Haematology Flashcards

1
Q

What is antiphospholipid syndrome?

A

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)

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2
Q

What are the complications of anti-phospholipid syndrome in pregnancy?

A

Recurrent miscarriage
IUGR
pre-eclampsia
placental abruption
pre-term delivery
venous thromboembolism

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3
Q

What is the treatment for antiphospholipid syndrome?

A

low-dose aspirin should be commenced once the pregnancy is confirmed on urine testing
low molecular weight heparin once a fetal heart is seen on ultrasound. This is usually discontinued at 34 weeks gestation
these interventions increase the live birth rate seven-fold

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4
Q

How does heparin work?

A

Heparin works by binding to antithrombin III, enhancing its anticoagulant effect by inhibiting the formation of thrombin and other clotting factors.

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5
Q

What deficiency may cause patients to be resistant to heparin?

A

Patients with antithrombin III deficiency may therefore by resistant to heparin treatment

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6
Q

What does antithrombin III do?

A

Antithrombin III inhibits several clotting factors, primarily thrombin, factor X and factor IX. It mediates the effects of heparin

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7
Q

What are the features of antithrombin III deficiency?

A

ecurrent venous thromboses
arterial thromboses do occur but are uncommon

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8
Q

What is the management of antithrombin III deficiency?

A

thromboembolic events are treated with lifelong warfarinisation
heparinisation during pregnancy*
antithrombin III concentrates (often using during surgery or childbirth)

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9
Q

What is haemophilia?

A

Haemophilia is a X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is due to a deficiency of factor VIII whilst in haemophilia B (Christmas disease) there is a lack of factor IX

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10
Q

What are the features of haemophilia?

A

haemoarthroses, haematomas
prolonged bleeding after surgery or trauma

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11
Q

Which blood test would be prolonged in haemophilia?

A

prolonged APTT
bleeding time, thrombin time, prothrombin time normal

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12
Q

What is the most common cause of antithrombin III deficiency?

A

CKD

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13
Q

What is burkitts lymphoma? what are the two forms?

A

Burkitt’s lymphoma is a high-grade B-cell neoplasm. There are two major forms:

endemic (African) form: typically involves maxilla or mandible
sporadic form: abdominal (e.g. ileo-caecal) tumours are the most common form. More common in patients with HIV
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14
Q

What gene translocation is burkitts lymphoma assoc. with? What virus is also implicated?

A

Burkitt’s lymphoma is associated with the c-myc gene translocation, usually t(8:14). The Epstein-Barr virus (EBV) is strongly implicated in the development of the African form of Burkitt’s lymphoma and to a lesser extent the sporadic form.

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15
Q

What is the management of burkitts lymphoma?

A

chemotherapy

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16
Q

What can chemo for burkitts lymphoma cause? what is given to reduce this risk?

A

This tends to produce a rapid response which may cause ‘tumour lysis syndrome’. Rasburicase (a recombinant version of urate oxidase, an enzyme which catalyses the conversion of uric acid to allantoin*) is often given before the chemotherapy to reduce the risk of this occurring.

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17
Q

What are the complications of tumour lysis syndrome?

A

hyperkalaemia
hyperphosphataemia
hypocalcaemia
hyperuricaemia
acute renal failure

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18
Q

Which cell transfusion is most commonly associated. With bacterial infection?

A

Platelets
Stored at room temp

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19
Q

Which antibodies cause delayed extra vascular haemolytic transfusion reactions more than acute intravascular haemolytic transfusion reactions?

A

IgG

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20
Q

Which antibodies cause acute intravascular haemolytic transfusion reactions?

A

IgM anti a and anti b

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21
Q

Are anti ABO antibodies and antigens present at birth?

A

Antigens are present at birth and antibodies are present at about 6months

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22
Q

Which antibody are 1 in 10000 people deficient in?

A

IgA
About 1 in 10 000 people are deficient in IgA and can form clinically significant, complement
binding, antibodies to IgA.

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23
Q

What is the commonly the cause of apparent anaphylaxis to blood transfusion?

A

In many cases of apparent anaphylaxis to a blood transfusion, the causative agent is unknown,
but is putatively thought to be due to allergens in the donation, such as penicillin or peanut antigens.

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24
Q

What are delayed transfusion reactions caused by and when do they occur?

A

occur 5-10 days post transfusion due to the development of red cell alloantibodies:

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25
Q

What are the clinical features of delayed transfusion reaction?

A

usually minimal but can include unexplained pyrexia, jaundice or unexplained drop in hemoglobin

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26
Q

How do you make the diagnosis for delayed transfusion reaction?

A

Urinalysis shows urobilinogenuria and a blood shows fragile ballooned spherocytes, diagnosis is confirmed by Coombs test which is done by adding antihuman globulin (AHG) (anti-Ig G and anticomplement) to the patient’s washed RBCs. A positive test results in red cell agglutination.

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27
Q

Autoimmune haemolytic anaemia cold
What antibody causes this?
What mediates haemolysis?
Intravascular or extra vascular?
Causes?
Respond well/less we’ll to steroids?

A

Cold AIHA is usually by IgM and causes hemolysis best at 4°C. Hemolysis is mediated by complement and is more commonly intravascular. Features may include symptoms of Reynaud’s and acrocynaosis. Patients respond less well to steroids.
Causes of cold AIHA
• Neoplasia: e.g. lymphoma
• Infections: e.g. mycoplasma, EBV

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28
Q

Autoimmune haemolytic anaemia warm

What antibody causes this?
What mediates haemolysis?
Intravascular or extra vascular?
Causes?
Management options?

A

Warm AIHA the antibody (usually IgG) causes hemolysis best at body temperature and hemolysis tends to occur in extravascular sites, for example the spleen. Management options include steroids, immunosuppression and splenectomy.
Causes of warm AIHA
• Autoimmune disease: e.g. Systemic lupus erythematosus*
• Neoplasia: e.g. Lymphoma, CLL
• Drugs: e.g. Methyldopa

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29
Q

Which is the most common hereditary haemolytic anaemia in Northern Europe?

A

Hereditary spherocytosis

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30
Q

What is Hereditary spherocytosis caused by? How does this lead to anaemia?

A

Autosomal Dominant defect of RBC cytoskeleton
• Biconcave disc → spherocyte
• Red cell survival ↓, destroyed by spleen

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31
Q

What are the clinical features of hereditary spherocytosis?

A

Presentation
• E.g. Failure to thrive
• Jaundice, gallstones
• Splenomegaly
• Aplastic crisis precipitated by parvovirus infection
• Degree of hemolysis variable
• ↓ MCV - ↑ MCHC - ↑ Reticulocytes
Splenic rupture is an important differential

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32
Q

How is hereditary spherocytosis diagnosed?

A

the osmotic fragility test was previously the recommend investigation of choice. However, it is now deemed unreliable and is no longer recommended
the British Journal of Haematology (BJH) guidelines state that ‘patients with a family history of HS, typical clinical features and laboratory investigations (spherocytes, raised mean corpuscular haemoglobin concentration[MCHC], increase in reticulocytes) do not require any additional tests
if the diagnosis is equivocal the BJH recommend the cryohaemolysis test and EMA binding
for atypical presentations electrophoresis analysis of erythrocyte membranes is the method of choice

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33
Q

What is the treatment for hereditary spherocytosis?

A

Folate replacement • Splenectomy

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34
Q

How is sickle cell disease inherited?
What is it caused by?
Which chromosome is involved?

A

Autosomal Recessive. It s caused by mutation in β-globin chain of hemoglobin, causing
hydrophilic amino acid glutamic acid to be replaced with the hydrophobic amino acid valine at the 6th
position. The β-globin gene is found on the short arm of chromosome 11.

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35
Q

What is the difference between sickle cell disease and sickle cell trait?

A

Sickle-cell anemia is a specific form of sickle-cell disease in which there is homozygosity for
the mutation, it is also known as “HbSS”, “SS disease”, “hemoglobin S”.
• Heterozygous: 1 sickle gene and 1 normal gene, it is known as “HbAS” or “sickle cell trait”.
• Other, rarer forms of sickle-cell disease include sickle-hemoglobin C disease (HbSC), sickle
beta-plus-thalassaemia (HbS/β+) and sickle beta-zero-thalassaemia (HbS/β0). These other
forms of sickle-cell disease are compound heterozygous states in which the person has only one
copy of the mutation that causes HbS and one copy of another abnormal hemoglobin allele.

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36
Q

What are the four main types of sickle cell crisis?
(TASH)

A

Thrombotic, ‘painful crises’
• Aplastic
• Sequestration (spleen, liver and kidney)
• Hemolytic

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37
Q

What is thrombotic sickle cell crisis?

A

Also known as painful crises or vaso-occlusive crises
• Precipitated by infection, dehydration, deoxygenation
• Infarcts occur in various organs including the bones (e.g. avascular necrosis of hip), hand-foot
syndrome in children, lungs, spleen and brain.

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38
Q

What is aplastic sickle cell crisis?

A

Caused by infection with parvovirus
• Sudden fall in hemoglobin

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39
Q

What is sequestration sickle cell crisis?

A

Sickling within organs such as the spleen or lungs causes pooling of blood with worsening of
the anaemia
• Acute chest syndrome: dyspnea, chest pain, pulmonary infiltrates, low PO2 - the most common
cause of death in adults (Hydroxyurea ↓ the incidence of acute chest syndrome)
• The most common cause of death in childhood: infraction and infection (Pneumococcus,
Chlamydia, Mycoplasm)

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40
Q

What is haemolytic crisis in sickle cell disease?

A

Rare
• Fall in hemoglobin due an increased rate of hemolysis

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41
Q

What antibodies are looked for in pernicious anaemia?

A

Anti gastric parietal cell antibodies in 90% (but low specificity)
• Anti intrinsic factor antibodies in 50% (specific for pernicious anemia)

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42
Q

What kind of anaemia is pernicious anaemia?
-WBC count? platelets?

A

Macrocytic anemia
• Low WBC and platelets

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43
Q

what do you see in blood films and in the marrow of patients with pernicious anaemia?

A

Also low serum B12, hypersegmented polymorphs on film, megaloblasts in marrow

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44
Q

What is shillings test for?

A

Radiolabelled B12 given on two occasions
• First on its own
• Second with oral Intrinsic Factor
• Urine B12 levels measured

used in the past

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45
Q

What is sideroblastic anaemia?

A

condition where red cells fail to completely form heme, whose
biosynthesis takes place partly in the mitochondrion. This leads to deposits of iron in the mitochondria
that form a ring around the nucleus called a ring sideroblast. It may be congenital or acquired

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46
Q

What is a congenital cause of sideroblastic anaemia?

A

Delta-aminolevulinate synthase-2 deficiency

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47
Q

What is an acquired cause of sideroblastic anaemia?

A

Myelodysplasia
• Alcohol
• Lead
• Chloramphenicol and Anti-TB medications (INH + Pyrazinamide)

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48
Q

What kind of anaemia is present in sideroblastic anaemia?

A

Hypochromic microcytic anemia (more so in congenital)
• Bone marrow: sideroblasts and ↑ iron stores

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49
Q

what is the management of sideroblastic anaemia?

A

Supportive
• Treat any underlying cause
• Pyridoxine may help

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50
Q

What is pure red cell aplasia?

A

is diagnosed when there is unexplained anaemia and reticulocytopenia,
with a complete absence of red cell precursors in the bone marrow, but with preservation of other cell
lines.

