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 and
practical. Please, read the course objectives prior to starting the course to exactly know what
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 sequence
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

2
 INDEX
Sr.
Particulars Page No
No.
1 AIM & OBJECTIVES 5
2 COURSE TIMETABLE 7
3 APPROACH TO ANEMIA 10
4 HEMATOLOGY LABORATORY – NORMAL VALUES 13
5 PRINCIPLES OF HEMATOLOGY TESTS 14
6 SLIDES 17

MODULE I – DISORDERS OF RED BLOOD CELLS

4 NUTRITIONAL ANEMIA 20
5 MEGALOBLASTIC ANEMIA 22
6 FOLIC ACID DEFICIENCY 23
7 ALCOHOL AND HEMATOPOIESIS 24
8 APLASTIC ANEMIA 24
9 THE HEMOLYTIC ANEMIAS 25
10 BLOOD TRANSFUSION PRACTICE 28
11 PROBLEMS FOR TUTORIALS 31

MODULE II- WBC DISORDERS

12 LYMPHADENOPATHY AND SPLENOMEGALY 37

13 BENIGN LEUKOCYTE DISORDERS 38
14 HEMATOPATHOLOGY TESTING 40
15 HODGKIN’S AND NON-HODGKIN’S LYMPHOMAS 42
16 MYELOMA 46
17 LEUKEMIAS 48
18 PROBLEMS FOR TUTORIALS 51
19 MYELOPROLIFERATIVE DISORDERS 54

MODULE III & IV - HEMOSTASIS AND THROMBOSIS

20 BLEEDING DISORDERS 57
21 COAGULATION DISORDERS 61
22 ANTITHROMBOTIC AGENTS 66
23 PROBLEMS FOR TUTORIALS 68

3
 PROBLEMS FOR TUTORIALS
Sr. Page
Particulars
No. No

MODULE I – DISORDERS OF RED BLOOD CELLS

1 ANEMIA AND CONFUSION 31

2 ANEMIA AND CONFUSION IN ALCOHOLIC 31
3 ANEMIA AND RETICULOCYTOSIS 32
4 ANEMIA AND ARTHRITIS 32
5 ANEMIA AND HEART DISEASE 32
6 ANEMIA, WEAKNESS AND JOINT PAIN 33
7 ANEMIA AND MACROCYTOSIS 33
8 FEVER, ANEMIA AND RETICULOCYTOSIS 33
9 CHRONIC FATIGUE AND ANEMIA 34
10 A YOUNG PATIENT WITH RECURRENT BONY ACHES 35

MODULE II- WBC DISORDERS

1 ADULT MAN WITH LYMPHOCYTOSIS 51

2 A YOUNG FEMALE WITH NECK LUMP 51
3 POLYCYTHEMIA 51
4 ATYPICAL LYMPHOCYTOSIS 51
5 LEUKOCYTOSIS AND SPLENOMEGALY 52
6 PANCYTOPENIA 52
7 LEUKOCYTOSIS 52
8 LYMPHADENOPATHY 52

MODULE III & IV - HEMOSTASIS AND THROMBOSIS

1 A YOUNG BOY WITH SWOLLEN KNEE 68

2 A BLEEDING YOUNG WOMAN 68
3 FEVER AND COAGULOPATHY 69
4 A BLEEDER BABY BOY 69
5 BLEEDING GUMS AND BRUISING 69
6 A YOUNG PATIENT WITH SUDDEN SHORTNESS OF BREATH 70
7 OFTEN MISSED BLEEDING PROBLEM 70
8 POST OPERATIVE DVT 71
9 ALCOHOLIC AND COAGULOPATHY 71
10 FEVER POST SPLENECTOMY 71
11 BLEEDING WITH SEVER THROMBOCYTOPENIA 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.
Objectives
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.
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
Module II : White Blood Disorders
At the completion of the study of disorders affecting
white blood cells, the students shall be able to:
- 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
6
 HAEMATOLOGY COURSE
TH
5 YEAR STUDENTS 2005-2006

FIRST WEEK
Date Time Topic Lecturer/Department
P.M.

Saturday 2 – 2.50 Lecture: Approach to Anemia Pathology

17/12/05
Medicine
3 – 3.50 Case Study: Microcytic Anemia in a Pathology
young woman

Sunday 2 – 2.50 Case Study: Macrocytic Anemia and Medicine

18/12/05 confusion Pathology

3 – 3.50 Lecture: Hemolytic Anemia Medicine

(Immune & Hereditary)

Monday 2 – 2.50 Case Study: Normocytic Anemia and Medicine

19/12/05 Reticulocytosis Pathology

3 – 3.50 Lecture: Hemoglobinopathy Pathology

(Thalassemia/SCA)

Tuesday 2 – 2.50 Communication Skills Community Med.

20/12/05
3 – 3.50 Case Study: A young man with recurrent Medicine
bony aches & jaundice Pathology

4 – 4.50 Case Study: Unexplained Microcytic Medicine

Anemia in a Kuwaiti patient Pathology

Wednesday 2 – 3.50 Practical (Anemia) Pathology

21/12/05

SECOND WEEK

Page 7 of 72
 Saturday 2 – 2.50 Lecture: Acute Leukemia Medicine
24/12/05
Medicine
3 – 3.50 Lecture: Myeloproliferative Disorders
(CML/ET/PRV/MF)
Date Time Topic Lecturer/Department
P.M.

Sunday 2 – 2.50 Case Study: Medicine

25/12/05 Polycythemia in a smoker Pathology

3 – 3.50 Case Study: Medicine

Leukocytosis and Splenomegally Pathology

Monday 2 – 2.50 Lecture: Lymphoproliferative Medicine

26/12/05 Disorders
3 – 3.50 Medicine
Pathology
Case Study:
A young girl with neck lump

Tuesday 2 – 2.50 Communication Skills Community Medicine

27/12/05
3 – 3.50 Lecture: Blood Component Therapy Pathology

Wednesday 2 – 3.50 Practical (WBC disorder) Pathology

28/12/05

THIRD WEEK
Saturday 2 – 2.50 Lecture: Approach to patient with Medicine
Page 8 of 72
31/12/05 bleeding tendency

3 – 3.50 Lecture: Medicine

Thrombocytopenia/Hemophilia

Sunday 2 – 2.50 Case Study: Medicine

01/01/06 Woman with recurrent bleeding Pathology

3 – 3.50 Case Study:

Medicine
A bleeder child Pathology

Monday 2 – 3.50 MDS: Thrombosis Medicine

02/01/06 Pathology
Radiology

Tuesday 2 – 2.50 Case Study: Elderly man with Medicine

03/01/06 unexplained thrombocytosis Pathology

Medicine
3 – 3.50 A boy with painful knee
Pathology

Wednesday 2 – 3.50 Pre-exam Revision

04/01/06

FOURTH WEEK
Saturday HOLIDAY
07/01/06

Sunday 9.30 – HAEMATOLOGY ASSESSMENT Medicine

08/01/06 11.00 Pathology
AM

Monday HOLIDAY
09/01/06

Tuesday
10/01/06 HOLIDAY

Wednesday
11/01/06 HOLIDAY

Page 9 of 72
 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 the
appropriate tests for each group as follows:

Microcytic Anemia

F e r r it in

R educed N o rm a l In c re a s e d

I r o n d e f ic ie n c y H B e l e c t r o p h o r e s is A n e m i a o f C h r o n i c D is e a s e B o n e m a rro w
R i n g e d s id e r o b l a s t s

If HB electrophoresis is
Further investigations to normal then do alpha gene
find the cause are mapping
necessary

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
> 13 < 13
MCV/RBC count

Red cell
distribution width Elevated Normal
(RDW)
Anisocytosis
Morphology Poikilocytosis / Target cells
Elliptocytes

Page 10 of 72
 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 investigations of
Normocytic anemia.

R e t ic u lo c y t e s

In c re a s e d N o rm a l
D e c re a s e d

H e m o ly s is P o s t H e m o r r h a g ic B o n e M a rro w E x a m

I m m u n e v s . n o n - im m u n e A b n o rm a l N o rm a l

LDH/Bili/haptoglobin / Urine H y p o b l a s t ic RFT

hemosiderin I n f ilt ra t io n LFT
Coomb's test / Cold
D y s e r y t h r o p o i e t ic E n d o c r in e
agglutinins
F e r r it in
G-6PD / HAMS test / Osmotic
fragility
Polychromasia: expressed as high reitcs
count.

Fragmented RBC: schistocyte

Page 11 of 72
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 detailed
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 r ro w M o r p h o lo g y

M e g a l o b l a s t ic N o n - M e g a l o b l a s t ic

C lin ic a l D a ta L iv e r d is e a s e
S e r u m V it a m in e s M yxed e m a
M D S

N o d e fic ie n c y F o la t e D e f ic ie n c y B 1 2 d e f ic ie n c y

C o n g e n it a l D ie t S c h ilin g t e s t
D ru g s

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).

Page 12 of 72
HEMATOLOGY LABORATORY –
NORMAL VALUES
(Expressed in S.I. Units) Thrombin Clotting Time 9 – 11 sec
GENERAL HEMATOLOGY
Bleeding Time (IVY) 2 - 10 min
Test Male Female
WBC (x109/L) 4.0 – 10.0 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 0.50 = 1.5 u/Ml

Het (L/L) 0.40 – 0.5 0.3 - 0.4 Antithrombin III 0.8 – 1.2 u/mL

MCV (fL) 79.0 – 97.0 79.0 – 97.0 D-dimer 0 – 0.5

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) 0.0 – 7.0 0.0 – 15.0

(Wintrobe)

WBC Differential % Absolute (x 109/L)

NEUT 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

COAGULATION
Prothrombin Time (P.T.) 9 – 13 sec

International Normalized Ratio

(INR) < 13

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

Page 13 of 72
 PRINCIPLES OF HEMATOLOGY TESTS
HEMOGLOBINOMETRY, CELL COUNTS
AND INDICES SIZE
Normocytic - normal size (7.5u diameter)
Accurate electronic cell counting has largely replaced Microcytic - 6u diameter
previous counting chamber methods in most Macrocytic - 9u diameter
laboratories. These procedures may, or may not, be Anisocytosis - variation in size
automated but either way the parameters shown below
may be measured or calculated. SHAPE
Normal
WBC 9
x 10 /L • Biconcave disc
RBC x 1012/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 post-
normocytic 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
Spurr cells (echinocytes)
RED CELL MORPHOLOGY • Uremia, often artifact
Careful examination of a peripheral blood film is an
integral part of the initial laboratory investigation STAINING
confirming abnormalities detected by the Coulter Normachromic
Counter and seeking further clues to a specific
• Central pallor occupies one-third of RBC
diagnosis. At the same time, leukocytes and platelets
Hypochromic
should be assessed. Morphologic assessement
includes: • Decreased Hgb concentration (increased central
pallor).
Polychromasia
• Bluish-gray staining (indicates reticulocytes).

Page 14 of 72
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
DISTRIBUTION
Rouleaux
• Suggest immunoproliferative disease if extensive,
but lesser amounts common in many acute and
chronic diseases.
Autoagglutination
• Aggregates of RBC's due to cold agglutinations.
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).
Reticulocytopenia
• Suggests bone marrow depression, infiltration (eg
leukemia) or lack of erythropoietin, iron, etc.
Reticulocytosis
• Suggests hemolysis, blood loss, or response to
treatment.
If the reticulocyte count is reported as a percentage
and the patient is anemic, it should be converted to an
absolute count to assess effectiveness of reticulocyte
response.
BONE MARROW EXAMINATION
Most common indications for marrow aspirations
include
1. Assessement of cytopenias (anemia, neutropenia,
thrombocytopenia)
• Quantitative – eg. Hypocellular vs
hypercellular
• Presence of absence of precursor cells (eg.
Megakaryocytes)
• 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
allowing the red cells to sediment for one hour. In
normal persons the red cells sediment only 7 – 15 mm
(Wintrobe) during this hour but this rate increases with
many illness due to an increase in globulins eg
increased gammaglobulins (in myeloma, liver disease
or chronic infection) or acute phase reactants such as
haptoglobin and fibrinogen (in any traumatic,
infectious, inflammatory or neoplastic illness)
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
A careful evaluation of some of all of the previous
basic laboratory tests may be sufficient for a diagnosis
but often they serve, in conjunction with clinical
assessment, to direct specific investigations. These
investigations are described elsewhere. From this
point, careful selection of laboratory tests is essential.
Widespread ordering of many expensive and
unnecessary investigations without regard to basic test
results is wasteful and unrewarding.
SPECIAL CONSIDERATIONS FOR
PEDIATRIC PATIENTS
The following differences between adult and pediatric
patients require emphasis:
1. Level of Hemoglobin: At birth, the Hb is very
high but shortly after birth, there is decrease in Hb
(as well as Hematocrit and RBC count). The
lowest point is reached between 3 and 6 months
with Hb as low as 100g/L being normal. By one
year of age infants are often physiologically
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.
Page 16 of 72
 Basophilic stippling Burr Cells Elliptocytes

Heinz Bodies Helmet cells Hemoglobin C crystals

Howell-Jolly bodies Hypochromia Macroovalocytes

Malaria-Plasmodium Malaria- Plasmodium Megakaryoblast and

Falcipuram Vivax promegakaryocyte

Megalocytes-1 Megalocytes-2 Microcytosis

Pappenheimer bodies- iron Pappenheimer bodies-

stain Wright stain Poikilocytes

Page 17 of 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.

