Haematology Flashcards
DVT risk factors
Virchow’s Triad.
Immobility, dehydration, oestrogen (pill, preg), clotting disorders, varicose v, trauma, infection, malignancy
Virchow’s Triad
Stasis of blood flow
Hypercoagulability
Vessel wall injury
Myeloma bloods
Monoclonal Antibodies + Bence-Jones proteins
IgG >30 g/L
Plasma cells >10%
Chronic Myeloid Leukaemia bloods
Low Hb, High platelets, High WBCs
:: ^myeloblast cell turnover > differentiate into basophils, neutrophils, eosinophils.
Leucocytosis :: ^^WBC proliferation
Iron deficiency anaemia presentations
= microcytic anaemia
- brittle hair/nails
- Koilonychia
- Pale conjunctivae
- Systolic flow murmur
- pica cravings (esp kids)
Presentations of anaemia 2o to hypothyroidism
= macrocytic anaemia
- reduced reflexes (also in B12 deficiency)
Acute management of Acute Coronary Syndrome
Aspirin + Ticagrelor
GTN
Morphine
LMW Heparin/Fondaparinux
PCI within 12hr
Acute management of DVT + pharmacology
Rivaroxaban - inhibits factor Xa, Fondaparinux - inhibits factor X
LMW Heparin if PREG - inhibits anti-thrombin III
IVC Filter (if bleeding).
DVT presentations
Asymmetric calf swelling, localised pain, red skin, vein dilation
What is thrombocytopenia?
Outline the pathophysiology of Idiopathic thrombocytopenic purpura and Thrombotic thrombocytopenic purpura
low platelets
ITP - IgG targeted by Macrophage’s Fc_Receptor
TTP - Low ADAMTS-13 > Platelet consumption
Pt presents with painless lymphadenopathy. There is some pain after drinking alcohol.
Likely diagnosis? Risk factors? Management?
Hodgkin’s Lymphoma
RF: Young, high socioeconomic class
Mx: ABVD Chemo
Non-Hodgkin’s Lymphoma: Types, Risk Factors, Management
EBV - Burkitt’s/ AIDS-related
H. pylori - MALT
Mx: HAART + R-CHOP-21 + Rituximab
Pt presents with pruritus, vision loss, headache and fatigue. They recently suffered a thrombotic event.
They complain of episodes burning pain in their feet and hands (erythomelalgia)
Likely diagnosis?
Absolute Polycythaemia
Pt presents with pruritus, vision loss, headache and fatigue. They recently suffered a thrombotic event.
They complain of episodes burning pain in their feet and hands (erythomelalgia)
Their face is ruddy and genetic tests show a JAK2 mutation.
Likely diagnosis?
Absolute Secondary Polycythaemia - Polycythaemia Rubra Vera
Gold standard investigation for Malaria
Giemsa-stained blood film - Plasmodium falciparum
Management of Malaria
Artemisinin Combination Therapy (ACT)
Quinines, Artesunate, Primaquine
Splenomegaly in the context of haematology can indicate
1)
2)
3)
1) Lymphoma
2) Leukaemia
3) Myeloproliferative disorders
Erythromelalgia indicates…
Polycythaemia Rubra Vera + essential thrombocytosis
= “dusky” extremities + burning pain with hot temperatures.
An IgG paraprotein spike in the context of haematology indicates…
Multiple myeloma
Macroglossia in the context of haematology indicates…
Amyloidosis
JAK2 mutations are associated with…
Polycythaemia Rubra Vera
Middle-age patient presents with massive splenomegaly and his toe is very painful and hot to touch.
A blood film is requested.
Likely diagnosis? What may genetic testing find? What may his blood film reveal?
Chronic Myeloid Leukaemia
Blood film - ^^mature myeloid cells , basophils, eosinophils
Genetics: Philadelphia chromosome
Pt presents with anaemia, bleeding and recurrent infections. Examination reveals hepatomegaly, splenomegaly and gum hypertrophy.
Likely diagnosis? Biopsy findings?