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51
Q

What is pure red cell aplasia associated with?

A

Either spontaneously or associated with
• Thymoma
• Autoimmune
• Lymphoproliferative disorders.

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52
Q

What is the management of pure red cell aplasia?

A

is supportive with immunosuppression with cyclosporin or related compounds. The
condition can rarely occur where recombinant erythropoietin is administered, where antierythropoietin
antibodies can be detected; these patients respond to withdrawal of erythropoietin with subsequent
falling of the antibody levels

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53
Q

What is Glucose-6-phosphate dehydrogenase (G6PD) deficiency?

A

is the commonest red
cell enzyme defect. It is more common in people from the Mediterranean and Africa and is inherited in
an X-linked recessive fashion. Many drugs can precipitate a crisis as well as infections and broad
(fava) beans

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54
Q

What are the features of G6PD? what is seen on blood film?

A

Neonatal jaundice is often seen
• Intravascular hemolysis
• Heinz bodies on blood films

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55
Q

How is the diagnosis of G6PD made?

A

Diagnosis is made by using a G6PD enzyme assay

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56
Q

What drugs can cause haemolysis in G6PD?

A

Anti-malarials: primaquine
• Ciprofloxacin
• Sulfonamides
• Co-trimoxazole (because it contains sulfa)

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57
Q

What drugs are safe in G6PD?

A

Penicillins
• Cephalosporins
• Macrolides (Azithro-Clarithro-Erythro mycins)
• Tetracyclines
• Trimethoprim

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58
Q

What is Paroxysmal nocturnal hemoglobinuria (PNH)
-inherited or acquired?
-what is it thought to be caused by?
-what are patients more prone to?

A

is an acquired disorder leading to
hemolysis (mainly intravascular) of hematological cells. It is thought to be caused by ↑ sensitivity of
cell membranes to complement due to a lack of glycoprotein glycosyl-phosphatidylinositol
(GPI). Patients are more prone to venous thrombosis

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59
Q

What is the pathophysiology of PNH?
-what does a lack of GPI cause?
-why causes thrombosis?

A

GPI can be thought of as an anchor which attaches surface proteins to the cell membrane
• Complement-regulating surface proteins, e.g. decay-accelerating factor (DAF), are not properly
bound to the cell membrane due a lack of GPI
• Thrombosis is thought to be caused by a lack of CD59 on platelet membranes predisposing to
platelet aggregation

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60
Q

What are the features of PNH?

A

Hemolytic anemia
• Red blood cells, white blood cells, platelets or stem cells may be affected therefore
pancytopenia may be present
• Hemoglobinuria: classically dark-colored urine in the morning (although has been shown to
occur throughout the day)
• Thrombosis e.g. Budd-Chiari syndrome
• Aplastic anemia may develop in some patients

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61
Q

How is PNH diagnosed?

A

Flow cytometry of blood to detect low levels of CD59 and CD55 has now replaced Ham’s test
as the gold standard investigation in PNH
• Ham’s test: acid-induced hemolysis (normal red cells would not)

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62
Q

How is PNH managed?

A

• Blood product replacement
• Anticoagulation
• Eculizumab, a monoclonal antibody directed against terminal protein C5, is currently being
trialled and is showing promise in reducing intravascular hemolysis
• Stem cell transplantation

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63
Q

What is the treatment for sickle cell disease?
-acute attack

A

analgesia e.g. opiates
rehydrate
oxygen
consider antibiotics if evidence of infection
blood transfusion
exchange transfusion: e.g. if neurological complications

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64
Q

What is the treatment for sickle cell disease
-prophylaxis

A

hydroxyurea
increases the HbF levels and is used in the prophylactic management of sickle cell anaemia to prevent painful episodes
NICE CKS suggest that sickle cell patients should receive the pneumococcal polysaccharide vaccine every 5 years

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65
Q

What are relative causes of polycythaemia?

A

Dehydration
• Stress: Gaisbock
syndrome

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66
Q

What are the primary causes of polycythaemia?

A

Polycythaemia Rubra Vera

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67
Q

What are the secondary causes of polycythaemia?

A

COPD
• Altitude
• Obstructive sleep apnoea
• Excessive erythropoietin: cerebellar
hemangioma, hypernephroma,
hepatoma, uterine fibroids*

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68
Q

How to differentiate between primary and secondary causes of polycythaemia?

A

Erythroid colony studies:
autonomous growth of erythroid colonies is taken as a sign of primary
polycythaemia, where erythropoiesis has escaped the control of erythropoietin; erythroid colony studies
are thought to have high specificity for detecting primary versus secondary polycythaemia.

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69
Q

How to differentiate between true and relative polycythaemia?

A

To differentiate between true (primary or secondary) polycythaemia and relative polycythaemia red cell
mass studies are sometimes used. In true polycythaemia the total red cell mass in males > 35 ml/kg and
in women > 32 ml/kg

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70
Q

What is polycythaemia rubra vera?

A

is a myeloproliferative disorder caused by clonal
proliferation of a marrow stem cell leading to ↑ RBCs, often accompanied by ↑ WBC (neutrophils) and
↑ platelets.

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71
Q

When does the incidence of polycythaemia rubra vera peak?

A

The incidence
of PRV peaks in the sixth decade (50-60s of age)

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72
Q

What are the main features of polycythaemia rubra vera?

A

Hyperviscosity (headaches, tinnitus, visual disturbance, cyanosis, joint pain)
• Pruritus, typically after a hot bath
• Splenomegaly ± Hepatomegaly
• Hemorrhage (secondary to abnormal platelet function not number)
• Plethoric appearance
• Low ESR
• Hypertension in a third of patients

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73
Q

what mutation is present in polycythaemia rubra vera?

A

a mutation in JAK2 is present in approximately 95% of
patients

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74
Q

What investigations are suggested when considering polycythaemia rubra vera - what will you find?

A

FBC/film (raised hematocrit; neutrophils, basophils, platelets raised in half of patients)
• JAK2 mutation
• Serum ferritin
• Renal and liver function tests

↑ Hemoglobin and hematocrit
• ↑ Leucocyte alkaline phosphatase (LAP) and low ESR
• Additional:
o ± ↑ WBC and ↑ PLT
o ± ↑ Plasma volume
o ↑ Vitamin B12
o ↑ Red cell mass
o ↓ Erythropoietin level

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75
Q

What further investigations are suggested when considering polycythaemia rubra vera and JAK2 is negative

A

Red cell mass
• Arterial oxygen saturation
• Abdominal ultrasound
• Serum erythropoietin level
• Bone marrow aspirate and trephine
• Cytogenetic analysis
• Erythroid burst-forming unit (BFU-E) culture

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76
Q

What is the management of polycythaemia rubra vera?

A

• Venesection - first line treatment
• Hydroxyurea -slight ↑ risk of secondary leukemia
• Allopurinol & Phosphorus-32 therapy

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77
Q

What is the diagnostic criteria for polycythaemia rubra vera?

A

Diagnosis: JAK2-positive PRV - diagnosis requires both criteria to be present
A1 High hematocrit (>0.52 in men, >0.48 in women) OR raised red cell mass (>25% above predicted)
A2 Mutation in JAK2

JAK2-negative PRV - diagnosis requires A1 + A2 + A3 + either another A or two B criteria

A1 Raised red cell mass (>25% above predicted) OR hematocrit >0.60 in men, >0.56 in women
A2 Absence of mutation in JAK2
A3 No cause of secondary erythrocytosis
A4 Palpable splenomegaly
A5 Presence of an acquired genetic abnormality (excluding BCR-ABL) in the hematopoietic cells
B1 Thrombocytosis (platelet count >450 * 109/l)
B2 Neutrophil leucocytosis (neutrophil count > 10 109/l in non-smokers; > 12.5109/l in smokers)
B3 Radiological evidence of splenomegaly
B4 Endogenous erythroid colonies or low serum erythropoietin

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78
Q

What is the definition of neutropenia?

A

on a routine full blood count (CBC) is one of the most common enquiries received
by hematologists from primary care physicians and hospital doctors. Neutropenia is defined as an
absolute peripheral blood neutrophil count of <2.0 × 109/l. There is a racial variation: black and
Middle Eastern people may have neutrophil counts of <1.5 × 10
9/l normally.

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79
Q

What are causes of congenital neutropenia?

A

• Kostmann’s syndrome
• Chediak–Higashi
• Schwachmann–Diamond syndrome
• Cyclical neutropenia

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80
Q

What are 5 causes of acquired neutropenia?

A

• Infection: viral e.g. influenza, HIV, hepatitis, bacterial sepsis.
• Drugs: anticonvulsants (phenytoin) – anti-thyroid (carbimazole) – phenothiazines
(chlorpromazine) – antibacterial agents (cotrimoxazole) – ACE-inhibitors (ramipril)
• Immune-mediated: SLE, Felty’s syndrome (Rheumatoid Arthritis + Neutropenia + Splenomegaly)
• Bone marrow failure: leukaemia, lymphoma, Hematinic deficiency
• Splenomegaly: any cause

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81
Q

What are the investigations for neutropenia

A

• Blood film
• Hematinics: factors that ↑Hb (Iron, TIBC, Vit B12, Folic Acid, Vit D)
• Autoimmune profile bone marrow aspirate/trephine are indicated if there are severe or
prolonged neutropenia or features suggestive of marrow failure

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82
Q

What is a leukemoid reaction?

A

describes the presence of immature cells such as myeloblasts,
promyelocytes and nucleated red cells in the peripheral blood. This may be due to infiltration of the
bone marrow causing the immature cells to be ‘pushed out’ or sudden demand for new cells

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83
Q

What are the different causes for a leukemoid reaction?

A

• Severe infection
• Severe hemolysis
• Massive hemorrhage
• Metastatic cancer with bone marrow infiltration

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84
Q

How do you differentiate between leukemoid reaction and CML?

A

Leukemoid reaction:
• High leukocyte alkaline phosphatase score
• Toxic granulation (Dohle bodies) in the
white cells
• ‘Left shift’ of neutrophils i.e. ↑neutrophils
or ≤ 3 segments of the nucleus

CML:
• Philadelphia chromosome
• Low leukocyte alkaline phosphatase score

Philadelphia chromosome is the most accurate test to distinguish

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85
Q

What is myelofibrosis?
-what is it thought to be caused by?

A

Abnormal fibrous deposition in bone marrow which = low blood count
• Thought to be caused by hyperplasia of abnormal megakaryocytes [bone marrow cell
responsible for the production of blood thrombocytes (platelets)]
• The resultant release of platelet derived growth factor is thought to stimulate fibroblasts
• Hematopoiesis develops in the liver and spleen

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86
Q

What are the features of myelofibrosis?

A

• E.g. Elderly person with symptoms of anemia e.g. Fatigue (the most common presenting
symptom)
• Massive splenomegaly
• Hypermetabolic symptoms: weight loss, night sweats etc

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87
Q

What are the investigations for myelofibrosis?

A

• Anemia
• High WBC and platelet count early in the disease
• ‘Tear-drop’ poikilocytes on blood film
• Unobtainable bone marrow biopsy - ‘dry tap’ therefore trephine biopsy needed
• High urate and LDH (reflect ↑ cell turnover)
• leucoerythroblastic change

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88
Q

What is the treatment for myelofibrosis?

