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1

Which one of the following is the most important component in the pathogenesis of β thalassaemia? 
 
A. Iron overload. 
 
B. α/β globin chain imbalance. 
 
C. Ineffective erythropoiesis. 
 
D. Dysfunctional β globin. 
 
E. Haemolytic anaemia.  

B. α/β globin chain imbalance. 

Excess alpha chains are unstable and precipitate - RBC membrane damage (target cell)

Results in:
- Intramedullary and peripheral haemolysis
- Erythroid hyperplasia, 
- Ineffective erythropoeisis due to intramedullary destruction of erythroid cells.

2

1.  What are the three different kinds of haemoglobin?

2.  Which forms the majority of adult Hb?

3.  On what genes are haemoglobin alpha and beta located?

1.  
HBA (A2B2)- a tetramer of two alpha and two beta chains 
HBA2 (a2δ2) tetramer forms - 1-2% adult Hb
HBF - a2γ2 tetramer forms - fetal Hb but <1% of adult Hb

2.  98% adult Hb primarily HBa

3. 
2 alpha-globin genes - Cr16, w/ no substitutes.
B-globin gene - Cr11, adjacent to B-like glob in genes delta δ and gamma γ

3

In the context of thalassaemia, define the following terms:

1.  Trait
2.  Intermedia
3.  Major

1.  Trait - lab features, no clinical impact
2.  Intermedia - occastional transfusion requirement
3.  Major - life threatening or transfusion dependent - most die of iron overload.

4

Describe the pathogenesis of alpha-thalassaemia

Alpha thalassaemia - Cr16 x 2
- due to gene deletions —> reduced a-globin chain synthesis
- each gene produces 1/4 of total alpha-globin quantity
- all adult Hb are alpha containing, so there will never be any change in percentage distribution of it on Hb EPG.
- Severe forms:  excess B chains will form B2B2 tetramer (H bodies), or HbH which are highly unstable.

5

Describe the clinical features of alpha thalassaemia

Southeast Asians and Chinese

- aa/a- : silent carrier
- aa/— or a-/a- : Clinically normal, mild microcytic anaemia
- a-/— : HbH disease - chronic haemolytic anaemia of variable severity (minor or intermedia) with pallor and splenomegaly.  Intermittent transfusions only (infection / stress or by RBC production shutdown (aplastic crisis) by certain viruses (i.e. parvovirus).)
- —/— : Hydrops fetalis (no normal Hb is produced only Bart’s y4) - fetus is stillborn

6

Describe the lab findings for alpha-thalassaemia trait and HbH disease.

Trait - MCV (60-75)
- normal or increased RBC count
- smear:  microcytes, hypochromia, occ target cells, acanthocytes.
- retic and iron counts normal
- Hb EPG:  no change in percent HbA2/F/or HbH
- dx of exclusion

HbH disease
- marked anaemia HCT 22-32%
- very low MCV 60-70
- smear:  hypochromia, microcytosis, target cells, poikilocytosis (annoying term that means ‘varied’!)
- elevated retics, elevated/normal RBC count
- Hb EPG: fast migrating haemoglobin (HbH) accounting for 10-40% of the Hb.
- Can stain smear with supra vital dye to show HbH

7

Describe the pathogenesis of beta-thalassaemia


Beta thalassamia - Cr 11 point mutation
- little to no B-Hb --> more HBA2 & HbF on EPG
- excess alpha chains precipitate --> RBC membrane damage
- intramedullary and peripheral haemolysis, erythroid hyperplasia
Absent b-chains:  B0
Reduced b-chains:  B+ (variable severity)

Severe disease
- marrow expansion --> bone deformities, osteopaenia, path fractures

8

Describe the clinical manifestations of all forms of beta-thalassaemia

Homozygotes (B0/B0 or B+/B+)
- thal major
- normal @ birth, severe tfusion dependence at 6/12 (HbF-->HbA)
- Stunted growth
- Bony deformities (frontal bossing, chipmunk facies, path fractures)
- Hepatosplenomegaly
- Cirrhosis, jaundice (due to gallstones), thrombophilia
- Iron overload (due to transfusion) --> heart failure & arrythmias, cirrhosis, endocrinopathies, pseudoxanthoma elasticum - calcification of epithelial cells of skin, retina, CVS) due to inability to excrete iron.  Poor survival.

Homozygosity for milder B+/B+: chronic haemolytic anaemia, transfusions only during aplastic crises.  May still develop iron overload, hepatosplenomegaly and bony deformities but survive into adulthood.

Heterozygosity for B/B0 or B/B+ : thalassaemia minor, clinically insignificant microcytic anaemia

9

What are the lab findings for beta-thal major and minor?

B-thal minor:
- Modest anaemia - HCT 28-40%, MCV 55-75
- RBC count normal or increased
- Retic count - normal or slightly elevated
- Smear:  Hypochromia, microcytosis, target cells, basophilic stippling
- Hb EPG: Increased HBA2 to 4-8%, occ increased HbF - 1-5%

B-thal major:
- severe anaemia - HCT to
- smear:  severe poikilocytosis, hypochromia, microcytosis, target cells, basophilic stiplling,  nucleated RBCs.
- HbEPG - little to no HbA, variable amt HBa2, major Hb present is HbF

10

How do you differentiate thalassaemia from iron deficiency anaemia?

How is the diagnosis of b-thal and a-thal made?

Compared to Fe+ deficiency anaemia
 - lower MCV
 - normal or elevated RBC count
 - more abnormal smear at modest lvld anaemia
 - normal or elevated transferrin sat/ferritin (or both)

Dx of b-thal made with above plus HbEPG showing elevated HbA2 and F (assuming iron replete)
Dx of a-thal is one of exclusion since HbEPG levels of a-globin remains the same.
Other microcytic anaemia with normal or elevated RBC count is Fe+ deficiency + PCV

11

Describe the treatment for all forms of thalassaemia

Treatment
Mild a or b - no treatment but need identification so they don’t keep getting investigated for Fe deficiency anaemia!
HbH - Folic acid, avoid medicinal iron and oxidative drugs (sulphonamides)
Severe thalassaemia - regular transfusion, folic acid and iron chelation.

Allogeneic SCT - treatment of choice for B-thal major, only cure, and in kids w/o Fe+ overload or chronic organ toxicity - long term survival of >80%.

12

Which one of the following occurs most frequently in the α thalassaemia syndromes? 
 
A. Mental retardation. 
 
B. Reduced mean corpuscular volume. 
 
C. Gene deletions. 
 
D. Haemoglobin H inclusion bodies. 
 
E. Reduced haemoglobin. 

C. Gene deletions. 

13

AMP 1999 Question 30 
 In which one of the following conditions has initial therapy with imatinib been shown to cause the best improvement in survival? 
 
A. Multiple myeloma. 
B. Low grade non-Hodgkin’s lymphoma. 
C. Chronic myeloid leukaemia. 
D. Chronic lymphocytic leukaemia. 
E. T-cell acute lymphocytic leukaemia. 

C. CML

TKIs (Imatinib, Dasatinib, Nilotinib, Ponatinib) • specific competitive binders in the ATP-pocket of BCR-ABL tyrosine kinase.  Associated with >80% progression free at 8 years.

14

What is the pathogenesis of CML?

Chromosomal abnormality
Reciprocal translocation of Cr9 to 22
Cr9q Abl protoncogene fused to BCR on Cr22q

then

Molecular abnormality
Fusion gene deregulates abl tyrosine kinase activity —> autophosphyrlation, altered adhesion, inhibition of apoptosis

then

Myeloid proliferation

15

What are the clinical findings of CML?

Middle aged, more men
May be asymptomatic - discovered incidentally on an FBC with elevated WCC
Hyper metabolic sx; night sweats, low-grade fever caused by overproduction of white cells
May have splenomegaly and or sternal tenderness from marrow overexpansion
Rarely; leukostasis:  blurred vision, resp distress, priapism (usually w/ very high white cell counts
Acceleration:  Fever in absence of infection, bone pain and splenomegaly.

16

What are the lab findings in CML?

Early CML:  normal BM function, normal WBCs, normal neutrophils
Untreated:  accelerated then acute blast phase - indistinguishable from acute leukaemia
Median WBC count >150
Blood film: Left-shifted (immature cells present) with cells present in proportion to their degree of maturation (i.e. blasts <5%), normal RBC morphology, normal or elevated platelets (abnormal megakaryocytes)
Basophilia and eosinophilia of granulocytes is pathognomic
• Peripheral blood PCR (required for diagnosis):  Increased levels of BCR-ABL gene.
BM:  Hypercellular w/ left shift myelopoesis

17

What is the diagnostic criteria for CML?

Peripheral blood:  bcr/able gene present on PCR - hallmark of the disease – this is diagnostic criterai
BMB is NOT necessary for dx but useful for prognosis and detecting additional chromosomal abnormalities

18

How is the blast phase of CML defined?

What is it associated with?

One or more of:
o Blasts composing >20% of nucleated bone marrow cells.
o Extramedullary blast proliferation 
o Large foci or clusters of blasts in the bone marrow biopsy 

Evolution to a blast cell crisis in CML associated w/:
o Non-random secondary chromosomal changes 
o Mutations or deletions of tumour suppressor genes

19

How do you differentiate CML from infection and other blood disorders?

Infection - no splenomegaly, WBC <50, no bcr/abl gene
Other blood disorders - normal RBCs, no nucleated RBCs, definitive finding of bcr/abl gene

20

Define the types and goals of therapy in CML

Treatment
Untreated progresses from chronic phase (3-5 years) to blast crisis
Chronic-phase CML:  TKI aiming for complete remission w/ normalisation of blood count and splenomegaly within 3 months initiation. Aim for MAJOR molecular response in 1 year.
Blast/accelerated phase:  ASCT + myelosuppressive therapy
Hyperleukocytosis (priapism, respiratory distress, visual blurring, altered mental state):  emergency leukapheresis + myelosuppressive therapy.

21

What do the terms major molecular response, and complete molecular response refer to in the context of CML?

Major molecular response
- 3-log reduction of bcr/abl transcript on PCR within a year (corresponds to bcr/abl RATIO (compared to alb) of <0.01).
- Goal is to achieve MMR within a year
- excellent prognosis - up to 100% progression-free at 8 years.

Complete MR = >4.5 log reduction ie undetectable

22

What is the mechanism of action of tyrosine kinase inhibitors?

What are the side effects?

Tyrosine Kinase Inhibitors
specific competitive binders in the ATP-pocket of BCR-ABL tyrosine kinase
Imatinib:  first line, MMR @ 30% at 1 year in chronic phase.  SEs:  NV, chronic diarrhea, intolerable fatigue
Dasatinib: pleural effusions esp. in the elderly, pneumonitis, pulmonary hypertension, bleeding, possibly increased infection risk
Nilotinib: cardiac SEs:  esp IHD, CVA, PAD (inc limb ischaemia, claudication), also increases cholesterol and LDL
3rd gen agents may be more effective - can salvage 90% of patients who do not respond to imatinib.  Are now approved as first line agents.

23

What is the mechanism of tyrosine kinase inhibitor resistance?

How is it managed in CML?

Due to:
- drug influx/efflux due to low OCT-1 expression
- amplification and over expression of BCR-ABL
- Mutations of BCR-ABL kinase domain (found in 50-90% w/ secondary resistance)

can increase dose with variable response (depends on mutation
or use alternative TKIs

24

How is disease progression in CML monitored?

Peripheral blood PCR, if it increases on therapy check compliance, check for a new abl mutation, may be able to get away with increased dose of Imatinib, otherwise switch to a new inhibitor.

25

What is the course and prognosis of CML?

Course & Prognosis
80% w/o progression at 9 years w/ TKIs
essentially 100% survival at 9 years if good molecular response
Complete (undetectable bcr/abl) response lasting > 2years may be able to cease therapy all together.

Untreated progresses from chronic phase (3-5 years) to blast crisis

26

What is the pathogenesis of CLL?

Pathogenesis
B Cell lymphocytosis w/ coexpression of CD19, CD5 (pathognomic:  aberrant T-cell marker) on lymphocytes.
indolent, long lived small (unactivated) lymphocytes
immunoincompetent, poorly antigenic responsive

immunosuppression, 
• BM failure
• organ infiltration with lymphocytes
inadequate antibody production
damage due to direct tissue introduction

27

What is the epidemiology of CLL?

Epidemiology
- 25% of all leukemias (2.7/100,000) , increasing
- Unknown aetiology
- Increased other malig (SCC)
- Only leukemia NOT linked to radiation
- M:F=2:1, less in Asian’s
- Disease of old age - median at presentation is age 70

28

What are the clinical findings in CLL?

Clinical Findings
incidental:  lymphocytosis - usually indolent
symptomatic:  fatigue or lymphadenopathy
80% will have lymphadenopathy, 50% splenomegaly
subtype prolymphocytic leukaemia (larger and more immature cells) is more aggressive but rare
maybe complicated by AIHA or autoimmune thrombocytopaenia
5% of systemic cases may have an isolated lymph node transform into an aggressive large cell lymphoma (Richter syndrome)

29

What is the Rai staging system used for?  Can you describe it?

Used to stage CLL

Staging - Rai
Stage 0 - lymphocytosis (low-risk)
Stage II - organomegaly (low risk)
Stage III - anaemia (high risk)
Stage IV - thrombocytopaenia (high risk)

30

What is the diagnostic criteria for CLL?

Diagnostic criteria
Peripheral absolute B lymphocyte count > 5 x 109/L w/ mainly morphologically mature lymphocytes
Flow cytometry: clonality of circulating B-lymphocytes w/ low levels of  SmIg and either kappa or lambda (not both) and expression of B-cell antigens (CD19, 20, 23), and expression of T-Cell associated antigen CD5.

31

Name the investigations you would do when working up CLL

Ix
• FBE,differential; lymphocytosis,cytopenias
• Flowcytometry: CD19/5,Ig(weak),CD23 
• Coombes test
• LDH, B2 microglobulin
• Uric acid, calcium
• BMBx – cytopenias– ‘assessment’ pre-treatment – cytogenetics
• +/-CTscan

32

Describe the lab findings in CLL for the

FBC
Smear
BMBx
Cytogenetics.

Lab Findings
hallmark:  isolated lymphocytosis
WBC >20k, >75% small and mature lymphocytes, normal HCT and platelets.
may have cytopaenias inc neutropaenia.
smear:  normal-looking small lymphocytes predominate with reduced numbers of larger activated lymphocytes, SMUDGE CELLS
BMBx:  Infiltrated w/ small lymphocytes

Immunophenotype (Flow):  Coexpression of CD19 with T-lymphocyte marker CD5 - ONLY found in CLL and mantle-cell lymphoma (Not mantle cell lymphoma if:  expression of CD23, low expression of surface Ig and CD20, absence of cyclin D1)

Cytogenetics (BMBx)
Associated mutation of Ig (Vh) gene = more indolent disease
Genomic changes assessed by flow cytometry or FISH
o Chromosome 17p (p53) deletion or 11q (ATM) = POOR prognosis
o Isolated 13q deletion = favourable prognosis (in Myeloma, it’s BAD!)
50% have hypogammaglobulinaemia, more common with advanced disease, may have a small amt of IgM paraprotein.

