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HAEMATOLOGY IN PRIMARY HEALTH CARE
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Haem
- 1. Hematology in Primary Care Nathan Kikku Mubiru Medical Laboratory Scientist(MLSO)
- 2. Referral Hit Parade Raised Hb Leucocytosis- neutrophilia/lymphocytosis Thrombocytosis/thrombocytopenia Paraproteins macrocytosis Low B12 Anaemia in the elderly Microcytosis/ iron deficiency/alpha thal
- 3. Common haematological issues in primary care Lecture Workshop âșInterpreting the blood count âșCommon referral issues ⊠White cell problems ⊠Platelet problems ⊠Paraproteins âșRed cell issues ⊠Erythrocytosis ⊠Haematinics inc low B12 âșHaemoglobinpathy inc alpha thal âșAnaemia in the elderly âșAny cases brought for discussion
- 4. Full blood count Normal range Adult male Range Hb 131-166 Hct 0.38-0.48 RBC count 3.6-4.8 MCV 80-98 MCH 27-34.2 WBC x109/l 3.5-9.5 Neutrophils 1.7-6.5 Lymphocytes 1.0-3.0 Platelets 140-370 Adult female Range Hb 110-147 Hct 0.32-0.42 WBC 3.5-9.5 Neutrophils 1.7-6.5 Lymphocytes 1.0-3.0 Platelets 140-370
- 5. What is the definition of normal?
- 6. White Blood Count Lymphocytosis History Male age 58 years Hypertension, Type II DM Smokes 10 cigs Drugs Simvastatin, Amlodopine Exam BMI 38 Bp 140/85 FBC September 2011 October 2011 November 2011 Hb 139 141 140 WBC Lymphocytes Neutrophils 6.7 3.9 2.8 6.9 4.1 2.8 6.9 4.2 2.5 Platelets 249 310 270
- 7. Lymphocytosis âșDoes the patient have haematological cancer? âșShould I refer to haematology? âșShould I continue to monitor the lymphocyte count? âșAre there any other tests I should do?
- 8. Lymphocytosis âșPrimary ⊠Lymphoid malignancies âșChronic Lymphocytic Leukaemia âșLymphoma âșMonclonal B Lymphocytosis âșReactive ⊠Viral (EBV, CMV, HSV, VZV) ⊠Stress Lymphocytosis âșDrug induced âșSeptic shock âșMyocardial infarct âșTrauma âșOther co-morbidities âșChronic ⊠Cigarette smoking ⊠Autoimmune disorder ⊠Chronic inflammation ⊠Sarcoid ⊠Raised BMI/metabolic syndrome
- 9. Malignant Lymphocytosis ? Lymphocyte count more than 10x109/L Lymphocyte count less than 10x109/L Refer to haematologist anaemia or thrombocytopenia recurrent infection? adenopathy, spleen, liver? Abnormal blood film? Yes No Repeat FBC, review 1yrly FBC
- 11. White Blood Count Neutrophil Leucocytosis History Male age 68 years Osteoarthritis, CABG 2001 Non smoker (stopped 2001) Type 2 DM Drugs Simvastatin, Aspirin, Gliclazide Exam Unremarkable FBC July 2009 December 2010 May 2011 Hb 163 163 165 WBC Lymphocytes Neutrophils 15.7 2.4 13.0 17.0 2.0 13.5 14.0 2.1 11.9 Platelets 430 420 400
- 12. Neutrophil leucocytosis âș Acute neutrophilia ⊠Reactive âșInfection/Inflammation âșneoplasia âșBleeding âșPain âșSmoking âșDrugs (glucocorticoids) âș Chronic neutrophilia ⊠Reactive ⊠Drugs ⊠BMI/metabolic syn ⊠Haematologic ⊠Eg CML 1/100000
- 13. (Neutrophil) Leucocytosis Important points âșUrgent referral âș>50 âșBlood film features of CML or CMML (film comment) âșConsider if âșChronic neutrophilia>20 âșChronic monocytosis >1 âșChronic eosinophila>2 History & Exam infection, inflammation, autoimmune, neoplasia rash, arthritis, weight loss CRP, U&E, LFT, TFT Ca Auto Ab Micro culture FBC, ESR CXR Urine Reactive screen negative Haematology referral
- 14. Neutropenia âșCaucasian female aged 36yrs, no significant medical history, no regular medication âșFH rheumatoid arthritis âșHb 126 g/l âșWCC 3.1 âșNeutrophils 0.4 âșPlatelets 180
- 15. Neutropenia (Neutrophils<1.7) What do I need to know? âșIs the patient unwell? (Viral assoc transient) âșAny previous counts? âșAny other cytopenia? âșIs the patient on chemotherapy? âșOther drugs âșHow severe is it? ⊠Mild (1.0-1.7), functionally normal ⊠Moderate (0.5-1.0) ⊠Severe (<0.5)-RISK OF INFECTION
- 16. Neutropenia What are the common causes? âșInfection âșDrugs (chemotherapy!) âșAutoimmune âșHereditary ⊠Racial (African origin 1.0-1.3)
- 17. Neutropenia <1.0 Patient on chemotherapy Discuss with haematologist and refer Unwell ? Moderate or Severe <0.5 No No B12, Folate, LFT, GGT, autoAb Haematology advice/referral Neutropenia pathway Yes Consider repeat particularly if recent infection
- 18. Thrombocytosis âșMale 65yrs, mild hypertension on ramipril. âșHb 160, Hct 0.50, WCC 11.0 plts 450 âșRefer or not?
