Haematology

Question 1

Define anaemia.

Answer 1

Hb: men<135g/L; women<115g/L

Question 2

What are the symptoms of anaemia?

Answer 2

Fatigue
Dyspnoea
Faintness
Palpitations
Headache
Tinnitus
Anorexia

Question 3

What are the signs of anaemia?

Answer 3

Pallor
In severe anaemia (Hb<80g/L):
-hyperdynamic circulation e.g. tachycardia, flow murmurs (ESM loudest over apex)
->heart failure

Question 4

What are the causes of microcytic anaemias?

Answer 4

FAST:
Fe-deficiency
Anaemia of chronic disease
Sideroblastic anaemia
Thalassaemia (in the absence of anaemia)

Question 5

What are the causes of normocytic anaemias?

Answer 5

Acute blood loss
Anaemia of chronic disease
Bone marrow failure
Renal failure
Hypothyroidism
Haemolysis
Pregnancy (no reduction in RBCs, but increase in plasma volume causes dilution resulting in anaemia)

Question 6

What are the causes of macrocytic anaemias?

Answer 6

FATRBC:
Foetus (pregnancy)
Antifolates (e.g. phenytoin)
Thyroid (hypothyroidism)
Reticulocytosis (release of larger immature cells e.g. with haemolysis)
B12/folate deficiency
Cirrhosis (alcohol excess or liver disease)
Myelodysplastic syndromes

Question 7

What are the signs of iron deficiency anaemia?

Answer 7

Koilonychia
Atrophic glossitis (smooth glossy tongue, often tender)
Angular cheilosis (inflammation/cracking at corners of mouth)
Brittle hair and nails
Post-cricoid webs (Plummer-Vinson Syndrome)

Question 8

What would a blood film for iron deficiency anaemia show?

Answer 8

Microcytic
Hypochromic
Anisocytosis
Poikilocytosis
Pencil cells

Question 9

What are the causes of iron deficiency anaemia?

Answer 9

Blood loss (until proven otherwise)

• Meckel’s diverticulum (older children)
• Peptic ulcers/gastritis (chronic NSAID use)
• Polyps/colorectal ca (most common cause in adults >50yrs)
• Menorrhagia (women <50yrs)
• Hookworm infestation (developing countries)

Increased utilisation

• Pregnancy/lactation
• Growth (infants/children)

Decreased intake

• Prematurity - loss of iron each day foetus is not in utero
• Suboptimal diet (infants/children/elderly)

Decreased absorption

• Coeliac - absence of villous surface in duodenum
• Post-gastric surgery - rapid transit; decreased acid

Intravascular haemolysis

• Microangiopathic
• Haemolytic anaemia
• Paroxysmal nocturnal haemoglobinuria (PNH)

Question 10

How should iron deficiency anaemia be managed?

Answer 10

Treat cause; if no obvious cause:

• OGD + colonoscopy
• urine dip
• coeliac investigations

Oral iron (SE: nausea, abdominal discomfort, diarrhoea/constipation, black stools)

For severe symptomatic anaemia: IV iron e.g. Ferrinject/Monofer (anaphylaxis risk)

Question 11

What is anaemia of chronic disease?

Answer 11

Cytokine-driven inhibition of red cell production

• Inflammatory markers like IFNs, TNF and IL-1 reduce EPO receptor production (and thus EPO synthesis) by kidneys
• Iron metabolism is dysregulated; IL-6 and LPS stimulate the liver to make hepcidin, which decreases iron absorption from gut (by inhibiting transferrin) and also causes iron accumulation in macrophages

Question 12

What are possible causes of anaemia of chronic disease?

Answer 12

Chronic infection, e.g. TB, osteomyelitis
Vasculitis
Rheumatoid arthritis
Malignancy

Question 13

What is the mechanism of anaemia of chronic disease in renal failure?

Answer 13

EPO deficiency (not cytokine-driven)

Question 14

What is the state of ferritin levels in anaemia of chronic disease, and why?

Answer 14

High: iron is sequestered in macrophages to deprive invading bacteria (unless there is a co-existing iron deficiency anaemia)

Question 15

What is sideroblastic anaemia?

Answer 15

Ineffective erythropoiesis causes iron loading (bone marrow) causing haemosiderosis (endocrine, liver and cardiac damage due to iron deposition)

Question 16

How is sideroblastic anaemia diagnosed?

Answer 16

Ring sideroblastic seen in the marrow (erythroid precursors with iron deposited in mitiochondria in a ring around the nucleus)

Question 17

What are the causes of sideroblastic anaemia?

Answer 17

Myelodysplastic disorders
Alcohol excess
Chemotherapy
Irradiation
Lead excess
Anti-TB drugs
Myeloproliferative disease

Question 18

How is sideroblastic anaemia managed?

Answer 18

Remove the cause

Pyridoxine (vitamin B6 promotes RBS production)

Question 19

What would plasma iron studies show for iron deficiency anaemia?

Answer 19

Low iron
High total iron binding capacity
Low ferritin

Question 20

What would plasma iron studies show for anaemia of chronic disease?

Answer 20

Low iron
Low total iron binding capacity
High ferritin

Question 21

What would plasma iron studies show for chronic haemolysis?

Answer 21

High iron
Low total iron binding capacity
High ferritin

Question 22

What would plasma iron studies show for haemochromatosis?

Answer 22

High iron
Low/normal total iron binding capacity
High ferritin

Question 23

What would plasma iron studies show in pregnancy?

Answer 23

High iron
High total iron binding capacity
Normal ferritin

Question 24

What would plasma iron studies show for sideroblastic anaemia?

Answer 24

High iron
Normal total iron binding capacity
High ferritin

Question 25

What are megaloblastic causes of macrocytosis?

Answer 25

B12 deficiency
Folate deficiency
Cytotoxic drugs

Question 26

What are non-megaloblastic causes of macrocytosis?

Answer 26

Alcohol (most common cause of macrocytosis without anaemia)
Reticulocytosis (e.g. in haemolysis)
Liver disease
Hypothyroidism
Pregnancy

Question 27

What haematological disorders cause macrocytosis?

Answer 27

Myelodysplasia
Myeloma
Myeloproliferative disorders
Aplastic anaemia

Question 28

What would you see on a megaloblastic blood film?

Answer 28

Hypersegmented polymorphism
Leucopenia
Macrocytosis
Anaemia
Thrombocytopenia