Hematology (5-10%) Complete Flashcards
Non-cancer-associated Proximal DVT and PE: ( ______ first line, if no contraindications)
– Provoked
• Tx for _______ months (up to ___ months)
– Unprovoked or chronic risk factor
• Tx for _____ months then ______
Non-cancer-associated Proximal DVT and PE: (DOAC first line, if no contraindications)
– Provoked
• Tx for 3 months (up to 6 months)
– Unprovoked or chronic risk factor
• Tx for 3 - 6 months then assess bleeding risk; continue indefinitely with regular reassessment of risk: benefit
Cancer-associated Proximal DVT and PE: ( _______ if no contraindications)
Low/mod bleeding risk: ________ therapy (1B) while active cancer (which means metastasis and also during +6 months in remission)
_______ preferred where bleeding risk is high
Cancer-associated Proximal DVT and PE: (LMWH or DOAC if no contraindications)
Low/mod bleeding risk: indefinite therapy (1B) while active cancer (which means metastasis and also during +6 months in remission)
LMWH is preferred where bleeding risk is high:
- high-risk GI lesions (e.g. angiodysplasia, varices)
- unresected intraluminal GI/GU cancer
- high-risk intracranial lesion (glioma, RCC, melanoma)
- Child-Pugh class B/C
- platelet < 50
- recent bleed
- DOAC Drug Interactions
DOAC:
CONTRAINDICATION IN:
1. _________________
2. _________________
3. _________________
4. _________________
5. _________________
CONTRAINDICATION IN:
1. Liver failure: Child-Pugh B and C
2. Anti-phospholipid antibody syndrome: arterial thrombosis, triple positive, small vessel thrombosis (livedo reticularis, nephropathy)
3. Pregnancy AND Breastfeeding
4. Drug-drug interactions (e.g. doxorubicin, cyclosporine, carbamazepine, phenytoin, azoles, protease inhibitors – bleeding risk): apix/riva CYP3A4/P-gp; dabi/edox P-gp)
5. Platelets < 50
PAXLOVID (ritonavir) and DOAC?
PAXLOVID (ritonavir) = contraindicated to use w apix and riva
When to Use Warfarin?
MNEMONIC?
Be CALM
Breastfeeding
– Therapeutic anticoagulation while breastfeeding [INR generally 2- 3 depending on the indication for anticoagulation]. DOACs contraindicated, LMWH is OK.
CKD (stage 4/5)
– INR generally 2-3 depending on the indication for anticoagulation
Antiphospholipid Ab Syndrome
– APLA Syndrome associated VTE [INR 2-3] (triple positive)
LV Thrombus (+ “Likes warfarin” – pt on warfarin stable for years)
– LV Thrombus (NB observational and 1 small RCT suggests DOAC may be non inferior to VKA)
Mechanical Valve
– Mechanical valves [INR 2.5-3.5 – mitral, INR 2-3 - aortic]
Role of thrombolysis in VTE:
DVT: ________________
- limb-threatening DVT (phlegmasia cerulea dolens)
Role of thrombolysis in VTE:
PE: ________________
What about intermediate-risk PE” (i.e.: RV dysfunction on ECHO/CT, elevated troponin)
hemodynamic instability (sBP <90 for over 15 mins) with no high bleeding risk (Gr 2B)
What about intermediate-risk PE” (i.e.: RV dysfunction on ECHO/CT, elevated troponin): Not indicated
Cancer-Associated VTE – Outpatient Prophylaxis?
When to consider full-dose anticoagulation in Distal (calf) DVT?
- Severe symptoms
- Multiple deep veins involved
- Active cancer
- ≥5 cm long
- Close to the popliteal vein
- Irreversible risk factor
- +Ddimer
- Progression on repeat U/S
Superficial femoral vein is ___________
Superficial femoral vein is DEEP VEIN (MISNOMER)
Superficial Vein thrombosis and anticoagulation:
- ≤3 cm from saphenofemoral junction = ___________________
- > 3cm from SFJ and ≥5 cm long = ___________________
- > 3cm from SFJ + <5cm long = ___________________
- ≤3 cm from saphenofemoral junction =
full dose anticoagulation x 3 months - > 3cm from SFJ and ≥5 cm long =
prophylactic anticoagulation x 45d (fondaparinux 2.5 mg sc daily or rivaroxaban 10 mg po daily) - > 3cm from SFJ + <5cm long =
NSAIDs and monitor with serial U/S. ** Exceptions: prophylactic anticoagulation in pregnancy, cancer, surgery, trauma, prior hx of SVT/DVT
Subsegmental PE and Anticoagulation:
Next step?