- 19. Thrombocytosis âșMaybe reactive to inflammation, infection other malignancy, iron deficiency or bleeding âșIn MPD very high counts >1500 assoc with vascular events and bleeding âșUrgent referral ⊠>1000 ⊠600-1000 if assoc with CVA, TIA, VTE âșConsider if ⊠>600 consistently ⊠>450 with vascular event ⊠High wcc or Hb
- 20. Thrombocytopenia âș>100 functionally normal âș<20 bleeding risk rises but most symptom free âșCauses âșImmune âșDrugs eg quinine âșBone marrow failure syndromes eg MDS âșALCOHOL âșLiver disease âșPregnancy
- 21. Thrombocytopenia âșRefer âș<50 âș50-100 if other cytopenia or planned surgery/dental work âșInvestigations âșBlood film- platelet clumping âșRepeat sample âșRenal & liver function âșClotting screen âșAutoantibodies
- 22. ?Myeloma History 68yr female, Back pain 4 months ESR 70 X Ray normal ï Hb 110 ï WCC & plts normal ï U&E normal ï Total Protein 66 (60-74) ï IgG * ï IgA 0.7 (0.8-4.0) ï IgM 0.5 (0.5-2.0) ï MIg 7.0 ï IgG Kappa monoclone Should I refer to haematology? ReminderâŠâŠ.Monoclonal or polyclonal?
- 23. Paraproteins âșRefer if ⊠IgG>15g, IgA>10g ⊠IgD or E ⊠Lower levels if assoc with CRAB âșIgM usually assoc with lymphoma ⊠Any other features? ⊠Paraprotein>10g ⊠?Hyperviscosity âșC- Hypercalacemia âșR- unexplained renal failure âșA- anaemia/cytopenia âșB-bone pain/fracture
- 24. Paraproteinaemia ï Most will be MGUS ï Present 3% over 70 and 5% over 80 ï 1% risk of progression to MM per annum ï A few secondary to auto-immune disease & rarely other malignancies ï If criteria for referral not met then monitor on a 6-12 monthly basis.
- 25. Common Red cell Problems âșMacrocytosis âșErythrocytosis âșHaematinic assessment âșAnaemia in the elderly âșHaemoglobinopathi es including alpha thal carriage
- 26. Macrocytosis âșApprox 8% population âșCommonest causes alcohol & hypothyroidism ⊠B12/ folate deficiency ⊠Drugs (including those used for HIV) ⊠Reticulocytosis ⊠Paraprotein ⊠Myelodysplasia (elderly population & associated with cytopenias)
- 27. Macrocytosis Raised MCV >100 Are there cytopenias? Check B12, Folate,, LFT, GGT, TFT, Igs, Refer to Haematology Yes No Isolated macrocytosis Monitor if screening normal
- 28. Erythrocytosis??
- 29. Erythrocytosis âșApparent ⊠Dehydration ⊠Diuretics ⊠Alcohol ⊠Raised BMI âșTrue Physiological ⊠Hypoxia eg COPD, sleep apnoea ⊠High altitude ⊠Smoking âșTrue none physiological ⊠Primary polycythaemia ⊠Certain rare tumours ⊠Anabolic steroid usage URGENT REFERRAL âą Hct >60 males or 0.56 females
- 30. Erythrocytosis Male Hct >0.52 for at least 2 months Female Hct >0.48 for at least 2 months Refer to Haematology Incidence of polycythaemia rubra vera ~5/100 000 Incidence of apparent polycythaemia~ HIGH!
