Heme Lymph CIS Handout Flashcards
Possible symptoms of CLL
Painless swelling of LNs, often in cervical area, which spontaneously wax and wane but do not disappear
Most pts feel entirely well with no symptoms and diagnosis is made based on routine blood count showing absolute lymphocytosis
5-10% will have B symptoms (fever, weight loss, drenching night sweats, extreme fatigue)
Most common abnormal finding on PE of a pt with CLL
LAD — most commonly cervical, supraclavicular, and axillary [described as firm, rounded, discrete, nontender, and freely mobile upon palpation]
Second most frequently enlarged organ in CLL
Spleen
[usually painless and nontender to palpation]
Besides the common findings of LAD and splenomegaly, what are some other PE findings associated with CLL?
Hepatomegaly
Leukemia cutis (skin is most commonly involved non-lymphoid organ) — usually involves the face and can manifest as macules, papules, plaques, nodules, ulcers, or blisters
Virtually any lymphoid tissue may be enlarged at dx, including Waldeyer’s ring in the pharynx [Note: in contrast to other lymphomas, clinically relevant GI mucosal involvement is rarely seen in CLL. Similarly, meningeal leukemia is unusual at the time of initial presentation]
MGGN has occasionally been described in CLL: paraneoplastic deposition and possibly processing of cryoprecipitating or noncryoprecipitating M-components
The most noteworthy lab abnormality found in CLL is lymphocytosis in the peripheral blood and bone marrow. What is the absolute blood lymphocyte threshold for diagnosing CLL?
> 5000/microliter [5x10^9/L]
Note: a significant proportion of pts present with counts as high as 100,000/microliter
Other than lymphocytosis, what other lab abnormalities are associated with CLL?
Cytopenias — neutropenia, anemia, and thrombocytopenia (usually not severe)
Immunoglobulin abnormalities — hypogammaglobulinemia (may affect IgG, IgA, and/or IgM)
The above findings contribute to increased vulnerability of CLL pts to major bacterial infections
What are the implications of cytopenias seen in CLL?
Increased incidence of autoimmune hemolytic anemia (AIHA) — thus the direct antiglobulin (Coombs) test (DAT) may be positive at some time during the course of the disease in up to 35% of cases
Pure red cell aplasia (rare)
Autoimmune thrombocytopenia is suggested when a bone marrow biopsy shows adequate numbers of megakaryocytes
Agranulocytosis (rare)
Diagnostic evaluation of a pt suspected of having CLL should include what?
CBC with diff
Exam of peripheral smear
Immunophenotypic analysis (flow cytometry) of circulating lymphocytes
[bone marrow aspirate/bx and LN bx are not required elements of diagnostic workup; chromosomal changes in CLL are not diagnostic features of the disease]
Morphology associated with CLL
Peripheral smear shows lymphocytosis (small, mature appearing lymphocytes with dense nucleus)
These PROLYMPHOCYTES usually account for minority of overall lymphocyte population. The smear often contains SMUDGE cells (aka BASKET cells)
2 criteria that must be met to make dx of CLL
Absolute B lymphocyte count in peripheral blood >5000/microL with a preponderant population of morphologically mature-appearing small lymphocytes
Demonstration of clonality of the circulating B lymphocytes by flow cytometry of peripheral blood (majority should express extremely low levels of SmIg and either kappa or lambda light chains; expression of B cell associated antigens — CD19, CD20, CD23; and expression of T cell associated antigen CD5
What are the prognostic variables on the CURB-65 mortality prediction tool for pts with community-acquired pneumonia?
Confusion BUN > 20mg/dL RR >30 breaths/minute BP (syst <90, diast <60) Age > 65
[0-1 points tx as outpatient, 2 pts tx as inpatient, >3 pts tx in ICU]
The following are genetic features of what neoplastic entity:
Deletion 13q, trisomy 12, deletion 11q, deletion 17p, TCR genes not clonally rearranged
CLL/SLL
Absolute increase in number of clonal B cells in peripheral blood does not exceed 5000/microL w/ immunophenotype identical to CLL, and pts have no LAD, organomegaly, cytopenias, or other symptoms
Monoclonal B cell lymphocytosis
> 55% of circulating lymphocytes are prolymphocytes; bone marrow is infiltrated in an interstitial or nodular pattern by similar cells
Express bright surface IgM +/- IgD and bright CD20 as well as other B cell Ags (CD19, CD22, CD79a, FMC7)
No associated paraproteinemia; TCR genes not rearranged
B cell prolymphocytic leukemia
t(11;14)
Mantle cell lymphoma
Unlike CLL, most cases of ____ are negative for CD5, express CD11c, CD103, CD123, cyclin D1, and/or annexin A1
HCL
Can have a leukemic phase that mimics CLL morphologically with circulating small lymphocytes with irregular or cleaved nuclei. Like CLL, coexpress CD20 and CD5 and do not express CD23 but stain strongly for cyclin D1 and surface membrane Ig
Mantle cell lymphoma
Peripheral blood involvement is usually less prominent; circulating malignant cells have plasmacytoid appearance; lacks CD23 expression and stains strongly for surface IgM, CD20, and cytoplasmic Ig
Lymphoplasmacytic lymphoma
Guidelines for pneumococcal vaccine in CLL pts (PCV13 and PPSV23)
Give PCV13 followed by PPSV23 at least 8 weeks later
Administer second dose of PPSV23 at least 5 years after the first dose of PPSV23
Vaccines that are recommended in immunocompromising conditions such as CLL
Influenza vaccine annually
Tdap then Td every 10 years
HPV (3 doses through age 26)
PCV13 and PPSV23
[meningococcal, Hep A, and Hep B recommended if some other risk factor is present; Hib is recommended for post-HSCT recipients only]
Vaccines that are contraindicated in immunocompromising conditions such as CLL
Varicella
Zoster
MMR
Common etiologies of community acquired PNA in outpatients
In order of frequency:
Unknown M.pneumoniae Respiratory viruses S.pneumoniae Chlamydophila pneumoniae Legionella Haemophilus influenzae
Most common (known) cause of community acquired pneumonia in hospitalized pts
S.pneumoniae
[others include respiratory viruses, legionella, M.pneumoniae, etc.]
Biomechanical OMM considerations for PNA pt
Indirect OMT to all somatic dysfunctions — especially cervicals, scalenes, pectorals, ribs, thoracics, diaphragm
