Haematology Flashcards
CMML
Monocytes >=10% total WBC and >=1E9 Blasts <20% Dysplasia in >= 1 myeloid lineage Other MPNs excluded Usually JAK2 neg
Anticoagulants: Prophylactic Doses for VTE
Apixaban 2.5 BID* Riva 10 OD* Dalteparin 5000-10000 U OD Enox 40 (30) OD Tinza 4500-10000 U OD Fonda 2.5 OD
(DVT ppx for high risk ambulatory cancer: brain, lung, GI/GU)
DOACs: Treatment doses for VTE
Apixaban 10 BID x 7 days –> 5 BID x6-12 mo –> 2.5 BID
Riva 15 BID x 3 wks –> 20 OD x6-12 mo –> 10 OD
Dabi 150 BID (bridge with LMWH x5-10 days)
Edoxaban 60 OD (bridge with LMWH x5 days)
Warfarin - target INR 2-3 (use in APLA, ESRD with CrCl <15, VTE in breast-feeding women)
LMWH: Treatment doses for VTE
Enoxaparin 1mg/kg BID or 1.5mg/kg OD
Dalteparin 200 units/kg OD
Tinza 175 units/kg OD
Fonda = weight based OD (5 if wt <50 kg, 10 if wt >100, 7.5 if wt 50-100)
Wells Score DVT
Active CA (within 6 mo) - 1 pt Lower limb immobilization - 1 pt Recent OR (within 4 wks) or bedbound >3 days - 1 pt Unilateral calf swelling - 1 pt Unilateral leg swelling -1 pt Collateral veins -1 pt Deep vein tenderness - 1 pt Pitting edema -1 pt Non varicose superficial veins -1 pt
3+ = high prob 0= low 1-2 = intermed
Well’s Score for PE
PE most likely dx -1 pt Active CA (within 6 mo) -1 pt Hemoptysis -1 pt Hx VTE -1.5 points Recent OR (within 4 wks) or bedbound >3 days - 1 pt Signs and symptoms c/w DVT - 3 points Tachycardia >100 - 1.5 point No alt dx -3 pts
4+ high probability, otherwise low
When to use alternate anticoagulation > DOAC for VTE
C/I:
Pregnancy (LMWH) or Breastfeeding (LMWH/Warfarin)
Triple pos APLA (Warfarin)
Child Pugh B/C Cirrhosis
Plts <50
Drug interactions (doxorubicin, cyclosporine, dilantin)
Caution:
Intraluminal GI/GU/?intracranial Ca (LMWH)
HD or ESRD with CrCl <30 (Apix<25, up to <15; use Warfarin)
High clot burden - extensive/submassive PE, postTPA, iliofemoral DVT
Riva and Apix appropriate for any BMI/weight (except post bariatric sx)
Old?: Wt >120 kg or BMI >40 (LMWH, Warfarin)
Indications for VTE prophylaxis in CA patients
High risk score >= 3 –> start VTE PPX (LMWH, Apix, Riva)
2 pts- Brain, GI CA
1 pt- Lung, GU, Heme Ca
1 pt - BMI >= 35
1 pt for each CBC abN: Hgb <100, Plt >=350, WBC >11
Indications for thrombolysis
sBP <90 for >15 mins despite aggressive fluids + no high risk bleeding features
Indications to extend anticoagulation >6-12 months in unprovoked VTE
MEN and HERDOO Male - always continue Or Female with 2+ of: -Hyperpigmented leg -Edema leg -Redness leg - Dimer >=250 -Obesity: BMI >=30 -Older age >= 65
Treatment of breakthrough VTE
If on DOAC/Warfarin –> LMWH x 1 month
If on LMWH –> increase dose by 25-33%
VTE PPX after hip/knee replacement
LMWH or DOAC x 14-35 days
VTE PPX after hip Fracture
LMWH x14-35 days
No DOAC (compared to hip/knee replacement)
Indications to anticoagulate LE distal DVT
Severe symptoms Active CA / other irreversible RF Dimer >=250 Multiple deep veins involved >5 cm long Close to popliteal vein Progression on repeat US
