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1 Haematology in Primary Care: The Full Blood Count Charles Crawley George Follows C ambridge H aematology P artners

2 The FBC

3 Haemoglobin  Low haemoglobin defines anaemia –Males 13-18g/l –Females 11.5-16g/l –Variations:  Children –Neonates – 14-24g/l –2 months – 8.9-13.2g/l –9-12ys - 11.5-15.4g/l  Pregnancy –3 rd Trimester – 9.8-13.7g/l  Age –5-7 th decade – falls in men rises in women  Exercise –Increases Hb  Altitude  Smoking

4 MCV  Mean Cell Volume: average size of RBC –Normal adult : 76 (80) - 100 fL  MCV < 76 fL (microcytic)  MCV > 100 fL (macrocytic)  MCV 80 - 100fL (normocytic)

5 Practical Classification of Anaemia Microcytic (<76fL) Normocytic Normocytic Macrocytic (>100) Macrocytic (>100) Iron deficiency ThalassaemiaHaemoglobinopathies Anaemia of chronic disease LeadHyperthyroidism Blood loss Haemolytic - RBC membrane - Enzyme defects - Extrinsic Stem cell defects Megaloblastic Megaloblastic Excess alcohol Excess alcohol Hypothyroid Hypothyroid Liver disease Liver disease Reticulocytosis Reticulocytosis Drug therapy Drug therapy Marrow failure Marrow failure Reticulocyte count : In the investigation of anaemia Reduced: Failure of erythropoiesis Increased:Appropriate BM erythroid response

6 35 year Male  Hx:Lethargy, SOB  Sx:Pale  FBC:Hb6.4 g/dL MCV 71 fL RDW0.19 WCC5.2 Platelets375  Film: Severe hypochromasia and microcytosis

7 Commonest Causes Iron Deficiency FemaleMale 1 – 5 yr NutritionNutrition 5 – 15 yr Increased utilisation/ growth 15 – 40 yr MenstruationPregnancy Coeliac disease (Malabsorption) > 40 yr Gastrointestinal Blood loss

8 Blood Film

9 Differential Diagnosis  Causes of microcytic hypochromic anaemia –Iron deficiency  Blood loss  Malabsorption - Coeliac disease; gastrectomy  Increased utilisation - parasites  Dietary deficiency - rare –Haemoglobinopathy –Anaemia of chronic disease

10 Fe Deficiency vs Anaemia of Chronic Disease Variable Fe deficiency Chronic disease Serum Iron  Transferrin  or Normal Transferrin Saturation  Ferritin  or Normal  or normal CRPNormal GIT studies: endoscopy etc

11 26 year Female  Hx:Antenatal visit; First trimester  FBC:Hb11.0 g/dL MCV73 fL MCH27 pg RDW0.14 WCC8.5 x 10 9 /L Platelets 164 x 10 9 /L  Film: Microcytic RBC

12 Fe Deficiency vs Hbinopathy  Check iron status: Ferritin  Family history / ethnicity: –Thalassaemia / haemoglobinopathy –Need to determine risk to fetus of severe thalassaemic syndrome (in 1 st rimester):  Homozygous thalassaemia (α or β)  Homozygous Hb S (sickle cell disease)  Severe compound heterozygous states –E.g.: HbS/β; HbE/β; HbSC –Determine need to check partner

13 Red Cell Distribution Width (RDW)  The degree of variation in size of RBC: N <14  Increased RDW corresponds with anisocytosis: –Iron deficiency (increased RDW is the earliest lab feature: anisocytosis precedes the anaemia) –Megaloblastic anaemia (can be very high >20) –Anaemia with bone marrow erythroid response (i.e. reticulocytosis)  RDW useful in DDx of microcytic anaemias. –Most cases of iron deficiency: raised RDW –Most cases thalassaemia trait: normal RDW

14 MCH  Mean Cell Haemoglobin (27-32 pg) –The mean haemoglobin per red blood cell  MCH usually rises or falls as the MCV is increased or decreased.  MCH < 25 pg used as a guide to the presence of thalassaemia or haemoglobinopathy. –MCH usually markedly reduced in thalassaemia (e.g. beta thalassaemia trait MCH 19 pg)

15 Haemoglobin Studies 1. Normal adult 2. HPFH (heterozygote) 3. Hb S--HPFH 4. Hb C--HPFH 5. Normal newborn A/F/S/C control

