Interactive Leukaemia Cases Flashcards
Indian, 5M presented with lymphadenopathy + mediastinal mass on CXR
WBC: 180
Hb: 93
Platelets: 43
Describe these results
WBC: V high (exceeds infection)
Hb: Low
Platelets: Low
Indian, 5M presented with lymphadenopathy + mediastinal mass on CXR
WBC: 180
Hb: 93
Platelets: 43
What is seen on the blood film?
Anaemia: blood less viscous, less Hb
Severe thrombocytopenia: No platelets
Abnormal large light purple cells: blasts
Indian, 5M presented with lymphadenopathy + mediastinal mass on CXR
WBC: 180
Hb: 93
Platelets: 43
What is the most likely cause of the mediastinal mass? Why?
A. Thymoma
B. AML
C. ALL
D. Haemorrhage into mediastinum
E. Pneumonia with a leukaemoid reaction
C. ALL
V high WBC in a child strongly indicative of leukaemia
Low Hb + Platelets result from BM infiltration
Mediastinal mass is the Thymus infiltrated by T lymphoblasts
(Thymoma unlikely due to high WCC)
Indian, 5M presented with lymphadenopathy + mediastinal mass on CXR
WBC: 180
Hb: 93
Platelets: 43
What would be the best technique to confirm the diagnosis of ALL? What approach to management should be taken?
A. Immunophenotyping
B. Cytochemistry
A. Immunophenotyping
For lymphoblasts cytochemistry does not predict anything
Combination chemotherapy + CNS directed therapy
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
Left subconjunctival haemorrhage
Small bruises over abdo
No enlarged LN
No hepatosplenomegaly
What test is most likely to reveal the cause of the problem?
A. Liver function tests
B. Creatinine
C. Coagulation screen
D. Blood count, film and coagulation screen
D. Blood count, film + coagulation screen
Blood film can confirm Thrombocytopenia
(exclude pseudothrombocytopenia from clumping)
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
LFTs:
ALT: 97
ALP: 72
BR: 24
Interpret these LFTs
ALT: HIGH
ALP: Normal
BR: HIGH
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
WBC: 7.5
Hb: 109
MCV: 83
Platelets: 21
Interpret this FBC
WBC: Normal
Hb: Low
MCV: Normal- Low
Platelets: Low
Borderline anaemia + severe thrombocytopenia
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
PT: 13.4 s
APTT: 21.5 s
Fibrinogen: 0.97 g/l
Interpret this coagulation screen
How could you explain a short APTT and a low fibrinogen?
What other test do you need?
PT: Normal
APTT: Low
Fibrinogen: Low
Consumption of fibrinogen + short APTT raises suspicion of DIC: activated coagulation factors in circulation making APTT short
Blood film +/- D-dimer
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
Short APTT, low fibrinogen
What cells can be seen on his blood film? How could you prove it?
Myeloid
Contain Auer rods + Granules
Prove difference between lymphoid + myeloid with cytochemistry or immunophenotyping
(but neither is actually necessary)
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
What can be seen on the bone marrow biopsy?
Granular blast cells replacing healthy BM cells
Uniform population- abnormal in the same way
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
Borderline anaemia, severe thrombocytopenia
Short APTT, low fibrinogen
Uniform, granular blast cells on BM biopsy
What diagnosis do you suspect?
A. CML
B. Acute promyelocytic leukaemia
C. Some other type of acute myeloid leukaemia
D. ALL
B. Acute promyelocytic leukaemia
Uniform population of promyelocytes with Auer rods + granules
Features of DIC
If CML would have myeloid hyperplasia in BM with differentiation into eosinophils, basophils + neutrophils
48M railway engineer.
2/52 bleeding gums
Attended dentist- severe bleeding
1 episode haematuria
Which test would be most useful to confirm the diagnosis of acute promyelocytic leukaemia?
A. Cytochemistry
B. Immunophenotyping
C. Cytogenetic analysis/ FISH/ molecular genetic analysis
What would you expect to see?
C. Cytogenetic analysis
Show t(15;17)
forming PML-RARA fusion gene (seen on FISH)
Want to determine APML from AML
Not immunophenotyping: already know this is myeloid- Auer rods
What is immunophenotyping good for in leukaemia?
Determine LYMPHOID from MYELOID
Will show antigens
What is cytogenetic analysis/ FISH/ molecular genetic analysis good for in leukaemia?
Identifying MUTATIONS
68F presenting with gradual onset fatigue, lethargy and exertion dyspnoea
Non smoker, not much alcohol, good diet
Pallor: conjunctival and nail bed
Mild ankle oedema
What one test would you do next?
FBC
68F presenting with gradual onset fatigue, lethargy and exertion dyspnoea
Non smoker, not much alcohol, good diet
Pallor: conjunctival and nail bed
Mild ankle oedema
Macrocytic anaemia on FBC
MCV: 110
Which test should be done next?
A. Blood film
B. BMA
C. LFTs
D. Thyroid function tests
E. Serum vitamin B12 and red cell folate
A. Blood film
Quick + simple
68F presenting with gradual onset fatigue, lethargy and exertion dyspnoea
Non smoker, not much alcohol, good diet
Pallor: conjunctival and nail bed
Mild ankle oedema
Her blood film looked like this. Describe the blood film.
