Year 5 haematology tutorial 2019

Prepared by Professor B. J. Bain

and Dr Donald Macdonald

Clinical presentation

• A young woman presented with a facial rash and vague aching in her joints

• A few months later she became very tired and on examination was found to have jaundice and her spleen was tipped on inspiration

Image from http://dxline.info/diseases/

Laboratory tests

• FBC: – WBC 12.3 x 109/l (NR 3.9‒11)

– RBC 2.17 x 1012/l (NR 3.88‒4.99)

– Hb 80 g/l (NR 118‒148)

– Hct 0.22 l/l (NR 0.36‒0.44)

– MCV 102 fl (NR 82‒98)

– MCHC 360 g/l (NR 316‒349)

– Platelets 110 x 109/l (NR 169-358)

– Reticulocyte count 257 x 109/l (NR 50-100)

Make a note of everything that

is abnormalBy the end of

the tutorial you should be able

to explain them all

Laboratory tests

• Biochemistry

– Bilirubin 33 µmol/l (<17)

– Alanine transaminase 50 iu/l (5-42)

– Alkaline phosphatase 178 iu/l (100-300)

– Lactate dehydrogenase 657 iu/l (200-450)

– Creatinine 72 µmol/l (60-125)

Make a note of everything

that is abnormal

By the end of the tutorial you should be able to

explain them all

What would you do next?

• What tests would you do?

Make a list

What would you do next?

• Bilirubin was largely unconjugated

• What types of jaundice do you know and how do you distinguish between them?

• What type of jaundice do you think this is?

Differential diagnosis of jaundice

What would you do next?

• The patient’s blood film looked like this

• What is the main abnormality seen?

• Name two causes of this abnormality and work out the mechanism of their formation

What are the arrows pointing to?

What is the underlying disease ?

• What test would you do to confirm the nature of the anaemia?

• Explain the principle of this test

• What is the underlying disease?

• How would you confirm this diagnosis?

• The platelet count was 110 x 109/l (NR 169-358) ‒ how do you explain this?

Test?Principle?

Underlying diagnosis?Platelet count?

How would you treat the patient?

• Would transfusion be a good idea?

• How would you manage her?

Transfuse?Management?

CASE 2

• A 22 year old women attends A+E

• 3 month history of cough, tiredness and losing weight

• Today feels “unable to breath “

• On examination, 4 cm supraclavicular fossa mass– Harsh bronchial breath sounds

What are the key investigations ?

• Describe the main abnormality. • State the differential diagnosis. • Next investigation?

Low power High power

Biopsy ‒ a lymphoid lesion showing fibrous bands in the background and a polymorphous infiltrate composed of histiocytes, small lymphoid cells, many eosinophils, few plasma cells and a good numbers of large atypical cells.

• What is the diagnosis?• Key next investigations?

PET CT scan

• What Stage is this ?• Is this a curable cancer?• How would you treat ?

Complete Metabolic Response(CMR)

• After ABVD x4 chemotherapy CMR• Would you now treat with radiotherapy?

• Benefits?• Risks?

•Is this young woman now infertile after ABVD chemotherapy ?

Case 3 (Leukocytosis)• A 40-year old woman attends a GP surgery with

tiredness and recurrent headaches. She has had a recent flu like illness

• On examination, there is 6 cm of splenomegaly

• FBC:

– WBC 120.3 x 109/l (NR 3.9‒11)

– Hb 150 g/l (NR 118‒148)

– Platelets 490 x 109/l (NR 120-400)

Is this a reactive leukocytosis or a leukaemia?Is a chronic or acute leukaemia more likely, why?What further information do you need about the WBC?

Marked leukocytosis. Left shifted granulopoiesis with all stages maturation seen. Blasts seen but represent <5% circulating WBCs. Apparent increase in basophils and eosinophils.

•What is the likely diagnosis?•One test to confirm this?•What is the natural history ?•How would you treat this disorder?

DAT (i)

Direct antiglobulin test (i)

From Bain BJ, Interactive Haematology Imagebank, 2nd Edn, Wiley-Blackwell, Oxford, 2014

Supplementary information

DAT (ii)Direct antiglobulin test (ii)

From Bain BJ, Interactive Haematology Imagebank, 2nd Edn, Wiley-Blackwell, Oxford, 2014