Leg dopplers
If positive: Def anticoagulation
If negative: Consider treatment if: active cancer/other
thrombotic risk, symptomatic, high D-dimer
Reversal Agents for Anticoagulants:
Warfarin:
Non-bleeding:
• INR >9: __________________________
• INR 4.5-9: __________________________
Non-life-threatening bleed:
• __________________________
Life-threatening bleed/imminent procedure:
• __________________________
When to use FFP?
Non-bleeding:
• INR >9: hold warfarin + VitK 2.5-5 mg po
• INR 4.5-9: hold warfarin + decrease dose
Non-life-threatening bleed:
• Vit K + supportive
Life-threatening bleed/imminent procedure:
• IV Vit K + prothrombin complex (PCC)
– PCC dosing per INR:
INR 1.5-3: PCC 1000U; INR 3-5: PCC 2000U; INR> 5: PCC 3000U
When to use FFP? PCC is superior to FFP for warfarin reversal. CHOOSING WISELY CANADA – do not use FFP for VKA reversal if PCC is available
Reversal Agents for Anticoagulants:
LMWH/Heparin: __________________________
Protamine 25-50 mg
Reversal Agents for Anticoagulants:
DOACs:
Non-life-threatening: __________________________
Life-threatening bleed: __________________________ +
- Dabigatran:
• __________________________ - Apixaban/Rivaroxaban/Edoxaban:
• __________________________
• __________________________
Non-life-threatening: supportive
Life-threatening bleed: supportive +
- Dabigatran:
• Idarucizumab (Praxbind) 2.5g x 2 doses; consider dialysis (~65% removal in 4 h) - Apixaban/Rivaroxaban/Edoxaban:
• 4-factor PCC (e.g. Octaplex, Beriplex); 2000U (can be repeated)
• Andexanet alfa (not available in Canada)
Primary hemostasis
Clinical Presentation:
• _________________________________
• _________________________________
• _________________________________
• _________________________________
Labs:
Platelets?
Coagulation profile?
DDx
1. _________________________________
_________________________________
- _________________________________
↓Quantity == e.g. _________________________________
↓ Quality == e.g. _________________________________
Primary hemostasis
Clinical Presentation:
• Mucocutaneous bleeding
• Easy bruising
• Heavy menstrual bleeding
• Petichiae (low plts)
Labs: +/- ↓ plts, often coags normal
DDx
1. VWF Deficiency
Von Willibrand Disease (VWD)
- Plt Disorder
↓Quantity == e.g. ITP
↓ Quality == e.g. ASA, uremia, congenital
Secondary Hemostasis:
Clinical Presentation:
• ___________________________
• ___________________________
• ___________________________
Labs:
___________________________
DDx [see slides specific to INR/PTT]
1. ___________________________
• ___________________________
• ___________________________
• ___________________________
- ___________________________
• ___________________________
• Medications: ___________________________
Secondary Hemostasis:
Clinical Presentation:
• Hemarthrosis
• Intramuscular bleeding
• Retroperitoneal bleeding
Labs: abnormal coag. tests
DDx [see slides specific to INR/PTT]
1. Coagulation factor deficiency
• Hemophilia A (Factor VIII)
• Hemophilia B (Factor IX)
• Warfarin (II, VII, IX, X)
- Coagulation factor inhibitor
• Idiopathic/various diseases
• Medications: DOACs
Approach to Isolated Elevated PT or aPTT
Approach to elevated aPTT & PT
VWF :↑ levels in _________________
VWF :↓ levels in _________________
VWF:↑ levels in stress, estrogens, pregnancy
VWF: ↓ levels in blood group O
Von Willebrand Disease Diagnosis
• Type 1:
• Type 2:
• Type 3:
Von Willebrand Disease Diagnosis
- Type 1:
- Quantitative deficiency (↓VWF:Ag [<30%] = ↓VWF Rco [<30%] ie. concordant; ratio>0.7)
– VWF < 30% or VWF 30-50% + abnormal bleeding = diagnostic
2 Type 2:
- Qualitative deficiency of VWD (↓/↔VWF Ag [<30-200%], ↓↓VWF:Rco [<30%] ie. discordant; ratio<0.7)
- Type 3:
- No VWF produced (↓VWF:Ag [<5%] =↓VWF:Rco [<5%]; ↓↓ factor VIII)
- Behaves like Hemophilia A
Von Willebrand Disease
Treatment:
1. Acute Bleeding/Peri-Op?
- Heavy menstrual bleeding?
Von Willebrand Disease:
Treatment:
1. Acute Bleeding/Peri-Op:
– DDAVP: boosts vWF level (can work for Type 1; not in type 2B/2N or 3)
– Blood products: plasma-derived concentrates of vWF and FVIII (e.g. Humate P)
2 Heavy menstrual bleeding:
- TXA +/- OCP
Immune Thrombocytopenia (ITP)
Treatment
1) NOT BLEEDING/MILD MUCOCUTANEOUS BLEEDING & PLT >30:
_________________________________________________________
2) NOT BLEEDING & PLT < 30
• 1st line:______________________________________________
• 2nd line:______________________________________________
3) ACTIVE BLEEDING
• ______________________________________________
• Life-threatening: ______________________________________
Immune Thrombocytopenia (ITP)
Treatment
1) NOT BLEEDING/MILD MUCOCUTANEOUS BLEEDING &
PLT >30 • Watch and wait
2) NOT BLEEDING & PLT < 30
• 1st line: Pred 0.5-2mg/kg or Dex 40 mg X 4d, IVIG (if C/I to pred; caution: hemolysis), anti-D (RhD+; caution: hemolysis)
– FLIGHT: MMF + steroids
• 2nd line: splenectomy, rituximab, TPO-R agonists
3) ACTIVE BLEEDING
• Steroids + Tranexamic Acid +/- IVIG
• Life-threatening: Plt transfusion +/- splenectomy
Immune Thrombocytopenia (ITP)
Treatment
PREGNANCY?
- Indication for treatment?
- How to treat?
- Platelet cut off for delivery?
- Platelet cut off for neuraxial anesthesia?
Immune Thrombocytopenia (ITP)
Treatment
PREGNANCY:
• Tx if bleed, plt <30, delivery or plt<50+≥36 wk GA
• Steroids or IVIG (Pred>Dex as Dex crosses placenta)
• plt>50 for delivery,
- plt>80 for neuraxial anesthesia
Secondary ITP treatment
If significant bleeding and HCV/HIV:
HCV? _________________
HIV? _________________
Secondary ITP treatment
1. If significant bleeding and HCV/HIV:
HCV: use IVIG (NO ROLE FOR STEROIDS)
HIV: Steroids or IVIG
DO NOT MISS:
Evan’s Syndrome?
DO NOT MISS:
Evan’s Syndrome = ITP + hemolytic anemia
- - 2⁰ Autoimm/Connective tissue diseases
- - Difficult to treat, frequent relapse
Heparin-induced Thrombocytopenia
4T score?
Management of HIT:
- Anticoagulant Choice:
- IV? ____________________________
- SC? ____________________________
- PO? ____________________________
- Pregnancy? ____________________________ - Duration of treatment?
- No thrombosis = ____________________________
- Thrombosis = ____________________________
Management of HIT:
Anticoagulant Choice:
- IV: Argatroban, Danaparoid
- SC: Fondaparinux
- PO: Warfarin, DOACs
- Warfarin: start when PLT ≥ 150 + overlap with non-heparin anticoagulation ≥5d once INR 2 – 3
- DOACs: (rivaroxaban 15 BID x 3 wks if VTE or until plt recovery, if no VTE –> Rivaroxaban 20 mg daily)
- Pregnancy: Danaparoid preferred
Duration:
- No thrombosis = min. until platelet recovery (>150), max 3 mon
- Thrombosis = 3-6 mn
Thrombotic Microangiopathy (TMA)?
