Hematology Quick review

Hematology : Hematology Gujarat Academy Of Medical Sciences www.gamspg.webs.com Dr. Tanmay Mehta

58 y female who had backache and recurrent chest infection for 6 months , develops sudden weakness of legs and urinary retention . Ix shows Hb 7.3 / Calcium 12.6/phosphate 2.6/ALP 100 /albumin 3 /globulin 7.1 /urea 178. most likely diagnosis : (AI 06) : 58 y female who had backache and recurrent chest infection for 6 months , develops sudden weakness of legs and urinary retention . Ix shows Hb 7.3 / Calcium 12.6/phosphate 2.6/ALP 100 /albumin 3 /globulin 7.1 /urea 178. most likely diagnosis : (AI 06) Lung cancer Disseminated TB Multiple myeloma Osteoporosis C

Slide 3 : Independent Plasma cell proliferation M spike / BJP NCNC anemia Infection bleeding Bone involvement Hypercalcemia Hyperviscocity Neurological involvement

Multiple Myeloma Kahler's disease : Multiple Myeloma Kahler's disease 60 years Hypercalcemia, osteoporosis,, Punched out lytic bone lesions, bone pain = precipitated by movement =most common symptom Persistent localized pain = pathologic fractures MC site = vertebra > rib > skull Easy fatigue—anemia (NCNC) MC cause of death =Recurrent infections > Renal failure (Hypercalcemia is the most common cause of renal failure)= The earliest manifestation of this tubular damage is the adult Fanconi syndrome (a type 2 proximal renal tubular acidosis)= pseudohyponatremia Neurologic symptoms Bleeding/clotting disorder= Hyperviscosity Normal/low ALP Max ESR IL-6 The most common infections are pneumonias and pyelonephritis, and the most frequent pathogens are Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae in the lungs and Escherichia coli and other gram-negative organisms in the urinary tract.

Slide 5 : 1major + 1 minor Or 3 minor MIMP

MM + bony lesion ; best marker for prognosis of disease :(AIIMS 99,00) : MM + bony lesion ; best marker for prognosis of disease :(AIIMS 99,00) BM plasma level Serum calcium Beta2 microglobulin Beta 1 microglobulin Serum creatinine Beta2 microglobulin + albumin Hb M component : Ig G ; Ig A ; BJP

Myeloma Staging Systems : Myeloma Staging Systems Durie-Salmon staging system Stages 1, 2 and 3 of the Durie-Salmon staging system can be divided into A or B depending on serum creatinine: A: serum creatinine < 2mg/dL (< 177 umol/L) B: serum creatinine > 2mg/dL (> 177 umol/L)

Best marker for prognosis : Best marker for prognosis B2 microglobulin level : single most imp B2 microglobulin + albumin : best S. creatinine Hb , S calcium , bone lesion , M component

Kylie & Greipp : Kylie & Greipp Plasma cell >10% M spike in serum and urine 1 evidenceof organ dysfunction Ca++ Renal failure Anemia Bony lesion- lytic lesion, osteoporosis, >30% plasma cell in BM BM plasma cell labelling index >1% Future Q

Treatment : Treatment Patients with symptomatic and/or progressive myeloma require therapeutic intervention In patients who are transplant candidates alkylating agents such as melphalan should be avoided since they damage stem cells, leading to decreased ability to collect stem cells for autologous transplant. High-dose pulsed glucocorticoids either alone or in combination VAD for initial cytoreduction Thalidomide + dexamethasone are as effective and convinient In patients who are not transplant candidates intermittent pulses of an alkylating agent L-phenylalanine mustard / melphalan and prednisone Bortezomib for treating relapsed multiple myeloma and mantle cell lymphoma. proteasome inhibition may prevent degradation of pro-apoptotic factors, permitting activation of programmed cell death in neoplastic cells dependent upon suppression of pro-apoptotic pathways.

Waldenström's Macroglobulinemia : Waldenström's Macroglobulinemia Disease of B-cell hybrid of lymphocyte & plasma cell Secrete IgM > 3 g/dl Hyperviscocity syndrome Lymphadenopathy & HSM No renal damage (large IgM cannot be excreted in urine) No osteolytic Lesion Rx: plasmapheresis for hyperviscocity Fludarabine & cladarabine

POEMS Syndrome : POEMS Syndrome Polyneuropathy = progressive sensorimotor polyneuropathy Organomegaly = hepatomegaly and lymphadenopathy Endocrinopathy =Hyperprolactinemia ; Type 2 diabetes mellitus ; Hypothyroidism and adrenal insufficiency multiple myeloma skin changes

