Hematology Course1

Dear 5th year student Re: Hematology course

The hematology course has been designed to be interactive and clinically oriented. Your hematology course consists of didactic lectures, multidisplinary seminars, case scenarios a practical. Please, read the course objectives prior to starting the course to exactly know wha is required from each of you at the end of the course. Case scenarios supplemented in this course are meant to enhance your abilities in problem solving: understanding the patient’s complaints, looking for proper signs of any hematological problem, understand the sequenc of events, formulate a plan, order the proper tests and be able to initiate a therapy and follow outcome of treatment. To gain the maximum benefit, you are requested to read these case scenarios upfront write your answer in a separate sheet of paper and be ready to give it to your tutor upon request. Active participation and discussion is required from every body in class, your tutor is only a facilitator and not information provider during these sessions. You will be divided into groups (seminar rooms) and be assigned different tutor each module. Please, send me your comments any time. This is the only way to improve our teaching abilities. Sincerely 5th year hematology course Coordinator

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INDEX Sr. No. 1 2 3 4 5 6

Particulars

AIM & OBJECTIVES COURSE TIMETABLE APPROACH TO ANEMIA HEMATOLOGY LABORATORY – NORMAL VALUES PRINCIPLES OF HEMATOLOGY TESTS SLIDES

Page No

5 7 10 13 14 17

MODULE I – DISORDERS OF RED BLOOD CELLS

4 5 6 7 8 9 10 11

NUTRITIONAL ANEMIA MEGALOBLASTIC ANEMIA FOLIC ACID DEFICIENCY ALCOHOL AND HEMATOPOIESIS APLASTIC ANEMIA THE HEMOLYTIC ANEMIAS BLOOD TRANSFUSION PRACTICE PROBLEMS FOR TUTORIALS

20 22 23 24 24 25 28 31

MODULE II- WBC DISORDERS

12 13 14 15 16 17 18 19

LYMPHADENOPATHY AND SPLENOMEGALY BENIGN LEUKOCYTE DISORDERS HEMATOPATHOLOGY TESTING HODGKIN’S AND NON-HODGKIN’S LYMPHOMAS MYELOMA LEUKEMIAS PROBLEMS FOR TUTORIALS MYELOPROLIFERATIVE DISORDERS

37 38 40 42 46 48 51 54

MODULE III & IV - HEMOSTASIS AND THROMBOSIS

20 21 22 23

BLEEDING DISORDERS COAGULATION DISORDERS ANTITHROMBOTIC AGENTS PROBLEMS FOR TUTORIALS

57 61 66 68

3

PROBLEMS FOR TUTORIALS Sr. No.

Particulars

Page No

MODULE I – DISORDERS OF RED BLOOD CELLS

1 2 3 4 5 6 7 8 9 10

ANEMIA AND CONFUSION ANEMIA AND CONFUSION IN ALCOHOLIC ANEMIA AND RETICULOCYTOSIS ANEMIA AND ARTHRITIS ANEMIA AND HEART DISEASE ANEMIA, WEAKNESS AND JOINT PAIN ANEMIA AND MACROCYTOSIS FEVER, ANEMIA AND RETICULOCYTOSIS CHRONIC FATIGUE AND ANEMIA A YOUNG PATIENT WITH RECURRENT BONY ACHES

31 31 32 32 32 33 33 33 34 35

MODULE II- WBC DISORDERS

1 2 3 4 5 6 7 8

ADULT MAN WITH LYMPHOCYTOSIS A YOUNG FEMALE WITH NECK LUMP POLYCYTHEMIA ATYPICAL LYMPHOCYTOSIS LEUKOCYTOSIS AND SPLENOMEGALY PANCYTOPENIA LEUKOCYTOSIS LYMPHADENOPATHY

51 51 51 51 52 52 52 52

MODULE III & IV - HEMOSTASIS AND THROMBOSIS

1 2 3 4 5 6 7 8 9 10 11

A YOUNG BOY WITH SWOLLEN KNEE A BLEEDING YOUNG WOMAN FEVER AND COAGULOPATHY A BLEEDER BABY BOY BLEEDING GUMS AND BRUISING A YOUNG PATIENT WITH SUDDEN SHORTNESS OF BREATH OFTEN MISSED BLEEDING PROBLEM POST OPERATIVE DVT ALCOHOLIC AND COAGULOPATHY FEVER POST SPLENECTOMY BLEEDING WITH SEVER THROMBOCYTOPENIA

68 68 69 69 69 70 70 71 71 71 72

4

COURSE IN CLINICAL HAEMATOLOGY Aim Extensive knowledge of common disorders as encountered in the practice of clinical hematology; to enable the students to acquire requisite clinical skills for their diagnosis, and for planning and carrying out appropriate interventions for their prevention and management; to emphasize the emotional response and to understand the consequences of patient’s sickness.

Ob j ectives

At the completion of the course in clinical hematology, the student shall demonstrate: Knowledge of cardinal manifestations of hematological diseases Comprehension of etiology, pathophysiology pathogenesis, diagnosis, and principles of management of hematological diseases. Understanding of the basic principles of laboratory investigations of hematological diseases, and the ability to interpret relevant data to arrive at appropriate diagnosis of a hematological disorder. Ability to correlate relevant aspects of basic sciences and molecular biology with the clinical manifestations of hematological diseases. Recognition of the impact of disease on patient's social, emotional and professional life.

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-

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Module II : White Blood Disorders At the completion of the study of disorders affecting white blood cells, the students shall be able to: -

-

-

Specific Learning Objectives The course in clinical hematology consists of 4 units with specified learning objectives for each unit.

Module I: Disorders of Red Blood Cells At the completion of the study of the disorders of red blood cells, the students shall be able to: -

-

describe causes and pathophysiology of common types of nutritional anemias. enumerate the common causes of haemolytic anemias. discuss the pathophysiologic and molecular mechanisms that cause hemolysis, and to differentiate between intravascular and extravascular cause of hemolysis describe the clinical presentation, plan of

investigations, and be able to interpret, integrate and correlate salient points in clinical history, physical findings and laboratory data with a view to making a diagnosis of the type and cause of anemia in a patient plan and prescribe a rational schedule of management, based on a sound knowledge of the mechanism of action, dose, duration and side effects of appropriate drug therapy identify patients with anemia requiring blood component therapy, and to plan a management schedule including the type, amount, rate and the frequency of such administration advise the patient and the family regarding measures to be adopted for prevention or recurrence of anemia

differentiate benign from malignant causes of leukocytosis describe the clinical presentation, plan of investigations, and be able to interpret relevant laboratory data, so as to reach likely diagnosis and prognosis in a patient who may present with leukocytosis and/or lymphadenopathy explain basic molecular abnormalities underlying malignant transformation of haematopojetic cells, and resulting in hematological malignancies plan and prescribe a rational schedule of management, based on a sound knowledge of the mechanism of action, dose, duration and side effects of appropriate drug therapy

Module III: Coagulation Disorders At the completion of the study of coagulation disorders, the students shall be able to: -

-

discuss common causes of bleeding disorders and their pathogenesis describe the clinical presentation, plan of investigations and interpret, integrate and correlate salient points in clinical history, physical findings and laboratory data so as to reach a correct diagnosis in a patient presenting with a bleeding disorder describe the common mode of clinical presentation and demonstrate ability to

5

-

-

interpret relevant laboratory data in patients with following bleeding disorders Haemophilia von Willebrand's disease Acquired coagulation deficiency secondary to vitamin K deficiency, liver disease, chronic renal failure, and DIC. discuss common causes of thrombocytopenia. plan and interpret salient points in clinical history, physical findings and relevant laboratory data to establish diagnosis of the type and cause of thrombocytopenia in a patient. Plan and administer rational therapy to a patient with thrombocytopenia. Describe the indications, schedule of administration and side effects of the use of fresh frozen plasma, cryoprecipitate and platelets concentrates in the management of bleeding disorders

Module IV: Thrombotic Disorders At the completion of this unit of study, the students shall be able to: -

-

discuss pathophysiologic mechanisms of thrombosis and describe molecular basis of inherited thrombophilia enumerate common causes of acquired and inherited thrombotic disorders demonstrate ability to correlate salient points in clinical history and physical findings and to plan and interpret laboratory investigations so as to make dignosis of a thromboembilic disorder describe mechanism of action, dose, frequency, mode of administration, and adverse effects of heparin and coumadin anticoagulants

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HAEMATOLOGY COURSE 5TH YEAR STUDENTS 2005-2006

Date Saturday 17/12/05

Time P.M.

FIRST WEEK Topic

2 – 2.50 Lecture: Approach to Anemia 3 – 3.50 Case Study: Microcytic Anemia in a young woman

Sunday 18/12/05

Monday 19/12/05

Tuesday 20/12/05

Lecturer/Department Pathology Medicine Pathology

2 – 2.50 Case Study: Macrocytic Anemia and confusion

Medicine Pathology

3 – 3.50 Lecture: Hemolytic Anemia (Immune & Hereditary)

Medicine

2 – 2.50 Case Study: Normocytic Anemia and Reticulocytosis

Medicine Pathology

3 – 3.50 Lecture: Hemoglobinopathy (Thalassemia/SCA)

Pathology

2 – 2.50 Communication Skills

Community Med.

3 – 3.50 Case Study: A young man with recurrent Medicine bony aches & jaundice Pathology 4 – 4.50 Case Study: Unexplained Microcytic Anemia in a Kuwaiti patient

Wednesday 2 – 3.50 21/12/05

Practical (Anemia)

Medicine Pathology Pathology

SECOND WEEK Page 7 of 72

Saturday 24/12/05

Date Sunday 25/12/05

2 – 2.50 Lecture: Acute Leukemia 3 – 3.50 Lecture: Myeloproliferative Disorders (CML/ET/PRV/MF)

Time P.M.

Topic

Medicine Medicine

Lecturer/Department

2 – 2.50 Case Study: Polycythemia in a smoker

Medicine Pathology

3 – 3.50

Medicine Pathology

Case Study: Leukocytosis and Splenomegally

Monday 26/12/05

2 – 2.50 Lecture: Lymphoproliferative Disorders 3 – 3.50 Case Study: A young girl with neck lump

Medicine

Tuesday 27/12/05

2 – 2.50 Communication Skills

Community Medicine

Medicine Pathology

3 – 3.50 Lecture: Blood Component Therapy Pathology

Wednesday 2 – 3.50 28/12/05

Practical (WBC disorder)

Pathology

THIRD WEEK Saturday

2 – 2.50

Lecture: Approach to patient with Medicine Page 8 of 72

31/12/05

Sunday 01/01/06

bleeding tendency 3 – 3.50 Lecture: Thrombocytopenia/Hemophilia

Medicine

2 – 2.50 Case Study: Woman with recurrent bleeding

Medicine Pathology

3 – 3.50 Case Study: A bleeder child

Medicine Pathology

Monday 02/01/06

2 – 3.50

Tuesday 03/01/06

2 – 2.50 Case Study: Elderly man with unexplained thrombocytosis

Medicine Pathology

3 – 3.50 A boy with painful knee

Medicine Pathology

Wednesday 2 – 3.50 04/01/06

MDS: Thrombosis

Medicine Pathology Radiology

Pre-exam Revision

FOURTH WEEK Saturday 07/01/06 Sunday 08/01/06 Monday 09/01/06

HOLIDAY

9.30 – 11.00 AM

HAEMATOLOGY ASSESSMENT

Medicine Pathology

HOLIDAY

Tuesday 10/01/06

HOLIDAY

Wednesday 11/01/06

HOLIDAY

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Approach to Anemia Classification of Anemia

The classification of anemias is based on the size of the red blood cell and thus, divided into Microcytic (hypochromic), Macrocytic and Normocytic (normochromic). Normograms for the anemias can be used to order appropriate tests for each group as follows:

Microcytic Anemia F e rritin R educed

N o rm a l

Iro n d e fic ie n c y H B

Further investigations to find the cause are necessary

Increased

electrophore A sni se m i a o f C h r o n i c D iBs e o n a se em a r r o w R in g e d s id e r o b la s ts

If HB electrophoresis is normal then do alpha gene ma pp ing

Hypochromia Microcytic

Note: Anisocyosis: RDW poikilocytes

Thalassemia Trait

Variables

IDA

RBC count

< 5 x1012/L

> 5 x1012/L

MCV to HB level

Proportional

Disproportional

Mesner criteria MCV/RBC count

> 13

< 13

Red cell distribution width (RDW)

Elevated

Normal

Morphology

Anisocytosis Poikilocytosis / Elliptocytes

Target cells

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Normocytic Anemia

It is important to have a retics count done in normocytic anemia. As a high retics count indicates a healthy proliferating bone marrow. And this usually indicates hemolytic process or bleeding episode. It is important to calculate the absolute retics count or retics production index. Please, look at tests listed above for the investigat Normocytic anemia.

R eticulocytes Increased

H e m o ly s is

Norm al Decreased

P o s t H e m o rr h a Bg o nice M a r r o w E x a m

Im m une vs. non-im m une LDH/Bili/haptoglobin / Urine hemosiderin Coomb's test / Cold agglutinins G-6PD / HAMS test / Osmotic fragility

Abnorm al

Norm al

Hypoblastic RFT In filtra tio n LFT D yserythropoieticE ndocrine F e rritin Polychromasia: expressed as high reitcs count.

Fragmented RBC: schistocyte

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Macrocytic anemia

Here we need to differentiate between megaloblastic and non-megaloblastic anemias. In cases of megaloblastic anemia we need to request schilling test in case of Vit.B12 deficiency. In case of Folate deficiency we need a det dietary history, as poor dietary intake is usually responsible. Please look at the investigations listed below for Macrocytic anemia.

B lo o d a n d M a rro w M o rp h o lo g y M e g a l o b l a s tN ico n - M e g a lo b la s ti C lin ic a l D a ta L iv e r d is e a s e S e r u m V i t a m i n e sM y x e d e m a M D S N o d e f i c i e n cFy o l a t e D e f i c i e B n 1c y2 d e f i c i e n c y C o n g e n ita l D ru g s

D ie t

S c h ilin g te s t

Dimorphic anemia

If things do not “compute’ i.e. the hematological picture dose not fit with scheme then consider dimorphic blood pictures (two different combined types of anemia).

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HEMATOLOGY LABORATORY – NORMAL VALUES (Expressed in S.I. Units)

GENERAL HEMATOLOGY

Thrombin Clotting Time

9 – 11 sec

Bleeding Time (IVY)

2 - 10 min

Test WBC (x109/L)

Male 4.0 – 10.0

Female 4.0 – 10.0

FDP Assay

0 – 10 ug/L

RBC (x 109/L)

4.5 – 6.5

4.0 – 5.6

Fibrinogen Level

1.7 – 3.4 g/L

Hb (g/L)

135-180

115-160

Factor Assays

Het (L/L)

0.40 – 0.5

0.3 - 0.4

Antithrombin III

MCV (fL)

79.0 – 97.0

79.0 – 97.0

D-dimer

MCH (pg)

27.0 – 32.0

27.0 – 32.0

MCHC (g/L)

320 – 360

320 – 360

MPV (fL)

7.5 – 11.1

7.5 – 11.1

RDW (um)

8.6 – 13.0

8.6 – 13.0

PLT (x109/L)

150 – 450

150 – 450

RETIC (x109/L)

10.0 – 75.0

10.0 – 75.0

ESR (mm/h) (Wintrobe)

0.0 – 7.0

0.0 – 15.0

WBC Differential

%

0 .40 - 0.75

2.5 – 7.5

Lymph

0.20 - 0.40

1.5 – 3.0

MONO

0.02 - 0.10

0.2 – 0.8

EOS

0.01 – 0.06

0.04 – 0.4

BASO

< 0.01

0.00 – 0.1

Prothrombin Time (P.T.)

0.8 – 1.2 u/mL 0 – 0.5

Absolute (x 109 /L)

NEUT

COAGULATION

0.50 = 1.5 u/Ml

9 – 13 sec

International Normalized Ratio (INR)

< 13

Partial Thromboplastin Time (P.T.T) 26 – 36 sec

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PRINCIPLES OF HEMATOLOGY TESTS HEMOGLOBINOMETRY, CELL COUNTS AND INDICES

SIZE

Normocytic - normal size (7.5u diameter) - 6u diameter Accurate electronic cell counting has largely replaced Microcytic Macrocytic - 9u diameter previous counting chamber methods in most Anisocytosis - variation in size laboratories. These procedures may, or may not, be automated but either way the parameters shown below SHAPE may be measured or calculated. Normal 9 • Biconcave disc WBC x 10 /L 12 RBC x 10 /L Poikilocytosis Hb g/L • Variation in size Hct L/L Oval (or elliptical cells) MCV fL • Large numbers suggest hereditary elliptocytosis, MCH pg but oval cells are also seen in many anemias MCHC g/L (common in iron deficiency and thalassemia). Oval RDW um macrocytes suggest megaloblastic anemia Spherocytes DIAGNOSTIC PATTERNS OF RBC INDICES • Due to membrane loss, producing round spheres which are densely staining, and appear small. 1. Normal MCV, MCHC Large numbers suggest hereditary spherocytosis or • Normocytic, normachromic. Consider aplastic immune hemolytic anemia (IgG type) anemia, chronic disease, malignancies, renal Target cells failure, endocrine hypofunction, hemolysis, or • Due to membrane excess. Suggest liver disease, acute blood loss. Iron deficiency may also be thalassemia, hemoglobinopathy or postnormocytic and normochromic initially. splenectomy state. 2. Low MCV ± low MCHC Fragmented cells • Microcytic ± hypochromic. Consider iron • Many forms (schistocytes, helmet cells). Suggest deficiency, chronic disease, thalassemia fragmentation hemolysis with prosthetic heart and rarely sideroblastic anemia and lead valves, micro-angiopathic process (DIC, TTP, poisoning. HUS) 3. Increased MCV Sickle cells • Macrocytic. Consider Vitamin B-12 or folate • In homozygous form, mainly deficiency, reticulocytosis, alcholism, liver disease Acanthocytes (spine cells) and myelodysplasia • Liver disease, post splenectomy state

RED CELL MORPHOLOGY

Careful examination of a peripheral blood film is an integral part of the initial laboratory investigation confirming abnormalities detected by the Coulter Counter and seeking further clues to a specific diagnosis. At the same time, leukocytes and platelets should be assessed. Morphologic assessement includes:

Spurr cells (echinocytes) • Uremia, often artifact

STAINING Normachromic • Central pallor occupies one-third of RBC Hypochromic • Decreased Hgb concentration (increased central pallor). Polychromasia • Bluish-gray staining (indicates reticulocytes).

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INCLUSIONS Basophilic stippling • Ribosome precipitation; seen in many anemias,

but helpful in diagnosis of thalassemia and lead poisoning. Howell-Jolly bodies – nuclear remnants, usually seen in post-splenectomy. Nucleated RBC's • Suggest extramedullary hematopoiesis (myeloid metaplasia), active erythropoiesis (bleeding, hemolysis) or metastatic cancer in bone marrow. Heinz Bodies • Require special supravital stain; represent denatured Hgb and seen with oxidative hemolysis, some enzymopathies and hemoglobinopathies. Parasites • Eg. Malaria

Qualitative – eg. Normoblastic vs megaloblastic erythropoiesis. Presence or absence of iron stores. Ring sideroblasts 2. Assessment of marrow infiltrates • Leukemia, myeloma, metastatic carcinoma Closed bone marrow biopsy (Jamshidi needle) provides a better sample for assessment of cellularity and is essential if the bone marrow examination is being performed to detect marrow fibrosis, or neoplastic infiltration (carcinoma, lymphoma, Hodgkin's disease)

•

SEDIMENTATION RATE

The popular "Sed rate" is one of the simplest, yet poorly utilized test in laboratory medicine. The usual method used involves placing a known volume of anticoagulated blood in a special tube of specified length (100 mm Wintrobe, or 200 mm Westergren) and DISTRIBUTION allowing the red cells to sediment for one hour. In Rouleaux normal persons the red cells sediment only 7 – 15 mm • Suggest immunoproliferative disease if extensive, (Wintrobe) during this hour but this rate increases with but lesser amounts common in many acute and many illness due to an increase in globulins eg chronic diseases. increased gammaglobulins (in myeloma, liver disease Autoagglutination or chronic infection) or acute phase reactants such as • Aggregates of RBC's due to cold agglutinations. haptoglobin and fibrinogen (in any traumatic, infectious, inflammatory or neoplastic illness)

RETICULOCYTE COUNT

Detects young erythrocytes (by precipitation of residual RNA with special stain) and usually provides a reliable source of erythropoiesis. Reticulocytes last upto 48 hours in circulation and 1% erythrocytes are made each day; therefore, up to 2% reticulocytosis is considered normal (absolute 10 – 75 x 109/L).

The Sedimentation Rate has been used to differentiate organic (elevated) from functional (normal) disease and to diagnose or to follow progress of inflammatory and infectious processes. A normal Sedimentation Rate does not rule out serious illness, and an elevated Sedimentation Rate is a non-specific finding.

OTHER LABORATORY PROCEDURES

Reticulocytopenia A careful evaluation of some of all of the previous • Suggests bone marrow depression, infiltration (eg basic laboratory tests may be sufficient for a diagnosis leukemia) or lack of erythropoietin, iron, etc. but often they serve, in conjunction with clinical Reticulocytosis assessment, to direct specific investigations. These • Suggests hemolysis, blood loss, or response to investigations are described elsewhere. From this point, careful selection of laboratory tests is essential. treatment. If the reticulocyte count is reported as a percentageWidespread ordering of many expensive and and the patient is anemic, it should be converted to an unnecessary investigations without regard to basic test absolute count to assess effectiveness of reticulocyte results is wasteful and unrewarding. response.

BONE MARROW EXAMINATION

SPECIAL CONSIDERATIONS FOR PEDIATRIC PATIENTS

Most common indications for marrow aspirations The following differences between adult and pediatric include patients require emphasis: 1. Assessement of cytopenias (anemia, neutropenia, 1. Level of Hemoglobin: At birth, the Hb is very thrombocytopenia) high but shortly after birth, there is decrease in Hb • Quantitative – eg. Hypocellular vs (as well as Hematocrit and RBC count). The lowest point is reached between 3 and 6 months hypercellular with Hb as low as 100g/L being normal. By one • Presence of absence of precursor cells (eg. year of age infants are often physiologically Megakaryocytes) slightly iron deficient. This is more marked in

Page 15 of 72

premature infants who require supplemental iron to avoid iron deficiency anemia.

2. White Blood Count and Differential: Initially in

neonates there is neutrophilic leukocytosis, but within a week a lymphocyte predominance develops and lasts until about five years of age when the percentage of lymphocytes and granulocytes is equal. Later the child develops the usual adult picture of neutrophil predominance. Pertusis causes a striking lymphocytosis with white counts up to 100 x 109/L. The lymphocytes

are small and not atypical as seen in viral infections.

3. Lymph nodes: There is a marked lymphoid

hyperplasia of the lymphoid system in children reaching a peak between 3 and 5 years. Tonsillar enlargement is a common finding and enlargement of the cervical axillary and inguinal lymph nodes is frequently found on routing examination.

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Basophilic stippling

Burr Cells

Elliptocytes

Heinz Bodies

Helmet cells

Hemoglobin C crystals

Howell-Jolly bodies

Hypochromia

Macroovalocytes

Malaria-Plasmodium Falcipuram

Malaria- Plasmodium Vivax

Megakaryoblast and promegakaryocyte

Megalocytes-1

Megalocytes-2

Microcytosis

Pappenheimer bodies- iron stain

Pappenheimer bodiesWright stain

Poikilocytes

Page 17 f 72

Polychromatophils

Rouleaux

Sickle Cell

Spherocytes

Target Cells

Teardrop cells

Page 18 of 72

MODULE I DISORDERS OF RED BLOOD CELLS OBJECTIVES •

Describe causes and pathophysiology of common types of nutritional anemias.