A

• Supportive care (blood transfusion, platelets, antibiotics)
• Allogeneic stem cell transplantation in a select few
• Splenectomy (CONTROVERSIAL)

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89
Q

Who does myelodysplasia effect? What can this transform into?

A

occurs mainly in the elderly, 30% transforms to AML

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90
Q

What is the presentation of myelodysplasia?

A

•Anaemia
• Infection
• Bleeding

= Due to pancytopenia

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91
Q

What are the investigations for myelodysplasia?

A

• Serial blood counts show evidence of increasing bone marrow failure
• Bone marrow shows increased cellularity.

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92
Q

What is the management for myelodysplasia?

A

• < 5% blasts in the bone marrow → manage conservatively.
• ↑ WBC → gentle chemotherapy.
• < 60 years old → Intensive chemotherapy

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93
Q

What chromosome is evident in CML?

A

The Philadelphia chromosome is present in more than 95% of patients with CML. It is due to a translocation between the long arm of chromosome 9 and 22 -
t(9:22)(q34:q11). This results in part of the ABL proto-oncogene from chromosome 9 being fused with
the BCR gene from chromosome 22. The resulting BCR-ABL gene codes for a fusion protein which
has tyrosine kinase activity in excess of normal.

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94
Q

What is the presentation of CML?

A

Presentation (40-50 years)
• Middle-age
• Anemia, weight loss
• Splenomegaly may be marked (lethargy, anorexia, abdominal discomfort – 75% palpable spleen)
• Hepatomegaly and lymphadenopathy are uncommon
• Spectrum of myeloid cells seen in peripheral blood
• ↓ neutrophil alkaline phosphatase
• May undergo blast transformation (AML in 80%, ALL in 20%)

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95
Q

How to diagnose CML?

A

• Philadelphia is confirmatory
• Peripheral blood film: (leukocytosis in all stages of differentiation within the myeloid linage)
• Basophilia is important diagnostic marker especially when Philadelphia is absent
• Monocytopenia
• Bone-marrow hypercellularity with ↑ myloid-erythroid ratio

↑ Granulocytes of all types, typically including mature myeloid cells. Basophils and eosinophils are almost universally ↑;
this feature may help differentiate CML from a leukemoid reaction. A bone marrow biopsy is often performed as part of the
evaluation for CML, and CML is confirmed by detecting the Philadelphia chromosome, this can be detected by routine
cytogenetics, by fluorescent in situ hybridization, or by PCR for the bcr-abl fusion gene.

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96
Q

What is the management of CML?

A

• Hydroxyurea (also used in PRV, painful attacks in sicklers and as antiretroviral in HIV)
• Interferon- α
• Imatinib (inhibitor of tyrosine kinase)
Inhibitor of the tyrosine kinase associated with the BCR-ABL defect, Very high response rate in chronic phase CML
• Allogenic bone marrow transplant (optimum management)

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97
Q

What is acute myeloid leukaemia?

A

Malignant disease of WBC’s and RBC’s

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98
Q

Is AML common? how does it occur?

A

is the most common form of acute leukemia in adults. It mayoccur as a primary disease or following a secondary transformation of a myeloproliferative disorder(e.g CML, myelofibrosis).
> 30% blasts are almost diagnostic of AML.

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99
Q

What is the presentation of AML?

A

• Early signs are vague and non-specific (influenza-like)
• Persistent or frequent infections (due to ↓ WBC)
• Bruising and petechiae (due to ↓ PLT)
• Splenomegaly may occur but typically mild and asymptomatic. Lymph node swelling is rare.

Symptoms are caused by Pancytopenia (↓RBC - ↓WBC - ↓PLT)

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100
Q

What test can distinguish ALL from AML

A

The combination of a myeloperoxidase or Sudan black stain and a non-specific esterase (NSE)
stain will provide distinction of AML from ALL and in subclassification of AML in most cases.

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101
Q

What is the treatment of AML?

A

Chemotherapy: divided into two phases
Induction and consolidation phases

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102
Q

What is the induction phase of chemotherapy in AML?

A

Induction: All types except M3 are given induction with cytarabine (ara-C) and an
anthracycline (such as daunorubicin or idarubicin).This regimen is known as “7+3”, because
the ara-C is given as a continuous IVI for 7 days while the anthracycline is given for 3
consecutive days as an IV push.

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103
Q

What is the consolidation phase of chemotherapy in AML?

A

Consolidation: even after complete remission, very few leukemic cells likely to remain
undetected with current diagnostic techniques. If no further post-remission therapy is given,
almost all patients will eventually relapse. Therefore, more therapy is necessary to eliminate
non-detectable disease and prevent relapse — that is, to achieve a cure. The specific type of
postremission therapy is individualized based on prognostic factors and general health:
For good-prognosis leukemias [t(8;21), and t(15;17)], patients will typically undergo
an additional 3–5 courses of intensive chemotherapy
For patients at high risk of relapse (e.g. those with high-risk cytogenetics, underlying
MDS, or therapy-related AML), allogeneic stem cell transplantation is usually
recommended

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104
Q

How to diagnose AML?

A

The first clue is typically an abnormal
CBC. While ↑ WBC is a common finding, and
leukemic blasts are sometimes seen, AML can also
present with isolated ↓ PLT, ↓ RBCs, or even ↓ WBC.
While a presumptive diagnosis of AML can be made
via examination of the peripheral blood smear when
there are circulating leukemic blasts, a definitive
diagnosis usually requires an adequate bone marrow
aspiration and biopsy.

Auer rod: an esoinophilic needle like inclusion in
cytoplasm of blast cells is pathgenomic of AML

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105
Q

What are the poor prognostic features of AML?

A

• > 60 years
• > 20% blasts after first course of chemo
• Cytogenics: deletions of chromosome 5 or 7

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106
Q

How many different classifications exist in AML?

A

7

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107
Q

Which classification of AML is +ve and strongly +ve for NSE

A

+ve: M4 - Granulocytic and monocytic maturation
strongly +ve: M5 - Monocytic

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108
Q

Which classification of AML is PAS stain positive

A

M6 - Erythroleukemia

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109
Q

How does Acute Promyelocytic Leukemia (APL) M3 present?

A

Younger age around 25
Chest infection, ↑WBC and DIC or thrombocytopenia often at presentation

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110
Q

What translocation is assoc with Acute Promyelocytic Leukaemia

A

• Associated with t(15:17)
• Fusion of PML and RAR-α genes

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111
Q

How is acute promyelocytic leukaemia treated?

A

• Treated with the ATRA in addition to induction chemotherapy. Care must be taken to prevent
DIC, complicating the treatment of APL when the promyelocytes release the contents of their
granules into the peripheral circulation. APL

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112
Q

How does ATRA work in acute promyelocytic leukaemia?

A

ATRA (all-trans-retinoic acid):
activates the RAR- α gene thus
helps the WBCs to differentiate
(i.e mature) but it will not
eliminate the leukemia.

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113
Q

What is CLL caused by?

A

is caused by a monoclonal proliferation of
well-differentiated lymphocytes which are almost always B-cells (99%)

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114
Q

What are the features of CLL?

A

• Often none
• Constitutional: anorexia, weight loss
• Bleeding, infections
• Lymphadenopathy more marked than CML

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115
Q

What are the complications of CLL? what is the most common cause of death?

A

• Hypogammaglobulinemia leading to recurrent infections → most common cause of death
• Warm autoimmune hemolytic anemia in 10-15% of patients
• Transformation to high-grade lymphoma (Richter’s transformation)

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116
Q

What is the investigation of choice in CLL?
What is seen on blood film?

A

• Immunophenotyping (flow cytmetry)
Immunophenotyping will demonstrate the cells to be B-cells (CD19 positive). CD5 and CD23 are also characteristically positive in CLL
• Blood film: smear or smudge cells

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117
Q

What are indications for treatment in CLL?

A

• Progressive marrow failure: the development or worsening of anemia and/or thrombocytopenia
• Massive (>10 cm) or progressive lymphadenopathy
• Massive (>6 cm) or progressive splenomegaly
• Progressive lymphocytosis: > 50% ↑ over 2 months or lymphocyte doubling time < 6 months
• Systemic symptoms: weight loss > 10% in previous 6 months, fever >38oc for > 2 weeks,
extreme fatigue, night sweats
• Autoimmune cytopenias e.g. ITP

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118
Q

What is the management of CLL?

A

• None early on (when to start Rx is mentioned above)
• Chlorambucil to ↓ lymphocyte count
• Other options include fludarabine (because fludarabine causes profound lymphopenia, thus
increases the risk of opportunistic infections significantly, prior to commensing fludarabine you
must give co-trimoxazole or to use monthly nebulised pentamidine to prevent Pneumocystis
carinii pneumonia)

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119
Q

What is the median survival in CLL?
What are poor prognostic indicators?

A

3-5 years
• ♂ Sex
• Age > 70 years
• Lymphocyte count > 50
• Prolymphocytes comprising > 10% of blood lymphocytes
• Lymphocyte doubling time < 12 months
• Raised LDH
• CD38 expression positive

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120
Q

What is Veno-occlusive disease? What is the treatment?

A

Veno-Occlusive Disease (VOD) or Hepatic veno-occlusive disease. It is a complication of high-dose
chemotherapy given before a bone marrow transplant (BMT). The name sinusoidal obstruction syndrome is
now preferred if VOD happens as a result of chemotherapy or bone marrow transplantation. Treatment is primarily supportive.

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121
Q

What are the features of veno-occlusive disease?

A

Features:
• Fluid retention (weight gain, generalized edema, pleural effusion)
• Hepatomegaly
• ↑ Bilirubin (Jaundice)
• Usually complicated by multi-organ failure

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122
Q

What is the diagnosis of veno-occlusive disease?

A

Diagnosis:
• U/S abdomen helps in diagnosis
• Liver biopsy shows centrolobar necrosis

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123
Q

What is hairy cell leukaemia?

A

is a rare malignant proliferation disorder of B cells lymphocytes. It is more common in ♂s (4:1) and is usually classified as a sub-type of chronic lymphoid leukemia. Hairy
cells are abnormal WBCs with hair-like projections of cytoplasm.

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124
Q

What are the features of hairy cell leukaemia?

A

• Pancytopenia (Monocytopenia is classical)
• Splenomegaly
• Skin vasculitis in 1/3 patients
• ‘Dry tap’ despite bone marrow hypercellularity (also seen in myelofibrrosis)
• Bone marrow biopsy migh show “fried egg appearance”
• Tartrate resistant acid phosphotase (TRAP) stain positive

Lymphadenopathy is very uncommon in hairy cell leukaemia

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125
Q

What is the management for hairy cell leukaemia?

A

• Chemotherapy is first-line: cladribine, pentostatin
• Immunotherapy is second-line: rituximab, interferon-α
• Splenectomy sometimes required

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126
Q

What is ALL?
What age does it affect people?

A

Acute lymphoblastic leukaemia
Malignant disease of lymphocytes (can also infiltrate lymph nodes)
causes damage and death by crowding out normal
cells in the bone marrow, and by metastasizing. ALL is most common in childhood with a peak
incidence at 2-5 years of age, and another peak in old age.

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127
Q

What is the cure rate of ALL?

A

The overall cure rate in children is ≈80%,
and ≈45%-60% of adults have long-term disease-free survival. Acute → relatively short course of the
disease (being fatal in as little as a few weeks if untreated)

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128
Q

What is the clinical presentation of ALL?

