Haemathopathology.ppt
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Transcript of Haemathopathology.ppt
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HAEMATOPATHOLOGY
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Anaemias and leukaemias
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Anaemia
• types (etiology):• 1) iron deficiency– most common type– chronic menstrual blood loss, peptic ulcer,
haemorrhoids
• 2) pernicious anaemia– macrocytic anaemia– +/- neurological disease– folate insufficiency
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Anaemia
• 3) leukaemia– cause of normocytic anaemia– childhood!
• 4) sickle cell trait• 5) thalasaemia
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Anaemia
• clinical features• tab 22.2, 3, 4
• mucosal disease• glossitis• recurrent aphthae• candidiosis and angular stomatitis
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Anaemia
• dangers of general anesthesia– any reduction of oxygenation → irreparable brain
damage, myocardial infarction → gen. anesthesia should be provided in hospital
• lowered resistence to infection – oral candidiosis– osteomyelitis
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Sickle cell disease and sickle cell trait
• people of African, Afro-Caribbean and Mediterranean or Middle Eastern origin
• sickle cell diease = homozygotes• sickle cell trait = heterozygotes• abnormal Hb (HbS) with the risk of
haemolysis, anaemia and other effects• in heterozygotes sufficient normal Hb (HbA) is
formed to allow normal life
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Sickle cell disease and sickle cell traitSickle cell disease:• complications from polymerisation of
deoxygenated HbS (less soluable than HbA)• → chronic haemolysis → chronic anaemia• exacerbation of sickling raises blood viscosity →
blocking of capillaries and sickling crisis• tab 22.5• + abnormal susceptibility to infections
(Pneumococcal, Meningococcal) and osteomyelitis
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Sickle cell disease and sickle cell trait
dental aspects of sickle cell disease and s.c.trait:• Hb ≤ 10g/dl → v. s. homozygote• s.c. trait: gn anaesthesia with full oxygenation s.c. disease: • +/- oral mucosa pale or yellowish due to
jaundice• +/- radiographics changes in skull and jaws• prompt atb treatment
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Sickle cell disease and sickle cell trait
• painfull crisis with analgesics• rigorous dental care necessary due to ↑
susceptibility to infection
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The thalassaemias• α-thalassaemias Asians, Africans and Afro-
Caribbean• ß-thalassaemias Mediterranean (Greeks)• diminished synthesis of globin chains → resulting
relative excess of other chains → precipitation in ery → +/- haemolysis
• severity of disease depends on the numbers of affected genes
• minor = heterozygotes• major = heterozygotes
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The thalassaemias
thalassaemia minor:• mild, but persistent microcytic anaemia,
otherwise asymptomatic• +/- splenomegaly
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The thalassaemias
thalassaemia major:• severe hypochromic, microcytic anaemia• great enlargement of liver and spleen• skeletal abnormalities (marrow expansion)• life saving transfusions, but iron depositions in
tissues → haemosiderosis → dysfunction of glands and other organs → xerostomia
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Leukaemia
• leukaemic white blood cells production → supress of other cell lines of the marrow
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Leukaemia
acute leukaemia• ALL most common leukaemia of children• AML in adults • tab 22.7• splenomegaly, hepatomegaly, +/-
lymphadenopathy• mucosal pallor, abnormal gingival bleeding• tab 22.8
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Leukaemia
• management:– biopsy of gingival swelling– vigorous oral hygiene to controll the bacterial
population before complications develop– extractions avoided, if necessary – blood
transfusion, generous atb cover
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Leukaemia
• chronic leukaemia
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Leukopenia and agranulocytosis