Page 19 of 72
NUTRITIONAL ANEMIA:
IRON ABSORPTION AND
METABOLISM
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
average daily iron loss in women during reproductive
life is about 2 mg.
IRON DEFICIENCY
Iron depletion without anemia is very common;
some degree of iron deficiency is present in
approximately 10% of most populations. Mild
anemia, due to iron deficiency, is frequently not
hypochromia and there are other causes of
hypochromic anemia other than iron deficiency; hence
hypochromic anemia and iron deficiency anemia are
not synonymous.
ETIOLOGY OF IRON DEFICIENCY
SPECIFIC CAUSES
1. Menstruation
The following points are important to assess the
severity of menstrual bleeding:
A. The number of pads used. Greater than 12
pads is considered abnormal.
B. If double pads are used, does blood soak
through?
C. Are there large clots?
D. How many days do the periods last; more than
five days being suggestive of increased
bleeding.
E. Pregnancy and Lactation:
2. Impaired Absorption of Iron
This is rarely a cause of iron deficiency except in
the presence of sprue or as the result
gastrointestinal surgery. Most patients who have
had total gastrectomy and up to 50% of patients
with sub-total gastrectomy develop iron
deficiency, although this may require several years
after surgery.
3. Gastrointestinal Bleeding
Determining the source of gastrointestinal
bleeding is a challenge. Radiologic examinations
and endoscopy are the chief aids to the diagnosis.
With respect to gastric bleeding, corrosive injury
from several drugs (e.g. Aspirin, phenylbutazone,
Indomethacin) occurs with considerable frequency.
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.
CLINICAL FEATURES OF IRON
DEFICIENCY
The iron deficient patient may be completely a
symptomatic, even in the presence of marked anemia if
this has developed gradually. There is good evidence
that the anemia itself may not be responsible for the
symptoms, muscle, etc. Symptoms frequently reported
include: fatigue, tinnitus, palpations, weakness and
lightheadedness. Sore tongue or sore mouth sometimes
occurs and there may rarely be severe stomatitis. There
may be some loss of papillae from the tongue and
fissures at the corners of the mouth. Mild
splenomegaly occurs rarely. Koilonychias (spoon
nails), a condition in which nails are flattened or even
concave and are brittle, occurs uncommonly but is of
considerable diagnostic help when it occurs.
LABORATORY INVESTIGATION
1. Examination of the Stained Blood Film and
Red Cell Studies.
The classical appearance of red cells in iron
deficiency is that of hypochromia and microcytosis.
These features are often helpful in making a
diagnosis but two problems prevent complete
reliance on it. One is that there are causes such as
"anemia of chronic disease", thalassemia and
sideroblastic anemia for erythrocyte hypochromia
other than iron deficiency. The second problem is
that the anemia of iron deficiency may be
normochromic and normocytic until quite severe.
2. Serum Iron and Iron Binding Capacity
Determination (these studies may be limited
values)
Normal Range
Total Iron Binding Capacity 45 - 81
umol/L (TIBC)
Unsaturated Iron Binding Capacity 27 - 54
umol/L (UIBC)
Serum Iron
*Percent saturation = serum iron x 100%
Total iron binding capacity
*Values of less than 15% are suggestive of
Page 20 of 72
 iron deficiency.
3. Serum Ferritin
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
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)
a. Iron deficiency is the only disorder that
responds to iron administration.
b. A search for chronic blood loss often must
accompany treatment.
c. An iron-deficient patient with normal
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.
2. 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.
Page 21 of 72
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).
In comparison to the
lymph, many RBC are Hypersegmented
large and oval Neutrophil
Bone Marrow: erythroid hyperplasia, and
megaloblastic maturation as shown below
. PERNICIOUS ANEMIA
Giant metamyelocyte Dysmegakaryopoiesis
Erythroblast
OTHER LABORATORY TESTS
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:
1. Serum bilirubin - mild increase, mainly indirect
fraction
2. Lactic dehydrogenase (LDH) - may be greatly
increase; LDH1 predominates
3. Decreased haptoglobin, and increased
methemalbumin.
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
Nutritional - vegans
MALABSORPTION
Gastric causes - pernicious anemia (P.A.)
­ gastrectomy
Intestinal causes - Blind loop syndrome
­ sprue, ileal resection
­ Crohn's disease
­ Fish tape
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).
AUTOIMMUNE ASPECTS:
It has been suggested that P.A. is an "autoimmune
disease". The B12 malabsorption is secondary to lack of
intrinsic factor production, due to gastric atrophy. The
gastric mucosa is invaded by lymphocytes and plasma
cells, and there is a high incidence of parietal cell
antibody (95%) and intrinsic factors antibody (30 -
60%).
Page 22 of 72
LABORATORY INVESTIGATION
The specific laboratory tests are:
1. Serum B12
Vitamin B12 is measured in the serum by
radioimmunoassay. Serum B12 should be measured
usually along with folate, before any treatment is
given, or a Schilling test performed. A low serum B12
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
severe folate deficiency. Serum B12 may be reduced in
patients on birth control pills.
FOLIC ACID DEFICIENCY
REQUIREMENTS AND DIETARY SOURCE
Man is unable to synthesize his estimated daily
requirement of about 50 ug per day (infants 25-50 ug
per day). Meats, particularly liver, and green
vegetables are good dietary sources of folic acid.
Boiling vegetables in excess water will efficiently
extract much of the folate content. Requirements are
increased in pregnancy, hemolytic anemia, and
hyperthyroidism.
ABSORPTION AND FUNCTION OF FOLIC
ACID
Folic acid is absorbed in the duodenum and jejunum
by an active transport mechanism. Folic acid
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
Especially gluten enteropathy (coeliac disease) and
tropical sprue.
3. Drugs
Commonly dilantin, primidone, and barbiturates.
Oral contraceptive agents also appear occasionally
to cause malabsorption. The folic acid antagonist
methotrexate inhibits dihydrofolate reductase
2. Gastric Juice
All adult patients with P.A. have achlorhydria but is
not common practice to measure this.
3. Defective B12 Absorption
The Schilling test may be performed if doubt exists as
to B12 absorption.
TREATMENT
In pernicious anemia, 1000 ugm cyano-cobalamin
intramuscularly each month will sustain a normal
blood picture.
activity and therefore conversion to active co-
enzyme forms.
4. Alcohol
The folate deficiency of alcoholics is complex and
probably involves dietary deficiency as well as
impaired absorption and perhaps also decreased
hepatic storage and altered utilization.
5. Pregnancy
Megaloblastic anemia of pregnancy usually
responds to folic acid and usually
laboratory evidence of folate depletion is obtained.
Requirements for the pregnant woman are not well
established, but are increased and pregnant women
should receive supplemental folic acid (as well as
iron) to prevent deficiencies.
LABORATORY INVESTIGAIONS OF
FOLATE DEFICIENCY
Normal Values
Serum Folate 6.8 - 18.4 nmol/L
Red Cell Folate 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).
TREATMENT OF FOLIC ACID
DEFICIENCY
In addition to removing causative factors where
possible, the administration of folic acid orally is
usually required.
Page 23 of 72
ALCOHOL AND HEMATOPOIESIS
Chronic and excessive alcohol ingestion causes many
hematological complications by direct toxic effects, by
contributing to nutritional deficiency or by
complicating liver dysfunction as follows:
1. Macrocytic Anemia
Usually due to folic acid deficiency on a
nutritional basis (megaloblastic anemia) but even
in the absence of folate deficiency, alcohol and
liver disease can cause macrocytic anemia.
2. Iron Deficiency Anemia
Usually due to chronic G.I. bleeding from
esophageal varices or gastritis
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: - Heriditary (Fanconi's
anemia)
- Acquired
SECONDARY - Chemical and Drugs
- Radiation
- Infection (viral hepatitis)
- Immunologic (?autoimmune)
The cause of about 50% cases cannot be determined
and these are termed idiopathic. Fanconi's anemia is an
extremely rare hereditary aplastic anemia, often
associated with short stature, skeletal abnormalities,
hypoplastic kidneys, etc.
Exposure to chemicals containing benzene is
particularly hazadarous. Drugs which most frequently
are associated include:
1. Antibiotics – chloraphenicol, sulfas, streptomycin
are the morphological clue to this type of
hemolysis.
4. Sideroblastic Anemia
Direct toxic effect of alcohol on hemesynthesis
causes ring sideroblasts, ineffective erythropoiesis,
and a hypochromic anemia.
5. Hypersplenism
Due to cirrhosis and portal hypertension causing
congestive splenomegaly. Pancytopenia is usually
present.
Thrombocytopenia, often severe, may be caused
by a direct toxic effect of alcohol, even in the
absence of folate deficiency.
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.
Thrombocytopenia is usually marked, and
megathrombocytes are absent.
MANAGEMENT
The role of red cell, granulocyte, and platelets
transfusions are discussed with the management of
leukemias. When aplastic anemia is severe
(granulocyte count 0.5 x 10 9/L, platelet count 20 x 10
9/L) and not reversible, the prognosis is very grave
(85% mortality in one year, with median survival of 3
Page 24 of 72
months). If an HLA-compatible sibling is available as
a bone marrow donor, then prompt bone marrow
transplantation is the treatment of choice (not that an
HLA-compatible sibling is only available in 1/4 to 1/3
of cases.
For milder cases, or those unsuitable for
marrow transplantation Antithymocyte globulin can
cause a significant improvement in a number of cases.
THE HEMOLYTIC ANEMIAS
Increased RBC destruction is the common factor in all
hemolytic anemias. Hemolysis is detected by:
1. Evidence of erythrocyte destruction.
2. Bone marrow compensation
3. Decreased erythrocyte survival
EVIDENCE OF ERYTHROCYTE
DESTRUCTION
a) Hemoglobin, hematocrit – both decreased unless
hemolysis is "compensated" (normal bone marrow
can increase RBC production at least 6 to 8 times)
b) Hyperbilirubinemia – increased serum bilirubin,
mainly indirect (unconjugated type), and increased
urobilinogen in urine.
c) * Increased plasma hemoglobin
* Decreased serum haptoglobin
* Hemoglobinuria
* Hemosideriuria
* Mainly intravascular hemolysis
BONE MARROW COMPENSATION
a) Reticulocytosis – seen as polychromasia on routine
blood films, but can be specifically demonstrated
on reticulocyte count.
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)
high dose androgen therapy may cause improvement in
anemia but not leucopenia nor thrombocytopenia.
Steroids are often given a trial of 2 -4 weeks but
should then be discontinued if not obviously helpful.
Splenectomy has no definite role to play in these cases.
The status of immunosuppressive treatment
(Cyclosporin) is investigational but helpful in some
cases.
II EXTRINSIC DEFECTS
(EXTRACORPUSCULAR)
1. Autoimmune hemolytic anemia (Coombs positive)
a. Warm antibody (IgG)- idiopathic, secondary
(lupus, lymphoma, Aldomet, etc)
b. Cold antibody (IgM) – idiopathic (cold
hemagglutinin disease), secondary
(mycoplasma, infectious mononucleosis)
2. Alloimmune hemolytic anemias – Hemolytic
disease of newborn, post transfusion
3. Drug induced hemolytic anemia
a. Chemical effect in absence of G6PD
deficiency, or with G6PD deficiency
4. Mechanical hemolytic anemia
a. Micro-angiopathic – hemolytic – uremic
syndrome, TTP, DIC, etc
b. Cardiac fragmentation hemolysis
5. Secondary hemolytic anemia – infectious, liver or
renal disease, etc.
I INTRINSIC DEFECTS
A. HEREDITARY HEMOLYTIC ANEMIAS
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.
Page 25 of 72
2. HEMOGLOBINOPATHIES:
Thalassemia is a complex group of anemias
usually classified with the hemolytic anemias
because hemolysis is marked in the severe
homozygous forms, but the primary defect is a
quantitative reduction in synthesis of globin
chains. Beta chain synthesis is decreased in beta
thalassemia which is mainly seen in individuals of
Mediterranean background.
The heterozygous form (beta thalassemia minor)
is fairly common is characterized by extreme
microcytosis, and hypochromasia but little or no
anemia. Diagnosis is confirmed by demonstrating
an increased Hb A2, and no treatment is required
(although laboratory findings resemble iron
deficiency, iron stores are usually normal or
increased and iron therapy is contradicted) The
homozygous form (beta thalassemia major) causes
severe hemolysis in childhood with splenomegaly,
and iron overload usually leading to death in
adolescence unless vigorous transfusion and iron-
chelation therapy is employed.
Alpha chain synthesis is decreased in
alpha thalassemia which is commoner in
Orientals; the inheritance is more variable
resulting in clinical disorders ranging from a very
mild anemia, through moderate hemolytic anemia
(Hb H disease), to a very severe form causing
death in utero.
Sickle cell Anemia- Sickle cell trait is common
(10% of American Blacks) but is usually
asymptomatic and detected only by the presence of
abnormal Hb electrophoresis (SA) or a positive
sickle cell preparation. If the heterozygous sickle
cell trait is combined with the gene for Hb C, then
a more severe disorder (Hb S-C disease) occurs
with hemolysis, splenomegaly, and hemolytic
crises. Sickle cell anemia (or disease) is the
homozygous form (Hb SS) characterized by a
severe hemolytic anemia beginning in early
childhood, causing splenic infarcts
(autosplenectomy), bone infarts, hemolytic or
aplastic crises and often death in young adult life.
Treatment is unsatisfactory (supportive care with
transfusions, fluid therapy and analgesia).
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.
Diagnosis of enzymopathies requires demonstration
of the specific enzyme deficiency by complex
laboratory procedures.
B. ACQUIRED HEMOLYTIC ANEMIAS
1. PAROXYSMAL NOCTURNAL
HEMOGLOBINURA (PNH);
Very rare hemolytic disorder. Acquired increased
sensitivity of the RBC membrane to complement,
causing intravascular hemolysis and hemoglobinura.
Diagnostic test is Ham's acidified serum test. PNH
may be associated with aplastic anemia or
myelofibrosis.
Treatment: supportive blood transfusions.
II EXTRINSIC DEFECTS
(EXTRA CORPUSCULAR)
1. AUTOIMMUNE HEMOLYTIC ANEMIA
(AIHA):
Requires the presence of:
a. Hemolytic anemia
b. Antibody directed against an intrinsic antigen
on the patient's own erythrocytes; find
antibody or complement on the surface of the
patient's erythrocytes (direct antiglobulin or
Coombs test), and often antibodies in the
patient's serum (indirect antiglobulin or
Coombs test)
IgG antibodies lead to destruction of RBC's in
the R-E system of spleen and liver mainly. IgM
antibodies usually fix complement and produce
intravascular hemolysis.
a. WARM ANTIBODY TYPE (IGG):
This is the commonest type, usually chronic,
and often (50%) secondary to other diseases
(lupus, lymphoma, chronic lymphocytic leukemia).
Splenomegaly and lymphadenopathy suggest
secondary type. Drug-induced hemolytic anemias
occur by these mechanisms:
i. Innocent bystander type- quinidine
ii. Hapten type – penicillin (massive
doses)
iii. Autoimmune type – Almodet (alpha
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.
Page 26 of 72
 2. Splenectomy – 50 % response; reserve for thrombotic thrombocytopenic purpura
cases unresponsive to steroids, or requiring (TTP) septicemia, DIC and carcinomatosis
large maintenance steroid dosage. may cause RBC fragmentation with or
3. Blood transfusion – difficult to crossmatch; without thrombocytopenia
use least incompatible blood and transfused ii. Cardiac Hemolytic Anemia – Due to
only if absolutely necessary. prosthetic aortic valve usually;
4. Immunosuppressive therapy (Imuran, occasionally with Teflon patch, or
Cyclophosphamide) – for cases unresponsive calcified valve. Iron deficiency is
to steroids and splenectomy. commonly associated because the chronic
5. Folic Acid (5 mg daily) – this is given to all intravascular hemolysis leads to chronic
chronic hemolytic anemias as prophylaxis for urinary iron (hemosiderin) loss.
folic acid deficiency due to increased folate
utilization 5. SECONDARY HEMOLYTIC ANEMIA:
A variety of infections (eg. Clostridia, malaria)
b. COLD ANTIBODY TYPE (IGM): may cause erythrocyte damage and hemolysis.
These are uncommon and Hepatic and renal disease result in mild chronic
characterized by RBC agglutination and hemolysis usually, but defective erythropoiesis
hemolysis when exposed to cold temperature. from chronic disease, iron deficiency may also
They may be: play a role
i. Idiopathic – chronic cold agglutinin
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.

