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Haematology Flashcards

1
Q

What is seen on a blood film in hypospenism (coeliac disease)

A

target cells, Howell-Jolly bodies, Pappenheimer bodies, siderotic granules, acanthocytes

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2
Q

Blood film in iron deficiency anaemia

A

target cells, ‘pencil’ poikkilocytes

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3
Q

Blood film in myelofibrosis

A

‘tear-drop’ poikilocytes

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4
Q

Blood film in intravascular haemolysis

A

schistocytes

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5
Q

Causes of microcytic anaemia

A

TAILS
Thalassaemia
Anaemia of chronic disease
Iron deficiency anaemia
Lead poisoning (rare)
Sideroblastic anaemia (rare)

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6
Q

Causes of normocytic anaemia

A

AAAHH
Acute blood loss
Anaemia of chronic disease
Aplastic anaemia
Haemolytic anaemia
Hypothyroidism

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7
Q

Causes of macrocytic anaemia

A

Megoblastic = Vit B12 deficiency, folate deficiency

Normoblastic = alcohol, liver disease, hypothyroidism, haemolysis, azathioprine

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8
Q

What is anaemia

A

Decrease of haemoglobin in blood below reference level for age and sex of individual

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9
Q

Presentation of anaemia

A
  • Fatigue
  • Headaches
  • Faintness
  • Dyspnoea, tachypnoeic
  • Anorexia
  • Palpitations, tachycardia
  • Pallor, Conjunctival pallor
  • Systolic flow murmur
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10
Q

Investigations for anaemia

A
  • Bloods  Hb, MCV, B12, folate, ferritin
  • Blood film
  • OGD/colonoscopy = GI cause
  • Bone marrow biopsy
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11
Q

Complications of anaemia

A
  • Reduced O2 transport
  • Tissue hypoxia
  • Compensatory changes
    o Increased tissue perfusion
    o Increased O2 transfer to tissues
    o Increased RBC production
  • Myocardial fatty change
  • Fatty change in liver
  • Aggravates angina and claudication
  • Skin and nail atrophic changes
  • CNS cell death
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12
Q

Risk factors for iron deficiency anaemia

A
  • Menstruating women
  • Undeveloped countries
  • High vegetable diet
  • Premature infants
  • Introduction of mixed feeding delayed = breast milk contains low iron
  • Crohn’s or coeliac
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13
Q

Causes of iron deficiency anaemia

A
  • Blood loss (adults)
  • Dietary insufficiency (children)
  • Poor iron absorption
  • Increased requirements during pregnancy
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14
Q

Features of iron deficiency anaemia

A
  • Brittle nails and hair
  • Hair loss
  • Pica = dietary cravings for abnormal things (dirt)
  • Spoon-shaped nails = koilonychia
  • Atrophy of papillae of tongue
  • Angular stomatitis = ulceration of corners of mouth
  • Post-cricoid webs
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15
Q

Management of iron deficiency anaemia

A
  • Oral iron = ferrous sulphate 3 times daily
  • IV/IM Iron infusion (cosmofer)
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16
Q

Side effects of oral iron

A

nausea, abdo discomfort, diarrhoea, black stools

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17
Q

What is thalassaemia

A

Autosomal recessive genetic defect in protein chains that make up haemoglobin
- Red blood cells more fragile and break down more easily
- Spleen acts as sieve to filter blood and remove older blood cells
- Spleen collects all destroyed red blood cells

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18
Q

Presentation of thalassaemia

A
  • Microcytic anaemia (low MCV)
  • Fatigue
  • Pallor
  • Jaundice
  • Gallstones
  • Splenomegaly
  • Poor growth and development
  • Pronounced forehead and malar eminences (cheek bones)
  • Failure to thrive (thalassaemia major)
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19
Q

Investigations for thalassaemia

A
  • FBC = microcytic anaemia
  • Haemoglobin electrophoresis = globin abnormalities
  • DNA testing
  • Pregnant women offered screening
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20
Q

Management of thalassaemia

A
  • Monitor serum ferritin levels, FBC
  • Alpha thalassaemia
    o Blood transfusions
    o Splenectomy
    o Bone marrow transplant (curative)
  • Beta Thalassaemia minor  no active treatment
  • Beta thalassaemia intermedia  Occasional blood transfusions
  • Beta thalassaemia major
    o Regular transfusions
    o Iron chelation
    o Splenectomy
    o Bone marrow transplant
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21
Q

