Haematology Flashcards by Aboudi el masri

What Hb levels would be considered anaemia for
Male:
Female:
Term 1 of Pregnancy:
Terms 2 and 3 of pregnancy:

Male: <13
Female: <12
Term 1 of Pregnancy: <11
Terms 2 and 3 of pregnancy: <10.5

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What is the presentation of anaemia

What exam findings?

Fatigue
SOB
Palpitations
Angina (chest pain)
Night cramps

Tachycardia
Pallor
Carotid bruits
HFpEF (High output HF)

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When determining ddx for anaemia, what is the best investigation to narrow down the diagnoses? Give the normal range

What are other relevant investigations

FBC: MCV 80-120 + Reticulocyte count
Blood Film!
Ferritin
CRP/ESR
Serum B12 and folate
Serum bilirubin
Renal function
TFTs
LFTs
+/- Hb Electrophoresis

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You conduct an FBC and obtain an MCV <80. What are your differentials?

Fe-deficiency
Thalassaemia
Anaemia of chronic disease

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You conduct an FBC and obtain an MCV 80-120 . What are your differentials?

Acute blood loss
Sickle cell
Anaemia of chronic disease
Haemolysis
Uraemia
Marrow failure

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You conduct an FBC and obtain an MCV >120. What are your differentials?

Folate/B12 deficiency
Alcohol
Liver disease
Thyroid disease
Marrow infiltration

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What is another word for B12?
In what dietary products are B12 found in?

Cobalamin
Liver, kidney and dairy products

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Where is the intrinsic factor for B12 formed?

Gastric parietal cells

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B12 deficiency causes Macrocytic anaemia. Give 3 causes

1) Inadequate intake (vegans)
2) Malabsorption: Gastritis, H.pylori, Gastrectomy, chronic pancreatitis, Ileal resection, coeliac disease, Crohn’s
3) Drugs: Metformin, PPIs, H2 antagonists, COCP (by reducing carrier protein)

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How does Macrocytic anaemia present?

Anaemia:
Fatigue
SOB
Palpitations
Angina (chest pain)
Night cramps

Tachycardia
Pallor
Carotid bruits
HFpEF (High output HF)

Glossitis
Mouth ulcers
Peripheral neuropathy
Ataxia
Optic atrophy
Memory loss
Degeneration of spinal cord
Psychosis (rarely)

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Dementia is associated with what type of anaemia

Folate-deficiency anaemia (otherwise exactly the same sx as B12 deficiency)

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What dietary products is Folate present in?

Liver, yeast, spinach, vegetables, nuts

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What are the causes of Folate-deficiency anaemia

1) Reduced intake: Old age, malignancy, anorexia, excess alcohol (spirits)
2) Malabsorption: Coeliac disease, Crohn’s, gastrectomy, lymphoma, Diabetic enteropathy
3) Drugs: Anticonvulsants, Methotrexate, Trimethoprim
4) Excess use: Pregnancy, lactation, increased cell turnover (malignancy, haemolysis)

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Define pernicious anaemia

What diseases (2) are associated with pernicious anaemia?

How is it managed?

Autoimmune condition characterised by with gastric atrophy and intrinsic factor/gastric parietal cell antibodies => reduced B12

Gastric and colorectal Ca

Mild B12 deficiency: Oral B12 supplements
Severe B12 deficiency: IM hydroxycobalamin 3x/week for 2 weeks then 2-3 monthly

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You order bloods for a 60-year old person with suspected Fe anaemia. What results would you expect to confirm the diagnosis?

What other investigation must be ordered?

reduced serum ferritin +/- reduced transferrin saturation

In patients >60 or >50 with rectal bleeding => FIT test

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What is the effect of vitamin C on Iron absorption

Increases it

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What are the causes of Iron-deficiency anaemia?

1) GI blood loss: Aspirin/NSAID use, colonic Ca, Gastric Ca, Gastric ulceration, oesophagitis, Oesophageal varices

2) Non-GI blood loss: Menstruation, blood donation, haematuria, epistaxis

3) Malabsorption: Coeliac disease, H. Pylori

4) Excess use: Pregnancy, lactation, premature infants, deficient diet

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What is the pathophysiology behind anaemia of chronic disease?

Inflammatory cytokines suppress bone marrow erythropoeisis => normocytic anaemia but microcytic if severe

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A 70 year old male presents for a review of routine bloods. Their MCV was 130 but their Hb is 15. What is the most likely diagnosis?

What other findings would be on the blood results?

Myelodysplastic syndrome. Macrocytosis preceeds anaemia by a few years

Also would have neutropenia, thrombocytopenia => pancytopenia

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What is Myelodysplastic syndrome?
What type of anaemia does it cause?

Common pre-leukaemia disorder in those >65 causing macrocytic anaemia.

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What is the management of Myelodysplastic syndrome?

Refer to haematology
Supportive: Blood transfusion, erythropoeitin, Chemo/immunosuppressive therapy

Curative: Stem cell transplant can be curative for young, fit patients

A patient presents with chest pain, SOB and angina. they appear pale on exam and is tachycardic. On examination you note splenomegaly. There is no history of trauma. What is their likely MCV?

