a soft ejection systolic murmur which doesnt radiate suggest
Anaemia
What is score for assessing risk of pressure ulcers
Waterlow
What is koilonychia
Spooning of the nails
How replace B12
Loading regime of IM 3/week
Then 1mg IM every 3 months
Polycythaemia presentation
VTE and thrombosis
Gastric ulcer disease
Aquagenic itch
Gout
Ruddy appearance and plethoric conjunctiva
Splenomegaly
In an urgent scenario how fast can transfusion be given
STAT
How investigate acute heamolytic reaction
Check patient details
Redraw blood for G&S and X match
Coombs test will give definitive diagnosis
What use to stage lymphomas
PET
What can AML develop from
PCV
Myelofibrosis
MDS
Auer rods
AML
Philadelphia chromosome
CML and ALL
BCR ABL gene
9:22
Imatinib treatment
What investigation is done for suspected leukaemia
FBC witin 48 hours
What investigation done to confirm leukaemia
Bone marrow biopsy at iliac crest
What are 2 types of bone marrow biopsy
Aspiration- just fluid
Trephine- take solid lump
What are smudge and smear cells seen in
CLL
Blood findings of TLS
High uric acid, potassium and phosphate
Low calcium
Complications of TLS
Uric acid kidney stones
AKI from build up of uric acid
Systemic inflammation from cytokine release
Arrythmias from hyperkalaemia
What do before chemo for patients with high risk of TLS
Hyperhydrate
What chemo give for all myeloproliferative diseases
Hydroxycarbamide
Essential thrombocytosis management
Aspirin
Hydroxycarbamide
Anagrelide
What can cause myelofibrosis
Primary myelofibrosis- radiotherapy etc
PCV
Essential thrombocytosis
Management of myelofibrosis
Hydroxycarbamide
Ruloxitinib
Allogenic stem cell transplant is gold standard
What gives ruddy complexion and conjunctival plethora
PCV
( conjunctival plethora is opposite to pallor)
Main investigation results of myelofibrosis
Dacrocytes or tear drop cells on blood film
Fibrosis in BM on biopsy
Spleno and hepatomegaly in myeloproliferative conditions
Caused by extramedullary haematopoeisis
Causes of MDS
Chemo
Radiation
Old age
Blood findings of MDS
Pancytopenia
Macrocytic anaemia
How diagnose MDS
Hypercellular with lots of blasts on bone marrow
Management of MDS
Supportive- transfusions, EPO and G-CSF
Allogenic SCT is curative
Thrombophillias
Protein S and C deficiency
Factor V leiden
APL
Antithrombin deficiency
Haemophillia inheritance
X linked recessive
Haemophilia management
If bleed give IV respective factor or if mild A then desmopressin
In severe cases can give prophylactic infusions throughout year
VWB management
No daily management just give desmopressin, tranexamic acid or VWB if active bleed
Long term SCD management
Hydroxyurea
5 yearly pneumococcal vaccine
Complications of SCD
Thrombotic crises
Sequestration
Aplastic
Acute chest syndrome
Management of sickle cell sequestration
Fluids and transfusions
Acute chest syndrome management
Oxygen
Fluids
Pain relief
MGUS vs smouldering myeloma
Plasma cells under 10% in MGUS
Myeloma management
Drugs- steroids, bortezomib and thalidomide
Allogenic stem cell transplant acceptable
If suspect myeloma what do in GP
Serum electrophoresis and urinary bence jones within 48 hours
If any come back suggestive of myeloma do 2WW
Blood findings of myeloma
Hypercalcaemia
Kidney injury
Anaemia
Raised ESR
Hyperviscosity
Heparin induced thrombocytopenia pathophysiology
Occurs 5 days after starting typically UFH
Get antibodies which activate and reduce platelets
Heparin induced thrombocytopenia management
Stop heparin
Refer to haem to start alternate anticoag like fondaparinux
What do schistocytes indicate
Microangiopathic haemolytic anaemia
Investigation for AIP
Urine sample
Causes of microcytic anaemia
TAILS
Thalassaemia
Anaemia of chronic disease
IDA
Lead poisoning
Sideroblastic anaemia
Thalassaemia diagnosis
Hb electrophoresis
Causes of normocytic anaemia
3 As 2 Hs
ACD
Aplastic
Acute blood loss
Haemolytic anaemia
Hypothyroidism
Macrocytic anaemia causes
Megaloblastic
- b12
- folate
Non-megaloblastic
- alcohol
- liver disease
- reticulocytosis
- hypothyroidism
- drugs like azathioprine
Causes of haemolytic anaemia
Acquired
- AIHA
- prosethic valve
- MAHA
- malaria
Genetic
- hereditary elliptocytosis and spherocytosis
- G6PD
MAHA causes
HUS
DIC
TTP
Adenocarcinoma
What causes dark urine in morning with thrombosis risk
Paroxysmal nocturnal haemoglobinuria- loss of proteins on surface of RBC
Warm AIHA causes
Idiopathic- most common
SLE
CLL
Lymphoma
Drugs- methyldopa