Franklin Disease is assosiated with (AIIMS 95) : Franklin Disease is assosiated with (AIIMS 95) Gamma chain heavy ds MM Alpha chain heavy ds Waldenstrom macroglobulinemia

Heavy Chain Diseases : Heavy Chain Diseases Gamma Heavy Chain Disease (Franklin's Disease) most distinctive symptom is palatal edema, resulting from involvement of nodes in Waldeyer's ring, and this may progress to produce respiratory compromise anomalous serum M component [often <20 g/L (<2 g/dL)] Alpha Heavy Chain Disease (Seligmann's Disease) most common of the heavy chain diseases Mediterranean lymphoma an infiltration of the lamina propria of the small intestine with lymphoplasmacytoid cells chronic diarrhea, weight loss, and malabsorption Demonstrating alpha heavy chains is difficult because the alpha chains tend to polymerize and appear as a smear instead of a sharp peak on electrophoretic profiles

Slide 15 : A 61-year-old woman presents with increasing fatigue and pain in her lower back and hip. X-rays reveal multiple punched-out lytic bone lesions, especially in the pelvis. Laboratory examination find increased serum calcium and protein but normal serum levels of albumin. Serum protein electrophoresis reveals a single large spike in the gamma region. Which of the following changes is most likely to be seen in a bone marrow biopsy from this individual? A. Diffuse infiltration of myeloblasts B. Few cells with increased reticulin C. Multiple sheets of plasma cells D. Paratrabecular lymphoid aggregates E. Scattered atypical and immature megakaryocytes

Slide 16 : A 61-year-old woman presents with increasing bone pain and is found to have multiple lytic bone lesions along with hypercalcemia. A bone marrow biopsy finds more than 80 percent plasma cells infiltrating the marrow, but no increased monoclonal protein (M spike) is found in the peripheral blood. Which of the following is the most likely diagnosis? A. Bence Jones proteinuria B. Heavy chain disease C. IgA multiple myeloma D. Plasma cell leukemia E. Waldenstrom macroglobulinemia

Slide 17 : The classic clinical triad of symptoms in individuals with MM is the combination of: hypercalcemia, multiple lytic bone lesions, and increased plasma cells in the bone marrow. These neoplastic plasma cells secrete large amounts of immunoglobulin, the components of which can be detected with serum and urine protein electrophoresis as M proteins (monoclonal immunoglobulins). However, this M spike may not be seen if Bence Jones proteins are present. These Bence Jones proteins are fee immunoglobulin light chains. They are small proteins and can be filtered into urine. Bence Jones proteins are important because if the neoplastic plasma cells secrete only Bence Jones proteins, they will be filtered into the urine from the blood, and no M spike will be seen with serum protein electrophoresis.

Slide 18 : During a routine physical examination, a 65-year-old asymptomatic man is found to have elevated serum proteins as a result of the presence of an abnormal M spike. His serum calcium level is normal, and no lytic bone lesions are found. A bone marrow aspiration and a biopsy reveal approximately 5 percent plasma cells within the marrow. Which of the following is the most likely diagnosis? A. Gamma heavy chain disease B. Immunoproliferative small intestinal disease C. Langerhans cell histiocytosis D. Monoclonal gammopathy of undetermined significance E. Waldenström macroglobulinemia

Diagnostic Criteria : Diagnostic Criteria

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CD markers : CD markers B-cell = 19,20,22 T-cell = 1-8 except 6 Lymphoid = Tdt Myeloid = 13,33,11b,15,117,cMPO Monocytic =14,11b Eryhtroid = glycophorin A Megakaryocyte = 41,61 Lineage independent LCA =45 Stem cell = 34 CALA(common acute lymphoblastic leukemia antigen) =10

Acute Leukemia : Acute Leukemia Acute ≥ 30% blasts in BM (FAB) ≥ 20 % blasts in BM (WHO)

Acute Myeloid Leukemia : Acute Myeloid Leukemia Men ; 15-39 years ; incidence increases with age Heredity Down syndrome defective DNA repair, e.g., Fanconi anemia, Bloom syndrome, and ataxia telangiectasia Congenital neutropenia (Kostmann syndrome) PNH ,AA , MDS

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Slide 34 : Cytochemistry : MPO = more specific Sudan black = more sensitive Nonspecific esterase = M4,5 ; 25% of M3 PAS = ALL ; M6,7AML Flow cytometry : AML = CD 13,33,43,117,15 , Anti MPO Monocyte = CD 14 (M4,5) Erythrocyte = glycophorin A ; CD 36 (M6) Megakaryocyte = CD 41,61