*if high risk bleed: serial US instead
Indications to anticoagulate superficial vein thrombosis
1) <= 3 cm saphenofemoral junction (–>therapeutic AC x 3mo)
2) >3 cm saphenofem jcn but 5+cm long (–> ppx AC x 45d: fonda 2.5 or riva 10); if <5cm = NSAID + serial US
3) Hypercoag: Pregnant, Ca, Surgery, Trauma, Past VTE (Tx ppx AC x 45 days)
Indications to anticoagulate subsegmental PEs
Symptomatic (ie. pleuritic CP, hypoxia, SOB)
Silent DVT on bilateral leg Doppler
Active CA or other irreversible RF
Elevated D-dimer
Indications to AC mesenteric vein thrombosis
- Worsening symptoms
- Thrombophilia
- Progression into larger veins or evidence bowel ischemia
Warfarin and LMWH Reversal
If non-bleeding:
- INR >9: VitK 2.5-5 mg PO, hold dose, resume @ lower
- INR 4.5-9: Hold dose, resume @ lower
If non life-threatening bleed: IV/PO Vitamin K, Hold warf
If life-threatening bleed: PCC (1000-3000 U based on INR) + Vit K IV
LMWH reversal = protamine 25-50mg
DOAC Reversal
If non-life threatening bleed: Hold
If life-threatening bleed:
- Dabi: Idarucizumab, consider dialysis
- Apix/Riva/Edox: PCC (1000-2000 units)
HIT 4T Score
Thrombocytopenia
- 2= 50% drop NADIR >20
- 1= 30-50% drop NADIR 10-19
Timing of heparin
- 2= D5-14 or <1 d if exposed within 30d
- 1= >14 ds or <1d if exp within 31-100 ds, or timing unclear
Thrombosis
- 2= proven clot, necrosis, anaphylactoid rxn
- 1=progressive thrombus, recurrent clot, skin redness
oTher cause
- 2= no other cause
- 1 = possible other cause
Score: <4 = low, 4-5= intermed, >5 = high
Treatment HIT
1 - STOP LMWH/ Heparin
2- START Argatroban/ Fonda/ Danaparoid (if preg)
3- B/L Leg Dopplers (silent DVT), UE doppler only if central venous line in situ
4- Once plts 150+ start warfarin overlap x5d (INR 2-3)
OR DOAC (riva 15BIDx3wk if VTE or 20daily until plt recovery if no VTE)
*no plt transfusion
Duration: no VTE = until plt >150 (max 3mo), if VTE 3-6mo
Diagnosis HIT
If 4T score = 4+ –> PF4/Heparin Assay
If Positive –> Fxnl Serotonin release assay to confirm
Coagulation cascade
Intrinsic: 12 –> 11 –> 9 –> 8 –>
Extrinsic: 7 +Tf –>
Common: 10 –> 5 –> 2 –> 1
VitK Dependent Coagulation Factors
10, 9, 7, 2
DDX Thrombocytopenia
Production Issue:
- B12/Fe deficiency
- Sepsis
- Malignant Blood: Leukemia, lymphoma, MM, MPNs
- Aplastic anemia
- Myelofibrosis
- Infiltration of BM: Mets, Tb, Sarcoid
Sequestration due to splenomegaly
Destruction:
1) Immune Mediated: Primary ITP, Secondary immune (Hep C, H. pylori, RA, SLE, APLA, ANCA), PTP, HIT
2) Non-immune (ie. TMAs): Mech valve, TTP, HUS, aTTP, HTN emerg, SRC, Vasculitis, DIC, HELLP, drugs (cyclo, tac, quinines)
Approach to isolated high INR
1 - confirm it is real, review meds (DOAC, warfarin)
2- 50:50 mixing study
a) Corrects= F deficiency (F7 defic, VitK defic, liver failure)
b) Does not correct = F7 inhib (order F7 + inhib) or LAC
Approach to isolated high PTT
1 - confirm it is real, review meds (LMWH, heparin, DOAC)
