Cytopenias The what, why and how Dr Esther Chan Associate - - PowerPoint PPT Presentation

Cytopenias

The what, why and how

Dr Esther Chan Associate Consultant Haematology

3 main cell lines

• RBC/Haemoglobin
• White cell counts
• Platelets

The WHAT

Anaemia

Leucopenia

• The only clinically relevant parameter is

neutropenia

• Risk is of severe infection and this correlates

to absolute neutrophil count

• ANC

– <1-0.5: Significantly increased risk of infection – <0.5: Highest risk of infection

Thrombocytopenia

• Generally not clinically significant if >100K
• Concern of bleeding increases once Plt<30k

Summary: The What

• Drop fm pt’s baseline
• Neutrophils <1
• Platelets <100 (<30)

The WHY

How is the FBC measured?

• Haematology Analysers

• Principle of WBC, RBC and Plt counts

– Cells forced in single file through aperture – Causes momentary decrease in electrical current – Creates pulse

• Amplitude proportional to size
• Number of pulses proportional to number

• Note that most modern machines combine

laser, impedance, radiofrequency, direct current, peroxidase staining to optimize sensitivity

However….

• Machine errors are still possible!

The WHY - Lesson 1

• Exclude spurious low counts!

Important Approach

• Concept of

– Production issues

• Empty
• Packed
• Faulty

– Peripheral consumption/ destruction

‘Empty’

• Aplastic anemia/ Marrow hypoplasia

Causes:

• idiopathic causes,
• viral infections,
• drug related causes,

(Chemotherapy)

• RT etc.

‘Packed’

• By marrow infiltration with abnormal cells

– hematological malignancies ie leukemias – non hematological malignancies (metastasis)

• By marrow fibrosis

– Myelofibrosis

Myelodysplastic Syndrome

• Defined as acquired bone marrow disorder
• Characterised by ineffective haematopoiesis
• Proliferation of abnormal clone of cells. which replaces

normal haematopoietic cells.

• Clinical manifestation of BM failure as well as tendency to

transform into acute leukaemic phase

• May be primary or secondary to other causes eg.

chemotherapy, radiotherapy or environmental toxins.

‘Faulty’

Peripheral destruction/consumption

• Infections

– Dengue

• Autoimmune

– SLE

• Hypersplenism

– Cirrhosis with splenomegaly

The WHY - Lesson 2

• For approach to cytopenias

– Is it

• Production problem?
• Destruction problem?

– Narrows down differentials

The HOW

On seeing cytopenias on the FBC…

• Do not interpret an FBC by itself!
• 1. Need for guidance from clinical history &

physical examination

• 2. Need to take cues from the FBC/PBF

Clinical History

• Symptoms/ Signs:
• Fever
• Chills
• Rigors
• Hypotensive
• Toxic
• Malar rash
• Arthritis
• Alcohol history Hypersplenism as cause of cytopenias
• Splenomegaly

Sepsis  as cause of cytopenia Possible SLE with concomittant cytopenias

Signs/Symptoms

Systemic Symptoms

• LOA
• LOW
• Fever

Clinical Signs

• HEPATOMEGALY
• SPLENOMEGALY
• LN SWELLING
• PALLOR

Possible Haematological Malignancy

• Leukaemia
• Lymphoma

Cues on the FBC/PBF

• ‘Empty’ Marrow

– Pancytopenia – No abnormal cells on the PBF – No early white/red cells

• ‘Packed’ Marrow

– Leucoerythroblastic picture

• Early RBC/WBC in the peripheral blood
• Tear drop cells

– Blasts – Abnormal lymphoid cells – Rouleux

• ‘Faulty’ marrow

– Dysplastic features

• RBC: Anisopoikilocytosis, Basophilic stippling
• WBC: Hypo/Hyper-granulated forms
• Plt: Plt anisocytosis, Hypogranular forms

Other factors

• Other cell lines

– Monocytopenia? Bicytopenia? Pancytopenia

• Differential Counts

Real life examples

• Case 1

• Describe the FBC
• What else would you want to know?
• What are the differentials?

Don’t forget!

• Clinical History

– Bruising – Loss of weight – Tired – Fever

• Physical Examination

– Lymph nodes palpable

Initial Impression

• Leuocytosis with reduced Hb/ plts
• Associated with systemic symptoms.

Differentials:

• Sepsis (Viral)?
• Hematologic malignancy?

Other Factors:

• Final diagnosis

– Acute leukaemia

Case 2

• How do you want to proceed?

• Clinical History

– 50 year old man – Loss of appetite and some loss of weight. – No bleeding complications. – Noted increased lethargy at home. – Admitted when noted Hb low and thrombocytopenia. – NO hypothyroidism symptoms. – NO history of liver disease – NO special drug use – PE: NO hepatosplenomegaly

Other factors

• PBF findings

– Hyposegmented Neutrophils seen

• Diagnosis

– Myelodysplastic syndrome

Case 3

• Any thoughts?

• Clinical history

– 50yr Female – Elective admission for Total knee replacement – Incidental finding

• What to do next?

– Cancel operation? – Bone Marrow Aspiration?

• Other factors

Case 4

• Clinical History

– 30yr Female – Brought to A&E by family – Fever for 3 days – Drowsiness, unable to rouse from bed for 1 day

• Other factors

• Diagnosis

– Thrombotic Thrombocytopenic Purpura

Case 5

• History

– 60yr Male – Well with no complaints – FBC done as part of health screening by his company

• Other factors

Classification of anemia – MCV and reticulocyte count

Microcytic

MCV

Normocytic Macrocytic

Low retics: Iron Deficiency anemia Sideroblastic Anemia Normal/high retics: Thalassemias Low retics Normal WBC/Platelets:

• AOCD
• Early IDA
• Renal failure
• Pure red cell aplasia

Pancytopenia

• Primary failure: AA
• Secondary failure:

chemo/RT, MDS Low retics: Megaloblastic anemias Non-megaloblastic:

• Liver disease
• Alcohol
• Hypothyroidism
• Drugs
• MDS

High retics: Reticulocytosis

Summary – The HOW

• Correlate FBC with

– pt ‘s clinical picture – & other factors (PBF/Differential counts)

• To evaluate and manage all cytopenias safely

The End!

Thank you for your attention

Email: Esther_hl_chan@nuhs.edu.sg