Complications of iron overload

A
  • Fatigue
  • Liver cirrhosis
  • Infertility
  • Impotence
  • Heart failure
  • Arthritis
  • Diabetes
  • Osteoporosis and joint pain
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22
Q

Risk factors for pernicious anaemia

A
  • Fair-haired, blue eyes
  • Blood group A
  • Thyroid and Addison’s disease
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23
Q

Causes of pernicious anaemia

A
  • Autoimmune = antibodies against parietal cells or intrinsic factor
  • B12 deficiency = diet or malabsorption
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24
Q

Presentation of pernicious anaemia

A
  • Mild jaundice
  • Red sore tongue and ulceration of corners of mouth
  • Peripheral neuropathy = numbness or paraesthesia
  • Loss of vibration sense or proprioception
  • Visual changes
  • cognitive changes
  • Progressive weakness and ataxia
  • Paraplegia
  • Dementia, psychiatric problems, hallucinations, delusions, optic atrophy
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25
Q

Investigations of pernicious anaemia

A
  • Intrinsic factor antibody
  • Gastric parietal cell antibody
  • Blood count and film = macrocytic
  • Raised serum bilirubin
  • Low serum B12 and Hb and reticulocyte count
  • Schilling test = assess B12 absorption
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26
Q

Management of pernicious anaemia

A
  • Diet = oral replacement with cyanocobalamin
  • IM hydroxycobalamin 3 times per week for 2 weeks
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27
Q

Risk factors for folate deficiency

A
  • Poverty
  • Alcoholic
  • Pregnant
  • Crohn’s or coeliac disease
  • Elderly
  • Antifolate drugs = methotrexate and trimethoprim
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28
Q

Presentation of folate deficiency

A
  • May be asymptomatic
  • Glossitis (sore red tongue)
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29
Q

Management of folate deficiency

A
  • Treat underlying cause
  • Give folic acid tablets daily for 4 months with B12
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30
Q

Causes of haemolytic anaemia

A
  • Inherited
    o Hereditary spherocytosis
    o Hereditary elliptocytosis
    o Thalassaemia
    o Sickle cell anaemia
    o G6PD deficiency
  • Acquired
    o Autoimmune haemolytic anaemia
    o Paroxysmal nocturnal haemoglobinuria
    o Microangiopathic haemolytic anaemia
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31
Q

Presentation of haemolytic anaemia

A
  • Splenomegaly
  • Jaundice
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32
Q

Investigations of haemolytic anaemia

A
  • FBC = normocytic anaemia
  • Blood film = schistocytes
  • Direct Coombs test positive = autoimmune haemolytic anaemia
  • High serum unconjugated bilirubin
  • High urinary urobilinogen
  • High faecal sterocobilinogen
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33
Q

Epidemiology of G6PD

A
  • Mediterranean, Middle Eastern and Africa
  • X-linked recessive (Male only)
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34
Q

Triggers of G6PD

A
  • Medications
    o Anti-malarials: primaquine
    o Ciproflaxacin
    o Sulph-group drugs = sulphonamides, sulphasalazine, sulfonylureas
    o Trimethoprim
  • Infections
  • Broad/fava beans
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35
Q

Presentation of G6PD

A
  • Neonatal jaundice + intermittent jaundice
  • Anaemia
  • Intravascular haemolysis
  • Gallstones
  • Splenomegaly
36
Q

Investigations of G6PD

A
  • Blood film = Heinz bodies, bite and blister cells
  • G6PD enzymes assay (measure enzyme activity)
37
Q

What is sickle cell anaemia

A

Autosomal recessive disorder causing production of abnormal beta globin chains

38
Q

Presentation of sickle cell anaemia

A
  • Asymptomatic until crises
  • Sickling precipitated by infection, dehydration, cold, acidosis and hypoxia
  • Pulmonary hypertension
  • Anaemia
39
Q

Investigations of sickle cell anaemia

A
  • Genetic testing
  • Newborn screen heel prick test
  • Sickle solubility test positive
  • Hb electrophoresis and blood films show sickled cells
  • FBC = low Hb and raised reticulocyte count
  • Painful attack = IV fluids, analgesia, O2, Abx
40
Q

Management of sickle cell anaemia

A
  • Avoid dehydration and other triggers of crises
  • Folic acid
  • Abx prophylaxis with penicillin V
  • Hydroxycarbamide = stimulation production of fetal Hb
  • Blood transfusion
  • Bone marrow transplant
41
Q

