Differential Diagnosis

Hematologic Disorders

Hematologic Disorders

Primary hematologic diseases are uncommon Commonly see hematologic manifestations

due to other diseases In PT setting, most commonly see symptoms

due to use of NSAIDs, neurologic complications associated with pernicious anemia and complications of chemotherapy or radiation

Common symptoms of hematologic disorders Changes in the hands and fingernail beds Symptoms of dyspnea, weakness, fatigue

and palpitations Neurologic symptoms

Headache Drowsiness Dizziness Syncope Polyneuropathy

Easy bruising and bleeding

Complete Blood Count (CBC)

Male Female Hematocrit (%) 39 - 49 33 - 43

Hemoglobin (gm/dl) 14 – 18 12 – 16

RBC Count (cell/mm3) 4.2 – 5.4 3.6 – 5

Diameter 7.3 – 7.5 μ MCV 85 – 100 μm3

MCH 28 – 31 pg

MCHC 30 – 35 gm/dl RDW 11.5 – 14.5 %

Complete Blood Count (CBC)

Total WBC 4 – 11 x 103 / mm3

Differential PMN (Segs) 45 – 70%

(Bands) 2 – 6% Lymphocytes 15 – 45%

Eosinophils 1 – 6% Basophils 0 – 2% Monocytes 1 – 10%

Platelets 145 – 400 x 103 / mm3

Erythrocyte Disorders - Anemia

Reduction in the oxygen-carrying capacity of the blood

Results from abnormality in either the quantity or quality of erythrocytes

Most common causes are excessive blood loss, increased destruction of erythrocytes and decreased production of erythrocytes

Erythrocyte Disorders - Anemia

4 broad categories seen in PT: Iron deficiency associated with GI blood loss

secondary to NSAID use Chronic and inflammatory disorders such as

RA or SLE Neurologic conditions seen with pernicious

anemia. Common complication of chemotherapy and bone marrow metastasis

Infectious diseases such as TB or AIDS and neoplastic disease or cancer

Erythrocyte Disorders - Anemia

With slow onset, symptoms may not be noticeable until hemoglobin concentration and hematocrit levels are 50% depleted

Symptoms of rapid onset include dyspnea, weakness and fatigue, and palpitations

No change in systolic BP, but diastolic BP may be lower than normal

Increased resting pulse rate

Erythrocyte Disorders - Anemia

Pale hands Evaluate at heart level Although pale, hands should feel warm

Diminished exercise tolerance With progression of anemia, dyspnea,

tachycardia and palpitations begin to occur at rest

Exercise should be prescribed cautiously and monitored closely in anemic patients

Erythrocyte Disorders - Polycythemia

AKA erythrocytosis Increase in both the number of RBCs and the

concentration of hemoglobin Increased whole blood volume and increased

blood viscosity Increased tendency and risk of clotting Increased viscosity diminishes blood supply

to the brain and other vital tissues May contribute to formation of thrombi

Erythrocyte Disorders - Polycythemia

Primary – Relatively rare neoplastic disease of the bone marrow

Secondary – As a result of decreased oxygen supply to the tissues High altitudes Heavy tobacco smoking Chronic heart and lung disorders (especially

congenital heart defects)

Erythrocyte Disorders - Polycythemia

Symptoms are often vague and unnoticeable Often diagnosed after a sudden complication

(stroke or thrombosis) Occasionally exhibit symptoms of increased

skin coloration and elevated blood pressure Gout is sometimes a complication Patients may develop peripheral neuropathies If untreated, can lead to gangrene and loss of

tissue

Erythrocyte Disorders – Sickle Cell Anemia Autosomal recessive disorder with an

abnormal form of hemoglobin Genetic defect causes the hemoglobin to

aggregate in long chains and alters the shape of the cell

The sickled or curved shape of the cell causes it to be unable to squeeze through tiny blood vessels

Tissue is therefore deprived of adequate blood supply and oxygen

Sickle Cell Anemia

Erythrocyte Disorders – Sickle Cell Anemia Pain is most common acute symptom

Due to formation of clots Ischemic tissue damage may last for 5-6 days

Stress from infection, dehydration, emotional disturbances, fever, strenuous physical exertion or fatigue may increase symptoms

CVA is the most severe manifestation

White Blood Cells

Neutrophils Increase – infection, glucocorticoids, uremia,

RBC destruction Decrease – chemotherapeutics, viral &

overwhelming bacterial infection, dialysis Increased risk of infection

Lymphocytes Increase – viral infections, TB, leukemia Decrease – HIV (TCD4)

