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Finals > Haematology > Flashcards

Haematology Flashcards

1
Q

Symptoms and signs of anaemia

A 
Symptoms
 Fatigue
 Dyspnoea 
 Faintness
 Palpitations 
 Headache 
 Tinnitus
Signs
 Pallor
 Hyperdynamic circulation
- Tachycardia
- Flow murmur: apical ESM - Cardiac enlargement
 Ankle swelling  ̄c heart failure
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2
Q

Cut off for anaemia

A

Men <13.5
Women <11.5
Children <11
Newborns<15

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3
Q

Classification of anaemia and causes

A 
Microcytic  - TAILS
Thalassaemia
Anaemia of Chronic Disease
Iron deficiency
Lead poisoning
Sideroblastic anaemia

Normocytic

  • recent blood loss
  • BM failure
  • Early ACD
  • Renal failure
  • Pregnancy (↑ plasma volume)
  • Hypothyroidism (may also be macrocytic)
  • Haemolysis (may also be macrocytic)
Macrocytic
- Megaloblastic
 Vit B12/ folate deficiency
 Anti-folate drugs: phenytoin, methotrexate 
 Cytotoxics: hydroxycarbamide
- Non-megaloblastic 
 Reticulocytosis
 Alcohol or liver disease 
 Hypothyroidism
 Myelodysplasia or Marrow infiltration
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4
Q

Bodies response to anaemia

A
  • ↑ CO (positive chronotrophy and inotrophy)
  • ↑ 2,3-BPG production - to reduce Hb affinity for O2 and shift saturation curve to the right,
  • ↑ erythropoesis levels
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5
Q

Iron deficiency anaemia - signs; causes; ix and mx

A

Signs
• Koilonychia
• Angular stomatitis / cheilosis
• Post-cricoid Web: Plummer-Vinson

Causes
- ↑ Loss Menorrhagia; GI; bleeding Hookworms
- ↓ Intake
Poor diet/ vegetarian
- Malabsorption. Coeliac; Crohn’s; gastrectomy
- ↑ utilisation Growth; pregnancy

Ix

  • Haematinics: ↓ferritin, ↑TIBC, ↓ transferrin saturation
  • Film: Anisocytosis, poikilocytosis, pencil cells
  • Upper and lower GI endoscopy

Rx
- Dietary advice
- Ferrous sulphate 200mg PO TDS
o SE: GI upset and black tarry stools

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6
Q

Sideroblastic anaemia - pathophysiology, signs; causes; ix and mx

A

Ineffective erythropoiesis
o ↑ iron absorption
o Iron loading in BM → ringed sideroblasts
o Haemosiderosis: endo, liver and cardiac damage

Causes
-	Congenital 
-	Acquired
o	Myelodysplastic / myeloproliferative disease
o	Drugs: chemo, anti-TB, lead

Ix

  • Microcytic anaemia not responsive to oral iron
  • ↑Ferritin, ↑ se Fe, ↔TIBC

Rx

  • Remove cause
  • Pyridoxine may help
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7
Q

Thalassaemia - pathophysiology

A 
Pathophysiology
Point mutations (β) / deletions (α) → unbalanced production of globin chains → precipitation of unmatched globin → membrane damage → haemolysis while still in BM and removal by the spleen
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8
Q

β Thalassaemia trait and major - sx, ix and mx

A

β Thalassaemia Trait ( Heterozygosity) - Mild anaemia which is usually harmless
• ↓ MCV (“too low for the anaemia”): e.g. <75
• ↑ HbA2 (α2δ 2) and ↑HbF (α2γ2)

β Thalassaemia Major
Features develop from 3-6mo
•	Severe anaemia
•	Jaundice
•	FTT
•	Extramedullary erythropoiesis
o	Frontal bossing
o	Maxillary overgrowth
o	HSM
•	Haemochromatosis after 10yrs (transfusions)