33

Describe the chromosomal abnormalities that are associated with good and poor prognoses in CLL

o Chromosome 17p (p53) deletion or 11q (ATM) = POOR prognosis
o Isolated 13q deletion = GOOD prognosis (in Myeloma, it’s BAD!)

34

DDx of CLL?

DDx
Exclude viral infections that cause lymphocytosis (i.e. Pertussis)
Fever in CLL may be concomitant bacterial infection
Other B-Cellopathies are distinguished on morphology and immunophenotype.
Monoclonal B-cell lymphocytosis (<5x109) is a precursor to B-CLL

35

Describe the treatment approaches and what you would use for each of the following groups in CLL:

Comorbid elderly
Robust older patient
Younger patient

Comorbid elderly - symptom control, QOL —> observe or ‘gently oral CTx with chlorambucil or cyclophosphmade

Robust older pt - QOL, bulk reduction, deepest achievable response —> observe is asymptomatic, otherwise multi drug CTx, ritux + fludarabine for prolonged remission.

Younger pt - as above, possible allogeneic BMTc

36

What prophylaxis should you use when giving fludarabine or alemtuzumab in CLL?

Prophylaxis
Fludarabine or alemtuzumab —> PJP pneumonia, HSV, HZV and fungal prophylaxis.
Alemtuzumab - monitor for CMV reactivation
Lower strength ‘nonmyeloablative’ transplant + drugs good for older people.

37

What are the prognostic features of CLL?

Prognostic features
Stage 0-1:  10-15 years, 
Stage 3-4:  >90% at 2 years w/ fludarabine

High risk  disease:  Allogeneic transplant may lead to long term disease control.

Serum LDH and B2-microglobulin
Unmutated IgH (adverse) vs mutated
ZAP 70 (zeta chain associated protein) (bad if positive) , CD38 + (bad if +)
Cytogenetic translocations (not trisomies or deletions)
~5% terminally  "Richter's syndrome"; consider if: B-Sx, painful, rapidly enlarging mass rapid unexpected rise in LDH

38

What is Richters Syndrome?

Transformation of CLL
5-10% of CLL patients
B-Sx, painful, rapidly enlarging nodal mass and rapid unexpected rise in LDH
fast-growing diffuse large B cell lymphoma
BAD prognosis

39

What is alemtuzumab and when is it used?

Alemtuzumab (mAb to mature lymphocyte CD52), but immunosuppression, severe and fatal infections.

Used in CLL

40

What is Ibrutinib and when is it used?

What is a Bruton's tyrosine kinase?

Used in CLL

Ibrutinib (PCI-02765) a Bruton’s TKI.  

Bruton's tyrosine kinase (BTK) BTK is a kinase that plays a crucial role in B-cell development

41

How do you treat AIHA in CLL?

AIHA:  rituximab, prednisone or splenectomy - AVOID fludarabine as may exacerbate (but concurrent rituximab reduces this risk)

42

What is the pathogenesis of multiple myeloma?

Monoclonal proliferation (kappa/lambda light chain restriction) of plasma cells in the BM (any percentage) or as a tumor (plasmacytoma) resulting in:

End-organ damage:

C - Hypercalcaemia
R - Renal failure
A - Anaemia
B - Bone disease

Recurrent infections w/ encapsulated organisms (due to b-cell deficiency)
Plasmacytomas
Hyperviscosity syndrome

43

Who is most susceptible to overwhelming infection with encapsulated organisms?

Asplenic patients
B-cell deficient patients
Complement deficiency (esp C3 and C5+ (MAC complex)
Children 6/12 - 1 year

44

Name the encapsulated organisms.  

Why are they important?

Streptococcus pneumoniae
Haemophilus influenzae type B (B polysaccharide)
Neisseria meningitidis
Klebsiella pneumoniae
Salmonella typhi
Pseudomonas aeruginosa
Cryptococcus neoformans
only encapsulated fungal pathogen
Other encapsulated bacteria

Anti-phagocytic - susceptible to antibody (B-Cells) and not cell mediated responses.  People w/ B-cell deficiencies are highly susceptible.

45

What is the mechanism and outcome of hyperviscosity syndrome in multiple myeloma?

Excess paraprotein production (monoclonal Igs) in addition to excess plasma cells —> hyperviscosity —> spont.bleeding, retinopathy/vision disturb, vertigo, nausea, seizures, coma

46

What is the mechanism of renal failure in multiple myeloma?

Cast nephropathy:  Tumour mass expansion —> FLC serum concentration exceeds renal absorptive capacity →excess light chains—> direct damage to PCT—> casts at distal tubules (containing BJP and tamm-horsfall proteins) —> FLC in urine, positive BJP

Monoclonal Ig deposition disease (usually light chains)—> glomerular disease, proteinuria

Hypercalcaemia —>nephrocalcinosis
Cryoglobulins, Fanconi syndrome (type2 RTA, phosphaturia, glycosuria, uricosuria & osteomalacia), hyperuricemia

47

What is the mechanism of recurrent infection in multiple myeloma?

Underproduction of normal Ig + neutropenia + CTx immunosuppression —> recurrent infections esp encapsulated organisms.

48

What are the clinical findings of multiple myeloma and who does it affect?

Older adults - i.e. 65 y old
Pallor, bone tenderness, soft tissue masses
Bone tenderness/pain: hips, back, ribs, path # esp fem neck, vertebrae
Neurologic signs: neuropathy, SC compression (plasmacytoma)
Primary amyloid —> enlarged tongue, peripheral/autonomic neuropathy, CHF, hepatomegaly

NO splenomegaly unless amyloidosis
NO fever unless infection

49

What are the lab findings of multiple myeloma?

What is the predominant paraprotein?

FBE: Rouleaux (high protein), cytopenias, macrocytosis
ESR elevated
Normal urine ‘dip-stick’ (i.e BJP): may be + if nephrotic (albumin)
Electrolytes: Renal function, calcium, ALP normal
Low B12

Protein EPG (serum or urine) - detects a clonal protein
- Monoclonal spike in b or gamma globulin region, known as ‘M-protein’

IEPG - identifies the clonal protein
- Paraprotein estimation: Serum/urine: IgG(70%) >IgA(20%) >IgD(5%) >LCD(5%) >NS(2.5) >>IgM
- no paraprotein = nonsecretory myeloma = BAD

Elevated B2 microglobulin (prognostic test)

50

What are free light chains and what is the role of the serum free light chain test?

Free Light Chains
 - Ig are heavy chains – the light chains (kappa or lambda) produced separately
 - kappa and lambda bound to heavy chains, but free light chains produced in healthy people when there are more light chains than heavy chains
- bound and free light chains are structurally identical
- Free light chains reach a threshold before detectable in urine - need for serum FLC.
- 15% will have no paraprotein due to free light chain only disease which pass freely into the urine.  

Serum FLC (free light chains)
Will pick up light chains in non-secretory myeloma (too low to be detected in urine)
- use at dx of all types of myeloma inc MGUS, plasmacytoma and AL amyloidosis
- use in combo with EPG/IEPG - sufficient to screen for all except AL amyloid (which needs more serum tests and urine IEPG)

51

When would you do a bone marrow in multiple myeloma?
What would it show?
How do you differentiate it from reactive (benign) plasmacytosis?

Bone marrow (only for symptomatic - i.e. paraprotein plus end organ damage)
Morphologically abnormal plasma cells
Skewing of kappa to lambda light chain ratio
May have reactive (benign) plasmacytosis -  but atypical cells, LC restriction and effacement of normal BM = myeloma

52

In multiple myeloma, when would you do a:

Skeletal survey
Nuclear bone scan
MRI/PET?

and what would they show?

Symptomatic myeloma:  Skeletal survey (whole body x-ray)
 - lytic lesions of axial skeleton; skull, spine, prix long bones, ribs
 - OR general OP only

Wouldn't - Nuclear bone scan - unuseful, no osteoblastic component

MRI - severe back pain, suspected vertebral compression, isolated plasmacytoma
- really good but expensive, pick up lesions that x-ray doesn’t

PET - pre CTx

53

What is the differential diagnosis of a positive paraprotein on EPG?

CLL
Waldenstrom
NHL
primary amyloid
cryoglubinaemia
MGUS

54

What is the definition and risk factors for progression of MGUS to MM?

BM monoclonal plasma cells <10% or serum M-protein <30g/L)
No end organ damage or other B-cell disorder

1/4 progresses to malignant disease in 10 years (1%/year)
Must be distinguished from reactive (benign) polyclonal hypergammaglobulinaemia

Risk factors for progression
Size of M-band (best predictor of risk)
IgM or IgA monoclonal protein
Eleveated serum FLC

55

What is the definition of smoldering myeloma?

BM monoclonal plasma cells >10% or serum M-protein >30g/L
No end-organ damage

56

What is the treatment for MGUS and smoldering myeloma?

Observe

57

What is the role of auto-sct and thalidomide in multiple myeloma?

Auto-SCT
- prolongs duration of remission and overall survival, long treatment-free intervals
- thalido/lenalidomide prolong remission and survival as post-transplant maintenance therapy

58

What is the treatment of symptomatic myeloma in the non-transplant candidate?

Non-transplant candidate:  Melphalan + Pred + Thalidomide > Melphalan, Pred, bortezomib

59

What is the treatment of symptomatic multiple myeloma in an eligible candidate?

–Auto-Transplant ‘candidate’ (<76)
» Induction therapy: chemotherapy +/- thalidomide, bortezomib, lenalidomide
» Melphalan (alkylator) stem cell transplant [tandem v single]
» Maintenance: steroids, thalidomide

60

What is bortezomib, when is it used and it's side effects?

Bortezomib (proteosome inhibitor) 
Relapsed MM /poor prognosis --> rapid response.  

SE:  neuropathy (peripheral/autonomic), less if given SC (instead of IV)

61

What is thalidomide/lenalidomide, when is it used and it's side effects?

Inhibits angiogenesis

Used for multiple myeloma and leprosy

Thalidomide/Lenalidomide SEs
Somnolence
Thalidomide neuropathy – painful neuropathy, reduced sens nerve AP (AP)
Constipation, tremor, skin rash and oedema
Thrombosis
Myelosuppression


62

Define the international staging system - what is it used for?

International Staging System
B2 microglobulin (both stages) and albumin (stage 1)
Stage 1 - low B2 (<3.5mg/L), normal albumin - survival >5 years
Stage 2 – not stage 1 or 3
Stage 3 - High B2 (>5.5mg/L), survival <2 years]

Multiple Myeloma

63

What are the cytogenetics of multiple myeloma and the associated prognoses?

Cytogenetics:  
Chrom 13 del (bad but good in CLL!), 
Hypodiploidy (bad), 
17p del (bad)

FISH:  T(4:14) T(14;16)(bad) – by FISH only
T(11;14) ‘good’

64

Describe the sites of mutations and cell heritage for the following
What do they all have in common?

Chronic lymphocytic leukaemia 
Acute lymphocytic leukaemia
Follicular lymphoma
Diffuse large b-cell lymphoma
Multiple myeloma

Chronic lymphocytic leukaemia- lymphoid tissue, mature naive b-cell
Acute lymphocytic leukaemia - bone marrow, pre-b-cell
Follicular lymphoma - lymphoid tissue, germinal centre b-cell
Diffuse large b-cell lymphoma - lymphoid tissue, germinal centre be cell
Multiple myeloma - plasma cell
Hodgkin lymphoma - lymphoid tissue, germinal centre b-cell

65

What are the unfavourable classifications of Hodgkin's lymphoma?

Unfavorable Early Stage (B-Sx, age >50,  ESR >50, bulky, 3+ areas)

Advanced Stage (III-IV)

66

What does ABVD stand for in the treatment of Hodgkin lymphoma?

What are the side effects?

Adriamycin
Bleomycin
Vinblastine
Dacarbazine

SEs
• Hair loss
• Neutropenia
• Cardiotoxicity from adriamycin
• Lung toxicity from bleomycin
Low risk of infertility

67

What does BEACOPP stand for in the treatment of Hodgkins lymphoma?
When is it used?
What are the drawbacks?

Bleomycin, Etoposide, Adriamycin, Cyclophosphomide, O-Vincristine, Procarbazine, Prednisone

Used for advanced Hodgkins or unfavourable stage

More risk of infertility and late-stage cancers

68

Why is low dose RTx used (where necessary) in Hodgkin's lymphoma?

Reduces risk of late breast cancer in young women

69

What are the adverse prognostic factors in Hodgkin's lymphoma? (Hasenclever Index)
What is the difference between having 1 or 5 or more of these?

Serum albumin < 40 g/L
Haemoglobin < 10.5 g/dL
Male gender
Stage IV disease
Total WCC > 15
Lymphocytes < 0.6, or < 8% of total WCC
Age > 45 years

Survival drops cumulatively - >5 = <50% PFS

70

Which chemotherapy drugs are associated with secondary CML?

Alkylators and etoposide

71

Aside from CML and breast cancer, what are the other cancers associated with Hodgkin's treatment?
Which treatment do they stem from?

Thyroid, lung, bone - mainly XRT

Brain - unknown cause

72

What is the mechanism of secondary cardiovascular disease due to Hodgkins lymphoma treatment?

XRT

73

What are the survivorship issues in long term survivors of Hodgkin's lymphoma?

Infertility - worse in men, worse if older

Second cancers - breast, lung, colon, leukaemia

Organ damage - heart (coronary disease), lung, thyroid

74

What is the significan of PET positive and PET negative disease in Hodgkin's lymphoma?

FAR worse survival if PET positive

75

What is nodular lymphocyte predominant Hodgkin's lymphoma?
Why is a misnomer?
How is it treated?

Unusual form of B-cell lympoma (Reed-Steenberg cells express CD20)
A misnomer due to the CD20 expression - it is a non-hodgkin's lymphoma
May progress to DLBCL

Long survival if localised (surg +/- RTx)
Responds to anti-CD20 agent Rituximab - long survival interspersed with relapses

76

What are the commonest types of Non-Hodgkin lymphoma?

What are the other main types?

Follicular lymphoma
Diffuse large b-cell lymphoma

Others
Burkitt
SLL/CLL
MALT
Mantle cell

77

What are the cytogenetics of follicular non-Hodgkin lymphoma?

t(14;18) and bcl-2 rearrangement in > 85%

Follicular
- t(14;18) —> overexpresson of BCL-2 —> failure of apoptosis (the usual mechanism of B-Cell death)

78

What is the epidemiology of follicular non-hodgkin lymphoma?

Median age at dx 60-65y
Male = Female
Western countries

79

What are the clinical features of follicular non-hodgkin lymphoma?

Generalised lymphadenopathy w/ BM involvement
+/- splenomegaly or hepatomegaly

Indolent clinical course
Cumulative risk of histologic transformation around 25%
B-symptoms in 10%

80

Should indolent stage IV non-hodgkin lymphoma be observed or treated?  Why?

Treated with anti-CD20 antibodies (Rituximab)

Much better survival

81

What are the prognostic factors of follicular lymphoma? (Follicular lymphoma international prognostic index - FLIPI)

Age >60
Ann Arbor stage III/IV
Hb <120
LDH > ULN (Upper limit of normal)
>4 involved nodal sites

82

What is CHOP and R-CHOP?
When is it used?

Cyclophosphamide, H -Doxorubicin (Adriamycin), O-Vincristine, Prednisone

R- Rituximab

Used for Non-Hodgkin Lymphoma

83

What is the role of rituximab-maintenance therapy in NHL?