Prognosis : Prognosis GOOd Age <40 No MDS TLC < 25,000 t(8;21)=M2 T(15;17)= M3 Inv(16)=M4E0 BAD Age : <2 & >55 Following MDS : Monosomy 5,7 or 5-/7- TLC > 1 lakh 11q23- : M4 ,M5 M0,M6,M7 Complex karyotype 1 question every year

Treatment : : Treatment : M3 = all tranretinoic acid  arsenic trioxide Bad prognosis = induction CT  allogenic BMT Good prognosis = only CT (no BMT required)

Acute Lymphoid Leukemia (ALL) : Acute Lymphoid Leukemia (ALL) Children ; <15 year B cell =MC = abdominal mass = < 4 yr= CD 19+ = t(12;21) T cell = mediastinal mass = adolescents =CD 1 =TALL gene rearrangement > 20 % blasts (>90% usually) PAS + (MPO- , SB – except L3) Tdt + = lymphoblasts Testes & CNS can be involved

Prognosis : Prognosis good Female 3 – 7 year TLC < 10,000 L1 No LN , HSM , testes ,CNS Early pre B Hyperploidy (>50) T(12;21) bAD Male <1,>10 yr > 2,00,000 L2 , L3 + Tcell Hypoploidy (<46) T(4,11)=MLL gene ;t(9,22) 1 Q every year Treatment : CT Intrathecal Mtx and cranial irradiation in CNS involvement

MPD : MPD Old age ; splenomegally (least size in ET) ; Hb/TLC/Pc = N/increased (D/D from MDS);eosinophil/basophil =increased ; BM = trilineage hyperplasia one predominate (monoclonal proliferation)  end stage : AML (ALL/CML) or myelofibrosis

Chronic myelogenous leukemia : Chronic myelogenous leukemia CML = philadelphia chromosome =t(9;22) =abl-bcr fusion protein (210 KD)= tyrosine kinase activity Philadelphia chromosome is also seen in acute leukemia = 190 KD protein is formed Most sensitive methods to detect Ph chromosome = FISH , RT-PCR

Prognostic factors : : Prognostic factors : Sokal index Based on CT treated patients Age Spleen size % of circulating blasts Platelet count Cytogenetic clonal evaluation Hasford system Based on IF-alpha treated patients Age Spleen size % of circulating blasts Platelet count % of basophils & eosinophils

Treatment : : Treatment : DOC : imatinib mesylate = Gleavac competitive inhibition at the ATP binding site of the Abl kinase in the inactive conformation, which leads to inhibition of tyrosine phosphorylation of proteins involved in Bcr/Abl signal transduction Imatinib induces apoptosis in cells expressing Bcr/Abl. It shows specificity for Bcr/Abl, the receptor for platelet-derived growth factor, and Kit tyrosine kinases. Imatinib is administered orally. The main side effects are fluid retention, nausea, muscle cramps, diarrhea, and skin rashes Myelosuppression is the most common hematologic side effect imatinib Dasatinib  IF-alpha  Allogenic BMT

Overlapping MDP-MDS : Overlapping MDP-MDS Jcml/jmml (juvenile myelomonocytic leukemia) <2 yr old Abrupt onset Monosomy 7 (7q-) Anemia , thrombocytopenia , HSM ,HbF raised , skin rash , PH –ve Monocytosis Poor prognosis CMML (chronic myelomonocytic leukemia) Middle age-elderly male MDS Ph –ve No basophilia/eosinophilia Thrombocytopenia

Polycythemia Vera : Polycythemia Vera MC MPD = high Hb or Hct a mutation in the autoinhibitory, pseudokinase domain of the tyrosine kinase JAK2[ janus kinase]—which replaces valine with phenylalanine (V617F), causing constitutive activation of the kinase—appears to have a central role in the pathogenesis of PV.{>90% pv & 50% ET ,MF} short arm of chromosome 9 aquagenic pruritus Thrombosis : Mc cause of death Relative polycythemia (pseudo) : N red cell mass = geissbock syndrome True polycyhtemia : high red cell mass Idiopathic (PV): N Epo Secondary to hypoxia and tumours : high Epo Treatment : periodic phlebotomy Lestaurtinib (CEP701) is a JAK2 inhibitor = under trial High red cell mass : >36 (M) & >32(F) ml/kg Arterial O2 saturation >92% (r/o hypoxia) Splenomegally In absence of splenomegally : leukocytosis (>12,000) & Thrombocytosis (>4 lakh) Max LAP score >100 ESR = zero Raised S.B12 & B12 binding capacity

