Haematology Flashcards
B12 and folate deficiency markers
B12 will have elevated homocysteine AND MMA
Folate will be only homocysteine
B12 deficiency - features, film, cause, abs
Macrocytic anaemia, glossitis, stomatitis, sub-acute combined degeneration
Additional features on film: oval microcytes, hyper-segmented neutrophils, low reticulocyte count
Most common:
Pernicious anaemia
- autoimmune destruction of gastric mucosa/ parietal cells
- intrinsic factor antibodies are specific
- parietal cell antibodies are sensitive
Causes of hemolysis
Intravascular = fragmentation (MAHA, DIC, mechanical), PNH, PCH
Extravascular = immune mediated, RBC membrane, RBC enzymes, metabolic defects, infections
Thrombotic thrombocytopenic purpura (TTP) - features, gene, management
– haemolysis with red cell fragmentation
– thrombocytopenia
– fever
– neurological changes
– renal impairment
ADAMTS13
- deficiency (<5%) due to acquired antibodies
- usually cleaves vWF»_space; nets formed that use up plt and shear RBCs
Management:
- PLEX (removes ab + vWF while replacing ADAMTS13)
- FFP will replace ADAMTS13
- steroids + rituximab
- Caplacizumab (prevents platelet interaction with vWF)
Eculizumab
Anti-C5 humanized chimeric monoclonal antibody
* Targets the terminal component of the complement cascade (reducing haemolysis)
* Vulnerability to infection by encapsulated organisms
Clinicaluses:
– Atypical haemolytic uraemic syndrome
– Paroxysmal nocturnal haemoglobinuria
PNH diagnosis and
Defective PIG-A
Diagnosis: current gold standard is flow cytometry
– loss of CD55 and CD59 on red cells and neutrophils
– FLAER: fluoroscein-labelled pro-aerolysin which binds selectively
to GPI-anchor
Management
– Transfusions; supportive care; SCT
– Thrombosis management: life long after first thrombosis
– Eculizumab: fewer transfusions and cessation of haemoglobinuria
Paroxysmal cold haemoglobinuria
Rare form of AIHA with acute intravascular haemolysis after exposure to cold
Causes
– Idiopathic, syphilis, viral infections (kids)
– Biphasic IgG anti-P antibody (Donath-Landsteiner Antibody): binds RBC at low temperatures and upon warming complement- mediated lysis occurs
Findings
– Blood film shows red cell agglutination
– Intra-vascular haemolysis
– anti-P antibody
Management
– Cold avoidance, supportive care
– Similar to AIHA discussed later
– Splenectomy not useful (haemolysis mainly intra-vascular)
Warm AIHA
DAT: IgG +/- complement components (C3d) - cleared by reticuloendothelial system
Anaemia, haemolysis, spherocytes, splenomegaly
Causes: Idiopathic
- SLE/autoimmune disease
– Lymphoproliferative disease: CLL/lymphoma
– Infection: Hep C, CMV
– Drugs: methyldopa, antibiotics
– Evan’s syndrome
Management
- transfusion as needed (can continue to lyse)
- prednisolone 1mg/kg
- IVIg
- splenectomy, rituximab, other immunosuppression
Cold AIHA
DAT: C3d only- most typically IgM antibody react with RBCs <37°C
Causes are secondary:
- lymphoproliferative disorder
- mycoplasma
- EBV
- autoimmune disease
- Rarely is “Primary cold agglutinin disease”
Management:
- cold avoidance, chlorambucil (underlying LPD), rituximab
(Does not respond to steroids or splenectomy)
- Inhibition of Complement C1s with Sutimlimab appears promising at increase hb, reducing fatigue, halting haemolysis
Hereditary spherocytosis
Most common inherited haemolytic anaemia
- Autosomal dominant
- Haemolysis of varying intensity – worsened by illness
- jaundice, cholelithiasis, splenomegaly
Investigations:
– Film: polychromasia, prominent spherocytes
– FBC: increased MCHC, RDW, reticulocytes
– Biochemical evidence of haemolysis
– DAT: negative
– Flow cytometry: eosin-5-maleimide (EMA) binding (Sensitive to HS, SEAO, congenital dyserythropoietic anaemia)
Management:
- folate supplementation
– Splenectomy
G6PD deficiency
- Most common RBC metabolic defect
- X-linked
- Required for NADPH and oxidation of G6P
- Benefit in survival with malaria
- Oxidative hemolyitic crisis»_space; bite cells