2- 50:50 mixing study
a) Corrects = F deficiency (8, 9, 11 >12) or T3 VWF (order these F levels and VWF assay)
b) Does not correct = F inhibitor or LAC (order above factor levels and inhibitor of those that are low)
Approach to combined elevated INR/PTT
1- Confirm it is real, review meds
2- Look at CBC + fibrinogen R/O DIC
3- 50:50 mixing study
a) Corrects = F defic in common pathway or multiple F deficiency (order F5,7,8 to determine)
- If all low = DIC
- If 5 and 7 low, 8 normal = liver failure
- If 7 low, 5 and 8 normal = Vit K defic
- If only 5 low = F5 defic
- If none low -> order F10, 2
b) Does not correct= F2/5/10 inhibitor or LAC
Types of vWD
-and factors that increase/decrease vwf
Type 1 = mild-mod quantitative (low Ag, low activ) *vwf<30% or vwf 30-50% + abn bleeding = diagnostic
Type 2 = qualitative (low/normal Ag, very low activ)
Type 3 = severe quantitative (low Ag, low activ, low F8) ~ to hemophilia A
vwf increase w/ stress/estrogen/preg; decrease in O blood group
Treatment of Bleeding in vWD
DDAVP (Type 1), vWF/VIII concentrate (=Humate P), cryoprecipitate
TXA+/-OCP if heavy menstrual bleeding
Treatment ITP
Not bleeding and plt >30 - observe
Not bleeding and plt <30
- 1st line: Dex 40/Pred 0.5-2 mg/kg x 4 days (peak 2-14 d, dur 7-28 d) or IVIG (peak 1-3 d, dur 2-7 d)
- 2nd line: Ritux (peak 7-56d, dur 180d), Splenectomy, TPO-R agonists
Pregnancy, treat if: bleed, plt <30, delivery or plt <50 + >=36GA
- IVIG or Prednisone > Dex bc it crosses placenta
(Pred for Preg)
Bleeding: Steroids + TXA +/- IVIG (+ Plt transfusion +/- splenectomy if life-threatening)
Treatment TTP
PLEX (send ADAMTS13 first)
+ FFP (4u then 1u q2hrs) + Solumedrol 1g + Folic acid +/- ASA if trop elevated
DVTp when plt>50 *no transfusion unless bleed
Caplacizumab or Ritux if refractory
DDX Hemolytic Anemia
Intravascular (schistocytes)
- Mechanical: TMAs, heart valves, post-bypass
- Complement mediated destruc: PNH, Cold AIHA
- Acute hemolytic transfusion RXN
Extravascular (spherocytes)
- Warm AIHA
- Intrinsic RBC defects (hemoglobinopathies, membrane defectsm, enzyme defects)
- Delayed hemolytic transfusion RXN
Warm AIHA
- Causes
- Blood film and bloodwork
CTD (SLE, RA)
LPD (eg CLL)
Drugs (NSAIDs, ABX, methyldopa)
spherocytes, IgG +/-C3d
Cold AIHA
- Causes
- Bloodwork
Waldenstrom’s, MGUS, lymphoma
Infectious: Mycoplasma, EBV
IgM, +C3d
Treatment Warm AIHA
Prednisone 1-1.5mg/kg
2nd line: Ritux or splenectomy (>8-12mo)
Folic acid
If requires transfusion: Ag matched blood
Treatment Cold AIHA
Trigger avoidance, warm enviro Plasmapharesis if very severe Tx underlying cause NO STEROIDS Ritux if refractory
Acute Leukemia: Major manifestations
1) BM Failure: Anemia, Thrombocytopenia, Neutropenia
2) Blast-related issues: Leukostasis, DIC, TLS
3) End organ infiltration: CNS, Heart, Skin (rash), Mucosa (gum hypertrophy)
Diagnosis Acute Leukemia
> =20% Blasts in peripheral blood or BM
Diagnosis APL
> =20% Blasts in blood or BM + Auer Rods + DIC(!!!)
