Heme Geriatrics Flashcards
MCC anemia worldwide
IDA
MCC IDA
chronic blood loss - in adults it’s colon CA until proven otherwise
sx IDA
pagophagia - craving for ice
PICA
koilonychia - spooning of nails
nonspecific - fatigue, weakness etc
dx IDA
CBC - decreased MCV and decreased MCHC
iron studies - decreased ferritin (< 30), decreased transferrin saturation, decreased serum iron, increased TIBC
tx IDA
iron replacement (can take with vitamin C - ascorbic acid to increase absorption) - GI ADE MC
325 mg once daily or every other day
B12 is also called
cobalamin
where do we get natural sources of B12
fish
meat
eggs
dairy products
where is B12 absorbed
distal ileum
MCC b12 deficiency
pernicious anemia - decreased intrinsic factor
other causes of B12 deficiency
Crohn dz
H2RA or PPI use
vegans
chronic alcohol use
sx B12 deficiency
similar to folate deficiency but associated with spinal cord involvement
symmetric paresthesias and numbness MC initial
gait ataxia, weakness, vibratory, sensory, and proprioception deficits
decreased DTR!!
dx B12 deficiency
CBC - increased MCV, megaloblastic anemia (macro-ovalocytes and hypersegmented neutrophils with > 5 lobes)
Decreased serum B12
Increased homocysteine
Increased methylmalonic acid (MMA)
tx B12 deficiency
sx - IM B12 weekly until corrected and then once monthly
patients with pernicious anemia need lifelong monthly IM therapy
otherwise can do oral
MC vitamin deficiency in US
folate deficiency
what is the function of folate
required for DNA synthesis; deficiency causes abnormal synthesis of DNA
how long do folate stores last
2-4 months
MCC folate deficiency
inadequate dietary intake - alcoholics, unbalanced diet, anorexia
other causes of folate deficiency
increased requirements - pregnancy, infancy, malignancy, psoriasis
impaired absorption - celiac, IBD, chronic diarrhea
meds - methotrexate, trimethoprim
dialysis
sx folate deficiency
NO NEURO ABNORMALITIES
fatigue, pallor
glossitis, aphthous ulcer, diarrhea
dx folate deficiency
CBC - increased MCV > 100, + megaloblastic anemia (hyperhsegmented neutrophils, macro-ovalocytes)
Decreased serum folate < 2
Increased homocysteine
Normal methylmalonic acid
tx folate deficiency
oral folic acid first line - 1-5 mg/day
diet rich in fruits and veggies
what is anemia of chronic disease
anemia due to decreased RBC production in the setting of chronic dz
pathophys of anemia of chronic disease
increased hepcidin - acute phase reactant that bocks the release of iron from macrophages and reduces GI absorption of iron
increased ferritin - acute phase reactant that sequesters iron into storage
dx anemia of chronic disease
CBC - normocytic normochromic anemia classic but may present with microcytic hypo chromic anemia early on
decreased reticulocytes
Iron studies - normal to increased ferritin + normal or decreased TIBC + decreased serum iron
tx anemia of chronic disease
treat underlying
erythropoietin-alpha if renal disease or low erythropoietin levels
chronic lymphocytic leukemia is also called
small lymphocytic lymphoma
MC leukemia in adults
CLL
sx chronic lymphocytic leukemia
usually asx
pancytopenia - fatigue MC
lymphadenopathy
splenomegaly
dx chronic lymphocytic leukemia
CBC - lymphocytosis hallmark; increased WBC with > 80% lymphocytes
absolute lymphocytosis > 5000/mcL
scattered smudge cells
hypogammaglobulinemia - decreased IgG, IgA, IgM
flow cytometry - most acute - clone of mature B cells
Bone marrow aspirate and bx required
tx chronic lymphocytic leukemia
stages 1 and 2 - observation
stages 3 and 4 - chemo
curative - allogeneic (from someone else) stem cell transplant
what is chronic myelogenous leukemia
myeloproliferative disorder of uncontrolled production of mature and maturing granulocytes (predominantly neutrophils)
pathophysiology of chronic myelogenous leukemia
BCR (on chromosome 22) and ABL1 (on chromosomes 9) –> BCR-ABL1 fusion –> Philadelphia chromosome
sx chronic myelogenous leukemia
70% asx
pruritus after hot shower/bath
splenomegaly
dx chronic myelogenous leukemia
CBC - leukocytosis with granulocytic cells (basophilia, neutrophilic, eosinophilia)
leukocyte alkaline phosphatase score - decreased LAP score due to dysfunctions WBC
bone marrow bx - granulocytic hyperplasia with elevated basophils and eosinophils; chronic < 5% blasts, acceletered 10-19% blasts, acute blast crisis > 20% blasts
genetic testing - fluorescence in situ hybridization (FISH) most accurate genetic test for Philadelphia chromosome
tx chronic myelogenous leukemia
tyrosine kinase inhibitors (Imatinib, Dasatinib, Nilotinib, Bosutinib) - they inhibit Philadelphia chromosome
if refractory - omacetaxine
what is Hodgkin lymphoma
B cell malignancy originating in the lymphatic system
ages affected by Hodgkin Lymphoma
bimodal - 15-34 and > 50
RF for Hodgkin Lymphoma
EBV
immunosuppression
smoking
caucasian
MC type of Hodgkin Lymphoma
nodular sclerosing - female predominance
4 main types of Hodgkin Lymphoma
nodular sclerosing
mixed cellularity
lymphocyte rich/predominance - best prognosis
lymphocyte depleted - worst prognosis
sx Hodgkin Lymphoma
asx painless lymphadenopathy - ETOH ingestion may induce lymph node pain
upper body lymph nodes - neck MC
hepatomegaly
splenomegaly
systemic B sx - fever, night sweats, weight loss; cyclical fever
dx Hodgkin Lymphoma
excision whole lymph node bx - Reed-Sternberg cell pathognomonic - large cells with Bi or multilobed nuclei (owl eye appearance) and inclusions in the nucleoli
tx Hodgkin Lymphoma
stage 1 and 2 - ABVD chemo followed by radiation
stage 3 and 4 - ABVD chemo
which lymphoma has a better prognosis
Hodgkin Lymphoma
major subtypes of non-hodgkin lymphoma
Diffuse large B cell - MC - fast growing and aggressive
Follicular - slow growing but hard to cure
Mantle cell
Marginal zone
Burkitt lymphoma - MC in peds and HIV patients ; involves the jaw
small lymphocytic
RF non-hodgkin lymphoma
age
immunosuppression - HIV
infections - EBV, HHV-8, H pylori associated with gastric lymphoma
sx non-hodgkin lymphoma
painless lymphadenopathy
GI tract MC site of extra nodal involvement
systemic B sx are rare in non-hodgkin lymphoma
dx non-hodgkin lymphoma
lymph node and/or tissue bx
for staging - CT/PET scan of chest, abdomen, pelvis
tx non-hodgkin lymphoma
stage 1 and 2 - radiation alone
R-CHOP chemotherapy