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,
Page 27 of 72
BLOOD TRANSFUSION PRACTICE
DONOR AND PATIENT SELECTION
Donors should be volunteers, and are carefully
screened for history of infectious disease and
medications. However, no transfusion can be
completely free of risk because:
1. Present screening procedures do not eliminate
hepatitis transmission (especially non-A, non-B
hepatitis). HIV screening of all blood products
occurs now.
2. Some patients may react to non-RBC components
– e.g. allergic and febrile reactions.
3. Auto-antibodies produced to RBC antigens (other
than ABO and Rh) may limit future transfusion
therapy.
In spite of this, most transfusions (95%) produce
no adverse effects, and serious reactions are rare.
Patient selection depends on clinical judgement but the
following guidelines might be used:
1. Degree and chronicity of anemia: Patients with
chronic anemia of moderate degree (Hb 60 – 80
g/L) often maintain reasonable activity, and the
need for transfusion should be correlated with
symptomatology (eg severe fatigue, aggravation of
angina, heart failure etc)
2. Active or potential bleeding: It is generally
accepted that Hb should be kept about 100 g/L in
bleeding patients and in patients who undergo
surgery.
3. Possible response of hemantinics. Usually better
to investigate anemia, and treat specifically (eg
iron, B12) if possible.
PRINCIPLES OF BLOOD TRANSFUSION
1. TYPE OF CROSSMATCH
a. Group and Reserve Serum – no crossmatch;
consists of blood group and antibody screen;
serum is reserved for cross-matching later, if
needed. Some institutions do not crossmatch if the
antibody screen is negative
b. Routine Crossmatch- complete; takes atleast one
hour.
c. Urgent or Emergency Crossmatch – shorter
incubation (about 30 minutes) to provide blood for
urgent clinical situations.
d. Uncrossmatched Blood – give ABO and Rh type
same as patient (rather than Rh negative). Only
given in most extreme emergencies, unless patient
has been previously tested (group and reserve
serum) in which the case the need for
crossmatching is much less
Each hospital will have guidelines for appropriate
procedure (cross match or group and reserve) for
each type of operation.
2. BLOOD COMPONENT THERAPY
a. Whole Blood – stored up to 5 weeks in CPD
anticoagulant. Used for treatment of acute blood
loss and replacement of red cell mass and volume)
rarely available; blood components are used to
provide the equivalent of whole blood in those
situations
b. Packed Red Cells – storage and cell survival same
as whole blood. Preferred for most anemias
requiring transfusion.
c. Plasma Products –fresh frozen plasma, stored
plasma, albumin, cryoprecipitate and factor
concentrates.
d. Platelet Concentrate
e. Gamma Globulin and Specific Antisera –
Intravenous and intramascular gamma globulin
preparations are available, as are specific antisera
(anti-hepatitis B, CMV, Zoster)
3. TRANSFUSION PROCEDURE
a. Rate of Transfusion. Depends on clinical situation.
One unit of blood may be infused in 15 minutes in
rapidly bleeding patients. Packed cell transfusions
for anemia usually take about 2 hours (longer than
4 hours should be avoided due to risk of
contamination)
b. Amount Transfused. Depends on clinical situation.
Single unit transfusions are generally avoided. The
patient's Hb should increase approximately 10 g/L
per unit of packed cells transfused, in average size
adult.
c. Diluents. Normal saline is the recommended
diluent for blood products. A small amount (50
mL) will correct the increased viscosity of packed
red cells (about 0.70). Plasma and 5% albumin are
possible alternatives. Glucose solutions cause RBC
agglutination and hemolysis so must not be used.
Ringer's solution contains calcium which can
overcome the citrate anticoagulant and cause clots
to form in the tubing; so red cells must not be
diluted with Ringer's solution.
ADVERSE EFFECTS OF BLOOD
TRANSFUSIONS
When any significant reaction, which cannot be
explained or treated, occurs during a transfusion, it is
advisable to terminate the transfusion and investigate
for hemolytic transfusion reaction. However, most
reactions are not hemolytic.
Types of reactions include:
Page 28 of 72
1. HEMOLYTIC REACTIONS:
a. Immediate. Chills, fever, dyspnea, bone pain,
hypotension, red urine, renal failure and bleeding
(D.I.C) may all occur. Terminate transfusion and
investigate by sending unused blood, venous
blood specimen and urine specimen to Blood
Bank (for repeat crossmatch, direct Coomb's test
and test for hemoglobinura) May need supportive
treatment for shock, bleeding or renal failure.
b. Delayed. Fever, jaundice, or recurrent anemia
occurring 3 days or more after transfusion.
Investigate for hemolysis, including Coomb's
test. This may reflect an amnestic antibody
response to previous antigen exposure.
2. FEBRILE REACTIONS:
Chills, fever and occasionally hypoxia usually in
multi-transfused or multiparous patients with
WBC antibodies. Treat with antipyretic, and try to
prevent in future with leukocyte poor blood or
washed packed cells. There are several methods to
produce leukocyte poor blood, leukocyte
centrifugation in line filters, washed packed cells,
frozen blood, but line filters are usually used.
3. ALLERGIC REACTIONS:
Usually urticaria. Common (up to 3% of
transfusions). Treat with antihistamina – may
finish transfusion if reaction not severe, responds
to therapy, and does not worsen when transfusion
is restarted carefully. If recurrent, prescribe and
antihistamine before future transfusions. Rarely
anaphylactic reactions occur and there are often in
patients with IgA deficiency. Such patients should
be given washed blood in the future.
4. VASCULAR OVERLOAD:
Congestive heart failure may be precipitated,
particularly in elderly patients with chronic
anemia, given whole blood, or too rapid
transfusion of packed cells and blood components.
5. OTHER:
Chills – rapid transfusion of refrigerated blood;
contaminated blood – very rare.
Disease transmission – hepatitis,
cytomegalovirus, malaria, AIDS
Iron overload – with large numbers of transfusions
Hyperkalemia – in renal failure
Citrate toxicity – rarely, with massive
transfusions and liver failure, or prematurity.
TRANSFUSION OF PLASMA AND
PLATELET COMPONENTS
Blood and blood component therapy is influenced by
problems of product availability and storage far more
than most branches of medicine. A thorough
knowledge of these limitations, and continuing
communication with Blood Bank staff will ensure that
these products are utilized to their best possible
advantage. The following guidelines are currently
employed:
1. FRESH FROZEN PLASMA (FFP):
Storage: 20oC for 1 year
Contents: Must be frozen within 12 hours of
blood donation so that it will contain all
coagulation factors. No platelets are present, and it
contains allo-antibodies as in stored plasma.
Use: Replacement of coagulation factors
which cannot be provided by other products (i.e.
for factor VIII alone, in hemophilia, factor VIII
concentrate would be used) Its main use is for
treatment of multiple coagulation deficiencies
occurring after massive transfusion (10 or more
units) or with D.I.C. Time is required for thawing
(up to 30 minutes) so stored plasma 5% albumin is
preferred for immediate replacement in severe
hemorrhage. It is evident that excessive use of this
component will mean less cryoprecipitate, or
factor VIII concentrate, can be made, thereby
limiting the treatment of hemophiliacs.
2. CRYOPRECIPITATE, FACTOR VIII
CONCENTRATE:
Storage: -20oC for 1 year (cryoprecipitate);
o
4 C (Factor VIII) or room temperature for several
months
Contents: Both are made from plasma frozen
within 12 hours of blood donation
Cryoprecipitate is a partly purified factor VIII
preparation containing about 50% of the factor
VIII in the original blood donation, in small
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
factor VIII equals the amount present in 1 mL of
plasma). Factor VIII concentrate is a more highly
purified preparation of factor VIII, requiring more
extensive fractionation procedures; it contains a
standardized amount of Factor VIII, per vial and is
more easily administered so is the preferred
product for factor VIII replacement in some
situations (particularly for home care programs for
severe hemophilia). Recently a recombinant factor
VIII product has become available and has
replaced Standard Factor VIII concentrate.
3. ALBUMIN:
Supply: 25% albumin solution (100 mL), salt
poor, stored at 4oC
Use: Hypoalbuminemia (usually with complicated
edema) where improvement in the patient can be
reasonable expected, i.e. do not just treat a
laboratory abnormality without regard to patient's
condition, or underlying disease – albumin is
usually not given for cirrhosis and nephritic
syndromes. It is commonly used for supportive
Page 29 of 72
 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:
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
plasma. It also contains allo-antibodies (anti-A or
B). In general 6 units of platelet concentrate are
given at a time, and one would expect an increase
in platelet count in the patient of approximately 10
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. Prophylactic 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.
5. PENTASTARCH:
10% hexastarch used for the plasma volume
expansion instead of 5% albumin. Used in
hypovolemia, secondary to sepsis, blood loss
Page 30 of 72
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
Questions: WBC 3.6 x 109/L
1. List the clinical problems. Platelets count 86 x 109/L
2. What other physical findings related to her Reticulocytes count 40 x 109/L
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
Page 31 of 72
 time was 24 seconds (INR: 2.5), and PTT was 60
seconds.
2. On the 4th hospital day, what changes would you
expect to see if the following tests were performed
that day
a. Reticulocytes count
b. Serum and RBC folate
c. Serum B12
d. Bone marrow
3. You are called that evening to manage this patient
after she vomited blood:
a. Explain why the hemoglobin hasn't fallen.
b. What would your first order for a laboratory
test be?
c. What type of I.V. solution would you order
immediately?
d. What further I.V. therapy would you
recommend?
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
cheeks. There was no lymphadenopathy or
hepatomegaly. Spleen was palpable 2 cm. below the
left costal margin. No joint abnormalities were
detected.
Laboratory Investigations:
Hemoglobin 60 g/L
MCV 90 fL
MCHC 360 g/L
Reticulocytes count 16% (300 x 109/L)
WBC 4.0 x 109/L
Platelets count 130 x 109/L
Direct Antiglobulin (Coombs') - Positive (+++)
Questions:
1. List the clinical problems.
2. What would you expect to see on the blood film?
3. Explain why the MCV is normal.
4. List 2 reasons for the thrombocytopenia.
5. In considering management of this patient:
a. What would your first choice of treatment be?
b. Would you recommend a blood transfusion?
c. If the splenectomy is considered later, what
precautions and advice to the patient should be
provided?
4. ANEMIA AND ARTHRITIS
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
which time she had noticed progressive joint
discomfort and stiffness mainly in her hands, elbows
and knees. She had been taking up to 8 aspirin tablets
daily for the past year and was on no other
medications. Her diet was good and she had no G.I.
symptoms except indigestion related to the aspirin. She
had no past history of serious illness and was 4 years
postmenopausal.
On examination, she was slightly pale and not
jaundiced. There was no lymphadenopathy or
hepatosplenomegaly. She had obvious rheumatoid
arthritis with joint deformity of both hands.
Laboratory Investigations:
Hemoglobin 94 g/L
MCV 74 fL
MCHC 310 g/L
WBC 6.3 x 109/L
Platelets count 230 x 109/L
Questions:
1. Classify the anemia.
2. List 2 possible causes for the anemia.
3. List 3 most appropriate laboratory tests.
4. Assume that you conclude the patient requires iron
therapy:
a. What type and amount of iron treatment would
you prescribe?
b. How long would you advise the patient to
continue iron treatment?
c. The patient wants to get better as quickly as
possible and asks for either a blood transfusion
or iron shots. Do you agree with either of these
treatments? If not, what advice would you give
to the patient to support your
recommendations?
d. With iron, at what rate would you expect the
Hb to rise?
5. ANEMIA AND HEART DISEASE
A 42-year-old man regularly visited his physician
for routine cardiac studies following open-heart
surgery three years ago. At that time an aortic valve
prosthesis was inserted for rheumatic aortic stenosis,
and he had been anticoagulated under careful
supervision since then. He had felt well until recent
weeks when he began to complain of dyspnea and
fatigue. He noticed a reddish discoloration to his urine
often during the day.
Page 32 of 72
 On the examination, he appeared pale, but was not
jaundiced. There was a tachycardia (100/minute), and a
moderate (grade III/VI) early diastolic murmur
maximal at the left sternal border. There was no
evidence of cardiac failure. Liver and spleen were not
enlarged.
Laboratory Investigations:
Hemoglobin 80 g/L
MCV 75 fL
MCHC 300 g/L
Reticulocytes count 2% (75 x 109/L)
WBC 7.5 x 109/L
Platelets count 300 x 109/L
Blood film RBC fragmentation, hypochromia
Questions:
1. List the clinical problems.
2. The Reticulocytes count is not appropriate to the
degree of anemia. Explain.
3. Classify the anemia.
4. Further tests indicate iron deficiency, why do you
think this occurred?
5. Outline your management of this patient.
6. ANEMIA, WEAKNESS AND JOINT PAIN
A 46-year old woman comes to your office
complaining of increasing fatigability and weakness
for the past 4 months. She has had rheumatoid arthritis
for 8 years and 12 to 16 tablets of aspirin per day have
controlled her joint symptoms. The patient says she
had no sever pain, tenderness, redness, swelling, or
heat in her joint for 2 years while on regular aspirin.
However, she is less energetic and she finds she must
stop and rest during her household work, and by the
end of the day she is exhausted. She denies crying
spells and has had no anorexia, weight loss or
insomnia. She denies any history of abdominal pain,
heartburn, jaundice, and black or tarry stools. She dose
like to chew on ice cubes. There is no history
suggestive of diabetes. Past history reveals no
additional pertinent information. Family history
reveals that she is of Italian origin and one sister was
mildly anemic and was told she had Mediterranean
anemia.
On physical examination, the patient is slightly obese,
vital signs are normal. Slight pallor is noted. Cardiac,
pulmonary and abdominal examination was normal.
There is no stool in the rectum for guaiac (occult
blood) testing. No signs of active rheumatoid arthritis.
Laboratory tests:
Hemoglobin 70 gm/l, hematocrit (Hct.) 28%
Mean corpuscular volume (MCV) 70u3
Mean corpuscular hemoglobin (MCH) 17.5 uugm
Mean corpuscular hemoglobin concentration (MCHC)
25%
White blood cells (WBC) 10/mm3 with normal
differential
Sedimentation rate: 62mm/hr
CXR / ECG: normal
Questions:
1. List the clinical problems?
2. After reviewing CBC results, what are the next
important simple tests you would order?
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
reported an incident of dizziness without loss of
consciousness. He has been feeling gradual
deterioration during the past few months. He did not
have any illness and was not on any medication. There
was no blood loss from any site and he had normal
eating habits. Apart from undergoing tonsillectomy at
the age of 5 years, there was no significant past history.
On examination, the patient was fully alert, pale with a
tinge of jaundice. The majority of his hair was gray
and upon further questioning, the patient admitted to
having gray hair since the age of 20 years.
There was no lymphadenopathy. Examination of the
heart revealed an ejection systolic murmur over the
apex. Examination of the abdomen was normal
Preliminary blood tests revealed the following:
WBC: 3.5 x 109 /L neutrophils 70%
Hb.: 83 g / L ( N: M: 140-180
F: 120-160)
MCV 115 fl (N 80 - 95)
Platelets: 100 x 109 / L (N 150 – 400)
s. Iron: 30 μmol / L (males N 14 – 31)
s. Transferrin 2.4 g / L (2 - 4)
Blood film showed the presence of macro-ovalocytes
and hypersegmented neutrophils
Questions:
1. What are the hematological abnormalities elicited
in the full blood count result?
2. What may be the cause of this abnormality?
3. What is the most likely diagnosis?
4. How would you confirm this diagnosis?
8. FEVER, ANEMIA AND
RETICULOCYTOSIS
A 24 –year old Kuwaiti man is admitted to the hospital
because of increasing fatigue following a respiratory
Page 33 of 72
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.
Blood film: reveals generally normocytic
normochromic red cells, but there is moderate
poikilocytosis with occasional fragmented cells and
microspherocytes. No true sickled cells are seen. There
are many large polychromatophilic red cells and rare
nucleated red cells.
Urine: is clear, brown-colored, protein +, specific
gravity 1.025, and glucose, ketons and urobilinogen
are negative. Dipstick test for blood is positive. No
cells or casts are seen on spun sediment.
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.
Questions
1. What does the history of jaundice as a newborn
indicates?
2. What are the causes of dark urine?
3. Why do we look for icterus under the upper
eyelid? What dose the Combination of icterus and
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:
1. How do you assess the severity of menstrual
period?
2. Comment on the hematological picture and what is
your differential diagnosis?
3. Comment on the HB electrophoresis?
4. If the HB electrophoresis was normal, what else
should you consider?
5. What would you council this patient?
Cellulose Acetate Method (pH 8.4)
Cathode - + Anode
Hemolyse C
d blood S A
E
applicatio A2 D F
n
Sample 4.5% 0.5% 95%
Page 34 of 72
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 1. Comment on the peripheral blood findings. What

CBC Reference Range are the Howell-Jolly bodies and what is their
WBC 15.0 (4 – 10 x 109/L) significance?
HB 87 (140 – 180 g/L)
Hematocrit 26 (42 – 50) 2. Comment on the hemoglobin electrophoresis
MCV 88 (80 – 94) findings.
MCH 30 (27 – 31 pg) 3. What is the diagnosis? And what do describe this
MCHC 340 (330 – 360 g/L) attack of pain?
RDW 17 (11.5 – 14.5 %)
Reticulocytes Count 150 (60 – 120 x 109/L) 4. What is the cause of the hyperbilirubinemia in this
s-Total Bilirubin 50 case?
s-Indirect Bilirubin 45 5. How do you manage this case?
s-Direct Bilirubin 5
6. What is the role of exchange transfusion in this
Differential WBC Count Range disease?
Neutrophils 11.5 (1.5 – 6.0 x 109/L) 7. What are the complications of this disease?
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 - + Anode