Complications of sickle cell anaemia

A
  • Increased risk of infection
  • Stroke/ MI/ cardiomyopathy
  • Avascular necrosis = large joints of hip
  • Pulmonary hypertension
  • Painful and persistent penile erection
  • CKD
  • Liver dysfunction
  • Aplastic crises  reduced reticulocyte count
  • Sequestration crises  increased reticulocyte count
  • Acute chest syndrome = Dyspnoea, chest pain, pulmonary infiltrates on CXR, low pO2
42
Q

Risk factors for DVT

A
  • Increased age
  • Pregnancy
  • Synthetic oestrogen (OCP)
  • Trauma
  • Recent Surgery (within last 3 months)
  • Past DVT
  • Obesity
  • Immobility
  • Leg fracture/plaster of Paris
  • Long haul flights
  • Malignancy
  • Thrombophilia = antiphospholipid syndrome
43
Q

Presentation of DVT

A
  • Asymptomatic
  • Unilateral calf/leg swelling and pain
  • Affected calf often warmer, redder
  • Tenderness
  • Dilated superficial veins
  • Oedema
44
Q

Investigations for DVT

A
  • Wells score (2 points or more DVT is likely)
  • Plasma D-dimer = normal excludes DVT but not diagnostic
  • Compression doppler ultrasound = cannot squash diagnoses DVT
    o If investigations cannot be done within 4 hrs start on treatment dose DOAC
45
Q

Management of DVT

A
  • DOAC (apixaban or rivaroxaban) for 3-6 months
  • Low molecular weight Heparin = SC dalteparin (min 5 days)
  • Oral warfarin with target INR of 2.5 for 6 months after
  • Compression stockings
  • Inferior vena cava filters = Reduce risk of pulmonary emboli
46
Q

Prevention of DVT

A
  • Early mobilisation post-op
  • Compression stockings/foot pumps
  • Thrombophylaxis for both low risk and high risk
  • Hydration
47
Q

Risk factors for leukaemia

A
  • Down’s syndrome
  • Kleinfelter’s syndrome
  • Noonan syndrome
  • Fanconi’s anaemia
48
Q

Red flags for leukaemia

A
  • Any features in 0-24 y/o should prompt urgent FBC
  • Pallor
  • Persistent fatigue
  • Unexplained fever
  • Unexplained persistent infections
  • Generalised lymphadenopathy
  • Persistent or unexplained bone pain
  • Unexplained bruising
  • Unexplained bleeding
49
Q

Investigations for leukaemia

A
  • FBC
  • Blood film
  • Lactate dehydrogenase raised
  • Bone marrow biopsy
  • CXR = infection or mediastinal lymphadenopathy
  • Lymph node biopsy = lymphoma
  • Lumbar puncture = CNS involvement
  • CT/MRI/PET scans = staging
50
Q

Features of Acute Lymphoblastic leukaemia

A

Childhood (2-4yo)
Down’s syndrome
Blood film = blast cells

51
Q

Features of acute myeloid leukaemia

A

Common in adults
Transformation from myeloproliferative disorder
Blood film = auer rods
Neutropenia with high WCC
Thrombocytopenia

52
Q

Features of chronic myeloid leukaemia

A

Philadelphia chromosome
Chronic, accelerated, blast phases
Gout
Blood film = left shift and basophilia

53
Q

Features of chronic lymphocytic leukaemia

A

Commonest in adults (>55)
Blood film = smear/smudge cells
Warm autoimmune haemolytic anaemia
High-grade lymphoma = Richter’s transformation

54
Q

Risk factors for Hodgkin’s lymphoma

A
  • EBV, HIV
  • Autoimmune = RA, SLE, sarcoidosis
  • Family history
  • Male > female
  • Bimodal age distribution = 20 and 75
55
Q

Presentation of Hodgkin’s lymphoma

A
  • B symptoms = fever, weight loss, night sweats, pruritus, loss of appetite
  • Fatigue
  • Cough
  • Shortness of breath
  • Recurrent infections
  • Painless cervical lymphadenopathy = ‘rubbery’
  • Sometimes alcohol-induced lymph node pain
  • Hepatosplenomegaly
56
Q

Investigations of Hodgkin’s lymphoma

A
  • Normocytic anaemia
  • Lactate dehydrogenase raised
  • Lymph node biopsy = Reed-Sternberg cells (owl’s eye appearance)
  • CT/MRI/PET = staging
  • High ESR or Low Hb = worse prognosis
57
Q