Essential Thrombocytosis : Essential Thrombocytosis Idiopathic Secondary = MPDs , IDA , splenectomy , h’ge 40-70 y , M=F Bleeding [ >10 lakh –acquired VWD ] & thrombosis DVT p/c > 4.5 lakh after r/o other causes Ph –ve , N red cell mass , marrow iron+ No MF , No MDS (5q deletion MDS – high platelet) Splenomegally An elevated platelet count in an asymptomatic patient without cardiovascular risk factors requires no therapy Acquired VWD -aminocaproic acid salicylates alone, IFN-, the quinazoline derivative, anagrelide, or hydroxyurea to decrease P/c

Idiopathic myelofibrosis : Idiopathic myelofibrosis r/o secondary causes ofmyelofibrosis : MPD, metastatic ca , TB , Sarcoidosis MC cause of myelofibrosis = Metastatic Ca Myelofibrosis  myelophthisic Anemia Intially trilineage hyperplasia (cellular phase) PDGF , TGF , EGF fibrotic phase Tear drop cells Leuco erythroblastosis NAP = high BMA – dry tap  BM Bx is essential.

MDS : MDS FAB RA (refractory anemia) RARS (>15% ring sideroblast) RAEB (5-20% excess blastsinmarrow) RAEB-t (21-30% blasts) CMML Last two are overlapping MDS-MPD, so not includedin WHO WHO RA RARS RCMD (refractory cytopenia with multiliniage dysplasia) RAEB-1 (5-9% blasts) RAEB-2 (10-19% blasts) MDS-U (unclassified) 5q deletion Hypolobulated megakaryocyte Bilobed neutrophil (pseudo pelger huet anomaly) Neutrophils are hypogranulated; have hyposegmented, ringed, or abnormally segmented nuclei; contain Dohle bodies; and may be functionally deficient Dimorphic anemia MC cytogenic abnormality in MDS =monosomy 5 > monosomy 7 5q deletion syndrome Best prognosis Respond to LENALIDOMIDE Old female

NHL : NHL

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Precursor B-cell acute lymphoblastic leukemia/ lymphoma : Precursor B-cell acute lymphoblastic leukemia/ lymphoma Bone marrow precursor B-cell expressing TdT and lacking surface Ig Diverse chromosomal translocations; t(12;21) involving CBFa and ETV6 most common rearrangement Predominantly children with symptoms relating to pancytopenia secondary to marrow involvement; aggressive

Chronic Lymphoid Leukemia/Small Lymphocytic Lymphoma : Chronic Lymphoid Leukemia/Small Lymphocytic Lymphoma BM > 20 % lymphocytes CLL & SLL differs only in degree of peripheral blood lymphocytosis (in CLL >5000/mm3) represents the most common lymphoid leukemia, and when presenting as a lymphoma, it accounts for ~7% of non-Hodgkin's lymphomas. Immunophenotyping : B-cell (98%) = CD 19,20 +,CD 23 +, CD 5 – ,FMC – , CD 27(Memory B-cell) T-cell (2%) [ normally T-cell>B-cell ; but in all NHL B-cell > T-cell] LN = proliferation centres, collection of large cells around small cells Peripheral blood = smudge cell = basket cell Warm Ab AIHA ;AI thrombocytopenia

Slide 55 : NOT asso with any environmental /occupational exposure Ataxia telengectasia increase risk 13q14 (Rb gene deletion) = MC ch anomaly = good prognosis 11q deletion = increase risk of LN Trisomy 12 = bad prognosis Elderly (>60) ; M:F= 2:1 ; mostly asymptomatic Generalised LN & hepatosplenomegally May transform to aggressive lymphoma in form of : Prolymphocytic transformation (15-30%) Diffuse large B-cell lymphoma = richter syndrome (10%) No acute leukemia

Slide 56 : TOC = CT ; rituximab (CD-20) & Alemtuzumab (IgG1) in resistant cases ;splenectomy for AIHA ; Allogenic BMT in younger patients MC cause of death = infection Increase risk of second malignancy = HD ,melanoma ,CNS , lung

Mantle zone lymphoma : Mantle zone lymphoma CD 5 + , CD 23- t(11:14)= overexpress the BCL-1 protein=cyclinD-1 combination chemotherapy followed by radiotherapy