Hemolys C S A
ed blood E D F
applicati A2
on

70% 10% 20%

Page 35 of 72
 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

Page 36 of 72
LYMPHADENOPATHY AND SPLENOMEGALY
GENERAL OBJECTIVES
The student should have a general
understanding of the spectrum of disorders presenting
with enlargement of lymph nodes and/or spleen,
including methods of presentation, investigations
required to diagnose these disorders, urgency with
which diagnosis should be made, and treatment
commence and finally the prognosis and complications
which might occur during the treatment program.
SPECIFIC OBJECTIVES
At the end of this section the student should be
able to:
1. Describe diagnostic possibilities, given a series of
white cell counts and differentials, and/or clinical
presentations of patients with enlarged lymph
nodes or spleen.
2. List the diagnostic tests required, if any, to confirm
the suspected diagnosis.
3. Describe the major clinical and laboratory features
of the common or important disease in this
category:
Infectious mononucleosis
Acute and chronic leukemias
Lymphomas and Hodgkin's disease
Myeloma
4. Differentiate between benign and malignant causes
of leukocytosis and polycythemia.
5. Describe the expected outlook for patients once
any of the above diseases are diagnosed
6. List the possible treatment options, when
available, for theses diseases, and describe the
risks / benefits expected with these treatments.
7. describe the management of the common
complications which might arise during the course
of these disorders; these complications include
bone marrow suppression, local effects of enlarged
lymph nodes and spleen, pain and hyperviscosity.
8. Describe the role of blood component therapy in
the management of these patients, including type
of component, rate of administration, and expected
responses
CLINICAL ASSESSMENT
Particular points in history include a search for
sites of local infection, or if the lymphadenopathy is
generalized and/ or splenomegaly is present, particular
attention must be paid to systemic symptoms (fever,
night sweats, pruritus, weight loss, anemia and
jaundice), medications, travel history, and presence of
other diseases (eg. Rheumatoid arthiritis, lupus, etc).
Physical examination should include a careful
documentation of the size and consistency of enlarged
lymph nodes in cervical, axillary and inguinal areas
(occasionally epitrochlear and popliteal as well), extent
of hepatosplenomegaly, presence of tonsillar
enlargement, skin lesions and bone tenderness
LABORATORY ASSESSMENT
The qualitative assessment of white blood cells
(leukocytes) is almost performed by automated cell
counters (Coulter Counter) rather than older inaccurate
and labor-intensive counting chambers. The normal
WBC count is 4.0 – 10.0 x 109/L
The qualitative assessment of white blood cells
is most commonly performed by manual microscope
techniques, with reporting of a WBC Differential
(percentage of cells assigned to each category) after
viewing 100 or more cells. If the WBC is too low (1.5
x 109/L) then a buffy coat preparation may be prepared
to increase the number of cells which can be viewed
microscopically in a reasonable period of time. Many
of the automated cell counters provide partial
differential counts. Most commonly granulocyte and
lymphocyte counts. Such differentials have the
advantages of precision since many more cells are
assessed than by manual methods, and less
technologist time is involved. However, most do not
give full differentials and do not give a printout when
abnormal cells are present or the differential counts are
significantly abnormal. Fully automated differential
counters require a large volume of tests to be cost
effective and are not as helpful in settings where a
large percentage of the differential are abnormal.
The bone marrow may provide information
about granulocyte production, and presence of
infiltrative disorders such as leukemia, lymphoma and
myeloma. The normal sequence of granulocyte
development is as follows:
Myeloblast → promyelocyte → myelocyte →
metamyelocyte → band → neutrophil
Normally there are 3 – 4 times as many
granulocyte precursors, than erythroid precursors, in
the bone marrow (M/E ratio 3/1). This reflects the
presence of a large granulocyte pool or reserve, and
also the short life span of granulocytes compared with
erythrocytes.
The maturation of granulocytes in the marrow
is sequential. If there are increased numbers of less
mature forms, then this is termed "shift-to-the-left". It
could represent a reactive process (granulocytic
hyperplasia) or a malignant process (leukemia and the
morphological distinction may be difficult.
Page 37 of 72
 BENIGN LEUKOCYTE DISORDERS
GRANULOCYTOPENIA
This term refers to neutropenia, or reduction in
the absolute neutrophil count; decreased in the
eosinophils and basophils cannot be accurately
measured, and are of no practical importance. The
severity of the neutropenia is usually graded as
follows:
Normal neutrophil count 2.5 – 7.5 x 109/L
Mild neutropenia 1.0 – 2.5 x 109/L
Moderate neutropenia 0.5 – 1.0 x 109/L
Severe neutropenia < 0.5 x 10 9/L
A serious risk of spontaneous infection is
usually not present until severe neutropenia develops.
CLASSIFICATION OF NEUTROPENIA
1. Decreased granulopoiesis – marrow infiltration /
fibrosis, drugs, radiation
2. Ineffective granulopoiesis – megaloblastic anemia
3. Decreased granulocyte survival – hypersplenism,
severe infection, immune
DECREASED GRANULOPOIESIS
This may be associated with decrease in other
marrow elements causing pancytopenia (see aplastic
anemia, leukemia, myelofibrosis, etc). When
granulocytopenia occurs selectively due to decreased
granulopoiesis, it is most frequently caused by drugs.
Even then, many of these may be due to drug-related
granulocyte antibodies which are not detectable by
current techniques.
Some drugs, such as chemotherapeutic agents,
will predict cause neutropenia, but usually also
thrombocytopenia and anemia. These are usually slow
in onset and dose-dependent. Other drugs may
unexpectedly cause neutropenia, often severe and
sometimes fatal, in a previously sensitized patient, or
by unknown mechanisms (idiosyncratic reaction).
Many drugs have been implicated, similar to those
which cause aplastic anemia. The major groups include
anti-inflammatory agents, anticonvulsants, antibiotics,
antimal arials, antithyroid drugs and phenothiazines.
The neutropenia may last for days / weeks.
INEFFECTIVE GRANULOPOIESIS
This is seen most often in megaloblastic
anemias, characterized by a pancytopenia but a
hypercellular megaloblastic bone marrow; the
precursors of all cells lines dies in the marrow cavity
before being released. Thus, ineffective hematopoiesis
is corrected by appropriate therapy such as B12 or
folate vitamin treatment or in the case of alcohol
excess cessation of alcohol consumption.
DECREASED GRANULOCYTE SURVIVAL
In severe bacterial infections such as lobar
pneumonia, and various septicemias, neutropenia can
occur due to granulocyte consumption or complement
activation, and depletion of the marrow granulocyte
pool. It is often an ominous sign. In hypersplenism,
there is usually a pancytopenia due to splenic pooling
of hematopoietic cells and hypercellular marrow, with
correction of blood counts after splenectomy.
Severe neutropenia may occur with
Rheumatoid arthritis (Fety's syndrome) usually with
splenomegaly as well. This may be due to auto-
antibodies against granulocytes, which also likely
occur in some patients with lupus, but laboratory
techniques are not presently available to detect these
antibodies.
The management of neutropenia involves
discontinuing any drugs which may be associated,
correcting any vitamin deficiency or nutritional
problems, and if possible, controlling any underlying
disease. If hypersplenism cannot be reversed by other
means, and if the cytopenias are severe enough to
warrant the risks involved, then a splenectomy may be
indicated.
LYMPHOPENIA
May also occur (absolute lymphocyte count <
1.5 x 109/L) due to drugs (steroids), hereditary
immuno-deficiency disorders or associated with some
other diseases, such as Hodgkin's disease & HIV
infection. It may be present, usually to a lesser degree
than neutropenia, in association with the pancytopenia
of aplastic anemia, hypersplenism, etc.
GRANULOCYTOSIS
When the numbers of granulocytes are
increased in comparison to the numbers of
lymphocytes, but in absolute terms, then this is called
"relative granulocytosis". It is usually seen with the
lymphopenias described previously. When the actual
number of granulocytes is increased (and this is
calculated from the percentage of granulocytes and the
total WBC count) this is termed "absolute
granulocytosis" and these conditions are now
considered further, depending on which granulocyte is
increased.
a. Neutrophilia (neutrophil granulocytosis)
An absolute neutrophil count greater than 7.5 x
109/L is called neutrophilia; the causes which
would be considered are:
i. Controlled proliferation
This is a normal response to infections
(mainly bacterial), trauma, inflammatory
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,
however, a leukemic process will almost always
be present. There will often be left-shift with
Page 38 of 72
 reactive neutrophilia but this will seldom extend
as far back as the myeloblast and promyelocyte
stages. When the reactive leukocytosis is so
extreme and/or left-shifted as to resemble a
leukemia, it is termed "leukemoid" reation.
ii. Uncontrolled proliferation
This represents a malignant myelproliferative
process such as leukemia, myeloid metaplasia
or polycythemia, rather than reactive or
secondary, neutrophilia.
iii. Storage pool activation
Roughly 1/3 of the total granulocyte mass is
present as a storage pool in the marrow. This
reserve may be rapidly mobilized in response to
many acute traumatic and inflammatory
processes resulting in a prompt neutrophilia in
peripheral blood. The mature granulocytes are
depleted in the marrow for several days until
granulocyte hyperplasia occurs.
iv. Marginal pool activation
2/3 of the total granulocyte mass is present
outside of the marrow, and this is divided equally
between a central pool (1/3 of total mass) and a
marginal pool (the last 1/3). The number of
marginating neutrophils may be changed acutely
due to catecholamines (any stressful situation) or
by migration inbibition with steroids, causing the
neutrophils to demarginate and be counted in the
central pool. The result is an absolute
neutrophilia on WBC counting, even though the
number of circulating granulocytes hasnot
actually changed.
b. Eosinophilia
Absolute eosionophilia (0.4 x 109/L) is
most commonly associated with the following
disorders:
• Allergies – allergic rhinitis, asthma, etc
• Parasitic infections – amebiasis, nematodes,
trematodes, etc
• Dermatitis – dermatis herpetiformis, eczema,
etc.
• Hypereosinophilic syndromes – Loefler's
syndrome, polyarteritis, etc
• Neoplasms – various carcinomas, Hodgkin's
disease,etc. It is extremely rare for
eosinophilia to occur as a primary
myeloproliferative disorder (eg. Leukemia)
c. Basophilia
Increase in basophils is rare, and virtually
always part of other leukocyte abnormalities in
myeloproliferative diseases (CGL, myeloid
metaplasia, polycythemia)
d. Monocytosis (0.8 x 109/L)
Elevation of monocytes is uncommon. If may
occur with some chronic infections, preleukemia
or monocytic leukemia.
e. Lymphocytosis
As noted previously, children have a large
proportion of lymphocytes on WBC differential than
adults, and frequently these lymphocytes appear
atypical, or reactive, in response to the
immunological challenges and frequent viral
infections during childhood.
Absolute lymphocytosis in adults requires a
lymphocyte count greater than 3.5 x 10 9/L. This will
usually be due to some underlying disease, usually a
viral infection, but if it is persistent, without
underlying cause, then it may represent an early stage
of chronic lymphocytic leukemia – the distinction
cannot be made on morphological grounds alone. Up
to 5% of lymphocytes in adults and 10% in children
may appear slightly atypical or reactive; these
lymphocytes are larger with less mature nucleus, and
the cytoplasm is often basophilic, and in large amount
so that the cell membrane appears compressed by
surrounding erythrocytes on the blood film.
Causes for lymphocytosis of moderate to
marked degree, include infectious mononucleosis,
cytomegalovirus, infectious lymphocytosis, Bordetella
pertussis (whooping cough), toxoplasmosis, HIV and
hypersensitivity reactions. The infectious
lymphocytosis of whooping cough is distinctive
because the lymphocytes are all small lymphocytes,
not atypical, and the lymphocyte count may reach
extreme degrees (50 -100 x 109/L) resembling chronic
lymphocytic leukemia, which is not seen in children.
For practical purposes, major degrees of atypical
lymphocytosis (20 – 40% of WBC's) in adults will be
due to infectious mononucleosis (EB virus) or
cytomegalovirus; the latter may cause an identical
clinical picture but with a negative mono test, and is
much less commonly diagnosed. Infectious
mononucleosis characteristically presents with fever,
sore throat and cervical lymphadenopathy; jaundice is
uncommon (5%) but laboratory evidence of hepatic
dysfunction is common (elevated transaminase in over
80%). Skin rash may occur, particularly if these
patients are treated with ampicillin. Occasionally
hemolytic anemia (cold agglutinins) and
thrombocytopenia may be prominent features.
Splenomegaly is present in half of the cases but must
be carefully examined because of the risk of splenic
rupture. The diagnosis is confirmed by a positive
monospot test in 95% of cases, and the treatment is
usually only supportive (bed rest, analgesics, or
antipyretics) Steroids are indicated only for serious
complications (CNS involvement, pharyngeal
obstruction, sever thrombocytopenia) Sometimes the
lymphocytes are fragile, and are ruptured during the
preparation of the blood film; they are then referred to
as "smudge cells". These are most common in chronic
lymphocytic leukemia but can also be seen with
reactive lymphocytosis (eg. Viral infection) so are not
diagnostic of C.L.L
Page 39 of 72
HEMATOPATHOLOGY TESTING
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.
Cytochemical Stains
It is often impossible to determine whether the
blasts in an acute leukemia are of myeloid or lymphoid
origin from morphology alone. For this reason,
cytochemical staining is performed.
Stain Cells stained
Myeloperoxidase Myeloid
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
establish clonality. If the leukemia is of plasma cell
origin (i.e. multiple myeloma), staining for
cytoplasmic immunoglobulin is performed by
immunofluorescent microscopy or flow cytometry.
This is done since plasma cells generally lose cell
surface expression of the useful markers, including κ
and λ.

Non-specific esterase Monocytes, blasts

in monocytic leukemia

Periodic acid-Schiff Normal granulocytes,

blasts in lymphocytic
Leukemia ("string of
pearls"), abnormal
Erythroblasts in DIAGNOSIS OF LYMPHOMA AND
erythroleukemia LYMPHOPROLIFERATIVE DISORDERS
("chunky")
Most lymphomas are characterized by
Tartrate-resistant Hairy cell leukemia cells immunophenotyping cells from the lymph node or
acid phosphatase (TRAP) other tissues in suspension or frozen tissue sections.

Leukocyte alkaline High in leukemoid Flow Cytometry

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

Page 40 of 72
κ, λ Immunoglobulin light chains, used to chromosome 22. The resulting fusion protein, BCR-
determine clonality in B cell ABL is thought to cause neoplastic transformation.
lymphomas This chromosomal translocation can be detected by
DNA blot analysis using a probe for the BCR gene.
CD2 Pan-T cell marker, also expressed on This particular probe easily detects the translocation if
NK cells as few as 1% of the cells present contain the
Philadelphia chromosome. This probe detects the
CD4, CD8 T cell subsets translocation in greater than 90% of CML. Because the
breakpoint is different, the probe only detects about
CD1 mature T cells, Langerhans cells 33% of Philadelphia chromosome-positive ALL. This
test can be used to make the differential diagnosis of
CD3, CD7 Pan-T cell markers CML vs. other reason for leukocytosis or
thrombocytosis. It can also be used to detect minimal
CD16/56, CD57 NK cell markers residual disease following bone marrow
transplantation, although it is not as sensitive as PCR.
CD25 IL2 receptor; present on In addition to increased sensitivity, this method will
activated T cells, some T cell allow detection of both types of t(9;22) breakpoints
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. When transplantation 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 proto- SKY allows for direct visualization of a specific chromosomal
oncogene on chromosome 9 with the BCR gene on abnormality (numeric and translocation

Page 41 of 72
 Result of FISH

Normal cell MCL – lymphoma 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
• 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:
LDHD: few lymphocytes seen
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)

Page 42 of 72
 MCHD: pleomorphism ,
mixed lymph, eosinophils, plasma cell.
The clinical stage or extent of the disease however is
more important in planning therapy and influencing
prognosis. The following simplified stages are
currently used:
Stage I – disease in one lymph node region
Stage II – disease in two or more lymph nodes but
confined to one side of diaphragm
Stage III – disease confined to lymph nodes or
spleen and present on both sides of
diaphragm
Stage IV – disease outside confines of lymph
nodes or spleen. (i.e. involves organs)
The presence or absence of systemic symptoms are
also important; these include:
A– absence of fever, night sweats or
weight loss (10% of body weight)
B– presence of any of the above.
The procedures required to stage patients with
Hodgkin's disease vary somewhat from centre to
centre, but generally include the following:
1. Routine hematology and biochemical tests
including liver function
2. Chest X-ray – PA and lateral; CT chest or
tomogram if indicated
3. CT Scan of abdomen
4. Nuclear scan:
Gallium scan: shows active uptake in the lymphoid
tumor. More recently PET scan is more utilized as
it is more sensitive and more specific
Gallium uptake –Anterior
mediastinal mass
PET Scan
FDG PET scan in a newly diagnosed lymphoma.
Widespread nodal disease is shown above and below
the diaphragm. Spleen (arrowheads) is diffusely
hypermetabolic, suggesting lymphomatous
involvement.
5. Bone marrow aspirate and biopsy are done as part
of staging work up to exclude bone marrow
involvement. This is more likely if there are 'B'
symptoms and hematological abnormalities.
The principles of management of HD include the
following:
a. LPHD : local radiotherapy
b. Classical HD stages I, IIA include 4
courses of chemotherapy and involved
field radiotherapy
c. Advanced stages (IIB, III, IV) includes
systemic chemotherapy of 6 – 8 cycles.
Local radiotherapy may be given for initial
bulk (tumors > 10 cm)
The potential for cure exists for all stages and
all therapies but is much higher for earlier stages and
asymptomatic disease. It is important to optimize
treatment to minimize side effects. Chemotherapy,
induces considerable morbidity; nausea and vomiting,
anorexia, hair loss and long term can lead to sterility.
However, the most commonly used protocol is known
as ABVD (Adriamycin, Bleomycin, Vinblastin ,
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.
The progression free survival is 50 % at 5 years.
LYMPHOMAS
The “non-Hodgkin's" lymphomas are a somewhat
variable group of malignant neoplasms primarily
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
Page 43 of 72
 • Mature B cell neoplasms The NHLs can be divided into two prognostic groups:
– T and NK Cell Neoplasms the indolent lymphomas and the aggressive
• Precursor T cell neoplasms lymphomas.
• Mature T and NK cell Indolent NHL types have a relatively good prognosis,
neoplasms with median survival as long as 10 years, but they
Examples of these cases: usually are not curable in advanced clinical stages.
• Diffuse large B cell lymphoma (DLBCL) Early stage (I & II) indolent NHL can be effectively
• Follicular lymphoma treated with radiation therapy along. Most of the
• Mucosa associated lymphoid tissue (MALT) indolent types are nodular (or follicular) in
• Burkitt lymphoma morphology.
• CLL/SLL The aggressive type of NHL has a shorter natural
• Cutaneous T-cell lymphomas MF/Sezary 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
CLL CLL aggressive course. Previously such lymphomas had a
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
Follicular NHL common chemotherapy protocol used is CHOP
(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 + Large 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
Burkitt lymphoma with starry sky appearance in this group, namely Lymphoblastic lymphoma and
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.
Mucosa associated lymphoid tissue Follicular (nodular) lymphomas of insidious
MALT) lymphoma of the stomach onset without significant symptomatology do not need
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
Page 44 of 72
systemic chemotherapy and monoclonal antibody
therapy may produce better results and long
remissions.. For localized treatment radiotherapy may
be indicated but this is not common as most cases have
generalized disease or are of more aggressive type
such that chemotherapy is the treatment of choice.
Radiptherapy may also be used in combination with a
chemotherapy programme to treat bulky disease. It
often plays an important role in treatment of relapsed
disease when chemotherapy has failed or to treat a
palliative symptomatic disease when cure is not
possible.

