haematology quiz

Question 1

83-year-old man with no abnormal physical findings

Answer 1

chronic lymphocytic leukaemia

Question 2

Answer 2

RBC, Hb and Hct are high

polycythaemia - need to decide if true or pseudo (ie shocked and lost plasma would -> high hb)
ddx:
* hypoxia from chronic lung disease or cyanotic heart disease
* inappropriate epo secretion - cyst/tumour
* intrinsic marrow disease

Question 3

Answer 3

Polycythaemia vera

High plt – so likely to be a bone marrow
high RBC Hb PCV, WBC, neutrophils and basophils
Smoking – wouldn’t explain the thrombocytosis

Combination of both thrombocytosis and Hb that make the dx

Question 4

test to confirm polycythaemia vera

Answer 4

Analysis for JAK2 V617F mutation
Bone marrow aspiration and trephine biopsy
Serum erythropoietin - Would expect epo to be low – suppress by high Hb

Would like to stop her smoking because at increased risk with polycythaemia vera

Question 5

Answer 5

left shifts

Question 6

Answer 6

reactive neutrophilia

toxic granulaton and vacuolation are reactive changes

Question 7

Answer 7

High red and white cell
High neutrophil, lymphocytes, monocytes, eosinophils, basophils
Normal Hb
Splenomeg

Chronic myeloid leukaemia – high neutrophil eosinoiphil and basophil, normal Hb

AML – not if normal Hb and plts

Question 8

Answer 8

Isolated thrombocytopenia in elderly man – expect immune thrombocytopenia

Question 9

Answer 9

Peripheral gangrene

can be due to abnormality of vasculature, or of circulating blood

Question 10

Answer 10

Non-accidental injury
Coagulation abnormality eg Haemophilia if inherited
Thrombocytopenia eg ALL, immune of thrombocytopenia

Question 11

Answer 11

Normal on L
R – pokilocytosis, hypochromia, microcytosis

Question 12

causes of microcytosis

Answer 12

IDA
thalassaemia

Question 13

FBC of a North African woman with an 18-month old baby—most likely diagnosis:

• Normal for a North African
• Beta thalassaemia major
• Lead poisoning
• Beta thalassaemia trait
• Iron deficiency anaemia

Answer 13

Iron deficiency anaemia

Major – would have to be transfusion dependant

Trait – would have normal Hb, low MCV

Question 14

questions to ask if suspecting IDA

Answer 14

Diet
Menstrual history
History of pregnancies
Blood loss

Question 15

what is haemoglobin A2 in IDA

Answer 15

low

Question 16

Answer 16

Rheumatoid arthritis:

Anaemia of chronic disease
Iron deficiency anaemia resulting from use of aspirin or non-steroidal anti-inflammatory drugs (NSAID)
Neutropenia or thrombocytopenia from drug toxicity
Felty syndrome – neutropenia and splenomegaly
Increased erythrocyte sedimentation rate (ESR)

Question 17

A 10-year-old girl presented with a painful right knee that had started when she knocked her knee in a swimming pool
The next day she had become unwell with malaise, anorexia and fever
Her GP prescribed amoxicillin for ‘otitis media’
Next day her mother took her to an Accident and Emergency Department

Question 18

A 10-year-old girl presented with a painful right knee that had started when she knocked her knee in a swimming pool
The next day she had become unwell with malaise, anorexia and fever
Her GP prescribed amoxicillin for ‘otitis media’
Next day her mother took her to an Accident and Emergency Department
She was afebrile
Her right knee was painful and swollen
X-ray of the knee showed patchy changes in density in the right medial tibial plateau
Blood tests showed
WBC 6.6 × 109/l
ESR 60 mm in 1 h (NR 0‒10)
C-reactive protein (CRP) 27 mg/l (NR 0‒10)
What is the most likely diagnosis?