A

• Generalized weakness and fatigue
• Anemia
• Frequent or unexplained fever and infections
• Weight loss and/or loss of appetite
• Excessive and unexplained bruising
• Bone pain, arthralgia.
• Dyspnea due to lung infiltration.
• Lymphandeopathy, hepatosplenomegaly.
• Pitting edema in the lower limbs and/or abdomen
• Petechiae due to thrombocytopenia
The signs and symptoms of ALL are variable but follow from bone marrow infiltration and/or
organ infiltration.

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129
Q

What genetic translocations are assoc. with ALL?

A

t(12:21) is the most common translocation and portends a good prognosis.
Philadelphia chromosome t(9:22) also has a bad prognosis. t(4:11) is the most common in children
under 12 months and portends a poor prognosis.

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130
Q

What investigations are used for ALL?

A

• Leukocytosis.
• Blast cells are seen on blood smear in 90% of cases
• Bone marrow biopsy is conclusive proof of ALL
• LP to detect CNS involvement.
• CXR: to look for mediastinal mass (common in ALL).
• U&E to look for Tumor Lysis Syndrome.
• Immunophenotyping, establish whether the “blast” cells origin is B or T lymphocytes
• DNA testing; different mutations reflect prognosis.

Terminal Deoxynucleotide Transferase (TdT) is present in 95% of ALL

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131
Q

What is the treatment of ALL?

A

Before treating with chemotherapy, if blast cell count is very ↑ (>100 x 109/L), the patient needs Leukapheresis to prevent sludging of capillary beds, this can be life-saving

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132
Q

What are good prognostic factors for ALL?

A

Good prognostic factors
• Common ALL
• Pre-B phenotype
• Low initial WBC
• FAB L1 type

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133
Q

What are poor prognostic factors for ALL?

A

Poor prognostic factors
• FAB L3 type
• T or B cell surface markers
• Philadelphia translocation, t(9;22)
• Age < 2 years or > 10 years
• ♂ Sex.
• CNS involvement
• High initial WBC (e.g. > 100 * 109/l)
• Non-Caucasian

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134
Q

What is leukoerythroblastic anaemia?

A

Any anemic condition resulting from space-occupying lesions in the bone marrow; the circulating blood contains immature cells of the granulocytic series and nucleated red blood cells, frequently in numbers that are disproportionately large in relation to the degree of anemia.

(left-shifted granulocytic series and nucleated red blood cells)
with pancytopaenia. Also defined when there are immature cells (e.g myelocytes, and nucleated red
blood cells) seen on the peripheral blood film.

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135
Q

What are 8 assoc. with a leukoerythroblastic anaemia?

A

• ↑ Bone marrow turnover e.g. in severe hemolytic anemia (in which case the reticulocyte count
would be high).
• Myelofibrosis and Chronic Myeloid Leukaemia (where there would be splenomegaly, and the
white cell and platelet count would usually be raised).
• Bone marrow invasion. Often in bone marrow invasion the invading malignancy will already
have been diagnosed previously.
• Myeloma
• Polycythaemia Rubra Vera
• Osteopetrosis
• Tuberculous infiltration of the bone marrow
• Sarcoidosis

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136
Q

What is hodgkins lymphoma?

A

is a malignant proliferation of lymphocytes characterized by the
presence of the Reed-Sternberg cell.

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137
Q

What age does hodgkins lymphoma affect?

A

It has a bimodal age distributions being most common in the third and seventh decades.

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138
Q

What virus is hodgkins lymphoma assoc. with?

A

Hodgkin’s lymphoma is associated with EBV.

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139
Q

What do 25% of patients with hodgkins lymphoma suffer?

A

25% of patients have a constitutional upset, (night sweats, weight loss, fever, pruritus and lethargy)

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140
Q

Describe the staging of hodgkins lymphoma?

A

Ann-Arbor staging of Hodgkin’s lymphoma
• I: single lymph node
• II: 2 or more lymph nodes/regions on same side of diaphragm
• III: nodes on both sides of diaphragm
• IV: spread beyond lymph nodes

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141
Q

Which is each stage of hodgkins lymphoma further divided into?

A

Each stage may be subdivided into A or B
• A = no systemic symptoms other than pruritus
• B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)

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142
Q

What features are assoc. with poor prognosis in hodgkins lymphoma?

A

• Age = 45 years
• Stage IV disease
• Hemoglobin < 10.5 g/dl
• Lymphocyte count < 600/μl or < 8%
• ♂
• Albumin < 40 g/l
• White blood count = 15,000/μl

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143
Q

How can classical hodgkins lymphoma be supclassified?

A

Classical Hodgkin’s lymphoma (excluding nodular lymphocyte predominant Hodgkin’s lymphoma) can
be subclassified into 4 pathologic subtypes based upon Reed-Sternberg cell morphology and the
composition of the reactive cell infiltrate seen in the lymph node biopsy specimen (the cell composition
around the Reed-Stenberg cell(s)).

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144
Q

What are the 4 pathological subtypes of hodgkins lymphoma?

A

nodular sclerosing
mixed-cellularity subtype
lymphocyte rich
lymphocyte depleted

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145
Q

Describe nodular sclerosing hodgkins lymphoma?

A

Is the most common subtype and is composed of large tumor nodules showing scattered
lacunar classical RS cells set in a background of reactive lymphocytes, eosinophils and
plasma cells with varying degress of collagen fibrosis/sclerosis.

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146
Q

Describe mixed-cellularity subtype hodgkins lymphoma?

A

Is a common subtype and is composed of numerous classic RS cells admixed with
numerous inflammatory cells including lymphocytes, histiocytes, eosinophils, and plasma
cells. Without sclerosis. This type is most often associated with EBV infection and may
be confused with the early, so-called ‘cellular’ phase of nodular sclerosing CHL. Good
Prognosis

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147
Q

describe lymphocyte rich hodgkins lymphoma

A

Is a rare subtype, show many features which may cause diagnostic confusion with
nodular lymphocyte predominant B-cell Non-Hodgkin’s (B-NHL). Best Prognosis

148
Q

Describe lymphocyte depleted hodgkins lymphoma

A

Is a rare, the least subtype, composed of large numbers of often pleomorphic RS cells
with only few reactive lymphocytes which may easily be confused with diffuse large cell
lymphoma. Many cases previously classified within this category would now be
reclassified under anaplastic large cell lymphoma. Worse Prognosis

149
Q

Which hodgkins lymphoma expresses CD20

A

Nodular lymphocyte predominant Hodgkin’s lymphoma expresses CD20, and is not currently considered a form of classical Hodgkin’s → Remember, Rituximab is anti-CD20.

150
Q

What is used for the diagnosis of hodgkins lymphoma?

A

• Hodgkin results in patchy bone marrow infiltration, an isolated bone marrow biopsy may yield
non-specific results.
• Bone marrow biopsy is more useful for staging of advanced disease.
• Lymph node biopsy would be more likely to be positive, Reed-Sternberg cell is evident on
microscopy

151
Q

What is the management of hodgkins lymphoma?

A

• Early stage (IA or IIA) are effectively treated with radiation therapy AND chemotherapy.
The choice of treatment depends on the age, sex, bulk and the histological subtype of the
disease.
• Later disease (III, IVA, or IVB) are treated with combination chemotherapy alone.
• Large mass in the chest (regardless of stage) are usually treated with combined
chemotherapy and radiation therap. Chemo includes: Doxorubicin, Bleomycin, Vincristine,
Cyclophosphamide and other cytotoxic drugs.

152
Q

What are non-hodgkins lymphomas?
-severity
-b or t cell phenotype?

A

are a diverse group of lymphomas that include any kind of lymphoma except Hodgkin’s lymphomas. Types of NHL vary significantly in their severity, from
indolent to very aggressive. Low-grade lymphoma is predominantly a disease of older people. Most
non-Hodgkin’s lymphomas are of B cell phenotype, though T cell tumours are increasingly being
recognized.

153
Q

What is the presentation of non-hodgkins lymphoma?

A

• Most present with advanced disease, bone marrow infiltration being almost invariable.
• Burkitt’s lymphoma is a high-grade lymphoma, which was first described in children in West
Africa who presented with a jaw tumour, extra-nodal abdominal involvement and ovarian
tumours.
• Extra-nodal presentation is more common than Hodgkin’s disease.
• Renal impairment in non-Hodgkin’s lymphomas usually occurs as a consequence of ureteric
obstruction secondary to intra-abdominal or pelvic lymph node enlargement.
• Anaemia, an elevated white cell count and/or thrombocytopaenia are suggestive of bone
marrow infiltration.

154
Q

What is the diagnosis of non-hodgkins lymphoma?

A

• Lymph node biopsy is sufficient for a definitive diagnosis.
• It is essential for modern classification to submit the lymphoid tissue for immuno-phenotyping
and cytogenetic/molecular analysis.

155
Q

What is the management of non-hodgkins lymphoma?

A

• High-grade lymphomas are responsive to chemotherapy and potentially curable,
• Low-grade lymphomas are incurable with conventional therapy.
• Chemotherapy is the mainstay of treatment in most cases.

156
Q

When does tumour lysis syndrome develop?

A

This occurs after the initiation of a
chemotherapeutic. TLS tends to occur in patients with bulky, rapidly proliferating,
treatment-responsive tumors

157
Q

What is tumour lysis syndrome assoc. with?

A

• Acute leukemia
• High-grade non-Hodgkin’s lymphomas.
• Pre-treatment ↑ LDH (levels of LDH correspond with tumor bulk)

158
Q

What is the management of tumour lysis syndrome?

A

• Prevention is with good hydration before starting chemotherapy.
• ↑ uricemia → urine alkalinisation and allopurinol
• Osmotic diuretics are NOT first line therapy and may contribute to the precipitation
of uric acid in the renal tubules.
• Dietary modifications include restricting dietary potassium.
• Further chemotherapy should be withheld until the patient has fully recovered

159
Q

Common Chromosomal translocations:
What is t(9;22) Philadelphia chromosome assoc with?

A

• Present in > 95% of patients with CML
• This results in part of the Abelson (ABL) proto-oncogene being moved to the BCR
gene on chromosome 22
• The resulting BCR-ABL gene codes for a fusion protein which has tyrosine kinase
activity in excess of normal
• Poor prognostic indicator in ALL and AML

160
Q

Common Chromosomal translocations:
What is t(15;17) assoc with?

A

• Seen in acute promyelocytic leukemia (M3)
• Fusion of PML and RAR-α genes

161
Q

Common Chromosomal translocations:
What is t(8;14) assoc with?

A

• Seen in Burkitt’s lymphoma

• MYC oncogene is translocated to an immunoglobulin gene

162
Q

Common Chromosomal translocations:
What is t(11;14) assoc with?

A

• Mantle cell lymphoma

• Deregulation of the cyclin D1 (BCL-1) gene

163
Q

What haematological malignancy is assoc with EBV?

A

Hodgkin’s and Burkitt’s lymphoma, nasopharyngeal carcinoma

164
Q

What haematological malignancy is assoc with HIV-1 ?

A

High-grade B-cell lymphoma

165
Q

What haematological malignancy is assoc with HTLV-1 (Human T-lymphotropic virus Type I)?

A

Adult T-cell leukemia/lymphoma

166
Q

What haematological malignancy is assoc with Helicobacter pylori

A

gastric lymphoma (MALT)

167
Q

what haematological malignancy is assoc with Malaria (protozoal infection)

A

Burkitt’s lymphoma

168
Q

In haematological malignancies - when are Stem cell transplants from unrelated or haploidentical donors used?