Common chromosome translocations in non-

Hodgkin 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

Page 45 of 72
MYELOMA
Myeloma is a disease caused by malignant
proliferation of plasma cells. It usually presents as a
bone disease, with bone pain, but multiple other
presentations are possible due to many complications
which may occur.
Most cases of myeloma are due to clones of
plasma cells producing immunoglobin G (IgG), but
IgA myeloma is also common – IgD and IgE myeloma
are rare. Myeloma must be differentiated from:
1. Benign Monoclonal Gammopathy – long-standing
non-progressive monoclonal increase in
immunoglobulin without marrow plasmacytosis or
bone lesions. Usually the Ig elevation is mild (25
g/L) and urinary light chain proteinuria is present.
2. Waldenstrom’s macroglobulinemia – this
uncommon disorder presents with monoclonal
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.
CLINICAL
As noted above, bone pain due to osteolytic bone
lesions with or without pathological fractures or
vertebral compression fractures from osteoporosis or
osteolytic lesions may all occur. Symptoms of anemia
(fatigue, pallor), leucopenia (infections) or
thrombocytopenia (bruising or bleeding) may all be
present due to myeloma replacement of bone marrow.
Renal failure may result from myeloma kidney (light
chain, or Bence-Jones protein, precipitation),
amyloidosis, hypercalcemia, hyperuricemia or
infection. Amyloidosis may also cause tongue
enlargement, arthropathy, hepatosplenomegaly,
purpura, carpal tunnel syndrome, etc. Hypercalcemia
may induce polyuria, polydipsia, vomiting and
confusion.
LABORATORY
Bone marrow
Infiltrated with
plasma cells
a. Blood picture
- anemia, leucopenia and thrombocytopenia
b. Bone marrow
- 10 – 20% plasma cells usually required for
diagnosis of myeloma. Multinucleated and
immature forms are common.
c. Biochemical tests for
- total protein (increased) and albumin
(decreased)
- hypercalcemia
- hyperuricemia
- renal function
- β-2 microglobulin
- LDH
- C- reactive protein
- Cytogenetic studies
- serum protein electrophoresis – detects and
quantitates the monoclonal protein; about 15%
however, have hypogammaglobulinemia.
- Urine protein (24 hour) and protein
electrophoresis – quantities the amount of light
chain proteinuria (routine urinary dipstick test
for protein does not detect light chains).
d. Immunology tests
- Ig quantitation Immunisation electropheris –
confirms Ig type (IgG, IgA, etc) and light
chain (kappa or lambda)
- Urinary light chains – selective kappa or
lambda light chain proteinuria
e. X-rays
- skeletal survey to detect osteolytic lesions or
diffuse osteoporosis. X-rays of skull, spine and
pelvis are particularly important, but ribs and
long bones can be involved and should be x-
rayed if clinically indicated. Note that alkaline
phosphatase is usually not elevated, and bone
scans are usually normal because the bone
lesions are almost totally osteolytic in nature.
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
Page 46 of 72
after improvement is complete, or stable, to be
restarted at the time of relapse. Cyclophosphamide
may be substituted for melphalan if it is no longer
effective. There is definite increase of leukemic
transformation in patient receiving alkylating agent
chemotherapy but the improved quality of life and
survival warrant this risk.
Treatment of multiple myeloma in
symptomatic patient is dictated by age and presence of
co-morbidities. For patients aged below 70 years initial
induction by combination chemotherapy of Vincristine,
Doxarubicin, Dexemethasone (VAD) 3-4 cycles
followed by high dose chemotherapy and autologous
stem cell transplantation is the treatment of choice and
results in longer progression free survival and overall
survival compared to conventional chemotherapy.
2. RADIOTHERAPY
Excellent treatment for symptomatic isolated
bone involvement, unresponsive to chemotherapy.
Radiotherapy is used in patients with cord compression
and in prevention of impending pathological fractures.
3. SURGERY
For pathological fractures
4. SUPPORTIVE CARE
1. Biophosphonates: Bone involvement in multiple
myeloma is a major reason for morbidity of the
disease. Biophosphanates inhibit bone
resorption. Pamidronate or the newer more
potent Zoledronate are usually used to prevent
skeletal events. Ideally such treatments should
be combined with calcium and hormone
replacement in patients with no contradiction to
their use.
2. Erythropoetin: Anemia is frequent in patients
with multiple myeloma. Recombiant human
erythropoietin decreases transfusion
requirement, increases means hemoglobin,
improves quality of life and performance status
in aneamic myeloma patients. Erythropoetin
may be used in weekly or three times weekly
schedules
3. Vertebroplasty and Kyphoplasty: Painful
vertebral compression is a major cause of
morbidity in multiple myeloma patients.
Vertebroplasty and Kyphoplasty helps in
relieving pain in most patients
4. Treatment of infection: Multiple myeloma and
its treatment including chemotherapy and
transplantation render patients extremely
vulnerable to infection. Prompt treatment of
infection and in selected cases prophylactic anti-
infective therapy reduces morbidity and
morbidity.
5. SPECIAL SITUATIONS
• Amyloidoisis is usually, but not always,
unresponsive to any treatment.
• Hypercalcemia – must be promptly and
aggressively treated with large volumes of
intravenous saline, steroids, and chemotherapy
or biphosphonates.
• Allogeneic bone marrow transplantation can
cure multiple myeloma, however, high rates of
treatment related mortality and poor overall
survival precludes its routine use. Low
intensity allogeneic bone marrow
transplantation following cytoreductive
chemotherapy, autologous transplantation may
however be used in high risk cases. Patients
not eligible for high dose therapy should be
treated with combination of Melphalan &
Prednisolone or Dexamethasone with
Thalidomide. Thalidomide and its analogoue
lenalidomide has antiangiogenic, antimyeloma
and immunnomodulatory effect and has been
found to be effective in newly diagnosed
myeloma as well as in relapsed patients.
Bortezomib (valcade), a proteosome inhibitor
has been found to be effective in relapsed
multiple myeloma and is under trial in patients
with newly diagnosed multiple myeloma.
• Renal failure – treatment of hypercalcemia,
hyperuricemia and the myeloma are all
important to reverse as much of the renal
failure as possible. If renal failure is
established and severe, then careful medical
management of the azotemia, and electrolytes,
will be needed; dialysis is sometimes
employed if the life expectancy and general
condition of the patient warrants this.
The treatment of myeloma improves the
quality of life (decreases bone pain, improves
blood counts, etc) and prolongs life (median
survival is now 3 – 4 years compared to 1 year
untreated). Current treatment does not cure the
disease.
Page 47 of 72
LEUKEMIAS
ACUTE LEUKEMIA
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
previously would have died quickly are now achieving
prolonged remissions with chemotherapy and
supportive care.
The hallmark of the acute leukemias is the
characteristic proliferation of immature (blast) cells in
the bone marrow, and often in the peripheral blood
where WBC counts can be increased up to 100 x 109/L
or more. If the diagnosis is obvious from the WBC
differential (large number of blast cells) then a bone
marrow is not essential, but if there is any doubt when
a bone marrow will be required to demonstrate the
involvement, or often complete replacement by rapidly
proliferating blast cells. The blast cells fail to
differentiate into more mature forms (i.e. granulocytes,
lymphocytes or monocytes) and inhibit maturation of
normal clones of marrow cells. The acute leukemias
are divided into the following categories.
5. Acute myeloblastic leukemia (AML) – variants
include acute myelomonocytic leukemia
(AMML), promyelocytic leukemia and
erythroleukemia
6. Acute lymphoblastic leukemia (ALL) – variants
include acute prolymphocytic leukemia,
undifferentiated leukemia
7. Acute monocytic leukemia
Morphological criteria (plus cytochemistry) used
to be the prime method of differentiating the various
types of leukemia. Now with the use of monoclonal
antibodies, cell surface antigens can be identified,
enable a more accurate differentiation of acute
leukemias. This is particularly important in
determining the type of acute lymphoblastic
leukemias. Cell surface marker analysis of ALL now
determines the type of treatment used and probable
prognosis. Morphological criteria are still important
and both techniques are necessary for diagnosis. In
AML the use of cell surface marker analysis has not
yet altered treatment approaches.
AML is the commonest acute leukemia in
adults (90%) whereas ALL is commonest in children
(90%), 70% are CALLA positive. Presentation of all
forms of leukemia is distressingly similar, a previously
healthy person develops symptoms from reduction in
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
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.
MANAGEMENT
CHEMOTHERAPY
The initial goal of chemotherapy is remission
induction ( a complete remission has occurred when
there is no evidence of leukemia in the blood and < 5%
blast cells in the bone marrow) This is readily achieved
in children with ALL (95%) but only in about 60%
adults with AML. Combination chemotherapy is
required with various protocols (drugs such as
vincristine, prednisone, L-asparaginase, methotrexate,
6-Mercaptopurine, adriamycin, cytosine, arabinoside,
and 6-thioguanine) are used in cyclic fashion to bone
marrow patient tolerance. In the treatment of AML this
aggressive chemotherapy is continued for two or more
courses after complete remission is achieved for
consolidation. Maintenance treatment is not usually
used as it has not been proven to prolong survival in
AML. In treatment of ALL following induction of
remission, consolidation therapy is given which is
followed by maintenance treatment. The total time
treatment undertaken is 2 – 3 years. Most maintenance
treatments are given on an outpatient basis and patients
return to regular routines of daily living.
In childhood ALL, the risk of CNS
involvement or meningeal leukemia is so high ( and
not counteracted by systemic chemotherapy) that these
patients receive prophylactic intrathecal chemotherapy
and is a subset cranial radiation to prevent CNS
relapse.
The outlook for childhood ALL is much
improved with modern chemotherapy protocols with
the prospect of cure in up to 70% of cases. In adults
results are not so encouraging. A median survival of 18
months for AML responders and 30% long term
survivors (5 years) can be achieved. For ALL recently
25-40% long term survival has been achieved.
Morbidity during aggressive induction
chemotherapy is high (nausea and vomiting, alopecia,
bleeding / bruising, infections, anxiety and
depression). Maintenance chemotherapy used in ALL
is generally well tolerated. Once relapse is occurred
second remissions are much more difficult to achieve
particularly in AML. If the patient has an HLA-
identical sibling then bone marrow transplantation may
be a viable alternative for AML (first remission) or
ALL (second remission)
Page 48 of 72
SUPPORTIVE CARE
At presentation these patients are often
anemic, infected and bleeding; during remission
induction these potential complications are very
common, and the following guidelines generally apply
to their management:
a. Anemia
- packed red cell transfusions are given as
needed for symptomatic anemia
b. Thrombocytopenia
- during remission induction, spontaneous
hemorrhage is common if the thrombocytopenia is
severe (platelet count 10 x 109/L) so many centers
provide prophylactic platelet transfusions during
this period; others are more selective, attempting
to monitor the seriousness of the
thrombocytopenia by clinical assessment (amount
of purpura, epistaxis, mucosal bleeding, etc). The
goal is to prevent intracerebral hemorrhage which
is rapidly fatal if it occurs. Any drugs which cause
platelet dysfunction must be omitted e.g. Aspirin,
and intramuscular injections are prohibited.
c. Granulocytopenia
- although reverse isolation procedures do not alter
the frequency of serious infections in these
patients, most acute leukemias are
provided with a private room, whenver possible,
and visitors with infections are discouraged. Masks
may help if attending staff have a potentially
transmittable upper respiratory infection and hands
should be washed before examining the patient.
If a neuropenic patient develops a chill and/or
fever, the patient should be promptly assessed for
site of infection, cultured immediately (Throat
swab, urine C & S, blood cultures etc) and if a
septicemia is likely, should be placed on broad
spectrum (eg. Cephalosporin plus aminoglycoside)
intravenous antibiotics as soon as cultures have
been obtained. Granulocyte transfusions have not
been proven to be of help in this situations.
d. Emotional support
- These patients require regular visits, frank
discussions and frequent reassurance from
compassionate and knowledgeable medical,
nursing and other personnel to cope with the
multiple physical and emotional problems
which routinely are encountered.
CHRONIC GRANULOCYTIC LEUKEMIA
Chronic granulocytic leukemia (CGL)
accounts for 20% of all cases of leukemias, and mainly
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
granulocytic series, often back to myeloblast state (but
the "hiatus" between blast cells and mature cells as
seen in acute leukemia is absent in CGL) Anemia is
usually mild, and a wide range of platelet counts may
be seen (to 1000 x 109/L)
The bone marrow also demonstrates the
increased and left-shifted granulopoiesis, but is
generally not required for diagnosis (there are no
diagnostic morphologic features which differentiate
CGL from reactive granulocyte hyperplasia) It may,
however, provide a sample for karyotyping for
Philadelphia chromosome if needed. The Philadelphia
chromosome (loss of short arm of chromosome
number 22 due to 22:9 translocation) is present in 85-
90% of CGL patients; if absent, in a patient who
appears to have CGL by other tests, the prognosis is
worsened. The Philadelphia chromosome is only rarely
present in other myeloproliferative diseases.
Another test which might help differentiate
between CGL and leukemoid reaction (granulocytic
hyperplasia) is leukocyte alkaline phosphatase
(LAP); this is a histochemical test for alkaline
phosphatase in leukocyte (neutrophil) granules – it is
characteristically decreased – absent in CGL but
normal – increased in leukemoid reactions. It is
performed on peripheral blood, rather than bone
marrow.
MANAGEMENT OF CML
1. Oral chemotherapy:
During chronic phase, hematological remission is
produced in more than 70% of patients treated
with Hydroxyurea or Busulphan. Hydroxyurea is
preferred over Busulphan because of better
toxicity profile, progression free survival and
overall survival. However, no significant
cytogenetic remission occurs with Hydroxyurea or
Busulphan and over all pace of progression to blast
crisis is unchanged. These treatments are therefore
considered to be palliative.
2. Allogeneic bone marrow transplantation:
Allogeneic hematopoietic cell transplantation is
the only known curative treatment for CML.
However only minority of patients have HLA
matched siblings. Treatment related morbidity and
mortality is significant and increase with
increasing age of the patient. Therefore currently
this modality is offered to patients less than 40
years of age. In younger patients HLA matched
unrelated donor transplantation is feasible.
3. 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
Page 49 of 72
 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.
CHRONIC LYMPHOCYTIC LEUKEMIA
Chronic lymphocytic leukemia (CLL) is the
commonest form of leukemia, appearing mainly in old
age, often symptomless and requiring no treatment.
Hypermetabolic symptoms such as fever, night sweats,
fatigue and weight loss may occur. Lymph nodes and
spleen are regularly enlarged often for many years,
without causing symptoms, but can achieve such
enlargement as to require treatment for pressure or
cosmetic symptoms.
The laboratory diagnosis is usually simple.
There is lymphocytosis which may reach extreme
degrees (500 x 109/L or more) without other obvious
causes (eg. Viral infection) The lymphocytes seen are
usually small lymphocytes and appear morphologically
normal. Frequently they are fragile so that they rupture
during preparation of the slide; they are then called
"smudge cells". Although not diagnostic of C.L.L they
are so frequently seen in this type of leukemia that they
are quite typical. The bone marrow contains a
lymphocytic infiltration but often is not needed to
make the diagnosis of CLL. Flow cytometry reveals a
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
choice. It produces higher incidence of remission
(complete and overall) compared to Chlorambucil or
combination chemotherapy. The drug may be
associated with cumulative myelotoxicity and
increased risk of opportunistic infection.
In older patients, intermittent Chlorambucil is an
appropriate therapy, because of it ease of
administration and relatively favourable toxicity
profile.
Moncolonal antibody, anti CD20 (Rituximab) is
effective when used in combination with
chemotherapy and anti CD52- Alemtuzumab
(Campath) have significant activity in CLL. These
agents are however used for patients who have failed
Fludarabine therapy.
Coomb's positive autoimmune hemolytic anemia and
immune thrombocytopnenic purpura are treated with
Prednisolone.
Radiotherapy is reserved for symptomatic lymph
node enlargement not responding to chemotherapy.
Page 50 of 72
PROBLEMS FOR TUTORIALS
Questions:
1. ADULT MAN WITH LYMPHOCYTOSIS 1. What are the B-symptoms and how do you define
A 65-years-old man was brought to the emergency unit them?
by his son because he has fainted at home. According 2. What is your differential diagnosis?
to his son, the man was gradually feeling week with 3. What initial tests would you like to order?
inability to do his daily routine. He had loss of appetite 4. How do reach a final diagnosis? What do the cells
and lost 5 Kg. over the last 6 months. He had no shown below imply?
previous history of cardiac disease or hypertension but
had diabetes for which he was on oral hypoglycemic
drugs for the past 5 years.
3. POLYCYTHEMIA
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%
Platelets 90 x 109 / L 1. Is this likely to be a primary or secondary
Blood Sugar: 8.5 mmol / L Na: 140 mmol/L erythrocytosis (polycythemia)? Why?
K: 4.2 mmol/L 2. What additional investigations would you
perform?
Questions: 3. Discuss treatment in terms of Polycythemia
1. What are the important findings in the history and
clinical examination of this patient? 4. ATYPICAL LYMPHOCYTOSIS
2. What is the differential diagnosis Problem: This 18 year old woman saw her
3. What is the most likely diagnosis? physician for increasing tiredness over the past two
4. What do you think is the cause of the anemia? weeks associated with a sore throat and fever.
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
WBC 12.4 x 109/L
.01 bands
.46 segmented neutrophils
2. A YOUNG FEMALE WITH NECK LUMP .26 lymphocytes
A 17-year-old Kuwaiti girl sought medical at tension .25 atypical lymphocytes
because she noticed lumps in the left side of her neck. .02 monocytes
She denied any B-Symptoms. Her past medical history Platelet count 110 x 109/L
is unremarkable. Required questions:
On examination, there is a 3x3-cm firm, non-tender, 1. List 2 causes of atypical lymphocytosis
freely movable nodule in the left neck just above the 2. What is the most likely cause in this patient
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
Page 51 of 72
5. What are the appropriate confirmatory tests?
5. LEUKOCYTOSIS AND SPLENOMEGALY
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
WBC 70 x 109/L
.02 blasts
.03 promyelocytes
.18 myelocytes
.17 metamyelocytes
.25 bands
.20 neutrophils
.04 lymphocytes
.02 monocytes
.05 eosinophils
Required Questions:
1. What is the most likely diagnosis?
2. What confirmatory tests might you order
3. The patient asks if her spleen should be removed
since it bothers her. Do you agreed and why?
4. The patient has just started a clothing business and
wants to make plans for the future. What advise
would you provide regarding:
a. Possibility of bone marrow transplantation
b. Side effects of the treatment you would
prescribe
c. Complication which is likely to occur and
when.
5. New treatment.
6. PANCYTOPENIA
Problem: This 59 year old woman was
referred to hospital because of a low WBC count. The
patient denied malaise of fatigue. Two weeks before
admission, she had an acute respiratory tract infection
treated with penicillin. Except for pallor and few
bruises, there were no other physical findings.
Laboratory Investigations
Hemoglobin 80 g/L
MCV 82 fL
MCHC 350 g/L
WBC 3.8 x 109/L
Platelet count 15 x 109/L
Required Questions
1. List any further laboratory tests you would
request
2. List 2 possible diagnosis for the blood changes
3. The day after admission, her temperature
spiked to 39oC and she had a chill. She also
developed many bruises, recurring nosebleeds
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
7. LEUKOCYTOSIS
Problem: This 78 year old man visited his
family physician for an annual "checkup" He was in
good health except for mild symptoms of congestive
heart failure being treated with digoxin and
hydrochlorothiazide daily.
On examination, there was no tonsillar
enlargement, lymphadenopathy or hepatosplenomegaly
Laboratory Investigations:
Hemoglobin 148 g/L
MCV 88 fL
MCHC 34- g/L
WBC 58.0 x 109/L
.15 neutrophils
.65 lymphocytes
.20 smudge cells
Platelet count 175 x 109/L
Required Questions:
1. What is the most likely diagnosis to explain
the blood findings?
2. Are any further tests required
3. What advise would you give this patient
regarding:
a. Need for treatment now?
b. Indications for treatment in the future
c. Side effects of treatment if required?
d. Overall disease course
8. LYMPHADENOPATHY
Problem: A 30-year old female who was
previously well until 4 weeks ago when she noted a
lump in her left axilla. During the past 2 weeks she has
complained of fatigue. Physical examination revealed
a 3 cm, non-tender soft mass in the left axilla. There
were no abnormalities detected on breast exam and
there as no evidence of splenomegaly or
lymphadenopathy elsewhere.
Laboratory Investigations:
Hemoglobin 115
Hematocrit .3
White Blood Count 4.5
Platelet count 200
Chest X-ray small mediastinal mass
Required Questions:
Page 52 of 72
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?
Page 53 of 72
 MYELOPROLIFERATIVE DISORDERS
The designation "myeloproliferative disorder"
is a general term given to wide range of malignant
proliferation of myeloid tissue, which can be classified
as follows:
MYELOPROLIFERATIVE DISORDERS
1. Polycythemia vera
2. Myelofibrosis (myelosclerosis)
3. Myeloid metaplasia (with or without
myelofibrosis)
4. Chronic granulocytic leukemia
5. Thrombocythemia
6. Acute myeloblastic leukemia
We have included CGL and AML under
leukemias, and will restrict further discussions to
polycythemia, myelofibrosis (myeloid metaplasia)
and thrombocythemia.
POLYCYTHEMIA VERA
Before deciding whether a patient has
polycythemia vera, the physician must first usually
exclude two other possibilities:
b. Spurious (stress, or relative) erythrocytosis –
patients with this disorder are detected by the
isolated findings of elevated Hb and Hct, often in
association with hypertension (Gias-bock's
syndrome) Blood volume studies (Cr51 labelled
RBC's) demonstrate a normal red cell mass,
however, and the "apparent" erythrocytosis is due
to a reduction in plasma volume. This condition
requires recognition, to differentiate it from true
polycythemia, but no treatment.
c. Secondary polycythemia (erythrocytosis)- this
represents a response to tissue hypoxia, or
autologous erythropoietin production and the
following should be considered:
i. Chronic lung disease – particularly chronic
bronchitis
ii. Congenital heart disease – cyanotic, with right to
left shunt
iii. Renal disease – renal cell carcinoma, cysts, renal
artery stenosis
iv. Liver disease – hepatoma
v. High altitude
vi. Hemoglobinopathy – high affinity hemoglobin
(rare)
vii. Cerebellar hemangioblastoma (rare)
Most of the above can be ruled out on clinical
assessment. The one diagnosis which must not be
missed is the renal cell carcinoma which may still be
curable if detected at a localized stage; if any doubt
exists as to a cause for erythrocytosis, appropriate
investigations of the urinary tract should be
considered.
In both of the above possible categories the
abnormality is usually limited to increased Hb, Hct,
and RBC count, without an elevation of WBC count or
platelet count. The red cell mass, as assessed by Cr51
blood volume, is increased in both secondary
polycythemia, and primary polycythemia (P. vera)
Polycythemia vera is a malignant proliferation of
myeloid cells usually involving all marrow cell lines
leading to erythrocytosis, leukocytosis (neutrophilia)
and thrombocytosis. Splenomegaly is present in 75%
of patients at diagnosis)
Common symptoms include plethora (ruddy
cyanosis of face and extremities), hyperviscosity
symptoms (transient bleeding, TIA's, angina,
claudication etc) bleeding and pruritus (which is
common, often sever, and aggravated by bathing "bath
pruritus")
Management includes control of red cell mass
(hyperviscosity) and prevention of bleeding
complications. If erythrocytosis is marked but not
leukocytosis or thrombocytosis, then a therapeutic
phlebotomy program (removal of 500 ml blood usually
weekly) may be instituted; usually this must be
continued till the patient develops iron deficiency,
limiting erythropoiesis and this may take several
months. If there is complicating thrombocytosis,
symptomatic splenomegaly or hypermetabolic
symptoms, then radioactive phosphorus (P32) will
provide good long term control of P.vera, and should
be considered particularly in older patients.
Chemotherapy has also been used, but there is a
definite leukemogenia potential with either
chemotherapy (chlorambucil, myleran) or P32 so this
must be carefully assessed for each patient. Younger
patients should receive hydroxyurea, as chemotherapy,
due to its lower leukemogenic risk. Recently Aspirin
has been shown to decrease the risk of thrombosis.
Uric acid is usually increased and most
patients are treated with allopurinol to prevent gout or
other complications of hyperuricemia.
MYELOFIBROSIS, MYELOID METAPLASIA
These two conditions often exist together,
although myeloid metaplasia can occur without
fibrosis in the bone marrow (called "agnogenia"
myeloid metaplasia). The marrow fibrosis may result
in bone proliferation as well (myelosclerosis) and be
visible on x-ray but usually it doesn't. It does result in
decreased hematopoiesis, and the concomitant myeloid
metaplasia present mainly in the liver and spleen is
rather inefficient. Accordingly, the patients with these
disorders usually have anemia and thrombocytopenia,
both of which may be severe, whereas the leukocytes
are often increased and left shifted.
Page 54 of 72
 The peripheral blood film is usually
characteristic, with a "leukoerythroblastic" blood
picture – nucleated RBC's and left-shifted granulocyte
series. Other features include teardrop poikilocytes,
and megathrombocytes – all of these abnormalities
result from abnormal hematopoiesis taking place
outside the bone marrow. Marrow biopsy is required to
demonstrate the marrow fibrosis.
Patients usually present with symptoms of
anemia and/or thrombocytopenia, with systemic
complains of fever, night sweats, and weight loss.
Splenomegaly is usually prominent and may be
massive producing major pressure symptoms. Splenic
infarcts are common.
Treatment is unsatisfactory – Supportive care
with red cell transfusions for symptomatic anemia and
platelet transfusions for thrombocytopenia bleeding
complications may be required. Androgens may
provide mild benefit for the anemia and folic acid may
be helpful if deficiency is documented. Splenectomy
may be required to control symptoms of massive
splenomegaly; this operation is risky, however, and
platelet function should be studied prior to surgery
since many patients have abnormally functioning
platelets in addition to the thrombocytopenia.
ESSENTIAL THROMBOCYTHEMIA
If the thrombocytosis is extreme (1,000 x
109/L) it should probably be controlled by
chemotherapy Hydroxyurea (myleran) particularly if
any surgery is planned and is elective enough to
provide time for this treatment to be effective (1-2
months) Emergency treatment with plateletphoresis is
rarely needed. These patients tend to develop other
myeloproliferative disorders (polycythemia, leukemia)
but usually many years pass before this occurs. Baby
Aspirin may reduce the risk of arterial thrombosis.
Page 55 of 72
 MODULE III & IV
HAEMOSTASIS & THROMBOSIS
OBJECTIVES
• 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 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.

