Presentation on theme: "Haematology in Primary Care"— Presentation transcript:
1 Haematology in Primary Care Dr Josh WrightConsultant HaematologistSheffield Teaching Hospitals
2 Referral Hit Parade Raised Hb Leucocytosis- neutrophilia/lymphocytosis Thrombocytosis/thrombocytopeniaParaproteinsmacrocytosisLow B12Anaemia in the elderlyMicrocytosis/ iron deficiency/alpha thal
3 Common haematological issues in primary care LectureWorkshopInterpreting the blood countCommon referral issuesWhite cell problemsPlatelet problemsParaproteinsRed cell issuesErythrocytosisHaematinics inc low B12Haemoglobinpathy inc alpha thalAnaemia in the elderlyAny cases brought for discussion
4 Full blood count Normal range Adult maleAdult femaleRangeHbHctRBC countMCV80-98MCHWBC x109/lNeutrophilsLymphocytesPlateletsRangeHbHctWBCNeutrophilsLymphocytesPlatelets
6 White Blood Count Lymphocytosis HistoryMale age 58 yearsHypertension, Type II DMSmokes 10 cigsDrugsSimvastatin, AmlodopineExamBMI 38Bp 140/85FBCSeptember 2011October 2011November 2011Hb139141140WBCLymphocytesNeutrophils126.96.36.199.188.8.131.52Platelets249310270
7 Lymphocytosis Does the patient have haematological cancer? Should I refer to haematology?Should I continue to monitor the lymphocyte count?Are there any other tests I should do?
13 (Neutrophil) Leucocytosis Important points Urgent referral>50Blood film features of CML or CMML (film comment)Consider ifChronic neutrophilia>20Chronic monocytosis >1Chronic eosinophila>2History & Examinfection, inflammation,autoimmune, neoplasiarash, arthritis, weight lossCRP,U&E,LFT,TFTCaAuto AbMicro cultureFBC,ESRCXRUrineReactive screen negativeHaematology referral
14 NeutropeniaCaucasian female aged 36yrs, no significant medical history, no regular medicationFH rheumatoid arthritisHb 126 g/lWCC 3.1Neutrophils 0.4Platelets 180
15 Neutropenia (Neutrophils<1.7) What do I need to know?Is the patient unwell? (Viral assoc transient)Any previous counts?Any other cytopenia?Is the patient on chemotherapy?Other drugsHow severe is it?Mild ( ), functionally normalModerate ( )Severe (<0.5)-RISK OF INFECTION
16 Neutropenia What are the common causes? Infection Drugs (chemotherapy!)AutoimmuneHereditaryRacial (African origin )
17 Neutropenia pathway Neutropenia <1.0 Consider repeat particularly if recent infectionPatient on chemotherapyNoModerate or Severe <0.5Unwell ?YesNoDiscuss with haematologist and referB12, Folate, LFT, GGT, autoAbHaematology advice/referral
18 Thrombocytosis Male 65yrs, mild hypertension on ramipril. Hb 160, Hct 0.50, WCC 11.0 plts 450Refer or not?
19 ThrombocytosisMaybe reactive to inflammation, infection other malignancy, iron deficiency or bleedingIn MPD very high counts >1500 assoc with vascular events and bleedingUrgent referral>1000if assoc with CVA, TIA, VTEConsider if>600 consistently>450 with vascular eventHigh wcc or Hb
20 Thrombocytopenia >100 functionally normal <20 bleeding risk rises but most symptom freeCausesImmuneDrugs eg quinineBone marrow failure syndromes eg MDSALCOHOLLiver diseasePregnancy
21 Thrombocytopenia Refer <50 if other cytopenia or planned surgery/dental workInvestigationsBlood film- platelet clumpingRepeat sampleRenal & liver functionClotting screenAutoantibodies
22 ?Myeloma Hb 110 WCC & plts normal U&E normal Total Protein 66 (60-74)IgG *IgA 0.7 ( )IgM 0.5 ( )MIg 7.0IgG Kappa monocloneHistory 68yr female, Back pain 4 months ESR 70 X Ray normalShould I refer to haematology?Reminder…….Monoclonal or polyclonal?
