haematology to work on Flashcards
what are the investigations for CLL?
● Normal or low Hb
● Raised WCC with very high lymphocytes
● Blood film – smudge cells may be seen in vitro
what is the treatment for CLL?
- Watch and wait
- Chemotherapy
- Monoclonal antibodies, e.g. rituximab
- Targeted therapy, e.g. bruton kinase inhibitors (ibrutinib)
- human IV immunoglobulins
what is the epidemiology of ALL?
Mainly a childhood disease
highest prevalence between 2-4yrs
Associated with Down’s syndrome
Associated with ionising radiation
what are the investigations for ALL?
● FBC and blood film
o WCC = high
o Blast cells on film and in bone marrow
● CXR and CT scan looking for mediastinal and abdominal lymphadenopathy
● Lumbar puncture to look for CNS involvement
What are signs and symptoms of Hodgkins lymphoma?
- Fever and sweating
- Enlarged rubbery non-tender nodes
- Systemic ‘B’ symptoms, e.g. fever
- Painful nodes on drinking alcohol
- some patients (commonly young women) have disease localised to the mediastinum
What blood results may you seen in someone with Hodgkins lymphoma?
High ESR FBC - anaemia (normochromic normocytic) Reed Sternberg cells Low Hb High serum lactase dehydrogenase
Describe the staging for Hodgkins lymphoma
Stage 1 = confined to a single lymph node region
Stage 2 = Involvement of two or more nodal areas on the same side of the diaphragm
Stage 3 = Involvement of nodes on both sides of the diaphragm.
Stage 4 = Spread beyond the lymph nodes e.g. liver.
Each stage is either ‘A’ - absence of ‘B’ symptoms or ‘B’ - presence of ‘B’ symptoms
What the treatment for Hodgkins lymphoma?
ABVD chemotherapy regime
marrow transplant
What are the possible complications of treatment for Hodgkins lymphoma?
- Secondary malignancies
- IHD
- Infertility
- Nausea
- Alopecia
what are the signs and symptoms of non-hodgkins lymphoma?
Fever and sweating
Enlarged rubbery non-tender nodes
Systemic ‘B’ symptoms, e.g. fever
GI and skin involvement
What is the treatment for non-hodgkins lymphoma?
Steroids
Monoclonal antibodies to CD20 -> Rituximab
CHOP regimen
what are the causes of microcytic anaemia?
- Iron deficiency
- Chronic disease - cancer, HF, CKD
- Thalassaemia
what are the causes of normocytic anaemia?
- Acute blood loss
- Chronic disease
- Combined haematinic deficiency (iron and B12 deficiency)
- renal failure
- pregnancy
- hypopituitarism, hypothyroidism, hypoadrenalism
Give 3 causes of macrocytic anaemia
- B12/folate deficiency
- Alcohol excess –> liver disease
- Haemolytic anaemia
- Hypothyroidism
- bone marrow infiltration/failure
- myeloma
What pathological changes occur due to anaemia?
- Heart/liver fat change
- Ischaemia
- Skin/nail atrophy
- CNS death
- Aggravate angina and claudication
Give 3 signs of anaemia
- Conjunctival pallor
- Hyper-dynamic circulation
- Tachycardia
- Systolic flow murmur
What investigations might you do in someone with anaemia?
- FBC and Blood film
- Reticulocyte count
- B12, folate and ferritin levels
- U+E’s, LFT’s, TSH levels
Give 3 causes of iron deficiency anaemia
- Blood loss
- Poor absorption
- Decreased intake in diet
- Increased demand - growth/pregnancy
- Hookworm
What would the results of investigations be for someone with iron deficiency anaemia?
MICROCYTIC HYPOCHROMIC ANAEMIA
Low ferritin, low reticulocyte
what are the causes of B12 deficiency/pernicious anaemia?
- Autoimmune parietal cell destruction (pernicious)
- Poor diet
- Ileectomy
What are the specific signs of B12 deficiency/pernicious anaemia?
Inflamed tongue (glossitis), angular stomatitis, mild jaundice
Neurological - paraesthesia, psychological problems, ataxia
- dementia and visual disturbances
What would the results of the investigations be for someone with B12 deficiency/pernicious anaemia?