Or promyelocytes or PML-RARA mutation
Diagnosis TLS
Low Ca, High K/Phos/Uric Acid +/- AKI
Treatment TLS
Fluids (UO 80-100cc/m2/h) Allopurinol (Rasburicase (check G6PD) if AKI, urate >535, or refractory to allopurinol) Manage lyte abn PPX - allopurinol
Blast threshold for leukostasis
AML: 50-100
ALL: 100s
CML: 100s
CLL: high 100s
Treatment Leukostasis
Fluids, fluids, fluids
AVOID transfusion
Hydroxyurea
Allopurinol for TLS ppx
Treatment of DIC in APL
ATRA
Plt transfusion if <30-50
Cryoprecipitate if fibrinogen <1.5
Treatment of DIC in non-APL acute leukemia
Supportive care
Plt transfusion if <10 or bleeding and <50
Cryo if bleeding and fibrinogen <1.5
FFP 15cc/kg if bleeding and PT/PTT >1.5x ULN
Indications for irradiated blood
Prevent GVHD:
- Allogenic-HSCT (always) or auto-HSCT within last 3 mo
- Hodgkin’s Lymphoma (if ever)
- Chemo with purine-based chemo (fludarabine) / ATG
- T-cell deficiency (Congenital)
- Previous transfusion GvHD
- Intrauterine transfusions
Indications for washed blood
Reduce allergies:
- IgA deficiency (documented anti-IgA)
- Anaphylactic transfusion rxn of unknown etiology.
- Recurrent/severe febrile or allergic transfusion reactions not ameliorated by pre-transfusion meds
Treatment AML (not APL)
Induction chemo (3+7)
Consolidation chemo if low risk
Allo-HSCT if intermed/high risk
Treatment APL
ATRA + Arsenic +/- chemo
Treatment ALL
Chemo: Induction, consolidation, maintenance
High risk CNS involvement –> intrathecal chemo +/- intracranial radiation
+/- allogenic HSCT
Phases of CML
1) CHRONIC (<10% blasts): Neutrophilia, Basophilia, Eosinophilia, anemia, high or low plts, splenomeg
2) ACCELERATED (10-19% blasts): worsening counts despite TKI (WBC >10, plts >1000 or plt<100), basophils >20%
3) BLAST: >=20% blasts = Acute Leuk (AML>ALL)
Treatment CML
TKIs (ie. Imatinib)
iMatinib: M for CML
(Ibrutinib = CLL)
Diagnosis Polycythemia Rubra Vera
3 Major or 2 major + 1 minor
Major:
- Hgb > 165M/160F or Hct > 49%M/48%F
- BM: Hypercellular, tri-lineage growth
- JAK2
Minor: Low serum Epo
Treatment Polycythemia Rubra Vera
For all: ASA 81 OD, Phlebotomy to target HCT <45%
If high risk (hx thrombosis or age >=60):
- Add hydroxyurea –> Ruxolitinib (JAKi) if resistant
- interferon if preg/young
Diagnosis Essential Thrombocytosis
4 Major or 3 Major + 1 Minor
Major:
- Plts >=450
- BM: Increased mature hyperlobulated megakaryocytes
- +JAK2/CALR/MPL
- Other MPNs excluded
Minor:
- No secondary cause: CA, CTD, Infxn, Post-op, post-splenectomy, trauma, Fe defic
Treatment Essential Thrombocytosis
For all: ASA 81 OD (up to BID if CV RFs), CV RF reduction
If high risk (hx thrombosis, Age>=60): Hydroxyurea (interferon if young/pregnant)
Diagnosis Myelofibrosis
3 major + 1 minor
Major:
- BM Bx: fibrosis, megakaryocyte proliferation, atypia
- Mutation status: JAK2 >CALR> MPL
- Other MPN/MDS excluded
Minor:
- High LDH (>ULN)
- Leukoerythroblastic film (L shift, teardrop, nuc RBC)
- Palpable splenomegaly
- Anemia
- WBC >= 11
Treatment Myelofibrosis
Supportive transfusions (eg EPO)
Ruxolitinib (JAKi) for splenomegaly/B-Sx
Allo-HSCT
Diagnosis MDS
BM Bx/aspirate:
- Hypercellular +/- ring sideroblasts (hypolobulated/ hypogranuloated neuts)
- > 10% dysplasia
- < 20% blasts
Treatment MDS
Low risk:
- Supportive transfusions +/- EPO, Fe chelation
- Lenalidomide (5q deletion), immunosuppression, luspatercept (ring sideroblasts)
High risk:
- Supportive (EPO, transfusions)
- Cure: allogenic SCT
- Ineligible for transplant: Azacytidine (hypomethlating agent)
Diagnosis CLL
Periph blood: Lymphocytes >= 5 with consistent flow cytometry
*do not need BMBx
Treatment CLL
If asymptomatic and no cytopenias: Watch and wait
Treat with TKI (Ibrutinib - afib/bleeding) if:
- B-Sx,
- BM failure: Cytopenias (Hb or plt <100)
- Warm AIHA refractory to steroid,
- Symptomatic LN or >10cm
- Symptomatic splenomegaly or >6cm below CM
- Extra-nodal sx: skin, lung, kidney, spinehod
How to diagnose lymphoma
EXCISIONAL LN Biopsy
Treatment Lymphoma
Hodgkin: Reed sternberg and aggressive
-Chemo (AVBD) +/- Rads
NHL: Indolent (follicular): Observe vs ritux + chemo Aggressive: -DLBCL = ritux + chemo (RCHOP) -Burkitt's (Magrath)
Staging lymphomas
CT Neck/C/A/P, PET, BMBx, +/- LP
1- 1 LN Region
2- >1 LN regions on same side of diaphragm
3- >1 LN regions on opposite sides of diaphragm
4- extra-nodal disease (skin, BM, CNS, kidney, spine)
A - no B-Sx; B - Yes B-Sx
MGUS Definition
M-spike <30 g/L
BM Plasma cells <10%
No end organ damage
No biomarkers of MM
Multiple Myeloma Dx
BM plasma cells >10% or plasmacytoma AND any SLIM CRAB
Biomarkers of Disease (SLIM)
Sixty: BM Plasma cells >= 60%
LIght chains: involved/uninvolved FLC Ratio >100 or <0.01
MRI: > 1 Focal osteolytic bone lesion on MRI that is >5mm
End Organ Damage: CRAB
C: Ca >2.75 or >0.25 above ULN
R: Renal - Cr >177 or CrCl <40 without other cause
A: Anemia - Hgb <100 or 20g/L below LLN
B: Bone - >=1 osteolytic lesion (skeletal survey, CT/PET)
*NO LYMPHADENOPATHY
Smouldering Myeloma Definition
M-spike>=30 g/L or UPEP spike >=500/24hr
BM Plasma cells 10-60%
No SLIM CRAB or amyloidosis
Criteria for high risk MGUS
-Ix/screening for high vs low risk
Any of:
- M-spike >=15
- Non-IgG M-spike
- Abnormal FLC ratio (normal = 0.26-1.65)
Need BMBx, whole body CT, CT abdo if IgM –> CBC, SPEP, FLC, Ca Cr in 6mo then q1y lifelong
If none of above = low risk: above BW in 6mo then q2-3y and NO imaging
Treatment MM
Transplant eligible: Induction chemo –> Auto HSCT (<70yo and fit) –> maintenance
Tx ineligible: CyBorD –> maintenance therapy
Isolated plasmacytoma: Radiation
Diagnosis AL Amyloidosis
Need all 4:
- M-spike or abn FLC or clonal plasma cell in BM
- Amyloid syndrome (liver, renal, GI, cardiac, neuro)
- Amyloid on tissue Bx or BM (apple green biefringence on Congo red stain)
- Amyloid light chain restricted (mass spectrometry or electron microscopy)
Treatment Waldenstrom’s (lymphoplasmaytic lymphoma + monoclonal IgM in blood)
Watch and wait if Asx
Chemo + Ritux +/- auto-BMT for cytopenias or symptoms
Cold avoidance of cold AIHA
PLEX for hyperviscosity (removes IgM)
Causes of Aplastic Anemia
Primary: Idiopathic
Secondary: Pregnancy, Autoimmune
Infxn: Parvo, Hepatitis B/C, EBV, CMV
Drugs: NSAIDs, PTU, carbemazapine, chemo
Clues to PNH