Ix
• ↓Hb, ↓MCV, ↑↑HbF, ↑HbA2 variable
• Film: Target cells and nucleated RBCs

Rx
• Life-long transfusions
• SC desferrioxamine Fe chelation
• BM transplant may be curative

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9
Q

α Thalassaemia- sx, ix and mx

A

 Trait
o Asymptomatic
o Hypochromic microcytes

 HbH Disease  –/-α
o Moderate anaemia: may need transfusions
o Haemolysis: HSM, jaundice

 Hb Barts  –/–
o Hydrops fetalis → death in utero

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10
Q

Ix for macrocytic anaemia

A

Ix

Film
o	B12/Folate
	Hypersegmented PMN
	Oval macrocytes 
o	EtOH/Liver
	Target cells

Blood
o LFT: mild ↑ bilirubin in B12/folate deficiency
o TFT
o Se B12
o Red cell folate: reflects body stores over 2-3mo

BM biopsy: if cause not revealed by above tests
o Megaloblastic erythropoiesis
o Giant metamyelocytes

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11
Q

Causes of haemolytic anaemia

A

Acquired
 Immune-mediated DAT+ve
- AIHA: warm (IgG mediated - extravascular haemolysis–> rx = immmunosupression +/- splenectomy), cold (IgN - intravasc haem –> rx = avoid cold +/- rituximab),
- Drugs: penicillin, quinine, methyldopa
- Allo-immune: acute transfusion reaction, HDFN

 PNH (Paraoxysmal nocturnal haemoglobinuria)
- abscence of RBC anchor molecule - IV lysis; sx = venous thrombosis of liver, mesentary and CNS; RX - anticoagulation

 Mechanical:

  • MAHA:
  • ->DIC
  • -> HUS (E.Coli O157:H7 - MAHA + Thrombocytopenia + renal failure; resolves spont.)
  • -> Thrombotic Thrombocytopenia Purpura ( sx - Fever; confusion/seizures; MAHA; Thrombocytopenia; Renal failure –> rx - plasmapheresis/ immunosup)
  • Heart valve

 Infection: malaria

 Burns

Hereditary
 Enzyme: G6PD and pyruvate kinase deficiency
 Membrane: HS, HE
 Haemoglobinopathy: SCD, thalassaemia

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12
Q

Pathophysiology of haemolytic anaemia

A

↑ red cell breakdown

  1. Anaemia ̄c ↑ MCV + polychromasia = reticulocytosis
  2. ↑ unconjugated bilirubin
  3. ↑ urinary urobilinogen
  4. ↑seLDH
  5. Bile pigment stones

Intravascular

  1. Haemoglobinaemia
  2. Haemoglobinuria
  3. ↓ se haptoglobins
  4. ↑ urine haemosiderin
  5. Methaemalbuminaemia

Extravascular
1. Splenomegaly

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13
Q

Causes and mx of folate deficiency

A

Reduced intake: Poor diet, alcoholics

Reduced absorption: Coeliac, Crohns, gastrectomy

Increased demand: Pregnancy, lactation,

Increased cell turnover – malignancy, chronic inflammation, dialysis, SCD or hereditary spherocytosis

Drugs – trimethoprim, methotrexate, sulphasalazine

Mx - assess for underlying cause; folate PO

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14
Q

Causes of B12 deficiency

A
  • ↓ intake – vegans
  • ↓ absorption – Gastrectomy, pernicious anaemia, Crohns, ileal resection
  • Increased utilization – Tapeworm
  • Drugs – metformin, Nitrous oxide.
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15
Q

Drugs that interfere with iron absorption

A
  • Cimetidine
  • Rantidine
  • Cholestyramine
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16
Q

What drugs can Iron decrease the absorption of?