SnS = BM Failure + BM infiltration
Acute Myeloid Leukaemia
Biopsy: Auer Rods + Blast cells
5 yr old presents with fatigue and easy bruising. They have had recurrent infections this year. The child complains of a sore back.
Examination reveals painless lymphadenopathy and meningism.
Likely diagnosis? Biopsy?
Acute Lymphoblastic Leukaemia
Biopsy: Leukaemic Lymphoblastic Cells!
Child under 6 with features of BM infiltration + Lymphadenopathy?
Acute Lymphoblastic Leukaemia
Features of Bone Marrow Failure
Anaemia - fatigue
Abnormal bleeding
Abnormal bruising (low platelets)
Pt presents with wt loss, tiredness, fever and sweating.
Exam reveals massive splenomegaly, bleeding and gout.
Diagnosis?
Chronic Myeloid Leukaemia
Rouleaux formations are associated with…due to…
associated with Multiple Myeloma
Due to Raised ESR
Imatinib uses
Chronic Myeloid Leukaemia
Imatinib = Tyrosine Kinase Inhibitor
(TK induced by philadelphia c/s mut)
Rituximab uses
= monoclonal Ab
- NHL (Non Hodgkin’s Lymphoma)
- CLL (Chronic Lymphocytic Leukaemia)
Lenalidomide uses
= Chemotherapy
Multiple Myeloma
58-F is becoming increasingly tired and has lost 2 stone. She initially put these fown to the menopause, but has recently developed mouth ulcers and pins and needles in the feet.
She is mildly jaundiced.
Likely diagnosis? Management?
Pernicious anaemia - autoimmune condition
- anaemia
- peripheral neuropathy
- lemon skin (mild jaundice + pallor)
- mouth ulcers
- depression
- dementia
Mx: B12 injections
Polycythaemia management
Venesection
7-F has a known haematological malignancy. Parents bring her to A&E as she is red in the face and her chest veins are dilated.
Her facial features include a small chin, slanted eyes and drooping of the left side of the face.
Likely haem diagnosis?
Acute Lymphoblastic Leukaemia
- young kids
- Down’s syndrome RF
- anaemia, bleeding, infection
- hepatosplenomegaly, peripheral lymphadenopathy
- SVC obstruction, facial nerve palsy
Red face, dilated chest veins
SVC Obstruction
Haemophilia B is associated with which clotting factor?
Factor 9
Haemophilia A is associated with which clotting factor?
Factor 8
A before B, 8 before 9
Define primary and secondary polycythaemia. Give examples of both.
Primary polycythaemia: RBC over production, eg Polycythaemia Rubra Vera
Secondary polycythaemia = RBC production upregulated, eg due to: chronic hypoxia (lung disease, smoking, low FiO2, COPD).
56-M is overweight and smokes 30 cigarettes a day. He has COPD and HTN.
He presents with a swollen red calf and is diagnosed with DVT. You notice he has red palms and soles.
Likely diagnosis?
Secondary Polycythaemia, secondary to hypoxia from smoking + COPD
Smudge cells are associated with
Chronic LYMPHOCYTIC leukaemia
76-M presents with urinary frequency, haematuria and night sweats. He reports 2 stone recent wt loss.
DRE reveals a hard craggy mass.
Likely diagnosis? Investigations? Management?
Prostate Cancer
1L: DRE, urine dipstick
Gold: Transrectal US Biopsy (TRUS Biopsy)
GnRH agonist (analogue) - Goserelin, Leuprolide Androgen antagonist - Biclutamide
Factors that raise PSA
Acute urinary retention
Recent ejaculation
PR Examination
BPH!!