A

Stem cell transplants from unrelated or haploidentical donors are not used in first complete
remission in most adult hematological malignancies due to the high treatment related
mortality/morbidity: they are reserved for first relapse/second complete remission.

169
Q

In haematological malignancies when would stem cell transplants be used as first line therapy?

A

Stem cell transplants from matched sibling donors are used as first line therapy in certain
circumstances, including chronic myeloid leukaemia.

170
Q

When is irridiated blood used in haematological malignancy

A

Irradiated blood is required in patients receiving a bone marrow transplant, patients with
previous purine analogue exposure and a diagnosis of Hodgkin’s disease.

171
Q

When should CMV negative blood be used in haematological malignancies?

A

Cytomegalovirus (CMV)-negative blood should be used in patients who may need a bone
marrow transplant in the future (since carriage of CMV increases transplant mortality).

172
Q

In CML when might imatinib not be used as first line therapy?

A

If patient had siblings then related stem cell transplant may be considered. in the absence of siblings, imatinib to induce remission is the initial therapy of choice in
patient with no siblings.

Imatinib mesylate used as first line therapy brings about complete cytogenetic
remissions in 76% of patients, with some patients becoming negative by polymerase chain
reaction for the 9:22 translocation. It is not however thought to be curative, and young patients
with a sibling donor are still referred for transplantation.

173
Q

Name some pulmonary causes of eosinophilia?

A

• Asthma
• Allergic bronchopulmonary
aspergillosis
• Churg-strauss syndrome
• Loffler’s syndrome
• Tropical pulmonary eosinophilia
• Eosinophilic pneumonia
• Hypereosinophilic syndrome

174
Q

Name some infective causes of eosinophilia?

A

• Schistosomiasis
• Nematodes: Toxocara,
Ascaris, Strongyloides
• Cestodes: Echinococcus

175
Q

Name some drug causes of eosinophilia?

A

sulfasalazine,
nitrofurantoin

176
Q

What does NAACCP stand for relating to eosinophilia causes?

A

Neoplasia, Addison Disease,
Allergy/Asthma, Collagen Vascular diseases, Cholesterol emboli, and parasites.

177
Q

What is Hyper Eesinophilic syndrome?

A

rare unknown cause disease, occurring most commonly in
♂ in the 30-40-year-age group with persistent and markedly raised peripheral blood eosinophil count.

178
Q

What is hyper eosinophilic syndrome assoc with?

A

• Lung involvement may occur
• Cardiovascular involvement with fibrosis and restrictive cardiomyopathy, which may lead to
mural thrombus formation and considerable morbidity and mortality.
• Angioedema or urticaria.

179
Q

What is the treatment of hyper eosinophilic syndrome?

A

is with high dose corticosteroids (e.g. prednisolone 50mg which leads to a response in
around 50% of cases). Steroid sparing agents such as cyclophosphamide or azathioprine may also be of
some value.

180
Q

In vitamin K deficiency what happens to:
Prothrombin time
Partial thromboplastin time
Bleeding time

A

Prothrombin time - prolonged
Activated Partial thromboplastin time - prolonged
Bleeding time- normal

181
Q

What are the vit K dependant clotting factors?

A

2 7 9 and 10, and protein C and protein S are all vit K dependant to be activated

182
Q

What are the causes of vit K deficiency?

A

λ Poor dietary intake
λ Malabsorption
λ Obstructive jaundice – bile salts can’t get into the gut
λ Vitamin K antagonists (warfarin)
λ Haemorrhagic disease of the newborn

183
Q

In DIC what happens to:
Prothrombin time
Activated Partial thromboplastin time
Bleeding time

A

all prolonged

184
Q

In haemophilia what happens to:
Prothrombin time
Activated Partial thromboplastin time
Bleeding time

A

Prothrombin time - normal
Activated Partial thromboplastin time -prolonged
Bleeding time - normal

185
Q

What happens to PT and APTT in Factor 7 deficiency

A

PT prolonged
APTT normal

186
Q

What happens to PT and APTT in factor 2,5,10 deficiency

A

both prolonged

187
Q

What happens to PT and APTT in factors VIII – IX – XI – XII deficiencyI

A

PT normal
APTT prolonged

188
Q

IS factor 7 deficiency common? how is it inherited? what does it cause?

A

Factor VII deficiency is very rare, is inherited in an autosomal recessive fashion, and tends to
cause a mild/moderate bleeding disorder, although the phenotype does vary.

189
Q

What is the treatment for factor 7 deficiency?

A

Treatment is by factor replacement with plasma-derived products or using recombinant activated factor VII.

190
Q

When an abnormality is detected in the PT/APTT studies what happens? what does this allow us to identify?

A

When an abnormality is detected in the PT/APTT the studies are repeated with a 50:50 mix of
test and normal plasma: straightforward factor deficiencies will correct with mixing, but
inhibitors (most commonly lupus anti-coagulant) do not correct. It should be noted however
that the results of PT mixing studies in patients on warfarin are consistent with factor
deficiencies, because warfarin acts as an anti-coagulant by decreasing the activity of factors II,
VII, IX, and X.

191
Q

What causes acquired factor VIII deficiency?

A

results from the development of inhibitors against factor VIII coagulation factor. It occurs mainly in elderly.

192
Q

How is acquire factor VIII deficiency diagnosed?

A

• Bleeding tendencies
• APTT: is prolonged (intrinsic pathway).
• APTT doesn’t correct/will only correct slightly with the adding of normal plasma.
• Bethesda titre can quantify the inhibitor. There is a 20% mortality rate from acquired factor VIII
deficiency.

193
Q

What is the treatment for acquired factor VIII deficiency?

A

• Replacement of factor VIII is usually ineffective as the inhibitor has rapid activity.
• Bleeding can be treated with recombinant activated factor VII or Factor Eight Bypassing Agent
(FEIBA), but the latter is a pooled donor product and is pro-thrombotic, causing myocardial
infarctions and DIC in a subset of patients.
• rFVIIa has been successfully used in patients with acquired hemophilia. It binds to the surface
of activated platelets, where it supports thrombin generation and bypasses the need for FVIII.
• Definitive removal of the auto-antibody: immunosuppression is successful in at least half of
patients, but carries significant morbidity and mortality in the elderly

194
Q

What is the most common thrombophilia?

A

Activated protein C resistance (Factor V Leiden) is the most common inherited thrombophilia

195
Q

What is factor V leiden caused by?

A

It is due to a mutation in the Factor V Leiden gene. Heterozygotes have a 5-fold risk of venous
thrombosis whilst homozygotes have a 50-fold ↑ risk. Any white pt aged <45 with thrombotic event
should make you think of factor V Leiden mutation.

196
Q

What is the most common inherited bleeding disorder?

A

Von Willebrand’s disease is the most common inherited bleeding disorder

197
Q

How is von willebrands disease inherited and how does it usually present?

A

The majority of cases are inherited in an autosomal dominant fashion* and characteristically behaves like a platelet
disorder i.e. epistaxis and menorrhagia are common whilst hemoarthroses and muscle hematomas are rare.

198
Q

What does von willebrand factor do?

A

• Large glycoprotein which forms massive
multimers up to 1,000,000 Da in size
• Promotes platelet adhesion to damaged
endothelium
• Carrier molecule for factor VIII

199
Q

What are the different types of von willebrands disease?

A

type 1: partial reduction in vWF (80% of patients)
type 2: abnormal form of vWF
type 3: total lack of vWF (autosomal recessive)

200
Q

How does von willebrand disease present?

A

• Petechial skin
• Slightly elevated APTT
• ↓ factor VIII activity

201
Q

What investigations are used in von willebrand disease?

A

• Prolonged bleeding time
• APTT may be prolonged
• Factor VIII levels may be moderately ↓
• Defective platelet aggregation with ristocetin

202
Q

What is the management of von willebrand disease?

A

• Tranexamic acid for mild bleeding
• Desmopressin (DDAVP): raises levels of vWF by inducing release of vWF from Weibel-Palade
bodies in endothelial cells. Used as prohyplaxis prior to procedures.
• Factor VIII concentrate

203
Q

What are the 4 causes of severe thrombocytopenia?

A

• ITP
• TTP
• DIC
• Hematological malignancy

204
Q

Name some causes of moderate thrombocytopenia?

A

Causes of moderate thrombocytopenia
• Heparin induced thrombocytopenia (HIT)
• Drug-induced (e.g. quinine, diuretics, sulphonamides, aspirin, thiazides)
• Alcohol and Vitamin B12 deficiency
• Liver disease
• Hypersplenism
• Viral infection (EBV, HIV, hepatitis)
• Pregnancy
• SLE/antiphospholipid syndrome

205
Q

What is ITP?

A

is an immune mediated reduction in the
platelet count. Antibodies are directed against the glycoprotein IIb-IIIa or Ib complex.

206
Q

Is ITP more common in men or women?

A

♀:♂=2.6:1.

207
Q

What is the cause of death in ITP?

A

Common cause of death is bleeding (mainly intracranial).

208
Q

What are the investigations used in ITP?

A

• Antiplatelet autoantibodies (usually IgG)
• Bone marrow aspiration shows megakaryocytes in the marrow. This should be carried out prior
to the commencement of steroids in order to rule out leukemia

209
Q

What are the different forms of ITP?

A

Acute and chronic

210
Q

Describe acute ITP
-what age is it commonly seen in?
-what can it follow?
-how long does it last?

A

Acute ITP

o More commonly seen in children
o Equal sex incidence
o May follow an infection or vaccination
o Usually runs a self-limiting course over 1-2 weeks

211
Q

Describe chronic ITP?
-who is this found in?
-what is the pattern of disease?

A

o More common in young/middle-aged women
o Tends to run a relapsing-remitting course

212
Q

What is evans syndrome?

A

• ITP in association with autoimmune hemolytic anemia (AIHA)

213
Q

What is the pathophysiology of TTP?

A

• Abnormally large and sticky multimers of vWF cause platelets to clump within vessels
• In TTP there is a deficiency of caspase which breakdowns large multimers of vWF.
• Overlaps with hemolytic uraemic syndrome (HUS)

214
Q

What are the features of TTP?

A

• Rare, typically adult ♀
• Fever
• Fluctuating neuro signs (microemboli)
• Microangiopathic hemolytic anemia
• Thrombocytopenia
• Renal failure

215
Q

How do you differentiate between HUS and TTP?

A

Neuro signs and purpura point towards TTP

216
Q

What are the different causes of TTP?

A

• Post-infection e.g. Urinary, gastrointestinal
• Pregnancy
• Drugs: cyclosporin, oral contraceptive pill, penicillin, clopidogrel, aciclovir
• Tumors
• SLE
• HIV

217
Q

What is the management of TTP?

A

• No antibiotics - may worsen outcome
• Plasma exchange is the treatment of choice
• Steroids, immunosuppressants
• Vincristine

The management of thrombotic thrombocytopenic purpura involves steroids and
immunosuppressants. Plasma exchange is the treatment of choice

218
Q

What is heparin induced thrombocytopenia?

A

is a severe immune-mediated drug
reaction that can occur in patients receiving unfractionated heparin (at full therapeutic doses and low prophylactic doses, including the minute amounts in heparin flushes and on heparin-coated catheters)
and those receiving low-molecular weight heparin (LMWH). Antibodies usually develop after a patient
has been on heparin for five or more days, but may develop sooner if there has been previous heparin
exposure.