Extranodal Marginal Zone B Cell Lymphoma of Malt Type : Extranodal Marginal Zone B Cell Lymphoma of Malt Type associated with H. pylori infection Most MALT lymphomas are gastric in origin autoimmune or inflammatory process such as Sjögren's syndrome (salivary gland MALT), Hashimoto's thyroiditis (thyroid MALT), Helicobacter gastritis (gastric MALT), C. psittaci conjunctivitis (ocular MALT), or Borelia skin infections (cutaneous MALT). Microscopic hallmark= lymphoepithelial lesion Localized- Rx- RT,Sx,anti pyloric drugs

Follicular Lymphoma : Follicular Lymphoma composed of small cleaved and large cells organized in a follicular pattern of growth- nodules t(14;18) and abnormal expression of BCL-2 most common presentation =new, painless lymphadenopathy most responsive to chemotherapy and radiotherapy

Diffuse Large B Cell Lymphoma : Diffuse Large B Cell Lymphoma most common type of non-Hodgkin's lymphoma 60 years Aggressive : Immunodef asso(EBV) Body cavity lymphoma (primary effusion lymphoma ) – HHV-8 /KSHV mediastinal diffuse large B cell lymphoma. has a younger median age (i.e., 37 years) and a female predominance (66%) CHOP plus rituximab

Burkitt's Lymphoma/Leukemia : Burkitt's Lymphoma/Leukemia t(8;14) =c-myc or one of its variants, t(2;8) (c-myc and the light chain gene) or t(8;22) (c-myc and the light chain gene) endemic,- mandible , lidney ,ovary , adrenal Sporadic – ileocecum,peritoneum immunodeficiency-associated (HIV) The neoplastic cells are homogenous, medium-sized B cells with frequent mitotic figures, a morphologic correlate of high growth fraction. Reactive macrophages are scattered through the tumor and their pale cytoplasm in a background of blue-staining tumor cells give the tumor a so-called starry sky appearance. Extranodal : metastasize to the CNS Very aggressive Children = L3 ALL CT - cyclophosphamide

Hairy cell leukemia : Hairy cell leukemia older males + pancytopenia +Splenomegaly (D/D –MDS) Flow cytometry markers = CD 11c , CD 25 , CD 103 –most important & most specific BMA :dry tapBMBx :fibrosis (honeycomb/fried egg appearance) [D/D:MF,AA] DBA 44 – markerof BMBx malignant cells ="hairy" projections =characteristic staining pattern with tartrate-resistant acid phosphatase(TRAP) cladribine

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Mycosis Fungoides : Mycosis Fungoides cutaneous T cell lymphoma 50 , male ,black indolent lymphoma generalized erythroderma and circulating tumor cells, called Sézary's syndrome Plaque ,nodules ,Pautrier microabcess (CD-4 T cell) Epidermotropism Monro’s abcess= psoriasis = neutrophils

Adult T Cell Lymphoma/Leukemia : Adult T Cell Lymphoma/Leukemia HTLV-I retrovirus pleomorphic abnormal CD4-positive cells with indented nuclei, which have been called "flower" cells RS like cells = CD 15- , CD 30-

Anaplastic Large T (indolent)/Null Cell Lymphoma (aggresive) : Anaplastic Large T (indolent)/Null Cell Lymphoma (aggresive) CD30 (Ki-1) antigen t(2;5) and/or overexpression of ALK protein [Anaplastic Lymphoma Kinase](good prognosis) Horseshoe nucleus , cytokeratin+ , CD45(LCA) + = bad prognosis Rx=DLBCL but B cell–specific antibody, rituximab, is omitted

Peripheral T Cell Lymphoma : Peripheral T Cell Lymphoma Extranodal T/NK cell lymphoma of nasal type angiocentric lymphoma lethal midline granuloma EBV Aggressive Hemophagocytic syndrome Enteropathy-type intestinal T cell lymphoma Untreated celiac disease

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Hodgkin's Disease : Hodgkin's Disease Nodular Lymphocyte-Predominant (LP) CD 45 , 20 + CD 15 ,30 – Best prognosis Can convert to NHL Classical Hodgkin's Disease = CD 15,30+ CD45,20- Lymphocyte rich (LR) Lymphocyte depleted (LD)= least common , worst prognosis Mixed = MC type in India Nodular scelrosis (NS) = MC type WW Popcorn cell = LP Reticular cell = LD Classical RS = mixed Lacunar cell =NS Bimodal age (young & >45) , Males (NS – M=F) Cervical & axillary LN (NS – mediastinal LN) B symptomps (fever , night sweats , wt loss) – poor prognosis

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All true regarding Hodgkin’s lymphoma except: : All true regarding Hodgkin’s lymphoma except: CNS is MC site of involvement Characteristic cell is RS cell Mediastinal involvement is common in nodular sclerosis Eosinophils , plasma cells and neutrophils increase A