• 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

Page 56 of 72
BLEEDING DISORDERS
GENERAL OBJECTIVES
The student should have a general
understanding of hemostasis, the types of common or
important bleeding problems which occur with
hemostatic defects, and the principles of management
for these problems.
SPECIFIC OBJECTIVES
At the end of this section, the student should
be able to:
1. list possible causes of bleeding problem given
either a clinical presentation of bleeding, abnormal
tests of hemostasis or both
2. List any additional tests required, if any to define
the precise cause of a bleeding problem.
3. Describe the clinical presentation and expected
laboratory abnormalities for common or important
bleeding problems; these include
Hemophilia, von Willebrand's disease,
Acquired coagulation deficiencies, secondary
to vitamin K deficiency, liver disease and DIC,
thrombocytopenia secondary to ITP,
consumption or decreased production.
4. Demonstrate an understanding of the use of
heparin and coumarin anticoagulants including
types of drugs, dosage, frequency and route of
administration for both prophylaxis and therapy of
thromboembolic disease
5. Describe the mode of inheritance for hereditary
coagulation disorders
6. Describe the use of Fresh Frozen Plasma,
Cryoprecipitate and Platelet concentrates in the
management of bleeding disorders, including
indications and contradictions for its use, expected
response and possible complications.
PLATELET / VASCULAR DISORDERS OF
HEMOSTASIS
CLASSIFICATION OF PURPURA (BRUISING)
THROMBOCYTOPENIC PURPURA
1. Decreased Production
a. Hereditary – very rare
b. Marrow suppression – medications, radiation,
alcohol, chemotherapy
c. Marrow infiltration – leukemia, metastatic
tumors
d. Marrow ineffective – megaloblastic,
dysmegakaryopoiesis
2. Decreased Survival
a. Immune – I.T.P, medications, sepsis, neonatal
3. Dilutional
a. Massive transfusion
NON-THROMBOCYTOPENIC PURPURA
1. Defective platelet function
a. Hereditary – von Willebrand's Disease
(VWD), defective aggregation
b. Acquired – medications, anemia, myelo-
proliferative diseases.
2. Vascular Disorders
a. Allergic (Henoch-Schonlein purpura)
b. Non-allergic – mechanical, senile, steroid,
dysproteinemia, connective tissue disorders.
APPROACH TO PATIENTS WITH BRUISING
(PURPURA)
In general, patients with thrombocytopenia,
defective platelet function, or vascular disorders tend
to bruise either with minimal trauma or even
spontaneously, depending on the severity of the
problem. The various factors tend to be additive ( i.e.
one would expect more bruising in an elderly patient
with defective connective tissues, who is
thrombocytopenia and taking Aspirin. Also the
combination of platelet/vascular disorders discussed in
this section with coagulation disorder discussed in
subsequent sections usually leads to more severe
bruising and bleeding problems than either would by
itself.
The commonest manifestations of these
disorders are bruises and petechiae involving the
muco-cutaneous surfaces. Petechiae appear as small (1
– 3 mm diameter) red spots, which do not blanch; they
may occur on any cutaneous or mucosal surface but
tend to be more evident on dependent areas, such as
legs in ambulatory patients. Widespread and/or
mucosal lesions indicate a serious problem.
In addition to these manifestations patients
with several platelet and vascular disorders may also
present with abnormal bleeding at many sites (e.g.
epistaxis, GI hemorrhage, cerebral hemorrhage,
intramascular hematomas, etc). Excessive bleeding
often occurs with surgery and trauma
CLINICAL ASSESSMENT
Special attention must be paid during the
interview to elicit information about current bleeding
and bruising problems as well as previous history,
including surgery, dental extractions and childbirth. A
meticulous enquiry into the use to drugs, medications
and alcohol is mandatory and the review of the family
history must be thorough to detect hereditary
problems. 70% of all hereditary bleeding diseases will
have an evident family pedigree
Physical examination should document the
extent and location of petechiae and bruises as well as
the presence of absence of other vascular
malformations e.g. telangiectasia, hematoma, confluent
hemorrhagic stomatitis. It is also important to rule out
Page 57 of 72
other underlying diseases such as liver disease or
hematologic disorders.
LABORATORY ASSESSMENT
1. CBC, Differential, Platelet count:
Platelet must be either estimated or counted in
a bleeding or bruising patient to document
thrombocytopenia. If the estimate made on
observation of the blood film is normal, this is
sufficient to rule out thrombocytopenia. If platelets
appear reduced, a platelet count is usually
performed to quantitate platlet number accurately.
Mordern cell-counter equipment provide accurate
counts rapidly, often alont with other
measurements (Hb, WBC, indices, etc); if this
equipment is not available then manual platelet
counts must be performed – these are more time
consuming and less accurate. When
thrombocytopenia is sever (<109/L) most
laboratories report it as such rather than providing
a figure since counts below that level cannot be
accurately measured.
All Abnormal platelet counts must be confirmed
by microscopic examination of a blood film.
The CBC and Differential are required to
determine whether a thrombocytopenia is selective
(usually indicating peripheral destruction, often
immune in origin) or associated with decrease in
other cellular elements (anemia, leucopenia)
and/or an abnormal differential (eg leukemia).
Morphology of the platelets is important to assess
eg. Abnormal shape or cytology
2. Coagulation Screening Tests:
If abnormal in a thrombocytopenic patient this
suggest involvement with coagulation system.
Certain diagnosis, such as D.I.C, liver disease /
hypersplenism and lupus require exclusion.
3. Bleeding Time:
This test is usually performed by making 2
short standard incisions on the patient's forearm,
often using a template to regulate the length and
depth of the incisions. The time taken for the
bleeding from the incisions to cease is a good
measure of the in vivo significance of
thrombocytopenia or platelet dysfunction.
It is usually performed in a bruising patient
with normal numbers of platelets to detect platelet
function abnormalities. If it is normal, and platelet
number is normal then no further platelet tests (eg
aggregation) are indicated. A prolonged bleeding
time in the presence of normal platelet number
implies a platelet function defect and further
studies may be indicated unless the cause is
evident (eg. Uremia) One should exclude the
recent ingestion of drugs which alter platelet
function (note that ASA may prolong the bleeding
time for up to 1 week) prior to ordering the test.
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.
4. Bone marrow:
A bone marrow aspirate and preferably a
biopsy will quickly differentiate between
thrombocytopenia due to decreased production
(decreased megakaryocytes) versus that due to
increased destruction (normal to increased
megakaryocytes) it is usually performed when the
cause for thrombocytopenia is not obvious by
other non-invasive tests, or clinical examination.
SIGNIFICANCE OF THROMBOCYTOPENIA
AND ASSOCIATED CLINICAL FINDINGS
Severe thrombocytopenia
(platelet count < 20 x 109/L and particularly < 10
x109/L) – risk of spontaneous bruising and
bleeding, which may be life threatening (eg.
Intracranial hemorrhage)
Moderate thrombocytopenia
(platelet count 20 – 80 x 109/L – may bruise with
mild trauma but usually not spontaneously;
excessive bleeding is likely to occur at surgery.
Mild thrombocytopenia
(platelet count 80 – 150 x 109/L) – no problem
expected with or without trauma or surgery.
NOTE:
1. Ingestion of drugs which affect platelet function
will make any degree of thrombocytopenia more
likely to cause bleeding/bruising and should be
avoided.
2. Intramuscular injections should be avoided in all
patients with platelet /vascular and coagulation
disorders to avoid development of intramuscular
hematomas.
3. Both the cause and the degree of
thrombocytopenia must be considered when
assessing the clinical significance of
thrombocytopenia (patients who are compensating
for increased platelet destruction such as I.T.P are
much likely to bleed than those suffering from
decreased platelet production such as patients with
leukemia and aplastic anemia.)
The role of platelet transfusions in the
management of patients with thrombocytopenia or
platelet dysfunction is outlined in a previous
section (Blood Transfusion Practice).
COMMON AND/OR IMPORTANT DISORDERS
Generally speaking the most common causes
of bleeding under the heading of “Platelet and Vascular
Page 58 of 72
Disorders" are thrombocytopenias. The most common
thrombocytopenias are probably:
1. Those seen with general marrow suppression or
aplasia produced whether accidentally (i.e.
Chloramphenicol, Phenylbutazone) or
therapeutically (i.e. Myelosuppressive drugs)
2. Those secondary to marrow infiltrations such as
leukemia and secondary tumor.
3. Hypersplenism
4. In association with D.I.C
5. The specific immune thrombocytopenias (ITP or
following certain drugs such as Quinine and
Quinidine, Heparin)
6. Association with infections, especially HIV
Other than the thrombocytopenias the platelet
function defect in association with Von Willebrand's
disease and with aspirin are important to be aware of
as are several of the vascular disorders such as the non-
allergic, non-thrombocytopenic simple purpuras seen
commonly in elderly and in patients on steroids, and
allergic (Henoch-Schonlein) purpura seen not
uncommonly in children.
The following are some comments regarding some
of the above subjects which are not covered elsewhere:
IMMUNE THROMBOCYTOPENIAS
Acute I.T.P
This disease occurs predominantly in children
of either sex consisting usually of a severe abruptly
onsetting thrombocytopenic purpura usually 2-21 days
following viral infection. Most recover spontaneously
in 1-2 months. It is important to rule out bacterial
sepsis as a cause.
Treatment with Prednisone 1-2 mg./kg or
intravenous gamma globulin 1g/kg is often given if
significant mucocutaneous hemorrhage is present. 80%
will recover regardless of treatment. 50% will have
normal platelets in 6 weeks and 80% are well in 6
months. Approximately 20% become chronic lasting 6
months or more and some remain severe enough to
require steroids or other immunosuppressive therapy
for 6-12 months with splenectomy only being
performed if no other therapies prevent significant
bleeding.
Chronic I.T.P:
This is a disease of adults occurring in 3:1 in
females, usually onsetting insidiously and rarely
resolve spontaneously.
Usual treatment is Prednisone 1 – 2 mg/kg
with a response in the platelet count usually occurring
in 3-4 days to 2 weeks. Splenectomy is considered if
no response occurs after several weeks of large doses
or in patients continuing to require Prednisone for
longer than 6 months or having major side effects and
continuing bruising and bleeding occurs. Because of
the extremely short life span of transfused platelets,
platelet transfusions are used only in life-threatening
hemorrhage.
PLATELET FUNCTION DEFECTS
VWD is one of the most common of the
hereditary hemostatic disorders. Other hereditary
platelet function disorders are rare.
The acquired platelet defect seen with ASA is
important as it is so common, and may aggravate other
hemostatic problems. The platelet defects seen in other
diseases are usually mild, but may cause serious
problems at surgery.
Treatment of vWD requires the injection of
DDAVP (arginine vasopressin) to release vWF from
the individual's endothelium or viral attenuated
products that contain vWF (eg. Humate-P)
VASCULAR DISORDERS
Allergic (Henoch-Scholein Purpura):
This disease is seen not uncommonly in
children, especially boys with peak incidence at 3- 7
years and usually occurring 1-3 weeks following an
upper respiratory infection. Onset is sudden with
malaise, headache, fever, urticarial rash, and 50% have
joint or abdominal pain. There are no specific lab
findings.
Treatment with corticosteroids is usually not
effective but commonly used in the sicker child with
joint and abdominal pain. The problem usually last 2-4
weeks but relapses are not uncommon.
Non-Allergic:
Non-thrombocytopenic purpuras such as
simple purpura (seen in 50% of healthy women) senile
purpura and steroid purpura are common but usually
very mild and require no treatment.
THROMBOCYTOSIS
Thrombocytosis applies to any patient with a
platelet count greater than normal (450 x 109/L). Mild
degrees are fairly common and usually not clinically
significant. Severe degrees (1,000 x 109/L) may result
in serious problems (eg CVA) particularly in patients
with underlying vascular disease or stasis. Therefore,
the management of these patients requires knowledge
of the platelet count, the cause of the increased
platelets, and the general medical/surgical condition of
the patient.
CLASSIFICATION
1. Primary:
a. Myeloproliferative disorders
b. Essential thrombocytosis
(thrombocythemia)
c. Associated with other myeloproliferative
disorders, eg. Myeloid metaplasia /
myelofibrosis, polycythemia, rubra vera,
chronic myelogenous leukemia
2. Secondary:
a. Post-splenectomy
b. Response to chronic bleeding
c. Iron deficiency
Page 59 of 72
 d. Chronic Inflammation / infection
e. Underlying malignancy
The diagnosis and management of patients
with primary thrombocytosis is discussed in the
myeloproliferative section of the Lymphadenopathy
and Splenomegaly Section.
In patients with secondary thrombocytosis the
cause may be obvious (post-splenectomy, iron
deficiency) but in others it may be very obscure (e.g.
underlying malignancy) and necessitate a thorough
search to detect what is sometimes a small primary
neoplasm. Patients with secondary thrombocytosis
rarely require treatment for the thrombocytosis itself
since it is usually mild (< 1000 x10 9/L),
uncomplicated and transient or reversible with
treatment of the underlying disease. Drugs that alter
platelet function (e.g ASA) may be used if
thrombocytosis is more sever, or occurs in a patient at
high risk for vascular occlusions but this is seldom
required.
Page 60 of 72
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
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
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
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)
3. 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.
4. 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.
5. 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
Page 61 of 72
 fibrinogen breakdown products. This test is
replacing FDP measurement in many laboratories
as it does not require special collection tubes.
HEREDITARY COAGULATION DEFICIENCIES
Hereditary deficiencies of each clotting factor
have been reported. Most of these deficiencies are very
rare; only deficiencies of Factor VIII (Hemophilia, and
VWD), Factor IX (Christmas Disease) and Factor XII
(Hageman deficiency) warrant more discussion. In
screening for all hereditary deficiencies, it is important
to remember what the INR, PTT tests measure at their
various levels of sensitivities.
Deficiencies of Factors XII, XI, IX, VIII
→ Prolonged PTT, Normal INR
Deficiency of Factor VII
→ Prolonged INR, Normal PTT
Deficiency of Factors X, V, II, I
→ Prolonged INR and PTT
CLASSICAL HEMOPHILIA (HEMOPHILIA A)
(Factor VIII Deficiency)
This is the commonest hereditary factor
deficiency. It is inherited as a sex-linked recessive
disorder, being manifest almost entirely in males, with
females as carriers. 25% of patients have no family
history.
The clinical problems vary with severity of the
deficiency. Mild hemophiliacs (5-30%) will only have
excessive bleeding with surgery or trauma, whereas at
the other end of the spectrum the severe hemophiliacs
(< 1% Factor VIII) are constantly threatened with
spontaneous hemorrhagic problems (mainly
hemarthrosis, intramuscular hematomas, and
hematuria)
All hemophiliacs must avoid injury, and
refrain from any medications (eg. ASA) which would
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
surgical procedures and then it should be given prior to
and post operatively until wound healing has occurred.
Moderate and severe hemophiliacs on the other hand,
will require regular infusions of Factor VIII
concentrate at onset of joint pain, or on a prophylactic
basis, often given by themselves on a home care
program monitored by a Hemophilia Centre; the
predictability, efficiency and ease of administration
outweigh the possible risks of disease transmission
such as hepatitis for these patients so commercial
factor VIII concentrates are favored. HIV infection is
not considered a significant contaminant since the
introduction of improved pasteurized concentrates in
1988. Further the recombinant factor IV is generated
through DNA technology. This makes it save from
infection point of view. However, formation of
antibodies directed to factor VIII is still a problem.
HEMOPHILIA B DISEASE (FACTOR IX
DEFICIENCY)
This deficiency is less common than
Hemophilia A but has the same inheritance and clinical
presentations depending on the severity of the
deficiency. It can only be differentiated by coagulation
factor assays which are only reliably performed in
laboratories experienced with these tests.
The same principle apply to the management
of factor IX deficiency as for factor VIII deficiency
regarding the need for surgical prophylaxis, and
adjusting type and frequency of coagulation factor
support depending on severity of deficiency and the
clinical circumstances. If the deficiency is mild to
moderate it should be corrected with plasma ( usually
FFP although stored plasma would suffice), but if
severe then adequate replacement would require
infusion of a commercial Factor IX concentrate (again
a pasteurized pooled lyophilized product with
decreased risk of viral borne disease transmission).
von WILLEBRAND’S DISEASE (VWD)
vWD is inherited as an autosomal dominant
disorder affected both males and females equally. In
addition to Factor VIII deficiency, which is usually
mild, the lack of von Willebrand factor also causes a
platelet dysfunction. Measurement of Factor VIII
coagulant and VWF antigen, VWF Ristocetin cofactor
are necessary for making a diagnosis. However they
carry a risk of thrombotic complications. Pure factor
IX also available.
The preferred treatment for such cases is
DDAVP. A cryoprecipitate is rich in vWF and is
generally administered in a dose of one bag per 10 kg
body weight. Certain virus-attenuated concentrates
(Humate-P) contain substantial amounts of vWF and
are preferred to cryoprecipitate if available.
HAGEMAN FACTOR DEFICIENCY (FACTOR
XII)
This deficiency is mentioned only to point out
that it may cause a prolonged P.T.T. and therefore must
be differentiated from other factor deficiencies (VIII,
IX, and XI) by appropriate Factor Assays. However, it
does not result in clinical bleeding problems since it is
a "contract factor" and therefore causes only an "in-
vitro" abnormality.
ACQUIRED COAGULATION DEFICIENCIES
VITAMIN K DEFICIENCY
The Vitamin K-dependent coagulation factors
are Factors II, VII, IX and X. If the factor deficiency is
mild only the INR is elevated, but if more severe then
both INR and P.T.T are elevated since coagulation
factors of both intrinsic and extrinsic systems are
Page 62 of 72
involved. The thrombin time and fibrinogen levels are
normal thereby differentiating Vitamin K deficiency
from either heparin effect (prolonged thrombin time
but normal fibrinogen) or liver disease (low fibrinogen,
also). Causes of Vitamin K deficiency include:
1. Dietary deficiency – this is most commonly seen
in ill patients on intravenous for 1-2 weeks
particularly if also on antibiotics which kill the
bacterial flora in the intestine.
2. New born (Hemorrhagic Disease of Newborn) –
prevented by routine vitamin K
3. Malabsorption
4. Chronic billiary tract obstruction
5. Oral anticoagulants – vitamin K antagonists
Patients who are at risk of developing Vitamin K
deficiency should receive prophylactic vitamin K,
usually by parenteral route.
Patients who have established vitamin K
deficiency should receive parenteral vitamin K (5-10
mg I.V) but this requires up to 8 hours to correct the
deficiency and up to 24 hours for this to be complete.
If the patient is bleeding and one cannot wait for
complete correction of the INR by the vitamin K then
plasma infusions can provide immediate but temporary
correction; 2-4 or more units, of FFP, are usually
required to correct the prolonged INR/PTT.
LIVER DISEASE
All coagulation factors except for factor VIII
are produced in liver, so severe liver disease is
associated with a decrease in most factors. Often
platelets are also reduced due to hypersplenism and
since fibrinolysis is also increased the multiple
abnormalities (prolonged INR, P.T.T, T.T., decreased
fibrinogen, platelets and increased FDP) mimic those
seen with D.I.C
Except in uncomplicated obstructive liver
disease the coagulation defects are not corrected by
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
completely correct the coagulopathy). If
thrombocytopenia is moderate to severe then platelet
transfusions may also be used.
DISSEMINATED INTRAVASCULAR
COAGULATION (D.I.C)
This occurs when there is a generalized
activation of the coagulation factors with the final
elaboration of thrombin turning fibrinogen to fibrin. It
results in fragmentation of RBC's, consumption of
coagulation factors and platelets, deposition of fibrin
and stimulation of secondary fibrinolysis. As a result
there is anemia, hemolysis, thrombocytopenia,
coagulation deficiencies (prolonged INR, P.T.T. , T.T.,
decreased fibrinogen), and increased FDP.
CAUSES
1. Pregnancy-related
- abruptio placenta, retained placenta
- septic abortion
- amniotic fluid embolism
- eclampsia
2. Infections