Improves event-free rate in comparison to observation alone.

Given for 2 years.

84

What is the potential role of lenalidomide in follicular lymphoma?

Augments rituximab, improves PFS - may replace CHOP in future.

85

What are the cytogenetics of DLBCL?

 t(14;18) and bcl-2 rearrangement in < 30%

86

What is the epidemiology of DLBCL?

Median age at dx 55-60
Male >female
Minimal geographic variation
Around 50% disseminated at dx

87

What are the clinical features of DLBCL?

Usually
- localised lymphadenopathy
- BM involvement uncommon 
- B-sx in 30-40%
- Aggressive but curable around 60% of cases
- Risk of CNS involvement around 5%

88

When is the international prognostic index used?  
What are it's factors?

Predicts survival in NHL.
Performance status > 2
Age > 60 years
Ann Arbor stage III or IV
LDH above normal
2 extranodal sites of disease

89

Describe the ECOG score

0 – Asymptomatic
1 – Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory. ie light housework, office work)
2 – Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
3 – Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
4 – Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
5 – Death

90

What two prognostic subgroups have been identified by DNA microarray analysis in DLBCL?  Which one has better survival?

Germinal-center B-Cell like (better survival)
Type 3 (worse)
Activated B-cell like (worst)

91

What is first line therapy for DLBCL?

R-CHOP

92

What are the most significant risk factors for CNS disease in lymphoma?
What are the independent risk factors?

- testicular involvement
- clinical stage
- IPI score

Independent
- elevated LDH
- >1 extranodal disease site
- ECOG >2

93

When is intrathethecal methotrexate used?  Why is concurrent IV used?

What is the role of rituximab?

Used in DLBCL if risk factors for CNS disease present (extranodal site + 1 other risk factor i.e. LDG, ecog, testicular)

Intrathecal does not get into brain parenchyma, high dose MTx crosses the BBB.

Reduces CNS disease in patients with IPI of 0 or 1

94

What is a 'double hit' lymphoma?
What is it's relevance?

Dual positivity for BCL-2 + C-MYC portends a poor  prognosis, either de novo or with t-FL
No standard treatment
Rituximab-containing therapy provides a benefit but is still inadequate

95

What are the cytogenetics of Burkitt's NHL?

Burkitt’s NHL: t(8;14) & c-myc, highly aggressive, curable

- t(8;14) —> overexpreesion of c-myc —> malignant transformation through excess b-cell proliferation
- associated with abdominal pain/fullness as disease prefers abdomen

96

What is associated with primary cerebral NHL?  What is the standard treatment?

HIV-related or sporadic
Standard is high dost MTx and XRT

97

What viruses are associated with HIV-related NHL?

HHV-8, EBV, also related to CD4 count

Often extra-nodal, aggressive.

98

What are the cytogenetics and location of disease in mantle-cell NHL?

- t(11;14) and bcl-1 translocation (cyclin D1)
- frequent GI involvement (lymphomatous polyposis)
- aggressive clinical behaviour, treatment difficult

99

What genetic mutation is associated with 100% of hairy-cell leukaemias?

B-RAF

100

What does overexpression of BCL-2 result in, in the context of lymphoma?

resistance to apoptosis

101

What is Bruton's tyrosine kinase?

When is an anti-BTK drug useful?

BTK is a kinase that plays a crucial role in B-cell development.

Ibrutinib Is Highly Effective in Relapsed /Refractory CLL

102

What are the marginal zone lymphomas?

MALT type 
Nodal type 
Splenic type

103

Name the indolent lymphomas

- follicular, marginal zone, SLL/CLL

104

What is the treatment for MALT lymphoma?

MALT - H-pylori and PPIs w/ frequent endoscopy, or whole-stomach XRT

105

Name the aggressive lymphomas

DLBCL, Mantle cell lymphoma, primary CNS lymphoma, T-Cell lymphoma, high grade (Burkitt or lymphoblastic)

106

What is the treatment for DLBCL and mantle-cell lymphoma?

R-CHOP
Maybe Auto-SCT

107

What is the treatment for primary CNS lymphoma?

Repetitive cycles of high-dose intravenous methotrexate with rituximab early in the treatment course produce better results than whole brain radiotherapy and with less cogni- tive impairment.

108

What is the treatment for high grade lymphomas?  (Burkitt or Lymphoblastic)

Intense, cyclic chemotherapy in the hospital similar to that given for ALL, and they also require intrathecal chemotherapy as central nervous system prophylaxis.

109

How do peripheral t-cell lymphomas fare compared to B-cell disease?

Peripheral T-cell lymphomas usually have advanced stage nodal and extranodal disease and typically have inferior response rates to therapy compared to patients with aggressive B-cell disease

110

What is the prognosis of indolent non-hodgkin lymphoma?

10–15 years. These diseases ultimately become refractory to chemotherapy.

111

What is the likelihood of survival after relapse of non-hodgkins lymphoma?

Depends on whether the lymphoma is still responsive to chemotherapy. If the lymphoma remains responsive to chemotherapy, autologous hematopoietic stem cell transplantation offers a 50% chance of long-term lymphoma-free survival.

112

Describe the Ann-Arbor staging system.

What is it used for?

Used for Hodgkin's lymphoma.

Ann Arbor
I - one LN
II - 2 or more on one side of diaphragm
III - Both sides of diaphragm
IV - disseminated w/ extranodal involvement

A - no constitutinal sx
B - 10% wt loss of six months, fever, drenching night sweats (one or more)

113

What are the clinical findings of Hodgkin Lymphoma?

Bimodal - age 20s and then age 50s
Painless mass, commonly in the neck
Constitutional symptoms
Pain in lymph node following alcohol ingestion
Starts in one lymph node then spreads contiguously

114

What is the treatment for Hodgkin lymphoma?

Treatment
- RTx for stage 1A with high cervical LN and low ESR

Otherwise - ABVD (BEACOPP if bad but toxic + infertility and no definite survival advantage)

Stage I-II - usually short course ABVD +/- RTx
- full course if bulky disease
II-IV - full course ABVD w/ no RTx

Must watch for bleomycin plum toxicity.

Relapse may still be curable with CTx - high dose + auto SCT - 35-50% chance of cure.

115

What is the prognosis of Hodgkin lymphoma?

Prognosis
Factors:  Stage, age, gender, Hb, alb, abc and lymphocyte count
Cure rate 75% if zero to two factors present, excess of 90% if Ia or IIa disease.

116

What is the pathogenesis of non hodgkin lymphoma?

Oncogene juxtaposed next to a either an Ig-gene (B-cell lymphoma) or t-cell receptor or related gene (t-cell lymphoma) —> painless lymphadenopathy —> indolent to rapidly progressive.

117

What are the prominent non-hodgkin lymphomas?

85% of NHL are B-cell, mainly DLBCL and follicular

118

What are the lab findings in non-hodgkin's lymphoma?

Normal peripheral blood, no circulating lymphoma cells
Elevated LDH (prognostic)
BMB - paratrabecular monoclonal lymphoid aggregates
LP - (high grade) - meningeal involvement w/ malignant cytology
CXR - mediastinal mass

119

How do you make the diagnosis of non-hodgkin's lymphoma?

Tissue bx (LN or extra nodal tissue) for dx and classification

120

What is the treatment for the indolent non-hodgkin lymphomas?

Indolent (follicular, marginal zone, SLL/CLL)
Limited disease (1-2 contiguous LNs) —> XRT for cure
Most are disseminated though.
- R-CHOP or R-CVP
- allo-SCT if aggressive and low grade
MALT - H-pylori and PPIs w/ frequent endoscopy, or whole-stomach XRT

121

What is the treatment for the aggressive non-hodgkin lymphomas?

DLBCL - RCHOP +/-Auto SCT if responsive to chemo
Mantle cell - as above
Primary CNS - high dose IV MTx + rituximab

High grade lymphoma (Burkitt/Lymphoblastic) - intense CTx plus intrathecal CTx as prophylaxis
Peripheral T-cell lymphomas - poor response, usually disseminated disease.

122

What is the prognosis for the indolent lymphomas?

Indolent - 10-15 years, ultimately becomes refractory and progresses

123

What is the IPI  (International Prognostic Index) used for in regards to non-hodgkin lymphoma? 

What are the factors?

IPI (International Prognostic Index) stratifies risk of those with intermediate grade lymphoma
factors:  

Age >60, 
elevated LDH, 
Stage III, or IV disease.

80% chance of complete response rate with no or one risk factors

124

What are the two critical histopathological features of Hodgkin lymphoma?

Reed-Sternberg cells in an appropriately reactive (inflammatory) cellular background

125

What are the clinical findings of Hodgkin lymphoma?

Bimodal - age 20s and then age 50s
Painless mass, commonly in the neck
Constitutional symptoms
Pain in lymph node following alcohol ingestion
Starts in one lymph node then spreads contiguously

126

What are the prognostic factors for Hodgkin lymphoma?

Prognosis
Factors:  Stage, age, gender, Hb, alb, WBC and lymphocyte count
Cure rate 75% if zero to two factors present, excess of 90% if Ia or IIa disease.

127

What is the aetiology of the acute leukaemias?

Aetiology
- AML:  adult disease around 60, increased incidence with age
- ALL: 20% of adult acute leukaemia’s
- no clear cause
- radiation, benzene
- prior Ctx -  cyclophos, melphalan, other alkylators, etoposide
- after toxins/CTx —> MDS w/ Cr 5 & 7 abnormalities; etoposide Cr 11q23

128

What is APL?  Why does it differ from the other acute leukaemias?

APL (Acute promyelocytic leukaemia)
- t(15;17) —> PML-RARa fusion gene -> interacts w/ retinoid acid receptor causing differentiation block.
- can give ATRA —> differentiated into neutrophils occur —> neutrophils apoptose within minutes —> cure!

129

What are the favourable cytogenetics in AML?

Favourable - ‘core binding factors’ 15% of cases
 - t(8;21)
 - inv(16)
 - p(13;q22)

130

What are the unfavourable cytogenetics in AML?

Unfavourable - poor prognosis
-5, -7, del(5q), Abnormal 3q, Complex cytogenetics
2 or more monosomy’s
3 or more separate cytogenetic abnormalities

131

What is the significance of the intermediate-risk subgroup of AML?  

- normal cytogenetics or abnormalities w/o strong prognostic significance
- new molecular markers
- FLT3-ITD (internal tandem duplication)
  - 30% of CN-AML (cytogenetically normal AML)
  - very poor prognosis
- NPM1 (nucleophospmin 1) - favorable prognosis

132

What are the molecular markers of AML and what are their prognoses?

- FLT3-ITD (internal tandem duplication)
  - 30% of CN-AML (cytogenetically normal AML)
  - very poor prognosis

- NPM1 (nucleophospmin 1) - favorable prognosis

133

What are the cytogenetics of ALL?

- Common, early B, or T-cell

Hyperdiploidy has a better prognosis but is in kids

Unfavourable:  Philadelphia chromosome and t(4;11) which has fusion genes involving the MLL gene at 11q23

134

What are the clinical findings of ALL?

Clinical findings
- presentation of days to weeks
- bleeding of skin and mucosal surfaces due to thrombocytopaenia
- DIC (APL and monocytic leukaemia)
- Infection due to neutropaenia; gram negative bacteria (e.coli, Klebsiella, pseudomonas), or fungi (candida, aspergillus —> cellulitis, pneumonia, perirectal infections.
- Gum hypertrophy, bone and joint pain
- Hyperleukocytosis - impaired circulation —> headache, confusion, dyspnoea, need urgent leukopheresis and chemotherapy - 40% mortality

135

What are the examination findings in ALL?

Pale, purpura, petechiae
Stomatits, gum hypertrophy and rectal fissues in monocytic leukaemia
Hepatosplengomegaly, lymphadenopathy
Bone tenderness:  sternum, tibia, femur

136

What are the lab findings in ALL?

Hallmark:  Pancytopaenia with circulating blasts
Bone marrow:  Hypercellular, >20% blasts
Hyperuricaemia
DIC:  low fibrinogen, fibrin degradations products
ALL:  Mediastinal mass on CXR
Meningeal leukaemia:  Blasts in spinal fluid - 5% of cases, mainly monocytic AML
Myeloperoxidase stain:  Auer rod - eosinophilic needle-like inclusion in the cytoplasm = pathognomonic of AML (but has been superceded by flow cytometry)
(Not in ALL because peroxidase is only in myeloid cells)

137

Describe the flow cytometry findings of AML and ALL.

Flow cytometry:
AML - CD13 or CD33 (myeloid antigens)
ALL - B-lineage: CD19 (all B-Cells), and CD10 (common ALL antigen)
T-lineage - CD2, 5, and 7 (some combo of), but NOT mature t-cell markers, i.e. 3, 4, or 8, and not surface iG.
Almost all ALL cells express terminal deoxynucleotidyl transferase (TdT) (but not Burkitt type ALL)

138

What is the treatment of AML?

- Anthracycline (daunorubicin or idarubicin) plus cytarabine - complete remission in 80-90% under 60, 50-60% older patients
- Intermediate risk - cure rates ascend from 35-40% w/ CTx to 50-60% with allo-transplant
- Positive core binding factor cytogenetics have a more favourable prognosis with CTx, while CTx alone is not helpful if unfavourable profile.
- FLT3 inhibitors are in trial.
Unfavourable - allo-transplant but poor cure rates 20-30%, worse if over 60 even if in first remission - may be a role for reduced intensity allo-transplant.
- Prognosis drops with recurrence after first remission.

139

What is the treatment of APL?


- Anthracycline plus ATRA - 90-95% CR
- High risk (higher WBC count) - added arsenic improves outcomes
- Arsenic can produce second remission in 90% of cases if required.

140

What is the treatment of ALL?  What if they are Ph+?

- Vincristine, Daunorubicin, Asparaginase, PreD (VDAC)
- CR in 90%
- Ph+ needs TKI in addition to standard CTx as T315i (resistant to all 3 TKIs) mutation much more common than in CML, unless older - 90% can achieve remission
-Need CNS prophylaxis to avoid meningeal sequestration of leukaemia cells.
- Low risk: 70% chance of cure with 
- Intermediate: 30-50% chance
- High risk (adverse cytogenetics or poor response to CTx) —> Allo-BMT

141

What is the prognosis in AML?

AML:  High dose post remission CTx —> cure in 35-40%, high dose cytarabine superior
Allo BMT curative in 50-60% of cases
Cure rates for older patients very low even with remission

142

How is complete remission (CR) 
in AML defined?

<5% blasts on bmbx

143

Which leukaemia is a widened mediastinum a hallmark of?

ALL

144

Question 5 
 
In females under 20 years of age treated successfully with radiotherapy for Hodgkin's disease, which one of the following is the most frequent second tumour occurring after 10 years? 
 
A. Acute leukaemia. 
 
B. Thyroid cancer. 
 
C. Non-Hodgkin's lymphoma. 
 
D. Breast cancer. 
 
E. Ovarian carcinoma. 

D

145

A 32-year-old man presents with weight loss, splenomegaly 20 cm below the left costal margin and a white cell count of 480 x 109/L [3.5-9.5].  Bone marrow examination confirms the diagnosis of an accelerated phase myeloid leukaemia in chronic phase. 
 
Which treatment option offers this man the best chance of long-term disease-free survival? 
 