Staging od Hodgkin’s lymphoma

A

Ann Arbor
- I = confined to single lymph node region
- II = involvement of 2+ nodal areas on same side of diaphragm
- III = Involvement of nodes on both sides of diaphragm
- IV = spread beyond lymph nodes  liver/bone marrow
- A = no systemic symptoms other than itching
- B = fever, weight loss, night sweats

58
Q

Complications of chemotherapy

A

leukaemia and infertility

59
Q

Complications of radiotherapy

A

risk of cancer, damage to tissues, hypothyroidism

60
Q

Risk factors for non-hodgkin’s lymphoma

A
  • Burkitt’s lymphoma = EBV
  • MALT lymphoma = H. pylori infection
  • Diffuse large B cell lymphoma = Over 65
  • Family history
  • HIV
  • Hep B/C
  • Pesticides exposure = trichloroethylene
61
Q

Presentation of myeloma

A
  • Calcium raised  Constipation, Nausea, Anorexia, Confusion
  • Renal failure  Thirst, Amyloidosis
  • Anaemia  Tiredness and malaise
  • Bone lytic lesions  Back/bone pain +/- fractures
  • Bleeding and bruising
  • Carpal tunnel syndrome
62
Q

Investigations for myeloma

A
  • FBC = low WCC, raised Ca, raised ALP, raised ESP, raised plasma viscosity
  • Blood film = rouleaux formation
  • Urine Bence-Jones protein test
  • Serum free Light chain assay
  • Serum immunoglobulins
  • Serum protein electrophoresis
  • Bone marrow biopsy
  • Plain XR = punched out lesions, lytic lesions, raindrop skull
63
Q

Diagnostic crtieria for myeloma

A
  • 1 major and 1 minor or 3 minor
  • Major
    o Plasmacytoma
    o 30% plasma cells in bone marrow sample
    o Elevated levels of M protein in blood or urine
  • Minor
    o 10-30% plasma cells in bone marrow sample
    o Minor elevations in level of M protein in blood or urine
    o Osteolytic lesions
    o Low levels of antibodies in blood
64
Q

Complications of myeloma

A
  • Recurrent bacterial Infection
  • Peripheral neuropathy
  • Spinal cord compression
  • Hyperviscosity
65
Q

Inheritance of Von Willebrand’s

A

Autosomal dominant

66
Q

Presentation of von willebrand’s disease

A

Epistaxis
Menorrhagia
Haemoarthoses
Muscle haematomas

67
Q

Investigations for von willebrand’s disease

A

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

68
Q

Management of von willebrand’s disease

A

Tranexamic acid for mild bleeding
Desmopressin
Factor VIII concentratin

69
Q

Causes of thrombocytopenia

A
  • Decrease in production
    o Congenital thrombocytopenia
    o Infiltration of bone marrow
    o Low B12/folate
    o Reduced thrombopoietin
    o Medication = methotrexate and chemotherapy
    o Toxins = alcohol
    o Infections = viral or TB
    o Aplastic anaemia
    o Myelodysplasia
  • Increase in destruction
    o Autoimmune
    o Hypersplenism
    o Drug related immune destruction
    o Disseminated intravascular coagulopathy
    o TTP
70
Q

Causes of immune thrombocytopenia purpura

A
  • Primary (acute)
    o Muco-cutaneous bleeding
    o History of recent viral infection = chickenpox/measles
    o May follow immunisation
    o Sudden self-limiting purpura = red/purple spots in skin caused by bleeding underneath
  • Secondary (chronic)
    o Chronic lymphocytic leukaemia, solid tumours, after viral infections (HIV/Hep C)
    o Platelet autoantibodies
71
Q

Presentation of ITP

A
  • Easy bruising
  • Epitaxis = nose bleed
  • Menorrhagia = heavy menstruation
  • Gum bleeding
  • Major haemorrhage (rare)
  • Purpura = red/purple spots on skin caused by bleeding underneath
  • Splenomegaly (rare)
72
Q

Investigations of ITP

A
  • Bone marrow examination = thrombocytopenia with increased or normal megakaryocytes in marrow
  • Platelet autoantibodies (60-70%)
73
Q

Management of ITP

A
  1. Prednisolone + IV immunoglobin = raises platelet count more rapidly
  2. Splenectomy + oral/IV azathioprine
74
Q

Causes of thrombotic thrombocytopenic purpura

A
  • Idiopathic
  • Autoimmune = SLE
  • Cancer
  • Pregnancy
  • Drug associated = quinine, ciclosporin, oral contraceptive pill, penicillin, clopidogrel, aciclovir
  • Post-infection = urinary, GI
  • HIV
75
Q

