Haematology + ID/ Travel Flashcards
Benign ethnic neutropenia is MOST common in which ethnic groups?
Black African and Afro-Caribbean ethnicity
If a patient has had a previous travel related DVT and has an essential long haul flight. What medication may be offered?
LMWH
(In addition to compression stockings)
(Aspirin good evidence for arterial prevention but not DVT)
In which groups of patients should wells not be used when assesing for potential DVT?
Pregnancy or up to 6 weeks post partum
How do you interpret the result of the two level wells score for DVT risk?
> 2 = Likely
Proximal leg USS within 4 hours, if not able within 4 hours then do d-dimer, start anti-coag and scan within 24 hours
0 or 1 = Unlikely
D-dimer with results within 4 hours, if not available in 4 hours then offer anticoag
You referred a patient with a wells score of 1 for a d-dimer which is postiive. How do you manage?
Proximal leg USS within 4 hours
- If not possible and not yet on anticoag then offer this and scan within 24 hours
What blood tests should be done before starting anticoagulation therapy?
FBC, renal and hepatic
PT and APTT
(But don’t wait for results before starting)
How should a patient with unprovoked proven DVT be managed?
Screen for undiagnosed cancer (review history and results but don’t offer further ix)
Offer thrombophillia testing
For a first episode of DVT how long should a patient be treated with a DOAC for?
3 months
(Longer if unprovoked or if high risk VTE recurrence)
How is MGUS managed?
There is no treatment for monoclonal gammopathy of undetermined significance (MGUS). The mainstay of management is regular monitoring for the rest of the patient’s lifetime. The purpose of monitoring is to detect potential progression to multiple myeloma, lymphoproliferative disease, or amyloidosis.
What is the gold standard imaging to best detect suspected myeloma?
MRI scan
(Better than x-ray at detecting lytic lesions)
How should an isolated thrombocytopenia be managed if mild (>100)?
If asymptomatic (no night sweats, lymphadenopathy etc) monitor in primary care
Name 3 B symptoms of lymphoma?
Night sweats
Fever
SOB
Pruitus
Weight loss
Alcohol induced lymph node pain is very specific to which condition?
Hodgkin’s lymphoma
What is the SINGLE MOST reliable primary care investigation indicator of leukaemia?
Cytopenia’s on FBC
(Low red cells, white cells and platlets - pancytopenia means all are low)
- Note often white cells are raised in leukaemia and others are low
Normal FBC makes leukaemia very unlikely
A patient is found to have a platlet count of 1100 with otherwise normal bloods.
a) What symptoms may accompany essential thrombocythemia?
b) What examination findings may you see?
a) Asymptomatic or vasomotor symptoms (headache, atypical chest pain), fatigue, itch, bleeding or thrombotic complications
b) Spleno or hepatosplenomegaly
An eight-year-old boy presents with a short history of fatigue, pallor and easy bruising. On examination you note that he is pale, has some petechiae and a systolic murmur. How should they be managed?
Symptoms suggest acute leukaemia
Needs same day specialist assessment as petechia (or if hepatosplenomegaly)
(Murmur likely from anaemia)
What is the prophylactic antibiotic recommendation post splenectomy?
PenV
For at least 2 years
Which drug is given orally and licensed for prophylaxis of venous thromboembolism following a total knee replacement?
Dabigatran
Which drug is a synthetic pentasaccharide that inhibits activated factor X, and is licensed for the treatment of deep vein thrombosis?
Fondaparineux
Differential diagnosis of microcytic anaemia?
IDA
Thalassaemia - MCV and MCH both reduced
Anaemia of chronic disease (20%, 80% are normocytic)
Siderblastic anaemia - rare (consider if alcoholism/ hepatosplenomegaly)
In what circumstances is ferritin not a reliable marker of iron stores?
Women in 2nd/3rd trimester
Infection or inflammation, chronic inflammatory conditions or maligancy
Name 3 dietary sources of iron?
Dark green veg
Iron fortified bread
Meat
Apricots, pruns and raisins
How should iron be prescribed for IDA?
Once daily ferrous sulphate, fumerate, or gluconate
Treat for 3 months after corrected to replenish stores
(Need 65mg elemental iron which is 200mg ferrous sulphate daily to treat IDA)
Differential diagnosis of macrocytic anaemia?