- especially gram negative septicemia
3. Surgery
- especially prostate surgery, and surgery on
cancer patients
4. Immediate Hemolytic Transfusion Reaction
- Eg. ABO incompatibility
5. Malignancies
- mainly prostate Ca., promylelocytic leukemia
As mentioned previously, the multiple hempostatic
abnormalities of liver disease closely mimic D.I.C and
diagnosis is very difficult in jaundiced patients. There
are also other conditions which present with
fragmentation hemolysis and thrombocytopenia (eg.
Thrombotic thrombocytopenic purpura or T.T.P., and
Hemolytic-Uremic Syndrome, or HUS) where fibrin
formation (thrombin activation) has not occurred.
MANAGEMENT OF D.I.C INVOLVES:
1. Aggressive treatment of underlying cause
- evacuation of uterus for obstetrical
complications
- broad spectrum I.V. antibiotics for septicemia
2. Replacement of deficient (consumed) factors and
platelets
- FFP or possibly cryoprecipitate for coagulation
defects
- Platelet concentrates for thrombocytopenia
- Some clinicians also advocate heparin to stop
the activation of coagulation, but most do not
since these patients frequently bleed much
more when heparinized. It is more likely to be
ordered for patients who have subacute or
chronic D.I.C. often when the underlying
cause cannot be quickly controlled (eg
promyelocytic leukemia, prostate cancer).
DILUTONAL COAGULOPATHY
During the management of serious bleeding
problems with massive transfusions (e.g. Greater than
50% of blood volume exchange in 24 hours) there is a
decline in coagulation factors since the replacement
products (packed red cells, crystalloid or albumin
solutions) do not contain coagulation factors. If stored
plasma is also used it will lack labile factors (V and
VIII)
Therefore it is appropriate to monitor INR and
P.T.T in massively transfused patients, or preferably to
supply FFP judiciously (e.g. 1 unit FFP for each 1-2
equivalent units of stored plasma, 5% albumin or
crystalloid) after a total blood volume exchange has
occurred in a short period to prevent the development
of a coagulopathy. Platelets are also not present, or
functionless, in most blood components, but significant
thrombocytopenia from dilution during massive
transfusion usually takes much longer to develop than
Page 63 of 72
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
transfusion usually takes much longer to develop than ­ Recurrent fetal loss
does the coagulopathy. Platelets are also not present, or
functionless, in most blood components, but significant Types of thrombophilia:
thrombocytopenia from dilution during massive 1. Hereditary
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
veins in the lower leg and the thigh. It involves the c. Dysfibrinolytic disorder:
formation of a clot (thrombus ) in the larger veins of ­ Dysplasminogenemia
the area. This clot may interfere with circulation, and it ­ tPA deficiency
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
when a blood clot, generally a venous thrombus, ­ G20210A prothrombin gene mutation
becomes dislodged from its site of formation and ­ Dysfibrinogenemia
embolizes to the arterial blood supply of one of the ­ Homocysteinemia
lungs.
2. Acquired
Pathogenesis:
Thrombosis is most often due to combinations of a. Antiphospholipid antibody syndrome
Virchow’s triad: b. Malignancy
­ Hematological : . PNH
• Problems with the vessel wall (i.e. . Acute promyelocytic leukemia
atherosclerosis) . PNH
• Problems with the blood flow (i.e. sluggish or
turbulant flow) - Oncologic: .Pancreatic
• Problems with the blood contents (i.e. low . Gastric
natural anticoagulant levels) . Mucin secreting
c. Nephrotic syndrome
Venous thrombosis is more predominantly a fibrin- d. 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
APCR
THROMBOPHILIA APTT <1.9 females
[HYPER COAGULABLE STATE] Secondary causes of Protein C deficiency:
­ Warfarin therapy
Who should be investigated? ­ Liver disease
­ DIC
­ Venous thrombosis < 40 years
­ Arterila thrombosis < 30 years Secondary causes of Protein S deficiency:
­ Recurrent thrombosis (more than one ­ Liver disease
episode) ­ DIC
­ Thrombosis at unusual sites (Buddchiari, ­ Nephrotic syndrome
Portal vein, Sagital sinus)
Page 64 of 72
 ­ Pregnancy
Secondary causes of AT-III deficiency:
­ Heparin therapy
­ Nephrotic syndrome
­ DIC
­ Liver disease
Symptoms and Investigations:
DVT: leg pain, tenderness, swelling (edema), increased
warmth, and change in skin color (redness)
The presence of deep venous thrombosis may be
detected by:
• venography of the leg
• doppler ultrasound
• plethysmography
• positive D-dimer test
PE
Signs of PE are sudden-onset dyspnea, tacypnea, chest
pain of "pleuritic" nature, cough hemoptysis, and in
severe cases, hypotension, shock, loss of
consciousness, and death. Although most cases have
no clinical evidence of deep venous thrombosis in the
legs, findings that indicate this may aid in the
diagnosis.
ECG may occasionally show right heart strain (the
"S1Q3T3 pattern).
The Gold standard for diagnosing pulmonary
embolism (PE) is still pulmonary angiography. In most
of the cases, however, when PE is suspected on the
basis of shortness of breath and chest pain, the
following scans may confirm the presence of an
embolus:
"Ventilation-perfusion scan" (or V/Q scan), which
shows that some areas of the lung are being ventilated
but not perfused with blood (due to obstruction by a
clot). Increasingly, the V/Q scan is being replaced with
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
at a rate of 18 u/kg/hr., then adjust dose
according to APTT.
­ Alternatively, start LMW heparin, dose per
body weight and no need for laboratory
monitoring.
- Start coumadin within 24 hour of starting heparin,
monitor INR that need to be maintained at 2 – 3. Once
this range achieved for at least 2 days you may
discontinue heparin. Warfarin therapy often requires
frequent dose adjustment and monitoring of the INR.
In proximal DVT and PE, INR between 2.0 and 3.0 are
generally considered ideal. If another episode of DVT
or PE occurs under warfarin treatment, the INR
window is often increased to 3.0-4.0 (unless there are
contraindications).
­ Continue with warfarin therapy for at least 6
months. or "lifelong" if there have been
previous DVTs or PEs.
Treatment outcome:
- DVT recurrence: during heparin therapy< 5 %
during warfarin therapy < 2 %
during the first year 2–5%
­ Most recurrence have hereditary or acquired
thrombophilia
­ 20 % of thrombophilic patients have recurrence in
1 year
­ > 50 % of thrombophilic patients have recurrence
in 5 years
Page 65 of 72
ANTITHROMBOTIC AGENTS
HEPARIN
Structure – A potent organic acid which is a
mixture of sulphate containing mucopolysacchiarides
with molecular weights between 3,000 – 30,000 strong
negative charge, prepared from animal tissues.
Mechanism of Action – combines readily
with plasma proteins, notably Antithrombin III
(heparin co-factor). Heparin markedly accelerated the
inhibition action of AT III on thrombin and Factors
XII, XI, IX and X. Heparin also activates lipoprotein
lipase. It does not cross the placenta.
Administration – continuous intravenous
infusion or intermittent bolus and subcutaneous (NOT
INTRAMUSCULAR)
Onset – I.V. – immediate maximum effect; s.c.
– gradual effect and maximum 2-3 hours
Duration of Effect – mean half life is 60
minutes in normal; shortened with extensive
thrombosis and pulmonary embolism; prolonged
slightly in renal failure.
Degradation and Excretion – Degraded in
the liver in large doses, some is taken up by R.E.S and
a small amount may remain unbound in the plasma.
Antidote – Protamine sulphate – I.V. – slowly;
effective immediately 10 mg for 1,000 units Heparin;
100 mg. maximum at one time; decrease dose
according to time elapsed since Heparin given to allow
for half life decline in the infused heparin.
Major Uses – thromboplebitis; pulmonary
embolism; artificial pumps and filters (i.e renal dialysis
and bypass pumps)
Contraindications – active bleeding sites –
i.e. GI tract; known hemostatic defect i.e. factor VIII
deficiency; recent CNS surgery; thrombocytopenia;
severe hypertension.
Problems – Bleeding; uncommon, rarely fatal;
occasionally produces thrombocytopenia; antiplatelet
drugs enhance bleeding and should not be used (i.e.
Aspirin)
Monitoring – Heparin prolongs various
clotting test times (anticoagulant effect) in direct
proportion to the amount of heparin in the sample
tested. P.T.T (activated partial throboplastin time);
therapeutic range is 60-80 seconds; dependent on
laboratory method and should be approximately 1½ - 2
times control range.
Dosage and Control:
1. Continous I.V: 5,000 u bolus I.V, then 280
u/hours in 5% d/W or saline, use hourly mini drip
chamber (syringe pump better if available); check
P.T.T 2 x daily and adjust accordingly; if too low,
give 5,000 u bolus and increase drip rate.
2. IV.Bolus: 5,000 – 10,000 u Q 4th P.T.T just prior to
next dose should be therapeutic
3. Prophylaxis: 5,000 u q.8h or q.12 h., sc for
surgical cases start on admission, or 2h.
preoperative and continue q. 8-12 h. postoperative;
peak P.T.T 2-3 hours after injection should be
below the therapeutic range.
Note: The P.T.T is also prolonged by warfarin
derivates. Perform a CBC count every three days while
on heparin to avoid heparin induced anemia or
thrombocytopenia.
Low-Molecular-Weight Heparin
Low-molecular-weight heparin is a relatively new
class of anticoagulants that are derived from standard
heparin through either chemical or enzymatic
depolymerization. Whereas standard heparin has a
molecular weight of 5,000 to 30,000 daltons, low-
molecular-weight heparin ranges from 1,000 to 10,000
daltons, resulting in properties that are distinct from
those of traditional heparin.
Mechanism of Action:
-Binding of LMW heparins to antithrombin accelerates
the inhibition of coagulation factor Xa and thrombin
about 1000-fold
-Unlike unfractionated heparin, which blocks thrombin
and factor Xa equally well, LMW heparins primarily
block coagulation factor Xa
Advantages of Low-Molecular-Weight
Heparin
The clinical advantages of low-molecular-weight
heparin include predictability, dose-dependent plasma
levels, a long half-life and less bleeding for a given
antithrombotic effect. Furthermore, immune-mediated
thrombocytopenia is not associated with short-term use
of low-molecular-weight heparin, and the risk of
heparin-induced osteoporosis may be lower than the
risk with the use of standard heparin. Low-molecular-
weight heparin is administered according to body
weight once or twice daily, both during the high-risk
period when prophylaxis for DVT is recommended
and also when waiting for oral anticoagulation to take
effect in the treatment of DVT. The activated partial
thromboplastin time (aPTT) does not need to be
monitored, and the dosage does not need to be
Page 66 of 72
adjusted. Since low-molecular-weight heparin is given
subcutaneously, outpatient administration by the
patient, with or without the assistance of a visiting
nurse or family member, is both possible and cost-
effective.
Preparation (trade name):
• Dalteparin sodium (Fragmin)
• Enoxaparin sodium (Clexane)
• Nadroparin calcium (Fraxiparin)
• Tinzaparin sodium (Innohep)
WARFARIN DERIVATES: (COUMADIN)
Structure – A water-soluble derivative of
Coumeric Acid;
Mechanism of Action – not clear; bound to
albumin; acts in the liver to block the synthesis of the
Vitamin K dependent Factors (II, VII, IX, X), and,
therefore, interfere with both the intrinsic (II, IX and
X) and extrinsic (II, VII, X) system – may block an
enzyme regulating Vitamin K metabolism or may be a
competitive inhibitor of Vitamin K for specific sites on
regular protein.
Administration – by mouth;
Onset and Duration of Effect – does not
destroy circulating factors but prevent production;
therefore dependent on half-life of the above factors
which range from 3 or 4 hours to 72 hours,
prothrombin time may be therapeutic in 3-4 days but
full therapeutic effect requires 3-5 days.
Degradation and Excretion – not absolutely
clear, probably the liver; degradation products excreted
in the urine.
Antidote – Vitamin K1 (p.o. or I.V. ; takes a
minimum of 8-12 hours for effect
a) mild INR increase – 1-2 mg Vit K po or SC
b) For severe hypoprothrombinemia alone – 5-10 mg
Vitamin K1
c) If accompanied by bleeding – 25 mg. Vitamin K1
+ plasma
Major uses – Prophylaxis + treatment of –
thrombophlebitis, pulmonary embolism, embolic heart
disease i.e rheumatic mitral valve disease
Treatment – follow Heparin therapy for the
above.
Contraindication – active bleeding sites, specially
GI; known hemostatic defet – i.e. Factor VIII
deficiency; recent C.N.S surgery, unreliable patient or
no laboratory control; liver and kidney disease
(relative); pregnancy; thrombocytopenia.
Problems
1. Enhance the Effect of Coumadin – decreased
Vitamin K absorption, i.e. malabsorption,
pancreatic disease; decreased gut production of
vitamin K, i.e. broad spectrum antibiotics;
displacement of albumin binding site, i.e.
phenylbutazone.
2. Decrease the Effect of Coumadin – (require
increased dosage of Coumadin) liver micro-
enzyme inducer, i.e. barbiturates.
Dosage and Control – 10 mg p.o. for 2-3 days
according to INR, and then a maintenance dose
according to INR (usually about4 mg daily). The
warfarin dose should be administered at a consistent
time of the day and the INR blood sample should be
drawn at a consistent time of day.
INR, therapeutic range:
a. Simple Venous Thromboembolism INR of 2.0 –
3.0
b. Arterial and Valvular Prosthesis INR of 3.5 – 4.5
Frequency should be daily initially, lengthening to one
weekly or at the most every other week once well-
controlled.
Page 67 of 72
PROBLEMS FOR TUTORIALS
HEMOSTASIS / THROMBOSIS
1. A YOUNG BOY WITH SWOLLEN KNEE
A 1-year old infant was noted to ooze intermittently
from a circumcision, and his thigh had become swollen
and tense following a vitamin K injection. He was born
at term to a 26-year old gravida IV para III woman
following an uneventful pregnancy. Delivery was
vaginal over a small midline episiotomy, and he cried
vigorously. The mother's health had always been
excellent, and she denied any abnormal bleeding or
bruising. Her family history was likewise unrevealing.
Before the infant was transferred to the neonatal
special unit, the following studies returned:
Hemoglobin 167g/L
Hematocrit 52%
Platelet count 339 x 109/L
White blood cell count 19.4 x 109/L
Prothrombin time (PT) 30 sec (nl 10-16 sec)
Activated partial thromb- 115sec (nl 31-55 sec)
oplastin time (aPTT)
On examination, the infant was pink, easily aroused,
and had good muscle tone. Bright red blood discolored
the circumsion dressing. The left thigh was swollen, its
circumference measurably larger than the right. A
repeat hematocrit several hours later was 37%, the
aPTT was 105 sec and the PT was 16 sec. Coagulation
studies were as follows: factor XII: 60% (nl 13-93%);
factor XI: 45% (nl 10-66%); factor IX: 39% (nl 25-
91%); factor VIII: less than 1%(nl 40-180%); factor
XIII screen: normal; fibrinogen: 2.55 g/L (nl 1.67-4.0)
Questions:
1. What is your interpretation of the Lab
findings?
2. How the presentation is different in those with
Platelet dysfunction?
3. How would you manage this patient?
4. What would be your advice for the parents ?
Two months later this mother brought her baby to the
emergency room because he had cried inconsolably all
night. By that age he had attained the expected
milestones and was generally an active, happy baby.
The mother denied that he had any fever but noted that
he did not use one arm at all. Any attempt to move it
caused him to cry. On examination, none of his joints
or muscles was swollen or tender; but trying to bend
one elbow made him cry. Within an hour of infusing
factor VIII concentrate, all symptoms subsided.
At age 6 years, the patient was seen at an annual
multidisciplinary clinic for routine evaluation. At age
5, his parents began home care, injecting him with
factor concentrates after thorough training by the
hemophilia center staff. Now he is bright, very active
boy who seems to seek out precisely those games and
stunts from which his parents have tried to discourage
his participation. His infusions are at times difficult
because he squirms. To avoid them he does not
consistently inform his parents until pain is severe, or
he begins to limp noticeably. A re-view of a year's
infusion records reveals he had 68 bleeding events
requiring 78 infusions, mostly involving knees and
ankles. A disproportionate number involved his right
ankle and were repeated the next day because of
persistent pain and swelling. For the most part, pain
began in school and his parents infused him at home,
often hours later. In the clinic he appeared to walk
normally, but his right ankle was swollen, nontender,
but boggy to palpation. Its range of motion was
slightly decreased. An X-ray revealed moderate
demineralization of the adjacent bones but no
narrowing of the joint spaces, subchondral cyst
formation, or bony spurs. Pertinent laboratory studies
showed only mildly elevated ALT: 65 U; AST: 72U
(normal levels less than 40 U/mL)
1. What do you make of this follow up
information and what would you recommend
to this patient
2. What further tests would you order
2. A BLEEDING YOUNG WOMAN
Brenda, a 14-year-old girl, came to the emergency
room with 18 days of profuse vaginal bleeding and
with pallor and weakness. This was her second
menstrual period, and because it was painful, she had
taken several aspirins. She denied any recent sexual
activity and said she had always been in perfect health.
A age 12, however, she had bled so much after a tooth
extraction that her dentist had to pact and suture the
bleeding site. Like one of her younger brothers, she
bruised easily. Her father had once required a blood
transfusion after a tonsillectomy but had an uneventful
postoperation course following a herniorrhaphy.
Her blood pressure was 110/60 recumbent and 90/50
sitting up; resting pulse was 100. She was dizzy and
anxious when she was upright. Her abdomen was soft
and nontender; and no masses were felt. On bimanual
pelvic examination, the uterus was midline, anteverted
and normal in size; the adnexae were soft and
nontender. There was much blood flowing from an
intact cervical os to the vagina.
The laboratory findings were as follows:
Hemoglobin 60g/L
MCV 85 fL
WBC 16.4 x 109/L, with normal differential
Page 68 of 72
aPTT 39 sec (nl 33-27 sec)
PT 14 sec
Pregnancy test negative
She was admitted to the hospital and received one unit
of packed red blood cells and two 25-mg doses of
conjugated equine estrogen, with some improvement.
She later received a progestational agent. She was
discharged on medroxyprogesterone for 10 days. On
next visit, a bleeding time was 12 min (nl less than 9
min), and the following clotting studies were obtained:
aPTT 38.5 sec (nl 27-37 sec)
PT 14 sec (nl 11-14 sec)
Factor XII 60% (nl 52-164%)
Factor XI 72% (nl 67-127%)
Factor IX 73% (nl 55-163%)
Factor VIII:C 38% (nl 40-149%)
Factor VIII:Ag 35% (nl 40-149%)
Ristocetin cofactor 45% (nl 50-150%)
Questions:
1. What is the clinical presentation suggests
2. How do you interpret the lab data
3. How would you manage this patient
4. Comment on inheritance mode
3. FEVER AND COAGULOPATHY
3 years old boy was brought to the emergency unit by
his mother. The child has been unwell for the past three
weeks with fever and loss of appetite. He has been
diagnosed to have an upper respiratory tract infection
by the family doctor and was given Amoxill but
without any improvement. Two days before
presentation, the mother noticed the appearance of
pinpoint reddish spots on his shins and arms.
The boy has been generally well, received all his
vaccinations and does not have any known illness or
allergies.
On examination, the boy was fully conscious but
irritable. Temp: 39ºC. There was a big bruise on his
forehead and petechial hemorrhages on his legs, arms
and abdomen. Examination of the neck revealed the
presence of two small lymph nodes in the cervical
region.
Examination of the chest and heart was normal.
Examination of the abdomen was normal apart from
feeling a splenic tip.
Investigations showed:
WBC: 40 x 109 /L
Hb.: 105 g/L Normal Male: 140-180, Female: 120-
140
Platelets: 25 x 109 /L N 150 - 400
Prothrombin time (PT): 20 sec (control 13 s) / INR:2
APTT: 60 (control 38 s)
Thrombin Time (TT): 20 (control 14 s)
Fibrinogen: 1.7 g/L (N2 – 4)
D- dimer 4000 (N < 500)
Questions:
1. Comment on the results of the tests? Comment
on the peripheral blood film below.
2. What is your presumptive diagnosis?
3. How would you manage this patient?
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,
which took place at a new teething site. The mother
mentioned that the child also bled profusely following
a circumcision, which was done at the age of two
months. Apart from these two incidents, the child has
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
non- consanguineous but the mother mentioned that
she has a brother who is a “bleeder”.
On examination, the child was healthy, a febrile,
oozing blood from a teething site. He also had few
bruises on his shins. Examination of the chest,
abdomen was normal
Investigations revealed:
WBC: 6.9 x 109 /L
Hb. 120 g /L
Platelets: 345 x 109 /L
PT : 15 s (N 10 – 14s)
APTT : 55 s (N 25 - 35 s)
Fibrinogen 3.2 g/L
D-dimer: 200 μg/ml (N <500)
Bleeding time 5 min (N 2-7)
Question:
1. What is your presumptive diagnosis?
2. How would you prove this diagnosis?
3. How would you manage this patient?
5. BLEEDING GUMS AND BRUISING
A 23- year woman came to the emergency room
complaining of bruises over the body and bleeding
gums for the preceding 36 hours. The patient never has
never had easy bruisability, epistaxis, gum bleeding, or
bleeding into the joints. Menarche was at age 13 and
Page 69 of 72
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
A Doppler ultrasound of the right leg revealed
thrombus in the popliteal and superficial femoral vein.