•

Enumerate the common causes of haemolytic anemias.

•

Discuss the pathophysiologic and molecular mechanisms that cause hemolysis, and to differentiate between intravascular and extravascular cause of hemolysis.

•

Describe the clinical presentation, plan ofinvestigations, and be able to interpret, integrate and correlate salient points in clinical history, physical findings and laboratory data with a view to making a diagnosis of the type and cause of anemia in a patient.

•

Plan and prescribe a rational schedule of management, based on a sound knowledge of the mechanism of action, dose, duration and side effects of appropriate drug therapy.

•

Identify patients with anemia requiring blood component therapy, and to plan a management schedule including the type, amount, rate and the frequency of such administration.

•

Advise the patient and the family regarding measures to be adopted for prevention or recurrence of anemia.

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NUTRITIONAL ANEMIA: IRON ABSORPTION AND METABOLISM

4. Intravascular Hemolysis

Paroxysmal nocturnal hemoglobinuria (an exceedingly rare disease) and much more commonly, intravascular hemolysis due to erythrocyte trauma from a cardiac valvular prosthesis may both result in an iron deficiency Intravascular hemolysis leads to trapping of hemoglobin in renal tubular cells followed by formation of hemosiderin which is lost in desquamated cells. Hence, hemosiderinuria occurs with a loss of as much as 15 mg of iron per day.

Iron is absorbed largely in the duodenum and upper jejunum. The absorption of ferric iron, but not ferrous or hemoglobin iron, is facilitated by hydrochloric acid, and impaired after gastrectomy. The rate of iron absorption is regulated by physiological needs, and is increased in iron deficiency and other anemias. Human control their total body iron by absorption and not iron excretion. The average North American diet contains about 10 - 15 mg of iron daily. Total daily iron loss in men is about 1 mg (0.5 mg in feces, 0.1 mg in sweat). The CLINICAL FEATURES OF IRON average daily iron loss in women during reproductiveDEFICIENCY The iron deficient patient may be completely a life is about 2 mg. symptomatic, even in the presence of marked anemia if this has developed gradually. There is good evidence IRON DEFICIENCY that the anemia itself may not be responsible for the Iron depletion without anemia is very common; symptoms, muscle, etc. Symptoms frequently reported some degree of iron deficiency is present in include: fatigue, tinnitus, palpations, weakness and approximately 10% of most populations. Mild lightheadedness. Sore tongue or sore mouth sometimes anemia, due to iron deficiency, is frequently not occurs and there may rarely be severe stomatitis. There hypochromia and there are other causes of may be some loss of papillae from the tongue and hypochromic anemia other than iron deficiency; hence fissures at the corners of the mouth. Mild hypochromic anemia and iron deficiency anemia are splenomegaly occurs rarely. Koilonychias (spoon not synonymous. nails), a condition in which nails are flattened or even ETIOLOGY OF IRON DEFICIENCY concave and are brittle, occurs uncommonly but is of SPECIFIC CAUSES considerable diagnostic help when it occurs.

1. Menstruation

The following points are important to assess the LABORATORY INVESTIGATION severity of menstrual bleeding: 1. Examination of the Stained Blood Film and A. The number of pads used. Greater than 12 Red Cell Studies. pads is considered abnormal. The classical appearance of red cells in iron B. If double pads are used, does blood soak deficiency is that of hypochromia and microcytosis. through? These features are often helpful in making a C. Are there large clots? diagnosis but two problems prevent complete D. How many days do the periods last; more than reliance on it. One is that there are causes such as five days being suggestive of increased "anemia of chronic disease", thalassemia and bleeding. sideroblastic anemia for erythrocyte hypochromia E. Pregnancy and Lactation: other than iron deficiency. The second problem is 2. Impaired Absorption of Iron that the anemia of iron deficiency may be This is rarely a cause of iron deficiency except in normochromic and normocytic until quite severe. the presence of sprue or as the result 2. Serum Iron and Iron Binding Capacity gastrointestinal surgery. Most patients who have Determination (these studies may be limited had total gastrectomy and up to 50% of patients values) with sub-total gastrectomy develop iron Normal Range deficiency, although this may require several years Total Iron Binding Capacity 45 - 81 after surgery. umol/L (TIBC) 3. Gastrointestinal Bleeding Unsaturated Iron Binding Capacity 27 - 54 Determining the source of gastrointestinal umol/L (UIBC) bleeding is a challenge. Radiologic examinations Serum Iron and endoscopy are the chief aids to the diagnosis. *Percent saturation = serum iron x 100% With respect to gastric bleeding, corrosive injury Total iron binding capacity from several drugs (e.g. Aspirin, phenylbutazone, *Values of less than 15% are suggestive of Indomethacin) occurs with considerable frequency.

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iron deficiency. 3. Serum Ferritin

c. An iron-deficient patient with normal

The level of ferritin in the plasma appears to be a reliable indicator of the size of body iron stores in most situations. The normal range is approximately (adult male: 15-350 ug/L; adult female: 15-200 ug/L). Values below the normal range indicate iron deficiency and correlate well with absent marrow iron. With chronic 2. inflammatory or malignant disease, ferritin tends to be elevated or at least normal, even when iron stores are absent. Therefore, a low serum ferritin is diagnostic of iron deficiency, whereas a normal level in a patient with chronic inflammation, may not actually reflect the iron stores.

4. Bone Marrow

Iron stores are usually evaluated following Prussian blue staining of the bone marrow smear. This is a highly reliable method of assessing iron deficiency, since this store is exhausted before anemia occurs.

5. Examination of Stools for Blood

Occult bleeding causing iron deficiency is usually of too small a volume to cause blackening of the stool. Testing for occult bleeding may be done with the use of benzidine, Guaiac or orthotolidine.

TREATMENT OF IRON DEFICIENCY 1. Principles of Treatment: (Determine the cause)

gastrointestinal absorptive function will respond to any oral iron preparation give in an adequate dosage for an adequate period of time. d. Patient tolerance is largely related to dosage. e. Ferrous sulphate is much cheaper than any other iron preparation.

Oral Iron Preparations

In a daily dose of 0.9 grams given as 300 mg t.i.d., p.o., ferrous sulphate results in rapid correction of iron deficiency anemia after a latent period of approximately 14 days. Three hundred (300) mg of ferrous sulphate t.i.d. provides 180 mg of elemental iron per day, of which about 10% is absorbed by the normal individual and up to 25 or even 40% in the iron-deficient individual. Replenishment of iron stores requires at least four months of treatment after the return of the hemoglobin concentration to normal. Thus, in the absence of continuing blood loss, oral iron therapy should be continued for at least six months. Continued blood loss requires more chronic therapy.

3. Parenteral Iron Therapy.

The indications for parenteral iron therapy are very limited since oral therapy is Generally well tolerated, effective and inexpensive.

a.

Iron deficiency is the only disorder that responds to iron administration. b. A search for chronic blood loss often must accompany treatment.

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MEGALOBLASTIC ANEMIA Megaloblastic anemia is a term used for an anemia with a macrocytic blood film and megaloblastic erythroid maturation in the bone marrow. These changes are due to defective DNA synthesis, most often secondary to deficiency of vitamin B12, or folic acid. Other organs, such as G.I. tract and CNS may be affected. The common findings are:

PERIPHERAL BLOOD

Pancyopenia: A moderate reduction in leukocytes and platelets is usual, and anemia may vary from mild to severe. Blood film: The erythrocytes vary greatly in size and shape, but macrocytes predominate and oval macrocytes may be seen. The neutrophils have hypersegmented nuclei (6 or more lobes). Polychromasia is not conspicuous (and reticulocyte count is not increased).

VITAMIN B12 DEFICIENCY NUTRITIONAL REQUIREMENTS Vitamin B12 is required in small amounts (1 - 2 ug) daily and since adequate B12 is found in all foods of animal origin it is also impossible for anyone other than a strict vegetarian to become B12 deficient on a dietary basis. Vitamin B12 is not present in vegetables and fruit. Body stores are 2 - 3 mg enough to last 3 - 4 years.

ABSORPTION

Normal B12 is absorbed selectively in the ileum by the intrinsic factor mechanism. Intrinsic factor is a glycoprotein, secreted by gastric parietal cells. It quickly binds with vitamin B12 released from food in the stomach, and transports the B12 to specific sites of attachment on the brush border of the ileal mucosa. The B12 is absorbed, after several hours delay in the ileal mucosa, and is carried in the blood stream attached to proteins (transcoballamins).

CAUSES OF VITAMIN B12 DEFICIENCY

In comparison to the lymph, many RBC are large and oval

Nutritional - vegans MALABSORPTION Gastric causes -

Hypersegmented Neutrophil

Intestinal causes -

pernicious anemia (P.A.) gastrectomy Blind loop syndrome sprue, ileal resection Crohn's disease

Bone Marrow: erythroid hyperplasia, and

megaloblastic maturation as shown below

.

Giant metamyelocyte

Dy smeg akary op oiesis Erythroblast

OTHER LABORATORY TESTS

Fish tape

PERNICIOUS ANEMIA

Adult P.A. occurs in both men and women, usually over the age of forty, and is characterized in the typical case by triad of: a) Megaloblastic anemia: b) Glossitis: recurrent sore tongue and mouth, with progressive atrophy of papillae, leading to a smooth, red tongue. c) CNS changes: peripheral neuritis is common, and subacute combined degeneration is unique to B12 deficiency (it does not occur with folate deficiency).

Due to the breakdown of erythroid cells, mainly in the bone marrow (intramedullary hemolysis) the following abnormalities may be seen, although there is no need for them to be ordered: AUTOIMMUNE ASPECTS: 1. Serum bilirubin - mild increase, mainly indirect It has been suggested that P.A. is an "autoimmune fraction disease". The B12 malabsorption is secondary to lack of 2. Lactic dehydrogenase (LDH) - may be greatly intrinsic factor production, due to gastric atrophy. The increase; LDH1 predominates gastric mucosa is invaded by lymphocytes and plasma 3. Decreased haptoglobin, and increased cells, and there is a high incidence of parietal cell methemalbumin. antibody (95%) and intrinsic factors antibody (30 60%).

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LABORATORY INVESTIGATION The specific laboratory tests are: 1. Serum B12

2. Gastric Juice

All adult patients with P.A. have achlorhydria but is not common practice to measure this.

Vitamin B12 is measured in the serum by radioimmunoassay. Serum B12 should be measured 3. Defective B12 Absorption usually along with folate, before any treatment is The Schilling test may be performed if doubt exists as given, or a Schilling test performed. A low serum B12 to B12 absorption. and normal serum folate is virtually diagnostic of B12 deficiency; further tests are necessary to determine the cause. A slight decrease in serum B12 may occur with TREATMENT In pernicious anemia, 1000 ugm cyano-cobalamin severe folate deficiency. Serum B12 may be reduced in intramuscularly each month will sustain a normal patients on birth control pills. blood picture.

FOLIC ACID DEFICIENCY REQUIREMENTS AND DIETARY SOURCE

activity and therefore conversion to active coenzyme forms.

Man is unable to synthesize his estimated daily requirement of about 50 ug per day (infants 25-50 ug 4. Alcohol per day). Meats, particularly liver, and green The folate deficiency of alcoholics is complex and vegetables are good dietary sources of folic acid. probably involves dietary deficiency as well as Boiling vegetables in excess water will efficiently impaired absorption and perhaps also decreased extract much of the folate content. Requirements are hepatic storage and altered utilization. increased in pregnancy, hemolytic anemia, and 5. Pregnancy hyperthyroidism. Megaloblastic anemia of pregnancy usually responds to folic acid and usually laboratory evidence of folate depletion is obtained. ABSORPTION AND FUNCTION OF FOLIC Requirements for the pregnant woman are not well ACID established, but are increased and pregnant women Folic acid is absorbed in the duodenum and jejunum should receive supplemental folic acid (as well as by an active transport mechanism. Folic acid iron) to prevent deficiencies. metabolites act as coenzymes in the metabolism of both DNA and RNA. There is a complex interrelationship between vitamin B12 and folic acid metabolism and function such that DNA synthesis is impaired with a deficiency of either vitamin and pharmacological doses of the opposite vitamin will partly correct the impaired DNA synthesis, megaloblastosis and anemia.

CAUSES OF FOLIC ACID DEFICIENCY 1. Dietary Deficiency

Requires approximately four months to produce anemia in the healthy subject.

2. Intestinal Disease

LABORATORY INVESTIGAIONS OF FOLATE DEFICIENCY Normal Values Serum Folate Red Cell Folate

6.8 - 18.4 nmol/L 363 nmol/L

Low serum and red cell Folate with normal or slightly reduced B12 levels is diagnostic of Folate deficiency. As with B12 deficiency, the megaloblastosis in the marrow is rapidly corrected, and reticulocytosis is prompt (3 - 7 days).

Especially gluten enteropathy (coeliac disease) andTREATMENT OF FOLIC ACID DEFICIENCY tropical sprue. In addition to removing causative factors where 3. Drugs Commonly dilantin, primidone, and barbiturates. possible, the administration of folic acid orally is Oral contraceptive agents also appear occasionally usually required. to cause malabsorption. The folic acid antagonist methotrexate inhibits dihydrofolate reductase

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ALCOHOL AND HEMATOPOIESIS Chronic and excessive alcohol ingestion causes many are the morphological clue to this type of hematological complications by direct toxic effects, by hemolysis. contributing to nutritional deficiency or by complicating liver dysfunction as follows: 4. Sideroblastic Anemia Direct toxic effect of alcohol on hemesynthesis causes ring sideroblasts, ineffective erythropoiesis, 1. Macrocytic Anemia and a hypochromic anemia. Usually due to folic acid deficiency on a nutritional basis (megaloblastic anemia) but even in the absence of folate deficiency, alcohol and 5. Hypersplenism liver disease can cause macrocytic anemia. Due to cirrhosis and portal hypertension causing congestive splenomegaly. Pancytopenia is usually present. 2. Iron Deficiency Anemia Usually due to chronic G.I. bleeding from Thrombocytopenia, often severe, may be caused esophageal varices or gastritis by a direct toxic effect of alcohol, even in the absence of folate deficiency. 3. Hemolytic Anemia Usually a complication of severe alcoholism with liver disease and often hyperlipidemia. Spur cells

APLASTIC ANEMIA

Aplastic anemia is an uncommon, but often serious, blood disorder characterized by pancytopenia due to the decreased functional capacity of a hypoplastic (fatty) bone marrow. Even in severe cases of aplastic anemia there may be small residual islands of functioning bone marrow which may cause confusion in diagnosis, and which lead to a concept that the micro-environment (the soil) rather than the stem cell (the seed) might be abnormal in these patients. However, the success of bone marrow transplantation strongly supports the concept that deficient or defective stem cells are responsible.

CLASSIFICATION IDIOPATHIC: anemia)

- Heriditary (Fanconi's - Acquired - Chemical and Drugs - Radiation - Infection (viral hepatitis) - Immunologic (?autoimmune)

2. Anti-inflammatory drugs – phenylbutazone, indomethacin, gold, etc 3. Diuretics – thiazides 4. Anticonvulsants – dilantin Chloramphenicol rarely causes a severe irreversible aplastic anemia (1 in 30,000 cases treated) which cannot be predicted, but frequently causes a mild reversible pancytopenia (Idiosyncratic reaction). Phenylbutazone is now the commonest cause, since the use to chloramphenicol has decreased. The aplastic anemia associated with viral hepatitis is severe and often fatal. Immunologic causes of some cases of aplastic anemia have been postulated but not proven

CLINICAL AND LABORATORY FEATURES

Pallor, bleeding and bruising are common and infections are frequent. Lymphadenopathy and hepatosplenomegaly are characteristically absent. The anemia may be severe, usually normocytic but sometimes slightly macrocytic. Granulocytopenia is regularly seen, and lymphopenia is variable. The cause of about 50% cases cannot be determined Thrombocytopenia is usually marked, and and these are termed idiopathic. Fanconi's anemia is anmegathrombocytes are absent. extremely rare hereditary aplastic anemia, often associated with short stature, skeletal abnormalities, MANAGEMENT hypoplastic kidneys, etc. The role of red cell, granulocyte, and platelets Exposure to chemicals containing benzene is transfusions are discussed with the management of particularly hazadarous. Drugs which most frequently leukemias. When aplastic anemia is severe are associated include: (granulocyte count 0.5 x 10 9/L, platelet count 20 x 10 SECONDARY

9/L) and not reversible, the prognosis is very grave 1. Antibiotics – chloraphenicol, sulfas, streptomycin (85% mortality in one year, with median survival of 3

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months). If an HLA-compatible sibling is available as high dose androgen therapy may cause improvement in a bone marrow donor, then prompt bone marrow anemia but not leucopenia nor thrombocytopenia. transplantation is the treatment of choice (not that an Steroids are often given a trial of 2 -4 weeks but HLA-compatible sibling is only available in 1/4 to 1/3 should then be discontinued if not obviously helpful. of cases. Splenectomy has no definite role to play in these cases. For milder cases, or those unsuitable for The status of immunosuppressive treatment (Cyclosporin) is investigational but helpful in some marrow transplantation Antithymocyte globulin can cause a significant improvement in a number of cases. cases.

THE HEMOLYTIC ANEMIAS Increased RBC destruction is the common factor in all II EXTRINSIC DEFECTS hemolytic anemias. Hemolysis is detected by: (EXTRACORPUSCULAR) 1. Evidence of erythrocyte destruction. 2. Bone marrow compensation 1. Autoimmune hemolytic anemia (Coombs positive) 3. Decreased erythrocyte survival a. Warm antibody (IgG)- idiopathic, secondary (lupus, lymphoma, Aldomet, etc) EVIDENCE OF ERYTHROCYTE b. Cold antibody (IgM) – idiopathic (cold DESTRUCTION hemagglutinin disease), secondary a) Hemoglobin, hematocrit – both decreased unless (mycoplasma, infectious mononucleosis) hemolysis is "compensated" (normal bone marrow 2. Alloimmune hemolytic anemias – Hemolytic can increase RBC production at least 6 to 8 times) disease of newborn, post transfusion b) Hyperbilirubinemia – increased serum bilirubin, 3. Drug induced hemolytic anemia mainly indirect (unconjugated type), and increased a. Chemical effect in absence of G6PD urobilinogen in urine. deficiency, or with G6PD deficiency c) * Increased plasma hemoglobin 4. Mechanical hemolytic anemia * Decreased serum haptoglobin a. Micro-angiopathic – hemolytic – uremic * Hemoglobinuria syndrome, TTP, DIC, etc * Hemosideriuria b. Cardiac fragmentation hemolysis * Mainly intravascular hemolysis 5. Secondary hemolytic anemia – infectious, liver or renal disease, etc. BONE MARROW COMPENSATION a) Reticulocytosis – seen as polychromasia on routine I INTRINSIC DEFECTS blood films, but can be specifically demonstrated on reticulocyte count. A. HEREDITARY HEMOLYTIC ANEMIAS b) Erythroid hyperplasia of bone marrow DECREASED ERYTHROCYTE SURVIVAL Seldom necessary Cr51 most often used as radioactive label for patient's own erythrocytes. Requires 10 to 14 days.

CLASSIFICATION

I INTRINSIC DEFECTS (INTRACORPUSCULAR) A. HEREDITARY 1. Membrane defect – HS, HE 2. Hemoglobinopathies a. Quantitative – Thalassemias b. Qualitative – Hb S, C, S-C etc 3. Enzymopathies – G6PD, PK, etc B. ACQUIRED 1. Paroxymal Nocturnal Hemoglobinuria (PNH)

1. MEMBRANE DEFECTS: Hereditary Spherocytosis is an uncommon form of hemolytic anemia (incidence of 1 in 5,000 population) with an autosomal dominant inheritance. Spherocytes are usually evident on examination a routine blood film. If not obvious, then an osmotic fragility test should be ordered to detect the osmotically fragile pre-spherocyte cells. Reticulocytosis and splenomegaly are usually prominent. Splenectomy is the definitive treatment after which hemolysis ceases, although spherocytes persist in the blood. Hereditary Elliptocytosis is also called hereditary ovalocytosis and is relatively common (1 in 2,000 population) with an autosomal dominant inheritance. Most cases have little or no hemolysis but 10% or less have significant hemolytic anemia requiring splenectomy.

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2. HEMOGLOBINOPATHIES: Diagnosis of enzymopathies requires demonstration Thalassemia is a complex group of anemias of the specific enzyme deficiency by complex usually classified with the hemolytic anemias laboratory procedures. because hemolysis is marked in the severe homozygous forms, but the primary defect is a B. ACQUIRED HEMOLYTIC ANEMIAS quantitative reduction in synthesis of globin 1. PAROXYSMAL NOCTURNAL chains. Beta chain synthesis is decreased in beta HEMOGLOBINURA (PNH); thalassemia which is mainly seen in individuals of Very rare hemolytic disorder. Acquired increased Mediterranean background. sensitivity of the RBC membrane to complement, The heterozygous form (beta thalassemia minor) causing intravascular hemolysis and hemoglobinura. is fairly common is characterized by extreme Diagnostic test is Ham's acidified serum test. PNH microcytosis, and hypochromasia but little or no may be associated with aplastic anemia or anemia. Diagnosis is confirmed by demonstrating myelofibrosis. an increased Hb A2, and no treatment is required Treatment: supportive blood transfusions. (although laboratory findings resemble iron deficiency, iron stores are usually normal or II EXTRINSIC DEFECTS increased and iron therapy is contradicted) The (EXTRA CORPUSCULAR) homozygous form (beta thalassemia major) causes severe hemolysis in childhood with splenomegaly, 1. AUTOIMMUNE HEMOLYTIC ANEMIA and iron overload usually leading to death in (AIHA): adolescence unless vigorous transfusion and ironRequires the presence of: chelation therapy is employed. a. Hemolytic anemia Alpha chain synthesis is decreased in b. Antibody directed against an intrinsic antigen alpha thalassemia which is commoner in on the patient's own erythrocytes; find Orientals; the inheritance is more variable antibody or complement on the surface of the resulting in clinical disorders ranging from a very patient's erythrocytes (direct antiglobulin or mild anemia, through moderate hemolytic anemia Coombs test), and often antibodies in the (Hb H disease), to a very severe form causing patient's serum (indirect antiglobulin or death in utero. Coombs test) Sickle cell Anemia- Sickle cell trait is common IgG antibodies lead to destruction of RBC's in (10% of American Blacks) but is usually the R-E system of spleen and liver mainly. IgM asymptomatic and detected only by the presence of antibodies usually fix complement and produce abnormal Hb electrophoresis (SA) or a positive intravascular hemolysis. sickle cell preparation. If the heterozygous sickle cell trait is combined with the gene for Hb C, then a. WARM ANTIBODY TYPE (IGG): a more severe disorder (Hb S-C disease) occurs This is the commonest type, usually chronic, with hemolysis, splenomegaly, and hemolytic and often (50%) secondary to other diseases crises. Sickle cell anemia (or disease) is the (lupus, lymphoma, chronic lymphocytic leukemia). homozygous form (Hb SS) characterized by a Splenomegaly and lymphadenopathy suggest severe hemolytic anemia beginning in early secondary type. Drug-induced hemolytic anemias childhood, causing splenic infarcts occur by these mechanisms: (autosplenectomy), bone infarts, hemolytic or i. Innocent bystander type- quinidine aplastic crises and often death in young adult life. ii. Hapten type – penicillin (massive Treatment is unsatisfactory (supportive care with doses) transfusions, fluid therapy and analgesia). Autoimmune type – Almodet (alpha iii. 3. ENZYMOPATHIES: Hereditary deficiencies of G6PD or Pyruvate kinase (PK) are commonest. The gene for G6PD deficiency is sex-linked and many isoenzyme types exist. Most lead to acute hemolysis on exposure to oxidant drugs, or possible FAVA beans, while others cause chronic hemolysis. Blacks and Mediterranean races are most commonly affected. Management involves avoidances of oxidant drugs. PK deficiency causes chronic hemolysis and splenomegaly; splenectomy is usually helpful.

methyl DOPA); a positive direct antiglobulin (Coombs) test occurs in one third of patients on drug for several months, but hemolysis is very rare. Diagnosis is suggested by hemolysis, spherocytosis and polychromasia, and confirmed by a positive direct antiglobulin (Coombs) test. Treatment includes: 1. Steroids – up to 60 – 80 mg Prednisone daily with gradual tapering depending upon response.

