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Flashcards in Hematologic and oncologic diseases Deck (53)
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1

Name 4 clinical manifestations of iron deficiency anemia.

  1. angular cheilosis
  2. atrophic glossitis
  3. pica
  4. koilonychia

2

Describe the 3 main etiologies of iron deficiency anemia.

1. Chronic bleeding, e.g. GI, menstrual
2. Decreased iron supply, e.g. malnutrition, celiac, Crohn's, etc.
3. Increased demand, e.g. pregnancy

3

What lab tests diagnose iron deficiency anemia?

  1. Decreased serum Fe
  2. Increased TIBC
  3. Decreased ferritin

4

Describe the main etiology of B12 deficiency anemia.

Decreased supply!

1. malnutrition (alcoholics, vegans)

2. malabsorption (lack of intrinsic factor, celiac, Crohn)

3. increased competition (intestinal bacteria overgrowth, tapeworm)

5

What lab tests diagnose B12 deficiency anemia?

Decreased B12

Increased homocysteine AND methylmalonic acid

6

Describe the 3 main etiologies of folate deficiency anemia.

1. Decreased supply (alcoholic malnutrion, elderly, celiac)

2. Impaired metabolism (methotrexate, trimethoprim)

3. Increased requirement (chronic hemolytic anemia, pregnancy, malignancy)

7

What lab tests are used to diagnose folate deficiency anemia?

Rule out B12 deficiency first, but:

Decreased folate

Increased homocysteine

NORMAL methylmalonic acid

8

Name 3 general causes of intrinsic hemolytic anemia and 3 general causes of extrinsic hemolytic anemia.

Intrinsic:

Enzyme deficiency - G6PD deficiency

Hemoglobinopathies - sickle cell

Membrane problems - hereditary spherocytosis, PNH

Extrinsic:

Immune-mediated

Infections, toxins

Entrapment - hypersplenism

 

purple book 5-4

9

What are the lab results for diagnosing a hemolytic anemia in general?

Increased reticulocyte count

Increased LDH

Decreased haptoglobin

Increased indirect bilirubin

10

What will the smear look like in G6PD deficiency?

Heinz bodies, bite cells

11

What lab test will be positive in an autoimmune hemolytic anemia?

Coombs test

12

What are some indications for bone marrow biopsy?

  • Unexplained anemia
  • Macrocytic anemia (to distinguish megaloblastic from normoblastic maturation)
  • Unexplained leukopenia
  • Unexplained thrombocytopenia
  • Pancytopenia
  • Presence of blasts on peripheral smear (investigation for possible leukemia)
  • Presence of teardrop red cells on peripheral smear (possible myelofibrosis)
  • Presence of hairy cells on peripheral smear (possible hairy cell leukemia)
  • Suspected multiple myeloma
  • Staging of non-Hodgkin's lymphoma
  • Unexplained splenomegaly (possible lymphoma)
  • Fever of unknown origin
  • Confirmation of normal marrow in potential allogeneic donor
  • Work-up of amyloidosis (to detect clonal plasma cell disorder)

 

UpToDate

13

Where does erythropoeitin have its effects (where are receptors for it)?

What are the indications for exogenous EPO?

  • Affects colony forming cells and proerythrocytes in bone marrow
  • Indications: 
    • CKD-related anemia
    • chemotherapy-related anemia
    • prep for surgery with high risk of blood loss

Medscape

14

There are 4 Black Box warnings associated with exogenous EPO. What are they?

(significant adverse effects)

1. Erythropoiesis-stimulating agents (ESAs) increase the risk of death, myocardial infarction (MI), stroke, venous thromboembolism, thrombosis of vascular access.

2. In controlled trials, CKD patients experienced greater risks of death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL.

3. ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in some clinical studies in patients with breast, non–small cell lung, head and neck, lymphoid, and cervical cancers. Because of these risks, health care providers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense epoetin alfa to patients with cancer.

4. Perisurgical: Due to increased risk of deep venous thrombosis (DVT), DVT prophylaxis is recommended.

15

Both iron deficiency and mild alpha thalassemia are a microcytic anemia with minimal, vague s/s. What lab tests can you use to differentiate between them?

Why is it so important to differentiate?