219
Q

What is the presentation of HIT?

A

Despite thrombocytopenia, bleeding is rare. HIT is strongly associated with thrombosis.
Thromboembolic complications can be venous, arterial, or both, and include:
• DVT
• Pulmonary embolism
• Myocardial infarction
• Thrombotic stroke
• Occlusion of limb arteries.

(HIT predisposes to thrombosis (the abnormal formation of blood clots inside a blood vessel) because platelets release microparticles that activate thrombin, thereby leading to thrombosis. When thrombosis is identified the condition is called heparin-induced thrombocytopenia and thrombosis (HITT).)

220
Q

What are the two different types of HIT?

A

• Type I: usually occurs 48 to 72 hours post commensing heparing and PLT rarely < 100. PLT
returns to normal over 4 days and there is no ↑ risk of thromboembolism
• Type II: much rarer and usually occurs 5 to 10 days after starting heparin, PLT usually <100,
patients are at ↑ risk of thromboembolic events. Heparin products should be stopped and the
patient commenced on alternative medication

221
Q

What is the treatment for HIT?
when should this be initiated?

A

• Stop all forms of Heparin
• Start alternative anticoagulant which do not cross-react with HIT antibodies, such as:
o Danaparoid
o Lepirudin
o Argatroban.
• Oral anticoagulation with warfarin should NOT be initiated for longer-term protection from
further events until substantial platelet count recovery has occurred. HIT patients who are
switched to warfarin alone after the discontinuation of heparin may paradoxically have
worsening thrombosis and develop venous limb gangrene and skin necrosis.

-initiate on suspicion before confirming diagnosis

222
Q

What is the diagnosis of HIT?
-what lab tests can support diagnosis?

A

clinical diagnosis
• Thrombocytopenia: PLT < 100 or <50% from the patient’s baseline
• The exclusion of other causes of thrombocytopenia
• The resolution of thrombocytopenia after cessation of heparin.

• Supportive lab tests: HIT antibodies can be demonstrated in vitro by functional tests (are more
specific) and immunoassays. Functional tests; measure platelet activity in the presence of the
patient’s serum and heparin include:
o Heparin Induced Platelet Aggregation (HIPA)
o Serotonin Release Assay (SRA)

223
Q

What is seen on blood films in hyposplenism?

A

• Target cells
• Howell-Jolly bodies
• Cabot’s rings
• Siderotic granules
• Acanthocytes
• Schizocytes

224
Q

What is seen on blood films in iron deficiency anaemia?

A

• Target cells
• ‘Pencil’ poikilocytes
• If combined with B12/folate deficiency a ‘dimorphic’ film
occurs with mixed microcytic and macrocytic cells

225
Q

What are the clinical features of iron deficiency anaemia?

A

• koilonychia
• atrophic glossitis
• post-cricoid webs
• angular stomatitis

226
Q

What is seen on the blood film of G6PD deficiency?

A

Heinz bodies
Bite and blister cells may also be seen

227
Q

Which condition is ‘Tear-drop’ poikilocytes seen in?

A

myelofibrosis

228
Q

What condition is Schistocytes seen in?

A

intravascular haemolysis

229
Q

When would you see Hypersegmented neutrophils on blood film?

A

megaloblastic anaemia

230
Q

When would you see smudge or smear cells on blood film?

A

CLL

231
Q

When do you see Lymphocytes with polar villi on blood film?

A

Splenic lymphoma with villous lymphocytes

232
Q

When do you see Lymphocytes (mature) with cleaved nuclei on blood film?

A

Follicular lymphoma

233
Q

When do you see Lymphocytes (immature) with prominent nuclei on blood film?

A

ALL

234
Q

when is Tartrate-Resistant Acid Phosphatase TRAP always positive?

A

Always +ve in hairy cell leukaemia

235
Q

When is Sudan black B stain and myeloperoxidase used?

A

acute myeloblastic leukaemia

236
Q

When is Terminal Deoxynucleotidyl Transferase Stain (TDT) used?

A

acute lymphoblastic leukaemia

237
Q

When is Leukocyte Alkaline Phosphatase (LAP) increased/decreased?

A

↑ in polycythemia RV and myelofibrosis
↓ in chronic myeloid leukaemia

238
Q

What is hereditary hemorrhagic telangiectasia
-what is it AKA
-how is it inherited
-what is it characterised by?
-will it ever occur spontaneously?

A

Also known as Osler-Weber-Rendu
syndrome, hereditary hemorrhagic telangiectasia is an autosomal dominant condition characterized by
(as the name suggests) multiple telangiectasia over the skin and mucous membranes. 20 % of cases
occur spontaneously without prior family history.

239
Q

how many types of hereditary haemorrhagic telangiectasia exist?

A

5 are identified HHT1 to HHT4 and JPHT (HHT and juvenile polyposis)

240
Q

Which type of hereditary haemorrhagic telangiectasia is assoc with chromosome 9? which is assoc with chromosome 12?

A

• HHT1: chromosome 9, associated with ↑ AVM (cerebral and pulmonary)
• HHT2: chromosome 12.

241
Q

What are the features of HHT?

A

• Epistaxis
• Telangiectasia develop ob skin, mucous membranes and internal organs
• Associated with pulmonary and other AV malformations in 10%
• May present as iron-deficiency anemia secondary to bleeding in the GI tract or nasal mucosa

242
Q

What is Waldenstrom’s macroglobulinaemia?
-what is it?
-who is it seen in?
-features?

A

It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein
older men

systemic upset: weight loss, lethargy
hyperviscosity syndrome e.g. visual disturbance

the pentameric configuration of IgM increases serum viscosity

hepatosplenomegaly
lymphadenopathy
cryoglobulinaemia e.g. Raynaud’s
high ESR

243
Q

What is the management of walenstroms macroglobulinaemia?

A

• Alkylating agents
• Young patient may benefit from doxorubicin.
• Treatment includes the monoclonal antibody rituximab, sometimes in combination with
chemotherapeutic drugs such as chlorambucil, cyclophosphamide, or Vincristine or with
thalidomide.
• Corticosteroids, such as Prednisone, may also be used in combination.
• Plasmapheresis can be used to treat the hyperviscosity (it does not address the underlying disease)

244
Q

What are the features of MGUS?

A

• Usually asymptomatic
• No bone pain or ↑ risk of infections
• Around 10-30% of patients have a demyelinating neuropathy
• M protein level < 30gm/l
• No end-organ damage.

245
Q

What are the differentiating features of MGUS from myeloma?

A

• Normal immune function
• Normal β-2 microglobulin levels
• Lower level of paraproteinemia than myeloma (e.g. < 30g/l IgG, or < 20g/l IgA)
• Stable level of paraproteinemia
• No clinical features of myeloma (e.g. Lytic lesions on x-rays or renal disease)

One of the key differentiating features between (MGUS) and myeloma is the absence of
complications such as immune paresis, hypercalcemia and bone pain

246
Q

What is the diagnostic criteria of MGUS?

A

• Serum paraprotein <30 g/L AND
• Clonal plasma cells <10% on bone marrow biopsy AND
• NO myeloma-related organ or tissue impairment

247
Q

What is methemoglobinaemia?

A

Methemoglobinemia = oxidation of Fe2+ in hemoglobin to Fe3+

describes hemoglobin which has been oxidised from Fe++ (Ferrous) to
Fe+++. This is normally regulated by NADH methemoglobin reductase, which transfers electrons from
NADH to methemoglobin resulting in the reduction of methemoglobin to hemoglobin. There is tissue
hypoxia as Fe3+ cannot bind oxygen, and hence the oxidation dissociation curve is moved to the left

248
Q

What are the congenital causes of methemoglobinaemia?

A

• Hemoglobin chain variants: HbM, HbH
• NADH methemoglobin reductase deficiency

249
Q

What are the acquired causes of methemoglobinaemia?

A

• Drugs: sulphonamides, nitrates, dapsone, sodium nitroprusside, primaquine
• Chemicals: aniline dyes

250
Q

What are th features of methemoglobinaemia?

A

• ‘Chocolate’ cyanosis
• Dyspnea, anxiety, headache
• Severe: acidosis, arrhythmias, seizures, coma
• Normal PO2 but ↓ oxygen saturation

251
Q

What is the treatment for methemoglobinaemia?

A

• NADH - methemoglobinemia reductase deficiency: ascorbic acid
• IV methylene blue if acquired

252
Q

Fanconi’s anaemia;
-how is it inherited?
-what does it increase the risk of?
-how does it present?

A

• Autosomal recessive
• Aplastic anemia
• ↑ risk of AML
• Neurological manifestation
• Skeletal abnormalities
• Skin pigmentation (café-au-lait spots)

253
Q

What is haemochromatosis?

A

is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*.

*there are rare cases of families with classic features of genetic hemochromatosis but no mutation in
the HFE gene

254
Q

Is haemochromatosis prevalent?

A

Hemochromatosis is the most prevalent genetic condition in Caucasian population with a carrier rate of 1 in 10 and is present in about 1 in 200-400 people.

Cystic fibrosis (CF) has a carrier rate of 1 in 25 and is present in about 1 in 2,500 births. CF is often quoted as being the most common lethal inherited condition in Caucasians

255
Q

How do you screen for haemochromatosis?

A

• General population: transferrin saturation is considered the most useful marker. Ferritin should
also be measured but is not usually abnormal in the early stages of iron accumulation
• Testing family members: genetic testing for HFE mutation
• These guidelines may change as HFE gene analysis become less expensive

256
Q

What are the diagnostic tests for haemochromatosis?

A

• Molecular genetic testing for the C282Y and H63D mutations
• Liver biopsy: Perl’s stain

257
Q

What is the typical iron studies for a patient with haemochromatosis?

A

Typical iron study profile in patient with hemochromatosis
• Transferrin saturation > 55% in men or > 50% in women
• Raised ferritin (e.g. > 500 ug/l) and iron
• Low TIBC

258
Q

How do you monitor the adequacy of venesection in haemochromatosis?

A

• BSCH recommend ‘transferrin saturation should be kept below 50% and the serum ferritin
concentration below 50 ug/l’

259
Q

What are the presenting features of haemochromatosis?

A

Presenting features
• Early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
• ‘Bronze’ skin pigmentation
• Diabetes Mellitus
• Liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition.
• Cardiac failure (2nd to dilated cardiomyopathy)
• Hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
• Arthritis (especially of the hands)

Joint x-rays characteristically show chondrocalcinosis

260
Q

What are the reversable complications of haemochromatosis?

A

• Cardiomyopathy
• Skin pigmentation

261
Q

What are the irreversable complications of haemochromatosis?

A

• Liver cirrhosis**
• Diabetes mellitus
• Hypogonadotrophic hypogonadism
• Arthropathy

**whilst elevated liver function tests and hepatomegaly may be reversible, cirrhosis is not

262
Q

Following a splenectomy what are patients at risk of?

A

Following a splenectomy patients are particularly at risk from pneumococcus,
Hemophilus, meningococcus and Capnocytophaga canimorsus (usually from dog bite) infections

263
Q

When should vaccination be given in splenectomy patients?

A

• If elective, should be done 2 weeks prior to operation
• Pneumococcal, HIB, meningitis A & C and annual influenza vaccination

264
Q

What antibiotic prophylaxis should splenectomy patients recieve? and how long for?