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2. Splenectomy – 50 % response; reserve for cases unresponsive to steroids, or requiring large maintenance steroid dosage. 3. Blood transfusion – difficult to crossmatch; use least incompatible blood and transfused only if absolutely necessary. 4. Immunosuppressive therapy (Imuran, Cyclophosphamide) – for cases unresponsive to steroids and splenectomy. 5. Folic Acid (5 mg daily) – this is given to all chronic hemolytic anemias as prophylaxis for folic acid deficiency due to increased folate utilization b. COLD ANTIBODY TYPE (IGM): These are uncommon and characterized by RBC agglutination and hemolysis when exposed to cold temperature. They may be: Idiopathic – chronic cold agglutinin i. disease (CAD); relatively benign hemolytic anemia in older persons, with Raynaud's syndrome and hemoglobinuria ii. Secondary – with lymphoma, or infectious (mycoplasma, infectious mononucleosis) Diagnosis is suggested by autoagglutination on blood film and hemolysis; it is confirmed by demonstrating increased cold agglutinatinins (anti-I or anti-i) Treatment involves avoiding cold temperature and possible blood transfusion. Chronic cases may need chemotherapy (Chlorambucil). Steroids and splenectomy are not indicated.

ii.

thrombotic thrombocytopenic purpura (TTP) septicemia, DIC and carcinomatosis may cause RBC fragmentation with or without thrombocytopenia Cardiac Hemolytic Anemia – Due to prosthetic aortic valve usually; occasionally with Teflon patch, or calcified valve. Iron deficiency is commonly associated because the chronic intravascular hemolysis leads to chronic urinary iron (hemosiderin) loss.

5. SECONDARY HEMOLYTIC ANEMIA: A variety of infections (eg. Clostridia, malaria) may cause erythrocyte damage and hemolysis. Hepatic and renal disease result in mild chronic hemolysis usually, but defective erythropoiesis from chronic disease, iron deficiency may also play a role

2. ALLOIMMUNE HEMOLYTIC ANEMIAS: These are due to passage of maternal antibodies across placenta to damage fetal RBC's (hemolytic disease of new born) or to blood transfusion with antibodies present acting against foreign RBC's. Delayed hemolytic transfusion reactions of varying severity may occur. 3. DRUG-INDUCED HEMOLYTIC ANEMIA: Chemical Effect – Many oxidant drugs (Phenacetin, Salazopyrine, etc) in high dosage cause hemolysis in normals, but G6PD deficient patients are particular susceptible to many drugs in small amounts. The end result is methemoglobin, sulfhemoglobin and Heinz body formation with resultant RBC fragmentation. 4. MECHANICAL HEMOLYTIC ANEMIA: The trauma to RBC membrane produces fragmentation (schistocytes, helmet cells, burr cells, spherocytes, etc). May be i. Micro-angiopathic Hemolytic Anemia. – Toxemia, abruption placenta, malignant hypertension, hemolytic-uremic syndrome,

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BLOOD TRANSFUSION PRACTICE DONOR AND PATIENT SELECTION

Each hospital will have guidelines for appropriate procedure (cross match or group and reserve) for each type of operation.

Donors should be volunteers, and are carefully screened for history of infectious disease and medications. However, no transfusion can be 2. BLOOD COMPONENT THERAPY completely free of risk because: a. Whole Blood – stored up to 5 weeks in CPD 1. Present screening procedures do not eliminate anticoagulant. Used for treatment of acute blood hepatitis transmission (especially non-A, non-B loss and replacement of red cell mass and volume) hepatitis). HIV screening of all blood products rarely available; blood components are used to occurs now. provide the equivalent of whole blood in those 2. Some patients may react to non-RBC components situations – e.g. allergic and febrile reactions. 3. Auto-antibodies produced to RBC antigens (other b. Packed Red Cells – storage and cell survival same as whole blood. Preferred for most anemias than ABO and Rh) may limit future transfusion requiring transfusion. therapy. c. Plasma Products –fresh frozen plasma, stored plasma, albumin, cryoprecipitate and factor In spite of this, most transfusions (95%) produce concentrates. no adverse effects, and serious reactions are rare. Patient selection depends on clinical judgement but thed. Platelet Concentrate e. Gamma Globulin and Specific Antisera – following guidelines might be used: Intravenous and intramascular gamma globulin preparations are available, as are specific antisera 1. Degree and chronicity of anemia: Patients with (anti-hepatitis B, CMV, Zoster) chronic anemia of moderate degree (Hb 60 – 80 g/L) often maintain reasonable activity, and the 3. TRANSFUSION PROCEDURE need for transfusion should be correlated with symptomatology (eg severe fatigue, aggravation of a. Rate of Transfusion. Depends on clinical situation. One unit of blood may be infused in 15 minutes in angina, heart failure etc) rapidly bleeding patients. Packed cell transfusions 2. Active or potential bleeding: It is generally for anemia usually take about 2 hours (longer than accepted that Hb should be kept about 100 g/L in 4 hours should be avoided due to risk of bleeding patients and in patients who undergo contamination) surgery. b. Amount Transfused. Depends on clinical situation. 3. Possible response of hemantinics. Usually better Single unit transfusions are generally avoided. The to investigate anemia, and treat specifically (eg patient's Hb should increase approximately 10 g/L iron, B12) if possible. per unit of packed cells transfused, in average size adult. PRINCIPLES OF BLOOD TRANSFUSION c. Diluents. Normal saline is the recommended 1. TYPE OF CROSSMATCH diluent for blood products. A small amount (50 a. Group and Reserve Serum – no crossmatch; mL) will correct the increased viscosity of packed consists of blood group and antibody screen; red cells (about 0.70). Plasma and 5% albumin are serum is reserved for cross-matching later, if possible alternatives. Glucose solutions cause RBC needed. Some institutions do not crossmatch if the agglutination and hemolysis so must not be used. antibody screen is negative Ringer's solution contains calcium which can b. Routine Crossmatch- complete; takes atleast one overcome the citrate anticoagulant and cause clots hour. to form in the tubing; so red cells must not be c. Urgent or Emergency Crossmatch – shorter diluted with Ringer's solution. incubation (about 30 minutes) to provide blood for urgent clinical situations. ADVERSE EFFECTS OF BLOOD d. Uncrossmatched Blood – give ABO and Rh type TRANSFUSIONS same as patient (rather than Rh negative). Only When any significant reaction, which cannot be given in most extreme emergencies, unless patient explained or treated, occurs during a transfusion, it is has been previously tested (group and reserve advisable to terminate the transfusion and investigate serum) in which the case the need for for hemolytic transfusion reaction. However, most crossmatching is much less reactions are not hemolytic. Types of reactions include:

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1. HEMOLYTIC REACTIONS: these products are utilized to their best possible a. Immediate. Chills, fever, dyspnea, bone pain, advantage. The following guidelines are currently hypotension, red urine, renal failure and bleeding employed: (D.I.C) may all occur. Terminate transfusion and investigate by sending unused blood, venous 1. FRESH FROZEN PLASMA (FFP): blood specimen and urine specimen to Blood Storage: 20oC for 1 year Bank (for repeat crossmatch, direct Coomb's test Contents: Must be frozen within 12 hours of and test for hemoglobinura) May need supportive blood donation so that it will contain all treatment for shock, bleeding or renal failure. coagulation factors. No platelets are present, and it contains allo-antibodies as in stored plasma. b. Delayed. Fever, jaundice, or recurrent anemia Use: Replacement of coagulation factors occurring 3 days or more after transfusion. Investigate for hemolysis, including Coomb's which cannot be provided by other products (i.e. test. This may reflect an amnestic antibody for factor VIII alone, in hemophilia, factor VIII response to previous antigen exposure. concentrate would be used) Its main use is for treatment of multiple coagulation deficiencies occurring after massive transfusion (10 or more 2. FEBRILE REACTIONS: units) or with D.I.C. Time is required for thawing Chills, fever and occasionally hypoxia usually in (up to 30 minutes) so stored plasma 5% albumin is multi-transfused or multiparous patients with preferred for immediate replacement in severe WBC antibodies. Treat with antipyretic, and try to hemorrhage. It is evident that excessive use of this prevent in future with leukocyte poor blood or component will mean less cryoprecipitate, or washed packed cells. There are several methods to factor VIII concentrate, can be made, thereby produce leukocyte poor blood, leukocyte limiting the treatment of hemophiliacs. centrifugation in line filters, washed packed cells, frozen blood, but line filters are usually used. 2. CRYOPRECIPITATE, FACTOR VIII 3. ALLERGIC REACTIONS: CONCENTRATE: Storage: -20oC for 1 year (cryoprecipitate); Usually urticaria. Common (up to 3% of transfusions). Treat with antihistamina – may 4oC (Factor VIII) or room temperature for several finish transfusion if reaction not severe, responds months Contents: Both are made from plasma frozen to therapy, and does not worsen when transfusion is restarted carefully. If recurrent, prescribe and within 12 hours of blood donation antihistamine before future transfusions. Rarely Cryoprecipitate is a partly purified factor VIII anaphylactic reactions occur and there are often in preparation containing about 50% of the factor patients with IgA deficiency. Such patients should VIII in the original blood donation, in small be given washed blood in the future. volume (10 mL). Each unit of cryoprecipitate (one unit is made from one blood donation) contains between 70 – 100 units of factor VIII ( 1 unit of 4. VASCULAR OVERLOAD: factor VIII equals the amount present in 1 mL of Congestive heart failure may be precipitated, plasma). Factor VIII concentrate is a more highly particularly in elderly patients with chronic purified preparation of factor VIII, requiring more anemia, given whole blood, or too rapid extensive fractionation procedures; it contains a transfusion of packed cells and blood components. standardized amount of Factor VIII, per vial and is more easily administered so is the preferred 5. OTHER: product for factor VIII replacement in some Chills – rapid transfusion of refrigerated blood; situations (particularly for home care programs for contaminated blood – very rare. severe hemophilia). Recently a recombinant factor Disease transmission – hepatitis, VIII product has become available and has cytomegalovirus, malaria, AIDS replaced Standard Factor VIII concentrate. Iron overload – with large numbers of transfusions Hyperkalemia – in renal failure 3. ALBUMIN: Citrate toxicity – rarely, with massive Supply: 25% albumin solution (100 mL), salt transfusions and liver failure, or prematurity. poor, stored at 4oC Use: Hypoalbuminemia (usually with complicated TRANSFUSION OF PLASMA AND edema) where improvement in the patient can be PLATELET COMPONENTS reasonable expected, i.e. do not just treat a Blood and blood component therapy is influenced by laboratory abnormality without regard to patient's problems of product availability and storage far more condition, or underlying disease – albumin is than most branches of medicine. A thorough usually not given for cirrhosis and nephritic knowledge of these limitations, and continuing syndromes. It is commonly used for supportive communication with Blood Bank staff will ensure that

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care in burn patients, and during hyperalimentation. Supply: 5% albumin solution (250 mL) Use: This product provides a hepatitis-free colloid substitute for stored plasma where volume replacement is needed (eg. Hemorrhage with shock, plasma exchanged) but where coagulation factors are not. It is much more expensive than crystalloid solutions (eg. Normal saline, Ringer's solution) so should only be used when colloid (protein) effect is really needed. NOTE: Albumin and immune globulin are the only blood products which are free of risk of hepatitis transmission due to methods of production. All other products carry this risk, albeit small, despite extensive donor screening and viral testing; fibrinogen had a greatly increased risk because it was pooled, as opposed to single donor product, and is no longer issued (cryoprecipitate may be used instead to treat hypofibrinogenemia). The factor concentrates (VIII and IX) are now specially treated ; this should prevent the viral transmissions which were previously high with these products.

4. PLATELET CONCENTRATE:

x 10 9/L for each unit transfused, 1 hour after transfusion in a patient of average size (eg, increase platelet count by 60 x 10 9/L if 6 units given). Use: Platelet concentrate should be infused promptly (1/2 an hour) through a regular blood transfusion set, not previously used for blood transfusion. Platelet response is limited by such factors as fever, splenomegaly and presence of auto-antiobodies or allo-antibodies. In general, the presence of these antibodies makes platelet transfusion almost worthless, although occasionally a therapeutic response may be seen in a bleeding thrombocytopenic patient of this type. Best results are obtained in patients who have not been previously transfused, or pregnant, and where thrombocytopenia is due to decreased production, rather than increased destruction or consumption of platelets. Prophylac tic platelet transfusion may be given to patients with severe thrombocytopenia (platelet count < 10 x 10 9/L) due to a disease of limited duration (eg. Leukemia during chemotherapy, drug toxicity, some aplastic anemias) and will be then required 2 to 3 times weekly. Sensitization to platelet and HLA antigens often occurs over 1 to 2 months and this limits further transfusions of random donor platelets. Platelets obtained by platelet-pheresis from donors who are selected for HLA compatibility may be helpful when patients become refractory to random-donor platelet transfusions.

Supply: Made by differential centrifugation of blood donation less than 2 hours old. Stored for 5 days at room temperature. Contents: One unit of platelet concentrate contains about 50 to 75% of platelets present in the original blood donation in a volume of about 50 ml 5. PENTASTARCH: 10% hexastarch used for the plasma volume plasma. It also contains allo-antibodies (anti-A or expansion instead of 5% albumin. Used in B). In general 6 units of platelet concentrate are hypovolemia, secondary to sepsis, blood loss given at a time, and one would expect an increase in platelet count in the patient of approximately 10

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PROBLEMS FOR TUTORIALS 1. ANEMIA AND CONFUSION

A 62-year-old woman was admitted to hospital after a progressive illness of approximately 6 months duration, characterized by progressive pallor, fatigue, and general weakness. More recently, she had developed shortness of breath on exertion and required 2-3 pillows at night for orthopnea. She had fallen several times at night getting up to the bathroom, and friends found her to be unsteady on her feet. Despite her frequent complaints of a sore mouth she had been eating well and had no G.I. complaints. Her past health has been good, and she had no operations. Bone marrow: Identify the labeled structures On physical examination, the intern found her to be pale, slightly jaundiced and in no respiratory distress with the head of the bed elevated. Her tongue was red 2. ANEMIA AND CONFUSION IN and smooth. There was slight jugular venous ALCOHOLIC distension, hepatomegaly, and pitting edema in the A 54-year-old woman was brought to the legs. Emergency department by her daughter who found her at the home, weak and confused. Since the patient's Laboratory Investigations: husband had died five years ago, she was known to Hemoglobin 50 g/L have increased her alcohol consumption and frequently WBC 3.0 x 109/L failed to eat properly. She denied any G.I. Symptoms, Platelets count 60 x 109/L except chronic constipation. MCV 120 fl On physical examination she was a febrile, pale and MCHC 350 g/L not jaundiced. Her breath smelt of alcohol and she was Reticulocytes count 3.0% (36 x 109/L) slightly confused. There were no focal neurological Normal (10-75 x 109/L) findings. Her tongue was smooth. On abdominal examination there was demonstrable ascites, the liver was not enlarged, and the spleen was palpable 4 cm Peripheral Blood below the left costal margin. Numerous spider nevi were present on her upper chest and shoulders, and several bruises were noted on her legs. Laboratory Investigations: Hemoglobin 50 g/L MCV 105 fL WBC 3.6 x 109/L Platelets count 86 x 109/L Reticulocytes count 40 x 109/L

Questions: 1. List the clinical problems. 2. What other physical findings related to her unsteadiness not mentioned but which you would expect to be present? Questions: 3. What do you expect the blood film to show? 1. List the likeliest causes for: Describe BM features seen below? a. Macrocytosis 4. What other laboratory tests you would order? b. Pancytopenia 5. Given the diagnosis, discuss the management, c. Low Reticulocytes count including: d. Confusion a. Where should she be treated (hospital or home)? Three days after admission, the patient was no b. Approximately when you would expect longer confused and was eating well. Further improvement to occur with regards to: investigation had been delayed by the weekend and i. Hemoglobin on the 4th hospital day further blood tests, as well as ii. Reticulocytes count a bone marrow aspirate, were performed. Later that iii. Pallor day she suddenly vomited a large amount of blood iv. Unsteadiness and became confused. Her heart rate increased to 130/minute and blood pressure fell to 70 mm Hg systolic. A STAT Hb. was 42 G/L., prothrombin

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time was 24 seconds (INR: 2.5), and PTT was 60 seconds.

A 46-year-old woman attended her doctor's office complaining of weakness and joint pains. The weakness had been present for several years, during th which time she had noticed progressive joint 2. On the 4 hospital day, what changes would you expect to see if the following tests were performed discomfort and stiffness mainly in her hands, elbows and knees. She had been taking up to 8 aspirin tablets that day daily for the past year and was on no other a. Reticulocytes count medications. Her diet was good and she had no G.I. b. Serum and RBC folate symptoms except indigestion related to the aspirin. She c. Serum B12 had no past history of serious illness and was 4 years d. Bone marrow postmenopausal. On examination, she was slightly pale and not 3. You are called that evening to manage this patient jaundiced. There was no lymphadenopathy or after she vomited blood: hepatosplenomegaly. She had obvious rheumatoid a. Explain why the hemoglobin hasn't fallen. arthritis with joint deformity of both hands. b. What would your first order for a laboratory test be? Laboratory Investigations: c. What type of I.V. solution would you order Hemoglobin 94 g/L immediately? MCV 74 fL d. What further I.V. therapy would you MCHC 310 g/L recommend? WBC 6.3 x 109/L Platelets count 230 x 109/L 3. ANEMIA AND RETICULOCYTOSIS A 22-year-old woman was admitted to hospital with the chief complaints of progressive weakness, and pallor of one-month duration. She had also noticed some joint discomfort over recent months, but denied any other significant complaints. Past history and family history were non-contributory. On physical examination, she appeared pale and slightly jaundiced. A faint skin rash was noted over her Questions: 1. Classify the anemia. cheeks. There was no lymphadenopathy or 2. List 2 possible causes for the anemia. hepatomegaly. Spleen was palpable 2 cm. below the 3. List 3 most appropriate laboratory tests. left costal margin. No joint abnormalities were 4. Assume that you conclude the patient requires iron detected. therapy: a. What type and amount of iron treatment would Laboratory Investigations: you prescribe? Hemoglobin 60 g/L b. How long would you advise the patient to MCV 90 fL continue iron treatment? MCHC 360 g/L c. The patient wants to get better as quickly as Reticulocytes count 16% (300 x 109/L) possible and asks for either a blood transfusion WBC 4.0 x 109/L or iron shots. Do you agree with either of these Platelets count 130 x 109/L treatments? If not, what advice would you give Direct Antiglobulin (Coombs') - Positive (+++) to the patient to support your recommendations? Questions: d. With iron, at what rate would you expect the 1. List the clinical problems. Hb to rise? 2. What would you expect to see on the blood film? 3. Explain why the MCV is normal. 5. ANEMIA AND HEART DISEASE 4. List 2 reasons for the thrombocytopenia. A 42-year-old man regularly visited his physician 5. In considering management of this patient: a. What would your first choice of treatment be? for routine cardiac studies following open-heart surgery three years ago. At that time an aortic valve b. Would you recommend a blood transfusion? prosthesis was inserted for rheumatic aortic stenosis, c. If the splenectomy is considered later, what precautions and advice to the patient should beand he had been anticoagulated under careful supervision since then. He had felt well until recent provided? weeks when he began to complain of dyspnea and fatigue. He noticed a reddish discoloration to his urine often during the day. 4. ANEMIA AND ARTHRITIS

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On the examination, he appeared pale, but was notMean corpuscular volume (MCV) 70u3 jaundiced. There was a tachycardia (100/minute), and aMean corpuscular hemoglobin (MCH) 17.5 uugm moderate (grade III/VI) early diastolic murmur Mean corpuscular hemoglobin concentration (MCHC) maximal at the left sternal border. There was no 25% evidence of cardiac failure. Liver and spleen were not White blood cells (WBC) 10/mm3 with normal enlarged. differential Sedimentation rate: 62mm/hr Laboratory Investigations: Hemoglobin 80 g/L CXR / ECG: normal MCV 75 fL Questions: MCHC 300 g/L 9 Reticulocytes count 2% (75 x 10 /L) 1. List the clinical problems? 9 WBC 7.5 x 10 /L 2. After reviewing CBC results, what are the next 9 Platelets count 300 x 10 /L important simple tests you would order? Blood film RBC fragmentation, hypochromia 3. Classify the anemia and what further tests would you order at this stage 4. How would you manage this patient?

7. ANEMIA AND MACROCYTOSIS

42-years-old clerk presented to his G.P complaining of inability to do his daily jogging and exercise and Questions: reported an incident of dizziness without loss of 1. List the clinical problems. consciousness. He has been feeling gradual 2. The Reticulocytes count is not appropriate to the deterioration during the past few months. He did not degree of anemia. Explain. have any illness and was not on any medication. There 3. Classify the anemia. was no blood loss from any site and he had normal 4. Further tests indicate iron deficiency, why do you eating habits. Apart from undergoing tonsillectomy at think this occurred? the age of 5 years, there was no significant past history. 5. Outline your management of this patient. On examination, the patient was fully alert, pale with a tinge of jaundice. The majority of his hair was gray 6. ANEMIA, WEAKNESS AND JOINT PAIN and upon further questioning, the patient admitted to A 46-year old woman comes to your office having gray hair since the age of 20 years. complaining of increasing fatigability and weakness There was no lymphadenopathy. Examination of the for the past 4 months. She has had rheumatoid arthritisheart revealed an ejection systolic murmur over the for 8 years and 12 to 16 tablets of aspirin per day have apex. Examination of the abdomen was normal controlled her joint symptoms. The patient says she had no sever pain, tenderness, redness, swelling, or Preliminary blood tests revealed the following: heat in her joint for 2 years while on regular aspirin. WBC: 3.5 x 109 /L neutrophils 70% However, she is less energetic and she finds she must Hb.: 83 g / L ( N: M: 140-180 stop and rest during her household work, and by the F: 120-160) end of the day she is exhausted. She denies crying MCV 115 fl (N 80 - 95) 9 spells and has had no anorexia, weight loss or Platelets: 100 x 10 / L (N 150 – 400) insomnia. She denies any history of abdominal pain, s. Iron: 30 μmol / L (males N 14 – 31) heartburn, jaundice, and black or tarry stools. She doses. Transferrin 2.4 g / L (2 - 4) like to chew on ice cubes. There is no history Blood film showed the presence of macro-ovalocytes suggestive of diabetes. Past history reveals no and hypersegmented neutrophils additional pertinent information. Family history reveals that she is of Italian origin and one sister was Questions: mildly anemic and was told she had Mediterranean 1. What are the hematological abnormalities elicited anemia. in the full blood count result? On physical examination, the patient is slightly obese, 2. What may be the cause of this abnormality? vital signs are normal. Slight pallor is noted. Cardiac, 3. What is the most likely diagnosis? 4. How would you confirm this diagnosis? pulmonary and abdominal examination was normal. There is no stool in the rectum for guaiac (occult blood) testing. No signs of active rheumatoid arthritis. 8. FEVER, ANEMIA AND Laboratory tests: Hemoglobin 70 gm/l, hematocrit (Hct.) 28%

RETICULOCYTOSIS

A 24 –year old Kuwaiti man is admitted to the hospital because of increasing fatigue following a respiratory

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infection. He felt well until 5 days ago when he developed nasal stuffiness, sore throat, and dry cough. Three days later his cough became productive of thick yellow sputum, the temperature rose to 39 o C, and he began to note sharp pain in the left posterior thorax with deep inspiration. His physician made clinical diagnosis of pneumonia and prescribed Septrin and 3 – 4 aspirin tablets daily for fever. Cough and fever abated, but he felt progressively weaker and was therefore hospitalized. Past history reveals that the patient had been healthy all his life. He had been told that he had” yellow jaundice” as a new born but that he had not required transfusion or other specific therapy. The review of systems is entirely negative except for the fact that he has noted his urine to be dark brown for the past 1 to 2 days. Family history is unobtainable. His parents are dead and his only sibling, a sister is in good health. On physical examination he appears acutely ill. There is pallor, the sclera is slightly icteric. T 37.4o C, P 95/min, BP 120/60, RR 16/min. Respiratory movements of the left thorax are asymmetrical with splinting on the left. There is dullness to percussion, breath sounds are high pitched bronchial, and many fine to medium rales are heard over the left lung posteriorly. The heart exam reveals a grade 1/6 systolic murmur heard best along the left sternal border. Abdominal exam revealed no organomegally. Laboratory tests HB 75 mg/l , hematocrit 25% (notice: the plasma appears pink), retics: 15% WBC: 14.5/mm3 with 81% neutrophils, 12% bands, 2% metamyelocytes and 5% lymphocytes. Platelets count is 250.

dark urine implies? What gives urine this color in this case? 4. What do you make out of the rticulocytes count? Why the plasma is pink-colored? 5. What is you differential diagnosis? What other tests would you like to order?

