Hematology Flashcards
What ethnicity most commonly has hemophilia C?
Ashkenazi Jews
What is the function of vWF?
facilitates attachment and aggregation of platelets, forming a plug
What is the inheritance pattern of hemophilia A? B?
A = XLR B = XLR
What is the MOA of heparin?
activates antithrombin
What is the MOA of argatroban, bivalirudin, and dabigatran?
Direct thrombin inhibitors (factor II)
What is MOA of aminocaproic acid?
Inhibits tPA
What is the MAO of tPA and other thrombolytics?
Inhibition of the conversion of plasminogen to plasmin
What does PTT measure? PT?
PTT = intrinsic PT = extrinsic
Which is prolonged PT or PTT with hemophilia A? B?
Both PTT
Describe the mixing study for screening for hemophilia?
Add in normal blood to patient’s blood. If blood clots, (since factors are now present), this strongly suggests hemophilia
What factor levels indicate the need for an immediate transfusion of platelets for hemophilia? What about for DDAVP?
Less than 1%
More than 5% = DDAVP
What is the inheritance pattern of vWF disease?
AD
What is the most common inherited bleeding disorder?
vWF disease
What factor levels are decreased in vWF disease?
VIII
What is the result of a ristocetin cofactor assay with vWF disease?
Decreased
What is the treatment for vWF disease?
DDAVP
What will coagulation studies show with vWF disease?
Increased bleedings time (from platelet dysfunction) and increased PTT (from loss of factor VIII)
What is the pathophysiology of HIT (heparin induced thrombocytopenia)
Administration of heparin induces the body to form antibodies to platelets, causing a paradoxical hypercoagulable state
What is antiphospholipid antibody syndrome associated with?
SLE
RA
Hospitalized patient on a heparin drip who develops thrombocytopenia should be suspicious for what disorder?
HIT
What is the treatment for HIT?
- D/c heparin
- Start argatroban or lepirudin
What must women with factor V leiden avoid?
OCPs
What is the pathophysiology DIC?
Deposition of fibrin in small blood vessels, leading to activation of the coag pathways, causing thrombosis and end-organ damage
What is the acute presentation of DIC?
- Bleeding from venipuncture sites
- Ecchymoses and petechiae
What is the chronic presentation of DIC?
- Bruising and bleeding
- thrombophlebitis
- Renal dysfunction
What is the treatment of DIC?
Transfuse RBCs, platelets, and manage shock
What is the major difference between DIC and liver disease in terms of coag results?
Unlike liver disease, factor VIII is depressed
What is the pathophysiology of thrombotic thrombocytopenic purpura (TTP)?
Deficiency of vWF enzyme (ADAMS-13) results in abnormally large vWF multimers, that aggregate platelets and crease platelet microthrombi
What are the five major s/sx of TTP?
- Thrombocytopenia
- microangiopathic hemolytic anemia
- Neurological changes
- Impaired renal function
- Fever
What will a PBS show with TTP?
Schistocytes
What is the pathophysiology of HUS?
E.coli O157:H7 infection causes renal dysfunction, resulting in uremia and thus platelet dysfunction.
What is the treatment of TTP?
Plasma exchange
Steroids
Why are platelet transfusions contraindicated in TTP?
Additional platelets will be consumed and further the activation cascade
What is the pathophysiology of idiopathic thrombocytopenic purpura?
IgG antibodies form against the patient’s platelets, cause splenic destruction
What diseases are associated with ITP?
SLE
HIV
CA
HCV
What is the usual presentation of ITP?
Asymptomatic
What is the acute presentation of ITP?
Abrupt onset of hemorrhagic complications following a viral illness
What is the chronic presentation of ITP?
Insidious onset of symptoms or incidental thrombocytopenia
True or false: ITP is a diagnosis of exclusion
True
What is the treatment for ITP?
If platelets more than 30,000, nothing
If not, then corticosteroids or IVIG
What is the treatment for symptomatic ITP when pharmacotherapy fails?
Splenectomy
What are the PE findings of Fe deficiency anemia?
Glossitis
Cheilosis
Koilonychia
What is the role of ferritin?
Stores of Fe in the body
What does a large RDW indicate?
Irregular erythropoiesis
What is the treatment for Fe deficiency anemia?
Replace Fe orally for 4-6 months.
What are the four major causes of microcytic anemias?
- Fe deficiency
- Thalassemias
- Chronic disease
- Sideroblastic anemia
What happens to ferritin levels in anemia of chronic disease?
Goes up, but serum Fe stores go down
What happens to TIBC in anemia of chronic disease?
Decreases
What happens to TIBC in Fe deficiency anemia?
Increases
What happens to RDW with Fe deficiency anemia vs anemia of chronic disease?