Pancytopenia + intravascular hemolysis + VTE (arterial or venous; commonly hepatic)
Diagnosis PNH
Peripheral flow cytometry: loss of CD55/59
Treatment Vaso-occlussive crisis in Sickle Cell Disease
Fluids
Analgesia: Standing tylenol, nsaid, HM, + PRN HM
Treatment acute chest crisis or CVA in sickle cell disease
Exchange transfusion to target HbS <30% and Hb <100
Simple transfusion ok if Hgb <100 and mild-mod chest sx
Indications for pRBC transfusion (1 unit at a time)
Hgb <70 for most
Hgb <75 if CVSx
Hgb <80 if CVD/MI, non-cardiac surgery (eg ortho)
Hgb <60 if young pt at low risk ischemia
Indications for Platelet transfusion (1 pool, 1 apharesed unit at a time)
<10 for all
<20 if low risk procedure (scope, central line)
<30 if AC can’t be held
<50 if LP, larger surgery, or bleeding, or DIC in APL
<80 neuraxial anesthesia
<100 if TBI, ICH, CNS surgery
Any plt count if plt dysfunction and marked bleeding
Indications for FFP (all factors + fibrinogen)
- Bleeding or signif procedure
- Liver dz or DIC and: INR>1.8
- Warfarin reversal if prior HIT
- TTP pre-PLEX
Indications for PCC (1000-3000 units) - vit k factors, prot c/s, heparin
- Warfarin or DOAC reversal with life-threatening bleed
- Before A-case OR within 6 hrs
Indications for cryoprecipitate (or fibrinogen concentrate) - 10 units at a time
Bleeding with fibrinogen <1.5
APML with fibrinogen <1.5
Intracranial bleed post tPA with fibrinogen <2
Bleeding in VWD/Hemophilia A if F8 conc not available
Major Transfusion Reactions
Febrile non-hemolytic transfusion reaction - 1:20 plts - 1:300 RBC
TACO - 1:100
Minor allergic RXN - 1:100 -
Delayed hemolytic transfusion RXN - 1:7000
TRALI - 1:10000 plts 1:250000 RBC
Bacterial sepsis - 1:10000
Acute hemolytic transfusion RXN - 1:40000
Anaphylaxis - 1:40000
Hep B - 1: 7.5 Mil
Hep C - 1: 13 Mil
HIV - 1: 21 Mil
Diagnosis of Acute Chest Crisis in Sickle Cell Disease
1) New segmental consolidation or infiltrate +
2) One of:
- Fever >= 38.5
- Hypoxia (>2% drop from baseline)
- Tachypnea
- Acces muscle use
- Cough
- Wheeze
- Rales
- CP
Treatment proximal DVT & PE
DOAC if no contraindication for non-cancer:
Provoked: 3 mo (up to 6)
Unprovoked/Chronic RF: 3-6mo, continue indefinitely w/ regular risk/benefit ax, consider lower dose DOAC (caution if >120kg, symptomatic PH, post lysis, thrombophilia)
Cancer: indefinite while active cancer +6mo in remission
LMWH or DOAC (apix/riva; edox req 5d therapeutic LMWH)
VTE recurrence risk
HERDOO and
DODS: Measure D-dimer on A/C
- Positive = resume AC
- Neg = stop AC and repeat D-dimer in 1 mo
- if positive in 1 mo - resume AC; if negative continue off AC
Treatment VITT
DOAC + IVIG (No heparin - send HIT ELISA first)
*Avoid platelet transfusion unless bleed
Primary vs Secondary Hemostasis manifestations
Primary:
- mucocutaneous/menstrual bleeding/bruising eg petechiae
- Low Plt quantity (eg ITP) or quality (eg ASA, uremia, congenital)
Secondary: intraarticular, muscular, retroperitoneal bleeding
TMA Presentation and Ddx
MAHA (schistocytes) + low platelet + microvascular thrombi
Primary:
- TTP (ADAMTS13 def; congenital/acquired),