Decreased immunosurveillance

White Blood Cells

Monocytes Increase – Leukemia, TB, collagen vascular

diseases Decrease – HIV (TCD4)

Eosinophils Increase – allergies, parasite infection, some

neoplasia Decrease – infections, stress, trauma

Basophils Increase – leukemia, some infections

Leukocyte disorders

Disorders of leukocytes are recognized as the body’s reaction to disease processes and noxious agents

Lymphocytes produce antibodies and initiate the immune response to fight infection

Monocytes form macrophages in response to foreign substances such as bacteria

Granulocytes contain lysing agents capable of digesting foreign materials, bacteria and infectious substances

Leukocyte disorders - Leukocytosis

Leukocyte count >10,000/mm3 Commonly seen with the body’s response to:

Bacterial infections Inflammation or tissue necrosis Metabolic intoxications Acute hemorrhage Acute appendicitis Pneumonia Acute rheumatic fever

Leukocyte disorders - Leukopenia

Reduction in number of circulating leukocytes (<5000/microliter)

Never beneficial Seen with bone marrow failure (common

following chemotherapy or radiation), overwhelming infections, dietary deficiencies and in autoimmune diseases

The lowest point the WBC count reaches after chemotherapy occurs 7-14 days after treatment. At this time the client is extremely susceptible to opportunistic infections.

Platelet disorders

Platelet functions Hemostasis (stopping bleeding) Maintaining capillary integrity

Life cycle is 8-10 days in circulation Affected by anticoagulation drugs, including

aspirin and heparin Affected by diet

Lecithin prevents coagulation Vitamin K promotes coagulation

Platelet disorders

Exercise boosts the production of chemical activators that destroy unwanted clots

Platelets are easily suppressed by radiation and chemotherapy

Liver disease often causes suppression of production of Vitamin K which will in turn lessen coagulation

Platelet disorders - Thrombocytosis

Abnormally high platelet count Usually a temporary condition

Compensatory mechanism after severe hemorrhage, surgery and splenectomy

Iron deficiency Occult neoplasm

Blood viscosity is increased resulting in clots and occasionally thrombosis

Symptoms of splenomegaly and easy bruising may not occur until platelet count exceeds 1 million/mm3

Platelet disorders - Thrombocytopenia

Platelet count is abnormally low Most common causes seen in PT

Bone marrow failure from radiation treatment, leukemia or metastatic cancer

Drug-induced platelet reduction (Sometimes seen with RA patients or with treatment of inflammatory conditions)

Platelet disorders - Thrombocytopenia

GI bleeding and CNS bleeding may be life threatening

PT should be observant for multiple bruising (without known injury), external hematomas and the presence of multiple petechiae

These symptoms indicate platelet count <100,000/mm3

Strenuous exercise, straining or bearing down could cause hemorrhage of the eyes or brain

Contact MD immediately

Hemophilia

Hereditary blood clotting disorder Due to abnormality in Factors VIII and IX Common clinical signs

Hemarthrosis – Bleeding into the joint Muscle hemorrhage

Hemophilia - Hemarthrosis

May result from trauma, stress or spontaneously Most often affects (in order) the knee, elbow, ankle,

hip and shoulder Severity of symptoms vary but include pain, swelling,

tingling, stiffness/decreased ROM, tenderness, heat Treat initial symptoms with Factor replacement and

joint immobilization Repeated hemarthrosis results in progressive loss of

motion, muscle atrophy and flexion contractures

Hemophilia – Muscle hemorrhage

Most common in the flexor muscle groups Iliopsoas Gastocnemius Flexor surface of the forearm

May result in deformities Hip flexion contracture Equinus position of the foot Volkmann’s deformity of the forearm

Hemophilia – Muscle hemorrhage

Loss of sensation in the anterior thigh may occur with bleeding into the iliopsoas

Distention of the muscles may also cause lower abdominal pain To reduce the distention and pain, a position

of hip flexion is preferred Sometimes mistaken for appendicitis

References

Goodman CC, Snyder TE. 2007. Screening for Hematologic Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p261-273.

Milone MC. Sickle Cell Anemia. Retrieved 06/04/07 from the World Wide Web http://www.nlm.nih.gov/medlineplus/ency/imagepages/1223.htm