16 73 year male  Hx:Tiredness  FBC:Hb4.0 g/dL MCV102 fL RDW0.24 WCC / PltNormal  Film:Macrocytes, fragmented red cells, occasional NRBC

17 Blood Film 73 yr old male

18 Severe Macrocytic Anaemia  Megaloblastic anaemia  Liver disease: end-stage failure  Red cell aplasia: –Parvovirus; thymoma, other malignancy  Bone marrow failure or infiltration: –Myelodysplasi –Multiple myeloma

19 Investigations 1.Serum vitamin B12 Red cell folate (serum folate) 2.Reticulocyte count (BM erythroid function) 3.Liver function 4.Parvovirus serology 5.Bone marrow examination

20 Don’t Forget the Alcohol

21 Other Causes of Macrocytic Anaemia  Severe liver disease  Excess alcohol  Haemorrhage / haemolysis: reticulocytosis  Drug therapy: esp. cytotoxics  Hypothyroidism  Myelodysplasia  Marrow infiltration –Bone marrow examination may be indicated

22 Myelodysplasia (MDS)  Clonal disorder  Ineffective haematopoiesis  Incidence increases with age –Age 50yrs - 1 per 100,000 –Age 70yrs – 25 per 100,000  RBC, WCC, and platelets affected

23 Myelodysplasia Bone Marrow Peripheral Blood

24 Myelodysplasia  Prognosis –Number of cytopenias –BM Blast percentage –Cytogenetics –Age  Survival –Varies 11.7 yrs – 0.4yrs  Management –Supportive –Stem cell transplantation –New drugs

25 Normocytic Anaemia  Multiple aetiologies  Primary marrow production defect –Myelodysplasia –Marrow infiltration –Haematinic deficiencies  Reduced red cell survival –Blood loss –Intrinsic defects (eg. Enzyme; membrane) –Extrinsic defects (eg. Plasma problems)

26 Approach to Normocytic Anaemia  History: –Acute blood loss ; jaundice; dark urine  Exclude treatable causes: –Check ferritin, folate, vitamin B12 –Renal and hepatic function –Acute phase reactants  Consider haemolysis The blood film may have the answer !

27 78 year male  Hx:Chest pain  PMHx:Myocardial infarct  FBC:Hb7.2 g/dL MCV97 fL WCC4.5 x 10 9 /L Platelets320 x 10 9 /L Reticulocytes: 320 (10-100)

28 Blood Film

29 Blood Film  RBC:Spherocytes Polychromasia Nucleated red cells Spherocytic haemolytic anaemia: Auto-immune haemolytic anaemia Hereditary spherocytosis

30 Other Investigations  Biochemistry: –Bilirubin100 μmol/L (<20) –Other LFTNormal –LDH1,500 U/L (120-240) –Haptoglobin<0.1  Haematology: –Reticulocyte count –Direct anti-globulin (Coombs) test: Positive  Enzymes,  Hereditary spherocytosis screen

31 Haemolytic Anaemia  Primary Red Cell Problem: –Red cell membrane: Hereditary spherocytosis –Enzyme defect: G6PD deficiency –Haemoglobin defect: thalassaemia –Abnormal red cells: dyserythropoiesis (MDS)  Secondary Red Cell Destruction –Autoimmune –Severe hepatic dysfunction –Red cell fragmentation: DIC; HUS; TTP –Infections: malaria; clostridium

32 Blood Film Glucose-6-phosphate dehydrogenase deficiency blister or helmet cells

33 Normocytic Anaemia  Blood film may have the answer: –Normal red cell morphology –Dimorphic (high RDW): 2x RBC populations –Marked anisocytosis: marrow dysfunction/MDS –Is there polychromasia?  Yes: Anaemia with marrow response  No:Impaired marrow response –Anaemia of Chronic Disease –BM failure –Red cell aplasia: Parvovirus; aplastic anaemia

34 Polycythaemia  Pseudopolycythaemia  Primary –Polycythemia vera  Secondary –Hypoxia  Altitude  Cardiac/Pulmonary disease  Cirrhosis  Abnormal Haemoglobins  Chronic CO exposure –Inappropriate erythropoietin  Renal lesions  Tumours  Drug

35 Clinical Features  Hyperviscosity –Headaches –Blurred vision –Breathlessness –Confusion –(Plethora)  Thrombosis –Venous + arterial –Bleeding  Other –Pruritis –Gout