Peripheral blood film?
Platelets?
Thrombi?
Thrombotic Microangiopathy (TMA):
– Micro-angiopathic hemolytic anemia (MAHA) -> schistocytes
– ↓Plt
– Microvascular thrombi –> end organ damage
TTP – a Hematologic Emergency:
Treatment?
–PLEX within 4-8h
• FFP to bridge: 3-4u then 1u q2h
–No plt transfusion unless life-threatening bleed
–Steroids (Pred 1 mg/kg/d or Solumedrol IV 1g/day)
–Folic acid 5 mg daily
–+/- ASA if ↑ trop/CNS symptoms
–DVT proph when plt >50
–Caplacizumab or Rituximab can be considered in refractory cases
Hemolytic Anemia:
Spherocytes
Spherocytes:
• Warm autoimmune hemolytic anemia (IgG)
• Hereditary spherocytosis
• Delayed hemolytic transfusion reaction
Hemolytic Anemia:
Agglutination
Agglutination:
• Cold autoimmune hemolytic anemia (IgM)
• Paroxysmal cold hemoglobinuria
Warm Autoimmune Hemolytic Anemia:
Diagnosis?
Etiology?
Treatment?
1st Line: ____________
2nd Line: ____________
Diagnosis:
- Hemolysis labs
- Blood film: spherocytes
- DAT: +IgG (+/- C3d)
Etiology: 1o vs 2o
– 2o: Lymphoproliferative disease (e.g. CLL), autoimmune (e.g. SLE), drugs (e.g. methyldopa, NSAIDs)
Treatment:
1st line:
- Prednisone 1 – 1.5 mg/kg/day
2nd line:
- Splenectomy (>8-12 mon)
- Rituximab
Cold Autoimmune Hemolytic Anemia:
Diagnosis?
Etiology?
Treatment?
1st Line: ____________
2nd Line: ____________
Diagnosis:
– Hemolysis labs
– Blood film: agglutination
– DAT +ve C3d (= IgM antibody)
– Thermal amplitude: significant if ≥28⁰C
Etiology: 1o vs 2o
– 2o: Infection (mycoplasma pneumonia, EBV), lymphoproliferative disorder (MGUS, Waldenstroms, lymphoma)
Treatment:
– #1: Warm patient!
– Treat underlying cause
– Steroids not helpful
– Rituximab for refractory cases
PCC (Prothrombin complex concentrate) vs Plasma in HIT?
PCC has heparin = do not use in warfarin reversal w HIT, give ffp instead
Platelet Refractoriness?
Myeloid Disorders
- Acute Myeloid Leukemia (AML)
– too many __________ myeloid cells (i.e. myeloid blasts) - Myeloproliferative Neoplasms (MPNs)
– too many ________ myeloid cells
• too many RBCs = ________________
• too many platelets = ________________
• too many granulocytes = ________________ - Chronic Myelomonocytic Leukemia (CMML)
– features of ________________ and ________________
• too many ________________
• myeloid cells are ________________ - Myelodysplastic Syndrome (MDS)
– bone marrow ________________
• ________________ hematopoiesis
• myeloid cells are ________________
Myeloid Disorders
- Acute Myeloid Leukemia (AML)
– too many immature myeloid cells (i.e. myeloid blasts) - Myeloproliferative Neoplasms (MPNs)
– too many mature myeloid cells
• too many RBCs = Polycythemia vera (PV)
• too many platelets = Essential thrombocytosis (ET)
• too many granulocytes = Chronic Myelogenous Leukemia (CML) - Chronic Myelomonocytic Leukemia (CMML)
– features of BOTH MPN and MDS
• too many monocytes
• myeloid cells are dysplastic - Myelodysplastic Syndrome (MDS)
– not enough myeloid cells (cytopenias) -> bone marrow failure
• ineffective hematopoiesis
• myeloid cells are dysplastic
Lymphoid Disorders
- Acute lymphocytic leukemia (ALL)
– too many __________ lymphoid cells - Lymphoproliferative disorders (LPDs)
– too many __________ lymphoid cells
• __________: burden of disease is in the peripheral blood
• __________: burden of disease is in lymph node
• Waldenstrom Macroglobulinemia /Lymphoplasmacytic lymphoma - Plasma cell dyscrasias
– Too many __________ cells → overproduction of a __________
• MGUS → smoldering myeloma → multiple myeloma
• Primary amyloidosis
Lymphoid Disorders
1. Acute lymphocytic leukemia (ALL)
– too many immature lymphoid cells (i.e. lymphoid blasts)
- Lymphoproliferative disorders (LPDs)
– too many mature lymphoid cells
• CLL: burden of disease is in the peripheral blood
• Lymphoma: burden of disease is in lymph node
• Waldenstrom Macroglobulinemia /Lymphoplasmacytic lymphoma - Plasma cell dyscrasias
– Too many plasma cells → overproduction of a single antibody / light chain
• MGUS → smoldering myeloma → multiple myeloma
• Primary amyloidosis
Acute Leukemia:
Diagnosis?