Prostate cancer
Infection
- urinary tract, prostate
Prostate cancer management for:
- low grade
- high grade
Low Gleason grade:
1. Active surveillance
High Gleason grade:
- Radiotherapy
- Laparoscopic prostatectomy
Management of METASTATIC prostate cancer
HORMONAL Mx:
- GnRH agonist (analogue)
a) Goserelin
b) Leuprolide - Androgen antagonist ADJUNCT
a) Bicalutamide
b) Enzalutamide - GnRH antagonist
a) Degarelix
Pharmacology + SE of hormonal management of prostate cancer
GnRH Agonist (Goserelin) > OVER stimulate pituitary > paradoxical blockade of LH & FSH
Problem = transient ^^testosterone > makes disease worse
SO…
add Androgen antagonist (Biclutamide)
SE: low libido, infertility, wt gain, osteoporosis, anaemia
Aplastic crisis
CLL transforms into NHL
Myelofibrosis pathophysiology and features
Myeloproliferative disorder –>
Clonal BM disorder chd by deposition of fibrous scar tissue (too many cells > BM compensates and kills itself off - fibrosis - to reduce output)
- Pancytopenia
- tear drop cells
- DRY tap (:: all fibrotic)
- MASSIVE splenomegaly
Myelodysplasia pathophysiology and features
How many progress to AML?
= pre-cancerous stage
BM disorder > pancytopenia + production of functionally immature blood cells
1/3 progress to AML
Blast crisis
Chronic leukaemia becomes acute leukaemia
- outputting a huge number of abnormal cells
Amyloidosis
protein aggregates deposit in body tissues
- proteinuria
- purpura (eyes)
- Carpal tunnel
- peripheral neuropathy
- glossitis
Management of major bleeding
Stop anticoagulants
IV Prothrombin Complex Concentrate/FFP + IV Vitamin K
Management of minor bleeding
Stop anticoagulants
IV Vitamin K
Repeat INR after 24Hr
Management of no bleeding with INR >8
Stop anticoagulants
IV/Oral Vitamin K
Repeat INR after 24Hr
Management of no bleeding with 8>INR>5
Withhold 1-2 doses anticoagulant
Review maintenance dose of anticoagulant
What is INR? When is it used
International Normalised Ration - measure of blood coagulation.
Used in pts
- on Warfarin
- at high risk of thromboembolic events - prosthetic valve, AF
- being treated for DVT/PE
Name the 4 products which are readily transfusable
1 - Red Blood Cells
2 - Fresh Frozen Plasma (coagulopathy)
3 - Platelets (1 pool from 4 donors. LS 10 days)
4 - Cryoprecipitate (= thawed FFP. Massive bleed + low fibrinogen)
Cryoprecipitate components
Fibrinogen
Factor VIII
Von Willebrand Factor
Management of a patient with a massive bleed and low fibrinogen
Cryoprecipitate
Management of a patient with Coagulopathy
Fresh Frozen Plasma
Whole blood transfusion indications
Major trauma, eg military trauma patients who need resus
Rapid corrects of acidosis, hypothermia, coagulopathy
Red blood cell transfusion indications
Acute haemorrhage
Chronic anaemia
Platelet transfusion indications
Thrombocytopenia + bleeding
Severe thrombocytopenia (prophylaxis)
Granulocyte transfusion indications
Neutropenic cancer patients developing bacterial sepsis AND unresponsive to ABX for 24-48Hr
Fresh Frozen Plasma indications
DIC
Liver disease - coagulation factor deficiency
Major trauma/ haemorrhage
Urgent warfarin anticoagulation
Cryoprecipitate indications
Von Willebrand Disease
Severe Hypofibrinaemia
IV Immunoglobulin transfusion indications
Immuno-thrombocytopenia
Guillain-Barre Syndrome
Autoimmune Haemolytic Anaemia
Antithrombin III transfusion indications and side effects
Normal action of antithrombin III
Congenital Antithrombin III deficiency - increased risk of thrombosis
AT III inhibits factors IIa, Xa, IXa, XIa
Antithrombin III deficiency homozygosity vs heterozygosity
Homozygosity = In Utero death
Heterozygosity = increased risk of VTE 50-fold
Factor VIIa transfusion indications
Haemophilia A and B
Most common inherited thrombophilia
Pathogenesis
Factor V Leiden
= mutation in clotting factor V > becomes resistant to inactivation by protein C
Protein C deficiency epidemiology
Protein C usual pathophysiology
Higher prevalence in Southeast Asian patients
Protein C inactivates Factor V and VIII
Inherited thrombophilia
Factor V Leiden
Protein C Deficiency
Antithrombin III deficiency