9. CHRONIC FATIGUE AND ANEMIA

A 28-year-old Kuwaiti lady has been complaining of chronic fatigue and known to have anemia for a long time on iron supplement but without any appreciable response. The first time she was told to have anemia at the age of 10 years in the range of 90 – 100 mg/L. She has been prescribed different types of iron supplements but with out any actual change in HB level. She is single and here menstrual period is regular and scanty in amount. She has a brother who was told to have a similar degree of anemia but she dose not know the exact nature of his problem. On examination, the patient is healthy and vital signs are normal. Slight pallor is noted. Cardiac, pulmonary, and abdominal examination is normal.

Laboratory tests:

White blood cells (WBC) 10/mm3 with normal differential Hemoglobin 110 gm/L, Hematocrit 37% Mean corpuscular volume (MCV) 58 u3 Mean corpuscular hemoglobin (MCH) 17.5 uumg Mean corpuscular hemoglobin concentration (MCHC) 25% Red cell distribution width (RDW) 15 Peripheral blood film: microcytic, hypochromic, target cells

Questions: Blood film: reveals generally normocytic 1. How do you assess the severity of menstrual normochromic red cells, but there is moderate period? poikilocytosis with occasional fragmented cells and 2. Comment on the hematological picture and what is microspherocytes. No true sickled cells are seen. There your differential diagnosis? are many large polychromatophilic red cells and rare 3. Comment on the HB electrophoresis? nucleated red cells. 4. If the HB electrophoresis was normal, what else should you consider? Urine: is clear, brown-colored, protein +, specific 5. What would you council this patient? gravity 1.025, and glucose, ketons and urobilinogen are negative. Dipstick test for blood is positive. No Cellulose Acetate Method (pH 8.4) cells or casts are seen on spun sediment. Cathode + Anode CXR: a homogenous density involves much of the left lower lung field. No pleural effusion seen. Renal and liver function is normal. Serum bilirubin is 50 mmol/l (normal< 25), 35 unconjugated, 15 conjugated. Hemolyse Questions d blood 1. What does the history of jaundice as a newborn applicatio n indicates? 2. What are the causes of dark urine? 3. Why do we look for icterus under the upper Sample eyelid? What dose the Combination of icterus and

C E A2

4.5%

S D

F

0.5%

A

95%

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10. A YOUNG PATIENT WITH RECURRENT BONY ACHES

A 17-year-old male high school student presented to the emergency department complaining of a sudden onset right-sided chest pain. He is known to have repeated pain attacks of similar nature that involving different sites of his body since childhood, requiring frequent hospitalizations. Family history revealed his sister to have similar problem. Physical examination revealed a pulse rate of 110/ Peripheral blood smear: minute, Bp 110/70, and temperature of 38 °C. He was Polychromasia / Occasional nucleated RBC seen pale and slightly icteric. Tonsils were congested. Chest Hemoglobin electrophoresis provided examination revealed the presence of decreased air entry on the right side. No organomegally. Questions: Lab Investigations Reference Range CBC WBC 15.0 (4 – 10 x 109/L) HB 87 (140 – 180 g/L) Hematocrit 26 (42 – 50) MCV 88 (80 – 94) MCH 30 (27 – 31 pg) MCHC 340 (330 – 360 g/L) 17 (11.5 – 14.5 %) RDW Reticulocytes Count 150 (60 – 120 x 109/L) s-Total Bilirubin 50 s-Indirect Bilirubin 45 s-Direct Bilirubin 5

Differential WBC Count Range Neutrophils 11.5 (1.5 – 6.0 x 109/L) Lymphocytes 2.5 (1.0 – 3.0 x 109/L) Monocytes 0.7 (0.2 – 0.6 x 109/L) Eosinophils 0.2 (0.1 – 0.5 x 109/L) Basophils 0.1 ( 0.1 – 0.3 x 109/L)

Cathode -

Hemolys ed blood applicati on

1. Comment on the peripheral blood findings. What are the Howell-Jolly bodies and what is their significance? 2. Comment on the hemoglobin electrophoresis findings. 3. What is the diagnosis? And what do describe this attack of pain? 4. What is the cause of the hyperbilirubinemia in this case? 5. How do you manage this case? 6. What is the role of exchange transfusion in this disease? 7. What are the complications of this disease ?

+ Anode

C E A2

S D

70%

F

10%

A

20%

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MODULE II WHITE BLOOD DISORDERS OBJECTIVES •

Differentiate benign from malignant causes of leukocytosis.

•

Describe the clinical presentation, plan of investigations, and be able to interpret relevant laboratory data, so as to reach likely diagnosis and prognosis in a patient who may present with leukocytosis and/or lymphadenopathy.

•

Explain basic molecular abnormalities underlying malignant transformation of haematopojetic cells, and resulting in hematological malignancies.

•

Plan and prescribe a rational schedule of management, based on a sound knowledge of the mechanism of action, dose, duration and side effects of appropriate drug therapy

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LYMPHADENOPATHY AND SPLENOMEGALY lymph nodes in cervical, axillary and inguinal areas (occasionally epitrochlear and popliteal as well), extent The student should have a general understanding of the spectrum of disorders presentingof hepatosplenomegaly, presence of tonsillar enlargement, skin lesions and bone tenderness with enlargement of lymph nodes and/or spleen,

GENERAL OBJECTIVES

including methods of presentation, investigations LABORATORY ASSESSMENT required to diagnose these disorders, urgency with The qualitative assessment of white blood cells which diagnosis should be made, and treatment commence and finally the prognosis and complications (leukocytes) is almost performed by automated cell counters (Coulter Counter) rather than older inaccurate which might occur during the treatment program. and labor-intensive counting chambers. The normal WBC count is 4.0 – 10.0 x 109/L SPECIFIC OBJECTIVES The qualitative assessment of white blood cells At the end of this section the student should be is most commonly performed by manual microscope able to: 1. Describe diagnostic possibilities, given a series of techniques, with reporting of a WBC Differential white cell counts and differentials, and/or clinical (percentage of cells assigned to each category) after viewing 100 or more cells. If the WBC is too low (1.5 presentations of patients with enlarged lymph x 109/L) then a buffy coat preparation may be prepared nodes or spleen. 2. List the diagnostic tests required, if any, to confirm to increase the number of cells which can be viewed microscopically in a reasonable period of time. Many the suspected diagnosis. 3. Describe the major clinical and laboratory featuresof the automated cell counters provide partial differential counts. Most commonly granulocyte and of the common or important disease in this lymphocyte counts. Such differentials have the category: advantages of precision since many more cells are Infectious mononucleosis assessed than by manual methods, and less Acute and chronic leukemias technologist time is involved. However, most do not Lymphomas and Hodgkin's disease give full differentials and do not give a printout when Myeloma 4. Differentiate between benign and malignant causesabnormal cells are present or the differential counts are significantly abnormal. Fully automated differential of leukocytosis and polycythemia. counters require a large volume of tests to be cost 5. Describe the expected outlook for patients once effective and are not as helpful in settings where a any of the above diseases are diagnosed large percentage of the differential are abnormal. 6. List the possible treatment options, when The bone marrow may provide information available, for theses diseases, and describe the about granulocyte production, and presence of risks / benefits expected with these treatments. infiltrative disorders such as leukemia, lymphoma and 7. describe the management of the common complications which might arise during the course myeloma. The normal sequence of granulocyte development is as follows: of these disorders; these complications include bone marrow suppression, local effects of enlarged Myeloblast → promyelocyte → myelocyte → lymph nodes and spleen, pain and hyperviscosity. 8. Describe the role of blood component therapy in metamyelocyte → band → neutrophil the management of these patients, including type of component, rate of administration, and expected Normally there are 3 – 4 times as many responses granulocyte precursors, than erythroid precursors, in the bone marrow (M/E ratio 3/1). This reflects the CLINICAL ASSESSMENT presence of a large granulocyte pool or reserve, and Particular points in history include a search for also the short life span of granulocytes compared with erythrocytes. sites of local infection, or if the lymphadenopathy is generalized and/ or splenomegaly is present, particular attention must be paid to systemic symptoms (fever, The maturation of granulocytes in the marrow night sweats, pruritus, weight loss, anemia and is sequential. If there are increased numbers of less jaundice), medications, travel history, and presence of mature forms, then this is termed "shift-to-the-left". It other diseases (eg. Rheumatoid arthiritis, lupus, etc). could represent a reactive process (granulocytic hyperplasia) or a malignant process (leukemia and the Physical examination should include a careful morphological distinction may be difficult. documentation of the size and consistency of enlarged

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BENIGN LEUKOCYTE DISORDERS occur due to granulocyte consumption or complement GRANULOCYTOPENIA This term refers to neutropenia, or reduction in activation, and depletion of the marrow granulocyte pool. It is often an ominous sign. In hypersplenism, the absolute neutrophil count; decreased in the there is usually a pancytopenia due to splenic pooling eosinophils and basophils cannot be accurately of hematopoietic cells and hypercellular marrow, with measured, and are of no practical importance. The correction of blood counts after splenectomy. severity of the neutropenia is usually graded as follows: Severe neutropenia may occur with 9 Normal neutrophil count Rheumatoid arthritis (Fety's syndrome) usually with 2.5 – 7.5 x 10 /L 9 1.0 – 2.5 x 10 /L splenomegaly as well. This may be due to autoMild neutropenia 9 Moderate neutropenia 0.5 – 1.0 x 10 /L antibodies against granulocytes, which also likely 9 Severe neutropenia < occur in some patients with lupus, but laboratory 0.5 x 10 /L techniques are not presently available to detect these A serious risk of spontaneous infection is usually not present until severe neutropenia develops. antibodies. The management of neutropenia involves discontinuing any drugs which may be associated, CLASSIFICATION OF NEUTROPENIA 1. Decreased granulopoiesis – marrow infiltration / correcting any vitamin deficiency or nutritional problems, and if possible, controlling any underlying fibrosis, drugs, radiation 2. Ineffective granulopoiesis – megaloblastic anemia disease. If hypersplenism cannot be reversed by other 3. Decreased granulocyte survival – hypersplenism, means, and if the cytopenias are severe enough to warrant the risks involved, then a splenectomy may be severe infection, immune indicated. DECREASED GRANULOPOIESIS This may be associated with decrease in other marrow elements causing pancytopenia (see aplastic LYMPHOPENIA anemia, leukemia, myelofibrosis, etc). When May also occur (absolute lymphocyte count < granulocytopenia occurs selectively due to decreased 1.5 x 109/L) due to drugs (steroids), hereditary granulopoiesis, it is most frequently caused by drugs. immuno-deficiency disorders or associated with some Even then, many of these may be due to drug-related other diseases, such as Hodgkin's disease & HIV granulocyte antibodies which are not detectable by infection. It may be present, usually to a lesser degree current techniques. than neutropenia, in association with the pancytopenia Some drugs, such as chemotherapeutic agents, of aplastic anemia, hypersplenism, etc. will predict cause neutropenia, but usually also thrombocytopenia and anemia. These are usually slow GRANULOCYTOSIS in onset and dose-dependent. Other drugs may When the numbers of granulocytes are unexpectedly cause neutropenia, often severe and increased in comparison to the numbers of sometimes fatal, in a previously sensitized patient, or lymphocytes, but in absolute terms, then this is called by unknown mechanisms (idiosyncratic reaction). "relative granulocytosis". It is usually seen with the Many drugs have been implicated, similar to those lymphopenias described previously. When the actual which cause aplastic anemia. The major groups includenumber of granulocytes is increased (and this is anti-inflammatory agents, anticonvulsants, antibiotics, calculated from the percentage of granulocytes and the antimal arials, antithyroid drugs and phenothiazines. total WBC count) this is termed "absolute The neutropenia may last for days / weeks. granulocytosis" and these conditions are now considered further, depending on which granulocyte is increased. INEFFECTIVE GRANULOPOIESIS a. Neutrophilia (neutrophil granulocytosis) This is seen most often in megaloblastic An absolute neutrophil count greater than 7.5 x anemias, characterized by a pancytopenia but a 9 10 /L is called neutrophilia; the causes which hypercellular megaloblastic bone marrow; the would be considered are: precursors of all cells lines dies in the marrow cavity before being released. Thus, ineffective hematopoiesis i. Controlled proliferation is corrected by appropriate therapy such as B12 or This is a normal response to infections folate vitamin treatment or in the case of alcohol (mainly bacterial), trauma, inflammatory excess cessation of alcohol consumption. diseases an d even neoplasm. Leukocytosis up to 50 x 109/L is common and elevations as high as 100 x 109/L can occur. Above this level, DECREASED GRANULOCYTE SURVIVAL however, a leukemic process will almost always In severe bacterial infections such as lobar be present. There will often be left-shift with pneumonia, and various septicemias, neutropenia can

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reactive neutrophilia but this will seldom extend As noted previously, children have a large as far back as the myeloblast and promyelocyte proportion of lymphocytes on WBC differential than stages. When the reactive leukocytosis is so adults, and frequently these lymphocytes appear extreme and/or left-shifted as to resemble a atypical, or reactive, in response to the leukemia, it is termed "leukemoid" reation. immunological challenges and frequent viral infections during childhood. ii. Uncontrolled proliferation This represents a malignant myelproliferative Absolute lymphocytosis in adults requires a process such as leukemia, myeloid metaplasia lymphocyte count greater than 3.5 x 10 9/L. This will or polycythemia, rather than reactive or usually be due to some underlying disease, usually a secondary, neutrophilia. viral infection, but if it is persistent, without underlying cause, then it may represent an early stage iii. Storage pool activation of chronic lymphocytic leukemia – the distinction Roughly 1/3 of the total granulocyte mass is cannot be made on morphological grounds alone. Up present as a storage pool in the marrow. This reserve may be rapidly mobilized in response to to 5% of lymphocytes in adults and 10% in children may appear slightly atypical or reactive; these many acute traumatic and inflammatory lymphocytes are larger with less mature nucleus, and processes resulting in a prompt neutrophilia in the cytoplasm is often basophilic, and in large amount peripheral blood. The mature granulocytes are so that the cell membrane appears compressed by depleted in the marrow for several days until surrounding erythrocytes on the blood film. granulocyte hyperplasia occurs. iv. Marginal pool activation Causes for lymphocytosis of moderate to 2/3 of the total granulocyte mass is present marked degree, include infectious mononucleosis, outside of the marrow, and this is divided equally cytomegalovirus, infectious lymphocytosis, Bordetella between a central pool (1/3 of total mass) and a pertussis (whooping cough), toxoplasmosis, HIV and marginal pool (the last 1/3). The number of hypersensitivity reactions. The infectious marginating neutrophils may be changed acutely lymphocytosis of whooping cough is distinctive due to catecholamines (any stressful situation) or because the lymphocytes are all small lymphocytes, by migration inbibition with steroids, causing the not atypical, and the lymphocyte count may reach neutrophils to demarginate and be counted in the extreme degrees (50 -100 x 109/L) resembling chronic central pool. The result is an absolute lymphocytic leukemia, which is not seen in children. neutrophilia on WBC counting, even though the For practical purposes, major degrees of atypical number of circulating granulocytes hasnot lymphocytosis (20 – 40% of WBC's) in adults will be due to infectious mononucleosis (EB virus) or actually changed. cytomegalovirus; the latter may cause an identical b. Eosinophilia 9 clinical picture but with a negative mono test, and is Absolute eosionophilia (0.4 x 10 /L) is much less commonly diagnosed. Infectious most commonly associated with the following mononucleosis characteristically presents with fever, disorders: sore throat and cervical lymphadenopathy; jaundice is • Allergies – allergic rhinitis, asthma, etc uncommon (5%) but laboratory evidence of hepatic • Parasitic infections – amebiasis, nematodes, dysfunction is common (elevated transaminase in over trematodes, etc 80%). Skin rash may occur, particularly if these • Dermatitis – dermatis herpetiformis, eczema, patients are treated with ampicillin. Occasionally etc. hemolytic anemia (cold agglutinins) and • Hypereosinophilic syndromes – Loefler's thrombocytopenia may be prominent features. syndrome, polyarteritis, etc Splenomegaly is present in half of the cases but must • Neoplasms – various carcinomas, Hodgkin's be carefully examined because of the risk of splenic disease,etc. It is extremely rare for rupture. The diagnosis is confirmed by a positive eosinophilia to occur as a primary monospot test in 95% of cases, and the treatment is myeloproliferative disorder (eg. Leukemia) usually only supportive (bed rest, analgesics, or c. Basophilia antipyretics) Steroids are indicated only for serious Increase in basophils is rare, and virtually complications (CNS involvement, pharyngeal always part of other leukocyte abnormalities in obstruction, sever thrombocytopenia) Sometimes the myeloproliferative diseases (CGL, myeloid lymphocytes are fragile, and are ruptured during the metaplasia, polycythemia) preparation of the blood film; they are then referred to 9 d. Monocytosis (0.8 x 10 /L) as "smudge cells". These are most common in chronic Elevation of monocytes is uncommon. If may lymphocytic leukemia but can also be seen with occur with some chronic infections, preleukemia reactive lymphocytosis (eg. Viral infection) so are not or monocytic leukemia. diagnostic of C.L.L e. Lymphocytosis

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HEMATOPATHOLOGY TESTING that is involved in the rearrangement of immunoglobulin and T cell receptor genes. If a leukemia is atypical (i.e. of T cell origin) additional antibodies can be used to further characterized the leukemic cells. If the leukemia cells. If the leukemia has a mature B cell phenotype (i.e. expresses CD19 and/or CD10 but not TdT, as in Burkitt’s leukemia), antibodies recognizing κ and λ immunoglobulin light chains are added to the panel to Cytochemical Stains establish clonality. If the leukemia is of plasma cell It is often impossible to determine whether the blasts in an acute leukemia are of myeloid or lymphoid origin (i.e. multiple myeloma), staining for cytoplasmic immunoglobulin is performed by origin from morphology alone. For this reason, immunofluorescent microscopy or flow cytometry. cytochemical staining is performed. This is done since plasma cells generally lose cell surface expression of the useful markers, including κ Stain Cells stained and λ. Myeloperoxidase Myeloid DIAGNOSIS OF ACUTE LEUKEMIA Classification of acute leukemias according to FAB criteria requires morphologic examination of a bone marrow aspirate smear. This is required to obtain a blast count, as well as to determine the blast morphology, the number and types of maturing cells, and whether dysplastic features are present.

Non-specific esterase

Monocytes, blasts in monocytic leukemia

Periodic acid-Schiff

Normal granulocytes, blasts in lymphocytic Leukemia ("string of pearls"), abnormal Erythroblasts in erythroleukemia ("chunky")

Tartrate-resistant Hairy cell leukemia cells acid phosphatase (TRAP) Leukocyte alkaline phosphatase

DIAGNOSIS OF LYMPHOMA AND LYMPHOPROLIFERATIVE DISORDERS

Most lymphomas are characterized by immunophenotyping cells from the lymph node or other tissues in suspension or frozen tissue sections.

High in leukemoid reactions , low in CML

Flow Cytometry Flow cytometry is the method of choice for characterizing lymphomas involving the peripheral blood or bone marrow. Since most lymphomas are of Flow Cytometry Flow cytometry is used to determine the cell type of mature B cell origin, finding a B cell population that expresses exclusively κ or λ light chains on the cell leukemic blasts. surface is sufficient for the diagnosis of malignancy. Actual classification requires morphologic Stem Cell CD34 examination, as well as determining the expression of other cell surface markers. The following table lists the Myeloid CD13, CD33 antibodies used for the characterization of lymphomas: ___________________________________________ B cell CD10 (CALLA), _ CD19 C ells Identified Cell Surface Marker T cell CD2, CD5, CD7 Pan-T cell marker; also expressed CD5 on some B cell lymphomas (small Megakaryocyte CD61 lymphocytic lymphoma/CLL, mantle cell lymphoma) In addition to the above markers, the "leukemic panel" includes immunofluorescent staining for terminal deoxynucleotidyl Tranferase (TdT). This is an CD19, CD20 Pan-B cell markers (CD20 is low or absent in SLL/CLL) enzyme present in the nuclei of immature lymphocytes

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κ, λ

Immunoglobulin light chains, used to determine clonality in B cell lymphomas

chromosome 22. The resulting fusion protein, BCRABL is thought to cause neoplastic transformation. This chromosomal translocation can be detected by DNA blot analysis using a probe for the BCR gene. This particular probe easily detects the translocation if CD2 Pan-T cell marker, also expressed on as few as 1% of the cells present contain the NK cells Philadelphia chromosome. This probe detects the translocation in greater than 90% of CML. Because the CD4, CD8 T cell subsets breakpoint is different, the probe only detects about 33% of Philadelphia chromosome-positive ALL. This CD1 mature T cells, Langerhans cells test can be used to make the differential diagnosis of CML vs. other reason for leukocytosis or CD3, CD7 Pan-T cell markers thrombocytosis. It can also be used to detect minimal residual disease following bone marrow CD16/56, CD57 NK cell markers transplantation, although it is not as sensitive as PCR. In addition to increased sensitivity, this method will IL2 receptor; present on CD25 allow detection of both types of t(9;22) breakpoints activated T cells, some T cell malignancies, and hairy (i.e. CML vs. ALL types). Detection of t(14;18) cell leukemia In up to 90% of follicular lymphomas, a translocation between chromosomes 14 and 18 can be found. This translocation results in the insertion of the MOLECULAR STUDIES Bcl-2 gene from chromosome 18 into the immunoglobulin locus on chromosome 14, Bcl-2 is a Immunoglobulin and T Cell Receptor Gene mitochonderial protein that regulates apoptosis or Rearrangement programmed cell death; the function of Bcl-2 appears As a part of normal development, lymphocytes to be the prevention of cell death by apoptosis. The rearrange their immunoglobulin (B cells) or T cll t(14; 18) results in over expression of Bcl-2 allows receptor genes (T cells). This results in alarge cells to survive longer, and thereby accumulate repertoire of receptors for antigen recognition. It also additional mutations which lead to neoplastic cell allows determination of B or T cell clonality, since transformation. each lymphocyte has a different DNA structure. In a mixed population of lymphocytes, no one lymphocyte The t (14; 18) can be detected by PCR. The main clone is of sufficient number to be detected by DNA use of this test is to determine whether peripheral blot analysis, however when one clone predominates, blood, bone marrow, or various stem cell its receptor gene rearrangement can be detected. Whentransplantation products are contaminated by a single clone is detectable, this is generally equivalent lymphoma cells. The test can also be used to make a to lymphoid malignancy, although there are a number diagnosis of follicular lymphoma, particularly on of specific conditions where clonality does not needle biopsy specimens where follicular architecture necessarily mean malignancy. may not be apparent. The technique used for detection of gene rearrangements is DNA blot analysis. Genomic DNA is isolated from a tissue biopsy, peripheral blood, or bone marrow specimen. Recently the polymerase chain reaction (PCR) has been used to detect immunoglobulin heavy chain gene rearrangement. BCR Gene Rearrangement Chronic myelogenous leukemia (CML) is caused by a translocation between chromosomes 9 and 22 (the Philadelphia chromosome). The result of the translocation is the juxtaposition of the c-abl protooncogene on chromosome 9 with the BCR gene on

SKY allows for direct visualization of a specific chromosomal abnormality (numeric and translocation

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Result of FISH

Normal cell

Microarray technology allows for a large number of genetic abnormalities to be screened on a single chip that is then scanned and analyzed by a computer

• • •

MCL – lymphoma cell

FISH allows for direct visualization of a specific chromosomal abnormality. FISH studies are less sensitive than PCR-based methods, but can detect abnormalities, such as monosomies and trisomies, that cannot be studied by PCR analysis.