On physical examination the patient is a well- Investigations:

developed young woman without pallor or jaundice. CBC
Vital signs are normal. Fundoscopic examination is HB 121 g/L
unremarkable. There is oozing of the gingivae with RBC Count 4 x 1012/L
several small hemorrhagic bullae on the buccal Hct 0.41
mucosa. There is an ecchymoses and oozing in the MCV 85 fl
right antecubital area secondary to venipuncture and MCH 31 pg/L
there are several ecchymoses and multiple petechiae MCHC 340 pg/L
on both lower extremities. There is no palpable RDW 13
adenopathy or splenomegaly. The remainder of the WBC 12 x 109/L
examination is normal. Platelets Count 280 x 109/L

Laboratory Data Coagulation Screen

APTT 26 seconds
PT 13 / 12 –second control INR: 1 PT 11.4 seconds
APTT / 33 –second control 30 second INR 1.0
WBC 6x109/L – normal differential Fibrinogen 2.5 g/L
HB 125 mg/L
Platelets 8,000/mm3 Specific Tests
Test 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
for? 2. What conditions or situations may have
5. What is your differential diagnosis of predisposed to this event?
thrombocytopenia in this patient? Given the most 3. What are the causes of hypercoagulable state?
likely diagnosis how would you manage this 4. Discuss the management of this patient under the
patient? following headings:
­ Anticoagulant therapy
­ 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.
Page 70 of 72
 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
8. POST OPERATIVE DVT
Four days after a left nephrectomy, a 45 year old man
developed a deep vein thrombosis in his left leg. He
had no respiratory symptoms. The foot of the bed was
elevated and he was given IV injection of Heparin,
5000 units, followed by a continuous IV heparin
infusion at 1000 units per hour. Later on his
anticoagulation was changed to coumadin orally.
Questions:
1. List 3 techniques which might have helped prevent
the DVT
2. The intern orders "Coumadin 10 mg daily", what is
wrong with this?
3. The intern orders "INR daily", what is wrong with
this order?
After 10 days of coumadin therapy, he
complained of nausea, and faintness. He
had a large melena stool. He was pale,
clammy and perspired profusely. Pulse
was 110/min and regular. Blood pressure
was 95/96 with significant postural drop.
Hemoglobin was 110 g/L., (down from his
last known Hb of 130 g/L. three days
earlier) INR = 6.1
4. Describe your management under the following
headings:
a. Amount of coumadin you would prescribe?
b. What medication would you order, how much
and by what route?
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?
2. List 3 possible causes for the thrombocytopenia.
3. Explain the elevated INR and P.T.T.
4. The intern orders:
a. bleeding time – is this a reasonable
order
5. Discuss your management regarding
a. Initial I.V. order
b. The anemia
c. The thrombocytopenia
d. The coagulation defect (2 points)
10. FEVER POST SPLENECTOMY
A 60 year old man was admitted to hospital with a
three day history of fever, rigors, cough and yellow
sputum and pleuritic left lower chest pain. He had been
previously been healthy except for a previous
splenectomy 12 years before following a traumatic
rupture of his spleen in a farm accident. On
examination he was very ill with a high fever and signs
of pulmonary consolidation in the lower lobe of his left
lung. Pulse was 140/minute and blood pressure 130/60.
He had many petechiae and bruises on his trunk and
extremities.
Laboratory Investigations:
Hemoglobin 116 g/L
WBC 15 .5 x 109/L
.68 neutrophils
.16 bands
.02 metamyelocytes
.01 myelocytes
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 .13 lymphocytes 5. After three weeks there has been little response to
RBC fragmentation ++ treatment, and splenectomy is advised; what
Howell Jolly bodies + chance is there of complete remission of the
Platelet count 26 x 109/L thrombocytopenia with splenectomy? – 50%, 80%,
Reticulocyte count 60 x 109/L 100%
INR 3.5 seconds 6. What is the main long-term risk of splenectomy?
P.T.T 80 seconds What could you do in an attempt to avoid this
Thrombin Time 18/9 seconds complication?
Fibrinogen 0.5 g/L 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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