What other examination finding is common here?

What would their FBC and Blood film show?

You decide to refer to haematology. In all cases what should you offer the patient?

Normocytic anemia due to haemolysis

Jaundice (scleral icterus)

Reduced Hb, Increased reticulocytes “spherocytes” and polychromasia

Refer to haematology and stop the drug causing it if applicable. In all cases, give folate supplements.

What virus is known for its association with haemolytic anaemia?

Parvovirus

Give 5 causes of haemolytic anaemia

Congenital:
1) Membrane abnormality: Spherocytosis, elliptocytosis
2) Haemoglobin abnormality: Sickle cell, thalassaemia
3) Metabolic: G6PD Deficiency, Pyruvate kinase

Acquired:
1) Autoimmune: SLE, CLL, EBV
2) Isoimmune: Transusion
3) Drug-induced
4) Hypersplenism: Malaria, lymphoma, RA, portal HTN
5) Artificial heart valves

What is aplastic anaemia?

Bone marrow failure characterised by pancytopenia

A patient suffers from recurrent infections and anaemia. What are the 2 most likely causes?

Myelodysplastic syndrome Aplastic anaemia

When are haemoglobinopathies screened for?

Pre-conceptual screening Antenatal screening Neonatal bloodspot screening

What is thalassaemia?

AR disorder of haemoglobin production

Have a review of this

And this. There will be questions

Homozygous alpha 0 thalassaemia will cause...

Bart's hydrops causing foetal death at 38 weeks

Heterozygous alpha + and alpha 0 will cause? what examination finding is associated with it?

Haemoglobin H Splenomegaly

Which thalassaemia is associated with mediterranean and southeast asia?

Alpha thalassaemia

Beta thalassaemia is present in all ethnic groups except the northern europeans. Explain its pathophysiology

Reduced beta chain production leads to increased alpha chain synthesis leading to destruction of RBC in spleen and bone marrow causing: 1) Proliferation of bone marrow 2) Bony deformities: Bossing of skull, Mongoloid facies, thinning of long bones 3) Splenomegaky

Homozygous beta thalassaemia newborns will die unless they have repeated transfusions. What is the risk of that and how is that managed? What is the curative management?

Iron overload => Chelation (removal of iron) and specialist care Stem cell transplant is curative

A stroke has occurred in an immigrant that is <10 yo. What would be the most likely reason?

Sickle cell anaemia causing infarction

Sickle cell anaemia is most common in the mediterranean, middle east, indian, and malarial populations. There are many types. What are they?

Homozygous SS Heterozygous AS Heterozygous SC, SD, SE or even S+ thalassaemia

Imagine a heterozygous patient with AS. They are asymptomatic. What does this mean? Even though there are normally asymptomatic, what might cause them to be symptomatic?

<40% are S-trait allele. Anaesthesia , infection, or anything affecting the demand of the body or reducing breathing (anaesthesia)

What is the pathophysiology of Sickle cell anaemia?

Haemoglobin S undergoes liquid crystal formation when de-oxygenated causing sickling of affected blood cells => 1) shortens lifespan of RBC => Haemolysis and splenomegaly 2) Aggregation of cells => Tissue infarction (stroke <10), organ sequestration (liver, spleen, lungs)

What are diagnostic findings of sickle cell anaemia?

FBC and blood film showing reduced Hb, and increased reticulocyte count with sickling on film. Confirmed with Haemoglobin electrophoresis!!

Sickle cell patients have a mean survival of 50y. What is the most common cause of death?

Infection

What is the management of sickle cell anaemia?

Referral and management in specialist centres Offered Hydroxycarbamide !! Considered asplenic => immunosuppressed => Give all vaccines, avoid cold, warn about danger of anaesthetics, treat infection early, lower threshold for analgesia and admission.

What is the anticoagulation for MI?

DAPT DOAC if A.fib also

What is the anticoagulation for HF

DAPT DOAC if A.fib also

How will you determine if the risk of a bleed?

HASBLED HTN Abnormal LFTs or creatinine Stroke hx Bled (prior major bleed) Labile INR Elderly (>65) Drugs (drugs predisposing to bleeding) 3+ = more regular reviews needed

How will you decide whether to give anti-coag in Primary stroke prevention?

CHADSVASC score 1+ oral anticoag depending on patient preference 2+ Give oral anti-coag Weighed against: HASBLED

How would you determine whether to give Anticoag after a stroke

After ruling our haemorrhagic stroke on non-contrast CT

In all cases, except <12 months after ACS, antiplatelet agents are stopped if initiating anti-coag. What is the mechanism of action of: Heparin: Warfarin: DOAC:

Heparin: Increases anti-thrombin 3 activity Warfarin: Vitamin K antagonist DOAC: Inhibits Factor X except Dabigatran (inhibits thrombin)

What is the target INR for warfarin?

Target INR is 2.5 unless thromboembolism. Then it is 3.5. Also special for prosthetic heart valves

What is the anti-coag of choice for prosthetic heart valves?

Warfarin

Patients on warfarin