HODGKIN’S AND NON-HODGKIN’S LYMPHOMAS HODGKIN'S DISEASE

Diagnostic Reed-Sternburg (RS) cell

Thomas Hodgkin’s Immune stain:

Hodgkin's disease is not common (annual CD15 & CD30 positive in classical HD incidence about 2 per 100,000) but it has generalized LPHD: intense interest because of its predilection to affect young people, and its potential for cure with either radiation or chemotherapy. It is generally considered to be a type of lymphoma but clearly differentiated from the other "non-Hodgkin's" lymphoma to be discussed abundant lymphocytes later. Common clinical features include fever, night sweats, pruritus, weight loss, lymphadenopathy and splenomegaly. Tissue diagnosis is mandatory, and achieved by lymph node biopsy or biopsy of another involved organ (eg. Liver, lung) Nodular Sclerosis: nodularity / RS cells abundant Pathological classification: The W.H.O. classification will be used for classification of Hodgkin's disease - Hodgkin's Disease, Lymphocyte predominance (LPHD) - Classical Hodgkin's disease Nodular Sclerosis (NSHD) Mixed cellularity (MCHD) Lymphocyte Depletion (LDHD) Lymphocyte-Rich (LRHD)

LDHD: few lymphocytes seen

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MCHD: pleomorphism , PET Scan

mixed lymph, eosinophils, plasma cell. The clinical stage or extent of the disease however is more important in planning therapy and influencing FDG PET scan in a newly diagnosed lymphoma. prognosis. The following simplified stages are Widespread nodal disease is shown above and below currently used: the diaphragm. Spleen (arrowheads) is diffusely Stage I – disease in one lymph node region hypermetabolic, suggesting lymphomatous Stage II – disease in two or more lymph nodes but involvement. confined to one side of diaphragm Stage III – disease confined to lymph nodes or 5. Bone marrow aspirate and biopsy are done as part spleen and present on both sides of of staging work up to exclude bone marrow diaphragm involvement. This is more likely if there are 'B' Stage IV – disease outside confines of lymph symptoms and hematological abnormalities. nodes or spleen. (i.e. involves organs) The principles of management of HD include the following: The presence or absence of systemic symptoms are a. LPHD : local radiotherapy also important; these include: b. Classical HD stages I, IIA include 4 A– absence of fever, night sweats or courses of chemotherapy and involved weight loss (10% of body weight) field radiotherapy B– presence of any of the above. c. Advanced stages (IIB, III, IV) includes systemic chemotherapy of 6 – 8 cycles. The procedures required to stage patients with Local radiotherapy may be given for initial Hodgkin's disease vary somewhat from centre to bulk (tumors > 10 cm) centre, but generally include the following: The potential for cure exists for all stages and 1. Routine hematology and biochemical tests all therapies but is much higher for earlier stages and including liver function asymptomatic disease. It is important to optimize treatment to minimize side effects. Chemotherapy, 2. Chest X-ray – PA and lateral; CT chest or induces considerable morbidity; nausea and vomiting, tomogram if indicated anorexia, hair loss and long term can lead to sterility. However, the most commonly used protocol is known as ABVD (Adriamycin, Bleomycin, Vinblastin , 3. CT Scan of abdomen DTIC) has less toxicity and is the most commonly used.. It has low infertility rate and less leukomogenic effect. Currently cure rates are high > 70 % for patients with good prognosis. However, the relapse rate is over 40% in patients with bad prognosis (advanced stages). For those who relapses a high dose chemotherapy and autologous peripheral stem cell transplant is offered. 4. Nuclear scan: Gallium scan: shows active uptake in the lymphoid The progression free survival is 50 % at 5 years. tumor. More recently PET scan is more utilized as LYMPHOMAS it is more sensitive and more specific The “non-Hodgkin's" lymphomas are a somewhat Gallium uptake –Anterior variable group of malignant neoplasms primarily mediastinal mass involving lymph nodes and/or spleen, although almost any organ can be involved. The clinical presentation is virtually identical to those of patients with Hodgkin's disease. Lymphomas are more likely to affect extra nodal sites e.g. gastrointestinal tract, than Hodgkin's disease in which this presentation is uncommon.

Classification of Non-Hodgkin’s Lymphoma –

B Cell Neoplasms • Precursor B-cell neoplasms

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• T and • •

Mature B cell neoplasms – NK Cell Neoplasms Precursor T cell neoplasms Mature T and NK cell neoplasms Examples of these cases: • Diffuse large B cell lymphoma (DLBCL) • Follicular lymphoma • Mucosa associated lymphoid tissue (MALT) • Burkitt lymphoma • CLL/SLL • Cutaneous T-cell lymphomas MF/Sezary

The NHLs can be divided into two prognostic groups: the indolent lymphomas and the aggressive lymphomas. Indolent NHL types have a relatively good prognosis, with median survival as long as 10 years, but they usually are not curable in advanced clinical stages. Early stage (I & II) indolent NHL can be effectively treated with radiation therapy along. Most of the indolent types are nodular (or follicular) in morphology. The aggressive type of NHL has a shorter natural history, but a significant number of these patients can be cured with intensive combination chemotherapy regimens) In general the well differentiated histological types and follicular (nodular) pattern have an indolent course. At present these cannot be cured but have a relapsing course and survive 7-10 years. Some live considerably longer. The high grade lymphomas have a more aggressive course. Previously such lymphomas had a CLL CLL bad reputation with early death. Combination chemotherapy with regime that usually contain cyclophosphamide, adriamycin (Doxorubicin), as well as other drugs have changed this outlook. The moast common chemotherapy protocol used is CHOP Follicular NHL (Cyclophosphamide, Hydrodunarubicin, Onconvin, Presnisone). Now approximately 50% of patients with diffuse large cell lymphomas may have long term remissions and probable cure. Recently it has been shown the use of monoclonal antibody therapy increases the chances of response and cure rate. The most widely effective and popular monoclonal antibody is an anti CD20 monoclonal antibody, known as Mabthera or Rituxan. Currently, the use of anti Diffuse large B cell Lymphoma express CD 20 antigen CD20 monoclonal antibody in addition to chemotherapy is the standard of care for the most CD20 + Lar g e B- cells common aggressive lymphoma (diffuse large B cell lymphoma).Once relapse occurs, patients usually undergo a high dose chemotherapy and autologous stem cell transplant.. Results are better too in the treatment of two very aggressive high grade lymphomas with increasing evidence for possible cures in this group, namely Lymphoblastic lymphoma and Burkitt lymphoma with starry sky appearance Burkitt’s lymphoma. The current therapy for these two lymphomas include intensive systemic chemotherapy and CNS directed prophylaxis. Most of the indolent lymphomas, particularly the follicular and small lymphocytic lymphoma, have reached a widespread stage at the time of presentation. Bone marrow and liver are frequently involved in addition to generalized lymphadenopathy and splenomegaly. Follicular (nodular) lymphomas of insidious Mucosa associated lymphoid tissue onset without significant symptomatology do not need MALT) lymphoma of the stomach treatment and many years may pass until treatment becomes indicated. When treatment is required, gentle chemotherapy with Chlorambucil will usually suffice for elderly patient. However, for younger patients a

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systemic chemotherapy and monoclonal antibody Radiptherapy may also be used in combination with a therapy may produce better results and long chemotherapy programme to treat bulky disease. It remissions.. For localized treatment radiotherapy may often plays an important role in treatment of relapsed be indicated but this is not common as most cases havedisease when chemotherapy has failed or to treat a generalized disease or are of more aggressive type palliative symptomatic disease when cure is not such that chemotherapy is the treatment of choice. possible.

Common chromosome translocations in nonHodgkin lymphoma Chromosome abberation

Lymphoma

Genes involved

t(14;18)(q32;q21)

Follicular lymphoma

BCL-2, IgH

Diffuse large B-cell lymphoma t(8;14)(q24;q32)

Burkitt lymphoma

C-MYC, IgH

t(8;22)(q24;q11)

Burkitt lymphoma

C-MYC, IgL

t(2;8)(p11;q24)

Burkitt lymphoma

C-MYC, IgK

t(11;14)(q13;q32)

Mantle cell lymphoma

CCND1, IgH

t(11;18)(q21;q21)

Marginal zone/extranodal MALT

API2, MALT1

t(14;18)(q32;q21)

Marginal zone/extranodal MALT

MALT1, IgH

t(1;14)(p22;q21)

Marginal zone/extranodal MALT

BCL-10, IgH

t(1;2)(p22;p12)

Marginal zone/extranodal MALT

BCL-10,IgK

t(3;14)(p13;q32)

”de novo” Diffuse large B cell

BCL-6, IgH

t(3;22)q27;q11)

”de novo” Diffuse large B cell

BCL-6, IgL

t(2;3)(p12;q27)

”de novo” Diffuse large B cell

BCL-6, IgK

t(2;5)(q23;q35)

Anaplastic large cell T/null

ALK, NPM

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MYELOMA

Myeloma is a disease caused by malignant b. Bone marrow proliferation of plasma cells. It usually presents as a - 10 – 20% plasma cells usually required for bone disease, with bone pain, but multiple other diagnosis of myeloma. Multinucleated and presentations are possible due to many complications immature forms are common. which may occur. c. Biochemical tests for Most cases of myeloma are due to clones of - total protein (increased) and albumin plasma cells producing immunoglobin G (IgG), but (decreased) IgA myeloma is also common – IgD and IgE myeloma - hypercalcemia are rare. Myeloma must be differentiated from: - hyperuricemia - renal function 1. Benign Monoclonal Gammopathy – long-standing - β-2 microglobulin non-progressive monoclonal increase in - LDH immunoglobulin without marrow plasmacytosis or - C- reactive protein bone lesions. Usually the Ig elevation is mild (25 - Cytogenetic studies g/L) and urinary light chain proteinuria is present. - serum protein electrophoresis – detects and 2. Waldenstrom’s macroglobulinemia – this quantitates the monoclonal protein; about 15% uncommon disorder presents with monoclonal however, have hypogammaglobulinemia. elevation of IgM; in contrast to myeloma, bone disease is usually absent, whereas lymphadenopathy and splenomegaly may occur. The cellular infiltrate is heterogeneous (lymphocytes, plasma cells and plasmacytoid lymphocytes) Hyperviscosity symptoms may be prominent. The disease is usually slowly progressive; if therapy is needed then Chlorambucil will usually suffice. Myeloma – the following presentations are worth noting. - Urine protein (24 hour) and protein CLINICAL electrophoresis – quantities the amount of light As noted above, bone pain due to osteolytic bone chain proteinuria (routine urinary dipstick test lesions with or without pathological fractures or for protein does not detect light chains). vertebral compression fractures from osteoporosis or d. Immunology tests osteolytic lesions may all occur. Symptoms of anemia - Ig quantitation Immunisation electropheris – (fatigue, pallor), leucopenia (infections) or confirms Ig type (IgG, IgA, etc) and light thrombocytopenia (bruising or bleeding) may all be chain (kappa or lambda) present due to myeloma replacement of bone marrow. - Urinary light chains – selective kappa or Renal failure may result from myeloma kidney (light lambda light chain proteinuria chain, or Bence-Jones protein, precipitation), e. X-rays amyloidosis, hypercalcemia, hyperuricemia or - skeletal survey to detect osteolytic lesions or infection. A myloidosis may also cause tongue diffuse osteoporosis. X-rays of skull, spine and enlargement, arthropathy, hepatosplenomegaly, pelvis are particularly important, but ribs and purpura, carpal tunnel syndrome, etc. Hypercalcemia long bones can be involved and should be xmay induce polyuria, polydipsia, vomiting and rayed if clinically indicated. Note that alkaline confusion. phosphatase is usually not elevated, and bone LABORATORY scans are usually normal because the bone

lesions are almost totally osteolytic in nature.

Bone marrow Infiltrated with plasma cells

a. Blood picture - anemia, leucopenia and thrombocytopenia

MANAGEMENT 1.

CHEMOTHERAPY Melphalan and Prednisone given for 4 days each month are helpful in palliative treatment, causing control or regression of myeloma in most, but not all, patients. Morbidity from chemotherapy is minimal. It may be continued as long as patient lives, or stopped

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after improvement is complete, or stable, to be 4. Treatment of infection: Multiple myeloma and restarted at the time of relapse. Cyclophosphamide its treatment including chemotherapy and may be substituted for melphalan if it is no longer transplantation render patients extremely effective. There is definite increase of leukemic vulnerable to infection. Prompt treatment of transformation in patient receiving alkylating agent infection and in selected cases prophylactic antichemotherapy but the improved quality of life and infective therapy reduces morbidity and survival warrant this risk. morbidity. Treatment of multiple myeloma in symptomatic patient is dictated by age and presence of5. SPECIAL SITUATIONS co-morbidities. For patients aged below 70 years initial • Amyloidoisis is usually, but not always, induction by combination chemotherapy of Vincristine, unresponsive to any treatment. Doxarubicin, Dexemethasone (VAD) 3-4 cycles • Hypercalcemia – must be promptly and followed by high dose chemotherapy and autologous aggressively treated with large volumes of stem cell transplantation is the treatment of choice and intravenous saline, steroids, and chemotherapy results in longer progression free survival and overall or biphosphonates. survival compared to conventional chemotherapy. • Allogeneic bone marrow transplantation can cure multiple myeloma, however, high rates of treatment related mortality and poor overall 2. RADIOTHERAPY survival precludes its routine use. Low Excellent treatment for symptomatic isolated intensity allogeneic bone marrow bone involvement, unresponsive to chemotherapy. transplantation following cytoreductive Radiotherapy is used in patients with cord compression chemotherapy, autologous transplantation may and in prevention of impending pathological fractures. however be used in high risk cases. Patients not eligible for high dose therapy should be 3. SURGERY treated with combination of Melphalan & For pathological fractures Prednisolone or Dexamethasone with Thalidomide. Thalidomide and its analogoue 4. SUPPORTIVE CARE lenalidomide has antiangiogenic, antimyeloma 1. Biophosphonates: Bone involvement in multiple and immunnomodulatory effect and has been myeloma is a major reason for morbidity of the found to be effective in newly diagnosed disease. Biophosphanates inhibit bone myeloma as well as in relapsed patients. resorption. Pamidronate or the newer more Bortezomib (valcade), a proteosome inhibitor potent Zoledronate are usually used to prevent has been found to be effective in relapsed skeletal events. Ideally such treatments should multiple myeloma and is under trial in patients be combined with calcium and hormone with newly diagnosed multiple myeloma. replacement in patients with no contradiction to • Renal failure – treatment of hypercalcemia, their use. hyperuricemia and the myeloma are all 2. Erythropoetin: Anemia is frequent in patients important to reverse as much of the renal with multiple myeloma. Recombiant human failure as possible. If renal failure is erythropoietin decreases transfusion established and severe, then careful medical requirement, increases means hemoglobin, management of the azotemia, and electrolytes, improves quality of life and performance status will be needed; dialysis is sometimes in aneamic myeloma patients. Erythropoetin employed if the life expectancy and general may be used in weekly or three times weekly condition of the patient warrants this. schedules The treatment of myeloma improves the 3. Vertebroplasty and Kyphoplasty: Painful quality of life (decreases bone pain, improves vertebral compression is a major cause of blood counts, etc) and prolongs life (median morbidity in multiple myeloma patients. survival is now 3 – 4 years compared to 1 year Vertebroplasty and Kyphoplasty helps in untreated). Current treatment does not cure the relieving pain in most patients disease.

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LEUKEMIAS ACUTE LEUKEMIA

nodes (including mediastinal) and splenomegaly, whereas these features are usually absent in the commoner AML in adults. Acute monocytic leukemia presents typically with gingival enlargement from monoblast infiltration.

The acute leukemias are not common (annual incidence rate of 3.5 / 100,000) but a major cause of morbidity and mortality particularly in young people (acute lymphoblastic leukemia is the commonest cancer in children). Although the incidence is not increasing, the prevalence is, since many cases who MANAGEMENT previously would have died quickly are now achieving CHEMOTHERAPY prolonged remissions with chemotherapy and The initial goal of chemotherapy is remission supportive care. induction ( a complete remission has occurred when The hallmark of the acute leukemias is the characteristic proliferation of immature (blast) cells in there is no evidence of leukemia in the blood and < 5% blast cells in the bone marrow) This is readily achieved the bone marrow, and often in the peripheral blood where WBC counts can be increased up to 100 x 109/L in children with ALL (95%) but only in about 60% adults with AML. Combination chemotherapy is or more. If the diagnosis is obvious from the WBC differential (large number of blast cells) then a bone required with various protocols (drugs such as marrow is not essential, but if there is any doubt when vincristine, prednisone, L-asparaginase, methotrexate, 6-Mercaptopurine, adriamycin, cytosine, arabinoside, a bone marrow will be required to demonstrate the involvement, or often complete replacement by rapidly and 6-thioguanine) are used in cyclic fashion to bone marrow patient tolerance. In the treatment of AML this proliferating blast cells. The blast cells fail to differentiate into more mature forms (i.e. granulocytes,aggressive chemotherapy is continued for two or more lymphocytes or monocytes) and inhibit maturation of courses after complete remission is achieved for consolidation. Maintenance treatment is not usually normal clones of marrow cells. The acute leukemias used as it has not been proven to prolong survival in are divided into the following categories. AML. In treatment of ALL following induction of 5. Acute myeloblastic leukemia (AML) – variants remission, consolidation therapy is given which is followed by maintenance treatment. The total time include acute myelomonocytic leukemia treatment undertaken is 2 – 3 years. Most maintenance (AMML), promyelocytic leukemia and treatments are given on an outpatient basis and patients erythroleukemia 6. Acute lymphoblastic leukemia (ALL) – variants return to regular routines of daily living. In childhood ALL, the risk of CNS include acute prolymphocytic leukemia, involvement or meningeal leukemia is so high ( and undifferentiated leukemia not counteracted by systemic chemotherapy) that these 7. Acute monocytic leukemia patients receive prophylactic intrathecal chemotherapy Morphological criteria (plus cytochemistry) used and is a subset cranial radiation to prevent CNS to be the prime method of differentiating the various relapse. The outlook for childhood ALL is much types of leukemia. Now with the use of monoclonal improved with modern chemotherapy protocols with antibodies, cell surface antigens can be identified, the prospect of cure in up to 70% of cases. In adults enable a more accurate differentiation of acute results are not so encouraging. A median survival of 18 leukemias. This is particularly important in months for AML responders and 30% long term determining the type of acute lymphoblastic survivors (5 years) can be achieved. For ALL recently leukemias. Cell surface marker analysis of ALL now determines the type of treatment used and probable 25-40% long term survival has been achieved. Morbidity during aggressive induction prognosis. Morphological criteria are still important chemotherapy is high (nausea and vomiting, alopecia, and both techniques are necessary for diagnosis. In bleeding / bruising, infections, anxiety and AML the use of cell surface marker analysis has not depression). Maintenance chemotherapy used in ALL yet altered treatment approaches. is generally well tolerated. Once relapse is occurred AML is the commonest acute leukemia in adults (90%) whereas ALL is commonest in children second remissions are much more difficult to achieve particularly in AML. If the patient has an HLA(90%), 70% are CALLA positive. Presentation of all forms of leukemia is distressingly similar, a previously identical sibling then bone marrow transplantation may healthy person develops symptoms from reduction in be a viable alternative for AML (first remission) or ALL (second remission) circulating blood cells (anemia, thrombocytopenia, fever or lymphadenopathy / splenomegaly, with the duration of illness usually being very short (a few days to a few months). ALL may cause enlarged lymph

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SUPPORTIVE CARE granulocytic series, often back to myeloblast state (but At presentation these patients are often the "hiatus" between blast cells and mature cells as anemic, infected and bleeding; during remission seen in acute leukemia is absent in CGL) Anemia is induction these potential complications are very usually mild, and a wide range of platelet counts may common, and the following guidelines generally apply be seen (to 1000 x 109/L) to their management: The bone marrow also demonstrates the increased and left-shifted granulopoiesis, but is a. Anemia generally not required for diagnosis (there are no - packed red cell transfusions are given as diagnostic morphologic features which differentiate needed for symptomatic anemia CGL from reactive granulocyte hyperplasia) It may, b. Thrombocytopenia however, provide a sample for karyotyping for - during remission induction, spontaneous hemorrhage is common if the thrombocytopenia is Philadelphia chromosome if needed. The Philadelphia severe (platelet count 10 x 109/L) so many centers chromosome (loss of short arm of chromosome provide prophylactic platelet transfusions during number 22 due to 22:9 translocation) is present in 85this period; others are more selective, attempting 90% of CGL patients; if absent, in a patient who to monitor the seriousness of the appears to have CGL by other tests, the prognosis is thrombocytopenia by clinical assessment (amount worsened. The Philadelphia chromosome is only rarely of purpura, epistaxis, mucosal bleeding, etc). The present in other myeloproliferative diseases. goal is to prevent intracerebral hemorrhage which Another test which might help differentiate is rapidly fatal if it occurs. Any drugs which cause between CGL and leukemoid reaction (granulocytic platelet dysfunction must be omitted e.g. Aspirin, hyperplasia) is leukocyte alkaline phosphatase and intramuscular injections are prohibited. (LAP); this is a histochemical test for alkaline c. Granulocytopenia phosphatase in leukocyte (neutrophil) granules – it is - although reverse isolation procedures do not altercharacteristically decreased – absent in CGL but the frequency of serious infections in these normal – increased in leukemoid reactions. It is patients, most acute leukemias are performed on peripheral blood, rather than bone provided with a private room, whenver possible, marrow. and visitors with infections are discouraged. Masks may help if attending staff have a potentially MANAGEMENT OF CML transmittable upper respiratory infection and hands1. Oral chemotherapy: should be washed before examining the patient. During chronic phase, hematological remission is If a neuropenic patient develops a chill and/or produced in more than 70% of patients treated fever, the patient should be promptly assessed for with Hydroxyurea or Busulphan. Hydroxyurea is site of infection, cultured immediately (Throat preferred over Busulphan because of better swab, urine C & S, blood cultures etc) and if a toxicity profile, progression free survival and septicemia is likely, should be placed on broad overall survival. However, no significant spectrum (eg. Cephalosporin plus aminoglycoside) cytogenetic remission occurs with Hydroxyurea or intravenous antibiotics as soon as cultures have Busulphan and over all pace of progression to blast been obtained. Granulocyte transfusions have not crisis is unchanged. These treatments are therefore been proven to be of help in this situations. considered to be palliative. d. Emotional support 2. Allogeneic bone marrow transplantation: - These patients require regular visits, frank Allogeneic hematopoietic cell transplantation is discussions and frequent reassurance from the only known curative treatment for CML. compassionate and knowledgeable medical, However only minority of patients have HLA nursing and other personnel to cope with the matched siblings. Treatment related morbidity and multiple physical and emotional problems mortality is significant and increase with which routinely are encountered. increasing age of the patient. Therefore currently CHRONIC GRANULOCYTIC LEUKEMIA Chronic granulocytic leukemia (CGL) accounts for 20% of all cases of leukemias, and mainly 3. onset is in middle age although cases in both adolescents and elderly patients are seen. The onset is insidious over several months, or more, and patients often present with significant splenomegaly, possibly symptomatic and hypermetabolic symptoms (fever, night sweats, etc) Diagnosis is usually obvious after clinical examination and assessment of the WBC differential. Leukocytosis is present with left shift in

this modality is offered to patients less than 40 years of age. In younger patients HLA matched unrelated donor transplantation is feasible. Interferon Alpha Before the use of Imatnib mesylate, interferon alpha was the standard therapy for CML in patients not eligible for allogenic bone marrow transplantation. Interferon alpha alone or in combination with Cytosinarabinoside produced hematological remission in most patients and cytogenetic responses in 20% patients. There is

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significant toxicity and interferon has even superseded by Imatnib 4. Imatinib Mesylate Imatinib (Gleevec) is a tyrosine kinase inhibitor. It inhibits PDGF, Abl & C-kit tyrosine kinases by interfering with the ATP binding site. It produces hematological responses in 94% patients and major cytogenetic responses in 83% patients. The drug has excellent toxicity profile with common side effects being mild nausea, myalgia, edema and diarrhea. However, it is not clear at present whether it is a curative modality for CML. More potent tyrosine kinase inhibitors are currently undergoing clinical trials.

characteristic antigenic profile in CLL lymphocytes. The lymphocytes are positive for CD45, 19,20,22,23, HLADR and characteristically show co-expression with T cell antigen CD5 and light chain restriction. The immunophenotyping helps to distinguish it from other lymphoproliferative disorders. Anemia and /or thrombocytopenia may result from marrow involvement, hypersplenism, or autoantibodies (immune hemolytic anemia of IgG type of secondary I.T.P) Hypogammaglobulinemia is common.

