Parietal cells produce intrinsic factor Intrinsic factor + ingested B12 = absorption in the terminal ileum

Hemato Oncology Flashcards by David Felipe Ortiz Paredes

↓Hb, ↓MCV. Dx and next step?

Microcytic Anemia.

• Iron studies: ferritin, Fe, TIBC, % of saturation

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↓Hb, ↑MCV. Dx and next step?

Macrocytic Anemia. Next step = smear to classify in:
• Megatloblastic (B12 or folate deficiency)
• Non-megaloblastic (liver disease, ETOH, drugs, metabolic)

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↓Hb, normal MCV, Reticulocyte index > 2%. Dx and next step?

Destruction Normocytic anemia. Get LDH, bilirrrubin, haptohemoglobin

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↓Hb, normal MCV, Reticulocyte index < 2%. Dx a possible cuases?

Production Normocytic anemia. Possible causes:
o Leukemia / myelodysplastic syndrome
o Kidney disease

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↓Hb, ↑MCV, smear with segmentation. Next step?

Measure B12 and folate

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↓Hb, ↑MCV, smear with segmentation, normal B12 and folate. Next step?

Get methyl malonic acid
o normal in folate deficency
o elevated in B12 deficency

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↓Hb, ↑MCV, normal smear. Dx?

Non-megaloblastic anemia

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Cuases of Non-megaloblastic anemia

•	Non-megaloblastic causes:
o	Cirrhosis
o	Alcohol (even if not cirrhosis)
o	Drugs 
	5 fluorouracil
	HAART (AZT) 
o	Metabolic inherited conditions

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Causes of folate deficency

Not ingestion of leafy greens (malnourish alcoholic, extreme diets)

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Absorption of B12

Parietal cells produce intrinsic factor

* Intrinsic factor + ingested B12 = absorption in the terminal ileum

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Cuses of B12 deficency

Strict uneducated vegan
Compromised absorption of B12
• Pernicious anemia: Auto-antibodies (IgA) attack parietal cells –> ↓ intrinsic factor
• Crohn’s disease: Inflammation of terminal ileum –> no absorption of B12
• Gastric bypass

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Complication of B12 megalobastic anemia

subacute combined degeneration of the posterior cord: Loss of 2-point discrimination, vibration and proprioception

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Schilling test

Discriminate between malabsorption and deficiency of B12
• IM B2 + PO B12 (saturation)
• Check B12 in the urine. If (+) : malnutrition -> Tx: PO B12; if (-) : absorption -> Tx: IM B12

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↓Hb, ↓MCV, ↓Fe, ↓Ferritin, ↑TIBC. Dx and next step?

Iron deficiency anemia. Iron replacement 324 mg TID + stool softeners AND look for the source of slow bleeding.

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↓Hb, ↓MCV, ↓Fe, ↑Ferritin, ↓TIBC. Dx and next step?

Anemia of Chronic inflammatory disease. Control underlying disease, but nothing for anemia +/- EPO in severe cases. Don’t give Fe replacement!

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ASx patient, ↓Hb, ↓MCV, normal Fe, normal Ferritin, normal TIBC. Dx, next step?

Minor thalasemia, get a Hb electrophoresis, but wont neet Tx

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Symptoms of anemia,↓Hb, ↓MCV, normal Fe, normal Ferritin, normal TIBC. Dx, next step?

Major thalasemia, get a Hb electrophoresis to differentiate between alfa and beta, monthly transfussion + de-ferox-amine if hemosiderosis (iron overload)

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↓Hb, ↓MCV, ↑ Fe, normal Ferritin, normal TIBC. Dx, next step?

Sideroblastic anemia. Next step, get a bone marrow Bx to see Ring sideroblasts (RBC with dark centre)

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Ring sideroblasts (RBC with dark centre) on bone marror Bx. Dx?

Sideroblastic anemia

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↓Hb, normal MCV. Next step?

Look for hemolysis
o	↓Haptoglobin
o	↑Bilirubin
o	↑LDH
o	Smear

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Bite cells and Heinz bodies on blood smear. Dx?

G6DP deficiency

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↓Hb, normal MCV, ↓Haptoglobin, ↑Bilirubin, ↑LDH, Spherocytes on blood smear. Dx and next step?

Two possible Dx: Hereditary spherocytosis or autoimmune hemolytic anemia.

Next step: Osmotic fragility and Coombs test to differentiate between the two

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↓Hb, normal MCV, normal smear, normal haptoglobin, normal bolirrubin, normal LDH. Possible Dx

Hemorrhage or CKD

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Male, afican american, with anemia, priapism/stroke/MI. Next step, possible Dx and Tx?

Next step: Smear with sickle cells, Hemoglobin electrophoresis (one time as a child).