36 Polycythaemia investigations  FBC + Film  CXR  Cardiac assessment  Red Cell mass  Blood gasses  Major advance – JAK 2 mutation screens

37 JAK2  Presence of the V617F mutation indicates that the patient has an acquired, clonal hematological disorder and not a reactive or secondary process.  Absence of the JAK2 V617F mutation does not exclude a MPD as up to 50% of patients with ET and IMF will have wildtype JAK2.  The V617F mutation does not help in sub- classifying the type of MPD of a given patient

38 Pathogenesis: Deregulated Tyrosine Kinases in MPD CML BCR-ABL CMML TEL-PDGFRB CEL FIP1L1-PDGFRA SM KIT D816V PV JAK2 V617F ET JAK2 V617F IMF JAK2 V617F

39 Questions so far?

40 Platelets  Too many (thrombocytosis)  Too few (thrombocytopenia)  Dysfunctional –When should we worry?

41 Thrombocytosis  > 450 x 10 9 /l  Causes –Reactive (almost anything!)  Common – bleeding, infection, malignancy  Tend to be less than 1000 x 10 9 /l –Primary bone marrow disorder  Myeloproliferative disorders (up to 3000+) (essential thrombocythaemia, myelofibrosis, polycythaemia, chronic myeloid leukaemia)

42  History, examination should guide investigations and referrals  Should the patient be on aspirin? –Only firm evidence is MPDs –Reactive often given if > 1000, but little evidence for this Thrombocytosis

43  Essential Thrombocythaemia (ET) –Long term management balancing thrombotic vs bleeding risk –Aspirin for intermediate risk –Cytoreduction + aspirin for higher risk (beware the pseudohyperkalaemia!!) Thrombocytosis

44 Thrombocytopenia  Is it real??? –Poor sample –Clumped in EDTA – blood film **If at all possible confirm with a repeat sample

45 Pancytopeniavs Isolated low platelets  Pancytopenia – –always serious (marrow failure)  Isolated – may be relatively unimportant Thrombocytopenia

46  Decreased production –Rare in isolation –Viral infections  Increased consumption –Autoimmune – ITP –Drugs –Pregnancy –Large spleen / portal hypertension –Infections (HIV) –RARE but serious TTP – HUS - DIC Thrombocytopenia

47  Investigations depend on clinical suspicion –Platelet volume may be helpful (small - think marrow)  10.5 –BM often not required Thrombocytopenia

48 Thrombocytopenia (not joint bleeds!)

49  How real is the bleeding risk? –Cause of low platelets –Wet vs dry purpura –Platelet transfusions often not useful Thrombocytopenia

50 ITP – a few useful reminders  Children –Acute, post viral, –spontaneous resolution (often no therapy)  Adult –More insidious onset –Chronic = common –Many (not all!) cases do require treatment –Steroids – splenectomy –Novel therapies

51 Platelet Dysfunction  Range of rare inherited causes –Family history –Refer the child that bleeds abnormally!  Don’t forget the acquired dysfunction –Renal failure –Liver disease –ASPIRIN

52 Questions and break!

53 White Cells

54 White Cells

55 White Cells  Important (and commonly problematic!) –Neutrophils –Lymphocytes  Important (less commonly problematic) –Monocytes –eosinophils  Less important –basophils

56 Neutrophils

57 Neutrophilia  Often result ‘expected’ –History –Examination –primary haematological cause NOT common

58 Neutrophilia  Infection  Inflammation / necrosis  Cancer – any sort reported  Bone marrow disease (MPDs, CML)  Drugs (steroids!!, growth factors) Not always pathological Pregnancy, smoking, normal variant!

59 Neutropenia (<1.5 x 10 9 /l) Isolated neutropenia vsPancytopenia

60 How worried should I be?  Pancytopenia is ALWAYS worrying  Many cases of isolated neutropenia are less serious  What should I do with a neutropenic patient?  How common is neutropenic sepsis?

