Hematology Flashcards
What is a sideroblast?
A ringed sideroblast?
RBC with excessive iron in its mitochondria.
Normal to see these in the bone marrow.
Ringed sideroblasts = never normal. Have a ring of iron around the nucleus.
Clinical conditions in which you might see ringed sideroblasts (6):
Lead poisoning Heme metabolism d/o EtOH Drugs Genetic disorders Myelodysplastic syndrome
Four scenarios in which you might see target cells:
THAL: Thalassemias HbC disease Asplenia Liver disease
Two pathologic RBC forms you might see in someone with liver disease:
Target cells
Acanthocytes
What is physiologic anemia of pregnancy?
Increase in maternal plasma volume -> dilution of iron in the serum.
Iron deficiency anemia is a _________ __________ anemia.
Microcytic
Hypochromic
This type of anemia may manifest as Plummer-Vinson syndrome:
The famous triad:
Iron deficiency
Fe-deficiency
Esophageal webs
Atrophic glossitis
How many copies of the gene for a-globin do you have?
Four.
Which thalassemia is more prevalant in people of Mediterranean descent?
In Asian people?
African people?
b-thal = Mediterranean a-thal = Asian, African
What is Hb Barts?
People make no a-globin.
In the fetus, so…
Gamma-globin makes a tetramer = Hb Barts
What is HbH disease?
HbH disease = 3-gene deletion of a-globin.
Make only a little a-globin
The extra b-globin makes tetramers = HbH
Four gamma-globin chains glued together, what am I?
Big trouble, you’re not making alpha-globin chains in utero.
Hb Barts -> hydrops fetalis.
Four beta-globin chains glued together, what am I? What disease is this associated with?
HbH -> HbH disease.
A type of alpha-thalassemia.
How many genes for b-globin do you have?
Two.
When might you see target cells?
THAL Thalassemia HbC disease Asplenia Liver disease
How do you confirm the dx of b-thalassemia minor?
Will see an increase in HbA2.
HbA2 = a-globin + d-globin
Which thalassemia commonly puts people at risk for hemochromatosis?
b-thalassemia major (homozygous)
Often require blood transfusions.
Two skeletal abnormalities seen in b-thalassemia major:
Marrow expansion ->
“Crew cut” appearance on X-ray
“Chipmunk” facies
What is the structure of HbF?
a2g2
The macrocytic anemias can be divided into these two functional distinctions:
What is the difference between them?
Megaloblastic = trouble synthesizing DNA Non-megaloblastic = unimpaired DNA synth.
Three causes of megaloblastic anemia:
Folate def.
B12 def.
Orotic aciduria
Common finding on blood smear in megaloblastic anemia (other than big-ass RBC):
Hypersegmented neutrophils
Anemia in which methylmalonic acid is normal:
Anemia in which methylmalonic acid is elevated:
Anemia 2/2 folate deficiency
Anemia 2/2 B12 deficiency
Four common causes of B12 deficiency:
Malabsorption Poor intake Pernicious anemia PPIs (Worms)
Which of the macrocytic anemias would you expect to see neurologic sx with?
B12 deficiency anemia
This macrocytic anemia is incurable by folate / B12 administration:
Anemia 2/2 orotic aciduria
What is the treatment for orotic aciduria?
Uridine monophosphate
In B12 and folate deficiency anemias, what is the homocysteine level like?
Increased.
What is the protein responsible for binding ferroportin in anemia of chronic disease?
Hepcidin
What kind of anemia is anemia of chronic disease?
Normocytic
May progress to microcytic, hypochromic
Four common causes of aplastic anemia:
Severe vitamin B12 and folic acid deficiency Radiation / drugs Viruses (parvo B19, EBV, HIV, HCV) Fanconi's (Idiopathic)
Hypocellular bone marrow with fatty infiltrate:
Aplastic anemia
Sickle cell patients are vulnerable to these viruses (4):
Parvovirus B19
EBV
HIV
HCV
Chronic kidney disease causes this kind of anemia:
Normocytic, normochromic
Triad for pancytopenia:
Severe anemia
Leukopenia
Thrombocytopenia
Protein that transports iron in blood:
Transferrin
The primary storage protein for iron in the body:
Ferritin
What effect do pregnancy and OCPs have on transferrin levels?
Increase
What would you expect to see in hemochromatosis: Serum Fe Transferrin Ferritin % Transferrin sat.
Hemochromatosis: Serum Fe HIGH Transferrin LOW Ferritin HIGH % Saturation HIIIIIGH
Iron studies in thalassemia:
Fe:
TIBC:
Ferritin:
Normal Fe, TIBC, ferritin…
Microcytic anemia with target cells.
