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DR SUTHANTHIRA KANNAN MD FRCPACONSULTANT HEMATO ONCOLOGIST
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WHY HEMATOLOGICAL CASES GETS MISDIAGNOSED OFTEN?
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Not doing a complete blood count in analyser
Peripheral smear reports not focussing on diagnosis
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HB 45 g/l
MCV 121
RDW 20.5
Wbc 3.5 Platlet 75
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Rbc show gross aniospoikilocytosis with numerous microcytes, fragments, few macrocytes, basophilic stippling
Wbc show normal differential with no left shift
Platelets are reduced.
?DIAGNOSIS
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Gross macrocytosis with many fragments, basophilic stippling, Wbcs show few hypersegmented and occasional large polymorphs, suggestive of megaloblastic anemia.
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20 year male, presenting with facial and mild pedal edema
Hb 6 g/dlTc 30,000/cu mmDC POLY 24 LYMPH 64PLT 134
Treated as interstitial nephrits
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Normocytic RBCsWbc show atypical lymphocyte.
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PURPOSE OF TALKIndia has far far less number of hemato
pathologistTry to arrive at a working diagnosis based on
CBC, which is possible in ~70% of patients.
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Doing a complete blood count is a basic necessity to diagnose most of the underlying haematological disorders/ANY OTHER DISORDER
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MCV and RDW are the key MCV and RDW are the key parameters in diagnosing any parameters in diagnosing any anemia, before looking at the blood anemia, before looking at the blood filmfilm
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MCV & RDWNormal MCV in adults is around 80-90fl.RDW (Red cell distribution width) normal
cv(16-18%)Reticulocytes are larger than RBCs and can
have MCV from 90-130fl.
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RDW50% of RBCs have MCV of 80fl (60)50% of RBCs have MCV of 100 fl (120)MCV will be 90.RDW 25% (gross anisocytosis)Normochromic anemia with reticulocytosis.
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RDW high in few conditionsReticulocytosis (Normal + Mild High MCV)
Transfusion (Transfused Rbcs are smaller)
Nutritional anemias (Gradual transition – microcytic + normal OR macrocytic + normal or + low)
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VERY LOW MCV (<70)
LOW MCV (70-80)
NORMAL (80-95)
HIGH MCV (95 -110)
V HIGH MCV (>110)
NORMAL RDWHIGH RDW
ANEMIA ONLY
WITH CYTOPENIA OF OTHE CELL LINES
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50 yr old male, came for elective surgery for hernia
Found to have HB 9G/dl
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Hb 9.2gWbc 5,700Plt 2,30,000
MCV 62RBC 5.2RDW 16
Normal diff
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? Iron deficiency
Any further tests?
Implications?
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58 year old male presents with tiredness and palpitations on exertion
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Hb 5.2g/dlWbc 6,300Plt 5,60,000
MCV 61RDW 18RBC 3.1
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? Need for transfusion
Further tests
?Further evaluation
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Very Low MCVIron deficiency (Low RBC, high RDW)
Thal trait (Normal RBC, Normal RDW)
Rare (Thal major, sideroblastic)
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Low MCV (70-80)Same as V L MCV
Anemia of chronic disease
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50 yr old male, with c/o poor appetite, altered taste came for master health check up
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Hb 6.4Wbc 2300Plt 85,000
MCV 118RDW18.5RBC 3.1
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Why Pancytopenia?
Can it be misdiagnosed?
Simpler tests to confirm?
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26 year old lady with sudden onset breathlessness on exertion
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Confirmation
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Pregnant lady presents with breathlessness on exertion
Tight MS Valvotomy done few years back
Now has features of MS/MR
Not in obvious CCF
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Hb 5.2Wbc 8900Plt 65,000
MCV 108RBC 3.8RDW 17.2
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Smear/Reticulocyte count
Retic 23%
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Diagnosis of hemolysis
Commonest hemolytic disorders in practice
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AIHASICKLE (Endemic)G6PDMICROANGIOPATHY (TTP/HUS/VALVE)PNH
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Very high MCV >110Hb 6.5MCV 115 RDW 19MCH 34RBC 3.6WBC 2500PLATELET 75,000
?Diagnosis? confirmation
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45 yr old lady sudden onset anemia, no bleedingHb 4.2MCV 130RBC 2.5RDW 21MCH 45WBC 12,300PLT 3,50,000
? Diagnosis
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AIHA with red cell clumps
AIHA with sphero/reticulocytosis
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Very high MCVTrue
High LDH, Bili PancytopeniaB12/folate
Spurious
High LDH, BiliLow Hb aloneAIHA
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NORMOCYTIC ANEMIAS14 yr old girl on anti epileptic, presents with
pallor, NO bleedingHb 4.2Wbc, Plat Normal
MCV 85RDW 16RBC 2.8
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Further tests?
Any other D/D?
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8 year old boy referred for evaluation of anemia
Hb 5.2Wbc plat Normal
MCV 86RDW 16RBC 2.9
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One test picked up
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Normocytic anemia (80-90)PRCA
Renal failure
Chronic hemolysis
Acute bleed
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Mild macrocytic anemia (95-110)Leave it for hematologists to diagnose !!!!
Usually indicates hypoxia, marrow stress.
Aplasia, MDS, myeloma
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Myeloma
Myelodysplastic syndromes
Aplastic anemia
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DiabetesSmokingHypothyroid
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Megaloblastic anemia - Very good prognostic pancytopenia
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Other good prognostic/bi-pancytopeniaVHF
Hypersplenism
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Pancytopenia what to do? Good pancytopenia
Viral Short lived (not more than a week) Hb, RBC count normal SGOT/PT often deranged
Megaloblastic (High MCV, high LDH, rapid response)
Hypersplenism (absolutely well looking patient, splenomegaly, normal diff – However, this needs evaluation.)
Lethal pancytopenia
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LETHAL PANCYTOPENIA90% of the time Leukemia can be suspected/
diagnosed in the peripheral blood
THERE IS NO POINT IN DOING A MARROW FOR DIAGNOSIS OF LEUKEMIA ITSELF
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Diagnostic evaluation of leukemia involves, CD marker analysis, karyotyping, FISH, molecular studies
Some times most of the tests can be done in PB (? Marrow for HP evidence )
When the blast number is lowTo check for MDS, fibrosis
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Palliative chemo is the preferred option in majority of elderly AML
Prognostication markers can be done in PB in majority of patients
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25 year old man with ankle joint pain and swelling comes to orthopedic clinic
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56 year old lady, presents with anemia, recurrent fever, body pains for the past 3 months
Has been to various hospitals
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26 Year old lady with chronic severe back acheHb 6g (transfused)TC 2200 MCV 82PLT 50000
DIFF: Poly 20 Lymph 70 Mono 10
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Has been having fevers for the past 2 months
Shown in various hospitals
MARROW done twice, reported as inadequate
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Diagnosis
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37 year old female presented with tiredness
Hb 6g/dlMCV 106TC 5.6 PLY 12
LDH, alb/glob ratio normal
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CARRY HOMEClassify MCV into low (<80), normal (80-95),
mildly high (95-110), severely high (>110)Check poly/lymph ratioDegree and number or cytopenias.
Bone marrows in periphery mostly not needed