Increases with Fe deficient
Normal with ACD
What happens to serum transferrin receptors with Fe deficiency anemia vs anemia of chronic disease?
Increase with Fe deficiency
Normal in ACD
What are the drugs/chemicals that can cause sideroblastic anemia?
- INH
- Amphenicol
- Pb
- EtOH
What is the pathophysiology of sideroblastic anemia?
Inhibition of heme synthesis causes build up of Fe around the nucleus of cells
How can you differentiate folate vs B12 deficiency?
Folate deficiency will have only elevated homocysteine, whereas B12 has both elevated levels of homocysteine, and methylmalonic acid
What are the bone marrow findings of megaloblastic anemias?
Hypersegmented PMNs
What are the steps of the Schilling test?
measures the absorption of cobalamin via ingestion of radiolabeled cobalamin with and without intrinsic factor. The patient is given an unlabeled B12 IM shot to saturate B12 receptors in the liver and an oral challenge of radiolabeled B12. The radiolabeled B12 will pass into the urine if properly absorbed
What is the fish tapeworm notorious for causing B12 deficiency?
Diphyllobothrium latum
What is the function of haptoglobin, and what happens to levels of it with hemolytic anemia?
Binds free Fe in the blood.
Decreased levels in hemolytic anemia 2/2 binding of now free Fe
What are the PBS findings of G6PD deficiency?
Bite cells
Heinz bodies
What is the pathogenesis of PNH?
PNH is a deficiency in GPI-anchor molecules that keep CD55/CD59 attached to cells, resulting in hemolysis by complement.
What is the best diagnostic modality to detect PNH?
CD55/CD59 flow cytometry
What is the pathogenesis of hereditary spherocytosis?
Autosomal dominant defect or deficiency in spectrin or ankyrin,
What is the best diagnostic modality to detect hereditary spherocytosis?
Osmotic fragility test
What type of anemia is had with hereditary spherocytosis?
Extravascular hemolytic anemia
What is the treatment for hereditary spherocytosis?
Splenectomy
What is the inheritance pattern of sickle cell disease?
AR
What are the three major vaccinations that should be given prophylactically to asplenic patients?
Pneumovax
HiB
Meningococcal
What extremity findings may be present in children with sickle cell disease?
dactylitis
What organ dysfunction can be caused by sickle cell?
Autosplenectomy
Renal
Lungs
What is acute chest syndrome?
a vaso-occlusive crisis of the pulmonary vasculature commonly seen in patients with sickle cell anemia. This condition commonly manifests with pulmonary infiltrate on a chest x-ray, and is preceded by a lung infection
What virus classically causes an aplastic crisis with sickle cell disease?
Parvovirus B19
What is the treatment for acute chest syndrome?
Abx
Blood transfusion
What are the PBS findings associated with sickle cell? (2)
- Sickle cells
- Howell-Jolly bodies (purple inclusion bodies)
What is the reasoning behind using hydroxyurea in sickle cell disease?
Increases HbF production, leading to less sickling
What antibody type is associated with warm and cold hemolytic anemia respectively?
Warm = IgG Cold = IgM
What can cause warm autoimmune hemolytic anemia?
SLE
CLL
What can cause cold autoimmune hemolytic anemia?
Mycoplasma pneumoniae
Mono
What is the diagnostic modality of choice for autoimmune hemolytic anemia?
Direct coomb’s test
What is the treatment for severe warm autoimmune hemolytic anemia?
Steroids
What is the MOA of rituximab?
Anti-CD20 antibody
Both AIHA and hereditary spherocytosis can present with spherocytes and positive osmotic fragility tests, but only (____) will have a ⊕ direct Coombs test.
AHIA
Which has four and which two genes: beta or alpha parts of Hb?
Alpha = 4 Beta = 2
What ethnicities usually develop thalassemias?
African
Middle eastern
Asians
What will Fe studies show with thalassemias?
Normal
What is the drug given to patients who require chronic transfusions to prevent cardiomyopathy?
Deferoxamine
What is the treatment for beta thalassemia major and HbH disease?
Chronic transfusions
What is the usual presentation of 0/4 alpha globin?
Hydrops fetalis
What is HbH disease?
1/4 alpha globin genes
Patients have chronic hemolysis, with increased reticulocyte counts, as well as skeletal changes
What is alpha thalassemia trait?
2/4 alpha genes
Usually asymptomatic
What is the presentation of 3/4 alpha globin genes?
Silent carrier
What is the genetic change that causes polycythemia major?
JAK2 mutation (Y-kinase)
What happens to EPO with PCV?
Decreased
What is the treatment for PCV?
Hydroxyurea and IFN
What is the telltale sign of porphyria?
Pink urine
What are the 5 Ps of AIP?