B12/ folate deficiency
Alcohol (most common cause raised MCV with no anaemia)
Drugs (Methotrexate, azothrioprine)
Pregnancy and neonatal period
Hypothyoid
Smoking
Liver disease
How may herediatary spherocytosis present?
How is it inherited?
Haemolytic anaemia
Jaundice (either haemolysis or gallstones)
Splenomegaly
Ask about FHx of anaemia (hereditary - usually autosomal recessive)
What is reticulocytosis and when is it usually seen?
Reticulocytes are immature RBC’s
Raised usually in haemolytic anaemic or haemorrhage where body is trying to rapidly replace RBC loss
How is herediatary spherocytosis usually managed?
Mild - observe for complications (gallstones etc)
Mod - May need folate suppliments, splenectomy, steroid courses etc
How should unexplained bleeding or brusing be managed in children and young people?
Very urgent FBC within 48 hours (leukaemia)
How should unexplained or persistent bone pain be managed in children and young people?
Very urgent FBC within 48 hours (leukaemia)
Name 3 characteristic features that would make you suspect myeloma?
Unexplained bone pain in lower/ thoracic back - particularly over 60
Hypercalcemia (bone pain, abdo pain, confusion, weakness, thirst, polyuria)
Hyperviscocity symptoms (headahce, congnitive disturbance, breathlessness)
A 62 year old male presents with back pain. You consider myeloma. Name your first investigations?
FBC
Bone profile including calcium
Plasma viscosity
ESR
(Then serum electrophoresis, serum free light chains and Bence-Jones protein in urine come after)
How do you manage a 62 year old man with back pain and hypercalcemia on bloods?
Serum electrophoresis, serum free light chains and Bence-Jones protein in urine < within 48 hours
(Assuming FBC, bone, viscocity and ESR already done)
Likely then needs 2ww
At what level of Ca would you arrange urgent hosptial admission?
Any corrected calcium of 3.01mmol or higher
How do hodgkin’s and non-hodgkin’s lymphoma’s differ on histology?
Reed-Sternberg cell = Hodgkin’s
A patient presents with a cervical lymph node. What are your considerations regarding cancer referrals?
If infective cause give upto 4 weeks for it to settle. If persistent:
If generalised lymphadenopathy - urgent FBC within 48 hours to consider leukaemia
If single lymph node - 2ww cancer pathway if over 25yrs old
If under 25yrs need to be seen within 48 hours
You suspect a child may have leukaemia. What are the indications for immediate specialist assessment?
Petechiae or hepatosplenomegaly
You suspect a child may have leukaemia. What are the indications for FBC within 48 hours? (Name 5)
Pallor
Persistent fatigue
Unexplained fever
Generalised lympadenopathy
Unexplained bruising or bleeding
Persistent bone pain
Persistent infection
How is herediatary haemochromatosis inherited?
What gene is affected?
Autosomal recessive
HFE gene (chromosome 6) in majority of cases
How does herediatary haemochromotosis classically present initially and then when more advanced? (3)
40-60’s
Initially vague and non specific:
Fatigue, weakness, arthropathy
Advanced: Diabetes, bronzing of skin, ED, cardiovascular issues, cirrhosis, neuro syx
What tests should be done and what is the typical investigation results pattern seen in herediatary haemochromotosis?
Ferritin - Raised (if normal rules out iron overload)
Transferin saturation - raised
Look for other raised ferritin causes (CRP) and then impact (LFT’s etc)
What is the pathology in sickle cell disease and sickle cell trait?
How is it inherited?
Abnormal beta-globin chain
Sickle cell disease - One gene of sickle hb (Hb S) and one other abnormal Hb
- If second abnormal Hb is also sickle Hb (Hb SS) then this is sickle cell anaemia and most severe form
Sickle cell trait - One normal Hb gene (Hb A) and one Hb S gene
- Rarely symptomatic
How is sickle cell inherited?
Which groups are classically more affected?
Autosomal recessive
(1 in 4 chance affected if both parents carriers, 50% chance will be carrier)
African or afro-carribean more affected
Name 3 classic presenting features of a sickle cell crisis?
How is it managed?