Possible Dx: Sickle cell disease

Tx: Hydroxyurea (induces formation of HbF), folic acid
o In acute setting: IVF, O2, pain killers, and underlying condition, transfusion

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Male, africanamerican, taking dapsone / TMP-SMX / nitrofurantoine, who has jaundice. o Smear with Bite cells and Heinz bodies Next step, possible Dx and Tx?

Next step: o G6PD level (check it 6-8 weeks after the attack) Dx: G6PD deficiency Tx: Supportive, folic acid, and avoid stress

Greek man who eats fava beans, who has jaundice. ``` ↓Hb, normal MCV ↓Haptoglobin ↑Bilirrubin ↑LDH Smear with Bite cells and Heinz bodies ``` Next step, possible Dx and Tx?

Next step: o G6PD level (check it 6-8 weeks after the attack) Dx: G6PD deficiency Tx: Supportive, folic acid, and avoid stress

Tx of Hereditary spherocytosis ?

splenectomy, folate, Fe

↓Hb, normal MCV, ↓Haptoglobin, ↑Bilirubin, ↑LDH, Spherocytes on blood smear, Coombs test (+) for IgM. Dx?

Cold Autoimmune hemolytic anemia (associated with Mycoplasma)

↓Hb, normal MCV, ↓Haptoglobin, ↑Bilirubin, ↑LDH, Spherocytes on blood smear, Coombs test (+) for IgG. Dx?

Warm Autoimmune hemolytic anemia (associated with • Autoinmune disease and cancer) • Tx: steroids, rituximab, splenectomy

Patient with dark urine during night. Dx, next step, and tx?

Paroxysmal nocturnal hemoglobinuria o Dx: Flow cytometry CD55 (-) o Tx: Supportive, but in refractory cases use Eculizumab

47-y-o patient, ASx, ↑↑WBC, ↑↑Polys. Possible Dx and next step?

Chronic myelocytic leukemia (CML). | Next step: BM Bx and cytogenetics

47-y-o patient, ASx, ↑↑WBC, ↑↑Polys, : Philadelphia chromosome: a t(9,22) translocation with overactive activity of a tyrosine kinase BCR-Abl. Dx, Tx and complication?

Chronic myelocytic leukemia (CML). Tx: Imatinib Complication: Blast crisis, i.e., when CML becomes resistant to Tx and turns into AML

87-y-o patient, ASx, ↑↑WBC, ↑↑Lymphocites. Dx and treatment?

Chronic lymphocytic leukemia Because of the age and ASx, no Tx is needed But if • > 65 + Sx (hyperviscocity syndrome); Tx= ChemoTx • Young + donor; Tx = Stem cell transplant

67-y-o patient with fever, bone pain, anemia, bleeding, petechiae, and infections. Has history of exposure to bezene or radiation +/- history of CML. Dx and next step?

Acute myelocytic leukemia (AML) Next step: Smear and BM Bx

67-y-o patient with fever, bone pain, anemia, bleeding, petechiae, and infections. Has history of exposure to bezene or radiation +/- history of Chronic myelogenous leukemia (CML). Blood Smear shows blasts of polys and Auer rots BM Bx with > 20% blasts Marker: (+) Myeloperoxidase Dx and Tx?

Acute myelocytic leukemia (AML) – M3 variant Tx: Vitamin A

67-y-o patient with fever, bone pain, anemia, bleeding, petechiae, and infections. Has history of exposure to bezene or radiation +/- history of CML. BM Bx with > 20% blasts Marker: (+) Myeloperoxidase Blood smear blasts Dx and Tx?

Not M3 Acute myelocytic leukemia (AML) Tx: ChemoTx

7-y-o patient with fever, bone pain, anemia, bleeding, petechiae, and infections. * BM Bx > 20% blasts * Markers: (+) cALL, (+) TDT Dx and Tx?

Acute lymphocytic leukemia (ALL) Tx: • ChemoTx • Intrathecal prophylaxis chemoradiation with Ara-C or Methotrexate

Non-tender fixed lymph node +/- B symptoms (fever, night sweats, weight loss). Next step?

Excisional Bx

Non-tender fixed lymph node. Reed Stenberg cell on Excisional Bx. Dx?

Hodgkin’s Lymphoma

Workup for staging lymphoma.

1. CxR 2. CT chest, abdomen, pelvis or PET 3. Bone Marrow Bx

Stages of lymphoma

I: One group of lymph nodes II: > one group of lymph nodes; one side of diaphragm III: > one group of lymph nodes; opposide sides of diaphragm IV: Difusse disease, in blood or bone marrow A: No B Sx B: (+) B Sx

Pel-Epstein fevers (cyclical fever) Alcohol lymph nodes (lymph node becomes painful after consumption of alcohol) Associated with?