≥ 20% blasts in peripheral blood or bone
marrow*
Blast cells + Auer rods + DIC
THINK: ___________
APL (Acute Promyelocytic Leukemia)
APL
• T(__;__)
• ________ mortality from ____:
Urgent treatment? ______
• T(15;17) PML-RARA
• ↑early mortality from DIC:
- Intracranial hemorrhage
- Blood clots
Urgent treatment: ATRA (all-trans-retinoic acid)
Acute Leukemia Associated Emergencies:
1. Tumor lysis
__ K, __ PO4, __ uric acid (UA), __ Ca
Treatment:
1. ______________
2. ______________
3. ______________
4. ______________
↑ K, ↑ PO4, ↑ uric acid (UA), ↓ Ca
Treatment:
1. Manage hyper-K, correct ext. lytes
2. IVF (target UO 80-100 mL/m2/h)
AND EITHER:
3. Allopurinol
OR
4. Rasburicase if: AKI, ↑↑ uric acid (>535 umol/L), no response to allopurinol (NOT in G6PD def)
Acute Leukemia Associated Emergencies:
2. Leukostasis
Treatment:
1. ______________
2. ______________ MOST IMPORTANT
3. ______________
4. ______________
Treatment:
1. IVF
2. Cytoreduction (e.g hydroxyurea, leukapheresis, induction chemo)
3. TLS prophylaxis
4. Avoid transfusion
Polycythemia vera:
Risk stratification (for thrombosis)
LOW RISK: Age _____ and ________
HIGH RISK: Age ____ or _______ history
Treatment:
EVERYONE: __________, optimize __________,
__________
HIGH RISK: __________
(__________ if young or pregnant)
Risk stratification (for thrombosis)
LOW RISK: Age < 60 and no thrombosis history
HIGH RISK: Age ≥ 60 yo or thrombosis history
Treatment:
EVERYONE: ASA 81 mg, optimize CV risk factors, Hct < 45% with phlebotomy (CYTO-PV NEJM 2013)
HIGH RISK: cytoreduction with Hydroxyurea
(interferon if young or pregnant)
Essential Thrombocythemia (ET)
Treatment:
Very low risk (no thrombosis, age<60, JAK2-): __________________
Low risk (no thrombosis, age<60, JAK2+): __________________
Intermediate risk (no thrombosis, age≥60, JAK2-): __________________
HIGH RISK (age≥60 and JAK2+ or thrombosis hx): __________________
JAK2+ with CV risk factors: __________________
*Hold __________________ if plt > 1000-1500 or acquired vWD
Essential Thrombocythemia (ET)
Treatment:
Very low risk (no thrombosis, age<60, JAK2-):
observation
Low risk (no thrombosis, age<60, JAK2+):
ASA 81 mg
Intermediate risk (no thrombosis, age≥60, JAK2-): ASA 81 mg
HIGH RISK (age≥60 and JAK2+ or thrombosis hx): add hydroxyurea (interferon if young or pregnant)
JAK2+ with CV risk factors: ASA 81 mg BID
*Hold ASA if plt > 1000-1500 or acquired vWD
Leukoerythroblastosis?