A

• Penicillin V: unfortunately clear guidelines do not exist of how long antibiotic prophylaxis
should be continued. It is generally accepted though that penicillin should be continued for at
least 2 years and at least until the patient is 16 years of age, although the majority of patients are
usually put on antibiotic prophylaxis for life

265
Q

What are 6 causes of hyposplenism?

A

• Splenectomy
• Sickle-cell
• Coeliac disease, dermatitis herpetiformis (HLA DR3)
• Graves’ disease
• SLE
• Amyloid

266
Q

What is aplastic anaemia?

A

o Autoimmune attack against haemopoietic stem cell (therefore no haemopoiesis)

267
Q

What is seen on blood film in aplastic anaemia?

A

This shows an aplastic anaemia pt’s bone marrow where cells or clusters of cells can’t be seen because they’ve been replaced by fat.

268
Q

what is the management of aplastic anaemia?

A

Supportive
• Blood products
• Prevention and treatment of infection

Anti-thymocyte globulin (ATG) and anti-lymphocyte globulin (ALG)
• Prepared in animals (e.g. Rabbits or horses) by injecting human lymphocytes
• Is highly allergenic and may cause serum sickness (fever, rash, arthralgia), therefore steroid
cover usually given
• Immunosuppression using agents such as Cyclosporin may also be given

Stem cell transplantation
• Allogeneic transplants have a success rate of up to 80%

269
Q

What are the megaloblastic causes of macrocytic anaemia?
(megaloblastic bone marrow)

A

• Vitamin B12 deficiency
• Folate deficiency
• Cytotoxics e.g. Hydroxyurea

270
Q

What should be replaced first - B12 or folate?

A

It is important in a patient who is also deficient in both vitamin B12 and folic acid to treat the
B12 deficiency first to avoid precipitating subacute combined degeneration of the cord

271
Q

What are the normoblastic causes of macrocytic anaemia?
(normoblastic bone marrow)

A

• Alcohol
• Liver disease
• Hypothyroidism
• Pregnancy
• Reticulocytosis e.g. Hemolysis
• Aplastic anemia
• Myelodysplasia
• Drugs: cytotoxics

272
Q

What is the structure of haemoglobin?

A

ν Tetramer made up of 2 alpha globin like chains and 2 beta globin like chains
ν One haem group attached to each globin chain

Each copy of chromosome 16 has two genes for the alpha globin subunit (four in total), and each copy of chromosome 11 has one gene for the beta subunit (two in total).

273
Q

What are thalassaemias?

A

ν Hereditary disorders of globin chain synthesis resulting in impaired haemoglobin production
Ð Alpha thalassaemia; α chains affected
Ð Beta thalassaemia; β chains affected
ν Inadequate Hb production → microcytic hypochromic anaemia
ν Unbalanced accumulation of globin chains → ineffective erythropoiesis and haemolysis

274
Q

Alpha thalassaemia:
How many alpha globulin genes are present on which chromosome?

A

2 separate α-globulin genes are located on each chromosome 16

275
Q

What is it called when only 1 alpha gene is defective on chromosome 16?

A

silent alpha thalassaemia trait
-no symptoms

276
Q

What is it called when 2 alpha genes are defective on chromosome 16?
-what is seen on blood film

A

α thal trait; two affected genes (–/αα or -α/-α)
ν Microcytic, hypochromic red cells with mild anaemia
ν Important as can be mistaken for iron deficiency ( but normal ferritin, raised red cell count)
ν Red cell inclusions (HbH bodies) can sometimes be seen with special stains
(golf ball cells)

277
Q

What is it called when 3 alpha genes are defective on chromosome 16?

A

HbH disease
ν Severe form of α thalassaemia
ν Only 1 working α gene per cell (–/-α )
ν α chain production < 30% of normal
ν Anaemia (Hb 30-130g/l) with very low MCV and MCH
ν Due to globin chain imbalance, excess β chains form tetramers (β4), called HbH, which cannot carry oxygen
ν HbH present in variable amounts (1-40%)

Extramedullary haematopoeisis: hepatosplenomegaly, englarged bone marrow,

278
Q

What is the management of HbH disease?

A

ν Mild: transfusion only needed at times of intercurrent illness
ν Severe cases transfusion dependent
ν Splenectomy may reduce transfusion need in severe cases (NB vaccinations)
ν Folic acid supplementation (↑ RBC turnover so ↑demand)

279
Q

What is it called when all 4 alpha genes are deleted on chromosome 16?

A

If all 4 α chains absent (i.e. homozygote) then death in utero (hydrops fetalis, Bart’s hydrops)

280
Q

How can Hydrops fetalis be treated?

A

intrauterine blood transfusion followed by bone marrow transplant

281
Q

What is beta thalassaemia?

A

ν Disorder of beta chain synthesis
ν Reduced ( β+), or absent ( β0 ) beta chain production
ν Only β chains and hence only HbA (α2β2) affected
ν Usually caused by point mutations (opposite of alpha thal)
ν Over 200 mutations identifed so far
ν Autosomal recessive inheritance

282
Q

What is beta thalassaemia trait?

A

β thalassaemia trait (usually β+ /β or β0/ β);
ν Asymptomatic
ν Low MCV/MCH
ν Raised HbA2 is diagnostic

283
Q

What is beta thalassaemia intermedia?

A

ν β thalassaemia intermedia (usually β+ /β+ or β0 /β+);
ν Moderate severity requiring occasional transfusion

284
Q

What is beta thalassaemia major?

A

ν β thalassaemia major;
ν Severe, lifelong transfusion dependency

285
Q

What are the lab features of beta thalassaemia major?

A

ν Moderate to severe anaemia (Hb 30-90g/l)
ν Very low MCV/MCH
ν Reticulocytosis
ν Film; anisopoikilocytosis and target cells (lack of central pallor)
ν HPLC:
Ð mainly HbF present
Ð small amounts of HbA
Ð HbA2 often elevated

286
Q

What are the clinical features of beta thalassaemia major?

A

ν Presents aged 6-24 months (adult Hb affected)
ν Failure to thrive
ν Pallor

Extramedullary haematopoiesis causing;
ν Hepatosplenomegaly
ν Skeletal changes – more haematopoiesis in bone medulla causes it to increase in size
ν Organ damage

‘hair on end’ appearance of bone

287
Q

What is haemoglobin E/thalassaemia?

A

Hemoglobin E/thalassemia: common in Cambodia, Thailand, and parts of India; clinically
similar to β thalassemia major or thalassemia intermedia.

288
Q

What is Hemoglobin S/thalassemia?

A

Hemoglobin S/thalassemia, common in African and Mediterranean populations; clinically
similar to sickle cell anemia, with the additional feature of splenomegaly

289
Q

what is Hemoglobin C/thalassemia?

A

Hemoglobin C/thalassemia: common in Mediterranean and African populations,

hemoglobin C/βo thalassemia causes a moderately severe hemolytic anemia with splenomegaly;

hemoglobin C/β+ thalassemia produce a milder disease.

290
Q

What are the mechanism of action and adverse effects of vincristine

A

Inhibits formation of microtubules,
mitotsis inhibitor (M stage of cell cycle)

Peripheral neuropathy (reversible)

291
Q

What are the mechanism of action and adverse effects of cisplatin

A

Causes Cross-linking in DNA

Ototoxicity, peripheral neuropathy, hypomagnesaemia

292
Q

What are the mechanism of action and adverse effects of bleomycin

A

Degrades preformed DNA

Lung fibrosis

293
Q

What are the mechanism of action and adverse effects of Doxorubicin

A

Stabilizes DNA-topoisomerase II
complex. Inhibits DNA & RNA synthesis

Cardiomyopathy

294
Q

What are the mechanism of action and adverse effects of methotrexate

A

Inhibits dihydrofolate reductase and thymidylate synthesis

Myelosuppression, mucositis

295
Q

What are the mechanism of action and adverse effects of Cyclophosphamide

A

Alkylating agent - causes Cross-linking in
DNA

Hemorrhagic cystitis (incidence ↓by the use of hydration and mesna), myelosuppression,
transitional cell carcinoma

296
Q

What are the mechanism of action and adverse effects of Docetaxel

A

Prevents microtubule depolymerisation &
disassembly, decreasing free tubulin

Neutropaenia + peripheral
neuropathy

297
Q

What are the mechanism of action and adverse effects of Imatinib*

A

Inhibitor of the tyrosine kinase associated
with the BCR-ABL defect →CML

Edema, nausea, rash and musculoskeletal pain are common but mild. Severe congestive cardiac failure is an uncommon but recognized side effect

298
Q

What are the mechanism of action and adverse effects of interferon-α*

A

Cytokines released by the body in response to viral infections and neoplasia. They are classified according to cellular origin and the type of receptor they bind
to. IFN-α and IFN-β bind to type 1 receptors whilst IFN-gamma binds only to type 2 receptors. IFN-α is produced by leucocytes and has an antiviral action

USES: CML, Hairy cell Leukemia, hepatitis B & C, Kaposi’s sarcoma, metastatic renal cell cancer.

The most frequent adverse effects are flu-like symptoms and depression. Erythema, pain and hardness on the spot of injection are also frequently observed. Interferon therapy causes immunosuppression, in particular through neutropenia and can result in some infections
manifesting in unusual ways

299
Q

When should you suspect extravasation of chemo? what is the management?

A

extravasation should be suspected if a patient complains of pain, burning, swelling or redness at the site of the infusion cannula.

• Immediate management would consist of stopping the infusion, immobilizing the arm and attempting to aspirate any accessible drug from the cannula and extravasation site before removal of the cannula.
• Agent specific antidotes can be given after receiving specialist advice. Cold compresses are generally applied except in the case of vinca alkaloids in which case a heat compress should be applied.
• Doxorubicin or daunorubicin extravasation injuries are particularly prone to causing ulceration, particularly on the back of the hand and hence a plastic surgery consultation is likely to be needed, Use topical corticosteroids to treat the site of inflammation.Consider reporting to the National Extravasation Information Service.

300
Q

What is CA 125 the tumour marker for?

A

Ovarian cancer

301
Q

What is CA 19-9 the tumour marker for?

A

Pancreatic cancer

302
Q

What is CA 15-3 the tumour marker for?

A

Breast cancer

303
Q

What is Prostate specific antigen (PSA) the tumour marker for?

A

Prostatic carcinoma

304
Q

What is α -feto protein (AFP) the tumour marker for?

A

Hepatocellular carcinoma, teratoma

305
Q

What is Carcinoembryonic antigen (CEA) the tumour marker for?

A

Colorectal cancer

306
Q

What is the carcinogen Aflatoxin (produced by Aspergillus) assoc with?

A

Liver - (hepatocellular carcinoma)

307
Q

what is the carcinogen Aniline dyes assoc with?

A

Bladder (transitional cell carcinoma)

308
Q

What is asbestos assoc with/

A

Mesothelioma and bronchial carcinoma

309
Q

What are Nitrosamines assoc with?

A

Oesophageal and gastric cancer

310
Q

What is Vinyl chloride assoc with?

A

Hepatic angiosarcoma

311
Q

What are the risk factors for nausea and vomiting in chemo?

A

Nausea and vomiting are common side-effects of chemotherapy. Risk factors for the development of symptoms include:

anxiety
age less than 50 years old
concurrent use of opioids
the type of chemotherapy used
312
Q

What antiemetics are used in patients at high risk of symptoms with chemo? what antimetics are used in patients with low risk of symptoms?