- Precipitants: primaquine, dapsone, bactrim, aspirin, Vitamin K analogues, moth balls, lava beans, amyl nitrite
- Management: avoid/stop precipitant, transfusion if severe
α-thalassaemia
α-thal trait: normal HPLC and electrophoresis; requires molecular studies to diagnose
HbH Disease (–/-α): chronic haemolysis, splenomegaly; HbH inclusions; HbH on HPLC; confirmation by genetic studies
Hydrops foetalis (–/–): incompatible with extra-uterine life; Hb Barts (γ4) only
β-thalassaemia
Minor
- Reduced Hb A (α2β2)»_space; compensatory increase in Hb A2 (α2δ2) and in 25% Hb F (α2γ2)
- Poikilocytosis, basophilic stippling, target cells
Major
- transfusion dependent (>90)
- Erythroid marrow expansion, haemolysis, extra-medullary haemopoiesis
- Developmental delay, skeletal abnormalities: secondary to both chronic anaemia and iron overload
- Iron overload major cause of morbidity/mortality: deferoxamine (<1000)
- features as above but more severe (Hb A may be absent)
Sickle cell disease
Autosomal recessive
β-globin gene - GAG to GTG > Valine to Glutamate
Polymerises leading to hemolysis
Hyposplenism
Management
- hydroxyurea (induces Hb F)
- transfusion
- Voxeletor = polymerisation inhibitor
Chemotherapy associated with AML/MDS (2)
Alkylating agents ( 5-10 years)
* Cyclophosphamide
* Melphalan
* Busulfan
Topoisomerase II inhibitors (1-5 years)
* Etoposide
* Mitoxantrone
Oncogenic viruses (3)
EBV (aka HHV4) in immunocompromised individuals
* Strong association with B cell lymphomas
* Burkitt lymphoma, Classical Hodgkin lymphoma, DLBCL, PCNSL, plasmablastic lymphoma
* Post transplant lymphoproliferative disorder (PTLD)
HTLV-1 - adult T-cell leukaemia/ lymphoma
HHV8 - kaposi sarcoma
Flow cytometry: lymphoma vs leukemia
Lymphoma
* Aberrant B-cell, T-cell, NK-cell antigens
* Clonality analysis in B-cell NHL: neoplastic cells exhibit monotypia (over expression of either kappa or lambda); TRBC1 for T cell clonality
Leukaemia
* CD45 (human leucocyte antigen) to gate blast population
* Lineage differentiation (ALL vs AML), and maturation stages
Cytogenetics and fish
Cytogenetics
- Grow cells in culture and arrest in metaphase
- Good for large gains, losses and translocations
FISH confirms abnormalities with specific probes
Risks to fertility with haematology treatments (5)
- Increasing age
- Pelvic radiotherapy increases risk of uterine rupture
- Alkylating agents
- Platinum based treatments
- Anthracyclines and anti metabolites – lower risk
Essential thrombocythemia - genes, features, management
Driver genes
* JAK2 (V617F) in 60%-65%
* CALR exon 9 indels in 20%-25%
* MPL exon 10 ~5%
* About 10% of patients do not carry any of the above (the so-called triple-negative cases)
Clinical features
* Platelet count ≥450
* Pseudohyperkalemia with marked thrombocytosis - in vitro phenomenon
* Normocellular bone marrow with proliferation of enlarged megakaryocytes
Clinical outcome
* risk of venous and arterial thrombosis (triple negative have low incidence)
* Leukemic transformation <1% at 10 years
Management (risk dependent - IPSET score)
- observation
- aspirin (<60yo and JAK2 V617F)
- aspirin + hydroxyurea (>60yo and JAK2 wild-type)
- systemic anticoagulation + hydroxyurea (>60 and JAK2 V617F OR previous thrombosis)
Polycythemia Vera - genes, features, management
- JAK2 (V617F) ~ 96%
- JAK2 exon12 ~ 4%
- Wild-type JAK2 extremely rare
Clinical features
* Hb >16.5g/dL in men, Hb >16.0g/dL in women or hematocrit >49% in men or > 48% in women
* Erythrocytosis frequently combined with thrombocytosis and/or leukocytosis
* Bone marrow hypercellularity for age with trilineage growth (panmyelosis)
* Supressed EPO
Clinical outcome
* risk of venous and arterial thrombosis
* Leukemic transformation 3% at 10years
Management
* Risk stratification (BSH guidelines 2018)
Low risk: Age <65, No hx PV associated arterial or venous thrombosis.
High risk: Age ≥65, hx of prior PV associated arterial or venous thrombosis.