A. Imatinib. 
 
B. Interferon and cytarabine. 
 
C. Hydroxyurea. 
 
D. Autologous bone marrow transplantation. 
 
E. Allogenic stem cell transplantation. 

A.  
Patients with advanced-stage disease (accelerated phase or myeloid/lymphoid blast crisis) should be treated with a tyrosine kinase inhibitor alone or in combination with myelosuppressive chemotherapy. The doses of tyrosine kinase inhibitors in that setting are usually higher than those appropriate for chronic-phase disease. Since the duration of response to tyrosine kinase inhibitors in this setting is limited, these patients should ultimately be con- sidered for allogeneic stem cell transplantation.

146

 
A 62-year-old woman underwent an elective cholecystectomy.  Routine full blood examination revealed:
 
  

Physical examination revealed no lymphadenopathy and no hepatosplenomegaly.  The woman was asymptomatic.  Flow cytometry revealed that the lymphocytosis marked as CD5+, CD19+ and CD23+. 
 
What is the most appropriate management of this patient? 
 
A. Observation alone. 
 
B. Prednis(ol)one. 
 
C. Chlorambucil. 
 
D. Combination chemotherapy. 
 
E. Autologous bone marrow transplantation. 

Answer - A

Treatment
Early stage - observation
Indications for tx:  progressive fatigue, symptomatic lymphadenopathy, anaemia or thrombocytopaenia (either symptomatic and progressive Rai II, or stage III/IV disease)

Staging - Rai
Stage 0 - lymphocytosis (low-risk)
Stage II - organomegaly (low risk)
Stage III - anaemia (high risk)
Stage IV - thrombocytopaenia (high risk)

147

Question 53 
 
A patient bleeds during low molecular weight heparin treatment. 
 
Which one of the following best indicates whether the heparin is contributing to bleeding? 
 
A. The activated partial thromboplastin time. 
 
B. The thrombin clotting time. 
 
C. The antifactor Xa activity. 
 
D. The prothrombin time. 
 
E. The tissue factor inhibitor assay.

Answer:  C

148

Describe the second test you would do after confirming a prolonged APTT and the meaning of it's results.

Mixing study: 50% pooled:50% pt plasma
Imm/Incubated Correction = factor deficiency
Imm/Incubated delay: Inhibitor (heparin)
Immediate correction/Incubated delay = delayed inhibitor present
Inhibitors:  Heparin, Lupus AC (in vivo), acquired factor inhibitors (commonly VIII)
Deficiencies: VIII (a), IX (b), VWF (VIII carrier)

149

Which cytotoxics cause peripheral neuropathy?

Platins
Vincristine

150

What are the indications, MOA, and main side effect of hydroxyurea?

Polycythaemia vera and essential thrombocytosis

Inhibits ribonucleotide reductase, decreasing DNA synthesis

Myelosuppression

151

What side effect does the antimetabolite drugs all have in common?

Myelosuppression

152

What is Haemophilia A?
What are it's clinical findings?
How is it diagnosed?
How is it treated?

Hamophilia A (VIII Deficiency)
- X-linked recessive (men get, women carry)
- 30% are spontaneously ACQUIRED
- less common than B, more severe
- mild >5% (no bleed) /mod 1-5% (variable)  / severe <1% (VIII deficiency)
- Once bleeding, all phenotypes bleed the same
- Haemarthroses (knee>elbow>ankle) 70-80%
- CNS bleeds in severe phenotype
- Tx:  prophylaxis in severe (aim to reduce to mod), early tx of bleeds with factor replacement (at home if simple), avoid antiplatelets, regular exercise, replace factors (plasma/recombinant, cry in developing world), DDAVP (increases VIII and VWB levels, transexamic acid (antifibrinolytics) to stop clot breakdown

153

What is vonWillebrands disease?

VWB (deficiency or dysfunction
- multimeric protein, plasma & endothelial cells (Weibel-palade bodies)
- Expressed on activated endothelial cells, released from alpha granules of activated platelets
- synthesized in megakaryocytes
- T ½ = 12 hours
- binds plt at injury site, carries VIII
- decreased plt adhesion, decreased VIII → bleeding
- Increased by: age, African, non O blood, inotropes (aderenaline), inflammation, hormones (OCP, pregnancy, periods)
- Type 1:  partial quantitative deficiency, decreased VWF levels, likely gene mutation, significant bleeding and FHx of.
- Type 3: Rare, near complete deficiency
Tx:  DDAVP (increases VIII and VWB levels), human derived VWF with VIII, antifibrinolytics (transexamic acid)

154

Which is more common, haemophilia A or B?

B.  Factor 9 deficiency

155

What are the causes of a prolonged APTT and INR?

Global dysfunction (APTT & INR)
DIC = plus low fibrinogen and high d-dimer
Liver disease → synthetic ftn (check albumin), TV factors
Direct thrombin inhibitors / Xa inhibitors (dabigatran and rivaroxaban)
Common pathway deficiency (rare)

156

What are the lab findings in DIC?

DIC = Low APTT and INR plus low fibrinogen and high d-dimer

157

What does the INR/PT look at in terms of the coagulation cascade?  What prolongs it?

INR/PT (Extrinsic/Tissue factor pathway)
Fibrinogen, prothrombin, V, VII, & X
Particularly sensitive to VII
Prolonged by Vit-K antagonism (Warfarin), deficiency (ETOH/malabsorption), undx VII deficiency
Relationship to factor-level is non-linear (still have 30% of factors if level is 2, low bleeding risk)
Curve plateaus at 3 and beyond so bleeding risk same between 3-14
This is the main pathway activated by endothelial damage

158

Which coagulation pathway is activated by endothelial damage?

Extrinsic pathway

159

What does the anti-Xa level test?

Anti-Xa assay
Measures heparin effect
Can use to titrate dose down

160

What is the Thrombin Clotting Time (TCT) test used for?

Thrombin Clotting Time (TCT)
Used when mixing study not corrected - looks for an inhibitor
Increased by heparin (reptilase normal), faulty fibrinogen, increased fibrin degradation products, and dabigatran

161

What to protein C & S do?

Protein C & S (anticoagulants)
Activated by thrombin to form a negative feedback loop.  Forms the APC (activated protein C) complex with protein S, which then degrades Factor V and VIIIa (so blocks the common pathway and last step of the intrinsic pathway respectively

162

What does the reptilase test do?

Reptilase test - looks for an acquired inhibitor that isn't heparin
Reptilase splits fibrinogen →fibrin
Not prolonged by heparin

163

Which factors belong to the intrinsic coagulation pathway?

12, 11, 9, and 8

164

Which factors belong to the extrinsic coagulation pathway?

7 and tissue factor

165

Which factors belong to the common coagulation pathway?

Factors 10, 5, 2 (prothrombin), and 1 (fibrinogen)

166

What does factor 12 do?

Starts the intrinsic pathway coagulation cascade

167

What does factor VII do?

The main role of factor VII (FVII) is to initiate the process of coagulation in conjunction with tissue factor (TF/factor III). Tissue factor is found on the outside of blood vessels - normally not exposed to the bloodstream. 

168

What does factor VIII do?

In response to injury, coagulation factor VIII is activated and separates from von Willebrand factor. 

169

What is the main role of the extrinsic pathway?

The main role of the tissue factor pathway is to generate a "thrombin burst", a process by which thrombin, the most important constituent of the coagulation cascade in terms of its feedback activation roles, is released very rapidly.

170

What is the role of factor V?

Factor V:  Procoagulant that amplifies thrombin production. Small amount of thrombin at a wound activates factor V via limited proteolysis, which in turn becomes a cofactor in the prothrombinase complex, cleaving prothrombin to generate more thrombin in a positive feedback loop.

Thrombin then generates a negative feedback loop by converted protein C to activated protein C.

171

What is the role of protein C in the coagulation cascade?

Activated protein C (APC): natural anticoagulant, cleaves and inactivates activated factor V and VIII which then reduces thrombin production. 

APC affects both factor V and factor Va (activated V) to increase clotting risk.
1.  When APC cleaves factor V (the inactive version),  it (factor V) becomes a cofactor in further degration of Va and VIIIa.  With the point mutation at position 506 on Factor V, APC can't cleave the factor, it becomes less effective as a cofactor and the degradation

2.  APC performs a series of sequential cleavages on Factor Va, the first of which is the position 506 point.  With this site removed, sequential cleavage cannot happen, resulting in 20x slower degration of the factor (factor V Leiden).  With the activated factor unable to be cleaved, more thrombin continues to be generated.

These effects contribute equally to thrombosis and explain the stronger presentation in homozygotes.

172

What is leucodepletion?  Why is it important?

Leucodepletion is the removal of white blood cells from a blood component. In Australia, this applies to whole blood, red cells and platelets.

The potential benefits of leucodepletion for patients include:
- Reduction in platelet refractoriness

- Reduction in febrile non-haemolytic transfusion reactions.  (FNHTR)

- Reduction in CMV transmission risk

- Improved chance of finding an organ transplant match if required

- Reduction in storage lesion effect


173

Which of the following transfusion reactions is leucodepletion most effective in preventing?
A.  Febrile non-haemolytic transfusion reaction. 

B.  Transfusion associated graft versus host disease. 

C.  Anaphylaxis. 

D.  Transfusion related acute lung injury. 

E.  Delayed haemolytic transfusion reaction. 

Answer:  A

174

What is a febrile non-haemolytic transfusion reaction?
What causes it?

1.  Unexpected temperature rise (≥38ºC or ≥1ºC above baseline, if baseline ≥37ºC) during or shortly after transfusion. Usually an isolated finding. 

2.  Caused by leucocyte antigen-antibody reaction and by cytokine accumulation produced by leucocytes in transfused blood.  Formation of cytokines can be avoided if the leucocytes can be removed immediately (leucodepletion)

FNHTR is also caused by the presence of recipient antibodies (raised as a result of previous transfusions or pregnancies) reacting to donor human leucocyte antigens (HLA) or other antigens. These antigens are present on donor lymphocytes, granulocytes, or platelets.

175

With regards to blood products, what is a storage lesion?
How can you reduce it?

The changes occurring in storage of RBCs including increased ammonium, free Hb, and potassium, and decreased ATP, 2,3DPG, labile proteins (complement, coagulation factors, fibronectin), sodium, and pH.  

Leucocyte degradation during storage results in cell fragments which may not be removed by post-storage filtration - can provoke HLA or platelet alloimmunisation. In leucodepleted blood - there is a lower incidence of alloimmunisation and (possibly) diminished immunomodulation that may result from the transfusion of membrane fragments.  

176

What is the most common cause of transfusion-related fatalities?
What are the symptoms, timeframe, and incidence?

TRALI

Symptoms:  Acute onset of fever, chills, dyspnoea, tachypnoea, tachycardia, hypotension, hypoxaemia and noncardiogenic bilateral pulmonary oedema leading to respiratory failure during or within 6 hours of transfusion.
Implicated in transfusion of unfractionated plasma-containing components.

Incidence:  1:10,000 most commonly reported. 

177

With regard to transfusion, what constitiutes a delayed haemolytic transfusion reaction?

Which blood groups are associated with it?

How do you treat it?


Patients may present with unexplained fever and anaemia usually 2 to 14 days after transfusion of a red cell component.  

Unexplained fever and anaemia 2-14 days after transfusion of red-cell component. May also have jaundice, high bilirubin, high LDH, reticulocytosis, spherocytosis, positive antibody screen and a positive Direct Antiglobulin Test (DAT).

Causes:  After transfusion, transplantation or pregnancy, a patient may make an antibody to a red cell antigen that they lack. If the patient is later exposed to a red cell transfusion which expresses this antigen a DHTR may occur.  DHTRs may also occur with transfusion transmitted malaria and babesiosis.

Blood group antibodies associated with DHTRs include those of the Kidd, Duffy, Kell and MNS systems, in order of decreasing frequency.

Most delayed haemolytic reactions have a benign course and require no treatment, however life-threatening haemolysis with severe anaemia and renal failure may occur.
If an antibody is identified, you may request for antigen-negative blood if further transfusion is needed.

178

Name the thrombin inhibitors

Dabigatran
Argotroban
Bivalriduin
Lepirudin

179

Name the XA inhibitors)

Xa Inhibitors
Rivaroxaban
Apixaban
Fondaparinux (via AT
Danaprinoid

180

Name the combined Xa & thrombin inhibitors

Heparin

181

Name the vitamin K antagonist and what it inhibits

Warfarin (Thrombin (II), VII, IX and X) via impaired hepatic synthesis.

182

What is the  mechanism of action, clearance and indications for Rivaroxaban?  What blood tests does it affect?

Factor Xa inhibitor
T ½ = 12-17h Peak 1-3h
Renally excreted
Minimally protein bound
Irreversible
Monitor: dilute thrombin time (special)
Prolongs APTT & INR
Does not affect fibrinogen level
Indicated for stroke prevention (non-valvular AF), thromboprophylaxis post hip and knee replacement

183

How do you manage bleeding associated with dabigatran and rivaroxaban?

Dabigatran or Rivaroxaban Bleeding
Coag screen, G&H, usual bloods, stop drug
Mild: compression, antifibrinolytics (tranexamic acid) QID, delay further oral anticoagulation
Mod/Severe: Antifibrinolytics, as for usual bleeding, transfuse, consider charcoal if <2h for dabigatran, <8h for rivaroxaban
Consider HD for dabigatran

184

How does dabigatran work?  What blood tests does it affect?  Indications?
How do you manage bleeding?

Direct thrombin (IIa) inhibitor
T ½ = 7-11h Peak 1-3h
50% renally excreted
Highly protein bound
Irreversible
Prolongs APTT & INR, TCT
Does not affect fibrinogen level
Indicated for stroke prevention (non-valvular AF), thromboprophylaxis post hip and knee replacement, treatment of DVT
Bleeding:  INR, APTT,TCT, Fibrinogen, check renal ftn, if TCT normal then low dabigatran level, supportive, tranexamic acid, charcoal, dialysis

185

What test would you do to see if the dabigatran level was low?

Thrombin clotting time.  It will be normal if the dabigatran level is low.

186

How does heparin work?

Heparin binds to the enzyme inhibitor antithrombin III (AT), causing a conformational change that results in its activation through an increase in the flexibility of its reactive site loop.  The activated AT then inactivates thrombin and other proteases involved in blood clotting, most notably factor Xa. 

187

What is tranexamic acid?  How does it work?  When is it useful?

It is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin, by binding to specific sites of both plasminogen and plasmin, a molecule responsible for the degradation of fibrin, a protein that forms the framework of blood clots. 

Useful where bleeding is going to be a problem, i.e dental extraction, certain surgeries.

188

Describe factor V leiden disease:
- mechanism
- epidemiology
- clinical findings
- when to test

Factor V Leiden
- mutant Factor V, can’t be switched off by APC so clotting continues.
- most common hereditary hyper coagulability disorder among caucasians.
- restricted to veins (so DVT and PE, not strokes or heart attaches)
- happens in 30% of unprovoked DVT/PE
- risk increases in pregnancy or oestrogen containing drugs.
- suspect in any DVT patient under the age of 45

189

How do you test for factor V leiden disease?

Most laboratories screen 'at risk' patients with either a snake venom (e.g. dilute Russell's viper venom time) based test or an aPTT based test. In both methods, the time it takes for blood to clot is decreased in the presence of the factor V Leiden mutation. This is done by running two tests simultaneously; one test is run in the presence of activated protein C (APC) and the other, in the absence. A ratio is determined based on the two tests and the results signify to the laboratory whether APC is working or not. These are quick, three minute, automated tests that most hospital laboratories can easily perform.