leukopenia • WBC ≤ 5000³/l• different causes tab 22.10• chance haematological finding x severe -
immunodeficiency
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Leukopenia and agranulocytosis
agranulocytosis• clinical effects of severe neutropenia: fever
prostration, mucosal ulceration
• drug induced leukopenias• tab 22.12
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Leukopenia and agranulocytosis
aplastic anaemia• failure of production of all bone marrow cells
(pancytopenia)• systemic and oral effects: purpura, anaemia,
susceptibility of infection• cause: unknown, ai, drug induced• management: stop drugs, give atb and
transfusions
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Haemorrhagic diseases
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Haemorrhagic diseases
• haemorrhagic diseases = purpura (platelet deffects) and clotting deffects
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Haemorrhagic diseases
• Investigation of a history of excessive bleeding:– careful history essential tab. 23.1– most of the haemorrhagical diseases are hereditary!– bleeding for up to 24hrs after an extraction usually
due to local causes or a minor defect of haemostasis → more prolonged bleeding is significant
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Haemorrhagic diseases
• Clinical examination: – signs of anaemia and purpura– examination of the mouth → planning of the
operation– haemophilia – all essential extractions carried out
at a single operation with fVIII cover– radiographs (to prevent complications)
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Haemorrhagic diseases
• Laboratory investigations:– tab 23.2– essential is look for anaemia– blood grouping
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Haemorrhagic diseases
A) Purpura• typical result of platelet disorders• bleeding time prolonged but clotting function
normal (with exception of of vW disease)
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Haemorrhagic diseases• general features of purpura:– purpura = bleeding into the skin or mucous
membranes causing petechiae or ecchymoses or „spontaneous bruising“
– haemorrhage immediately follows the trauma and ultimately stops spontaneously as a result of normal coagulation
– thrombocytopenia = platelets ≤ 100 000 mm³– spontaneous bleeding uncommon until platelets ≤
50 000 mm³
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Haemorrhagic diseases
– typical site palate– +/- excessive gingival bleeding or blood blister – tab 23.3
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Haemorrhagic diseases
ITP• IgG auto Ab• ↓ number of platelets• children or young adult women• first sign could be profuse gingival bleeding or
postextraction haemorrhage • +/- spontaneous bleeding into the skin
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Haemorrhagic diseases
• management: – corticosteroids– transfusions of platelets– anti…???
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Haemorrhagic diseases
AIDS• ai thrombocytopenia can be early signdrug associated purpura• aspirin + others interfere with platelet
function • others act as haptens → immune destruction
of platelets or suppress marrow function• tab 23.4
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Haemorrhagic diseases
localised oral purpura • sometimes blood blister without haemostatic
defect • choking sensation („angina bullosa
haemorrhagica“)• rupture → ulcer• systemic purpura should be excluded
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Haemorrhagic diseases
von Willebrand´s disease• both by prolonged bleeding time and
deficiency of fVIII• usually inherited, AD• deficiency of fVIII mild → purpura more
common manifestation
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Haemorrhagic diseases
B) Clotting disorders• tab 23.5
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Haemorrhagic diseases
Haemophilia A• most common, severe• fVIII deficiency• 6/100 000• severe haemophilia typically effects in
childhood – bleeding into muscles or joints after minor injuries
• mild haemophilia (fVIII ≥ 25%) – no symptoms until an injury, surgery or dental extraction
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Haemorrhagic diseases
• severe and prolonged bleeding can also follow local anaesthetic injections! (inferior dental blocks!)