- 31. Haematinics âșThere is no entirely reliable blood test for iron status âșThere is no entirely reliable blood test for folate âșThere is no entirely reliable blood test for B12
- 32. âșFerritin is the test of choice âșInaccurate in the presence of inflammation âșA trial of iron remains a valid approach âșALCOHOL/FATTY LIVER & FERRITIN âșSerum folate is a good reflection of what you have just eaten âșIâm not sure what B12 is a good reflection of! âșInterpret borderline values with caution âșSchilling test no longer available
- 33. Reduced serum B12 âșB12< 100 True deficiency highly likely parenteral replacement âșB12 100-145 replace especially if raised MCV, cytopenia, neuropathy âșB12>140 deficiency unlikely âșB12 is an unreliable test âșAlways reduced in pregnancy âșUncomplicated B12/folate deficiency does not require OP referral.
- 34. Anaemia in the elderly âșFrequency of anaemia increases with age âșIncidence 10-40% âșMany have diagnosable/treatab le cause âș25% no identified cause âșInvestigations âșFBC & film âșReticulocytosis âșRenal/ liver function âșImmunoglobulins âșHaematinics âșCoeliac screen âșDietary history âșGI investigations âșBone marrow
- 35. Anaemia in the elderly CAUSE OF ANEMIA PERCENTAGE OF CASES Anemia of chronic disease 30 to 45 Iron deficiency 15 to 30 Posthemorrhagic 5 to 10 Vitamin B12 and folate deficiency 5 to 10 Chronic leukemia or lymphoma 5 Myelodysplastic syndrome 5 No identifiable cause 15 to 25
- 36. The lost 25%? âșMULTIFACTORIAL âșDecline in erythropoetin âșDecline in androgens âșIncreased inflammatory cytokines even in absence of a recognised disease âșAge associated decline in stem cell function âșEarly MDS without other cytopenias or BM changes
- 37. Indications for haematology referral Pancytopenia Monoclonal gammopathy Suspicion of myelodysplastic syndrome Blood smear showing immature white cells or nucleated red cells Indeterminate status of iron stores Unexplained progressive or unresponsive anemia
- 38. What are haemoglobinopathies? âșCommonest single gene disorders worldwide âșAutosomal recessive âșDisease states homozygous or combined heterozygotes âșDefects of quality or quantity of haemoglobin âșQuality Variant Hbs eg sickle âșQuantity Under production eg thals
- 39. National Screening Plan âșNHS Plan commits to âa new national linked antenatal & neonatal screening programme for haemoglobinopathy & sickle cell disease by 2004â âșUniversal neonatal âșAntenatal ?selective ?universal
- 40. The haemoglobinopathy screen âșHaemoglobin âșMCV, MCH âșHb A2 âșHPLC âșZPP/ferritin âșSickle solubility test, electrophoresis, molecular analysis
- 41. Case study âș32 year old female of Pakistani origin attends c/o fatigue âșHb 11.9, MCV 71, MCH 23 âșFerritin 109 âșHb A2 normal, no evidence of b thal
- 43. b thalassaemia b/b No Normal b0 /b Thal trait Low MCV/MCH b+ /b Thal trait Mild anaemia b0 /b0 Thal major Transfusion dependant b0 /b+ Thal intermedia Anaemia, splenomegally b0 /HbE Thal major
- 44. a thalassaemia aa/aa Normal -a/aa Heterozygous a+ Low MCV/ MCH -a/-a Homozygous a+ Low MCV/MCH --/aa Heterozygous a0 Low MCV/MCH --/-a Haemoglobin H disease Thal Intermedia --/-- Hb Barts Hydrops Stillbirth
- 46. a thalassaemia heterozygotes a0 a+ âșCypriot 2% âșIndia rare âșAfrican rare âșHong Kong 5% âșChina 3-9% âșPhillipines 10% âșUK Africans 25% âșIndia 5-58% âșPNG 20- 80% âșThailand 3-17% âșMaori 5-10%
- 47. Summary points âșOther than for individuals of E. Med or SE Asian origin a thal trait is insignificant âșMicrocytosis is commonly due to thal trait âșA national antenatal/neonatal screening programme is now in place