- Painful abdomen
- Port wine urine
- Polyneuropathy
- Psych
- Precipitated by drugs
What is the best way to diagnose AIP? (2)
Urine plasma and porphyrin levels
Specific mutated enzyme assay
What is the treatment for an acute attack of AIP?
High dose glucose to decrease heme synthesis during attacks (negative feedback)
What is the pathophysiology of febrile nonhemolytic transfusion reaction?
Cytokine formation during storage of blood
What is the pathophysiology of allergic transfusion reaction?
AB formation against donor proteins
What is the pathophysiology of hemolytic transfusion reaction?
Preformed antibodies against donor erythrocytes
What is the presentation of febrile nonhemolytic transfusion reaction?
Fever, chills, and malaise 1-6 hours post transfusion
What is the presentation of allergic transfusion reaction?
Prominent urticaria
What is the presentation of hemolytic transfusion reaction?
Anaphylaxis
What is the treatment for hemolytic transfusion reaction?
IVFs
What is the treatment for febrile nonhemolytic transfusion reaction?
acetaminophen
What is the treatment for allergic transfusion reaction?
Antihistamines
What are auer rods, and in which diseases are they seen?
Crystallized myeloblastic protein (MPO)
AML
What is the most common childhood malignancy?
ALL
What is the usual presentation of ALL?
Rapid onset of anemia, thrombocytopenia etc
What are the usual PE findings of ALL?
HSM
Bleeding ums
What is the treatment to prevent renal damage from AML (besides adequate hydration)?
allopurinol
Rasburicase
What, generally, is CLL?
A malignant proliferation of crappy lymphocytes
What are the usual s/sx of CLL?
B symptoms
Infections
HSM
Smudge cells are seen in which malignancy?
CLL
Which have MPO: myeloblasts or lymphoblasts?
Myeloblasts
Which has prominent nucleoli, and which have inconspicuous: myeloblasts vs lymphoblasts?
prominent in myeloblasts
Inconspicuous in lymphoblasts
What are the sequale of infiltration of bone marrow from CLL?
- Granulocytopenia
- Thrombocytopenia
- Hypogammaglobulinemia
What is the treatment for CLL? Prognosis?
Fludarabine and chlorambucil
Used to alleviate symptoms.
What are the usual s/sx of CML?
Anemia
Splenomegaly
B symptoms
What are the three phases of CML?
- Chronic (several years)
- Accelerated (transition)
- Blast crisis (acute leukemia phase, few months left)
What is the translocation the produces CML?
t(9;22)
What is the treatment for CML?
imatinib
What are the granulocytes?
PMNs
Eosinophils
Basophils
What is the usual age of presentation for: ALL?
Less than 13
What is the usual age of presentation for: AML?
13-40 years
What is the usual age of presentation for: CML?
40-60
What is the usual age of presentation for: CLL?
60+
How can you differentiate a leukemoid reaction from CML?
LAP is high is leukemoid reaction
LAP is low in CML
What is hairy cell leukemia?
Malignant proliferation of B cells
What protein does hairy cell leukemia usually produce?
TRAP
What is the treatment for hairy cell leukemia?
Cladribine
What is the characteristics cell fro HL? What are the CD markers for this?
Reed-sternberg cells
CD15 and CD30
What cell line is usually involved with NHL?
Mainly B cell, but sometimes T cells
What is the difference between NHL and HL in terms of presentation?
HL = Many peripheral nodes involved
NHL = Single group of localized nodes spread contiguously
What is the age distribution for NHL?
65-75 year olds
What is the age distribution for HL?
Bimodal
What is the infectious associated for HL and NHL?
HL = EBV NHL = HIV, autoimmune
What is the natural history of follicular lymphoma?
Indolent course
Painless waxing and waning adenopathy
What is the natural h/o diffuse large B cell lymphoma?
Intermediate grade
Single rapidly growin mass
What is the treatment regimen for diffuse large B cell lymphoma? Prognosis?
R-CHOP
Good prognosis
What are the histological characteristics of Burkitt’s lymphoma?
“Starry sky”
What infection is associated with Burkitt’s lymphoma?
EBV
What is the CD marker that is positive in Mantle cell lymphoma?
CD5 (although it is a B cell lymphoma)
What is the natural history of adult T cell lymphoma?
HIgh grade–can progress to ALL
What is the viral etiology of adult T cell lymphoma?
HTLV
What is mycosis fungoides / sezary syndrome?
T cell lymphoma of the skin, that presents with cutaneous lesions and pruritus
Skin bx of mycosis fungoides usually shows what?
Cerebriform lymphoid cells
What is the gold standard for diagnosing lymphomas?