- HUS: atypical (complement mediated), typical (shiga toxin)
Secondary:
- Preg (HELLP, preeclampsia),
- Ca,
- Infxn (HIV/HepC, H1N1),
- Malignant HTN,
- AI (scleroderma renal crisis, APLA, SLE, vasculitis),
- Transplant (BMT+solid organ) assoc’d,
- DIC,
- Drugs (cocaine, calcineurin inhibitors, VEGFi)
IDA dx and indications for IV replacement
Dx: Ferritin<30 or
Ferritin>30 + Tsat<20% + increased TIBC and sTFR
Venofer 300mg IVx3 or Monoferric 1gx1 for:
- Mod/severe IDA (Hgb <80-100)
- Intolerant to PO
- Limited time (preop or preg <1mo from delivery)
PO: treat for 3mo after ferritin normalizes
IDA clinical and blood film findings
S/S: anemia, RLS, pica, fatigue, glossitis, koilonychia
Film: hypochromia, pencil/target cells, thrombocytosis
Plt transfusion refractoriness
Increased <10 after 1h = immune (HPA/HLA antibodies, ITP)
> 10 at 1h = nonimmune (sepsis, DIC, splenomegaly, bleeding/thrombosis, drugs)
Indication for IVIG (pooled IgG)
Replacement: Hypogammaglobulinemia, CVID
Immunosuppression eg ITP
MPN genes
- CML (granulocytes: neut, eos, baso) - BCR-ABL+ (Philadelph)
- PV (RBC) - JAK2
- ET (Plt) - JAK2
- MF (fibrosis) - JAK2 and Calreticulin
MDS differential diagnoses
Deficiencies: Vit B12, Folate, Cu, Zn
Drugs: MTX, azathioprine, EtOH
Infxns: HIV
Lymphoma RFs
Infections: HIV, Hep C, EBV, H pylori,
Immunosuppression:
- DMARDs and biologics
- Post-transplant lymphoproliferative disease
Autoimmune:
- Sjögren’s (salivary gland MALT),
- Celiac or Crohn’s (GI lymphoma),
- SLE and RA associated with NHL
Treatment aplastic anemia
If severe (ANC<0.5, Plt <20, Retic<60)
- Supportive IRRADIATED transfusion
- Immunosuppression (antithymocyte globulin or allo HSCT)
- Stop offending drug
Treatment PNH
- Anticoag VTE (no ppx)
- Eculizumab or pegcetacoplan (inhib complements)
- Transfusions
Teardrop cells
Myelofibrosis (B sx, high LDH, splenomegaly, cytopenias, leukoerythroblastosis)
CLL blood smear
smudge cells and lymphocytes
Rouleaux
MM, inflammation, pregnancy
Spherocytes
immune mediated hemolysis (auto or allo immune)
Hypersegmented neutrophils (>6lobes)
Megaloblastic anemia (folate or B12 deficiency)
Schistocytes
TMA
Indication for CMV negative blood
Intrauterine transfusion
Nonmalignant causes of increased Hgb
Decreased O2: OSA, hypoventilation, smoking/CO poisoning, chonic lung disease, high altitude, cyanotic heart disease
Production: EPO, testosterone, tumors (RCC, hepatoma, uterine fibroids), renal artery stenosis,
Nonmalignant causes of increased Plt
- Iron deficiency
- Infection/Inflammation
- CTD
- Malignancy, LPD
- Surgery or Post-splenectomy
Felty Syndrome
RA + Splenomegaly + Neutropenia
-Anemia/Thrombocytopenia can happen with sequestration
Dabi vs Warfarin
Dabi 150mg BID vs Warfarin = superior efficacy, equivalent “major and minor bleeding”
Dabigatran 110mg BID vs Warfarin = equivalent efficacy, lower bleeding rates
Intracranial bleeding: Both Dabi doses = less intracranial bleeding vs warfarin
Extracranial bleeding: Both Dabi doses = less extracranial major bleeding vs warfarin in younger patients
-both doses = more major bleeding/extracranial major bleeding vs warfarin