Sudden onsent:
Pain
Infection
Anaemia
Priapism or stroke
Manage if severe pain/ fever over 38.5/ systemic unwell - admit
If temp over 38 but managing at home - broad spectrum ABx and pain management (paracetamol, ibuprofen, codeine)
What is rhesus disease of newborn and how is it managed?
If mother is rhesus negative and baby is rhesus positive and mum sensatised to +ve blood (previous pregnancy, complications)
Now all women have blood tests and if rhesus negative will have anti-D injectons during pregnancy (if already sensatised anti-D pointless and just need to monitor more)
What management advice is given to patients with lymphoedema?
Skin and nail care
Positioning limb above heart
Excercise - mild can often improve
Massage (Manual lymph drainage) can be helpful
No use for diuretics
What is myelodysplasia and what are the main risk factors?
How may it present?
A group of malignant disorders which causes dysplastic changes in one or more cell lines (myeloid = white, erythroid = red, megakaryocyte = platelets)
Disease of older people. 10% are secondary to radiotherapy or chemotherapy (usually about 5 years after)
Presents - any combo of anaemia, neutropenia, thrombocytopenia
What is polycythemia ruba vera and how does it present?
Erythrocytosis (increased red cells)
Classic: Pruritus on contact with warm water - ruddy complexion, splenomegaly
Hyperviscocity symptoms: Chest/ abdo pain, headache, weakness, blurred vision, tinnitus, vasomotor etc
How should haematocrit be used to guide investigation/ referral in suspected polycythemia ruba vera?
Hct > 0.6 in men or > 0.56 in female - absolute erythrocytosis, investigate
Hct > 0.52 in men or > 0.48 in women - if persistent or symptoms will need referral
How should EPO be used to guide investigation/ referral in suspected polycythemia ruba vera?
Low EPO suggests polycythemia ruba vera
Raised EPO suggests a secondary erythrocytosis
What mutation is associated with polycythemia ruba vera?
JAK2 (95%)
How should thrombocytosis be managed in primary care?
Suspect cancer? - 2ww
If over 1000 - Urgent referral
600-1000 - urgent referral if over 60, associated bleeding, neuro syx or any coagulation (MI, PVD, DVT, PE etc)
Persisently over 450 (for more than 3 months) or over 600 on two occasions (4 weeks apart) - Refer to haem for further ix
Which drugs commonly cause neutropenia? Name 5
Immunosuppressant
(Azathioprine, methotrexate, sulfasalazine, infliximab etc)
Also carbimazole, valproazte, clozapine, olanzapine, phenytoin, penicillin and NSAIDS can
Name 3 causes of raised EPO/ secondary polycythemia?
Hypoxia (from cardiac or lung disease, smoking, OSA etc)
Exogenous testosterone
Kidney or liver cancers that can secrete EPO
Name 3 differentials for pancytopenia?
Aplastic anaemia
Myelodysplastic syndromes
Acute leukaemia
Fanconi anaemia
Myelofibrosis
Key characteristics of:
a) ALL
b) CML
c) AML
d) CLL
a) Most common childhood cancer (usually under 6)
b) Usually 60-65’s, philadelphia chromosome
c) Most common leukaemia in adults, usually age 70’s - Auer rods always present
d) Often asymptomatic
Most common organisms causing osteomyelitis? 2
Staph aureus (long way most common)
Staph epidermis
Name 3 RF’s for infective endocarditis?
Valvular heart disease
Valve replacement
Structural heart disease
Previous IE
Hypertrophic cardiomyopathy
Which organism is most commonly responsible for IE?
Staph aureus
(Followed by streptococci) - strep viridans 50% subacute cases
Name 3 possible presenting characteristics of infective endocarditis?
Non-specific infective syx (fever, flu syx, pain etc)
New murmur
Splinter haemorrhages, roth spots
Brain, lung or spleen emboli - 30% the presenting feature
How should suspected IE be managed? Which criteria is used to diagnose infective endocarditis?
Same day admissionR (needs echo within 24 hours) + blood cultures etc
Duke’s criteria (maj and min) used to make diagnosis
Rheumatic fever is caused by what organism?
What are the most important complications to note?