190

A 42-year-old previously healthy woman presents with an above-knee deep venous thrombosis of the right leg complicated by probable pulmonary thrombo-embolism.  She has no clinical risk factors such as recent surgery or trauma.   
 
In the investigation of her thrombo-embolic disease, which one of the following is the most likely abnormality to be found? 
 
A. Lupus anticoagulant. 
 
B. Protein C deficiency. 
 
C. Protein S deficiency. 
 
D. Dysfibrinogenaemia. 
 
E. Factor V Leiden.

Answer E.  The most common of the inherited disorders of DVT.

191

What does the prothrombin time measure?

PROTHROMBIN TIME (PT) — The prothrombin time (PT) (figure 1) is used to assess the extrinsic pathway of clotting, which consists of tissue factor and factor VII, and coagulation factors in the common pathway (factors II [prothrombin], V, X, and fibrinogen). 

192

What does the aptt measure?

ACTIVATED PARTIAL THROMBOPLASTIN TIME (aPTT) — The activated partial thromboplastin time (aPTT or PTT) is used to assess the integrity of the intrinsic coagulation pathway (prekallikrein, high molecular weight kininogen, factors XII, XI, IX, VIII) and final common pathway (factors II, V, X, and fibrinogen), and to monitor therapy with unfractionated heparin. 

193

What does FFP contain and when is it used?

Fresh frozen plasma comprises the acellular component of blood and contains all of the coagulation factors. It is used in patients with coagulopathy who are bleeding, or at risk of bleeding, when more specific therapy is not appropriate or available. Fresh frozen plasma is most commonly used in massive transfusion, cardiac bypass, liver disease or acute disseminated intravascular coagulopathy.

It is essential as the exchange product in plasmapheresis for TTP

194

What is in cryoprecipitate and when is it used?

Mainly used in DIC to replace fibrinogen.  Sometimes to correct platelet dysfunction in CKD.

Derived from FFP.

Cryoprecipitate contains most of the factor VIII, factor XIII, von Willebrand factor, and fibrinogen. 

Cryodepleted plasma can be used in plasma exchange for thrombotic thrombocytopenic purpura.

195

What does Factor XIII do?

Factor XIII or fibrin stabilizing factor is an enzyme (EC 2.3.2.13) of the blood coagulation system that crosslinks fibrin.  Upon activation by thrombin, factor XIIIa acts on fibrin to form γ-glutamyl-Є-lysyl amide cross links between fibrin molecules to form an insoluble clot.

196

Transfusion transmitted infections are now most likely to occur in Australasia following the infusion of which one of the following: 
 
A. red blood cells. 
 
B. platelets. 
 
C. factor VIII concentrate. 
 
D. fresh frozen plasma. 
 
E. anti D immunoglobulin. 

B.  Bacterial contamination of blood products, especially in platelets that are stored at room temperature, is the most common infectious risk of blood transfusion, occurring in approximately 1 of 2000-3000 platelet transfusions. Transfusion–transmitted sepsis, while less common, can cause severe illness and death. 

197

Why don't pregnant patients with Von Willebrands disease need treating?

Pregnant patients with vWD usually do not require treatment because of the natural physiologic increase in vWF levels 

198

Which drug is useful in the treatment of mild von Willebrands disease?

DDAVP is useful in the treatment of mild bleeding in most cases of type 1 

199

What are the lab findings in Von Willebrands disease?

vWF activity (by ristocetin co-factor assay) and Ag are mildly depressed, whereas the vWF multimer pattern is normal.

Except in the more severe forms of vWD that feature a significantly decreased factor VIII activity, the aPTT and PT in vWD are usually normal.

200

What are the clinical findings of vonWillebrand disease?

Type 1 vWD usually have mild or moderate platelet-type bleeding (especially involving the integument and mucous membranes).

201

What is the main type of vonWillebrands disease?  What proportion does it make up?

Between 75% and 80% of patients with vWD have type 1. It is a quantitative abnormality of the vWF molecule that usually does not feature an identifiable causal mutation in the vWF gene.

202

What is von Willebrand factor?  What does it do?

vWF is an unusually large multimeric glycoprotein that binds to its receptor, platelet glycoprotein Ib, bridging platelets together and tethering them to the subendothe- lial matrix at the site of vascular injury. vWF also has a binding site for factor VIII, prolonging its half-life in the circulation.

203

What is the most common inherited bleeding disorder?
What does the factor do normally?

The most common inherited bleeding disorder.
von Willebrand factor aggregates platelets and prolongs the half-life of factor VIII.

204

What is the significance of the lupus anticoagulant other than it's presence in connective tissue disease?

Which test confirms it's presence?

May occur with increased frequency in individuals with underlying infection, inflammation, or malignancy, and they also can occur in asymptomatic individuals in the general population. A prolongation in the aPTT is observed that does not correct completely on mixing.

Russell Viper Venom test.

205

How does uremia cause bleeding?

Damages platelets via --> Increased Nitric oxide; decreased release of granules

206

How do salicylates cause bleeding?

Irreversible inhibition of platelet cyclooxygenase

207

How do NSAIDS cause bleeding?

Reversible inhibition of platelet cyclooxygenase

208

How do SSRIs induce bleeding?

Decreases serotonin in dense granules in platelets

209

What is a Heinz body?

In what condition would you see them?

Heinz bodies appear as small round inclusions within the red cell body and are formed by damage to the hemoglobin component molecules, usually through oxidant damage, or from an inherited mutation (i.e. change of an internal amino acid residue).  In the spleen, macrophages attempt to remove these, leaving bite cells.

Found in
G6PD deficiency
Alpha thalassaemia
NADPH deficiency
Liver disease.

210

What is HbH?

The excess β chains form unstable tetramers (called Hemoglobin H or HbH of 4 beta chains) which have abnormal oxygen dissociation curves. The excess γ chains form tetramers which are poor carriers of O2 since their affinity for O2 is too high so it is not dissociated in the periphery.

211

What are Howell-Jolly bodies?

Howell–Jolly bodies are histopathological findings of basophilic nuclear remnants (clusters of DNA) in circulating erythrocytes. During maturation in the bone marrow late erythroblasts normally expel their nuclei, but in some cases a small portion of DNA remains. Its presence usually signifies a damaged or absent spleen.

212

What is autoagglutination?

Autoagglutination represents clumping of an individual's red blood cells (RBCs or erythrocytes) by his or her own serum due to the RBCs being coated on their surface by antibodies.  Happens in COLD haemagglutinin disease.

213

Which haematological malignancy is AIHA most commonly associated with?

CLL

214

What is a schistocyte?

What causes it?

Fragmented red blood cell
Also known as 'helmet cell'

Associated with microangiopathy
Most commonly mechanical valves or AS
HUS
TTP
DIC

215

What is the general pathogenesis of thrombotic microangiopathy?

TTP?

HUS?

Thrombotic microangiopathy

Pathogenesis
Platelet aggregation due to either endothelial damage (HUS) or protease insufficiency (ADAMST-13, TTP) —> shearing of circulating erythrocytes —> thrombocytopaenia and haemolytic anaemia.

TTP —> Autoantibodies against ADAMST-13, a protease that cleaves ultra-large vWF multimers —> accumulation of uncleaved multimers —> TTP
(Congenital TTP is a gene mutation resulting in decreased levels of Adamst-13)
Adults

HUS —> damage to endothelial cells (E.coli, cancer, stem cell transplant, HIV, drugs) —> platelet aggregation.
Kids

216

What are the clinical findings in TTP and HUS?  What is required for diagnosis?

For diagnosis:
Microangiopathic haemolytic anaemia
Thrombocytopaenia

Pentad (not req for dx)
Microangiopathyc haemolytic anaemia
Thrombocytopaenia
Fever
Renal insufficiency
Neurological abnormalities

Recent diarrhoeal illness (HUS)

217

What are the lab findings in TTP and HUS?

Haemolysis:  elevated LDH, bili, low haptoglobin, reitculocytosis, negative DAT, schistocytes on blood smear)
Thrombocytopaenia
ARF (usually HUS)
Positive stool culture for E.coli or shiga-toxin
Coagulation studies are normal

218

What is the treatment for TTP and HUS?

Plasma exchange and replace w/ FFP —> essential, 95% mortality without it
Supportive only if diarrhoea-HUS
Continue to exchange for two days until platelet count and LDH are normal for at least 2 days.
Give FFP if no plasma available
Platelet transfusions are CONTRAINDICATED as may make it worse
Dialyse if significant renal failure
Relapse —> Plasma exchange

219

What the main differences between TTP and HUS?

TTP —> autoantibody to ADAMST-13
Usually has fever and neurological defects

HUS —> Endothelial damage - usually due to e.coli
Usually has renal failure, no fever or neurological defects
Recent history of diarrhoea

220

What is the pathogenesis of hereditary spherocytosis?

Familial defect of red cell membrane due to an abnormality in spectrin, actin or other proteins.
Scaffolding defect results in decrease surface to volume ratio and loss of central pallor of the RBC —> less deformability —> trapping of RBCs in the spleen —> removal by splenic macrophages.

221

What are the clinical findings in hereditary spherocytosis?

Autosomal dominant
Variable anaemia
May have aplastic crisis due to infection (Parvo B19) or folate deficiency
Gallstones from a young age
Jaundice
Icterus
Palpable spleen

222

What are the lab finding in hereditary spherocytosis?

Smear:  Reticulocytosis always, large amount of spherocytes on the blood film, microcytosis
Increased MCHC
Negative coombs
Increased osmotic fragility (abnormal vulnerability to swelling induced by hypotonic media)

223

What is the treatment of hereditary spherocytosis?

Daily folic acid
Splenectomy (if severe) cures it (stops destruction, doesn’t cure abnormal RBCs)

224

What is the pathogenesis of paroxysmal nocturnal haemoglobinuria?

Pathogenesis
Acquired defect in PIG-A (phosphatidylinositol class A) gene —> deficient GPI anchor for cell membrane protein —> deficient complement regulating proteins CD55 and CD59 —> unregulated formation of MAC attack complex on RBC membranes —> intravascular haemolysis.
Free haemoglobin is released into the blood —> scavenges nitric oxide —> oesophageal spasm, erectile dysfunction, renal damage, thrombosis (primary cause of death)

In short - abnormal sensitivity of the RBC membrane to complement.

225

What are the clinical findings in PNH?

Episodic haemoglobinuria on first morning urine (pH drops at night —> haemolysis)
Thrombosis (mesenteric and hepatic veins, CNS veins (sagittal), skin vessels (painful nodules)
May arise on it’s own or in setting of aplastic anaemia with progression to myelodysplasia or AML

226

What are the lab findings in PNH?

Variable anaemia
May or may not have reticulocytosis
Smear is non diagnostic - may have macro-ovalocytes and polychromasia
Urine haemosiderin (chronic haemolysis)
Iron deficiency due to haemoglobinuria
Flow cytometry:  Deficiency of CD55 and 59
Low WBC and PLT, esp if aplastic anaemia

227

What is the treatment of PNH?

Mild - do nothing
Severe or thrombosis —> Eculizumab
Aplastic anaemia or MDS —> allo STC
Replace iron
Corticosteroids can be useful

228

What is eculizumab and what are the benefits?

Anti-terminal complement protein C5 (initiator of MAC) - used for PNH.
Improves QOL, reduces haemolysis, transfusion requirements and thrombosis risk

229

What is the pathogenesis of G6PD deficiency?

Hereditary enzyme (G6PD) defect (deficiency) —> excess oxidised glutathione —> haemoglobin denatures —> precipitates Heinz bodies causing RBC membrane damage —> premature removal of RBCs by spleen (extravascular haemolysis)

230

What are the clinical findings in G6PD deficiency?

X-linked
Found in Africans (milder), and Mediterraneans (severe), and Ashkenazi Jews.
Episodic haemolysis in response to oxidative stress on RBCs (infection, exposure to certain drugs

231

Why is the haemolysis in G6PD deficiency often self limiting?

Self limited haemolysis because old RBCs w/ low enzyme activity are removed and replaced with young RBCs (reticulocytes) which are G6PD replete.

Severe deficiency (Mediterranean variant) —> chronic haemolytic anaemia.

232

What are the lab findings in G6PD deficiency?

Between episodes —> normal blood
During —> Hb rarely drops below 80, reticulocytosis, increased bill
Smear:  Bite/blister cells (pitting of Hb aggregates by the spleen).  Heinz bodies on cresyl violet stain
Low G6PD levels BETWEEN episodes (false normal during or shortly after due to replete retics), check weeks later.
Severe disease - permanently low enzyme levels

233

What is the treatment of G6PD defiency?

Avoid oxidant drugs

234

What drugs should you avoid in G6PD deficiency and why?

They are oxidant drugs causing oxidant stress --> haemolysis.

Drugs to avoid:  Dapsone (leprosy), methylene blue, phenazopyridine, primaquine (malaria, PCP), rasburicase (gout, tumor lysis syndrome), toluidine blue, nitrofurantoin

235

What is the pathogenesis of sickle cell anaemia?

Autosomal recessive disorder —> DNA base change of valine for glutamine on the B-globin change —> Bs —> A2BS2 —> HbS —> unstable, polymerises under stress (dehydration, acidosis, hypoxia) —> sickled RBCs —> splenic sequestration —> haemolytic crises & eventual splenic infarction

* HbF cannot polymerise —> retards sickling when present

236

What are the clinical findings in sickle cell anaemia?

Onset in 1st year of life (HbF levels fall due to y-globin switching to B-globin
Chronic haemolytic anaemia —> jaundice, pigment gallstones (young) splenomegaly (young), poorly healing ulcers over lower tibia
Life threatening severe anaemia during haemolytic or aplastic crises (viral or other infections, folic acid deficiency)
Acute painful episodes due to acute vaso-occlusion
Delayed puberty, increased incidence of infection due to hyposlenism
Chronically ill, jaundice, hepatomegaly but no splenomegaly
Cardiac enlargement with hyper dynamic and systolic murmurs
Nonhealing lower leg ulcers

237

What are the features of the vaso-occlusive disease in sickle-cell anaemia?

Acute painful episodes due to acute vaso-occlusion from clusters of sickled cells (spontaneous, infection, dehydration, hyopxia)
Pain —> back and long bones, chest, lasts hours to days
Acute vaso occlusion —> sagital sinus thrombosis (strokes), priapism, organ and bone necrosis, renal medullary papillae infarcts —> gross haemoturia (more in trait), retinopathy, plum HT  Not assoc w/ increased haemolysis
Ischaemic necrosis of bone due to vascular occlusion —> salmonella osteomyeletis

238

What are the lab findings of sickle cell anaemia?

Lab findings
Chronic haemolytic anaemia
Smear:  Irreversibly sickled cells, nucleated RBCs, hyposplenism:  Howell-Jolly bodies and target cells
Elevated WBC and reactive thrombocytosis
Elevated indirect bili

Hb EPG (diagnostic):  HbS comprises 85-98% of the haeoglbonin
Homozygous - no HbA present, elevated HbF (high = better prognosis)

239

What is the treatment of sickle-cell anaemia?

