Interactive case hx in haematology Flashcards
Which of the following is the most convincing indication of iron deficiency? Please rank:
Anaemia and low MCV
Jaundice
Pencil cells on the blood film
Low transferrin saturation plus low serum iron
Fatigue
?
Give 2 symptoms and 2 signs of anaemia
weakness/ lethargy
Breathlessness
Pallor
Tachycardia + cardiomegaly
extra signs: koilynychia, glossitis, jaundice
Scenario A&E
Age 36
Sex Female
History 2years SOBOE
FBC Hb 32 g/l (116-150g/dl)
WBC 7 x 109/l (2-10.5 x 109/l)
platelets 452 x 109/l (150-400 x 109/l)
MCV 54fl ( 80-100fl)
What are the 3 most likely causes of this anaemia ?
Iron Deficiency Anaemia
Thalassaemia
ACD
What further investigations would be useful?
Reticulocyte count
- Haemoglobin electrophoresis
Iron studies..e.g. ferritin, transferrin saturation
Blood film
When is reticulocytosis absent?
Inadequate haematinics
Bone marrow failure (e.g. infiltration)
Acute major haemorrhage…reticulocyte response within 6 hours which increases over 6-10 days
What is on a blood film in IDA?
Iron deficiency
- Pencil cells
- Anisocytosis
- Poilkilocytosis
- Hypochromic
What does this show?
- Pencil cells
- Anisocytosis
- Poilkilocytosis
- Hypochromic
What causes IDA?
Uterine blood loss
GI loss
Hb 60 g/l (135-175g/l)
WBC 0.1 x 109/l (2-10.5 x 109/l)
Platelets 4 x 109/l (150-400 x 109/l)
What is abnormal about this blood count?
- Hb is LOW
- WBC is LOW
- Platelets LOW
What could cause this combination of abnormalities?
GIVE THREE POSSIBILITIES
- Aplastic anaemia
- Leukemia
- Infiltration e.g.Lymphoma, carcinoma
- Drugs e.g. chemotherapy
- B12/folate deficiency
Give 2 useful further investigations
- Blood film
- Vitamin B12
- Folic acid
- bone marrow
Suggest one diagnosis
ACUTE MYELOID LEUKAEMIA
What are the likely clinical problems going to be?
AML
What are the principles of managing this condition?
Supportive
- Red cell transfusions
- Platelet transfusions
- Nurse in isolation; prompt antibiotics
Disease related management
Consider chemotherapy
Hb 120g/l (135-175g/l)
WBC 10 x 109/l (2-10.5 x 109/l)
Platelets 28 x 109/l (150-400 x 109/l)
What is abnormal about this blood count?
Anemia
Thrombocytopenia
What are the causes of the MAIN abnormality on this FBC ?
NOT MAKING PLATELETS
- drugs e.g. chemotherapy, thiazides,
- bone marrow disorders e.g. leukemia, aplastic, myelodysplasia, myeloma, infiltration with carcinoma
PREMATURE DESTRUCTION OF PLTS
- ITP (auto-immune)
- Disseminated intravascular coagulation
- heparin
What further investigations could you do? GIVE 3 POSSIBILITIES
- Coagulation screen
- Blood film
- Bone marrow aspirate/trephine
- ANA/RAPA
- HIV
COAGULATION SCREEN
- APTT 54 seconds (control 40s)
- INR 2.1
What is abnormal about this coagulation screen?
- Prolonged APTT
- INR increased
What further investigations would be useful now?
- Blood film
- D-dimers/FDPs
- fibrinogen
- Blood cultures/CSR/MSU (Septic screen)
- Liver function tests
What is the diagnosis?
Disseminated intravascular coagulation
What is the management of DIC?
LIAISE WITH HAEMATOLOGY TEAM AND THE HAEM LAB
- Antibiotics
- Blood products….Red cells, platelets, cryoprecipitate, FFP
- Regular blood tests to assess response to products
What can alter myeloblasts?
<5% in BM is normal
5-10% is myelodysplasia
>20% is AML
If in peripheral blood, may be AML or leukoerythroblastic anaemia
Auer Rods
What can alter lymphoblasts?
<5% is normal in BM
>20% = ALL
TdT positive (NO AUER RODS)
What are the B cell markers?
CD19 and 20
What are the T cell markers?
CD3
CD4
CD8
CD5
What are the lymphocyte makrers of maturity?
TdT = immature T/B lymphoblasts
Surface Ig = mature B/ plasma cells
Hereditary spherocytosis
Spherocytes: Auto Immune or Inherited. One test to confirm acquired ?
Hb elctrophoresis
DAT (direct antiglobulin)
Sickle solubility
Unconjugated hyperbilirubinaemia
DAT (direct antiglobulin)
What is the difference between inherited and acquired haemolytic anaemias?
Inherited = inherited defect of cell
Acquired = environment causes damage
MAHA
Malaria
Snake bites
Aortic stenosis
Woman with SLE and menorrhagia
ACD
Why does ACD happen?
What causes isolated single lineage cytpaenia with otherwise normal FBC?
B12 deficiency
Leukoerythroblastic anaemia- Metastatic prostate cancer
What causes pancytopaenia?
Single most useful haematological test
DAT
Immunophenotyping for CD19/CD5/CD3 expression
HTLV1 serology
BCR ABL1 RT-PCR assay
JAK2V617F mutation analysis
Factor V Leiden screen
BCR ABL1 RT-PCR assay
What is the clinical picture of someone with CML?
How do leukaemia markers correlate with levels of residual leukaemia in the body?
Tyrosine Kinase Inhibitor- Imatinib/ dasatinib
Blast crisis
JAK2V617F mutation analysis
Immunophenotyping for CD19/CD5/CD3 expression (for CLL)
What is CLL?
Ibrutinib
Multiple Myeloma
Cast Nephropathy