Macrocytes + Microcytes (dimorphic)
Hypochromic microcytes
Neutrophils look normal
No oval macrocytes/ no hyper-segmentation to suggest B12 or folate deficiency
68F presenting with gradual onset fatigue, lethargy and exertion dyspnoea
Non smoker, not much alcohol, good diet
Pallor: conjunctival and nail bed
Mild ankle oedema
serum B12, red cell folate, LFTs, TFTs = normal
Ferritin 875 (grossly elevated)
BMA: 12% blast cells, 45% of erythroblasts were ring sideroblasts
What is the diagnosis?
Myelodysplastic syndrome (MDS with excess of blasts)
Dimorphic blood films suggestive of acquired sideroblastic anaemia: macrocytosis + subpopulation of hypo chromic microcytes
BMA: normal blast cells <5%
Ringed sideroblasts- ring of haemodesrin around nucleus on blood film (top arrow)
Abnormal sideroblasts- not ringed, random assortment (bottom arrow)
Indian 72F
Vegetarian, teetotal, non smoker
SOBOE, fatigue, painful gums and tongue, unable to eat spicy food
Pallor
WBC normal
Hb 52
MCV 122
Platelet count normal
Describe her blood film.
What should be measured next?
Oval macrocytes
Hypersegmented neutrophil
Tear drop poikilocytes
Severe anaemia
Vitamin B12 and folate as classic film of pernicious/ other megaloblastic anaemia
Indian 72F
Vegetarian, teetotal, non smoker
SOBOE, fatigue, painful gums and tongue, unable to eat spicy food
Pallor
B12, folate, TFT normal
LFTs mildly impaired
LDH 3870
What would you do next? Why?
Bone marrow aspirate as potentially a high cell turnover
Indian 72F
Vegetarian, teetotal, non smoker
SOBOE, fatigue, painful gums and tongue, unable to eat spicy food
Pallor
What can be seen on this bone marrow aspirate? Do you think this patient has a myelodysplastic syndrome?
LHS: Giant metamyelocytes
RHS: Megaloblasts
Not MDS
Indian 72F
Vegetarian, teetotal, non smoker
SOBOE, fatigue, painful gums and tongue, unable to eat spicy food
Pallor
Parietal cell antibodies: +ve
Intrinsic factor antibodies: +ve
Schilling test: 0% excretion
Interpret these results
+ve parietal cell + intrinsic factor antibodies suggest Pernicious anaemia
Schilling test: proves can’t absorb bit B12
(had normal B12 assay- sometime defective assays when IF antibodies in serum)
70F referred to vascular surgeon due to gangrenous toes
Non diabetic, 50-pack-year-hx
SOBOE and morning cough
Reduced femoral and distal pulses on side of affected toes
Not SOB at rest, no cyanosis
Plethora, conjunctival suffusion
No spleen felt
WBC: 18.6
Hb: 180
Platelets: 1648
USAP: normal kidneys, increased splenic size
What is the most likely diagnosis?
A. CML
B. Essential thrombocytopenia
C. Polycythemia vera
D. COPD
C. Polycythaemia vera
In ET would NOT get high Hb
In COPD would NOT get high platelets
In CML would NOT get high Hb
70F referred to vascular surgeon due to gangrenous toes
Non diabetic, 50-pack-year-hx
SOBOE and morning cough
Reduced femoral and distal pulses on side of affected toes
Not SOB at rest, no cyanosis
Plethora, conjunctival suffusion
No spleen felt
WBC: 18.6
Hb: 180
Platelets: 1648
USAP: normal kidneys, increased splenic size
What test would you do to confirm diagnosis of polycythaemia vera?
A. Molecular analysis for JAK2 mutation
B. Measure total volume of red cells in circulation
C. BMA and trephine biopsy
A. Molecular analysis for JAK2 mutation
70F referred to vascular surgeon due to gangrenous toes
Non diabetic, 50-pack-year-hx
SOBOE and morning cough
Reduced femoral and distal pulses on side of affected toes
Not SOB at rest, no cyanosis
Plethora, conjunctival suffusion
No spleen felt
WBC: 18.6
Hb: 180
Platelets: 1648
USAP: normal kidneys, increased splenic size
How would you treat this patient with polycythaemia vera?
A. Venesection alone
B. Imatinib
C. Venesection plus hydroxycarbamide
D. 32P
C. Venesection plus hydroxycarbamide
Venesection reduces Hb quite fast + depletes iron stores to prevent rapid rise again
Hydroxycarbamide to reduce platelets
70F referred to vascular surgeon due to gangrenous toes
Non diabetic, 50-pack-year-hx
SOBOE and morning cough
Reduced femoral and distal pulses on side of affected toes
Not SOB at rest, no cyanosis
Plethora, conjunctival suffusion
No spleen felt
WBC: 18.6
Hb: 180
Platelets: 1648
USAP: normal kidneys, increased splenic size
Why is venesection alone unsuitable treatment for this patient?
Venesection alone will not address the high platelet count, thus need hydroxycarbamide