MANAGEMENT OF CLL Patients with early stage of CLL do not require treatment. In young patients, Fludarabine + Cyclophosphamide is currently the treatment of CHRONIC LYMPHOCYTIC LEUKEMIA choice. It produces higher incidence of remission Chronic lymphocytic leukemia (CLL) is the commonest form of leukemia, appearing mainly in old (complete and overall) compared to Chlorambucil or age, often symptomless and requiring no treatment. combination chemotherapy. The drug may be Hypermetabolic symptoms such as fever, night sweats, associated with cumulative myelotoxicity and fatigue and weight loss may occur. Lymph nodes and increased risk of opportunistic infection. spleen are regularly enlarged often for many years, In older patients, intermittent Chlorambucil is an without causing symptoms, but can achieve such enlargement as to require treatment for pressure or appropriate therapy, because of it ease of administration and relatively favourable toxicity cosmetic symptoms. profile. The laboratory diagnosis is usually simple. Moncolonal antibody, anti CD20 (Rituximab ) is There is lymphocytosis which may reach extreme 9 degrees (500 x 10 /L or more) without other obvious effective when used in combination with causes (eg. Viral infection) The lymphocytes seen are chemotherapy and anti CD52- Alemtuzumab usually small lymphocytes and appear morphologically (Campath) have significant activity in CLL. These normal. Frequently they are fragile so that they ruptureagents are however used for patients who have failed Fludarabine therapy. during preparation of the slide; they are then called "smudge cells". Although not diagnostic of C.L.L they Coomb's positive autoimmune hemolytic anemia and are so frequently seen in this type of leukemia that theyimmune thrombocytopnenic purpura are treated with Prednisolone. are quite typical. The bone marrow contains a Radiotherapy is reserved for symptomatic lymph lymphocytic infiltration but often is not needed to make the diagnosis of CLL. Flow cytometry reveals a node enlargement not responding to chemotherapy.

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PROBLEMS FOR TUTORIALS

Questions: 1. What are the B-symptoms and how do you define 1. ADULT MAN WITH LYMPHOCYTOSIS them? A 65-years-old man was brought to the emergency unit by his son because he has fainted at home. According 2. What is your differential diagnosis? 3. What initial tests would you like to order? to his son, the man was gradually feeling week with inability to do his daily routine. He had loss of appetite 4. How do reach a final diagnosis? What do the cells shown below imply? and lost 5 Kg. over the last 6 months. He had no

previous history of cardiac disease or hypertension but had diabetes for which he was on oral hypoglycemic 3. POLYCYTHEMIA drugs for the past 5 years. Problem: A 60 year old man with history of heavy smoking and chronic bronchitis was admitted to On examination, the man was conscious, oriented, a hospital with the onset of severe dyspnea. This man's febrile, pulse: 90 b. / min. B.P: 130 / 80, he was not chronic chest disease has been present for twenty jaundiced but had pale conjunctiva. Examination of the years. At the time of admission to hospital, he was neck revealed bilateral cervical and supraclavicular dyspneic and plethoric with both central and peripheral lymphadenopathy. There were also two axillaries and cyanosis. There was no clubbing. Examination of the one inguinal lymph node. Examination of the heart and chest revealed diffuse wheezing. chest was normal. Abdominal examination revealed a Laboratory Investigations: splenomegaly of 10 cm. below the left costal margin Hemoglobin 210 g/L (LCM) Hematocrit 0.69 WBC 19 x 109/L Investigations showed: Platelet Count 950 x 109/L Hb. 95 g/L N M: 140-160 Chest X-ray showed over inflation of the lungs F: 120-160 bilaterally MCV: 105 fl (N 80- 95) Required questions: WBC count: 50 x 109/L Lymphocytes 80% 1. Is this likely to be a primary or secondary Platelets 90 x 109 / L erythrocytosis (polycythemia)? Why? Blood Sugar: 8.5 mmol / L Na: 140 mmol/L 2. What additional investigations would you K: 4.2 mmol/L perform? 3. Discuss treatment in terms of Polycythemia Questions: 1. What are the important findings in the history and 4. ATYPICAL LYMPHOCYTOSIS clinical examination of this patient? Problem: This 18 year old woman saw her 2. What is the differential diagnosis physician for increasing tiredness over the past two 3. What is the most likely diagnosis? weeks associated with a sore throat and fever. 4. What do you think is the cause of the anemia? Physical examination revealed a young woman who had bilateral slightly tender anterior cervical nodes 2.5 cm in diameter. The spleen was palpable 3 cm below the left costal margin Laboratory Investigations: Hemoglobin 132 g/L 12.4 x 109/L WBC .01 bands .46 segmented neutrophils .26 lymphocytes 2. A YOUNG FEMALE WITH NECK LUMP .25 atypical lymphocytes A 17-year-old Kuwaiti girl sought medical at tension .02 monocytes because she noticed lumps in the left side of her neck. Platelet count 110 x 109/L She denied any B-Symptoms. Her past medical history Required questions: is unremarkable. 1. List 2 causes of atypical lymphocytosis On examination, there is a 3x3-cm firm, non-tender, 2. What is the most likely cause in this patient freely movable nodule in the left neck just above the sternoclavicular joint, and several smaller nodes to the 3. The patient worries about having cancer. List 3 left along the clavicle. All vital signs are normal. There reasons why you think it is unlikely is no fever or icterus. The thyroid gland is normal. The 4. The patient requests an antibiotic for new sore chest, heart, breasts are normal. The spleen is palpable throat. You do not agree with this. Why not, and 2 cm below the left costal margin on deep inspiration. what would you do instead

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5. What are the appropriate confirmatory tests? 5. LEUKOCYTOSIS AND SPLENOMEGALY

and some gum bleeding. By this time it was known that her neutrophil count was very low (less than 0.5 x 109/L) Describe your management with regard to: a. Tests to investigate the fever b. Any treatment for the febrile illness. What should she avoid? c. Treatment of the thrombocytopenia? i. What blood products should be ordered? ii. How much? iii. Expected response

Problem: This 51 year old woman was referred to hospital. One month prior to admission she had sharp pains in the left upper quadrant of her abdomen. She palpated a large mass herself, and consulted her private physician who thought the mass was spleen. He noted that the leukocyte count was elevated. Laboratory investigations Hemoglobin 100 g/L Platelet count 650 x109/L 7. LEUKOCYTOSIS 9 WBC 70 x 10 /L Problem: This 78 year old man visited his .02 blasts family physician for an annual "checkup" He was in .03 promyelocytes good health except for mild symptoms of congestive .18 myelocytes heart failure being treated with digoxin and .17 metamyelocytes hydrochlorothiazide daily. .25 bands On examination, there was no tonsillar .20 neutrophils enlargement, lymphadenopathy or hepatosplenomegaly .04 lymphocytes Laboratory Investigations: .02 monocytes Hemoglobin 148 g/L .05 eosinophils MCV 88 fL Required Questions: MCHC 34- g/L 1. What is the most likely diagnosis? 58.0 x 109/L WBC .15 neutrophils 2. What confirmatory tests might you order .65 lymphocytes 3. The patient asks if her spleen should be removed .20 smudge cells since it bothers her. Do you agreed and why? Platelet count 175 x 109/L 4. The patient has just started a clothing business and Required Questions: wants to make plans for the future. What advise 1. What is the most likely diagnosis to explain would you provide regarding: the blood findings? a. Possibility of bone marrow transplantation 2. Are any further tests required b. Side effects of the treatment you would 3. What advise would you give this patient prescribe regarding: c. Complication which is likely to occur and a. Need for treatment now? when. b. Indications for treatment in the future 5. New treatment. c. Side effects of treatment if required? 6. PANCYTOPENIA d. Overall disease course Problem: This 59 year old woman was referred to hospital because of a low WBC count. The 8. LYMPHADENOPATHY Problem: A 30-year old female who was patient denied malaise of fatigue. Two weeks before admission, she had an acute respiratory tract infectionpreviously well until 4 weeks ago when she noted a treated with penicillin. Except for pallor and few lump in her left axilla. During the past 2 weeks she has bruises, there were no other physical findings. complained of fatigue. Physical examination revealed Laboratory Investigations a 3 cm, non-tender soft mass in the left axilla. There were no abnormalities detected on breast exam and Hemoglobin 80 g/L there as no evidence of splenomegaly or MCV 82 fL MCHC 350 g/L lymphadenopathy elsewhere. 9 Laboratory Investigations: WBC 3.8 x 10 /L 9 Platelet count 15 x 10 /L Hemoglobin 115 Required Questions Hematocrit .3 White Blood Count 4.5 1. List any further laboratory tests you would Platelet count 200 request Chest X-ray small mediastinal mass 2. List 2 possible diagnosis for the blood changes 3. The day after admission, her temperature Required Questions: spiked to 39oC and she had a chill. She also developed many bruises, recurring nosebleeds

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1. List 3 additional pieces of information from the history you would require 2. What test would you arrange to make the diagnosis? 3. What are the most likely diagnoses?

4. What other investigations are necessary if this

is either Non-Hodgkin's Lymphoma or Hodgkin's Disease? 5. Assuming the diagnosis of Hodgkin's Disease, what additional investigations may be done? 6. What is the importance of the information gained in the above questions?

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MYELOPROLIFERATIVE DISORDERS

The designation "myeloproliferative disorder" In both of the above possible categories the is a general term given to wide range of malignant abnormality is usually limited to increased Hb, Hct, proliferation of myeloid tissue, which can be classified and RBC count, without an elevation of WBC count or as follows: platelet count. The red cell mass, as assessed by Cr51 blood volume, is increased in both secondary polycythemia, and primary polycythemia (P. vera) MYELOPROLIFERATIVE DISORDERS Polycythemia vera is a malignant proliferation of 1. Polycythemia vera myeloid cells usually involving all marrow cell lines 2. Myelofibrosis (myelosclerosis) leading to erythrocytosis, leukocytosis (neutrophilia) 3. Myeloid metaplasia (with or without and thrombocytosis. Splenomegaly is present in 75% myelofibrosis) of patients at diagnosis) 4. Chronic granulocytic leukemia Common symptoms include plethora (ruddy 5. Thrombocythemia cyanosis of face and extremities), hyperviscosity 6. Acute myeloblastic leukemia symptoms (transient bleeding, TIA's, angina, We have included CGL and AML under leukemias, and will restrict further discussions to claudication etc) bleeding and pruritus (which is polycythemia, myelofibrosis (myeloid metaplasia) common, often sever, and aggravated by bathing "bath pruritus") and thrombocythemia. Management includes control of red cell mass (hyperviscosity) and prevention of bleeding POLYCYTHEMIA VERA complications. If erythrocytosis is marked but not Before deciding whether a patient has leukocytosis or thrombocytosis, then a therapeutic polycythemia vera, the physician must first usually phlebotomy program (removal of 500 ml blood usually exclude two other possibilities: weekly) may be instituted; usually this must be b. Spurious (stress, or relative) erythrocytosis – continued till the patient develops iron deficiency, patients with this disorder are detected by the isolated findings of elevated Hb and Hct, often in limiting erythropoiesis and this may take several months. If there is complicating thrombocytosis, association with hypertension (Gias-bock's symptomatic splenomegaly or hypermetabolic syndrome) Blood volume studies (Cr51 labelled symptoms, then radioactive phosphorus (P32) will RBC's) demonstrate a normal red cell mass, however, and the "apparent" erythrocytosis is due provide good long term control of P.vera, and should be considered particularly in older patients. to a reduction in plasma volume. This condition requires recognition, to differentiate it from true Chemotherapy has also been used, but there is a definite leukemogenia potential with either polycythemia, but no treatment. chemotherapy (chlorambucil, myleran) or P32 so this must be carefully assessed for each patient. Younger c. Secondary polycythemia (erythrocytosis)- this patients should receive hydroxyurea, as chemotherapy, represents a response to tissue hypoxia, or due to its lower leukemogenic risk. Recently Aspirin autologous erythropoietin production and the has been shown to decrease the risk of thrombosis. following should be considered: i. Chronic lung disease – particularly chronic bronchitis Uric acid is usually increased and most ii. Congenital heart disease – cyanotic, with right to patients are treated with allopurinol to prevent gout or other complications of hyperuricemia. left shunt iii. Renal disease – renal cell carcinoma, cysts, renal MYELOFIBROSIS, MYELOID METAPLASIA artery stenosis These two conditions often exist together, iv. Liver disease – hepatoma although myeloid metaplasia can occur without v. High altitude fibrosis in the bone marrow (called "agnogenia" vi. Hemoglobinopathy – high affinity hemoglobin myeloid metaplasia). The marrow fibrosis may result (rare) in bone proliferation as well (myelosclerosis) and be vii. Cerebellar hemangioblastoma (rare) visible on x-ray but usually it doesn't. It does result in decreased hematopoiesis, and the concomitant myeloid Most of the above can be ruled out on clinical metaplasia present mainly in the liver and spleen is assessment. The one diagnosis which must not be missed is the renal cell carcinoma which may still be rather inefficient. Accordingly, the patients with these disorders usually have anemia and thrombocytopenia, curable if detected at a localized stage; if any doubt both of which may be severe, whereas the leukocytes exists as to a cause for erythrocytosis, appropriate are often increased and left shifted. investigations of the urinary tract should be considered.

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The peripheral blood film is usually be helpful if deficiency is documented. Splenectomy characteristic, with a "leukoerythroblastic" blood may be required to control symptoms of massive picture – nucleated RBC's and left-shifted granulocyte splenomegaly; this operation is risky, however, and series. Other features include teardrop poikilocytes, platelet function should be studied prior to surgery and megathrombocytes – all of these abnormalities since many patients have abnormally functioning result from abnormal hematopoiesis taking place platelets in addition to the thrombocytopenia. outside the bone marrow. Marrow biopsy is required to demonstrate the marrow fibrosis. ESSENTIAL THROMBOCYTHEMIA Patients usually present with symptoms of If the thrombocytosis is extreme (1,000 x 9 anemia and/or thrombocytopenia, with systemic 10 /L) it should probably be controlled by complains of fever, night sweats, and weight loss. chemotherapy Hydroxyurea (myleran) particularly if Splenomegaly is usually prominent and may be any surgery is planned and is elective enough to massive producing major pressure symptoms. Splenic provide time for this treatment to be effective (1-2 infarcts are common. months) Emergency treatment with plateletphoresis is Treatment is unsatisfactory – Supportive care rarely needed. These patients tend to develop other with red cell transfusions for symptomatic anemia and myeloproliferative disorders (polycythemia, leukemia) platelet transfusions for thrombocytopenia bleeding but usually many years pass before this occurs. Baby Aspirin may reduce the risk of arterial thrombosis. complications may be required. Androgens may provide mild benefit for the anemia and folic acid may

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MODULE III & IV HAEMOSTASIS & THROMBOSIS OBJECTIVES

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Discuss common causes of bleeding disorders and their pathogenesis.

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Describe the clinical presentation, plan of investigations and interpret, integrate and correlate salient points in clinical history, physical findings and laboratory data so as to reach a correct diagnosis in a patient presenting with a bleeding disorder.

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Describe the common mode of clinical presentation and demonstrate ability to interpret relevant laboratory data in patients with following bleeding disorders.

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Haemophilia

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von Willebrand's disease

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Acquired coagulation deficiency secondary to vitamin K deficiency, liver disease, chronic renal failure, and DIC.

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Discuss common causes of thrombocytopenia.

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Plan and interpret salient points in clinical history, physical findings and relevant laboratory data to establish diagnosis of the type and cause of thrombocytopenia in a patient.

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Plan and administer rational therapy to a patient with thrombocytopenia.

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Describe the indications, schedule of administration and side effects of the use of fresh frozen plasma, cryoprecipitate and platelets concentrates in the management of bleeding disorders.

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Discuss pathophysiologic mechanisms of thrombosis and describe molecular basis of inherited thrombophilia.

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Enumerate common causes of acquired and inherited thrombotic disorders.

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Demonstrate ability to correlate salient points in clinical history and physical findings and to plan and interpret laboratory investigations so as to make dignosis of a thromboembilic disorder.

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Describe mechanism of action, dose, frequency, mode of administration, and adverse effects of heparin and coumadin anticoagulants

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BLEEDING DISORDERS

1. Defective platelet function a. Hereditary – von Willebrand's Disease The student should have a general (VWD), defective aggregation understanding of hemostasis, the types of common or b. Acquired – medications, anemia, myeloimportant bleeding problems which occur with proliferative diseases. hemostatic defects, and the principles of management 2. Vascular Disorders for these problems. a. Allergic (Henoch-Schonlein purpura) b. Non-allergic – mechanical, senile, steroid, SPECIFIC OBJECTIVES dysproteinemia, connective tissue disorders. At the end of this section, the student should be able to: APPROACH TO PATIENTS WITH BRUISING 1. list possible causes of bleeding problem given either a clinical presentation of bleeding, abnormal(PURPURA) In general, patients with thrombocytopenia, tests of hemostasis or both 2. List any additional tests required, if any to define defective platelet function, or vascular disorders tend to bruise either with minimal trauma or even the precise cause of a bleeding problem. spontaneously, depending on the severity of the 3. Describe the clinical presentation and expected laboratory abnormalities for common or important problem. The various factors tend to be additive ( i.e. one would expect more bruising in an elderly patient bleeding problems; these include with defective connective tissues, who is Hemophilia, von Willebrand's disease, Acquired coagulation deficiencies, secondary thrombocytopenia and taking Aspirin. Also the to vitamin K deficiency, liver disease and DIC, combination of platelet/vascular disorders discussed in this section with coagulation disorder discussed in thrombocytopenia secondary to ITP, subsequent sections usually leads to more severe consumption or decreased production. bruising and bleeding problems than either would by 4. Demonstrate an understanding of the use of itself. heparin and coumarin anticoagulants including The commonest manifestations of these types of drugs, dosage, frequency and route of administration for both prophylaxis and therapy of disorders are bruises and petechiae involving the muco-cutaneous surfaces. Petechiae appear as small (1 thromboembolic disease – 3 mm diameter) red spots, which do not blanch; they 5. Describe the mode of inheritance for hereditary may occur on any cutaneous or mucosal surface but coagulation disorders tend to be more evident on dependent areas, such as 6. Describe the use of Fresh Frozen Plasma, legs in ambulatory patients. Widespread and/or Cryoprecipitate and Platelet concentrates in the mucosal lesions indicate a serious problem. management of bleeding disorders, including In addition to these manifestations patients indications and contradictions for its use, expected with several platelet and vascular disorders may also response and possible complications. present with abnormal bleeding at many sites (e.g. epistaxis, GI hemorrhage, cerebral hemorrhage, PLATELET / VASCULAR DISORDERS OF intramascular hematomas, etc). Excessive bleeding HEMOSTASIS often occurs with surgery and trauma

GENERAL OBJECTIVES

CLASSIFICATION OF PURPURA (BRUISING)

CLINICAL ASSESSMENT Special attention must be paid during the THROMBOCYTOPENIC PURPURA interview to elicit information about current bleeding 1. Decreased Production and bruising problems as well as previous history, a. Hereditary – very rare b. Marrow suppression – medications, radiation, including surgery, dental extractions and childbirth. A meticulous enquiry into the use to drugs, medications alcohol, chemotherapy and alcohol is mandatory and the review of the family c. Marrow infiltration – leukemia, metastatic history must be thorough to detect hereditary tumors problems. 70% of all hereditary bleeding diseases will d. Marrow ineffective – megaloblastic, have an evident family pedigree dysmegakaryopoiesis Physical examination should document the 2. Decreased Survival extent and location of petechiae and bruises as well as a. Immune – I.T.P, medications, sepsis, neonatal the presence of absence of other vascular 3. Dilutional malformations e.g. telangiectasia, hematoma, confluent a. Massive transfusion hemorrhagic stomatitis. It is also important to rule out NON-THROMBOCYTOPENIC PURPURA

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other underlying diseases such as liver disease or hematologic disorders.

In thrombocytopenic patients a bleeding time is usually contraindicated unless the result would have a direct influence on management. Limitation: This test is not precise and does not have predictive value.