GroupA beta haemolytic streptococci
Complication carditis, mitral stenosis and CCF
How should suspected Covd-19 be managed in:
a) A high risk patient
b) A low risk patient
a) Rapid LFT, if +ve manage as covid, if -ve take 3 LFT’s over 3 days
b) Advise to stay at home if unwell, if mild symptoms and well can continue to attend school or work
How should confirmed Covid-19 be managed in high risk patients?
Antibody and antiviral treatements may be offered if:
- Symptomatic and not improving
- Age over 12
How should confirmed Covid-19 be managed in low risk patients?
Stay at home, avoid contact with others for 5 days after test was taken (3 days if child)
Avoid contact with high risk people for 10 days since test was taken
According to NICE if a patient attends for a covid vaccine and has suspected covid symptoms - what should they do about recieving the vaccine?
Defer until at least 4 weeks after onset of symptoms/ first PCR result
Note not likely to make illness worse but can spread to others having the vaccine is rationale
What organism is responsible for malaria transmission?
Plasmodium parasites from the bite of infected female anopheles mosquitoes
Plasmodium falciparum is main organism (also vivax, ovale, malariae)
Name 5 classic presenting features of malaria?
Fever, headache, confusion, malaise, fatigue
Myalgia and arthralgia
GI disturbance, anorexia
Jaundice
Sore throat, cough, LRTI symptoms
How should suspected malaria be managed in primary care?
High risk- Immediate admission
All others - Discuss same day with ID specialist
Notifiable disease
Antimalarial drugs - Quinine, chloroquine, primaquine, quinine plus doxycycline, artesunate
What is viral haemorrhagic fever, what symptoms may suggest it as a differential?
Group of virus’ (mild such as dengue and zika) to sever
Suspect in any returning travellor with fever - especially if any signs suggesting bleeding
How should suspected viral haemorrhagic fever be managed (3 point)?
All labels sampled
Public health notified - imported fever service
Barrier nursing, quarantine patient
Can use Ribavirin (antiviral) for Lassa fever
What organism is responsible for spreading denge fever, chikungunya and yellow fever?
Female mosquitoes (aedes aegypti and ae. albopictus)
What organism causes typhoid and paratyphoid? How is it managed?
Different strains of salmonella spp
Mx - Abx (Azithromycin, fluroquinolone (ciprofloxacin) - usually 5 days
A 34-year-old man, who uses intravenous drugs recreationally, presents with a week’s history of abdominal pain, malaise, arthralgia and fever. You are concerned about the possibility of hepatitis C (HCV) infection, and you have referred him to have a blood test.
What is the SINGLE BEST diagnostic test for acute infection?
HCV RNA
(HCV core antigen is offered at some centres but is not as sensitive a test)
Anti- HCV antibodies would show infection at some stage but not neccesarily acute
Name 3 vaccines which are live vaccines?
MMR
Yellow fever
Chickenpox/ small pox/ shingles
Rotavirus (Nasal flu)
BCG
Which organism causes scarlet fever?
Group A streptococcus
(Sore throat, fever, sandpaper rash, strawberry tongue)
Which organism is the most common cause of travellers diarrhoea?
How long do symptoms usually last?
If symptoms were lasting > 14 days, name 3 other organisms you may consider?
E.coli
Symptoms usually last < 72hrs
If ongoing past 14 days look for more unusual organisms
Giardia spp., Entamoeba spp. Cyclospora spp. and Cryptosporidium spp. is required.N
Name two organisms that usually cause blood diarrhoea? How may you distinguish between the two?
Bloody diarrhoea (dysentery) occurs more commonly with some pathogens (Salmonella spp., Shigella spp. and Campylobacter spp.)
Campylobactor more likely to cause pain, salmonella and shigella less so
Which organism commonly causes travellers diarrhoea in:
a) Adults
b) Under 5’s
a) E.coli
b) Rotavirus
How should campylobactor GI infection be managed?
Most self-limiting
If severe, immunocompromised, not getting better - Clarithromycin (or erythro/ azithro)
Notifable disease - alert public health
How does giardasis classcially present and how is it managed?
2 week incubation period
Watery diarrhoea
Treat: Metronidazole
How should a decision on malaria prophylaxis be reached? What are the propylaxis options?
How should they be taken?