A

For patients at low-risk of symptoms then drugs such as metoclopramide may be used first-line. For high-risk patients then 5HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone

313
Q

What is the most important risk factor for cervical cancer?

A

Human papilloma virus (HPV) infection is the most important risk factor for developing cervical cancer. Subtypes 16,18 & 33 are particularly carcinogenic. The other most common subtypes (6 & 11) are non-carcinogenic and associated with genital warts.

314
Q

What characteristics do infected endocervical cells have when infected with HPV?

A

Infected endocervical cells may undergo changes resulting in the development of koilocytes. These have the following characteristics:

enlarged nucleus
irregular nuclear membrane contour
the nucleus stains darker than normal (hyperchromasia)
a perinuclear halo may be seen
315
Q

What is the ECOG score?

A

The ECOG score is a ‘performance status’ scale, or a score that measures the functional status a patient. It is used to decide if a patient is a good or poor candidate for future oncological therapies.
Those with a poor functional status is a poor candidate for further chemotherapy.

316
Q

Describe the different levels of the ECOG score?

A

0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
5 Dead

317
Q

What is meigs syndrome?

A

This patient has Meig’s syndrome - an ovarian fibroma associated with a pleural effusion and ascites

318
Q

What are the mechanism of action and adverse effects of Fluorouracil (5-FU)

A

Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase)

Myelosuppression, mucositis, dermatitis

319
Q

What are the mechanism of action and adverse effects of 6-mercaptopurine?

A

Purine analogue that is activated by HGPRTase, decreasing purine synthesis
Myelosuppression

320
Q

What are the mechanism of action and adverse effects of Cytarabine?

A

Pyrimidine antagonist. Interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase

Myelosuppression, ataxia

321
Q

What are the mechanism of action and adverse effects of Irinotecan?

A

Inhibits topoisomerase I which prevents relaxation of supercoiled DNA

Myelosuppression

322
Q

What is tamoxifen and what is it used in?

A

Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.

323
Q

what are the adverse effects of tamoxifen?

A

menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer

324
Q

What are anastrozole and letrozole?

A

Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.

325
Q

what are the adverse effects of aromatase inhibitors?

A

osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia

326
Q

what are the features of lead poisoning?

A

abdominal pain
peripheral neuropathy (mainly motor)
fatigue
constipation
blue lines on gum margin (only 20% of adult patients, very rare in children)

327
Q

what are the investigation of lead poisoining?

A

the blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are considered significant
full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology
raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria
urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased)
in children, lead can accumulate in the metaphysis of the bones although x-rays are not part of the standard work-up

328
Q

What is the management of lead poisoning?

A

Management - various chelating agents are currently used:

dimercaptosuccinic acid (DMSA)
D-penicillamine
EDTA
dimercaprol
329
Q

What is the prognostic indicator used in myeloma?

A

B2-microglobulin is a useful marker of prognosis - raised levels imply poor prognosis. Low levels of albumin are also associated with a poor prognosis

330
Q

Describe the international prognostic index score for myeloma

A

I B2 microglobulin < 3.5 mg/l Albumin > 35 g/l
62 mths median survival

II Not I or III
45mths median survival

III B2 microglobulin > 5.5 mg/l 29

331
Q

what is protein c deficiency?

A

Protein C deficiency is an autosomal codominant condition which causes an increased risk of thrombosis

332
Q

What are the features of protein C deficiency?

A

venous thromboembolism
skin necrosis following the commencement of warfarin: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis

333
Q

What is hereditary angioedema?

A

Hereditary angioedema is an autosomal dominant condition associated with low plasma levels of the C1 inhibitor (C1-INH) protein. C1-INH is a multifunctional serine protease inhibitor - the probable mechanism behind attacks is uncontrolled release of bradykinin resulting in oedema of tissues.

334
Q

What are the investigations for hereditary angioedema?

A

• C1-INH level is low
• Low C2 and C4 levels are seen, even between attacks

335
Q

What are the symptoms of hereditary angioedema?

A

• Attacks may be proceeded by painful macular rash
• Painless, non-pruritic swelling of subcutaneous/submucosal tissues
• May affect upper airways, skin or abdominal organs (can occasionally present as abdominal
pain due to visceral edema)
• Urticaria is not usually a feature

336
Q

What is the management for hereditary angioedema?

A

• Acute: IV C1-inhibitor concentrate or FFP
• Anabolic steroid; Danazol may help

337
Q

What is acquired haemophilia?

A

is associated with anti-factor VIII IgG antibodies and is idiopathic in
the majority of cases.

338
Q

What is assoc with acquired haemophilia?

A

• Autoimmune diseases: (Rheumatoid Arthritis or IBD)
• Drugs such as phenytoin.

339
Q

What is the management of acquired haemophilia?

A

• Where there are ↓ anti-factor VIII antibodies, factor VIII replacement may be all that is
required.
• Where bleeding is a serious problem then immunosupression with corticosteroids +/- steroid
sparing agents such as cyclosporine may be required.

340
Q

what is Wiskott-Aldrich syndrome?

A

Wiskott-Aldrich syndrome causes primary immunodeficiency due to a combined B- and T-cell dysfunction. It is inherited in a X-linked recessive fashion and is thought to be caused by mutation in the WASP gene.

341
Q

What are the features of wiskott-aldrich syndrome?

A

recurrent bacterial infections (e.g. Chest)
eczema
thrombocytopaenia
low IgM levels

342
Q

what are haematological risk factors for DVT?

A

• Thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency
• Polycythemia
• Paroxysmal nocturnal hemoglobinuria
• Hyperviscosity syndrome

343
Q

what are autoimmune risk factors for DVT?

A

Autoimmune
• Antiphospholipid syndrome • Behcet’s

344
Q

what drugs are a risk factor for DVT?

A

Drugs
• Combined oral contraceptive pill: 3rd generation more than 2nd generation
• Antipsychotics (especially olanzapine) have recently been shown to be a risk factor

345
Q

what does Homocystinuria increase the risk of?

A

DVT

346
Q

what are porphyrias? how are these inherited? are these acute or non-acute?

A

• Abnormality in enzymes responsible for the biosynthesis of heme.
• Results in overproduction of intermediate compounds (porphyrins)
• All Porphyrias has autosomal dominant inheritance excpet congenital porphyrias (recessive)
• May be acute or non-acute

347
Q

what level increases in all three types of porphyria?
when does faecal porphyria increase?

A

• Urinary porphyria is ↑ in all the 3 types
• Fecal porphyria is ↑ in Variegate porphyria and hereditary porphyrias

348
Q

which porphyrias are photosensitive?

A

• All porphyrias are photosensitive except AIP

349
Q

Acute intermittent porphyria:
-how is this inherited?
-what is the defect?
-what does this result in?

A

• Autosomal dominant
• Defect in porphobilinogen deAminase
• Results accumulation of delta aminolaevulinic acid and porphobilinogen

350
Q

Acute intermittent porphyria: who does this normally present in?

A

• ♀s, 20-40 year olds more likely to be affected (♀5:1)

351
Q

how does acute intermittent porphyria present?
Abdominal
Neurological
Psychiatric
Cardiovascular

A

• Abdominal: abdominal pain, vomiting
• Neurological: motor neuropathy
• Psychiatric: e.g. Depression
• Hypertension and tachycardia common
• No feces porphyria (can not be detected in
stool)

• Typically present with abdominal symptoms, neuropsychiatric symptoms
• Hypertension and tachycardia common
• Urine turns deep red on standing

352
Q

what is the diagnosis of acute intermittent porphyria?

A

Diagnosis
• Classically urine turns deep red on standing
• Raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)
• Assay of red cells for porphobilinogen deaminase
• Raised serum levels of delta aminolaevulinic acid and porphobilinogen

353
Q

what is the management of acute intermittent porphyria?

A

• Hematin: needs to be given very early in an attack to be effective. Effectiveness varies among individuals. They are not curative drugs, but can shorten attacks and reduce the intensity of an attack

354
Q

Porphyria cutanea tarda (non-acute):
-how is this inherited?
-what is this a result of?

A

• Most common hepatic porphyria
• 80% sporadic and 20% autosomal dominant
• No neurological consequences only urine porphyria
• The exact frequency is not clear because many people with PCT never experience symptoms
• Defect in uroporphyrinogen decarboxylase

355
Q

what may cause porphyria cutanea tarda?
-what is the presentation?
-what is seen in the urine?

A

• May be caused by hepatocyte damage e.g. Alcohol, estrogens
• Classically photosensitive rash with bullae, skin fragility on face and dorsal aspect of hands
• Urine: elevated uroporphyrinogen and pink fluorescence of urine under wood’s lamp

356
Q

what is the management of porphyria cutanea tarda?

A

• Manage with chloroquine

357
Q

Variegate porphyria (Acute):
-how is this inherited?
-what is this caused by?

A

• Autosomal dominant
• Defect in protoporphyrinogen oxidase

358
Q

how does Variegate porphyria present and who is this more common in?

A

• Photosensitive blistering rash
• Abdominal and neurological symptoms
• More common in south africans

359
Q

what is POEMS syndrome?

A

POEMS Syndrome: Polyneuropathy, Organomegaly, Endocrinopathy or Edema, M-protein and Skin abnormalities (including hyperpigmentation and hypertrichosis), also known as Crow–Fukase syndrome, Takatsuki disease. It is a rare syndrome, defined as the combination of a plasma-cell proliferative disorder (typically myeloma), polyneuropathy and organomegaly.

360
Q

what is the average age of onset and the male:female distribution of POEMS syndrome?

A

Average age of onset is 50 years, ♂:♀ 2:1. Its 5 years survival is 60% if untreated

361
Q

what is the presentations of POEMS syndrome?

A

Presentation:
• Polyneuropathy: bilateral symmetric disturbance, involves both motor and sensory nerves, begins distally, and has a progressive proximal spread. No cranial or autonomic nerves involvement. Both demyelination and axonal degeneration are noted.
• Organomegaly: liver, lymph nodes, and spleen are most frequently involved.
• Multiple endocrinopathies, most patients have more than one endocrine abnormality.
• POEMS syndrome is seen in the setting of a plasma cell dyscrasia. Although many plasma cell
disorders have been reported in patients with POEMS syndrome, most patients are seen with osteosclerotic myeloma or monoclonal gammopathy of unknown significance (MGUS). Classic multiple myeloma has not been associated with the disease.

362
Q

what is the management of POEMS?

A

Management:
• No treatment was found, just correct the hematological abnormality
• Conventional treatments for demyelinating neuropathy (Steroids, IV immunoglobulin and
plasma exchange) are ineffective; treatment must be aimed at the hematological disorder.

363
Q

what is systemic masocytosis?

A

Systemic Mastocytosis results from a neoplastic proliferation of mast cells

364
Q

what are the features of systemic mastocytosis?

A

Features
• Urticaria pigmentosa - produces a wheal on rubbing (Darier’s sign)
• Flushing
• Abdominal pain
• Monocytosis on the blood film

365
Q

what is the diagnosis of systemic mastocytosis?

A

Diagnosis
• Raised serum tryptase levels
• Urinary histamine

366
Q

For flying - what should haemoglobin be?

A

• Patients with a hemoglobin of greater than 8 g/dl may travel without problems