LABORATORY ASSESSMENT 1. CBC, Differential, Platelet count: Platelet must be either estimated or counted in a bleeding or bruising patient to document 4. Bone marrow: thrombocytopenia. If the estimate made on A bone marrow aspirate and preferably a observation of the blood film is normal, this is biopsy will quickly differentiate between sufficient to rule out thrombocytopenia. If platelets thrombocytopenia due to decreased production appear reduced, a platelet count is usually (decreased megakaryocytes) versus that due to performed to quantitate platlet number accurately. increased destruction (normal to increased Mordern cell-counter equipment provide accurate megakaryocytes) it is usually performed when the counts rapidly, often alont with other cause for thrombocytopenia is not obvious by measurements (Hb, WBC, indices, etc); if this other non-invasive tests, or clinical examination. equipment is not available then manual platelet counts must be performed – these are more time SIGNIFICANCE OF THROMBOCYTOPENIA consuming and less accurate. When AND ASSOCIATED CLINICAL FINDINGS 9 thrombocytopenia is sever (<10 /L) most laboratories report it as such rather than providing Severe thrombocytopenia a figure since counts below that level cannot be (platelet count < 20 x 109/L and particularly < 10 accurately measured. x109/L) – risk of spontaneous bruising and All Abnormal platelet counts must be confirmed bleeding, which may be life threatening (eg. by microscopic examination of a blood film. Intracranial hemorrhage) The CBC and Differential are required to determine whether a thrombocytopenia is selectiveModerate thrombocytopenia (usually indicating peripheral destruction, often (platelet count 20 – 80 x 109/L – may bruise with immune in origin) or associated with decrease in mild trauma but usually not spontaneously; other cellular elements (anemia, leucopenia) excessive bleeding is likely to occur at surgery. and/or an abnormal differential (eg leukemia). Morphology of the platelets is important to assess Mild thrombocytopenia eg. Abnormal shape or cytology (platelet count 80 – 150 x 109/L) – no problem 2. Coagulation Screening Tests: expected with or without trauma or surgery. If abnormal in a thrombocytopenic patient this NOTE: suggest involvement with coagulation system. Certain diagnosis, such as D.I.C, liver disease / 1. Ingestion of drugs which affect platelet function hypersplenism and lupus require exclusion. will make any degree of thrombocytopenia more likely to cause bleeding/bruising and should be 3. Bleeding Time: avoided. This test is usually performed by making 2 short standard incisions on the patient's forearm, 2. Intramuscular injections should be avoided in all often using a template to regulate the length and patients with platelet /vascular and coagulation depth of the incisions. The time taken for the disorders to avoid development of intramuscular bleeding from the incisions to cease is a good hematomas. measure of the in vivo significance of 3. Both the cause and the degree of thrombocytopenia or platelet dysfunction. thrombocytopenia must be considered when assessing the clinical significance of It is usually performed in a bruising patient thrombocytopenia (patients who are compensating with normal numbers of platelets to detect platelet for increased platelet destruction such as I.T.P are function abnormalities. If it is normal, and platelet much likely to bleed than those suffering from number is normal then no further platelet tests (eg decreased platelet production such as patients with aggregation) are indicated. A prolonged bleeding leukemia and aplastic anemia.) time in the presence of normal platelet number implies a platelet function defect and further The role of platelet transfusions in the studies may be indicated unless the cause is management of patients with thrombocytopenia or evident (eg. Uremia) One should exclude the platelet dysfunction is outlined in a previous recent ingestion of drugs which alter platelet section (Blood Transfusion Practice). function (note that ASA may prolong the bleeding time for up to 1 week) prior to ordering the test. COMMON AND/OR IMPORTANT DISORDERS Generally speaking the most common causes of bleeding under the heading of “Platelet and Vascular

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Disorders" are thrombocytopenias. The most common thrombocytopenias are probably: PLATELET FUNCTION DEFECTS 1. Those seen with general marrow suppression or VWD is one of the most common of the aplasia produced whether accidentally (i.e. hereditary hemostatic disorders. Other hereditary Chloramphenicol, Phenylbutazone) or platelet function disorders are rare. therapeutically (i.e. Myelosuppressive drugs) The acquired platelet defect seen with ASA is important as it is so common, and may aggravate other 2. Those secondary to marrow infiltrations such as hemostatic problems. The platelet defects seen in other leukemia and secondary tumor. diseases are usually mild, but may cause serious 3. Hypersplenism problems at surgery. 4. In association with D.I.C Treatment of vWD requires the injection of 5. The specific immune thrombocytopenias (ITP or DDAVP (arginine vasopressin) to release vWF from following certain drugs such as Quinine and the individual's endothelium or viral attenuated Quinidine, Heparin) products that contain vWF (eg. Humate-P) 6. Association with infections, especially HIV Other than the thrombocytopenias the platelet VASCULAR DISORDERS function defect in association with Von Willebrand's disease and with aspirin are important to be aware of Allergic (Henoch-Scholein Purpura): This disease is seen not uncommonly in as are several of the vascular disorders such as the nonallergic, non-thrombocytopenic simple purpuras seen children, especially boys with peak incidence at 3- 7 commonly in elderly and in patients on steroids, and years and usually occurring 1-3 weeks following an upper respiratory infection. Onset is sudden with allergic (Henoch-Schonlein) purpura seen not malaise, headache, fever, urticarial rash, and 50% have uncommonly in children. The following are some comments regarding some joint or abdominal pain. There are no specific lab of the above subjects which are not covered elsewhere:findings. Treatment with corticosteroids is usually not effective but commonly used in the sicker child with IMMUNE THROMBOCYTOPENIAS joint and abdominal pain. The problem usually last 2-4 Acute I.T.P This disease occurs predominantly in children weeks but relapses are not uncommon. Non-Allergic: of either sex consisting usually of a severe abruptly Non-thrombocytopenic purpuras such as onsetting thrombocytopenic purpura usually 2-21 days following viral infection. Most recover spontaneously simple purpura (seen in 50% of healthy women) senile purpura and steroid purpura are common but usually in 1-2 months. It is important to rule out bacterial very mild and require no treatment. sepsis as a cause. Treatment with Prednisone 1-2 mg./kg or THROMBOCYTOSIS intravenous gamma globulin 1g/kg is often given if Thrombocytosis applies to any patient with a significant mucocutaneous hemorrhage is present. 80% platelet count greater than normal (450 x 109/L). Mild will recover regardless of treatment. 50% will have degrees are fairly common and usually not clinically normal platelets in 6 weeks and 80% are well in 6 9 months. Approximately 20% become chronic lasting 6 significant. Severe degrees (1,000 x 10 /L) may result in serious problems (eg CVA) particularly in patients months or more and some remain severe enough to require steroids or other immunosuppressive therapy with underlying vascular disease or stasis. Therefore, the management of these patients requires knowledge for 6-12 months with splenectomy only being of the platelet count, the cause of the increased performed if no other therapies prevent significant platelets, and the general medical/surgical condition of bleeding. the patient. Chronic I.T.P: CLASSIFICATION This is a disease of adults occurring in 3:1 in 1. Primary: females, usually onsetting insidiously and rarely a. Myeloproliferative disorders resolve spontaneously. b. Essential thrombocytosis Usual treatment is Prednisone 1 – 2 mg/kg (thrombocythemia) with a response in the platelet count usually occurring c. Associated with other myeloproliferative in 3-4 days to 2 weeks. Splenectomy is considered if disorders, eg. Myeloid metaplasia / no response occurs after several weeks of large doses myelofibrosis, polycythemia, rubra vera, or in patients continuing to require Prednisone for chronic myelogenous leukemia longer than 6 months or having major side effects and continuing bruising and bleeding occurs. Because of 2. Secondary: a. Post-splenectomy the extremely short life span of transfused platelets, b. Response to chronic bleeding platelet transfusions are used only in life-threatening c. Iron deficiency hemorrhage.

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d. Chronic Inflammation / infection e. Underlying malignancy

search to detect what is sometimes a small primary neoplasm. Patients with secondary thrombocytosis rarely require treatment for the thrombocytosis itself The diagnosis and management of patients since it is usually mild (< 1000 x10 9/L), with primary thrombocytosis is discussed in the uncomplicated and transient or reversible with myeloproliferative section of the Lymphadenopathy treatment of the underlying disease. Drugs that alter and Splenomegaly Section. platelet function (e.g ASA) may be used if In patients with secondary thrombocytosis the thrombocytosis is more sever, or occurs in a patient at high risk for vascular occlusions but this is seldom cause may be obvious (post-splenectomy, iron deficiency) but in others it may be very obscure (e.g. required. underlying malignancy) and necessitate a thorough

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COAGULATION DISORDERS Coagulation disorders comprise a wide variety of both hereditary and acquired hemostatic problems. The hereditary disorders vary from uncommon to very rare, and only the more common types will be discussed in some detail; the general principles, however, apply to them all. The acquired disorders are more common, usually being secondary to other conditions (infections, pregnancy, liver failure), medications (Coumadin) or poor nutrition. APPROACH TO PATIENTS WITH BLEEDING PROBLEMS Whereas patients with platelet / vascular 3. disorders predominantly with excessive bleeding involving the mucocutaneous surfaces, the coagulopathies present mainly with bleeding of potential spaces eg. Joints or soft tissue eg muscles as opposed to bruising, although there is some overlap. With minor surgery, mild trauma, and dental extractions, bleeding is usually prompt with platelet disorders but may be delayed with coagulation defects since initial hemostasis is provided by platelets (platelet plug) and backed up later by a fibrin 4. thrombus. In coagulation disorders bleeding may occur from any orifice and in almost any organ. Typically, in hereditary coagulation factor deficiencies, hemarthrosis are most frequent and disabling. During the clinical examination of patients with bleeding problems careful attention must be paid to past history and family history. The pattern of 5. inheritance will be helpful (e.g. males affected and females as carriers of sex linked recessive for hemophilia, but equal distribution in males and females for VWD) LABORATORY TESTS FOR COAGULATION DISORDERS The end result of most coagulation test is the formation of a fibrin clot which is usually detected by a variety of automated equipment. The main tests are: 1. International Normalized Ration (INR) (Prothrombin Time (P.T.)) This test measures the extrinsic clotting system by adding extrinsic thromboplastin to citrated plasma. Prolongation greater than 1.2 is considered abnormal. An isolated deficiency of factors VII, X, V, II or I will prolong the INR (note that deficiencies of the common pathway usually prolong both INR and PTT; isolated factor VII deficiency will only prolong the INR) 2. Partial Thromboplastin Time (P.T.T): This is also known as activated P.T.T since current tests incorporate some form of activator

increasing the reliability and reproductivity. The normal range varies from one laboratory to another, but usually the upper limit is less than 40 seconds; it will be prolonged when the amount of any single factor decreases to less than approximately 30% ( 0.30 u/ml) The test measures the intrinsic clotting system as mentioned previously, defects in the common pathway (Factors X, V, II and I) prolong the P.T.T. as well as the INR; isolated deficiencies in factors XII, XI, IX, and VIII result in prolongation of P.T.T. only) Thrombin Time (T.T) or Thrombin Clotting Time (T.C.T) The thrombin time measures the brief time (about 9 seconds) required to convert fibrinogen to fibrin after the addition of thrombin to citrated plasma. It is most often prolonged when there is a deficiency of fibrinogen, a defect in fibrinogen (dysfibrinogenemia) or if heparin is present in the samples. Fibrinogen (Factor I) The fibrinogen level can be measured in plasma; since it is an “acute phase reactant” it is frequently elevated in many infections, inflammatory or traumatic illnesses. A decreased fibrinogen level may be isolated as a rare hereditary deficiency, but more commonly is reduced along with other factors in liver disease, D.I.C or fibrinolysis. Fibrin-Fibrinogen Degradation Products (FDP) FDP are the result of fibrin and fibrinogen proteolysis, indicating excess plasmin activation. They do not differentiate between primary and secondary fibrinolysis and mild to moderate elevations are commonly seen in seriously ill patients or physiologically stressed individuals. Marked elevations, particularly when associated with other coagulation deficiencies and thrombocytopenia, require that D.I.C be ruled out. Elevated FDP are also seen in severe liver disease, since plasmin is not metabolized properly in the damaged liver. Since other coagulation deficiencies and thrombocytopenia may be seen in liver disease, as well as D.I.C, it is extremely difficult to differentiate between these two problems. A test for fibrin monomers (protamine sulphate test) may help since it should not be positive if intravascular thrombin activation has occurred e.g. deposition of fibrin monomer and polymer. More recently, a test called D. Dimer has been developed. These tests measures degradation products of cross linked fibrin and thus not

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fibrinogen breakdown products. This test is replacing FDP measurement in many laboratories HEMOPHILIA B DISEASE (FACTOR IX as it does not require special collection tubes. DEFICIENCY) This deficiency is less common than Hemophilia A but has the same inheritance and clinical HEREDITARY COAGULATION DEFICIENCIES Hereditary deficiencies of each clotting factor presentations depending on the severity of the have been reported. Most of these deficiencies are verydeficiency. It can only be differentiated by coagulation rare; only deficiencies of Factor VIII (Hemophilia, and factor assays which are only reliably performed in laboratories experienced with these tests. VWD), Factor IX (Christmas Disease) and Factor XII (Hageman deficiency) warrant more discussion. In The same principle apply to the management screening for all hereditary deficiencies, it is importantof factor IX deficiency as for factor VIII deficiency to remember what the INR, PTT tests measure at their regarding the need for surgical prophylaxis, and various levels of sensitivities. adjusting type and frequency of coagulation factor support depending on severity of deficiency and the clinical circumstances. If the deficiency is mild to Deficiencies of Factors XII, XI, IX, VIII moderate it should be corrected with plasma ( usually → Prolonged PTT, Normal INR FFP although stored plasma would suffice), but if Deficiency of Factor VII severe then adequate replacement would require → Prolonged INR, Normal PTT infusion of a commercial Factor IX concentrate (again Deficiency of Factors X, V, II, I a pasteurized pooled lyophilized product with → Prolonged INR and PTT decreased risk of viral borne disease transmission). CLASSICAL HEMOPHILIA (HEMOPHILIA A) (Factor VIII Deficiency) von WILLEBRAND’S DISEASE (VWD) This is the commonest hereditary factor vWD is inherited as an autosomal dominant deficiency. It is inherited as a sex-linked recessive disorder affected both males and females equally. In disorder, being manifest almost entirely in males, with addition to Factor VIII deficiency, which is usually females as carriers. 25% of patients have no family mild, the lack of von Willebrand factor also causes a history. platelet dysfunction. Measurement of Factor VIII The clinical problems vary with severity of the coagulant and VWF antigen, VWF Ristocetin cofactor deficiency. Mild hemophiliacs (5-30%) will only have are necessary for making a diagnosis. However they excessive bleeding with surgery or trauma, whereas at carry a risk of thrombotic complications. Pure factor the other end of the spectrum the severe hemophiliacs IX also available. (< 1% Factor VIII) are constantly threatened with spontaneous hemorrhagic problems (mainly The preferred treatment for such cases is hemarthrosis, intramuscular hematomas, and DDAVP. A cryoprecipitate is rich in vWF and is hematuria) generally administered in a dose of one bag per 10 kg body weight. Certain virus-attenuated concentrates All hemophiliacs must avoid injury, and (Humate-P) contain substantial amounts of vWF and refrain from any medications (eg. ASA) which would are preferred to cryoprecipitate if available. alter platelet function and enhance the bleeding problem. Patients with mild hemophilia or who are carriers may only require DDAVP to temporarily boost the individual’s endogenous Factor VIII for minor HAGEMAN FACTOR DEFICIENCY (FACTOR surgical procedures and then it should be given prior toXII) and post operatively until wound healing has occurred. This deficiency is mentioned only to point out Moderate and severe hemophiliacs on the other hand, that it may cause a prolonged P.T.T. and therefore must will require regular infusions of Factor VIII be differentiated from other factor deficiencies (VIII, concentrate at onset of joint pain, or on a prophylactic IX, and XI) by appropriate Factor Assays. However, it basis, often given by themselves on a home care does not result in clinical bleeding problems since it is program monitored by a Hemophilia Centre; the a "contract factor" and therefore causes only an "inpredictability, efficiency and ease of administration vitro" abnormality. outweigh the possible risks of disease transmission such as hepatitis for these patients so commercial ACQUIRED COAGULATION DEFICIENCIES factor VIII concentrates are favored. HIV infection is not considered a significant contaminant since the VITAMIN K DEFICIENCY introduction of improved pasteurized concentrates in The Vitamin K-dependent coagulation factors 1988. Further the recombinant factor IV is generated are Factors II, VII, IX and X. If the factor deficiency is through DNA technology. This makes it save from mild only the INR is elevated, but if more severe then infection point of view. However, formation of both INR and P.T.T are elevated since coagulation antibodies directed to factor VIII is still a problem. factors of both intrinsic and extrinsic systems are

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involved. The thrombin time and fibrinogen levels are - septic abortion normal thereby differentiating Vitamin K deficiency - amniotic fluid embolism from either heparin effect (prolonged thrombin time - eclampsia but normal fibrinogen) or liver disease (low fibrinogen, 2. Infections also). Causes of Vitamin K deficiency include: - especially gram negative septicemia 1. Dietary deficiency – this is most commonly seen 3. Surgery in ill patients on intravenous for 1-2 weeks - especially prostate surgery, and surgery on particularly if also on antibiotics which kill the cancer patients bacterial flora in the intestine. 4. Immediate Hemolytic Transfusion Reaction - Eg. ABO incompatibility 2. New born (Hemorrhagic Disease of Newborn) – 5. Malignancies prevented by routine vitamin K - mainly prostate Ca., promylelocytic leukemia 3. Malabsorption As mentioned previously, the multiple hempostatic 4. Chronic billiary tract obstruction abnormalities of liver disease closely mimic D.I.C and 5. Oral anticoagulants – vitamin K antagonists diagnosis is very difficult in jaundiced patients. There Patients who are at risk of developing Vitamin K are also other conditions which present with deficiency should receive prophylactic vitamin K, fragmentation hemolysis and thrombocytopenia (eg. usually by parenteral route. Thrombotic thrombocytopenic purpura or T.T.P., and Patients who have established vitamin K deficiency should receive parenteral vitamin K (5-10 Hemolytic-Uremic Syndrome, or HUS) where fibrin mg I.V) but this requires up to 8 hours to correct the formation (thrombin activation) has not occurred. deficiency and up to 24 hours for this to be complete. MANAGEMENT OF D.I.C INVOLVES: If the patient is bleeding and one cannot wait for complete correction of the INR by the vitamin K then 1. Aggressive treatment of underlying cause - evacuation of uterus for obstetrical plasma infusions can provide immediate but temporary complications correction; 2-4 or more units, of FFP, are usually - broad spectrum I.V. antibiotics for septicemia required to correct the prolonged INR/PTT. 2. Replacement of deficient (consumed) factors and platelets LIVER DISEASE - FFP or possibly cryoprecipitate for coagulation All coagulation factors except for factor VIII defects are produced in liver, so severe liver disease is - Platelet concentrates for thrombocytopenia associated with a decrease in most factors. Often - Some clinicians also advocate heparin to stop platelets are also reduced due to hypersplenism and the activation of coagulation, but most do not since fibrinolysis is also increased the multiple since these patients frequently bleed much abnormalities (prolonged INR, P.T.T, T.T., decreased more when heparinized. It is more likely to be fibrinogen, platelets and increased FDP) mimic those ordered for patients who have subacute or seen with D.I.C chronic D.I.C. often when the underlying Except in uncomplicated obstructive liver cause cannot be quickly controlled (eg disease the coagulation defects are not corrected by promyelocytic leukemia, prostate cancer). parenteral vitamin K. For temporary correction, during times of significant bleeding, infusions of FFP may be required (again usually 4 or more units are needed to DILUTONAL COAGULOPATHY During the management of serious bleeding completely correct the coagulopathy). If thrombocytopenia is moderate to severe then platelet problems with massive transfusions (e.g. Greater than 50% of blood volume exchange in 24 hours) there is a transfusions may also be used. decline in coagulation factors since the replacement products (packed red cells, crystalloid or albumin DISSEMINATED INTRAVASCULAR solutions) do not contain coagulation factors. If stored COAGULATION (D.I.C) plasma is also used it will lack labile factors (V and This occurs when there is a generalized VIII) activation of the coagulation factors with the final Therefore it is appropriate to monitor INR and elaboration of thrombin turning fibrinogen to fibrin. It P.T.T in massively transfused patients, or preferably to results in fragmentation of RBC's, consumption of coagulation factors and platelets, deposition of fibrin supply FFP judiciously (e.g. 1 unit FFP for each 1-2 equivalent units of stored plasma, 5% albumin or and stimulation of secondary fibrinolysis. As a result crystalloid) after a total blood volume exchange has there is anemia, hemolysis, thrombocytopenia, occurred in a short period to prevent the development coagulation deficiencies (prolonged INR, P.T.T. , T.T., of a coagulopathy. Platelets are also not present, or decreased fibrinogen), and increased FDP. functionless, in most blood components, but significant CAUSES thrombocytopenia from dilution during massive 1. Pregnancy-related transfusion usually takes much longer to develop than - abruptio placenta, retained placenta

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does the coagulopathy. Platelets are also not present, or Unexplained neonatal thrombosis functionless, in most blood components, but significant Family history of thrombosis thrombocytopenia from dilution during massive Recurrent fetal loss transfusion usually takes much longer to develop than does the coagulopathy. Platelets are also not present, or functionless, in most blood components, but significantTypes of thrombophilia: 1. Hereditary thrombocytopenia from dilution during massive transfusion usually takes much longer to develop than b. Natural anticoagulant deficiencies: does the coagulopathy. The final amounts of Activated protein C resistance (Factor V replacement platelet and coagulation factors will be leiden) 25 – 40 % determined by the clinical status of the patient eg. Age, Protein C deficiency 5% underlying conditions etc. Protein S deficiency 5% AntithrombinIIIdeficiency 5 %

Venous thrombo-embolic disorders

Deep venous thrombosis (DVT) affects mainly the c. Dysfibrinolytic disorder: veins in the lower leg and the thigh. It involves the Dysplasminogenemia formation of a clot (thrombus ) in the larger veins of tPA deficiency the area. This clot may interfere with circulation, and it may break off and travel through the blood stream PAI dysregulation (embolize). A resulting embolus can lodge in the alpha-2 microglobulin deficiency lungs, heart, or other area, causing severe damage to that organ. d. Others: A pulmonary embolism (thromboembolism) occurs G20210A prothrombin gene mutation when a blood clot, generally a venous thrombus, Dysfibrinogenemia becomes dislodged from its site of formation and embolizes to the arterial blood supply of one of the Homocysteinemia lungs.

Pathogenesis:

Thrombosis is most often due to combinations of Virchow’s triad:

• •

Problems with the vessel wall (i.e. atherosclerosis) Problems with the blood flow (i.e. sluggish or turbulant flow) Problems with the blood contents (i.e. low natural anticoagulant levels)

2. Acquired a. Antiphospholipid antibody syndrome b. Malignancy Hematological : . PNH . Acute promyelocytic leukemia . PNH

-

. Pancreatic . Gastric . Mucin secreting c. Nephrotic syndrome Venous thrombosis is more predominantly a fibrind. Surgery and immobolization dependent process involving the pro-coagulant cascade Normal ranges: of proteins. In contrast, arterial thrombosis is more Protein C 70 – 140 % predominantly a platelet-dependent process. These Protein S 60 – 140 % different pathophysiologies influence the efficacy of AT-III 80 – 125 % treatment strategies. APTT/APC < 2.2 males

•

THROMBOPHILIA [HYPER COAGULABLE STATE] Who should be investigated? Venous thrombosis < 40 years Arterila thrombosis < 30 years Recurrent thrombosis (more than one episode) Thrombosis at unusual sites (Buddchiari, Portal vein, Sagital sinus)

Oncologic:

APCR

APTT <1.9 females Secondary causes of Protein C deficiency: Warfarin therapy Liver disease DIC Secondary causes of Protein S deficiency: Liver disease

DIC Nephrotic syndrome

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Pregnancy Secondary causes of AT-III deficiency: Heparin therapy

Nephrotic syndrome DIC Liver disease

computed tomography (spiral CT). Advantages are clinical equivalence, better access for patients and the possibility of picking up other lung disorders from the differential diagnosis in case there is no pulmonary embolism

Treatment of deep vein thrombosis:

Unfractionated Heparin : intravenous bolus dose 80 u/kg followed by continuous infusion DVT: leg pain, tenderness, swelling (edema), increased at a rate of 18 u/kg/hr., then adjust dose warmth, and change in skin color (redness) according to APTT. The presence of deep venous thrombosis may be Alternatively, start LMW heparin, dose per detected by: body weight and no need for laboratory • venography of the leg monitoring. • doppler ultrasound - Start coumadin within 24 hour of starting heparin, • plethysmography monitor INR that need to be maintained at 2 – 3. Once • positive D-dimer test this range achieved for at least 2 days you may discontinue heparin. Warfarin therapy often requires frequent dose adjustment and monitoring of the INR . PE Signs of PE are sudden-onset dyspnea, tacypnea, chest In proximal DVT and PE, INR between 2.0 and 3.0 are generally considered ideal. If another episode of DVT pain of "pleuritic" nature, cough hemoptysis, and in or PE occurs under warfarin treatment, the INR severe cases, hypotension, shock, loss of consciousness, and death. Although most cases have window is often increased to 3.0-4.0 (unless there are no clinical evidence of deep venous thrombosis in the contraindications). legs, findings that indicate this may aid in the Continue with warfarin therapy for at least 6 diagnosis. months. or "lifelong" if there have been ECG may occasionally show right heart strain (the previous DVTs or PEs. "S1Q3T3 pattern). The Gold standard for diagnosing pulmonary Treatment outcome: embolism (PE) is still pulmonary angiography. In most - DVT recurrence: during heparin therapy< 5 % of the cases, however, when PE is suspected on the during warfarin therapy < 2 % basis of shortness of breath and chest pain, the during the first year 2 – 5 % following scans may confirm the presence of an Most recurrence have hereditary or acquired embolus: thrombophilia "Ventilation-perfusion scan" (or V/Q scan), which 20 % of thrombophilic patients have recurrence in shows that some areas of the lung are being ventilated 1 year but not perfused with blood (due to obstruction by a > 50 % of thrombophilic patients have recurrence clot). Increasingly, the V/Q scan is being replaced with in 5 years

Symptoms and Investigations:

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ANTITHROMBOTIC AGENTS

2. IV.Bolus: 5,000 – 10,000 u Q 4th P.T.T just prior to

HEPARIN

next dose should be therapeutic

Structure – A potent organic acid which is a mixture of sulphate containing mucopolysacchiarides 3. Prophylaxis: 5,000 u q.8h or q.12 h., sc for surgical cases start on admission, or 2h. with molecular weights between 3,000 – 30,000 strong preoperative and continue q. 8-12 h. postoperative; negative charge, prepared from animal tissues. peak P.T.T 2-3 hours after injection should be Mechanism of Action – combines readily below the therapeutic range. with plasma proteins, notably Antithrombin III Note: The P.T.T is also prolonged by warfarin (heparin co-factor). Heparin markedly accelerated the derivates. Perform a CBC count every three days while inhibition action of AT III on thrombin and Factors on heparin to avoid heparin induced anemia or XII, XI, IX and X. Heparin also activates lipoprotein thrombocytopenia. lipase. It does not cross the placenta. Administration – continuous intravenous infusion or intermittent bolus and subcutaneous (NOT Low-Molecular-Weight Heparin INTRAMUSCULAR) Onset – I.V. – immediate maximum effect; s.c. – gradual effect and maximum 2-3 hours Low-molecular-weight heparin is a relatively new Duration of Effect – mean half life is 60 class of anticoagulants that are derived from standard minutes in normal; shortened with extensive heparin through either chemical or enzymatic thrombosis and pulmonary embolism; prolonged depolymerization. Whereas standard heparin has a slightly in renal failure. molecular weight of 5,000 to 30,000 daltons, lowDegradation and Excretion – Degraded in molecular-weight heparin ranges from 1,000 to 10,000 the liver in large doses, some is taken up by R.E.S and daltons, resulting in properties that are distinct from a small amount may remain unbound in the plasma. those of traditional heparin. Antidote – Protamine sulphate – I.V. – slowly; effective immediately 10 mg for 1,000 units Heparin; Mechanism of Action: 100 mg. maximum at one time; decrease dose according to time elapsed since Heparin given to allow -Binding of LMW heparins to antithrombin accelerates for half life decline in the infused heparin. the inhibition of coagulation factor Xa and thrombin Major Uses – thromboplebitis; pulmonary embolism; artificial pumps and filters (i.e renal dialysisabout 1000-fold -Unlike unfractionated heparin, which blocks thrombin and bypass pumps) and factor Xa equally well, LMW heparins primarily Contraindications – active bleeding sites – i.e. GI tract; known hemostatic defect i.e. factor VIII block coagulation factor Xa deficiency; recent CNS surgery; thrombocytopenia; severe hypertension. Problems – Bleeding; uncommon, rarely fatal; Advantages of Low-Molecular-Weight occasionally produces thrombocytopenia; antiplatelet Heparin drugs enhance bleeding and should not be used (i.e. Aspirin) The clinical advantages of low-molecular-weight Monitoring – Heparin prolongs various heparin include predictability, dose-dependent plasma clotting test times (anticoagulant effect) in direct levels, a long half-life and less bleeding for a given proportion to the amount of heparin in the sample antithrombotic effect. Furthermore, immune-mediated tested. P.T.T (activated partial throboplastin time); thrombocytopenia is not associated with short-term use therapeutic range is 60-80 seconds; dependent on of low-molecular-weight heparin, and the risk of laboratory method and should be approximately 1½ - 2 heparin-induced osteoporosis may be lower than the times control range. risk with the use of standard heparin. Low-molecularDosage and Control: weight heparin is administered according to body 1. Continous I.V: 5,000 u bolus I.V, then 280 weight once or twice daily, both during the high-risk u/hours in 5% d/W or saline, use hourly mini drip period when prophylaxis for DVT is recommended chamber (syringe pump better if available); check and also when waiting for oral anticoagulation to take P.T.T 2 x daily and adjust accordingly; if too low, effect in the treatment of DVT. The activated partial give 5,000 u bolus and increase drip rate. thromboplastin time (aPTT) does not need to be

monitored, and the dosage does not need to be

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adjusted. Since low-molecular-weight heparin is given a) mild INR increase – 1-2 mg Vit K po or SC subcutaneously, outpatient administration by the b) For severe hypoprothrombinemia alone – 5-10 mg patient, with or without the assistance of a visiting Vitamin K1 nurse or family member, is both possible and costc) If accompanied by bleeding – 25 mg. Vitamin K1 effective. + plasma Major uses – Prophylaxis + treatment of – thrombophlebitis, pulmonary embolism, embolic heart Preparation (trade name): disease i.e rheumatic mitral valve disease Treatment – follow Heparin therapy for the • Dalteparin sodium (Fragmin) above. • Enoxaparin sodium (Clexane) Contraindication – active bleeding sites, specially • Nadroparin calcium (Fraxiparin) GI; known hemostatic defet – i.e. Factor VIII deficiency; recent C.N.S surgery, unreliable patient or • Tinzaparin sodium (Innohep) no laboratory control; liver and kidney disease (relative); pregnancy; thrombocytopenia. WARFARIN DERIVATES: (COUMADIN) Problems Structure – A water-soluble derivative of 1. Enhance the Effect of Coumadin – decreased Coumeric Acid; Vitamin K absorption, i.e. malabsorption, Mechanism of Action – not clear; bound to pancreatic disease; decreased gut production of albumin; acts in the liver to block the synthesis of the vitamin K, i.e. broad spectrum antibiotics; Vitamin K dependent Factors (II, VII, IX, X), and, displacement of albumin binding site, i.e. therefore, interfere with both the intrinsic (II, IX and phenylbutazone. X) and extrinsic (II, VII, X) system – may block an enzyme regulating Vitamin K metabolism or may be a 2. Decrease the Effect of Coumadin – (require increased dosage of Coumadin) liver microcompetitive inhibitor of Vitamin K for specific sites on enzyme inducer, i.e. barbiturates. regular protein. Dosage and Control – 10 mg p.o. for 2-3 days Administration – by mouth; according to INR, and then a maintenance dose Onset and Duration of Effect – does not according to INR (usually about4 mg daily). The destroy circulating factors but prevent production; therefore dependent on half-life of the above factors warfarin dose should be administered at a consistent time of the day and the INR blood sample should be which range from 3 or 4 hours to 72 hours, prothrombin time may be therapeutic in 3-4 days but drawn at a consistent time of day. INR, therapeutic range: full therapeutic effect requires 3-5 days. a. Simple Venous Thromboembolism INR of 2.0 – Degradation and Excretion – not absolutely 3.0 clear, probably the liver; degradation products excreted b. Arterial and Valvular Prosthesis INR of 3.5 – 4.5 in the urine. Frequency should be daily initially, lengthening to one Antidote – Vitamin K1 (p.o. or I.V. ; takes a weekly or at the most every other week once wellminimum of 8-12 hours for effect controlled.

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PROBLEMS FOR TUTORIALS

factor concentrates after thorough training by the hemophilia center staff. Now he is bright, very active HEMOSTASIS / THROMBOSIS boy who seems to seek out precisely those games and 1. A YOUNG BOY WITH SWOLLEN KNEE stunts from which his parents have tried to discourage his participation. His infusions are at times difficult A 1-year old infant was noted to ooze intermittently because he squirms. To avoid them he does not from a circumcision, and his thigh had become swollenconsistently inform his parents until pain is severe, or and tense following a vitamin K injection. He was born he begins to limp noticeably. A re-view of a year's at term to a 26-year old gravida IV para III woman infusion records reveals he had 68 bleeding events following an uneventful pregnancy. Delivery was requiring 78 infusions, mostly involving knees and vaginal over a small midline episiotomy, and he cried ankles. A disproportionate number involved his right vigorously. The mother's health had always been ankle and were repeated the next day because of excellent, and she denied any abnormal bleeding or persistent pain and swelling. For the most part, pain bruising. Her family history was likewise unrevealing. began in school and his parents infused him at home, Before the infant was transferred to the neonatal often hours later. In the clinic he appeared to walk special unit, the following studies returned: normally, but his right ankle was swollen, nontender, but boggy to palpation. Its range of motion was Hemoglobin 167g/L slightly decreased. An X-ray revealed moderate Hematocrit 52% demineralization of the adjacent bones but no Platelet count 339 x 109/L narrowing of the joint spaces, subchondral cyst White blood cell count 19.4 x 109/L formation, or bony spurs. Pertinent laboratory studies Prothrombin time (PT) 30 sec (nl 10-16 sec) showed only mildly elevated ALT: 65 U; AST: 72U Activated partial thromb- 115sec (nl 31-55 sec) (normal levels less than 40 U/mL) oplastin time (aPTT) 1. What do you make of this follow up On examination, the infant was pink, easily aroused, information and what would you recommend and had good muscle tone. Bright red blood discolored to this patient the circumsion dressing. The left thigh was swollen, its 2. What further tests would you order circumference measurably larger than the right. A repeat hematocrit several hours later was 37%, the 2. A BLEEDING YOUNG WOMAN aPTT was 105 sec and the PT was 16 sec. Coagulation studies were as follows: factor XII: 60% (nl 13-93%); Brenda, a 14-year-old girl, came to the emergency factor XI: 45% (nl 10-66%); factor IX: 39% (nl 25room with 18 days of profuse vaginal bleeding and 91%); factor VIII: less than 1%(nl 40-180%); factor with pallor and weakness. This was her second XIII screen: normal; fibrinogen: 2.55 g/L (nl 1.67-4.0) menstrual period, and because it was painful, she had taken several aspirins. She denied any recent sexual Questions: activity and said she had always been in perfect health. 1. What is your interpretation of the Lab A age 12, however, she had bled so much after a tooth findings? extraction that her dentist had to pact and suture the 2. How the presentation is different in those with bleeding site. Like one of her younger brothers, she Platelet dysfunction? bruised easily. Her father had once required a blood 3. How would you manage this patient? transfusion after a tonsillectomy but had an uneventful 4. What would be your advice for the parents ? postoperation course following a herniorrhaphy. Two months later this mother brought her baby to the Her blood pressure was 110/60 recumbent and 90/50 emergency room because he had cried inconsolably all sitting up; resting pulse was 100. She was dizzy and night. By that age he had attained the expected anxious when she was upright. Her abdomen was soft milestones and was generally an active, happy baby. and nontender; and no masses were felt. On bimanual The mother denied that he had any fever but noted that pelvic examination, the uterus was midline, anteverted he did not use one arm at all. Any attempt to move it and normal in size; the adnexae were soft and caused him to cry. On examination, none of his joints nontender. There was much blood flowing from an or muscles was swollen or tender; but trying to bend intact cervical os to the vagina. one elbow made him cry. Within an hour of infusing factor VIII concentrate, all symptoms subsided. The laboratory findings were as follows: Hemoglobin 60g/L At age 6 years, the patient was seen at an annual MCV 85 fL multidisciplinary clinic for routine evaluation. At age WBC 16.4 x 109/L, with normal differential 5, his parents began home care, injecting him with

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aPTT 39 sec (nl 33-27 sec) PT 14 sec Pregnancy test negative

Thrombin Time (TT): 20 (control 14 s) Fibrinogen: 1.7 g/L (N2 – 4) D- dimer 4000 (N < 500)

She was admitted to the hospital and received one unitQuestions: of packed red blood cells and two 25-mg doses of 1. Comment on the results of the tests? Comment conjugated equine estrogen, with some improvement. on the peripheral blood film below. She later received a progestational agent. She was 2. What is your presumptive diagnosis? discharged on medroxyprogesterone for 10 days. On 3. How would you manage this patient? next visit, a bleeding time was 12 min (nl less than 9 min), and the following clotting studies were obtained: aPTT PT Factor XII Factor XI Factor IX Factor VIII:C Factor VIII:Ag Ristocetin cofactor

38.5 sec (nl 27-37 sec) 14 sec (nl 11-14 sec) 60% (nl 52-164%) 72% (nl 67-127%) 73% (nl 55-163%) 38% (nl 40-149%) 35% (nl 40-149%) 45% (nl 50-150%)

4. A BLEEDER BABY BOY

A 1-year-old boy was referred from a dentist to the emergency unit after failing to control a gum bleed, Questions: which took place at a new teething site. The mother 1. What is the clinical presentation suggests mentioned that the child also bled profusely following 2. How do you interpret the lab data a circumcision, which was done at the age of two 3. How would you manage this patient months. Apart from these two incidents, the child has 4. Comment on inheritance mode been generally well and growing normally. The boy was the second child in the family, has a 5 years old sister who has no medical problem. The parents were 3. FEVER AND COAGULOPATHY non- consanguineous but the mother mentioned that 3 years old boy was brought to the emergency unit by she has a brother who is a “bleeder”. his mother. The child has been unwell for the past three weeks with fever and loss of appetite. He has been On examination, the child was healthy, a febrile, diagnosed to have an upper respiratory tract infection oozing blood from a teething site. He also had few by the family doctor and was given Amoxill but bruises on his shins. Examination of the chest, without any improvement. Two days before abdomen was normal presentation, the mother noticed the appearance of pinpoint reddish spots on his shins and arms. Investigations revealed: The boy has been generally well, received all his WBC: 6.9 x 109 /L vaccinations and does not have any known illness or Hb. 120 g /L allergies. Platelets: 345 x 109 /L On examination, the boy was fully conscious but PT : 15 s (N 10 – 14s) irritable. Temp: 39ºC. There was a big bruise on his APTT : 55 s (N 25 - 35 s) forehead and petechial hemorrhages on his legs, arms Fibrinogen 3.2 g/L and abdomen. Examination of the neck revealed the D-dimer: 200 μg/ml (N <500) presence of two small lymph nodes in the cervical Bleeding time 5 min (N 2-7) region. Examination of the chest and heart was normal. Question: Examination of the abdomen was normal apart from 1. What is your presumptive diagnosis? feeling a splenic tip. 2. How would you prove this diagnosis? 3. How would you manage this patient? Investigations showed: WBC: 40 x 109 /L 5. BLEEDING GUMS AND BRUISING Hb.: 105 g/L Normal Male: 140-180, Female: 120A 23- year woman came to the emergency room 140 complaining of bruises over the body and bleeding Platelets: 25 x 109 /L N 150 - 400 gums for the preceding 36 hours. The patient never has Prothrombin time (PT): 20 sec (control 13 s) / INR:2 APTT: 60 (control 38 s)

never had easy bruisability, epistaxis, gum bleeding, or bleeding into the joints. Menarche was at age 13 and

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menses have been normal. The last menstrual period was 16 days prior to admission. And was normal in amount and duration. The patient had several dental extractions at age 17 and oozed for 12 hours thereafter. There has not been excessive bleeding with minor trauma. She has not had surgery or pregnancies. Family history is negative for bleeding disorders.

Examination reveals a respiratory rate of 26/min, HR 110/min, BP 110/60. The right calf was plethoric, swollen and tender. The reminder of the examination, including the chest examination, was normal

On physical examination the patient is a welldeveloped young woman without pallor or jaundice. Vital signs are normal. Fundoscopic examination is unremarkable. There is oozing of the gingivae with several small hemorrhagic bullae on the buccal mucosa. There is an ecchymoses and oozing in the right antecubital area secondary to venipuncture and there are several ecchymoses and multiple petechiae on both lower extremities. There is no palpable adenopathy or splenomegaly. The remainder of the examination is normal.

Investigations: CBC HB RBC Count Hct MCV MCH MCHC RDW WBC Platelets Count 280

Laboratory Data

Coagulation Screen APTT 26 seconds PT 11.4 seconds INR 1.0 Fibrinogen 2.5 g/L

PT 13 / 12 –second control INR: 1 APTT / 33 –second control 30 second WBC 6x109/L – normal differential HB 125 mg/L Platelets 8,000/mm3

A Doppler ultrasound of the right leg revealed thrombus in the popliteal and superficial femoral vein.

Specific Tests Test

121 g/L 4 x 1012/L 0.41 85 fl 31 pg/L 340 pg/L 13 12 x 109/L x 109/L

Results

Normal

Questions: 1. What dose the combination of bruising and oral ATIII 0.9 0.75 – 1.15 mucosal bleeding implies? What dose the negative Protein S (free) 0.75 0.50 – 1.50 clues in the history suggests? Protein S (Total) 1.10 0.75 – 1.20 2. Based on the history what is your differential Protein C Activity 0.12 0.50 – 1.75 diagnosis? Protein C Antigen 0.15 0.65 – 1.50 3. Looking at the CBC results, what is the next APCR Ratio 2.8 >2 immediate test you would ask for? What dose the normal INR and APTT results imply? Questions 4. Considering the low platelets count, what relevant 1. Discuss the investigations of suspected deep piece of history you would ask the patient? And venous thrombosis and pulmonary embolism what are the other relevant tests you would ask What conditions or situations may have for? predisposed to this event? 5. What is your differential diagnosis of thrombocytopenia in this patient? Given the most 3. What are the causes of hypercoagulable state? 4. Discuss the management of this patient under the likely diagnosis how would you manage this following headings: patient? Anticoagulant therapy

2.

Monitoring therapy

6. A YOUNG PATIENT WITH SUDDEN Family study SHORTNESS OF BREATH A 24-year-old female university student presented to 7. OFTEN MISSED BLEEDING PROBLEM the emergency room complaining of a sudden onset A 34-year old woman was seen by a gynecologist for left sided pleuritic chest pain and Shortness of breath tubal ligation. During the interview, she described a of one-hour duration. She admitted to having a painful lifelong problem with easy bruising with minimal swollen right calf of several days duration. She has trauma. She also described the frequent nosebleeds as recently returned from a summer holiday in Florida. a child and heavy menstrual periods, particularly in the She had been taking the oral contraceptive pills for 6 last two years. months. She has a younger brother with a history of deep venous thrombosis. Her father has taken warfarin for many years. Her mother and 3 siblings are well.

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Physical examination was entirely normal, except for a few small bruises on her legs. There were no petechiae. Laboratory Investigations Hemoglobin 130 g/L WBC 7.9 x 10 9/L Platelet count 280 x 109/L P.T.T 47 seconds Thrombin Time 9/9 seconds Bleeding time 12 minutes INR 1.0 Questions: 1. List 2 additional points in the history which you would require 2. What is the most likely diagnosis? 3. How is this disorder inherited? 4. The patient is booked for tubal ligation a. What precautions would you advise her about daily lifestyle? b. Which of the following would be most appropriate before the operation or post-operatively i. FFP ii. Cryoprecipitate iii. Factor VIII concentrate iv. None of the above

c. If the bleeding progressed is there anything

you could prescribe to correct the coagulation problem more quickly?

9. ALCOHOLIC AND COAGULOPATHY A 53 year old formed alcoholic and previously been investigated during a G.I. bleed and was found to have cirrhosis and esophageal varices. She was brought to the Emergency Room by friends who had found her lying on the floor of her apartment. In the Emergency Room she vomited "coffee-ground" material, and had a melena stool. On examination, her pulse was 100/minute and blood pressure was 106/70 supine. She had mild scleral icterus, spider nevi on her face and chest, moderate splenomegaly (4 cm below left costal margin) and mild ascites. The liver was palpable. Laboratory Investigations: Hemoglobin 84 g/L MCV 100 fL MCHC 320 g/L WBC 3.6 x 109/L Platelet count 70 x 109/L INR 4.0 seconds P.T.T 54 seconds Questions: 1. List 3 possible causes for the anemia? 8. POST OPERATIVE DVT Four days after a left nephrectomy, a 45 year old man 2. List 3 possible causes for the thrombocytopenia. 3. Explain the elevated INR and P.T.T. developed a deep vein thrombosis in his left leg. He had no respiratory symptoms. The foot of the bed was 4. The intern orders: a. bleeding time – is this a reasonable elevated and he was given IV injection of Heparin, order 5000 units, followed by a continuous IV heparin 5. Discuss your management regarding infusion at 1000 units per hour. Later on his a. Initial I.V. order anticoagulation was changed to coumadin orally. b. The anemia c. The thrombocytopenia Questions: d. The coagulation defect (2 points) 1. List 3 techniques which might have helped prevent the DVT 10. FEVER POST SPLENECTOMY 2. The intern orders "Coumadin 10 mg daily", what is A 60 year old man was admitted to hospital with a wrong with this? three day history of fever, rigors, cough and yellow 3. The intern orders "INR daily", what is wrong with sputum and pleuritic left lower chest pain. He had been this order? previously been healthy except for a previous After 10 days of coumadin therapy, he splenectomy 12 years before following a traumatic complained of nausea, and faintness. He rupture of his spleen in a farm accident. On had a large melena stool. He was pale, examination he was very ill with a high fever and signs clammy and perspired profusely. Pulse of pulmonary consolidation in the lower lobe of his left was 110/min and regular. Blood pressure lung. Pulse was 140/minute and blood pressure 130/60. was 95/96 with significant postural drop. Hemoglobin was 110 g/L., (down from his He had many petechiae and bruises on his trunk and extremities. last known Hb of 130 g/L. three days Laboratory Investigations: earlier) INR = 6.1 Hemoglobin 116 g/L 4. Describe your management under the following WBC 15 .5 x 109/L headings: .68 neutrophils a. Amount of coumadin you would prescribe? .16 bands b. What medication would you order, how much .02 metamyelocytes and by what route? .01 myelocytes

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.13 lymphocytes RBC fragmentation ++ Howell Jolly bodies + Platelet count 26 x 109/L Reticulocyte count 60 x 109/L INR 3.5 seconds P.T.T 80 seconds Thrombin Time 18/9 seconds Fibrinogen 0.5 g/L

5. After three weeks there has been little response to

treatment, and splenectomy is advised; what chance is there of complete remission of the thrombocytopenia with splenectomy? – 50%, 80%, 100% 6. What is the main long-term risk of splenectomy? What could you do in an attempt to avoid this complication? What is the role of IVIgG in this disease?

Questions: 1. Give a brief explanation for: a. abnormal WBC differential b. RBC fragmentation c. Howell-Jolly bodies d. Thrombocytopenia e. Normal reticulocyte count f. Coagulation defects 2. Discuss your management under the following headings: a. Thrombocytopenia – type, amount and rate of blood products; expected response b. Coagulation defect 11. BLEEDING WITH SEVERE

THROMBOCYTOPENIA

A 25-year old woman with no previous history of abnormal bleeding or bruising visited her doctor after 3 week history of increasing spontaneous bruising. Her last menstrual period, two weeks before was normal, but she did have a prolonged nosebleed two days ago. Her only medications included multivitamin tablet, occasional diazepam for sleeping, and aspirin tablets for headaches (her last aspirin was three days ago). Her doctor noticed some crusted blood in both nostrils, a few hemorrhaging bullae on her tongue and buccal mucosa, and numerous petechaie and bruises on her extremities. She was afebrile, and appeared otherwise healthy. Laboratory Investigations Hemoglobin 130 g/L MCV 88 fl MCHC 340 g/L WBC 6.5 x 109/L Differential normal Platelet count 10 x 109/L Required Questions: 1. What is the most likely diagnosis? 2. Should the patient be treated at home or in hospital? 3. What additional test or procedure would usually be done? 4. What medication would you initially prescribe?

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