Hodgkin’s Lymphoma

Burkitt’s lymphoma. Extranodal disease Associated with?

Non-Hodgkin’s Lymphoma

Side effects of Cisplatin

Ototoxicity, nephrotoxicity

Side effects of Bleomycin

Pulmonary fibrosis

Side effects of Adriamycin/Doxorubicin

Cardiac (CHF)

Side effects of Vincristine/Vinblastine

Peripheral neuropathy

Side effects of Cyclophosphamide

Hemorrhagic cystitis

70-y-o patient, recurrent infections, hyperCa, anemia, renal failure, pathologic fractures. Possible Dx and next step?

Multiple myeloma. Next steps: - Serum electrophoresis showing an M spike (because of the excess of protein) - Urine electrophoresis showing an M spike (Bence Jones protein) - Skeletal surveys (xRs) with litic lessions - Bone marrow Bx to confirm de Dx (> 10% plasma cells)

Bence Jones protein in urine electrophoresis. Dx?

Multiple myeloma.

Mutiple myeloma Tx

> 70, no donor  ChemoTx: melphalan + prednisone + (thalidomide or bortezomib) <70 with donor  stem cell transplant

> 85, ↑protein gap, ASx, Serum electrophoresis showing an M spike, but… Negative urine electrophoresis Negative skeletal surveys BM Bx < 10% of plasma cells Dx and Tx?

Monoclonal Gammopathy of Uncertain Significance o Tx: observe, watch for conversion to MM

> 65 years, Hyperviscosity syndrome, constitutional Sx (sweets, weight loss), anemia, CHF Serum electrophoresis showing an M spike, but… Negative urine electrophoresis Negative skeletal surveys BM Bx > 10% lymphocytosis Dx and Tx?

Waldenstorm’s (a form of Plasma cell dyscrasia of secretion of IgM) Tx: Rituximab-based chemoTx If Hyperviscosity -->plasmapheresis

Factor II is called

Prothrombine

Factor IIa is called

Thrombine

Factor I is called

Fibrinogen

Factor Ia is called

Fibrin

Example of thombophilias and treatment

Factor V Leiden Prothrombin 20210A Protein C deficiency / Protein S deficiency Antithrombin deficiency Tx: After a second episode of DVT, thrombophilia is suspected and Tx with heparin-to-warfarin-bridge

Why Heparin-to-warfarin-bridge is done?

Warfarin initially inhibits protein C and S --> More risk of cloth Then once Proteins C and S are depleted, it inhibits factors 1972 --> Less risk of cloth

Women, history of autoimmune disease, Multiple miscarriages, Arterial and venous cloths. Possible Dx, cuase of that Dx, next step and tx?

Antiphospholipid antibody syndrome Cause by the lupus anticoagulant (in vivo is procoagulant) Next step: Russel’s viper venom test Tx: warfarin (INR 2-3)

Patient with Fever, Anemia (micro angiopathic hemolytic), Thrombocytopenia, Renal failure, and Neuro Sx (stroke). ``` CBC: low Plts Smear: Schistocytes PT/PTT: normal Fibrinogen: normal D-dimer: normal ``` Dx and tx?

Thrombotic thrombocytopenic Purpura (TTP) Tx: Exchange transfusion

Patient at the ICU who is critically ill, in sepsis and starts bleeding ``` CBC: low Plts Smear: Schistocytes PT/PTT: elevated Fibrinogen: low D-dimer: elevated ``` Dx and tx?

Disseminated Intravascular Coagulation (DIC) Tx: Supportive (e.g., transfusion), fix underlying disease

Patient who is hospitalized on heparin and after 7-14 days , platelets rapidly decrease. Dx and tx?

Heparin-induced thrombocytopenia Stop heparin Start argatroban Bridge-to-warfarin

Woman with lupus and low platelets. Dx and management?

Immune thrombocytopenic purpura Steroids IV Ig in acute setting if plts are really low Splenectomy If splenectomy fails, Rituximab

Patient with superficial bleeding (epistaxis, gingival bleeding, menorrhagia). Is it primary or secondary bleeding?

Primary bleeding (platelets)

Patient with deep bleeding (hemarthrosis, hematoma, prolomged bleeding). Is it primary or secondary bleeding?

Secondary bleeding (factors)

Patient with superficial bleeding (epistaxis, gingival bleeding, menorrhagia). Not on clopidogrel, ASA or NSAIDS Normal plt count Dx, next step, and tx?

Von Willebrand Disease Next step: Von Willebrand factor assay Tx: DDAVP (desmopressin)

Four causes of microcytic anemia.

TICS—Thalassemia, Iron defi ciency, anemia of Chronic | disease, and Sideroblastic anemia.

An elderly man with hypochromic, microcytic anemia is | asymptomatic. Diagnostic tests?