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Heparin-Induced Thrombocytopenia : Heparin-Induced Thrombocytopenia not usually severe not associated with bleeding and, in fact, markedly increases the risk of thrombosis antibodies to heparin/PF4 HIT and thrombosis (HITT). ELISA prompt discontinuation of heparin use of alternative anticoagulants :direct thrombin inhibitors (DTIs) argatroban and lepirudin . Bivalirudin & antithrombin-binding pentasaccharide fondaparinux : not approved by FDA Danaparoid After few days of DTI patients with thrombosis, patients can be transitioned to warfarin, with treatment usually for 3–6 months. In patients without thrombosis, the duration of anticoagulation needed is undefined

ITP : ITP peripheral antibody induced platelet consumption =no reliable test for detecting In children =an acute following an infection = self-limited course. In adults = chronic course No splenomegally

Wiscott-Aldrich syndrome : Wiscott-Aldrich syndrome XR = males Thrombocytopenia[Initial bleeding episodes usually occur during adolescence and are severe (e. g., cerebral hemorrhage).], immune deficiency, and eczematoid dermatitis predominantly affecting the face WASP gene autoimmune diseases such as ulcerative colitis and vasculitis

Hemophilia : Hemophilia XR : males mutations in the F8 gene (hemophilia A-classic hemophilia=80%) or F9 gene (hemophilia B). most common hemophilia A mutations intron 22 hemarthroses , hemorrhages,hematomas The FVIII half-life of 8–12 h requires injections twice a day to maintain therapeutic levels, whereas the FIX half-life is longer, ~24 h, so that once-a-day injection is sufficient Non-Transfusion Therapy DDAVP: moderate or mild only (no store in severe) EACA Hepatitis C virus (HCV)> HIV

Inhibitor Formation: : Inhibitor Formation: Patient do not respond to factor replacement at therapeutic doses. aPTT mixed with normal plasma 1:1 abnormally prolonged Bethesda assay: BU is the amount of antibody that neutralizes 50% of the FVIII or FIX present in normal plasma after 2 h of incubation at 37°C low responders, those with titers <5 BU:high doseshuman or porcine factor8 50–100 U/kg high-responder patients—those with initial inhibitor titer >10 BU : prothrombin complex concentrates (PCCs) or activated PCCs /recombinant activated Factor VII (FVIIa) rituximab

von Willebrand Disease : von Willebrand Disease most common inherited bleeding disorder Types : 1 = AD = Mc type 2A, 2B,2M = AD 2N = AR = factor 8 binding is low= affect both femaleand male [D/D hemophilia affect male only]= autosomal hemophilia 3 = AR Acquired vWD= lymphoproliferative disorders,MGUS,MM, Heyde's syndrome (aortic stenosis with gastrointestinal bleeding) -type 2 BT ,aPTT prolonged ;PT=N Defective ristocetin induced agglutination (hyper in 2B & pseudoVWD (gp1b) and absent in other types) Hemophilia C = AR = factor 11 deficiency

AR disorders : BT & VWF normalrecurrent episodes of severe mucosal hemorrhage : AR disorders : BT & VWF normalrecurrent episodes of severe mucosal hemorrhage Bernard solieur syndrome Ib –IX Platelet ADHESION Binds VWF to platelt Platelet aggregation is normal in response to collagen , ADP , thrombin but FAILS in risotectin Thrombocytopenia Large platelet local application of pressure, topical thrombin and platelet transfusion. Glanzman thromboasthenia IIb-IIIa Platelet AGGREGATION Binds fibrinogen to platelet Platelet aggregation is abnormal in response to collagen , ADP , thrombin but aggregate normally in response to risotectin

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DIC : DIC The most common causes are bacterial sepsis, malignant disorders such as solid tumors or acute promyelocytic leukemia (APL), and obstetric causes widespread intravascular fibrin formation in response to excessive blood protease activity that overcomes the natural anticoagulant mechanisms coagulation tests [aPTT, PT, thrombin time (TT)] FDP (most sensitive) D-dimer (most specific) Platelet count ,BT

Slide 87 : DIC Rx Control hemorrhage: The replacement of 10 U of cryoprecipitate for every 2–3 U of FFP is sufficient to correct the hemostasis Clotting factor concentrate not recommended. Platelet concentrate in thrombocytopenia in DIC Control coagulation : heparin, antithrombin III (ATIII) concentrates, or antifibrinolytic drugs Protein c concentrate