Allo SCT is curative >80% of kids
Hydroxyurea increases HbF levels epigenetically, reduces painful crises and overall survival
Supportive care is mainstay - folic acid, transfuse in aplastic or haemolytic crises, pneumovax.
Hydrate and oxygenate through acute painful episodes.
Acute vaso-occlusive crises (pain, acute chest, priapism, stroke) —> exchange transfusion

240

What is the clinical significant of sickle-cell trait?

Heterozygotes —> may be positive on screening test, HbS 40% on EPG
Haematologically normal
May experience sudden cardiac death and rhabdo during vigorous exercise esp at high altitude
Increased risk of VTE
May have renal medullary disease as it’s acidotic —> microscopic and gross haematuria.
No treatment.

241

What is the mechanism of autoimmune haemolytic anaemia?

Acquired IgG autoantibody binds RBC at body temp —> Antibody directed at basic component of Rh system present on most human RBCs —> splenic macrophage recognises Fc portion of antibody —> removal of RBC membrane by macrophage —> spherocyte formed —> decreased deformability -> trapped in splenic red pulp —> haemolysis

242

What is the second mechanism of haemolysis in autoimmune haemolytic anaemia?

If large amounts of IgG —> fixation of complement —> presence of C3b on RBC —> destruction of RBC by hepatic Kupffer cells

(Direct complement driven lysis anywhere else is rare).

243

What is the aetiology of autoimmune haemolytic anaemia?

50% idiopathic
Rest:  SLE, CLL, or lymphoma
Drug induced:  Antibody is against membrane-drug complex. (Penicillim ceftriaxone, piperacllin, cefotetan, and fludarabine (immunosuppresson —>defective immune surveillance)

244

What are the clinical findings in autoimmune haemolytic anaemia?

Rapid onset haemolytic anaemia
Fatigue and dyspnoea
Angine or cognitive heart failure
Jaundice and splenomegaly

245

What are the lab findings in autoimmune haemolytic anaemia?

Variable anaemia, may be v severe
Reticulocytosis and spherocytosis on smear, nucleated RBCs if severe
Indirect hyperbilirubinaemia
10% have concurrent immune thrombocytopaenia (Evans syndrome)

DAT positive for IgG +/- C3b

246

What is Evans syndrome?

AIHA + concurrent immune thrombocytopaenia

247

What is the difference between the direct antiglobulin test (Coombs) and indirect?

DAT:  rabbit IgM antibody against Human iG or complement —> agglutination = presence of antibody on RBC surface

Indirect: patient SERUM mixed with type O RBCs —> agglutination = presence of free antibody

Positive IDAT = large amount of autoantibody that has saturated RBC binding sites, winding up in the serum.

248

What is the treatment of AIHA?

Autoantibody makes it difficult to get a compatible cross-match
Pred 1mg-2mg/kg
Transfused RBCs will survive similarly to the patient’s own
Splenectomy potentially curable
Rapid + severe —> therapeutic plasmapheresis
Rituximab may be effective

249

What is the prognosis for AIHA like?

The long-term prognosis for patients with this disorder is good, especially if there is no underlying autoimmune disorder or lymphoma.

250

What is the pathogenesis of cold agglutinin disease?

IgM autoantibody (cold agglutinin) against I antigen on RBCs —> binds and fixes complement at peripheries (cool areas) —> RBC returns to warmer circulation —> IgM dissociates —> only complement (C3b) left behind —> recognised by hepatic Kupffer cells —> RBC sequestration and destruction, sometimes MAC attack

251

What is the aetiology of cold agglutinin disease?

Idiopathic
Waldenstrom or CLL due monoclonal iGm paraprotein
Infectious:  Mycoplasma pneumonia, mono, measles, mumps

252

What are the clinical findings of cold agglutinin disease?

Mottled or numb fingers or toes
Episodic low back pain
Dark coloured urine one exposure to cold
Haemolytic anaemia is rarely severe

253

What are the lab findings in cold agglutinin disease?

Mild anaemia w/ reticulocytes
Agglutinated RBCs on smear at room temp
DAT + for C3b only
Serum cold agglutinin titer semi-quantitative

254

What is the treatment of cold agglutinin disease?

Avoid cold!
Splenectomy and pred ineffective unless underlying lymphoproliferative disease (haemolysis takes place in liver and blood)
Rituximab is treatment of choice, relapse is effectively retreated
May need to use alkylators in severe disease
May be difficult to find compatible blood
TRANSFUSE THROUGH A BLOOD WARMER

255

What is the hallmark of microangiopathic haemolytic anaemia?

The finding of fragmented red blood cells (schistocytes, helmet cells) on the peripheral blood smear.

The anemia is intravascular, producing hemoglobinemia, hemoglobinuria and, in severe cases, methemalbu-minemia

256

Is the anaemia of cold-agglutinin disease intravascular or extravascular?

Mainly extravascular --> liver
Intravascular due to fixation of complement

257

What is the mechanism of iron deficiency in chronic microangiopathic haemolytic anaemia?

Continuous low-grade haemoglobinuria

258

Question 66 
 
A 45-year-old woman presents with progressive lethargy over 10 days.  There is no history suggestive of infection.  There has been no previous medication. 
 
Initial investigations show: 

  
 
Which one of the following is most likely to be present on the blood film? 
 
A. Plasma cells. 
 
B. Red cell autoagglutination. 
 
C. Red cell fragmentation. 
 
D. Hypersegmented neutrophils. 
 
E. Target cells. 

Answer:  B - cold agglutinin disease is DAT positive of complement only

259

Question 69 
 
A 38-year-old woman presents with a one-week history of dyspnoea on exertion.  She has had no previous medical problems and is taking no medications.  Physical examination is unremarkable apart from mild pallor and a palpable splenic tip.  Initial investigations are as follows: 

  

The blood film is shown below.
 
  
 
 
Which one of the following conditions is the most likely cause of these findings? 
 
A. Hereditary spherocytosis. 
 
B. Systemic lupus erythematosus. 
 
C. Infectious mononucleosis. 
 
D. Mycoplasma infection. 
 
E. Cold haemagglutinin disease. 

Answer:  B

This is autoimmune haemolytic anemia - there are minimal spherocytes on the film so it's not A - and C, D, and E all cause cold agglutinin disease and are only positive for C3 on the DAT as the Ig hs dissociated (it's IgM anyway)

260

A 69-year-old woman commences a chronic transfusion program for anaemia secondary to myelodysplasia.  She experiences a non-haemolytic febrile transfusion reaction during each of two red cell transfusions administered four weeks apart. 
 
Which one of the following reasons best explains the benefit of using filtered blood to prevent further reaction?  
Reduced exposure to: 
 
A. donor leucocytes. 
 
B. donor cytokines. 
 
C. bacterial antigen. 
 
D. cytomegalovirus (CMV). 
 
E. donor isohaemagglutinins. 

A. donor leucocytes. 

261

A 62-year-old woman underwent an elective cholecystectomy.  Routine full blood examination revealed:
 
 

Physical examination revealed no lymphadenopathy and no hepatosplenomegaly.  The woman was asymptomatic.  Flow cytometry revealed that the lymphocytosis marked as CD5+, CD19+ and CD23+. 
 
Which one of the following is the most appropriate management option? 
 
A. Observation alone. 
 
B. Prednis(ol)one therapy. 
 
C. Chlorambucil therapy. 
 
D. Combination chemotherapy. 
 
E. Autologous bone marrow transplantation. 

Answer - A, this is asymptomatic CLL.

262

A 65-year-old man with a history of osteoarthritis and mild chronic obstructive pulmonary disease presents with several days of nausea and vomiting and is now confused, febrile and icteric.  He has extensive bruising and some oral mucosal bleeding.  His medications are intermittent piroxicam and a salbutamol inhaler. 
 
His full blood count shows: 

   

Blood film as shown in the photograph below. 

 
 
The most likely diagnosis is: 
 
A. gram-negative sepsis. 
 
B. leptospirosis. 
 
C. disseminated intravascular coagulation. 
 
D. thrombotic thrombocytopenic purpura. 
 
E. piroxicam toxicity. 

Answer:  D

This is TTP - there is fragmented red cells (hallmark) and thrombocytopaenia due to platelets clumping.  The absence of a recent diarrhoeal infection and presence of neurological symptoms makes it more likely to be TTP over HUS (if that were an option).

263

What is the hematocrit?

Percentage of red blood cells in the full blood count.

It is usually 45% for men and 40% for women.

264

What is anisocytosis?

Variations in red blood cell size

265

What is poikilocytosis?

Variations in red blood cell shape

266

What is the difference between horse and rabbit ATG?

Horse is twice as effective, rabbit is not used in Australia.

267

Which drug causes a delayed neutropaenia of around 2-3 months?

Rituximab

268

What are the central causes of pancytopaenia?

Drugs
B12/folate deficiency
• AA
MDS
Haem malignancy
Myelofibrosis
Non-haem infiltration
– Solid tumour
– Storage disorders
Haemophagocytic Syndrome

269

What are the peripheral causes of pancytopaenia?

Peripheral Destruction
• Hypersplenism
• Dilutional (pregnancy)
• Severe sepsis

270

Which is the only cause of pancytopaenia that does not result in a hypercellular bone marrow?

Aplastic anaemia (any cause)

271

What is the epidemiology of aplastic anaemia?

• RARE – 1-2/million) 
• 3 peaks
– 2-5 yrs (inherited)
– 20-25 yrs
– >55 yrs (acquired)

272

What is the clinical presentation of aplastic anaemia?

– Bleeding
– Fatigue & pallor
– Fevers/mouth ulcers/bacterial infections

273

What is the basic pathogenesis of aplastic anaemia?

Stem cell failure – inherited or acquired

274

What are the causes of childhood aplastic anaemia?

• 75% inherited
• Fanconi Anaemia (FA)
• Dyskeratosis Congenita (DC)
• Congenital Amegakaryocytic 
Thrombocytopenia (CAMT)
• Schwachmann-Diamond Syndrome (will 
be discussed under neutropenia)

275

What are the pathogenesis and features of Fanconi's anaemia?

AR or X linked
All involved in DNA repair & stabilisation - 8 of these form complex in response to  replicative stress, esp crosslinking and reactive O2 species
All ethnic/racial groups (more in Ashkenazi)
• congenital malformations in 60-70%
– Café-au-lait spots & hypopigmentation
– Abnormal thumbs
– Microcephaly & short stature
– Hypogonadism & delayed development
- Bone marrow failure, MDS --> AML (later)

276

What is the natural history of fanconi's anaemia?

 By age 40 progression to:
• Complete BM failure 90%
• Acute Leukaemia/MDS 33%
• Solid CA 28% 
– SCC head & neck & vulva commonest 
• 80% mortality by age 40yrs

277

What is the treatment of Fanconi's anaemia

Fanconi Anaemia - Treatment
• Allogeneic Stem Cell Transplant – curative
– problem of affected family donors (harder to 
find unaffected but HLA-matched donor)
– May inc risk solid tumours 
• Androgens (oxymethalone)
– If no transplant available
– 50% respond
– Anaemia responds best
• Supportive care – transfusion, GCSF

278

What are the features of dyskeratosis congenita?

Classic triad of ectodermal abnormalities
- reticulated rash face/shoulders/trunk
- mucosal leukoplakia
- progressive nail dystrophy, small thin bed, longitudinal ridges, nails disappear with age
75% have one, 46% have all 3 at Diagnosis

Childhood cause of aplastic anaemia

279

How do drugs cause pancytopaenia?

Drugs as cause of pancytopenia
• Direct toxic effect of drugs 
– eg chemotherapy or immunosuppression
– commonest cause of pancytopenia
– Recovery in days-weeks
– G-CSF speeds recovery when some 
precursors present
• Adverse interaction 
– Eg azathioprine + allopurinol
– Eg Methotrexate in renal impairment

280

What are the drugs that cause aplastic anaemia?

• Idiosyncratic effect of drugs 
• Rare effect
• Cause unclear in most cases
– Chloramphenicol 1:20,000
– Gold (dose-related >200mg)
– NSAIDs
– Sulphonamides
– Antiepileptics
– Arsenics

281

What are the non-drug causes of acquired aplastic anaemia?

– Irradiation
– Viral – Parvo B19 (more commonly causes PRCA) , 
Hepatitis, HIV, EBV
– Chemical – benzene (rubber factories), lindane, glue 
vapours
– Immune – eosinophilic fasciitis, SLE, GvHD
PNH – 1/3 will develop AA
– Pregnancy – usually resolves with delivery
– Thymoma/thymic CA
– But most adult cases are IDIOPATHIC (80%)

282

What is the basis for aplastic anaemia having an underlying immune cause?

– Most respond to immunotherapy
– Assoc w rare immune eosinophilic fasciitis
– AA can develop in GvHD

283

What are the outcomes in aplastic anaemia for allogeneic BMT vs Immunosuppression?

15 year surivival 69% for BMT vs 38% for immunosuppression
Much less risk of malignancy with BMT, higher risk of MDS/AML with immunosuppression
HOWEVER
only 30% will have matched donor, risk goes up with age, and GvHD with BMT

284

What is the prognosis in aplastic anaemia?

With immunosuppression:

Best case around 50% in over 60s and 72% in under 50s

Worst, 21% and 50% respectively

285

Who do you give an allo-BMT to in aplastic anaemia?

<20 years old if available, up to age 50 if no comorbidities

Avoid pre-transfusion wherever possible.

286

What is the treatment for relapsde and refractory aplastic anaemia?

 Relapse – 50-60% respond to retreat with 
ATG (horse or rabbit), CAMPATH similar
• Refractory – 30% respond to rabbit ATG, 
CAMPATH similar
• OS in responders same as those with 
initial response but no relapse 

287

What is campath/alemtuzumab?

Monoclonal antibody that binds to CD52, (mature lymphocytes), but not  stem cells.

288

What is the septic risk in isolated neutropaenia?

Blood neuts = 3% total body neutrophil 
reserve => markers of reserve can 
indicate septic risk
• Febrile, raised CRP, gingivitis, mucositis – poor reserve – high septic risk
• Abscess formation – good reserve – lower septic risk

289

When is septic risk greatest in neutropaenia?

Septic Risk relatively low down to 
around 0.5 x 10^9/L, then rises sharply
• Risk is greater in context of:
– a falling count (progressively decreasing  availability)
– lack of early precursors/empty BM rather  than when maturation arrest)
– prolonged length of neutropenia

290

What is the most common fatal cause of transient neutropaenia?

 Drug idiosyncratic
V rare 1-10/million
May be v severe
Direct toxic effect on BM orimmune destruction

291

What are the commonly implicated drugs in drug induced neutropaenia?

Carbimazole
NSAIDS
Sulphonamides
Antiepileptics
Captopril
Dapsone
PTU
Rituximab

292

When should you give G-CSF in neutropaenia?

When precursors appear in the bone marrow, without them, G-CSF will not work

293

What is the mechanism of dialysis induced neutropaenia?

 Haemodialysis –
– Severe neutropenia on blood taken during dialysis
– Complement activation on dialysis membrane causes attachment of neutrophils onto lung endothelium
– Not true neutropenia - repeating the test off dialysis shows a normal neutrophil count

294

Aside from drugs, what are the two very clinically relevant causes of transient acquired neutropaenia?