A
  • Tetracyclines
  • Quinolone Abx
  • Bisphosphonates
  • Levodopa
  • Levothyroxin
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17
Q

Causes of Anaemia of Chronic Disease

A
  • Malignancy
  • Inflammation – RA, temporal arteritis
  • Chronic Infection – TB
  • Renal Failure
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18
Q

Pernicious anaemia cause, ix and mx

A

AI atrophic gastritis caused by autoAB agaisnt pareital cells or intrinsic factor –> achlorhydria and low intrinsice factor

  • B12 needs intrinsic factor for absorption and is absorbed in terminal ileum.

Ix - parietal cell and intrinsic factor Ab

Mx - Give B12 injection

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19
Q

Complications of blood transfusions

A

IMMEDIATE -stop transfusion
- haemolytic due to ABO incompatibilioty (IV haemolysis) Sx - Agitation; Fever; Abdo/chest pain; ↓ BP → shock; DIC → haemorrhage Renal failure
-bacterial contamination (sx - ↑↑ temp + rigors; ↓BP)
- febrile non-haemolytic (slow transfusion)
- anaphylaxis (Anti-IgA IgE)
- TRALI (ADRS - Anti-WBC ab)
- Fluid overload (CCF)
- Massive transfusion (Sx - ↑K
↓ Ca (citrate chelation); dilutional coagulopathy –>↓ F5 + F8 +↓ plats; Hypothermia); ?lactic acidosis

DELAYED

  • delayed haemolytic (Jaundice; Anaemia / ↓ing Hb Fever± Haemoglobinuria - extravas haem)
  • Fe overload –> Desferrioxamine SC
  • Post-transfusion Purpura (?thrombocytopenia - rx - IVig and plat transfusion)
  • GvHD (sx - d; skin rash; liver failure; pancytopenia)
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20
Q

What is Virchow’s triad

A

Abnormalities in blood flow
o Stagnation, turbulence

Abnormalities in vessel wall
o Atheroma, injury, inflammation

Abnormalities in blood components

21
Q

Causes of increased reticulocytes

A 
haemolytic anaemia
recent blood loss
response to vit b12/folate/iron replacement
response to EPO
Recovery from BM suppression
22
Q

Causes of reduced reticulocytes

A

BM failure

Haematinic deficiency

23
Q

How are RBC destroyed

A

Extravascularly by macrophages - then broken down into haem and taken to liver

Intravascularly - abnormal

1) bind haptoglonin and removed by liver
2) filtered by glomerulus
3) oxidised and bound to albumin

24
Q

Features, ix and Rx of B12 deficiency

A

Sx - sxof anaemia

  • Lemon tinge: pallor + mild jaundice
  • Glossitis (beefy, red tongue)
  • Neuro–> Paraesthesia; Peripheral neuropathy; Optic atrophy; Subacute Combined Degeneration of the Cord

Ix
 ↓ WCC and plats if severe
 Intrinsic factor Abs: specific but lower sensitivity
 Parietal cell Abs: 90% +ve in PA but ↓ specificity

Rx
- Malabsorption → parenteral B12 (hydroxocobalamin) –> Replenish: 1mg/48h IM; Maintain: 1mg IM every 3mo

  • Dietary → oral B12 (cyanocobalamin)
  • Parenteral B12 reverses neuropathy but not SACD
25
Q

What is Subacute Combined Degeneration of the Cord

A
  • Usually only caused by pernicious anaemia

Combined symmetrical dorsal column loss and
corticospinal tract loss. → distal sensory loss: esp. joint position and vibration → ataxia ̄c wide-gait and +ve Romberg’s test

Mixed UMN and LMN signs
 Spastic paraparesis 
 Brisk knee jerks
 Absent ankle jerks
 Upgoing plantars
- Pain and temperature remain intact
26
Q

Presentation of SCD

A

 Splenomegaly: may → sequestration crisis
 Infarction: stroke, spleen, AVN, leg ulcers, BM
 Crises: pulmonary, mesenteric, pain
 Kidney disease
 Liver, Lung disease
 Erection
 Dactylitis

