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Hematology
2
INVESTIGATIONS:
Specific
BASIC
o CBC
Low Hb/Hct High RDW
Low MCV/MCH/MCHC
o PERIPHERAL BLOOD FILM
Microcytic & Hypochromic anemia
o BONE MARROW EXAMINATION
IRON STUDIES
o Serum Iron/Ferritin/Transferrin saturation is decreased
o TIBC & Soluble transferrin receptor(TfR) is increased
OTHERS
o RFTS/LFTS o Stool examination for ova, cyst & occult
o Urine for hematuria blood
MANAGEMENT:
Supportive
Specific
IRON SUPPLEMENTATION
1. ORAL
Ferrous sulphate
(200 mg TDS)
OR
Ferrous gluconate
(300 mg BD)
OR
Ferrous fumarate
2. PARENTERAL
Iron sorbitol
1.5 mg/kg (i.m)
OR
Iron dextran
(infusion of LMW)
OR
Iron sucrose
Transfusion
o Severe anemia
o Angina, heart failure or evidence of cerebral hypoxia
3
MEGALOBLASTIC ANAEMIA
INVESTIGATIONS:
Specific
BASIC
o CBC
Low Hb/Hct/count High MCV > 120 fL
o PERIPHERAL BLOOD FILM
Neutrophil hypersegmentation Oval macrocytosis
o BONE MARROW EXAMINATION
Increased cellularity increased iron in stores
OTHERS
o Serum Ferritin is ELEVATED *** o Heptoblobin is decreased
o LDH/Bilirubin is raised
SPECIFIC
o Folate levels o Schilling test
o Serum B12 /Methylmalonic acid o FIGLO test
o Anti-parietal /Anti-intrinsic factor ABs
MANAGEMENT:
Specific
HEMOLYSIS
Increased
o Retics
o Indirect bilirubin
o LDH
Decrease
o Heptoglobin
4
INVESTIGATIONS:
Specific
BASIC
o CBC
Low Hb/Hct/count WBC/platelets are elevated
o PERIPHERAL BLOOD FILM
A reticulocytosis is present Sickle cells, target cells and features
of hyposplenism
OTHERS
o LDH/Bilirubin is raised o Heptoblobin is decreased
SPECIFIC
o Exposing red cells to a reducing agent (sodium dithionite)
o Hemoglobin electrophoresis
MANAGEMENT:
Supportive
Specific
VASO-OCCLUSIVE CRISES
o Aggressive rehydration o Adequate analgesia (which often requires
o Oxygen therapy opiates)
o Antibiotics
REGULAR TRANSFUSION PROGRAMME
o In severe aplastic crisis
o Cerebrovascular accidents in children or chest syndromes in adults
EXCHANGE TRANSFUSION
o In severe aplastic crisis/before surgery
HYDROXYUREA
o It increases Hb F level o To prevent recurrence
BMT (Allogenic)
5
ITP
INVESTIGATIONS:
Specific
BASIC
o CBC
Isolated Thrombocytopenia
o PERIPHERAL BLOOD FILM
Normal
o BONE MARROW EXAMINATION
Increased megakaryocytes
SPECIFIC
o Bleeding time is prolonged *** o Platelets antibodies (IgG/IgM)
o PT/PTT normal
OTHERS
o Rule out infections (HIV) o Connective tissue disorders (ANA/ds-DNA)
DDs:
Leukemia/Lymphoma DIC
Aplastic anemia SLE
MANAGEMENT:
Supportive
Specific
CLINICAL:
INVESTIGATIONS:
BASIC
o CBC
Hb: Normal/Low (normochromic & normocytic) Platelets: Low/Raised/Normal
TLC: Raised (>100 109/L)
o PERIPHERAL BLOOD FILM
Neutrophilia Elevated basophils/monocytes
Occasional blasts
o BONE MARROW ASPIRATE
Increase cellularity Increased myeloid precursors
SPECIFIC
o CYTOGENETIC & MOLECULAR TECHNIQUES
FISH/RT-PCR
Philadelphia chromosome = t(9:22) translocation = BCR-ABL fusion
Also used to monitor treatment response
o LEUKOCYTE ALKALINE PHOSPHATASE (LAP) SCORE
LAP Score is low in CML
OTHERS
o LDH & Uric acid are elevated due to increase cell breakdown
MANAGEMENT:
Chronic phase
1st Line
o Initial therapy
Imatinib (tyrosine kinase inhibitor)
2nd line
o Dasatinib/Nilotinib o Alpha interferon alone or combination
o Hydroxyurea with Ara-c
o Allogeneic BMT cures CML
DIAGNOSTIC CRITERIA:
CRAB
C=Calcium elevation (> 10.5 mg/dL)
R=Renal dysfunction (Cr > 2 mg/dL)
A=Anemia (Hb < 10g/dL)
B=Bone lesion (lytic lesion/osteoporosis)
INVESTIGATIONS:
BASIC
o CBC
Hb: Anemia Platelets: Normal/Low
TLC: Normal/Low ESR/CRP almost always raised ***
o PERIPHERAL BLOOD FILM
Rouleaux formation as a consequence of paraproteins
o BONE MARROW EXAMINATION
Plasma cell infiltration (> 10%) Amyloid may be present
SPECIFIC
o SERUM PROTEIN ELECTROPHORESIS & IMMUNOFIXATION
Monoclonal band M-spike
o 24 HRS. URINE ELECTROPHORESIS & IMMUNOFIXATION
Bence-Jones proteins
o SKELETAL SURVEY
X-ray Skull MRI Spine
o CYTOGENETIC/MOLECULAR TECHNIQUES
FISH
o PROGNOSIS
Beta2-microglobulin (2M) & s. albumin correlates with severity of disease
OTHERS
o RFTs (Urea & creatinine) o Hypercalcemia & Hyperuricemia
o Electrolytes o Total proteins/Albumin
DIFFERENTIALS:
Metastatic carcinoma
STAGING:
Specific
Before 70 years
o VAD (Vincristine/Adriamycin/Dexamethasone)
o Autologous Stem cell transplantation
After 70 years
o If healthy (Thalidomide) o If fragile (Melphalan)
APLASTIC ANEMIA
CAUSES:
PRIMARY
o Idiopathic acquired (67%)/Fanconis anemia
SECONDARY
o Chemical (benzene/toluene/OPs)
9
o Drugs (ABXs/DMARDs/Antithyroid/Anticonvulsant/Immunosuppressive)
o Insecticides/Ionizing radiations/infection (HIV, EBV, CMV, Hepatitis, Tuberculosis)
o PNH/Pregnancy
INVESTIGATIONS:
BASIC
o CBC
Pancytopenia Virtual absence of reticulocytes
o BONE MARROW EXAMINATION
Hypocellular/Aplastic bone Increase fat spaces
marrow
DDs:
Drugs
Bone marrow infiltration (Lymphoma/Ac. Leukemia/Myeloma/Myelofibrossis)
Megaloblastic anemia
Hypersplenism/Sepsis
SLE/PNH/DTB
MANAGEMENT:
Supportive
Specific
TRANSPLANTATION
o Allogenic BMT
IMMUNOSUPPRESSIVE TREATMENT (IF ABOVE 50 OR NO MATCHED DONOR)
o Antithymocyte globulin (ATG)/Antilymphocyte globulin (ALG)
o Cyclosporine/Tacrolimus
o Prednisolone