Answer 18

Osteomyelitis

ddx - septic arthritis, haemorrhage into the joint following minor trauma, non-accidental injury

osteomyelitis more likely than septic arthritis because:
* radiological abnormality, which indicated something wrong with the bone
* osteomyelitis slightly more common

Not haemophilia – because female
Thrombocytopenia – wouldn’t account for ESR, fever etc

Question 19

A 1-year-old boy, an only child, presented to an Accident and Emergency department with a swollen right elbow following minor trauma
On clinical examination and radiology there was no evidence of bony injury
He was sent home
brought back with increased pain and swelling
Joint aspiration yielded haemorrhagic fluid
brought back as the effusion had not resolved
The joint was surgically explored (dark blood) and a biopsy was taken (‘synovitis’)
Post operatively the wound bled persistently
what test would you do

Answer 19

A coagulation screen showed a normal prothrombin time (PT) and a prolonged activated partial thromboplastin time (aPTT)
Severe deficiency In factor 8

Question 20

A 21-year-old woman presented with abdominal pain, bruising and altered level of consciousness
She had a low grade fever
Her platelet count was 15 × 109/l
Her bilirubin was increased and LDH was greatly increased
Her creatinine was marginally increased

Microspherocytes
Red cell fragments
Anaemia
Circulating nucleated red cells

dx?

Answer 20

Thrombotic thrombocytopenic purpura - MAHA

Autoimmune – wouldn’t have fragments and microspherocutes

ddx - HUS, meningococcal septicaemia, TTP

Question 21

features of TTP

Answer 21

classic pentad of clinical features:
* Microangiopathic haemolytic anaemia
* Thrombocytopenia
* Fever
* Neurological abnormalities
* Renal impairment

Question 22

pathophysiology of TTP

Answer 22

defect in vWF cleaving protease (or ADAMTS13)
autoimmune
-> large multimers of vWF -> plt thrombi -> Clinical features

Question 23

rx of TTP

Answer 23

plasma exchange

Question 24

On this presentation, temperature 39.70C, BP 115/95, pulse rate 96 beats/minute, generalized lymphadenopathy, pharynx inflamed, mild hepatomegaly, spleen palpable 2 cm below left costal margin
WBC 11.2 × 109/l, lymphocyte count 7.8 × 109/l, Hb 109 g/l, numerous atypical lymphocytes
What test would you do?

Answer 24

screening test for infectious mononucleosis

Question 25

what does IgM antibodies to EBV viral capsid antigen tell us

Answer 25

had recent EBV infection

Question 26

if anaemia, tachycardic, abdo pain and tender and have EBV - what are you thinking

Answer 26

Splenic damage and intraperitoneal haemorrhage should be suspected
urgent imaging should be done

Question 27

splenomegaly with EBV

Answer 27

occurs in 50%
rupture in 0.1-0.5%
mortality - 30% - due to delayed dx
hx of recent trivial trauma

Question 28

risks of hyposplenism

Answer 28

Overwhelming bacterial sepsis (particularly pneumococcal or Haemophilus influenzae)
Fatal malaria
Fatal Capnocytophaga canimorsus infection
Babesiosis

Question 29

what should we do if people have been given a splenectomy

Answer 29

Vaccinate for pneumococcus, meningococcus and Haemophilus influenzae
Vaccinate against influenza
Prescribe life-long penicillin
Advise the patient on
* Dog bites
* Travel to malaria zones
* Prompt treatment of infection

Issue a splenectomy card and information sheet

Question 30

pathophysiology of anaemia of chronic disease

Answer 30

Reduction in red cell lifespan
Cytokine release - IFNg, IL1 and TNF
Reduced proliferation of erythroid precursors
Suppression of endogenous erythropoietin production
Impaired iron utilisation

Question 31

treatment of anaemia of chronic disease

Answer 31

treat underlying disease
recombinant epo
transfusion

Question 32

summarise hodgekin lymphoma

Answer 32

peak incidence - adolescence and >50yrs
presents with painless, supradiaphragmatic lymphadenopathy
1/3 present with B sx - fever, night sweats, wht loss

Question 33

aetiology of hodgekin’s lymphoma

Answer 33

Increased risk in families of affected patients
Association with HLA DPB1
Epstein‒Barr virus found in >79% of over 50s

Question 34

ix for hodgekin lymphoma

Answer 34

Expert histopathological review of biopsy
ESR still useful for prognosis and monitoring
Staging laparotomy obsolete
CT/ MRI/ PET

Question 35

staging of hodgekin lymphoma

Answer 35

Staging involved anatomical stage (I, II, III, IV)
Absence or presence of B symptoms (A or B)