Excisional lymph node bx
What is the treatment for lymphomas in general?
if low grade, palliative
If high, aggressive
HL is generally a B or T cell malignancy?
B cell
Above what anatomical landmark do HLs usually present?
Above the diaphragm
What are the Pel-Ebstein fevers associated with HL?
Alternating febrile/nonfebrile fevers that last 1-2 weeks
What are the three major factors of staging for HL?
- Number of lymph nodes
- Presence of B symptoms
- If above and below diaphragm are involved
What subtype of HL has the best prognosis?
Lymphocyte predominant
What causes the hypercalcemia associated with MM?
Osteoclast activation with resulting lytic bone lesions
Why are patients with MM immunocompromised?
Shoddy, monoclonal IgG and/or IgA production
What are the characteristic findings of a serum protein electrophoresis?
Monoclonal spike
What is the classic PBS findings with MM?
Rouleaux formation
What happens to the total protein:albumin ratio with MM?
Increased
What are the characteristics urinary findings in MM?
Bence jones proteins
What is the treatment for young patients with MM?
Autologous bone marrow transplant
What is the treatment for old patients with MM?
Melphalan (oral alkylating agent) and prednisone
What causes adult fanconi syndrome?
MM damaging renal tubules
M protein spike = ?
Waldenstrom’s macroglobulinemia
What, generally, is Waldenstrom’s macroglobulinemia?
Clonal disorder of B cells that leads to a malignant monoclonal gammopathy–INcreased levels of IgM
What are the hemodynamic changes that can occur with Waldenstrom’s macroglobulinemia?
Hyperviscosity syndrome
What are the usual s/sx of Waldenstrom’s macroglobulinemia?
- Raynaud phenomenon
- Neuro problems
- Blurred vision 2/2 engorged blood vessels
What can MGUS progress to?
Waldenstrom’s
MM
What is the dolg standard for diagnosing Waldenstrom’s macroglobulinemia? What will this show?
Bone marrow bx
Dutcher bodies (PAS+ IgM deposits around the nucleus)
What is the treatment for Waldenstrom’s?
Chemo for the underlying malignancy
Plasmapheresis to remove excess immunoglobin
What is the cause of AL amyloidosis?
Plasma cell dyscrasia with deposition of monoclonal light chain fragments
What is the cause of AA amyloidosis?
Deposition of the acute phase reactant serum amyloid A
e.g. chronic inflammatory diseases
What is the cause of dialysis related amyloidosis?
Beta-2 microglobulin deposits
What is the cause of Heritable amyloidosis?
Deposition of abnormal gene products (prealbumin)
What is the senile-systemic amyloidosis?
Deposition of otherwise normal transthyretin
What are the the three major organs that are affected by amyloidosis?
Kidneys
Heart
Liver
What is the diagnostic test of choice for amyloidosis?
Bx with congo red stain
What is the treatment for primary amyloidosis?
Experimental chemo
autologous stem cell transplant
What is the technical definition of neutropenia?
ANC less than 1500
What is the most common cause of neutropenia?
infections followed by drugs
What is the usual presentation of chronic neutropenia?
Recurrent sinusitis
Gingivitis
Perianal infections
What lab tests should be ordered in the work up of neutropenia?
ANA levels
What is the treatment for neutropenia?
ABx
G-CSF
IVIG
What is the treatment for neutropenic fever?
Broad spectrum abx–cefepime
What are the components of the NAACP mnemonic for eosinophilia?
- Neoplasm
- Allergies
- Asthma
- Collagen vascular dz
- Parasites
CSF analysis showing eosinophilia is suggestive of what?
of a drug reaction or infection with coccidioidomycosis or a helminth.
Hematuria + eosinophilia may be ?
Schistosomiasis
What is a syngeneic transplant?
From identical twin
What is the cause of GVHD?
Minor histocompatibility complex antigens
What are the s/sx of GVHD?
- Skin changes
- Cholestatic liver dysfunction
- obstructive lung path
Down syndrome patients are predisposed to what neoplastic process?
ALL
What condition is associated with SCC and BCC of the skin?
Xeroderma pigmentosum
What condition is associated with malignant melanomas?
Multiple dysplastic nevi
What cancer is associated with chronic atrophic gastritis?
Gastric adenocarcinoma
What cancer is associated with ulcerative colitis?
Colonic adenocarcinoma
What cancer is associated with tuberous sclerosis?
AStrocytoma and cardiac rhabdomyomas
What cancer is associated with Paget’s disease of the bone?
osteosarcoma and fibrosarcoma
What cancer is associated with Plummer vinson syndrome?
SCC of the esophagus
What cancer is associated with autoimmune disease?
Malignant thymomas
What is the treatment for an acute transplant rejection?
- Corticosteroids
- Antilymphocyte abs
- Tacrolimus