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Slide 89 : Inherited Intracellular Defects Membrane : hereditary spherocytosis Enzyme : G6PD , PK Hemoglobinopathies : Hb S thalasemia Extracellular Defects Intravascular Hemolysis Extravascular Hemolysis Intracellular : Acqired : PNH

Hemoglobinuria does not occur in: : Hemoglobinuria does not occur in: Cuso4 poisoning Snake bite Mismatched BT Thalassemia D Only point that differentiate betwwen extra/intra vascular hemolysis is presence of Hb/hemosiderin in urine

HEREDITARY SPHEROCYTOSIS : HEREDITARY SPHEROCYTOSIS AD Increased OF : "pink test” : diagnostic Ankyrin > Band 3 (anion channel) >Band 4.2 {pallidin}>Spectrin Splenomegally + gall stones Normocytic anemia : high MCHC splenectomy spleen itself is a major site of destruction; on the other hand, transit through the splenic circulation makes the defective red cells more spherocytic and therefore accelerates their demise, even though lysis may take place elsewhere current guidelines (not evidence-based) are as follows. Avoid splenectomy in mild cases. Delay splenectomy until at least 4 years of age, after the risk of severe sepsis has peaked. Antipneumococcal vaccination before splenectomy is imperative, whereas penicillin prophylaxis postsplenectomy is controversial. HS patients often may require cholecystectomy. It used to be considered mandatory to combine this procedure with splenectomy, but this may not be always necessary. High OF (RBC lysis at >o.5% saline)= spherocyte on P/S = coomb’s test (r/o AIHA)

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Not a feature of HS : Not a feature of HS Increased OF Increased MCHC Increased MCV Decreased surface area perunit volume C Loss of membrane  low suraface area per unit volume

G6PD DEFICIENCY : G6PD DEFICIENCY X-linked : males Most common enzymatic disorder of RBCs Asymptomatic > neonatal jaundice (NNJ) bizarre poikilocytes with red cells that appear to have unevenly distributed hemoglobin (hemighosts) and red cells that appear to have had parts of them bitten away (bite cells or blister cells). Heinz bodies, consisting of precipitates of denatured hemoglobin with methyl violet MetHb reduction test (screening) :pink(N),Brown (G6PD : metHb not reduced)

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Hb-S : Hb-S B-6 glu  val AR Homo/hetero Pain crisis Autosplenectomy Acute chest syndrome Aplastic crisis Hydroxyurea HbC = B6 glulys Hb E = B26 glu  lys ESR = low Sickling test = 2% Na-K metabisulphate Solubility test = Na dithionite. Hb Electrophoresis: 2 bands HPLC

Thalessemia : Thalessemia MC congenital HA in India. Intron mutation (IVS 15) > 619 bp deletion are MC cause of beta thalassemia in INDIA Reduced or absent production of one or more hemoglobin chains silent (trait), to mild, intermediate or severe (major). Screening test – NESTROF (Naked Eye Single Tube Red Cell Osmotic Fragility Test) -Low OF HPLC > Hemoglobin electrophoresis is the gold standard.[Hb A2 > 3.5 to 8 gm% diagnostic of Bthal trait ]

Slide 100 : 4 genes Alpha = ch 16 2 genes Beta = ch 11

Slide 101 : Intron/prmoter mutation = B+ Exon /splice junction mutation = B0

Autoimmune Hemolytic Anemia (AIHA) : Autoimmune Hemolytic Anemia (AIHA) most common form of acquired hemolytic anemia Evans's syndrome: AIHA + AI thrombocytopenia first-line treatment of AIHA is glucocorticoids second-line treatment measures include long-term immunosuppression Severe acute AIHA can be a medical emergency : transfuse incompatible blood The immediate treatment almost invariably includes transfusion of red cells. This may pose a special problem because if the antibody involved is "unspecific," all the blood units cross-matched will be incompatible. In these cases it is often correct, paradoxically, to transfuse incompatible blood, the rationale being that the transfused red cells will be destroyed no less but no more than the patient's own red cells, and in the meantime the patient stays alive Idiopathic Lymphoma : CLL,NHL SLE methyldopa + DCT (RBC) + ICT (serum) Warm Ab IgG