Presentation of TTP

A
  • Florid purpura
  • Fever
  • Fluctuating neuro signs (due to microemboli)
  • Haemolytic anaemia with red cell fragmentation
    o Often accompanied by acute kidney injury
  • Thrombocytopenia
76
Q

Investigations of TTP

A
  • Coagulation screen is normal
  • Lactate dehydrogenase is raised as result of haemolysis
77
Q

Management of TTP

A
  • Plasma exchange
  • IV methylprednisolone
  • IV rituximab
78
Q

Causes of disseminated intravascular coagulation

A
  • Massive activation of coagulation cascade
  • Initiating factors are
    o Extensive damage to vascular endothelium exposing tissue factor
    o Enhance expression of tissue factor by monocytes in response to cytokines
  • Sepsis
  • Major trauma and tissue destruction
  • Advanced cancer
  • Obstetric complications
  • Pancreatitis
79
Q

Presentation of DIC

A
  • Acutely ill and shocked
  • Bleeding may occur from mouth, nose and venepuncture sites
  • Widespread ecchymoses = discolouration of skin due to bleeding caused by bruising
  • Confusion
  • Bruising
  • Thrombotic event = skin, brain, kidney
80
Q

Investigations of DIC

A
  • Severe thrombocytopenia
  • Decreased fibrinogen
  • Elevated FDPs
    o D-dimer
    o Intense fibrinolytic activity that is stimulated by presence of fibrin in circulation
  • Blood film = fragmented RBCs
  • Prolonged Prothrombin time, activated partial thromboplastin time and thrombin time
81
Q

Management of DIC

A
  • Treat underlying condition
  • Replace platelets if low via transfusion
  • Fresh frozen plasma to replace the coagulation factors
  • Cryoprecipitate to replace fibrinogen and some coagulation factors
  • Red cell transfusion in patients who are bleeding
82
Q

Presentation of polycythaemia vera

A
  • Asymptomatic
  • Headaches
  • Itching (worse after hot bath/when patient warm)
  • Tiredness
  • Dizziness
  • Tinnitus
  • Visual disturbance
  • Erythromelagia = burning sensation in fingers and toes
  • Gout = due to increased turnover
  • Intermittent claudication
  • Plethoric complexion = congested or swollen with blood in facial skin
  • Hypertension
  • Angina
  • Hepatosplenomegaly
83
Q

Investigations of polycythaemia vera

A
  • FBC = raised WCC, platelets, Hb
  • Genetic screen = Presence of JAK2 mutation
  • Bone marrow biopsy = Prominent erythroid, granulocytic and megakaryocytic proliferation
  • Serum erythropoietin low
84
Q

Management of polycythaemia vera

A
  • Treatment aims to maintain normal blood count
  • Venesection = Removal of 400-500ml of blood weekly
  • Chemotherapy = Not tolerate venesection/ poorly controlled features
  • Low dose aspirin
  • Radioactive phosphorus = over 70
  • Allopurinol = block uric acid production  reduce gout
85
Q

Complications of polycythaemia vera

A
  • Thrombosis
  • Haemorrhage
86
Q

Blood transfusion complications

A
  • Non-haemolytic febrile reaction
    o Fever + chills
    o Mx: slow or stop transfusion, paracetamol, monitor
  • Minor allergic reaction
    o Pruritus, urticaria
    o Mx: temporarily stop transfusion, antihistamine, monitor
  • Anaphylaxis
    o Hypotension, dyspnoea, wheezing, angioedema
    o Mx: stop transfusion, IM adrenaline, ABCDE support
  • Acute haemolytic reaction
    o Fever, abdominal pain, hypotension, chest pain, agitation
    o Mx: stop transfusion, generous fluid resuscitation, send blood for direct Coombs test and repeat typing and cross-matching
    o Complications: disseminated intravascular coagulation, renal failure
  • Transfusion-associated circulatory overload (TACO)
    o Pulmonary oedema, hypertension
    o Mx: slow or stop transfusion, consider IV furosemide and O2
  • Transfusion-related acute lung injury (TRALI)
    o Hypoxia, pulmonary infiltrates on CXR, fever, hypotension
    o Within 6 hours of transfusion
    o Stop transfusion, O2 and supportive care
  • Infective
    o Transmission of vCJD

Finals (23 decks)

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