Prepared by Professor B. J. Bain and Dr Donald Macdonald · Year 5 haematology tutorial 2019...
Transcript of Prepared by Professor B. J. Bain and Dr Donald Macdonald · Year 5 haematology tutorial 2019...
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Year 5 haematology tutorial 2019
Prepared by Professor B. J. Bain
and Dr Donald Macdonald
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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/
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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
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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
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What would you do next?
• What tests would you do?
Make a list
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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
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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?
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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?
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How would you treat the patient?
• Would transfusion be a good idea?
• How would you manage her?
Transfuse?Management?
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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 ?
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• Describe the main abnormality. • State the differential diagnosis. • Next investigation?
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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?
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PET CT scan
• What Stage is this ?• Is this a curable cancer?• How would you treat ?
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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 ?
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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?
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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?
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DAT (i)
Direct antiglobulin test (i)
From Bain BJ, Interactive Haematology Imagebank, 2nd Edn, Wiley-Blackwell, Oxford, 2014
Supplementary information
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DAT (ii)Direct antiglobulin test (ii)
From Bain BJ, Interactive Haematology Imagebank, 2nd Edn, Wiley-Blackwell, Oxford, 2014