Slide 103 : Cold Agglutinin Disease (CAD) chronic AIHA Elderly IgM Ab : anti-I specificity hemolysis is more prominent the more the body is exposed to cold Waldenström macroglobulinemia Blood transfusion is not very effective because donor red cells are I-positive and will be removed rapidly. rituximab gave a response rate of 60% Mycoplasma , IM (EBV) Paroxysmal Cold Hemoglobinuria (PCH) rare form of AIHA Children Ig G Ab self-limited viral infection Donath- Landsteiner Ab In vitro this antibody has unique serologic features: it has anti-P specificity and binds to red cells only at a low temperature (optimally at 4°C), but when the temperature is shifted to 37°C, lysis of red cells takes place in the presence of complement. Consequently, in vivo there is intravascular hemolysis, resulting in hemoglobinuria

Coomb’s positive HA seen in : Coomb’s positive HA seen in Alcoholic cirrhosis Chronic active hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis A Alcoholic cirrhosis is not an autoimmune condition

Paroxysmal Nocturnal Hemoglobinuria (PNH) : Paroxysmal Nocturnal Hemoglobinuria (PNH) normo-macrocytic sucrose hemolysis test is unreliable acidified serum (Ham) test is carried out in few labs[CDA-2] gold standard today is flow cytometry, which can be carried out on granulocytes as well as on red cells CD59(MIRL)–, CD55(DAF)– PNH AA TOC : BMT[any young patient with severe PNH] eculizumab, directed against the complement C5 PNH-AA syndrome, immunosuppressive treatment with antilymphocyte globulin (ALG or ATG) and cyclosporine A may be indicated Low LAP score = PNH , chronic phase of CML High LAP score = polycythemia , leukemoid reaction , infection

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True about PNH except : : True about PNH except : Hemosiderinuria Pancytopenia Raised ALP Cellular Marrow C Raised LDH

Thrombotic Thrombocytopenic Purpura (TTP) : Thrombotic Thrombocytopenic Purpura (TTP) Hemolysis with fragmentocytes renal insufficiency thrombocytopenia, fever, and central nervous system dysfunction, due to microinfarctions , myocardial infarction Inherited as well as an inhibitor-induced deficiency of the protease that cleaves von Willebrand factor (vWF) (ADAMTS-13, a disintegrin and metalloprotease with thrombospondin motif 13)  increased VWF  activates platelets  thrombosis of small vessels = HUS (no CNS manifestation)

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Slide 114 : Hb = 14-18 (M) ; 12-16 (F) Hb A2 = 1.5 -3.5 % of total Hb Hb F = <2 % of total Hb S. Iron = 50 -150 µg/dl % saturation transferrin = 30-50% S. Ferritin = 50-250 µg/L TIBC = 300 -600 µg/dl

Sideroblastic Anemia : Sideroblastic Anemia Sideroblast = erythroid precursors with demonstrable cytoplasmic iron Defect = in incorporating iron into Hb within RBC Hypochromic microcytic / dimorphic Iron indices high Hereditary – XL Chronic Alcoholism Pyridoxine deficiency Lead poisoning ATT / chloramphenicol

Aplastic Anemia : Aplastic Anemia pancytopenias with diminished production of all cell lineages in the bone marrow and lack of an apparent cause for the aplasia chloramphenicol, phenytoin, gold preparations, and probably the sulfonamides non-A, non-B, non-C hepatitis, or acute mononucleosis Pallor + bleeding + infections No spleomagally D/D = MDS

Pure Red Cell Aplasia (PRCA, Erythroblastopenia) : Pure Red Cell Aplasia (PRCA, Erythroblastopenia) Congenital = Diamond–Blackfan anemia Acquired =parvovirus B19 (acute) ; thymoma (chronic) in adults and children Normochromic reticulocyte count is extremely low, close to zero

congenitaldyserythropoietic anemias (CDA) : congenitaldyserythropoietic anemias (CDA) childhood or youth and may be normocytic or macrocytic. The bone marrow shows increased erythropoiesis with multinucleated erythroblasts,nuclear fragmentation, and cytoplasmic bridges. There are three types type II carries the so-called HEMPAS antigen: hereditary multinuclearity with positive acidified serum lysis test.

Reticulocytosis is not seen in : Reticulocytosis is not seen in PNH Acute blood loss HS Anemia in CRF D High Rc in hemolysis/bloodloss Low Rc in AA/nutritional def anemia

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Iron Overload : Iron Overload Hereditary Hemochromatosis Cys282Tyr mutation in HFE gene, on chromosome 6p Transferrin saturation. If >50% (women) or >60% (men), AR Thalassemias Chronic Transfusion Hereditary Aceruloplasminemia Friedreich’s Ataxia • Frataxin gene, located on chromosome 9 HCC DCM DM Arthropathy Pitutary Hypogonadism Listeria & yersinia enterocolitica Hyperpigmentation Freidriech’s ataxia

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