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Flashcards in Haematological changes in systemic disease Deck (46):

What can be the first presentation of cancer?



What are the 4 main types of anemia associated with cancer/systemic disease?

- Iron deficiency anemia - Anaemia of chronic disease - Leucoerythroblastic anaemia - Haemolytic anaemias


What two types of cancer can also cause secondary polycythemia?

Renal cell cancer and liver cancer


What is the most common cause of Fe deficiency anaemia?

Occult blood loss e.g. GI cancers, urinary tract cancers


What are the laboratory findings for Fe deficiency anaemia?

- Reduced ferritin - Transferrin saturation - Low Hb - Low MCV


What is leuco-erythroblastic anemia?

Red cell and white cell precursor anaemia. Causes a variable degree of anaemia


What the morphological features of leuco-erythroblastic anaemia on a blood film?

  • Tear drop red blood cells (aniso and poikilocytosis)
  •  Nucleated RBCs
  • Immature myeloid cells


What does this blood film show?


Leuco-erythroblastic anaemia 

  • tear drop poikilocytes
  • Nucleated red blood cells
  • myelocytes 


What are the 3 main causes of bone marrow infiltration that causes a leucoerythroblastic film?

  • Cancer - haemopoietic e.g    leukemia/lymphoma/myeloma.  Or non-haempoitetic e.g. breast/bronchus/prostate
  • severe infection e.g. miliary TB, severe fungal infection 
  • myleofibrosis - massive splenomegaly, dry tap on BM aspirate


What are the most common distinguishing features of haemolysis? (any aetiology)

  • anaemia - though may be compensated
  • reticulocytosis
  • raised bilirubin (unconjugated)
  • raised LDH - intracellular enzyme 
  • Reduced haptoglobins 


What are the two pathogenic groups of haemolytic anaemias?

  • Inherited - defects of the red cell
  • Acquired - defects of the environment in which the red cell finds itself. Can be immune or non-immune 


What test can distinguish between immune and non-immune types of acquired haemolytic anaemias?

Direct Antiglobulin (DAT or Coombs test)


  1. What are findings on haematological studies are associated with auto-immune haemolysis?
  2. What can be the underlying cause of auto-immune haemoloysis?

  1.  Anaemia, reticulocytosis, raised unconjugated bilirubin, raised LDH, Positive DAT 
  2. Idiopathic or underlying lymphoma/CLL/SLE


What are the two main causes of acquired haemolytic anaemia/non-immune/DAT negative?

  • Infection - malaria
  • Micro-angiopathic Haemolytic anaemia (MAHA)


  1. What are the main findings in blood studies for MAHA?
  2. What conditions are MAHA associated with?

  1. Red cell fragments, low platelets, DIC/bleeding 
  2. Underlying adenocarcinoma and Haemolytic Uremic syndrome (E.coli infection)


What does this blood film show?

MAHA - Micro-angio-pathic haemolytic anaemia 

  • red cell fragments
  • thrombocytopenia


Micro angiopathy can happen because of malignancy e.g. adenocarcinomas.

Describe the underlying mechanism

  • Adenocarcinoma, low grade DIC
  • Platelet consumption occurs 
  • Leading to fibrin deposition and degradation
  • Red cell fragmentation occurs - microangiopat 
  • Bleeding occurs 


What are the two main causes of true polycythemia in cancer?

True polycythemia is raised red cell mass 

1. Secondary raised EPO appropriate/inappropriate e.g. hepatocellular cancer, bronchial cancer, renal cancer

2. Polycythemia vera (PV) e.g. Clonal myleoproliferative disorder acquired mutations in JAK2 


What types of white blood cells are there?

  1. Normal mature phagocytes - neutrophils, eosinophils and basophils
  2. monocytes
  3. immunocytes - T and B lymphocytes, NK cells

Immature - blasts present in a small percentage. Many immature cells are not normal  


What does this blood film show?

Chronic lymphocytic leukemia 

  • WBC increased mature cells


What does this blood film show?

Acute myeloid leukemia 

  • WBC increased immature cells 


What can cause neutrophilia?

  • Corticosteroids
  • Underlying neoplasia
  • Tissue inflammation e.g. colitis, pancreatitis
  • myeloproliferative/leukaemic disorders
  • infection


Most localised and systemic infections cause a neutrophilia. Which infections characteristically do not cause a neutrophilia?