MACROCYTIC NORMOCHROMIC ANAEMIA with polysegmented neutrophils
Autoantibodies = intrinsic factor and coeliac antibodies(intrinsic factor antibodies are diagnostic)
Give 3 inherited causes of haemolytic anaemia
- RBC membrane defect
- Abnormal Hb - thalassaemia’s, sickle cell
- Enzyme defects - Glucose-6-phosphate dehydrogenase deficiency
Give 3 acquired causes of haemolytic anaemia
- Autoimmune
- Drug induced
- Secondary to systemic disease
- Malaria
What is the management for haemolytic anaemia
Dietary = folate and iron supplementation
AI cause = immunosuppression
Surgical = splenectomy
Give 3 acute complications of sickle cell disease
- Painful crisis
- Sickle cell syndrome - blockage of blood vessels within bone leading to pain
- Strokes in children
- Infections
Give 3 chronic complications of sickle cell disease
- Renal impairment
- Pulmonary hypertension
- Joint damage
- growth and development problems
- cardiomegaly, MI
- hepatomegaly
- retinopathy
- impaired placental blood flow
Describe the treatment for sickle cell disease
- Precipitating factors should be avoided - e.g. infection, dehydration, cold
- Folic acid
- Acute attacks:
- IV fluids
- Analgesia
- Oxygen - Possible blood transfusions
- Oral hydroxycarbamide to reduce frequency of crises
- Stem cell transplant
long term management
- hydroxyurea - increases HbF levels so is used as prophylaxis
- pneumococcal vaccine
what are the clinical features of G6PD deficiency?
Most are asymptomatic Pallor Fatigue Palpitations Shortness of breath Jaundice Exacerbated by ingesting fava beans
Name 3 things that can precipitate G6PD deficiency
- Broad beans / fava beans
- Infection
- Drugs - Primaquine, sulphonamide, quinolones
What is polycythaemia?
- increased RBC count
- increased haematocrit
- Due to a JAK2 mutation
What stimulates EPO?
Tissue hypoxia
what are the secondary causes of absolute polycythaemia?
hypoxia
- Smoking - Lung disease - Cyanotic heart disease - High altitude - obstructive sleep apnoea
Excess EPO - renal disease
alcohol
what are the clinical features of polycythaemia?
Headaches and dizziness Itching Fatigue Tinnitus Erythromelalgia – burning sensation in fingers and toes Hypertension Angina Hepatosplenomegaly (distinguishes 1o from 2o)
What is the treatment for polycythaemia?
No cure Treatment aim is to maintain normal blood count Venesection - relieves symptoms Low does aspirin Radioactive phosphorus in those over 70
What can cause decreased platelet production?
- Congenital causes (e.g. malfunctioning megakaryocytes)
- Infiltration of bone marrow (e.g. leukaemia)
- Alcohol
- Infection (e.g. HIV/TB)
- Reduced TPO
- Aplastic anaemia
What can cause increased platelet destruction?
- Autoimmune (e.g. ITP)
- Hypersplenism
- Drug related (e.g. heparin induced)
- DIC and TTP –> increased consumption
What can cause reduced platelet function?
- Congenital abnormality
- Medications - aspirin
- VWF disease
- Uraemia
Give 4 causes of bleeding
- Trauma
- Platelet deficiency - thrombocytopenia
- Platelet dysfunction - aspirin induced
- Vascular disorders
Give 3 things that can cause coagulation disorders
- Vitamin K deficiency
- Liver disease
- Congenital - haemophilia
What is thrombotic thrombocytopenia (TTP)?
- Widespread adhesion and aggregation of platelets leads to microvascular thrombosis and consumption of platelets
- Occurs due to a reduction in ADAMTS-13 – a protease that is normally responsible for the degradation of vWF
what are the clinical features of thrombotic thrombocytopenia (TTP)
- Flu-like symptoms
- fever, fatigue, aches
- Purpura
- Epistaxis (nosebleeds)
- Easy bruising
- Menorrhagia (heavy periods)
- Haemoptysis (coughing up blood)
- Headache
- Abdominal pain
- GI bleeding
- Chest pain (rare)
What is the treatment for thrombotic thrombocytopenia (TTP)?
- Plasma exchange (removed ADAMTS13 autoantibodies)
- Splenectomy
- IV steroids
- IV methylprednisolone
- IV rituximab
- folic acid
- platelet transfusion = contraindicated
What is immune thrombocytopenia (ITP)?
Antibodies formed against platelet –> autoimmune platelet destruction via reticuloendothelial system
Give 3 causes of immune thrombocytopenia (ITP)
Primary = viral infection (children) Secondary (chronic, adults) - Autoimmune conditions - Malignancies - CLL - Infections - HIV/Hep C
what is the clinical presentation of immune thrombocytopenia (ITP)?
Can by asymptomatic
- Purpura
- bruising and purple/red rash
- Epistaxis (nosebleeds)
- Menorrhagia (heavy periods)
- Prolonged bleeding from the gums
- Severe headache
- Vomiting
- Fatigue
What is the management for immune thrombocytopenia (ITP)?
- first line = Corticosteroid (prednisolone) or IV immunoglobulin - IV IgG
- second line = Splenectomy or immunosuppression (rituximab)
Give 4 causes of folate deficiency
- Dietary
- Malabsorption
- Increased requirement - pregnancy
- Folate antagonists - methotrexate