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Haemorrhagic diseases• clinical features:– positive family history– 30% patients negative history!– bleeding starts after a short delay (normal platelet and vascular
responses) → persistent bleeding, can continue for weeks – haemarthroses– intracranial haemorrhage!– deep tissue bleeding → obstruction of airways!– HBV, HCV+!– +/- formation of anti fVIII Ab
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Haemorrhagic diseases• principles of management:– radiographs (local status, prevention of
complications)– admission to hospital – replacement therapy– as much surgical work as possible in one session 23.6– for dental extraction fVIII level 50-75%– postoperatively: atb, risk of bleeding greatest 4-10
days postoperatively
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Haemorrhagic diseases
– aspirin and related analgesics avoided!– extractions in mild haemophilia with
antifibrinolytic drugs
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Haemorrhagic diseases
Christmas disease (haemophilia B)• fIX• inherited• more stable → replacement therapy in longer
intervals• other the same as in haemophilia A
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Haemorrhagic diseases
Acquired clotting defectsa) vitamin K deficiency• causes: obstructive jaundice, malabsorption • surgary delayed to haemostasis recover• +/- vitamin K
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Haemorrhagic diseasesb) anticoagulant treatment • coumarin (warfarin)• dental extraction save with INR 2-3• few teeth extracted in one session, trauma should be
minimal, sockets can be sutured• anticoagulation should not be stopped • for large surgery → stopped with agreement of
physician• short term: heparin (acts only about 6hrs) → surgery
delayed for 12-24hrs
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Haemorrhagic diseases
c) liver disease• obstructive jaundice• extensive liver damage (viral hepatitis,
alcoholism)• haemorrhage can be severe and difficult to
control• → vitamin K• antifibrinolytic agents• fresh plasma infusion
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Lymphomas
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Lymphomas
• any type of lymphocytes, most frequently B cells
• all malignant• Hodgkin + non Hodgkin lymphomas (NHL)• relatively frequently involve cervical lymph
nodes x rare in the mouth
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Lymphomas
A) NHL• adults predominantly affected• nondescript, soft, painless swelling +/-
ulcerated• histologically:• + invasion of adjacent tissues• + if traumatised – inflammatory cells can
obscure the lymphomatous nature of the tu
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Lymphomas
• management:– biopsy!– staging!
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Lymphomas
• Burkitt´s lymphoma• nasopharyngeal (T cell) lymphoma – mlg
midline granuloma• MALT!• + local manifestation of gn disease
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Cervical lymphadenopathy
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Cervical lymphadenopathy
• dental and periodontal infections most common cause
• lymphomas• HIV infection• tab 26.1• investigation: recent viral illness –
lymphadenopathy resolves after some months
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Cervical lymphadenopathy
TBC• Mcb tuberculosis + atypical Mcb• clinical features:• pathology: granulomas, Mcb → Mcb culture
or DNA tests• management: suspicion of TBC – affected
nodes should be excised intact
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Cervical lymphadenopathy
Syphilis• lymph nodes enlarged, soft and rubbery• primary or secondary stage• Treponema pallidum in a direct smear or by
serological finding• management: atb
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Cervical lymphadenopathy
Cat scratch disease• tab 26.4• pathology: destruction of lymph node
architecture, necrosis and lymphocytic infiltration, formation of histiocytic granulomas and central suppuration
• WS staining• x deep mycoses
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Cervical lymphadenopathy
• management: history, clinical features, exclusion of other causes, disease is mild and self limiting, +/- suppuration and sinus formation
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Cervical lymphadenopathy
Lyme disease• transmitted by insects, deer ticks• tab 26.5• management: history + clinical picture• confirmed serologically• atb!
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Cervical lymphadenopathy
Infectious mononucleosis• self-limiting lymphoproliferative disease• tab 26.6• +/- more persistent lymphadenopathy which
may mimic a lymphoma• management: peripheral blood picture (atypical
lymphocytes), Paul-Bunnell test, anti EBV Ab, ampicillin or amoxicilin should be avoided!
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Cervical lymphadenopathy
AIDS• soon after infection transient glandular fever
like-illness• later +/- wide spread lymphadenopathy (GLS)• → AIDS
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Cervical lymphadenopathy
Toxoplasmosis• intestinal parasite of many domestic animals
(cats)• management: serologically, antimicrobial
treatment
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Cervical lymphadenopathy
Mucocutaneous lymph node syndrome (Kawasaki´s disease)
• tab 26.8• management: clinical and ECG finding• aspirin, γ-globulin
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Cervical lymphadenopathy
Drug-associated lymphadenopathies• occasional toxic effect of long term treatment
with the antiepileptic drug, phenytoin can mimic lymphoma
• management: