Haematology

FBC

• Red Cells: Hb, MCV• WBC: cell type and presence of abnormal or

immature forms• Platelets

Anaemia

• Hb• MCV

Microcytic Normocytic MacrocyticIron defThalessaemiaACD

Acute blood lossHaemolyticMarrow infiltrationACD

B12FolateAlcoholReticulocytosisHypothyroid

Haematinics• Deficiencies can cause anaemia:

IronB12Folate

Duodenum

Terminal ileum

Duo and jej

Iron absorption

Iron deficiency

Intake vs Utilisation

PubertyDiet

Malabsorption not common

• Blood loss

• Atrophic tongue!

IDA vs ACD

Iron parameter IDA ACD

Serum iron

TIBC

Serum ferritin

Serum sTfR N

B12 absorption

B12 deficiency

• Pernicious anaemia – autoantibodies• Neurological problems• Beefy tongue!• Schilling test – radioactive; im. With IF

Not commonDiet RARE

Small bowel diseaseReduction in IF

Intake vs Utilisation

Folate defiency

Intake vs Utilisation

• Neural tube defects• NO neuropathy

PregnancyLactationAdolescence

Excess turnover of cells:Haemolysis, malignancy

Diet COMMON

Coeliac diseaseAntifolate drugs

Haemolytic anaemia

• Intravascular vs Extravascular : bilirubin, LDH• Polychromasia, reticulocytosis

Hereditory spherocytosisThalassaemiaSickle cell anaemiaG6PD deficiencyPyruvate kinase deficiency

Damage to red cell membraneMalariaOxidant damage

Aquired vs Inherited

G6PD deficiency

• X-linked • Inability to detoxify oxidising agents • Heinz bodies, spherocytosis

Polycythaemia

True Apparent

Primary:

PRV

Secondary

Hypoxia: chronic smoking

high altitude lung disease

Excess erythropoietin

Dehydration

Production byBone marrow

Cell loss/destruction

Polycythemia

1. Haematinic deficiency2. BM infiltration/failure

• Haemopoietic cancer• Metastatic cancer• Aplasia

Shortened survival bleeding haemolysis

•Acquired (environment)•Immune•Microangiopathic•Malaria•**PNH

• Inherited •Haemoglobin•Enzyme•Membrane

RBC

Reduced cell counts

Three cell lines reduced/involved• Think bone marrow failure/infiltration (but don’t forget Vit B12/folate deficiency)

One cell line reduced• Think increased destruction/loss (but don’t forget iron deficiency in low RBC/Hb)

PlateletsProduction byBone marrow

Cell loss/destruction

Primary: CMLSecondary: infection, inflammation, pregnancy, post-splenectomy

1. Drug induced2. BM infiltration/failure

• Haemopoietic cancer• Metastatic cancer• Aplasia

Immune mediatedHypersplenismDisseminated intravascular coagulation

• AML vs CML• ALL vs CLL

ALL• Clinical features:

- bone pain- hepatomegaly- splenomegaly- lymphadenopathy- thymic enlargement- testicular enlargemenrs- fatigue, lethargy, pallor, breathlessness (anaemia –

normocytic, normochromic)- fever and infection features (neutropenia)- bruising, petechia, bleeding (thrombocytopenia)

• Replacement of normal bone marrow by lymphoblasts

Bleeding disorders

Coagulation screen

What do you get?

Prothrombin time (± INR)Activated partial thromboplastin time (APTT)Thrombin time (TT)

Haemostasis screeningINR (Prothrombin Time)Measuresextrinsic & common pathwayCommon abnormalitywarfarinliver diseaseDIC

APTTMeasuresintrinsic and common pathwayCommon abnormalityheparinliver diseaseDIC haemophiliaTT (thrombin time)

Measuresfibrinogen&thrombin inhibitionCommon abnormalityDIC heparin

What you need to know• normal ranges for WBC, Hb, MCV, platelet count in

adults• If the WBC is abnormally high or abnormally low we

expect you to be able to work out whether it is the count of neutrophils, lymphocytes or eosinophils that is causing the abnormality in the total WBC

• We expect you know that there are variations in haematological normal ranges related to gender, age and ethnic origin

Questions

SBA

• What event is this?• When is it?• When are you getting

tickets?

White cells

• Neutrophilia: bacterial infections, inflammation, malignancy, necrosis, treatment with corticosteroids?

• Neutropenia: post-chemo, viral, adverse drug reactions eg. carbimazole

• Lymphocytosis: viral, lymphomas, chronic infections eg TB, chronic lymphocytic leukaemia

• Eosinophilia: parasite infection, atopic allergic, Hodgkin

EMQ• A Anaemia• B Lymphocytosis• C Lymphopenia• D Neutropenia• E Neutrophilia• F Pancytopenia• G Polycythaemia• H Reticulocytosis• I Thrombocytopenia• J Thrombocytosis

1. A patient with infectious mononucleosis.

2. A patient who has just started treatment with B12 and folatefor megaloblastic anaemia.

3. A patient with chronic renal failure.

4. A patient with chronic obstructive pulmonary disease.

5. A patient with disseminated intravascular coagulation.

SBA• A 61-year-old woman with pancytopenia, mild jaundice, and peripheral

neuropathy is found to have decreased serum levels of vitamin B12. Which of the abnormal cell morphologies listed below is most likely to be present in a smear made from her peripheral blood?

• A. Hypersegmented PMNs

• B. Large granular lymphocytes

• C. Oval microcytes

• D. Pelger-Huet neutrophils

• E. Plasmacytoid lymphocytes

SQA• A 16-year-old girl has a sore throat, enlarged tender cervical

lymph nodes, and low-grade fever for 3 days. In addition to erythematous pharyngeal mucosa and cervical lymphadenopathy, physical examination reveals mild splenomegaly. A complete blood count (CBC) shows an increased number of white blood cells with a lymphocytosis and many reactive lymphocytes.

• What is the most likely diagnosis?

• What laboratory tests would be helpful in confirming the diagnosis?

SQA• 3 year old girl referred with failure to thrive. • Hepatosplenomegaly. • Hb 5.1 (13.0-16.5)• MCV 58 (80-100)• WCC 9.1 x 109 (4-11 x 109)• Platelets 317 x 109 (150-400 x 109)• Bilirubin 38 (1-22) • AST (19-48)

SQA• 63 year old man presents with a left-sided TIA • Similar episode 1 week earlier. Results of FBC: • Hb 21.2 (13.0-16.5)• Haematocrit 0.61• WCC 15.3 x 109 (4-11 x 109)• Increased neutrophils and eosinophils• Platelets 897 x 109 (150-400 x 109)• Bilirubin 8 (1-22) • AST 30 (19-48)• Cholesterol 3.6 (0.1-1.6)

SQA

• 78 year old man• Hepatolsplenomegaly• Hb 10.1 (13.0-16.5)• WCC 227 x 109 (4-11 x 109)• Platelets 741 x 109 (150-400 x 109)• Uric acid 490 (110-420)

SQA

• 58 year old woman with pallor, decreased sensation in both legs below the knee, absent ankle jerk

• Hb 8.2 (13.0-16.5)• MCV 124 (80-100)• WCC 2.4 x 109 (4-11 x 109)• Platelets 102 x 109 (150-400 x 109)