27
Q

Complications of SCD

A

 Sequestration crisis
 Splenic pooling → shock + severe anaemia
 Splenic infarction: atrophy and hyposplenism
 ↑ infection: osteomyelitis
 Aplastic crisis: parvovirus B19 infection
 Gallstones

28
Q

What causes an increased APTT and what does it measure

A

Intrinsic pathway - F 12,11,9,8 (+ common 10,5,2,1)

Increased
 Lupus anti-coagulant
 Haemophilia A or B
 vWD (carries factor 8) 
 Unfractionated heparin
 DIC
 Hepatic failure
29
Q

What causes an increased PT and what does it measure

A

Extrinsic: 7 (+ common 10,5,2,1)

Increased
 Warfarin / Vit K deficiency  Hepatic failure
 DIC

30
Q

Causes and Sx of vascular and platelet disorder

A

Causes
- vascular: ehlers danlos; cit C def; meningococcus; steroids; HSP
- Thrombocytopenia
↓ production
 BM failure: aplastic, infiltration, drugs (EtOH, cyto)
 Megaloblastic anaemia
↑ destruction
 Immune: ITP , SLE, CLL, heparin, viruses
 Non-immune: DIC, TTP , HUS, PNH, anti-phospholipid
Splenic pooling
 Portal hypertension
 SCD

Sx
 Bleeding into skin: petechiae, purpura, echymoses
 Bleeding mucus mems: epistaxis, menorrhagia, gums
 Immediate, prolonged bleeding from cuts

31
Q

Causes and Sx of coagulation disorder

A

Causes

  • Severe liver disease
  • anti-coagulants
  • Vit K def
  • Haemophilia A/B
  • vWD

Sx
 Deep bleeding: muscles, joints, tissues
 Delayed but severe bleeding after injury

32
Q

Sx of anti-phospholipid syndrome

A 
CLOTs: venous and arterial
 Coagulation defect: ↑APTT
 Livido reticularis
 Obstetric complications: recurrent 1st
trimester abortion
 Thrombocyotpenia
33
Q

Causes of pancytopenia

A

Congenital
 Fanconi’s anaemia: aplastic anaemia

Acquired
 Idiopathic aplastic anaemia
 BM infiltration
 Haematological -->Leukaemia; Lymphoma; Myelofibrosis; Myelodysplasia; Megaloblastic anaemia
 Infection: HIV
 Radiation
 Drugs
- cyclophos, azathioprine, methotrexate; chloramphenicol, sulphonamide; thiazides; carbimazole; clozapine; phenytoin
34
Q

Pathophysiology; characteristics and Mx of myelodysplastic syndrome

A

Heterogeneous group of disorders → BM failure

Clone of stem cells–> abnormal development
→ functional defects
→ quantitative defects

May be primary or secondary (Chemo/RT)

Characteristics
 Cytopenias
 Hypercellular BM
 Defective cells: e.g. ringed sideroblasts
 30% → AML

Mx - Supportive: transfusions, EPO, G-CSF

  • Immunosuppression
  • Allogeneic BMT: may be curative
35
Q

Features and mx of Polycythaemia Vera

A

↑RBC; Hb; Hct; WCC; plats

Hyperviscosity
 Headaches
 Visual disturbances
  Tinnitus
 Thrombosis -  Arterial (strokes, TIA, peripheral emboli) or Venous (DVT, PE)

Erythromelalgia - Sudden, severe burning in hands and feet + redness of the skin

HSM; Gout; Histamine Release - pruritus

99% JAK2+ve

Mx - Aspirin 75mg OD
 Venesection if young

36
Q

Differentials of polycythaemia

A 
True Polycythaemia: ↑ total volume of red cells
 Primary: PV 
 Secondary
- Hypoxia: altitude, COPD, smoking 
- EPO: renal cysts/tumours

Pseudopolycythaemia: ↓ plasma volume
 Acute
- Dehydration; Shock; Burns
 Chronic - Diuretics; Smoking

37
Q

Amyloidosis definition and features

A

Group of disorders characterised by extracellular deposits of a protein in an abnormal fibrillar form that is resistant to degradation.