Bacterial Sepsis –
- destruction exceeds production, 
- bad prognostic indicator
- Commonest in neonates

Neonatal Isoimmune –
– transplacental passage of maternal Ab to paternal 
neutrophil Ag (cf Rh HDN). 
– Can be severe and prolonged (ie months after birth)
– May respond to G-CSF

295

What are the features of chronic benign neutropaenia?

Chronic Idiopathic Neutropenia/ Benign 
Chronic Neutropenia
– Neutrophil equivalent to adult ITP
– May be seen with SLE or other AI diseases
Most are mild & never require Rx

(Can do antibody testing but no one does)

296

What is ‘Large Granular Lymphocyte’ Syndrome?

– Neutropenia associated with increased circulating LGLs (NK cells)
– Total lymphocyte count often normal
– Not malignant
– May regress spontaneously

One of the causes of acquired neutropaenia - it is a chronic condition

297

What is Felty's Syndrome?

– Commonest mild-mod chronic neutropenia
– Triad of seropositive RA, neutropenia and splenomegaly (but only 25% have 
splenomegaly)
– about 1% RA patients
– Probably AI basis (higher RF & ANA)
– Can occur in ‘burnt-out’ RA
– Often have "LGL’ syndrome

298

What is Severe Congenital Neutropaenia?

– Life threatening neutropenia from birth
– Neutrophils < 0.5
– RARE - 2/million
AR/AD -mixed bag of molecular defects found eg ELANE, HAX-1, 40% not known
HAX-1 maintains mitochondrial membrane & prevents myeloid apoptosis
@15yrs G-CSF– 10% death by sepsis, 22% AML
HSCT curative

299

What is Chediak-Higashi Syndrome?

Oculocutaneous albinism, 
Severe neutropenia & life-threatening 
pyogenic infections (most die by 7yr)
Mild coagulopathy
Progressive neurological deterioration –
pp neuropathy (if don’t die of infection)
Accelerated phase – lymphohistiocytosis 
usually fatal

300

What is WHIM (lazy leucocyte syndrome?)

Warts, Hypogammaglobulins, Infections, Myelokathexis)
– CXCR4 mutation 
– Abnormal apoptosis & migration (hypercellular BM)
– Rarely fatal
• Myelokathexis can also occur alone

301

What is cyclic neutropaenia?

– Neuts cycle over 3 weeks (14-35d) –consistent within individual, lessens with age
– 1-2/million
– AD - Neutrophil elastase (ELANE) mutations (Chrom 19p13.3)
– Usually mild but can be severe (death)
– regular G-CSF reduces nadir and infections
– NO somatic abnormalities, NO inc risk  malignancy

302

What are the acquired transient causes of neutropaenia?

– Drug
– Viral
– Bacterial
– nutritional
– Iso-immune

303

What are the acquired chronic causes of neutropaenia?

– Benign chronic neutropenia
– LGL syndrome
– Felty’s syndrome

304

What are the inherited causes of neutropaenia?

– Severe congenital neutropenia
– Cyclical neutropenia

305

What is the primary concern in febrile neutropaenia?

Enteric gram negative organisms

306

What is the primary concern in prolonged neutropaenia?

How should you treat it?

Fungal infections - candida or aspergillus

Treat with azoles or echinocandins (the 'fungins' ie caspofungin)

307

What are the clinical features of significant neutropaenia?

Stomatitis and in infections due to gram-positive or gram-negative aerobic bacteria or to fungi such as Candida or Aspergillus. 

308

What is the treatment for aplastic anaemia?

Mild —> EPO, transfusions and antibiotics as necessary

Severe —:> ALLO BMT is curative

Over 40/ or no HLA match —> horse ETG plus cyclosporine or tac
MUST give with pred to avoid serum sickness and infusion reactions
Need to give ongoing cyclosporine for several years post ATG
Androgens can be considered as may have some response.

309

What are the two main proposed mechanisms behind aplastic anaemia?

Immunological
Telomere length maintenance defects

310

Which groups have lower limit of normal neutrophil count ranges but are healthy?

Higher?

Lower --> blacks and asians

Higher --> third tri pregnant women

311

What is the pathophysiology of aplastic anaemia?

Haematopoetic stem cell injury (congenital: telomere length maintenance defect, acquired: autoimmune) —> marrow hypoplasure —> failure to produce all mature blood cells —> pancytopaenia

312

What are the factors that predict response to immunological treatment of aplastic anaemia ?

Age, 
Reticulocyte count, 
Lymphocyte count, 
Age-adjusted telomere length of leukocytes at the time of diagnosis.

313

What is hemaphagocytic syndrome?

Severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages characterised by proliferation of morphologically benign lymphocytes and macrophages that secrete high amounts of inflammatory cytokines. It is classified as one of the cytokine storm syndromes.

314

What are the clinical manifestations of haemophagocytic syndromes?

HLH clinically manifests with fever, hepatosplenomegaly, lymphadenopathy, jaundice and a rash.

315

What are the lab findings of haemophagocytic syndrome?

The blood count typically shows pancytopenia — anemia, neutropenia and thrombocytopenia.
The blood film may show hemophagocytosis.
The liver function tests are usually elevated. Hypoalbuminemia is common.
The serum C reactive protein, erythrocyte sedimentation rate and ferritin level are markedly elevated.
The serum fibrinogen level is usually low and the D-dimer level is elevated.
The sphingomyelinase is elevated.[4]
BMB - histiocytosis

316

What are the causes of secondary haemophagocytic syndrome?

Secondary haemophagocytic lymphohistiocytosis (acquired haemophagocytic lymphohistiocytosis) occurs after strong immunologic activation, such as that which can occur with systemic infection, immunodeficiency, or underlying malignancy. Both forms are characterized by the overwhelming activation of normal T lymphocytes and macrophages, invariably leading to clinical and haematologic alterations and death in the absence of treatment.

317

What is the cause of primary haemophagocytic syndrome?

Autosomal recessive with 5 genetic subtypes.

318

What are the most common infections associated with neutropaenia?

Most common infections:  Sepsis, cellulitis, pneumonia, and fever

319

Other than cytotoxic chemotherapy, which drugs can cause neutropaenia?

Sulfonamides, chlorpromazine, procainamide, penicillin,
cephalosporins, cimetidine, methimazole, phenytoin, chlorprop-
amide, antiretroviral medications, rituximab

320

What's in prothrombinex and when is it used?

Provision of factors II, IX and X

- bleeding and warfarinized
- bleeding from factor deficiency
- prophylaxis

321

Question 52 
 
A 58-year-old previously well man presents with a two-week history of spontaneous bruising and a large, painful left thigh haematoma following minimal trauma.  He is on no medication and his blood count has been documented as normal 18 months earlier prior to elective surgery.  There is no previous history of bleeding with trauma or with surgery and no family history of bleeding disorder.  Physical examination is normal apart from scattered ecchymoses and the swollen, bruised left thigh.  The haematoma is confirmed on ultrasound examination. 
 
Investigations show:
 
 

The most likely diagnosis is: 
 
A. haemophilia A. 
 
B. haemophilia B. 
 
C. primary antiphospholipid antibody syndrome. 
 
D. von Willebrand’s disease. 
 
E. acquired factor VIIIc inhibitor. 

Answer: E

322

Question 96 
 
A 62-year-old previously well woman is referred for evaluation of recurrent mouth ulceration and several bacterial skin and urinary tract infections over 12 months, with one episode requiring parenteral antibiotic therapy.  She is on no medication apart from intermittent antibiotics.  Physical examination shows some mouth ulcers and pustular skin lesions.  Full blood count (as follows) is essentially unchanged compared with previous counts measured three times during the preceding few weeks. 
 
Investigations show: 

  

Antinuclear and rheumatoid factors are negative and a marrow examination is unremarkable except for left- shifted granulopoiesis. 
 
The most appropriate therapy is: 
 
A. granulocyte colony stimulating factor (G-CSF). 
 
B. lithium. 
 
C. intravenous gamma globulin. 
 
D. granulocyte transfusions from a family member. 
 
E. long-term prophylactic antibiotics. 

A

323

QUESTION 7  
 
A 64-year-old man is taking oral prednis(ol)one (7.5 mg/day) for polymyalgia rheumatica.  He reports progressive lethargy, shoulder girdle pain and stiffness and also recent indigestion. 
 
Full blood examination reveals: 

  

Blood film shows normocytic and microcytic red cells with mild hypochromasia and rouleaux, as well as neutrophilia, lymphopenia, monocytosis and thrombocytosis 
 
Iron studies reveal: 

  

What is the most likely cause of the patient’s anaemia? 
 
A. Chronic inflammation. 
 
B. Beta thalassaemia trait. 
 
C. Iron deficiency. 
 
D. Autoimmune haemolysis. 
 
E. Sideroblastosis. 

Answer A

324

QUESTION 28  
 
A 26-year-old previously well woman presents with several weeks lethargy and the recent onset of pallor and dark urine.  She is on no medication except an oral contraceptive.  On examination she is afebrile, anaemic, slightly icteric and has mild splenomegaly. 
 
Full blood examination reveals: 

  

Her blood film is shown below. 
 
  
 
 
 
The most appropriate next investigation is: 
 
A. Heinz bodies preparation. 
 
B. glucose-6-phosphate dehydrogenase level. 
 
C. unconjugated bilirubin. 
 
D. direct antiglobulin (Coombs’) test. 
 
E. urinary haemosiderin. 

Answer:  D

325

QUESTION 57  
 
A 48-year-old previously well man is receiving a transfusion of four units of packed red cell concentrate via a peripheral intravenous line after presenting with melaena secondary to a bleeding duodenal ulcer.  He has not been previously transfused.  Admission biochemistry (including urea, electrolytes and creatinine) is normal and pre-transfusion blood counts are normal apart from anaemia (haemoglobin 64 g/L [135-170]).  Less than five minutes after transfusion of the third unit of blood is commenced, he complains of feeling very unwell and abruptly develops fever, chills, rigors and profound hypotension. 
 
In the absence of ABO, Rhesus or minor blood group donor-recipient incompatibility, the most likely diagnosis is: 
 
A. bacterial contamination of the transfused blood. 
 
B. transfusion-associated graft-versus-host disease. 
 
C. electrolyte disturbance. 
 
D. citrate toxicity. 
 
E. reaction to plasticiser in infusion bag. 

A

326

QUESTION 8  
 
A 65-year-old woman presents for inguinal hernia repair.  She is otherwise well, apart from several years of hypertension, currently controlled by captopril.  There is no history of excessive infection.  Physical examination reveals borderline cervical lymphadenopathy. 
 
A preoperative full blood count shows: 
  

The blood film is shown in the photograph below. 
 
  
 
The most appropriate initial investigation for diagnosis is: 
 
A. a computed tomography (CT) scan of the neck, chest, abdomen and pelvis. 
 
B. Epstein-Barr virus serology. 
 
C. peripheral blood cytogenetic analysis. 
 
D. bone marrow examination. 
 
E. immunophenotypic analysis of peripheral blood mononuclear cells. 

E

327

QUESTION 33  
 
A 70-year-old woman with chronic lymphocytic leukaemia and mild chronic airways disease presents for routine review.  In the past eight months, she has been hospitalised twice for community-acquired pneumonia.  
 
Examination reveals minor cervical lymphadenopathy.  There is no peripheral lymphadenopathy elsewhere and no hepatosplenomegaly. 
 

The most appropriate treatment is: 
 
A. prophylactic antibiotics. 
 
B. regular granulocyte colony-stimulating factor (G-CSF). 
 
C. oral corticosteroid. 
 
D. oral chlorambucil. 
 
E. regular immunoglobulin infusions. 
 

E

328

QUESTION 45  
 
A 62-year-old man with a history of controlled hypertension presents with worsening lethargy over several months and more recently, weight loss, night sweats and easy bruising.  Examination reveals anaemia, bruising and firm splenomegaly 12 cm below the left costal margin; no lymphadenopathy is evident. 
 
Full blood examination reveals: 

The blood film is shown below. 
 

The most likely diagnosis is: 
 
A. metastatic carcinoma. 
 
B. megaloblastosis. 
 
C. primary myelofibrosis. 
 
D. systemic lupus erythematosus. 
 
E. chronic myeloid leukaemia. 

C

329

QUESTION 58  
 
A 72-year-old woman presents with confusion after a minor fall and is found to have a subdural haematoma on computed tomography (CT) scanning which requires urgent surgical drainage.  She takes warfarin for atrial fibrillation and has been taking an antibiotic for urinary infection. 
 
Full blood examination reveals: 
  

In addition to parenteral vitamin K therapy, she should receive: 
 
A. fresh frozen plasma. 
 
B. cryoprecipitate. 
 
C. recombinant factor VIIIc. 
 
D. packed red cells. 
 
E. platelet concentrate. 

Answer:  A

330

QUESTION 84  
 
A 63-year-old woman is recovering from induction chemotherapy commenced 28 days previously for acute myeloblastic leukaemia.  She is receiving granulocyte colony-stimulating factor (G-CSF) and is no longer neutropenic.  A Hickman’s catheter is in situ.  She remains intermittently febrile and Candida albicans continues to be cultured from samples obtained from the Hickman’s catheter and peripheral blood, despite therapy with intravenous amphotericin B (1 mg/kg/day) from day 20. 
 
The most appropriate course of action is to: 
 
A. increase the daily dose of amphotericin B. 
 
B. arrange granulocyte transfusion. 
 
C. change to liposomal amphotericin. 
 
D. exclude hepatosplenic candidiasis radiologically. 
 
E. remove the Hickman’s catheter. 

E. remove the Hickman’s catheter. 

331

QUESTION 20  
 
A 36-year-old previously well woman presents with lethargy of two to three weeks duration and gum bleeding over the previous week.  Examination shows her to be afebrile and anaemic with scattered bruises and petechial haemorrhages.  A chest X-ray is normal. 

  

A bone marrow aspirate shows that 90% of nucleated cells have the appearance as seen in the photograph below. 

  
 
The most appropriate initial therapy is: 
 
A. idarubicin. 
 
B. all-trans-retinoic acid. 
 
C. vincristine and prednis(ol)one. 
 
D. fludarabine. 
 
E. high-dose cyclophosphamide.

Answer B.


The aspirate shows a hypergranular myelocyte which is characteristic of APML

332

QUESTION 70 
 
A 25-year-old previously well male student presents with recent exertional dyspnoea, epistaxis and bruising.  There is no history of medication, toxic chemical exposure or infection. 
 
Examination reveals significant anaemia with scattered bruises and petechial haemorrhages. 
 
Full blood examination reveals: 
  

B12, folate and iron studies are normal.  Hepatitis/human immunodeficiency virus (HIV) serology is negative. 
 
Attempted marrow aspiration results in a ‘blood tap’.  A marrow trephine biopsy section is shown below. 
  
 
 
 
QUESTION 70 CONTINUED

The therapy most likely to be associated with long-term remission is: 
 
A. granulocyte colony-stimulating factor (G-CSF) and erythropoietin. 
 
B. stem cell allograft from a human leucocyte antigen (HLA)-matched sibling. 
 
C. oxymetholone. 
 
D. antithymocyte globulin. 
 
E. high-dose cyclophosphamide. 

Answer B

333

Question 84 
 
A 78-year-old man presents with progressive lethargy for several months and the recent onset of bruising, epistaxis, headaches and visual deterioration.  Physical examination shows him to be anaemic with scattered ecchymoses; he has reduced visual acuity bilaterally and fundoscopy reveals retinal venous distension with numerous retinal haemorrhages. 
 