Definition? ___________________
Differentials?
The presence of leuko-erythroblastosis raises concern for transformation from ___/__ to ____________________
Leukoerythroblastosis?
Definition: (left shift in myeloid series with myelocytes/ metamyelocytes/ blasts along with nucleated RBCs)
Differentials?
- GCSF
- infection/marrow stress
- myelophisitic processes (ie. metastatic cancer to bone)
- MPNs including myelofibrosis/CMML
The presence of leukoerythroblastosis raises concern for transformation from PV/ET to prefibrotic myelofibrosis.
CLL:
Presentation:
• Peripheral blood: “_________” cells
Diagnosis:
• ______________________
*Do not need _______ to make dx
CLL:
Presentation:
• Peripheral blood: “smudge” cells
Diagnosis:
• peripheral blood flow cytometry
*Do not need BMBx to make dx
CLL Treatment options:
Which is associated with bleeding and Atrial fibrillation?
CLL Treatment options:
Tyrosine kinase inhibitors i.e. Ibrutinib (SE =
bleeding, A.fib)
Lymphoma Classification + Treatment
Chimeric Antigen Receptor (CAR)-Therapy
Toxicities:
- Cytokines release syndrome (CRS)
Sx?
Labs?
Tx? - Immune effector cell-associated neurotoxicity (ICANS)
Sx?
Tx?
Chimeric Antigen Receptor (CAR)-Therapy
Toxicities
- Cytokines release syndrome (CRS)
Sx? Fever, tachypnea, headache, tachycardia, HTN, rash, hypoxia due to cytokines storm
Labs: elevated CRP/ferritin
Tx based on CRS grade: supportive care, +/-steroids, +/- tocilizumab - Immune effector cell-associated neurotoxicity (ICANS) due to disruption in BBB, cytokines
Sx: aphasia, tremor, altered LOC, impaired cognition, motor weakness, seizures, cerebral edema
Tx: supportive care, CNS imaging, seizure prophylaxis/treatment; Tx concurrent CRS
Plasma Cell Dyscrasias
Waldenstrom’s Macroglobulinemia:
DEFINITION:
AKA ______________
AND
______________ in the peripheral blood
Other key features to distinguish from others?
AKA Lymphoplasmacytic lymphoma (an indolent lymphoma with features between B-cells & plasma cells)
AND
Monoclonal IgM in the peripheral blood
Other key features to distinguish? Hepatosplenomegaly, lymphadenopathy
Bone Marrow Failure Syndromes?
Myelodysplastic Syndrome (MDS)
– Cytopenia(s) + dysplastic cells/genetic abnormalities/blasts
Aplastic anemia (AA)
– Hypocellular bone marrow
– Primary vs. secondary
Paroxysmal nocturnal hemoglobinuria (PNH)
– Bone marrow failure
– Hemolysis
– Thrombosis
Myelodysplastic Syndrome (MDS):
Definition:
Myelodysplastic Syndrome (MDS):
Presentation:
• _______ pt. w/ a _____ (often ___ Hb + ____ MCV)
• Blood film: ________________ neutrophils,
____________ platelets, macrocytosis, _____ retics
Diagnosis? _______________
Presentation:
• Older pt. w/ a cytopenia (often ↓Hb + ↑MCV)
• Blood film: hypolobated/hypogranular neutrophils,
hypogranular platelets, macrocytosis, ↓ retics
Diagnosis:
• Bone marrow biopsy/aspirate:
– Hypercellular (usually) +/- ring sideroblasts
– Dysplasia >10%
– Blasts <20%
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Characterized by?
1. _______________
2. _______________
3. _______________
4. ________________
Work-up?
Diagnosis?
• ___________________
• Can overlap with ___________________
Treatment?
Characterized by?
1. Bone marrow failure
2. Chronic intravascular (+ extravascular) hemolysis –> uncontrolled complement activation
3. Thrombosis (venous + arterial) –> common site = splanchnic, hepatic
4. thrombosis in atypical locations (ie. abdominal or cerebral veins), anemia Sx, hemolysis Sx (jaundice, red urine), pHTN Sx, decr NO Sx (erectile dysfxn, dysphagia)
Work-up?