Sx
 Renal: proteinuria and nephrotic syndrome
 Heart: restrictive cardiomyopathy, arrhythmias, echo (“Sparkling”)
 Nerves: peripheral and autonomic neuropathy, CTS
 GIT: macroglossia, malabsorption, perforation,
haemorrhage, hepatomegaly, obstruction.
 Vascular: periorbital purpura (characteristic)

38
Q

Causes, signs, ix and rx of DIC

A

Widespread activation of coagulation from release of pro- coagulants into the circulation. CF and plats are consumed → bleeding
Fibrin strands → haemolysis

Causes
 Malignancy: e.g. APML
 Sepsis
 Trauma
 Obstetric events: e.g. PET

Signs
 Bruising
 Bleeding
 Renal failure

Ix
↓plats, ↓Hb, ↑APTT, ↑PT, ↑FDPs, ↓fibrinogen (↑TT)

Rx - treat cause; FFP/ cyroprecipitate

39
Q

Functions of the spleen

A

 Phagocytosis of old RBCs, WBCs and opsonised bugs
 Antibody production
 Haematopoiesis
 Sequestration of formed blood elements

40
Q

Causes of splenomegaly (and massive specifically)

A

Massive –> CML; Myelofibrosis; Malaria

All
Haematological
 Haemolysis: HS
 PV 
 Leukaemia, lymphoma
Infective
 EBV, CMV, hepatitis, HIV,
 TB, infective endocarditis
Portal HTN: cirrhosis, Budd-Chiari
Connective tissue: RA, SLE, Sjogrens
Other -->Sarcoid; Amyloidosis; 1O Ab deficiency (e.g. CVID)
41
Q

Causes of hepatomegaly

A

Malignancy
RHF
Fatty Liver
Hepatitis

42
Q

Causes of HSM

A 
CLD and portal HTN
Leukaemia
HBV/CMV/HCV
Malaria
Sarcoidosis
43
Q

Indications for splenectomy

A 
 Trauma
 Rupture (e.g. EBV infection) 
 AIHA
 ITP
 HS
 Hypersplenism
44
Q

Complications of splenectomy

A

 Redistributive thrombocytosis → early VTE  Gastric dilatation (ileus)
 Left lower lobe atelectasis: v. common
 ↑ susceptibility to infections (daily Abx)
 Encapsulates: haemophilus, pneumo, meningo (immunise)

45
Q

Causes of raised ESR >100

A 
 Myeloma
 SLE
 GCA
 AAA
 Ca prostate
46
Q

Causes of neutrophilia and neutropenia

A 
Neutrophilia
 Bacterial infection 
 Stress: trauma, surgery, burns, haemorrhage
 Steroids
 Inflammation: MI, PAN
 Myeloproliferative disorders: e.g. CML
Neutropenia
 Viral infection
 Drugs: chemo, cytotoxics, carbimazole, carbimazepine, colchine, sulphonamides
 Severe sepsis
 Hypersplenism: e.g. Felty’s
47
Q

Causes of lymphocytosis and lymphopenia

A

Lymphocytosis
 Viral infections: EBV, CMV
 Chronic infections: TB, Brucella, Hepatitis, Toxo
 Leukaemia, lymphoma: esp. CLL

Lymphopenia
 Drugs: steroids, chemo
 HIV

48
Q

Features of cells on blood film

A 
Howell-Jolly bodies- Hyposplenism 
Heinz bodies- G6PD deficiency
Pencil cells- IDA
Reticulocytes- Haemolysis / Haemorrhage
Spherocytes - AIHA; Hereditary spherocytosis
Schistocytes- MAHA; Prosthetic valve
Tear-drop cells - BM infiltration

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