1. Hemoglobin electrophoresis (abnormal in alpha thalassemia)

2. Measure serum iron and ferritin (low in IDA)

3. RDW likely to be low (not much size variation) in thalassemia; RDW likely to be high (lots of size variation) in IDA.

You really don't want to treat thalassemia with iron - leads to hemochromatosis and end organ damage.

16

What are the indications for transfusion therapy in thalassemia?

1. facial deformities (developing infants/children)

2. growth impairment

3. fractures/skeletal impairments

4. extramedullary hematopoeisis/hepatosplenomegaly

17

What is the pathophysiology of sickle cell anemia?

1. Autosomal recessive point mutation in gene for B-globin chain of hemoglobin

2. Hemoglobin S molecules aggregate & polymerize into needle-like fibers when deoxygenated and RBCs assume a sickle shape.

3. Microvascular occlusions lead to ischemic damage.

4. Severe hemolytic anemia

5. Painful vasoocclusive crises.

18

Describe the general approach to managing sickle cell pain crises.

  • Majority of symptoms are secondary to nociceptive pain and therapy should be directed to the treatment of nociceptive pain and not neuropathic pain.
  • Many health care providers perceive that patients with SCD are addicted to opioids and exhibit drug-seeking behavior - NOT TRUE.
  • Adults with SCD treated for pain should have an objective pain measurement to assess the impact of the treatment - the most common measurement for adults is the Visual Analog Scale (VAS), a continuous line, 100 mm in length, ranging from no pain to severe pain.
  • Given that individuals with SCD have most of their acute pain episodes at home, a standard care plan for treatment outside of the hospital is required, and pain treatment plans must be tailored to the individual.
  • Plans will range from treatment with non-opioid analgesics, such as NSAIDs or acetaminophen with codeine, to prompt presentation to a day hospital for intravenous opioids.
  • Successful management of pain in the hospital setting is typically achieved with scheduled opioid dosing or continuous infusion of opioids.
  • The most reasonable solution for breakthrough pain in hospitalized patients is the use of patient-controlled analgesia (PCA) that allows the individual to administer an immediate dose of pain medication without having to call the nurse.

19

List some common triggers for hospital admission in a patient with sickle cell anemia.

Number one reason for admission: pain crisis

infection

acute chest syndrome

aplastic crisis

sequestration crisis

20

What are the most common causes of thrombocytopenia?

1. sepsis

2. liver disease -> hypersplenism

3. medications

4. DIC

5. infection

6. massive transfusion

7. alcoholism

21

What are the most common causes of reactive thrombocytosis?

  • Infection
  • Post-surgical status
  • Malignancy
  • Post-splenectomy state
  • Acute blood loss or iron deficiency

 

UpToDate

22

What are some causes of autonomous thrombocytopenia?

Chronic myeloid leukemia

Polycythemia vera

Myelodysplastic syndromes

Acute myeloid leukemia

23

What are the steps of lab evaluation of thrombocytosis?

1. CBC with smear (Howell-Jolly bodies, neutrophilia)

2. Serum ferritin

3. Acute phase reactants e.g. CRP

If the above tests don't reveal a reactive cause of the thrombocytosis, then need a bone marrow biopsy to check for autonomous causes.

24

What lab tests are used to work up thrombocytopenia?

1. CBC with smear

2. If asymptomatic/mild, repeat CBC in a month

3. If symptomatic, test according to clinical picture for associated conditions e.g. liver, autoimmune, infection, etc.

25

Review the ABO blood typing system.

26

What is the initial management of a transfusion reaction?

Vigorous IV fluids, maintain urine output with diuretics or mannitol

27

What are the s/s of a transfusion reaction?

Acute hemolytic fever
Hypotension
Flank pain
Renal failure

28

Definition of neutropenic fever:

Fever: single oral temp > 101, or 100.4 for > 1 hr

101=38.3

100.4=38

Neutropenia: absolute neutrophil count < 500

 

purple book 5-36

29

Treatment for neutropenic fever:

Low-risk patients: cipro + amoxicillin-clavulanate

IV abx: no clear winner

  • ceftazidime or cefepime or imipenem

OR

  • aminoglycoside + antipseudomonal B-lactam

 

purple book 5-36

 

30

What are the clinical manifestations of vitamin K deficiency?

  • easy bruisability
  • mucosal bleeding
  • splinter hemorrhages
  • melena
  • hematuria

UTD