• Hemoglobinuria (rare), hemolysis labs, Cr (renal failure from pigment nephropathy)
Diagnosis?
• Peripheral blood flow cytometry (loss of CD55 + CD59)
• Overlap w/ aplastic anemia
Treatment?
• Anti-coagulate if thrombotic events
– No role for primary prophylactic anticoagulation
• Eculizumab or pegcetacoplan (complement inhibitors)
- ↓ hemolysis + transfusion need (not curative)
Blast with Auer rod
If you see blasts with Auer rods, think APL
Arrow = Auer rod
Teardrops
Think myelofibrosis
(B symptoms, high LDH, splenomegaly, cytopenias, leukoerythroblastosis)
CLL
ROULEAUX
Associated with multiple myeloma as well as
inflammation, pregnancy (high ESR states)
Spherocyte
Spherocytes lack central pallor and are smaller than normal RBC.
Think immune-mediate hemolysis (e.g. auto or allo immune)
Hyper-segmented Neutrophil
≥6 lobes = hypersegmented. Think megaloblastic anemia (e.g. folate or B12 deficiency)
Schistocytes (aka fragments)
All arrows pointing to examples of schistocytes. Think TMA (eg. TTP)
Malaria
Sickle Cell
Blood Product “Modification”
Indications for CMV-negative blood:
- Intrauterine transfusion
Blood Product “Modification”
Indications for irradiated blood - prevent transfusion-associated ______:
1. _____________
2. _____________
3. _____________
4. _____________
Indications for irradiated blood - prevent transfusion-associated GVHD:
Ø T cell deficiency
Ø Hodgkin’s lymphoma
Ø Chemotherapy with purine antagonists or purine-like antagonists
Ø HSC transplant recipients:
• Allogeneic: for life
• Autologous: for 3 months
Blood Product “Modification”
Indications for washed platelets:
- ______________
- ______________
3, ______________
Indications for washed platelets:
Ø Anaphylaxis to transfusion NYD
Ø Recurrent/severe allergic transfusion reactions
Ø IgA deficiency with no IgA deficient donor available
Thrombocytopenia:
1) Rule out ___________________
2) Should I be worried?
– Other lineages down? → __________________
– Abnormal coags? → _______________________
– Recent heparin → _________________________
– Recent transfusion → _____________________
– Is this sepsis?
Thrombocytopenia:
1) Rule out pseudo-thrombocytopenia
• Secondary to EDTA-associated agglutinins
• Repeat in citrated tube
2) Should I be worried?
– Other lineages down? → Marrow process, MAHA, Evans
– Abnormal coags? → DIC, APLA
– Recent heparin → HIT
– Recent transfusion → Post-transfusion purpura
– Is this sepsis?
Pancytopenia ddx
Primary?
Secondary?
Pancytopenia ddx
Primary
1. Paroxysmal Nocturnal Hemoglobinuria (PNH)
2. Aplastic Anemia
3. Leukemia
4. MDS
5. Myelofibrosis
Secondary
1. Deficiency - B12/Folate, anorexia, êT4
2. Infection – granulomatous, HIV, sepsis
3. Iatrogenic – chemo, rads, ETOH
4. Infiltrative – mets, amyloid, Gaucher
5. Hypersplenism
B12 deficiency or syphilis?
Distinguish Neuro B12 deficiency from Neuro Syphilis
– BOTH: Mental status changes/Dementia
– Pupils: B12: Normal
- Pupils: Syphilis: Argyle Robertson (small, no reaction to light but does accommodate)
– B12 = subacute combined degeneration of cord = corticospinal tract (UMN weakness, increased tone in legs, hyperreflexia/clonus) AND dorsal column (dec. vibration, proprioception)
– Syphilis = “Tabes Dorsalis” = dorsal column (vibration, proprioception impaired) and dorsal roots (absent reflexes in LE). Unlike B12 deficiency, tone/power should be normal.
Differentials: DIC vs other hemolysis
