Haematology

Question 1

1. Define anaemia.
2. When is a patient considered anaemic?

Answer 1

1. Decrease RBC which is detected by [Hb]
2. Adults: M < 130g/L & F < 120g/L

Question 2

What symptoms and signs will you ask/look for in an anaemic patient? What additional things will you ask for in history?

Answer 2

Symptoms: fatigue, SOB, headache, palpitations, syncope

Signs: pale conjunctiva + palmer creases + mucosal membranes, tachycardia

History: diet? menstrual cycle? alcohol? family history?

Question 3

What are 3 causes of microcytic anaemia?

Answer 3

Microcytic (<80):

1. iron deficiency anaemia
2. thalassemia
3. sideroblastic anaemia

Question 4

What are 3 causes of normocytic anaemia?

Answer 4

Normocytic (80-100):

1. acute blood loss (GI/GU)
2. anaemia of chronic disease
3. sickle cell disease
4. multiple myeloma

Question 5

What are 3 causes of macrocytic anaemia?

Answer 5

Macrocytic (>100):

1. B12 or folate deficiency
2. drugs that impair DNA synthesis (e.g. methotrexate)
3. alcoholism (or liver disease)

Question 6

What investigations do you run to identify the type of anaemia?

Answer 6

1. FBC with MCV & RDW
2. reticulocyte count
3. blood film
4. vitamin B12 and folate

Question 7

Do anaemic patients need a transfusion? What other treatments are there?

Answer 7

Usually not, it depends on how severe the anaemia is (when Hb <70g/mL). Typically, iron supplements are a safer and less costly method to raise Hb levels.

Question 8

In what foods in vitamin B12 found and how much does the body store?

Answer 8

• Found in meat, fish and dairy products, but not in plants
• Body stores up to 4 years worth

Question 9

What are the causes of vitamin B12 deficiency anaemia?

Answer 9

• Diet: vegan - Malabsorption: Crohn’s disease, ileum resection, tapeworms, gastritis - Genetics: transcobalamin II deficiency (congenital abnormality in metabolism)

Question 10

Where is folate and vitamin B12 absorbed?

Answer 10

Jejunum and ileum respectively

Question 11

How is vitamin B12 absorbed into the body?

Answer 11

Vitamin B12 binds to intrinsic factor that is secreted by gastric parietal cells. B12-IF complexes protects B12 from other enzyme degradation. Later absorbed in terminal ileum and binds to transcobalamin.

Question 12

What are the clinical features of vitamin B12 deficiency?

Answer 12

Symptoms of anaemia Neurological symptoms (some reversible and irreversible) - cerebral (reversible): dementia, delirium, confusion - cord (irreversible): subacute combined degeneration - peripheral neuropathy

Question 13

What is the pathophysiology of pernicious anaemia?

Answer 13

Auto-Ab produced against gastric parietal cells leading to achlorhydria (absent or low gastric acid secretions) and lack of IF i.e. an autoimmune disorder resulting in vitamin B12 deficiency which is common in >60yo.

Question 14

What test can you run to distinguish pernicious anaemia from other causes?

Answer 14

Schilling test - basically tracing radio-labelled B12 and measuring the urinary excretion

Question 15

What is the treatment of pernicious anaemia?

Answer 15

Vitamin B12 injections (IM, 1000ug) monthly for life

Question 16

Define leukaemia, lymphoma and myeloma.

Answer 16

• Leukaemia = malignant cells arising in bone marrow - Lymphoma = malignant cells arising in lymph nodes and lymphoid tissues - Myeloma = malignant plasma cells which collect on the outer part of bones forming tumours i.e. multiple myeloma

Question 17

What are B symptoms?

Answer 17

1. Fever > 38C (Pel-Ebstein fever is associated with Hodgkin Lymphoma) 2. Drenching night sweats 3. Unintentional weight loss >10% in <6 months

Question 18

What is used to stage lymphomas?

Answer 18

Ann Arbor System of Staging Lymphoma (also used for prognosis): Given a stage I-IV and a subtype A or B. I = confined to singly lymph node region II = involvement of 2+ lymph nodes on same side of diaphragm III = involvement of lymph nodes on both sides of diaphragm IV = spread beyond lymph nodes e.g. liver or bone marrow A = absence of B symptoms B = presence of B symptoms

Question 19

How is Hodgkin Lymphoma distinguished from Non-Hodgkin Lymphoma?

Answer 19

Presence of Reed-Sternberg cells.

Question 20

What are the risk factors of Hodgkin’s Lymphoma?

Answer 20

• EBV or HIV infection - age: 20’s and >55 - M > F - caucasian > asian

Question 21

Are low-grade lymphomas more treatable or high-grade lymphomas? And what are examples of each?

Answer 21

High-grade (acute): they are more aggressive but long-term cure is achievable e.g. Burkitt’s lymphoma, DLBCL Low-grade (chronic): they are indolent but often incurable e.g. follicular lymphoma

Question 22

What is the type of chemotherapy is used for Non-Hodgkin’s and Hodgkin’s Lymphoma?

Answer 22

HL = ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) NHL = R-CHOP (Rituximab Cyclophosphamide, Hydroxydaunorubicin, Oncovin & Prednisolone)

Question 23

What is the name of a rare stem cell disorder leading to pancytopenia (reduction in all major cell lines) and hypoplastic marrow (the marrow stops making cells)?

Answer 23

Aplastic anaemia

Question 24

What are the symptoms of myeloma?

Answer 24

Calcium (increased) (due to increased osteoclast activity) Renal impairment & Recurrent bacterial infections Anaemia Bone lesions (typically long bones, ribs, vertebra causing back pain)

Question 25

If you suspect myeloma, what investigations should you run and what will they show?

Answer 25

1. FBC: normocytic, normochromic anaemia 2. Blood film: rouleaux formation 3. ESR, urea, Cr, Ca: increased 4. Serum and urine electrophoresis: monoclonal protein band 5. CXR: lytic ‘punched-out’ lesions e.g. pepper-pot skull, vertebral collapse, fractures or osteoporosis