Individual risk assessment
Chlorquine - Start 1 weeks before
Mefloquine - Start 2/3 week before
Doxycycline - start 1/2 days before
All continued until 4 weeks after left area
How should a wound, not responding to ABx and found to have MRSA be managed?
Urgent micro discussion
Review again in 48hrs
Name 3 risk factors for c.diff infection?
Age > 65
Antibiotic use
Hx of c.diff/ exposure
Current use PPI
Prolonged hospitalisation/ nursing home
How do you test for c.diff. When should you retest?
Stool sample
Don’t retest unless symptoms resolve and then reoccur - note can still be positive after succesful tx
How should confirmed c.diff be managed?
Vancomycin 125mg QDS for 10/7
Stop AB’s not being used for treating c.diff, avoid loperamide and opiods
Consider stopping PPI
Consider dehydration drugs (NSAID, ACEI, diuretics etc)
What are the recommendations for PEP if HIV+ve partner is adherant to treatment and viral load is < 200copies/ml (sustained for >6months)
PEP generally no longer recommended
Who is PEP recommended for (name 3 groups)?
- When should it be given (timeframe)?
UPSI with infective person
OR
Person in high risk group if infection status unknown
OR
Victim sexual assult
Ideally within 24hours but can be initiated within 72hrs
What are the recommendations for PEP around:
a) Needlestick injuries in the community
b) Human bites
c) Occupational HIV exposure
a) Not recommended
b) Not recommended
c) Follow local guidance for urgent advice but if HIV patient may need PEP
How quickly following diagnosis should a patient with new HIV be seen?
Refer urgently
Preferably seen with 48 hours, latest within 2 weeks
What is shown by the CD4 count in a person with HIV?
Measure of immunosupression
> 500 = Normal in healthy unaffected persion
CD4< 200 = Increased risk opportunistic infections and cancer
What is PrEP and when is it indicated?
A combination of two antiretroviral drugs taken before and after sex to reduce risk of aquiring HIV
Offered case by case to people who are -ve for HIV but high risk of getting it/ not using condoms
- Signpost anyone who may be eligeable to sexual health clinic
What should be noted regarding contraception for female patients with HIV?
Oral contraceptives/ patches may have reduced effectiveness with ART
IUS/ IUD/ depot seem to be unaffected by HIV enzyme inducing drugs
Emergency contraception should be copped IUD (unless CD4<200 with detectable viral load - high risk infection from insertion)
Name 3 AIDS defining conditions for patients living with HIV?
Cancer: Cervical, non-hodgkin lymphoma and kaposi’s sarcoma
Bacteria: TB, 2 or more pneumonia in 12 months, mycobacterium
Fungal: PCP (pneumocystitis pneumonia), oesopheal candidiasis, pulmonary/ tracheal candidiasis
(Plus lots more)
Name 5 body fluids that can transmit HIV?
Blood
Semen
Vaginal secretion
Breast milk
Amniotic fluid
CSF
Pleural effusions
With regard to infectious mononucleosis (glandular fever):
a) Causative organism
b) Incubation period
c) Natural history
d) Classic symptoms (3)
a) EBV
b) 4-7weeks
c) Self limiting, lasts 2-4 weeks
d) Sore throat, fever, lymphadenopathy
What tests are used for glandular fever?
FBC (lymphocytosis)
Monospot test - immunocompetent adults
EBV serology - Children under 12 or immunocompromised
What is the most common antihelminitic drug used for conditions such as roundworm?
Mebendazole
How long does the yellow fever vaccine provide immunity for?
Lifelong
What is the classic presentation of typhoid/ partyphoid Enteric fever)?
- What countries most common?
- How to distinguish from malaria?
80% india, pakistan or bangaldesh
Similar to malaria but higher fever initially, may develop rash and rose spots on chest and abdomen
A 32-year-old man requests a human immunodeficiency virus (HIV) test because of unprotected sex with a sex worker when on holiday in sub-Saharan Africa six weeks ago. He is asymptomatic.
What HIV test should he be offered?
Laboratory HIV-1 and 2 antibodies plus p24 antigen immediately and three months from initial exposure
If risk more than 4 weeks can test immediately
All patients tested before 12 weeks need retesting to confirm. If after 12 weeks only need single test
(NB: PoC testing is less sensative)
