haematology interactive cases Flashcards
describe this blood film
Anaemic – space between the blood cells
No plts
Abnormal cells – blast cells
Acute lymphoblastic leukaemia
v high WCC in child - highly likely it is leukaemia
low Hb dn plts - suggest bone marrow failure
mediastinal mass is thymus - infiltrated by T lymphocytes
best technique to dx acute lymphoblastic leukaemia
immunophenotyping
treatment for ALL
need combination chemo and CNS directed therapy
ALL Can cross the BBB
Many drugs don’t cross BBB – so either have to choose drugs that can – or inject into the brain
a high WCC lessens chance of cure
48-year-old male – railway engineer
2-week history bleeding gums
Attended dentist - severe bleeding
1 episode of haematuria
Minor bruising
Attended Accident and Emergency department
Left subconjunctival haemorrhage
Small bruises over abdomen
No enlarged lymph nodes
No hepatosplenomegaly
What test is most likely to reveal the cause of the problem?
* Liver function tests
* Creatinine
* Coagulation screen
* Blood count, film and coagulation screen
Blood count, film and coagulation screen
Want to know if thrombocytopenic
Need film to make sure not pseudothrombocytopenia/false counting on blood count
How could you explain a SHORT APTT and a low fibrinogen?
DIC
consumption of fibrinogen
Short APTT is affecting activation of coagulation
test to help dx of DIC
D-dimer
Do you think these are myeloid cells or lymphoid?
How would you prove it?
Big compared to red cells
Have Auer rods – so are myeloid cells
Cytochemistry
Immunophenotyping
But note that neither test is actually necessary because can see auer rods
describe this bone marrow
Brightly stained granules – uniformal population – obliterated the normal marrow cells/.
difference between CML and acute promyelocytic leukaemia
bopth have myeloid hyperplasia
but CML would have more differentiated cells
test to confirm acute promyelocytic leukaemia
Cytogenetic analysis/FISH/molecular genetic analysis
Want to be sure have the fusion gene
Immunophenytyping can be done quickly – but still not definitive
FISH is fast while waiting for cyto and molecular genetics - PML-RARA fusion
treatment for acute promyelocytic leukaemia
with platelets, chemotherapy and all-trans-retinoic acid (ATRA)
good px
A 68-year-old retired secretary
Gradual onset of fatigue, lethargy and exertional dyspnoea
Non-smoker, not much alcohol, good diet
On examination
Pallor (conjunctival and nail bed)
Mild ankle oedema
What one test would you do next?
fbc
FBC
WBC 4.7 × 109/l (3.7–9.5)
Hb 76 g/l (115–150)
MCV 110 fl 82–98 fl
Neutrophil count 1.4 × 109/l (NR 1.7–6.1)
Platelet count 182 × 109/l (NR 145–350)
Which test should be done next?
blood film
describe this blood film
macrocytes but no oval macrocytes or hypersegmentation of neutrophils
Aisocytosis – more variation in size of cell
Some hypochromic cells
describe this marrow and the dx
12% blast cells (normal < 5%)
45% of erythroblasts were ring sideroblasts
acquired sideroblastic anaemia
DIAGNOSIS: myelodysplastic syndrome (MDS) (MDS with excess of blasts)
if only going to live a year - does ferritin of 875 μg/l (NR 20–200) matter
Probably not because we think only going to last a yr
Not likely to get haemosiderin deposition in tissues until ferritin was in the 2000s – so just need to monitor
describe this blood film
Oval macrocytes
Tear drop
6 lobes of neutrophil – hypersegmentatuion
A 72-year-old Indian woman
Vegetarian, teetotal, non-smoker
Shortness of breath on exertion
Fatigue
Painful gums and tongue
Unable to eat spicy food
On examination: pallor only
what is the most important test
Vitamin B12 and folate assays
Don’t need marrow – can take dx from film
Vitamin B12 180 ng/l (NR 125‒600)
Red cell folate 227 pg/l (NR 215‒650)
Thyroid function normal
Liver function tests mildly impaired (bilirubin 20 μm/l, AST 110 iu/l (NR 40‒135)
Lactate dehydrogenase (LDH) 3870 iu/l (NR 50‒450)
What would you do next?
bone marrow aspirate
note: B12 can be normal ie false normal, when have intrinsic factor ab
Blood gases were normal
Blood count was not
WBC 18.6 × 109/l
Hb 180 g/l
Platelet count 1648 × 109/l
Ultrasound examination of the abdomen showed normal kidneys and increased splenic size
gangrenous toes
reduced distal pulses
breathless on exertiion and morning cough
smoker
dx?
polycythaemia vera
test to confirm polycythaemia vera
Molecular analysis for JAK2 mutation
Most people with polycythaemia vera have mutation in JAK2
mx for polycythaemia vera
Venesection plus hydroxycarbamide
Venesection – get iron down
Hydroxycarbamide to reduce plts