Investigations show: 

  

The most appropriate initial therapy is: 
 
A. melphalan and prednis(ol)one. 
 
B. platelet transfusion. 
 
C. plasma exchange. 
 
D. renal dialysis. 
 
E. intravenous gamma globulin. 

E

334

QUESTION 3  
 
The predominant site of gastrointestinal absorption of dietary iron is the: 
 
A. proximal small intestine. 
 
B. gastric fundus. 
 
C. terminal ileum. 
 
D. pyloric antrum. 
 
E. colon. 

A

335

QUESTION 25  
 
In a transfusion-dependent patient with idiopathic acquired sideroblastic anaemia, the most appropriate treatment for prevention of transfusional iron overload is: 
 
A. vitamin C. 
 
B. phlebotomy. 
 
C. desferrioxamine. 
 
D. ethylene-diamine tetra-acetic acid (EDTA). 
 
E. pyridoxine. 

Answer:  C

336

QUESTION 35  
 
Infusion of cryoprecipitate is principally indicated for the replacement of: 
 
A. factor IX. 
 
B. fibrinogen. 
 
C. immunoglobulin A (IgA). 
 
D. anti-thrombin. 
 
E. protein C. 

Answer:  B

337


QUESTION 58  
 
A 72-year-old woman presents with confusion after a minor fall and is found to have a subdural haematoma on computed tomography (CT) scanning which requires urgent surgical drainage.  She takes warfarin for atrial fibrillation and has been taking an antibiotic for urinary infection. 
 
Full blood examination reveals: 
  

In addition to parenteral vitamin K therapy, she should receive: 
 
A. fresh frozen plasma. 
 
B. cryoprecipitate. 
 
C. recombinant factor VIIIc. 
 
D. packed red cells. 
 
E. platelet concentrate. 

Answer:  A

338

QUESTION 51  
 
A 48-year-old previously well man, currently smoking 10 to 20 cigarettes/day, presents with the progressive onset over several months of lethargy and headache.  He takes no medications. 
 
Examination reveals him to be plethoric and hypertensive with no other significant findings. 
 
 

Which one of the following would most strongly support a diagnosis of polycythaemia vera? 
 
A. Raised serum vitamin B12 level. 
 
B. Elevated total red cell mass. 
 
C. Normal marrow karyotype. 
 
D. Elevated serum uric acid level. 
 
E. Lowered serum erythropoietin level. 
 

Answer:  E

339

A 19-year-old woman presents with recent-onset right leg swelling and pleuritic chest pain and is found to have iliofemoral thrombosis on Doppler ultrasound examination.  Results of a ventilation-perfusion lung scan indicate a high probability of pulmonary emboli.  She had been taking the oral contraceptive pill for the last three years but has now ceased.  She is a non-smoker.  There is no significant medical history and no known family history of venous thromboembolism. 
 
The results of which one of the following investigations for an underlying hypercoagulable state are most likely to be affected by the presence of the extensive thrombosis? 
 
A. Anti-phospholipid antibody screen. 
 
B. Anti-thrombin level. 
 
C. Assessment of prothrombin and factor V genotypes. 
 
D. Activated partial thromboplastin time (APTT). 
 
E. Full blood count including blood film. 

Answer:  B

340

QUESTION 10  
 
A 25-year-old man presents with recent onset of lethargy, fever, bruising and abdominal pain. 
 
On examination, he is clinically anaemic and is noted to have scattered bruises, bilateral pleural effusions, an abdominal mass and cervical and axillary lymphadenopathy. 
 


Full blood examination shows:  

  

More than 90% of the nucleated cells in the bone marrow aspirate have the appearance shown below (examples indicated by arrows). 


Coagulation parameters are normal. 
 
The most likely marrow karyotypic abnormality is: 
 
A. monosomy 7. 
 
B. t (9;22). 
 
C. 5q minus. 
 
D. t (8;14). 
 
E. t (15;17). 

Answer:  D.  Burkitt's lymphoma

341

QUESTION 52  
 
A 47-year-old man with severe haemophilia A and a high titre factor VIII inhibitor is scheduled for hip replacement surgery.  The peri-operative replacement coagulation product of choice is: 
 
A. recombinant activated factor VII. 
 
B. recombinant factor VIII. 
 
C. recombinant factor IX. 
 
D. fresh frozen plasma. 
 
E. cryoprecipitate. 

A

342

QUESTION 65  
 
A 36-year-old man presents in a post-ictal state after an observed generalised seizure. 
 
Full blood investigation shows: 

  

The blood film is shown below. 

  
 
The most likely cause of the peripheral blood macrocytosis is: 
 
A. β-thalassaemia trait. 
 
B. myelodysplasia. 
 
C. alcoholic liver disease. 
 
D. hereditary spherocytosis. 
 
E. myelofibrosis. 

Answer:  C

343

A 24-year-old woman, who has recently arrived in Australia from Vietnam, presents for evaluation of abnormal menstrual bleeding.  There are no abnormalities on examination. 
 
Results of investigations are listed below.

  

The most likely diagnosis is: 
 
A. homozygous alpha+ thalassaemia (−α/−α). 
 
B. early iron deficiency. 
 
C. congenital sideroblastic anaemia. 
 
D. sickle cell anaemia. 
 
E. heterozygous beta thalassaemia. 

A

344

QUESTION 3 

A 68-year-old man scheduled for herniorrhaphy presents for pre-anaesthetic assessment and is found to have non-tender cervical lymphadenopathy. Full blood examination shows: 

 

The blood film is shown below. 

 

With respect to the peripheral blood lymphoid cell immunophenotype, which of the following surface antigens is most likely to be co-expressed with CD19 (cluster of differentiation 19)?

A. CD3. 

B. CD5. 

C. CD8. 

D. CD10. 

E. CD34. 

B.  This is CLL as there are smudge cells on the film along with the other findings.

345

QUESTION 16 

In a 50-year-old woman, which of the following isolated laboratory abnormalities would be associated with the highest level of blood viscosity? 

A. Serum immunoglobulin M (IgM) level of 40.0 g/L [0.5-3.0]. 

B. Peripheral blood leucocytosis of 25.0 x 109/L [3.9-12.7]. 

C. Haematocrit of 0.46 [0.32-0.42]. 

D. Serum immunoglobulin G (IgG) level of 40.0 g/L [7.5-15.6]. 

E. Peripheral blood thrombocytosis of 500 x 109/L [150-396]. 

A

346

What is a Pelger-Huet anomaly?

In which condition is it seen?

Dumbbell-shaped bilobed nuclei on peripheral blood film

Myelodysplastic syndromes inc MDS, AML and CML

347

QUESTION 44 

A previously well 32-year-old man presents with progressive lethargy and no other symptoms. Physical examination shows him to have an enlarged spleen 6 cm below the left costal margin. There is no jaundice or lymphadenopathy and he is not clinically anaemic. 

The full blood examination shows: 

 
The blood film is shown below. 
 

The most likely marrow cytogenetic abnormality is: 

A. hyperdiploidy. 

B. t(9;22). 

C. t(15;17). 

D. 5q minus. 

E. trisomy 21. 

B

348

QUESTION 59 

Megaloblastosis is least likely to be seen in which one of the following? 

A. Transcobalamin I deficiency. 

B. Pernicious anaemia. 

C. Strict veganism. 

D. Coeliac disease. 

E. Post-gastrectomy. 

A

349

QUESTION 62 

The delay in the onset of the anticoagulant effects of warfarin is most dependent on the: 

A. loading dose of warfarin. 

B. rate of catabolism of clotting factors. 

C. rate of absorption of warfarin. 

D. clearance rate of the S-isomer of warfarin. 

E. clearance rate of the R-isomer of warfarin. 

B

350

QUESTION 22

A 75-year-old patient with chronic atrial fibrillation has been stable on warfarin 4 mg/day (international normalised ratio (INR) ranges from 2.1 to 2.5). The patient takes thyroxine 100 μg/day for hypothyroidism. 

Which one of the following actions is most likely to potentiate the risk of bleeding? 

A. Reducing the dose of thyroxine. 

B. Increasing dietary vegetable intake. 

C. Treatment with cholestyramine. 

D. Treatment with omeprazole. 

E. Treatment with amiodarone. 

E

351

QUESTION 33

A 72-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with an intercurrent lower respiratory tract infection. Apart from plethora and pulmonary signs associated with his respiratory disease, no other abnormalities are found. 

Full blood examination shows: 

 

The most likely cause of the elevated haematocrit is: 

A. dehydration. 

B. chronic hypoxaemia. 

C. polycythaemia vera. 

D. spurious polycythaemia. 

E. low affinity haemoglobin. 

B

352

A 35-year-old man who is receiving erythropoietin (EPO) therapy for anaemia associated with end stage renal disease presents with lethargy. There is no obvious source of bleeding. 

Blood investigations show: 
 

The most likely cause of his anaemia is: 

A. red cell aplasia. 

B. reduced iron stores. 

C. non-neutralising anti-EPO antibodies. 

D. aluminium toxicity. 

E. myelodysplasia. 

 A. Red cell aplasia. Due to NEUTRALISING EPO antbodies.

353

QUESTION 46

Which of the following is most likely to prevent recurrent febrile non-haemolytic transfusion reactions in a patient requiring regular transfusion? 

A. Warm blood to 37°C. 

B. Leucodepletion. 

C. Gamma-irradiation. 

D. Cytomegalovirus (CMV)-negative donors. 

E. Slow transfusion time. 

B

354

QUESTION 48

A 68-year-old man is sent for a second opinion regarding recurrent iron deficiency anaemia requiring blood transfusion. 

Over the last three years, he has required an average of 4 units of packed cells every three months despite oral iron supplements. There is no history of melaena. Bone marrow examination is normal except for absent iron stores. Gastroscopy and colonoscopy have been negative on three separate occasions, the last being two months ago. Small bowel biopsy is normal. The patient had a barium meal and follow-through six months ago which was normal. 

General health is good and he is on no regular medications. 

Which of the following investigations is most likely to find the cause of his iron deficiency? 

A. Small bowel enema. 

B. Repeat gastroscopy and colonoscopy. 

C. Enteroscopy. 

D. Abdominal angiography. 

E. Labelled red cell scan. 

C

355

QUESTION 66

A 28-year-old man presents with a fractured ankle requiring surgical fixation. 

 

The most likely explanation for his anaemia is: 

A. β-thalassaemia trait. 

B. chronic blood loss. 

C. anaemia of ‘chronic disease’. 

D. congenital sideroblastosis. 

E. sickle cell trait. 

A

356

QUESTION 84

A previously well 46-year-old woman presents acutely unwell with right iliac fossa pain and fever. A laparotomy is planned. 

 

Which of the following is the most likely cause of the prolonged APTT? 

A. Disseminated intravascular coagulation. 

B. Heparin contamination. 

C. Lupus inhibitor. 

D. Factor XI deficiency. 

E. Haemophilia carrier. 

C

357

QUESTION 93

A 16-year-old adolescent male presents with lethargy and lower respiratory tract infection. Physical examination shows him to be febrile, icteric and pale in addition to respiratory findings. 

Full blood examination shows: 

 

The blood film is shown below. 
 

The most likely cause of the anaemia is: 

A. paroxysmal cold haemoglobinuria. 

B. glucose-6-phosphate dehydrogenase (G6PD) deficiency. 

C. red cell aplasia. 

D. cold agglutinin haemolysis. 

E. sickle cell anaemia. 

B

358

QUESTION 9 

Which of the following transfusion-related events is most frequently reported (episodes/unit transfused) with transfusion of unmodified red cells? 

A. Acute haemolytic transfusion reaction. 

B. Febrile non-haemolytic transfusion reaction. 

C. Transmission of hepatitis B. 

D. Graft-versus-host disease. 

E. Transfusion-associated acute lung injury. 

B

359

QUESTION 18 

A 67-year-old woman develops symptomatic anaemia and jaundice nine days after subtotal colectomy for adenocarcinoma of the colon, at the time of which she received a transfusion of 3 units of red cells. She is on therapy (which includes sulfasalazine) for ulcerative colitis. 

Review of the pre-operative antibody screen shows this to be negative for red cell alloantibodies. 

Her current full blood examination includes the following: 
haemoglobin 82 g/L [120-155] 
mean cell volume 99 fL [80-97] 
reticulocyte count 162 x 109/L [8-104] 

Her blood film is shown below. 

 

The most likely cause of her anaemia is: 

A. iron deficiency. 

B. peri-operative blood loss. 

C. red cell aplasia. 

D. delayed haemolytic transfusion reaction. 

E. megaloblastosis. 

D

360

QUESTION 41 

During normal haemostasis, von Willebrand factor (vWF) plays a role in platelet adhesion/aggregation. During this process, which of the following is the primary binding site of vWF to platelets? 

A. Collagen receptor. 

B. Platelet glycoprotein Ib-IX-V. 

C. Adenosine diphosphate receptor. 

D. Platelet glycoprotein IIb-IIIa. 

E. Ristocetin. 

B

361

QUESTION 60 

Intravenous infusion of which of the following blood components is most likely to be associated with a septic transfusion reaction? 

A. Red cell concentrate. 

B. Fresh frozen plasma. 

C. Pooled gammaglobulin. 

D. Platelet concentrate. 

E. Cryoprecipitate. 

D

362

What does antithrombin III do?

What is it's clinical significance?

Deactivates factors 2 and 10, and thrombin.

Heparin potentiates it as it has a very high affinity for the part that inactivates thrombin.

LMWH has less of a charge and as a result, binds more to factor 10.

As a result, the thrombin clotting time is only affected by heparin.

363

QUESTION 20

A 65-year-old man presents to the emergency department with ischaemic chest pain. No abnormalities are noted on examination apart from mild hypotension. 
 

The most likely cause of the coagulation test abnormalities is: 

A. disseminated intravascular coagulation. 

B. administration of low-molecular weight heparin. 

C. administration of thrombolytic agent. 

D. lupus inhibitor. 

E. administration of unfractionated heparin. 

E

364

QUESTION 36

A 30-year-old man has previously undergone splenectomy (six months prior) for chronic idiopathic thrombocytopenic purpura (ITP). Apart from occasional bruising, there are no haemorrhagic symptoms. 

His full blood examination shows:
 
 
Repeated autoimmune and viral serology remain negative. 

The most appropriate management of his thrombocytopenia is: 

A. danazol. 

B. immunoglobulin. 

C. prednis(ol)one. 

D. azathioprine. 

E. observation. 

E

365

QUESTION 47

A 36-year-old healthy male with no siblings is found incidentally to have mild anaemia. 

 
 
In addition to informing him of the diagnosis, which of the following is the most appropriate next step? 

A. Globin gene analysis. 

B. Provide information on partner screening. 

C. Commence iron therapy. 

D. Haemoglobinopathy screening for parents. 

E. Gastrointestinal endoscopy. 

B

366

QUESTION 51

A 35-year-old man who is receiving erythropoietin (EPO) therapy for anaemia associated with end stage renal disease presents with lethargy. There is no obvious source of bleeding.

 
 
The most likely cause of his anaemia is: 

A. red cell aplasia. 

B. reduced iron stores. 

C. non-neutralising anti-EPO antibodies. 

D. aluminium toxicity. 

E. myelodysplasia. 

A