This test is used to dx b-thal minor:
Hb electrophoresis
Look for HbA2 (>3.5%)
Normocytic anemia + red urine in the morning:
Paroxysmal nocturnal hemoglobinuria
Microcytic anemia reversible with B6:
Sideroblastic anemia
This megaloblastic anemia is not correctable with B12 or folate:
Orotic aciduria
Sideroblastic anemia can be congenital or acquired.
What is the defect in congenital sideroblastic anemia?
What mode of inheritance?
Defective d-ALA synthase = no protoporphyrin, Fe accumulates in mitochondria.
X-linked recessive.
Name 3 reversible etiologies of sideroblastic anemia:
EtOH
Lead poisoning
Isoniazid administration
What is the treatment for acquiredsideroblastic anemia?
Why does it work?
B6 = pyridoxine
This is the co-factor for ALA-synthetase.
What is haptoglobin?
A hemoglobin scavenger molecule, binds up Hb outside the cell.
In what case might you see a decrease in serum haptoglobin?
Generally, intravascular hemolysis.
What is the difference between intravascular and extravascular hemolysis?
Intravascular = destruction in the vessels Extravascular = destruction by the spleen
Three common causes of intravascular hemolysis:
- PNH = complement-mediated lysis, defect is in GPI anchor or decay accelerating factor in complement pathway
- Autoimmune hemolytic anemia
- Mechanical damage to RBC
Extravascular hemolysis, 5 causes:
Hereditary spherocytosis G-6-PD deficiency Pyruvate kinase deficiency Sickle cell disease HbC disease
Expect elevated LDH in:
Hemolysis (both intra and extravascular)
Bilirubin is more an indicator of this kind of hemolysis:
Intravascular
Two defective proteins in hereditary spherocytosis:
Ankyrin
Spectrin
Small, round RBCs with no central pallor:
Hereditary spherocytosis
High RDW with high MCHC:
Hereditary spherocytosis
Heinz bodies and bite cells:
G6PD deficiency
Oxidant stress causes hemolytic anemia:
G6PD deficiency
Positive osmotic fragility test:
Hereditary spherocytosis
Aplastic crisis (2):
Sickle cell disease
Hereditary spherocytosis
Rigid RBCs:
Pyruvate kinase deficiency, inability to maintain RBC membrane 2/2 decreased ATP
Mode of inheritence for G6PD deficiency:
X-linked recessive
Triad seen in paroxysmal nocturnal hemoglobinuria:
Remember, it’s complement mediated:
Hemolytic anemia
Pancytopenia
Thrombosis (platelets lysed too)
CD55/59(-) RBCs on flow cytometry:
Paroxysmal nocturnal hemoglobinuria
Hemolytic anemia in a newborn:
G6PD deficiency
Why are newborns initially asymptomatic in SS disease?
They still have HbF to protect them
Organisms you are at risk for infection from if you do not have a spleen:
Encapsulated
ESoHPNC
Glutamic acid to lysine in b-globin:
Glutamic acid to valine in b-globin:
lysine = HbC valine = HbSS
Treatment for paroxysmal nocturnal hemoglobinuria:
Eculizumab
Two ways of diagnosing paroxysmal nocturnal hemoblobinuria:
Ham's test Flow cytometry (CD55/59- cells)
Drug used in sickle cell disease:
What does it do?
Hydroxyurea
Increases HbF
Wedge-shaped splenic infarcts on CT:
Splenic sequestration crisis in sickle cell disease
Rate-limiting step in hemoglobin synthesis:
Enzyme:
Glycine + succinyl CoA -> d-ALA
Catalyzed by d-ALA synthetase
Warm agglutinin antibodies tend to be ___.
Cold agglutinin antibodies tend to be ___.
IgG
IgM
Four common sources of cold-agglutinin Ab:
Viruses SLE Malignancies Congenial Immune
Cold-agglutinin Ab are associated with (3):
Mycoplasma
EBV
CLL
What is a direct Coomb’s test?
Indirect Coomb’s test?
Direct = patient’s RBC + prepped Ab.
Indirect = patient’s serum + normal RBC.
Looking for Ig bound to RBC.
When might you use a direct Coomb’s?
An indirect Coomb’s?
Direct used in hemolytic disease.
Indirect used in blood screening before transfusion.
Microangiopathic anemia – you would see this kind of cell on peripheral smear:
Schistocyte
Splenectomy cured this guy:
Hereditary spherocytosis
Ham’s test was positive:
Paroxysmal nocturnal hemoglobinuria