23 Paraproteins Refer if IgM usually assoc with lymphoma IgG>15g, IgA>10gIgD or ELower levels if assoc with CRABIgM usually assoc with lymphomaAny other features?Paraprotein>10g?HyperviscosityC- HypercalacemiaR- unexplained renal failureA-anaemia/cytopeniaB-bone pain/fracture
24 Paraproteinaemia Most will be MGUS Present 3% over 70 and 5% over 80 1% risk of progression to MM per annumA few secondary to auto-immune disease & rarely other malignanciesIf criteria for referral not met then monitor on a 6-12 monthly basis.
25 Common Red cell Problems MacrocytosisErythrocytosisHaematinic assessmentAnaemia in the elderlyHaemoglobinopathies including alpha thal carriage
26 Macrocytosis Approx 8% population Commonest causes alcohol & hypothyroidismB12/ folate deficiencyDrugs (including those used for HIV)ReticulocytosisParaproteinMyelodysplasia (elderly population & associated with cytopenias)
27 Isolated macrocytosis Raised MCV >100Monitor if screening normalCheck B12, Folate,, LFT, GGT, TFT, Igs,NoAre there cytopenias?Isolated macrocytosisYesRefer to Haematology
30 Erythrocytosis Incidence of polycythaemia rubra vera ~5/100 000 MaleFemaleHct >0.52for at least 2 monthsHct >0.48for at least 2 monthsRefer to HaematologyIncidence of polycythaemia rubra vera ~5/Incidence of apparent polycythaemia~ HIGH!
31 Haematinics There is no entirely reliable blood test for iron status There is no entirely reliable blood test for folateThere is no entirely reliable blood test for B12
32 Ferritin is the test of choice Inaccurate in the presence of inflammationA trial of iron remains a valid approachALCOHOL/FATTY LIVER & FERRITINSerum folate is a good reflection of what you have just eatenI’m not sure what B12 is a good reflection of!Interpret borderline values with cautionSchilling test no longer available
33 Reduced serum B12B12< 100 True deficiency highly likely parenteral replacementB replace especially if raised MCV, cytopenia, neuropathyB12>140 deficiency unlikelyB12 is an unreliable testAlways reduced in pregnancyUncomplicated B12/folate deficiency does not require OP referral.
34 Anaemia in the elderly Frequency of anaemia increases with age Incidence 10-40%Many have diagnosable/treatable cause25% no identified causeInvestigationsFBC & filmReticulocytosisRenal/ liver functionImmunoglobulinsHaematinicsCoeliac screenDietary historyGI investigationsBone marrow
35 Anaemia in the elderly CAUSE OF ANEMIA PERCENTAGE OF CASES Anemia of chronic disease30 to 45Iron deficiency15 to 30Posthemorrhagic5 to 10Vitamin B12 and folate deficiencyChronic leukemia or lymphoma5Myelodysplastic syndromeNo identifiable cause15 to 25
36 The lost 25%? MULTIFACTORIAL Decline in erythropoetin Decline in androgensIncreased inflammatory cytokines even in absence of a recognised diseaseAge associated decline in stem cell functionEarly MDS without other cytopenias or BM changes
37 Indications for haematology referral PancytopeniaMonoclonal gammopathySuspicion of myelodysplastic syndromeBlood smear showing immature white cells or nucleated red cellsIndeterminate status of iron storesUnexplained progressive or unresponsive anemia
38 What are haemoglobinopathies? Commonest single gene disorders worldwideAutosomal recessiveDisease states homozygous or combined heterozygotesDefects of quality or quantity of haemoglobinQuality Variant Hbs eg sickleQuantity Under production eg thals
39 National Screening Plan NHS Plan commits to “a new national linked antenatal & neonatal screening programme for haemoglobinopathy & sickle cell disease by 2004”Universal neonatalAntenatal ?selective ?universal
46 thalassaemia heterozygotes a0 a+ UK Africans 25%India 5-58%PNG %Thailand 3-17%Maori 5-10%Cypriot 2%India rareAfrican rareHong Kong 5%China 3-9%Phillipines 10%
47 Summary pointsOther than for individuals of E. Med or SE Asian origin a thal trait is insignificantMicrocytosis is commonly due to thal traitA national antenatal/neonatal screening programme is now in place