61 Pancytopenia  Marrow Failure –Drugs (chemotherapy) –Infiltration (cancer, MF,lymphoma etc.) –Myelodysplasia / leukaemia / myeloma –Aplastic anaemia / PNH –Don’t forget B12 / folate (anorexia)  Peripheral consumption –hypersplenism

62 Pancytopenia  Referral usually required  Bone marrow biopsy usually required

63 Isolated Neutropenia  Not always easy to identify a cause!  Always think drugs (idiopathic vs dose)  Viral infection  Auto-immune disease  Marrow causes (sepsis / very ill elderly)  Don’t forget –Racial variation –cyclical neutropenia (clinical and lab details) –If child, think congenital

64  Investigations will depend on clinical presentation –Chance finding vs ill patient –Viral serology may be indicated (hepatitis, EBV etc – Think HIV!) –Autoimmune (SLE, sjorgrens, RA – Felty’s) –Serial blood counts –Referral may be required Isolated Neutropenia

65  When to refer urgently –Cause of neutropenia –Is the patient acutely ill?  Neutropenic fever vs sepsis –Incidence etc –Antibiotic policies etc. –Prophylactic antibiotics - controversial Isolated Neutropenia

66 Lymphocytes Lineage B vs T vs NK OriginRole

67  Causes –Reactive (CMV, EBV, hepatitis, toxo, adenov) Pertussiss Inflammatory reaction (not common) –Lymphoproliferative disorder Acute and chronic leukaemias lymphomas Lymphocytosis

68  Priorities for investigation –Clinical picture –If other FBC abnormalities, speak to a haematologist –If in doubt, ask for an opinion on a blood film –Monospot test vs viral serology –Flow cytometry –Molecular tests Lymphocytosis

69 Lymphocytosis (>4 x 10 9 /l)  Blasts vs more mature cells  Clinical picture very important –Young sick child vs older well patient vs

70  Young patient with clinical picture of infectious mononucleosis –Monospot useful –Film useful (rule out ALL) –Flow cytometry less helpful –Serology as second line investigation –ID referral occasionally required –(worth thinking about acute HIV) Lymphocytosis

71  Acute lymphoblastic leukaemia –Children >> adults –Often presents very acutely –Range of clinical features –Laboratory features typical –Referral mandatory Lymphocytosis

72  Older patient with lymphocytosis –Blood film required (CLL vs LGL) –Flow cytometry usually required –? Refer  Clinical picture  Underlying diagnosis Lymphocytosis

73  CLL –Relatively common (300 + / year) –New entity of Monoclonal B Lymphocytosis (MBL) –Age –Clinical presentation Asymptomatic stage A VS Symptomatic stage C Lymphocytosis

74  CLL –History  Night sweats, weight loss, INFECTIONS –Examination  Lymphadenopathy, hepato-splenomegaly –Investigation  Flow cytometry Lymphocytosis

75  Flow cytometry Lymphocytosis T cells Leukaemic B cells

76 Lymphocytosis  Should I refer CLL? –Long stage A phase in many patients –Patients and the ‘leukaemia’ word! –Rough guide  Symptomatic  Unusual / lymphoma phenotype  Lymphadenopathy / splenomegaly  Lymphocyte doubling time < 12 months with lymphocytes > 30 x 10 9 /l  Hb < 10 g/dl (or haemolysing)  Platelets < 100x 10 9 /l

77  CLL – beware –Not always benign –Infections (hypogamma) –Haemolysis –ITP Lymphocytosis

78  Rarer lymphoproliferative disorders –LGL –PLL –Leukaemic phase of most lymphomas –Hairy cell leukaemia Lymphocytosis

79 Lymphopenia (<1.0 x 10 9 /l)  Many cases reflect normal variants  How hard should you chase a cause?  More common causes –HIV / hepatitis / Hodgkin’s (steroids)  Rarer causes –Autoimmune disease / sarcoidosis

80  Investigations –Clinical picture –Lymphocyte subset analysis –RARE – bone marrow Lymphopenia

81 Enlarged LN ? cause  Clinical context is critical –? Symptom profile –(?spleen)  Please do first line investigations –FBC may save a LN biopsy  Neck nodes – ENT fast track referral  Axillary and groin nodes –Much depends on the clinical context –Haematology review first? –Biopsy first? –CT first?

82 Eosinophils  High –Allergic disorders –Drug Hypersensitivity –Skin Diseases –Parasitic infections –Myeloproliferative disorders –Connective tissue disorders  Churg Strauss

83 Monocytes  High –Range of infectious and inflammatory stimuli –Primary BM conditions  CMML (overlap between myelodysplasia and myeloproliferative disorder)  CML Clinical picture and blood film important If no clear cause consider haematology referral

84 Questions? C ambridge H aematology P artners

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