- Low dose aspirin for all
- HCT target <0.45
- Venesection
- Addition of cytoreductive therapy (hydroxyurea or interferon) in high risk patients
Primary Myelofibrosis - genes, features, management
Driver genes
* JAK2 (V617F) in 60%-65%
* CALR exon 9 indels in 25%-30%
* MPL exon 10 mutations 5%
* About 5%-10% of patients do not carry any of the above somatic mutations (triple-negative
cases)
Clinical features
* Pre fibrotic phase
* Anaemia, leucocytosis, raised LDH, splenomegaly
Clinical outcome
* DIPSS score
* Risk of leukaemic transformation
Management
* Supportive
* Disease modifying – JAK2 inhibitor
* Allogeneic stem cell transplant for younger patients
Chronic myeloid leukaemia - genes, features, management
Driver genes
- Philadelphia chromosome (Ph) - reciprocal translocation between 9 and 22 [t(9;22]
- Gives rise to a BCR-ABL1 fusion gene
- deregulated tyrosine
kinase activity (p210)
Clinical features
- Chronic phase – 90% of patients at diagnosis
- Blast phase - myeloid or lymphoid
Management
* Risk stratification – Sokal, Hasford or EUTOS scores
* TKIs – three generation, IRIS trial – imatinib vs IFN/cytarabine, imatinib demonstrated superior safety and efficacy with 11 year PFS>90%
* Major and deep responses are achieved faster and more frequently with second-
generation TKIs
* PFS only marginally improved
* OS same irrespective of which TKI is used first-line
Mastocytosis
Increased accumulation of abnormal mast cells in various organs or tissues - spectrum to mast cell leukaemia
Classification
* Cutaneous
* Systemic
* Localised mast cell tumours
Activation mutation of the KIT receptor >80% D816
Chronic myelomonocytic leukaemia - features and treatment
MPN features
* Leucocytosis , monocytosis >1 x 109/L for longer than 3 months (excluded a
reactive cause)
* Splenomegaly
* Circulating immature myeloid cells
* Absence of MPN driver mutations (JAK2 / BCR-ABL1)
* Somatic mutations commonly encountered – TET2 , SRSF2, ASXL1
MDS features
* Dysplasia of myeloid lineages
Treatment
* Supportive
* Cytoreductive agents if proliferative – hydroxyurea
* Hypomethylating agents – azacitidine
Myelodysplastic syndrome (MDS)
Heterogeneous group of clonal haematopoietic stem cell malignancies Significant morbidity
> 60 years of age
Associated with :
1. Bone marrow failure
2. Peripheral cytopenia(s)
3. Propensity for progression to acute myeloid leukaemia
Diagnosis
- Blood film: microcytic anaemia, dysplasia
- BM biopsy: cellularity, morphology, blasts, cytogenetics
Factors for MDS prognosis (5)
Cytogenetics
Blast %
Hemoglobin
Platelets
ANC
Treatment of MDS
Supportive
- transfusions Hb<80g/L, Platelets <10 or <20 if febrile
- EPO, G-CSF
Low risk
- Luspatercept or sotatercept = fusion protein blocking TGF B thus allowing effective erythropoiesis through maturation
High risk
- Azacitidine = hypomethylating agent decreases inhibition of tumor supressor genes»_space; decreases transformation to AML and improves survival
Acute myeloid leukaemia diagnosis (2)
- FBE and blood film
* Pancytopenia
* Blasts in peripheral blood
* Morphology - BM aspirate and trephine
* percentage of blasts in the bone marrow
* >20% of leucocytes
* Blasts with Auer rods = myeloid leukaemia
* Immunophenotyping of the blasts
AML curative treatment, targeted therapy, and definition of relapse
Curative
- 3 days of an anthracycline and 7 days of cytarabine»_space; allogenic stem cell
- Unfit >70yo»_space; azacitidine an dvenetoclax (70% response, similar to 7+3)
Targeted
- Midosaturin = FLT3 inhibitor
- Gilteritinib = more potent and specific FLT3 inhibitor for relapsed/ refractory
Measurable residual disease defines response and outcomes
Relapse = one of:
1. >5% blasts in BM
2. Reappearance of blasts in peripheral blood
3. Development of new extra medullary disease
Acute Promyelocytic Leukaemia - path, features, treatment
Balanced chromosomal translocation t(15;17)(q24;q21)»_space; fusion of promyelocytic leukaemia (PML) and the retinoic acid receptor alpha (RARA) genes»_space; impairs myeloid differentiation