Fecal occult blood test and sigmoidoscopy; suspect | colorectal cancer.

Precipitants of hemolytic crisis in patients with G6PD deficiency.

Sulfonamides, antimalarial drugs, fava beans.

The most common inherited cause of hypercoagulability.

Factor V Leiden mutation.

The most common inherited bleeding disorder.

von Willebrand’s disease.

The most common inherited hemolytic anemia.

Hereditary spherocytosis.

Diagnostic test for hereditary spherocytosis.

Osmotic fragility test.

Pure RBC aplasia.

Diamond-Blackfan anemia.

Anemia associated with absent radii and thumbs, diffuse hyperpigmentation, café au lait spots, microcephaly, and pancytopenia.

Fanconi’s anemia.

Medications and viruses that lead to aplastic anemia.

Chloramphenicol, sulfonamides, radiation, HIV, | chemotherapeutic agents, hepatitis, parvovirus B19, EBV.

How to distinguish polycythemia vera from 2° polycythemia.

Both have ↑ hematocrit and RBC mass, but polycythemia vera should have normal O2 saturation and low erythropoietin levels.

Thrombotic thrombocytopenic purpura (TTP) pentad?

“FAT RN”: Fever, Anemia, Thrombocytopenia, Renal | dysfunction, Neurologic abnormalities.

Hemolytic uremic syndrome (HUS) triad?

Anemia, thrombocytopenia, and acute renal failure.

Treatment for TTP.

Emergent large-volume plasmapheresis, corticosteroids, | antiplatelet drugs.

Treatment for idiopathic thrombocytopenic purpura (ITP) in children.

Usually resolves spontaneously; may require IV Ig and/or | corticosteroids.

Which of the following are ↑ in DIC: fi brin split products, | D-dimer, fi brinogen, platelets, and hematocrit.

Fibrin split products and D-dimer are elevated; platelets, | fi brinogen, and hematocrit are ↓.

An eight-year-old boy presents with hemarthrosis and ↑ PTT with normal PT and bleeding time. Diagnosis? Treatment?

Hemophilia A or B; consider desmopressin (for hemophilia A) or factor VIII or IX supplements.

A 14-year-old girl presents with prolonged bleeding after dental surgery and with menses, normal PT, normal or ↑ PTT, and ↑ bleeding time. Diagnosis? Treatment?

von Willebrand’s disease; treat with desmopressin, FFP, or cryoprecipitate.

A 60-year-old African-American man presents with bone pain. Workup for multiple myeloma might reveal?

Monoclonal gammopathy, Bence Jones proteinuria, “punched-out” lesions on x-ray of the skull and long bones.

Reed-Sternberg cells.

Hodgkin’s lymphoma.

A 10-year-old boy presents with fever, weight loss, and night sweats. Exam shows an anterior mediastinal mass. Suspected diagnosis?

Non-Hodgkin’s lymphoma.

Microcytic anemia with ↓ serum iron, ↓ total iron-binding | capacity (TIBC), and normal or ↑ ferritin.

Anemia of chronic disease.

Microcytic anemia with ↓ serum iron, ↓ ferritin, and ↑ TIBC.

Iron defi ciency anemia.

An 80-year-old man presents with fatigue, lymphadenopathy, splenomegaly, and isolated lymphocytosis. Suspected diagnosis?

Chronic lymphocytic leukemia (CLL).

The lymphoma equivalent of chronic lymphocytic leukemia (CLL).

Small lymphocytic lymphoma.

A late, life-threatening complication of chronic myelogenous | leukemia (CML).

Blast crisis (fever, bone pain, splenomegaly, pancytopenia).

Auer rods on blood smear.

Acute myelogenous leukemia (AML).

AML subtype associated with DIC.

M3.

Electrolyte changes in tumor lysis syndrome.

↓ Ca2+, ↑ K+, ↑ phosphate, ↑ uric acid.

Treatment for AML M3.

Retinoic acid.

A 50-year-old man presents with early satiety, splenomegaly, and bleeding. Cytogenetics show t(9,22). Diagnosis?

Chronic myelogenous leukemia (CML).

Heinz bodies?

Intracellular inclusions seen in thalassemia, G6PD deficiency, and postsplenectomy.

An autosomal-recessive disorder with a defect in the GPIIbIIIa platelet receptor and ↓ platelet aggregation.

Glanzmann’s thrombasthenia.

Virus associated with aplastic anemia in patients with sickle cell anemia.

Parvovirus B19.

A 25-year-old African-American man with sickle cell anemia has sudden onset of bone pain. Management of pain crisis?

O2, analgesia, hydration, and, if severe, transfusion.

A significant cause of morbidity in thalassemia patients. Treatment?

Iron overload; use deferoxamine.

Hemato Oncology Flashcards

(103 cards)