  • Brucella
  • Typhoid
  • many viral infections 


What are the differences between 

1. Reactive neutrophilia

2. Malignant neutrophilia?



  1. Reactive neutrophilia - reaction and increase in neutrophils in response to infection/inflammation. Presence bands and toxic granulation
  2. Malignant neutrophilia - neutrophilia, basophilia, plus immature cells myleocytes, and splenomegaly. This suggests a myleoproliferative (CML)


*neutroPENIA plus myeloblasts - AML - Acute Myeloid Leukemia  


What does this show? 

Reactive neutrophilia

  • Nuclear polymorphs
  • neutrophilia
  • toxic granulation 


What does this blood film show?

Chronic Myeloid Leukemia

  • Neutrophilia
  • Basophilia
  • Immature cells such as myleocytes 
  • splenomegaly


What can cause a reactive eosinophilia?

  • Parasitic infection
  • Allergic diseases e.g. asthma, rheumatoid
  • Underlying neoplasms esp. Hodgkin's, T-cell NHL
  • Drugs - reaction erythema multiforme


What are the underlying cause of Chronic Eosinophilic leukemia?

Eosinophils form part of the 'clone'.

FIP1L1-PDGFRa fusion gene 


What conditions/chronic infections/ haematological disorders can moncytosis be seen?

  • TB, Brucella, typhoid
  • Viral, CMV, Varicella zoster
  • Sarcoidosis
  • Chronic myelomonocytic leukemia (MDS)


What in the following categories causes an elevated neutropil count?

  1. Infection 
  2. Inflammation
  3. Neoplasia
  4. Myeloproliferative 

  1. Bacterial infections
  2. Auto-immune and Tissue necrosis
  3. All types 
  4. CML


What in the following categories causes an elevated eosinophil count?

  1. Infection 
  2. Inflammation
  3. Neoplasia
  4. Myeloproliferative 

  1. Parasitic infections
  2. Allergic e.g. asthma, atopy, drug reactions
  3. Hodgkin's and NHL
  4. N/A


What in the following categories causes an elevated Basophil count?

  1. Infection 
  2. Inflammation
  3. Neoplasia
  4. Myeloproliferative 

  1. Pox viruses
  2. N/A
  3. N/A
  4. CML


What in the following categories causes an elevated monocyte count?

  1. Infection 
  2. Inflammation
  3. Neoplasia
  4. Myeloproliferative 

  1. Chronic e.g. TB, Brucella
  2. N/A
  3. N/A
  4. CMML


What is the difference between a secondary and primary lymphocytosis?

SECONDARY lymphocytosis - is reactive, and is a polyclonal response to an infection or chronic inflammation

PRIMARY lymphocytosis - is a monoclonal lymphoid proliferation, as seen in CLL, NHL 


What are the causes of a reactive lymphocytosis?

  • EBV, CMV, Toxoplasma
  • Infectious hepatitis, rubella, herpes infections
  • Autoimmune disorders
  • Sarcoidosis


What conditions has the following lymphocytes?

  1. Normal blood film
  2. Infective mononucleosis
  3. CLL and NHL
  4. Acute lymphoblastic leukemia 

  1. Normal blood - mature lymphocytes
  2. IM - Recactive/atypical lymphocytes 
  3. CLL and NHL - small lymphocytes and smear cells
  4. ALL - Lymphoblasts 


  1. What does this blood film show?
  2. What could this be a sign of?

  1. Lymphocytosis
  2. Could be EBV infection or early CLL


What does this blood film show?

CLL - Chronic lymphocytic leukemia


What does this blood film show?

Acute lymphoblastic leukemia 

presence of lymphoblasts 


What does flow cytometry show?

Known as immunophenotyping - flow cytometry looks at the antigens expressed on the cells. 

Blue - CD4

Green - CD34

Purple - CD7


Is EBV monoclonal or polyclonal?

Polyclonal, and B cells so amount of kappa and lambda light chains are normal, and in usual proportions


What are the 2 different light chains that B cells can have?

Kappa and Lambda


Is CLL monoclonal or polyclonal?

CLL is monoclonal. One mother B cell with the mutation will proliferate meaning only one of the light chains, either kappa or lambda will be produced. This means that one light chain is measured to be a lot higher than the other. This is usually a sign of a worse prognosis. 


What is the diagnosis?

39 year old woman

Had breast cancer over 4 years ago

Presents with jaundice and hepatomegaly

Hb = 87

Bilirubin = 50, conjugated (elevated)

DAT negative

Blood film - nucleated red blood cells 



Bone marrow metastases from breast cancer


What is the diagnosis?

45 year old male

3 week history of sore throat

Recent episode of shingles

EBV IgG serology positive

FBC: Raised lymphocytes, normal neutrophils

Blood film: Reactive lymphocytes, no abnormal cells


Mature B cells, monoclonal