High risk due to coagulopathy and DIC risk
Treatment
* Standard-risk vs High-risk (WBC ≥10)
* all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) +/-
chemotherapy (anthracycline), CR 96%
* Differentiation syndrome is a potentially life-threatening complication of treatment
Acute Lymphoblastic Leukaemia diagnosis and prognosis (5)
Diagnosis
- film: pancytopenia + blasts
- biopsy: >20% blasts with lymphoid antigens
- extra medullary involvement common in B cell, T cell will have mediastinal mass
Prognosis
- excellent in children, worsens with age
- Poor risk
1. BCR-ABL1 (9;22)
2. Ph-like
3. Early thymocyte precursor (ETP) phenotype
4. 11q23
5. Ikaros deletion
ALL treatment
- Induction chemotherapy with a number of different regimens – ongoing trials
- BCR-ABL inhibitor if Ph+ALL (e.g. imatinib, dasatinib)
- Maintenance chemotherapy (up to 2 years)
Allogeneic BMT - graft versus leukemia
* Ph+ ALL in CR1
* MRD+
* Relapsed disease
Targeted therapy
- Bispecific t-cell engaging (BiTE) abs promote elimination of lymphoblasts by cytotoxic T cells
- Bilnatumomab (CD19/CD3)
- relapsed/ refractory
- SE - neurotoxicity (ICANS), and cytokine release syndrome
Chronic Lymphocytic Leukaemia diagnosis (2) and staging via Rai and Binet
FBE and blood film
* Isolated lymphocytosis , > 5 x 109/L clonal B
lymphocytes > 3 months
* Cytopenias
Immunophenotyping peripheral blood
* CD5 + CD19 + clonal B cells
Rai and Binet classification
Low-risk
* Stage 0 - lymphocytosis only
Intermediate risk
* Stage I - lymphocytosis
* Stage II – lymphadenopathy at any site , hepatosplenomegaly
High risk
* Stage III – anaemia Hb < 10g/dL
* Stage IV – thrombocytopenia
* These cytopenias are non immune and due to bone marrow replacement
CLL good (2) and poor prognosis (4)
Good
- 13 q deletion
- IGHV gene mutation
Poor
- 11q deletion
- 17p deletion
- unmate
CLL treatment - when (4) and immunotherapy (3)
When
1. Autoimmune complications
2. Bone marrow failure – cytopenias
3. Lymphocyte doubling time–>50% 2 months OR doubled in<6months
4. Disease related symptoms
Immunotherapy
1. Venetoclax
* Inhibits BCL‐2, an anti‐apoptotic protein. BCL‐2 is over-expressed in CLL mediates tumour cell survival and has been associated with resistance to chemotherapeutics
*can be combined with obinutuzumab
2. Ibrutinib
* B-cell–receptor signaling has emerged as a driving factor for CLL tumor-cell survival
* Downstream of the B-cell receptor and of critical importance to its function is a member of the Tec
family of kinases, Bruton’s tyrosine kinase (BTK)
* Monotherapy in relapsed/refractory disease
3. Acalabrutinib
Plasma Cell Dyscrasias (5)
- MGUS
- protein <30, plasma cells <10%, no end-organ - Plasmacytomas
- bone or soft tissue lesion with clonal plasma cells, none in bone marrow, and no end-organ - POEMS
- polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma proliferative disorder, skin changes - Systemic AL amyloidosis
- MGUS + deposition
- Kidney, cardiac, GI, skin
- Congo stain
- Bortezomib based or autologous transplant - MM (detailed in another card)
Multiple myeloma diagnosis, prognosis and treatment
Diagnosis = >10% plasma cells and one of the following:
1. Hypercalcemia
2. Renal insufficiency
3. Anaemia
4. Bone lesions
5. >60% plasma cells
6. Ratio >100
7. 2 or more lesions on MRI at least 5mm
Prognosis - stage 2 = B2 micro globulin 3.5-5.5 and albumin <35
Treatment
- autologous stem cell
- induction/ alone for frail: dexamethasone + bortezomib + lenalidomide (VRD)
- daratumumba + lenalidomide = gold standard
Diffuse large B cell lymphoma (DLBCL) - presentation, prognosis, treatment
Rapidly enlarging mass - single or multiple sites»_space; diagnose via biopsy (excisional)
Risk
1. Age >60yo
2. Ann arbor stage III or IV (extensive)
3. ECOG >2
4. Serum LDH
5. Extra nodal sites
Treatment
- R-CHOP +/- radiotherapy
- refractory > high dose chemo + autologous stem cell transplant
Burkitt lymphoma - presentation, histology, translocations (3), treatment
Doubling time of 25hrs - very aggressive
Endemic to Africa + PNG
Histology
- atypical lymphoid cells with high proliferation and apoptosis
- starry-sky = large histiocytes with ingested apoptotic tumor cells on a background of basophilic tumor cells
Diagnosis = translocation involving myc
1. Ig heavy chain 8;14
2. Kappa light chain 2;8
3. Lambda light chain 8;22
Multiagent chemo
Follicular Lymphoma - diagnosis, prognosis (5), and treatment
Indolent
Diagnosis
- follicles composed of centrocytes and centroblasts
- BCL2 overexpression
- t(14;18) - IGH and BCL2
Prognosis
1. >4 nodal groups
2. LDH
3. Age >60
4. Extensive stage III/IV
5. Hb <120
Watch and wait unless symptomatic/ end-organ
- obinutuzumab = glycoengineered anti CD20, greater B cell killing then rituximab
+ bendamustine or CHOP
Waldenstrom Macroglobulinemia / Lymphoplasmacytic Lymphoma - pathophys (6) and diagnosis
Symptoms related to IgM
1. Acts an autoantibody – peripheral neuropathy
2. May precipitate out of the serum in cold temperatures – cryoglobulinemia
3. Pentamer – hyperviscosity syndrome
4. Can deposit as amorphous extracellular material in GIT – malabsorption
Infiltration of haematopoietic tissue by neoplastic B cells
5. Cytopenias
6. Hepatosplenomegaly
Diagnosis
- IgM paraprotein + >10% small lymphocyte infiltrate in BM
- MYD88 L256P in >90% of patients
Plasma exchange for hyper viscosity syndrome
Hairy cell leukaemia - mutation and treatment
BRAF V600E
Cladribine
Post-transplant lymphoproliferative disorders
95% b-cell lineage > CD20+
Associated with EBV
Decrease immunosupression
Rituximab followed by chemotherapy
Hodgkin lymphoma identifying feature and treatments
multinucleated Reed-Sternberg cells
CD30+
Early stage - non bulky»_space; ABVD + RT
Advanced stage - IIB-IV, bulky, B symptoms»_space; ABVD +/- IFRT or escalated BEACOPP
Refractory
- salvage chemo
- brentuximab (anti CD30) vedotin (anti-tubulin)
- PD-1 inhibitors - Nivolumab
Hereditary hemorrhagic talengectasia diagnosis
Autosomal dominant
Definite requires 3:
1. Epistaxis
2. Telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
3. visceral lesions: for example gastrointestinal telangiectasia, pulmonary, hepatic, cerebral or spinal AVM
4. first-degree relative
A 27 year old patient is being prepared for an urgent splenectomy in the next week. What pneumococcal vaccine regime should be given?
A. Conjugate vaccine (PCV13) before polysaccharide vaccine (PPSV23) 8 weeks apart
B. Give both PCV13 and PPSV23 vaccines at same time
C. Polysaccharide vaccine (PPSV23) before conjugate vaccine (PCV13) 8 weeks apart
D. Give 2 polysaccharide vaccine (PPSV23) 8 weeks apart
Answer = A
For emergency/urgent splenectomy give the vaccine series 14 days after splenectomy
- A pneumococcal protein‐conjugate vaccine (PCV13; Prevnar 13) that includes capsular polysaccharide antigens covalently linked to a nontoxic protein that is nearly identical to diphtheria toxin.
- A pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23, Pnu‐Immune) that includes 23 purified capsular polysaccharide antigens
The recommendation is to give the PCV13 first followed by the PPSV23 8 weeks later.
If this is for an elective/planned splenectomy this can be completed 10‐12 weeks prior to surgery so that the last vaccination is given at least 14 days prior to the operation.
Stem cells are recognised by the presence of which cluster of differentiation?
A. CD45
B. CD34
C. CD4
D. CD24
Answer = B
Stem cells are recognised by CD34+. CD45 is found on all leukocyte groups. CD4 on monocytes and T helper cells, and CD24 on B lymphocytes and granulocytes.
Three-drug regimens are common as the first line management of multiple myeloma. Which of the following medications used to treat multiple myeloma is most likely to cause peripheral neuropathy as a side effect?
A. Lenalidomide
B. Bortezomib
C. Cyclophosphamide
D. Dexamethasone
B. Bortezomib
Major side effect = painful glove-and-stocking neuropathy, usually after the first few cycles of therapy
