Michael Joffe ST6 Haematology SpR

Transcription

1 Michael Joffe ST6 Haematology SpR

2 Mrs SB 71 year old female on AMU Telephone referral to haematology by medicine with Hb 102 MCV 89, normal B12, Folate, Ferritin. PMH DM General decline over several weeks Dysuria AKI cr 326 egfr 8 Nausea Shoulder pain

3 History Was well a month ago Reduced appetite 3 UTIs in past 6 months Shoulder pain has come on over about 6 weeks No fevers or night sweats

4 Blood film Myeloma screen Urine dip US KUB Virology Shoulder x-ray

5 Serum electrophoresis IgA 0.5 ( ) IgG 6.1 ( ) IgM 0.53 ( ) 1.5g IgG paraprotein detected Blood film mild rouleaux only

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7 Serum Free Light Chain assay Bence Jones Protein

8 20% MM is light chain myeloma Cant do a screen with Serum electrophoresis alone. NICE and IMWG guidance to do both

9 Serum Free Light Chain assay Bence Jones Protein ACR PCR remember to look back. Common test often performed by GPs

10 09/06/14 30/09/13 21/08/12 Urine PCR Urine ACR Urine 5.51 g/l 6.32 g/l 3.62 g/l Protein Urine 78 mg/l 81 mg/l albumin Hb 89 g/l Not done Not done Serum Creatinine

11 Serum electrophoresis IgA 0.5 ( ) IgG 6.4 ( ) IgM 0.58 ( g/L paraprotein detected Serum free light chains Kappa ( ) Lambda 7.1 ( ) K:L ( )

12 Unexplained anaemia esp NCNC Unexplained macrocytosis Abnormal/discrepant Urine PCR and ACR Unexplained proteinuria esp in diabetics i.e. high PCR but low ACR Non resolving bone pain esp backache Bone pain needing morphine based analgesia Vertebral fractures. Pathological fractures Unexplained renal impairment Unexplained high calcium Nephrotic syndrome Unexplained cardiac failure All neuropathies, carpel tunnel syndrome Recurrent bacterial infections Incidental persistent elevated inflammatory markers

13 MGUS Myeloma Plasmacytoma Waldenstroms Macroglobulinaemia Low grade NHL Amyloid

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16 Calcium Renal Failure Anaemia Bone Lesions

17 Minnesota population study, MGUS was present in 1 2% of people in their sixth decade, 2 4% in their seventh decade, rising to 4 5% in their eighth decade (Kyle et al, 2006) Can be IgG, A or M, or light chain Not a cancer. But has a risk of progression.

18 Patient forgot to mention headaches for past week. Unusual for her

19 Neurology Renal failure HYPERVISCOSITY Immune complications High plasma viscosity that is unexplained Look for a paraprotein May need plasma exchange

20 83 year old male Admitted to AMU after a fall Urine dip + nitrites FBC shows Hb123 Platelets 121 WCC 29.2

21 WCC 29.2 Neutrophils 19.2 Lymphocytes 1.8 Monocytes 0.8 Eosinophils 0.9? Infection or CML

22 WCC 29.2 Neutrophils 14.4 Lymphocytes 3.6 Monocytes 8.6 Eosinophils 0.2 CMML likely Persistnent inflammation causes monocytosis

23 WCC 29.2 Neutrophils 4.7 Lymphocytes 24.1 Monocytes 0.4 Eosinophils 0.2 Low grade lymphoproliferative disorder CLL most likely. Remember lymphocyte count can rise with infection too.

24 WCC 29.2 Neutrophils 8.7 Lymphocytes 2.1 Monocytes 0.4 Eosinophils 15.2

25 WCC 29.2 Neutrophils 0.23 Lymphocytes 1.3 Monocytes 0.4 Eosinophils 0.2? AML Needs urgent haematology input

26 CML CMML

27 CML MPD - Proliferation of myeloid cell lines CMML MPD/MDS with proliferation of monocytic cell line. It is characterised by the presence of monocytes. NOT INTERCHANGEABLE

28 Different pathology Different treatment approach Tki vs supportive/cytoreductive treatment

29 CML CMML PV ET SM Eosinophilia associated with PDGFRA

30 72 year old male, Caucasian 3 weeks cough yellow sputum improving Hb 104 platelets 162 neutrophils 1.1 PMH Diabetes and HTN

31 Medications - Phenytoin, Bisoprolol, Gliclazide. Had Amoxicillin 2 weeks ago for LRTI from GP. No FH Never smoked. 4 units alcohol/week

32 Differential? Possibilities

33 Infection related Drug induced Immune Nutritional Bone marrow disease Familial

34 REPEAT Review the drug chart Film B12, folate, ferritin Serum electrophoresis Autoimmune (ANA, RF) Viral infection Coagulation screening tests Bone Marrow aspirate and trephine

35 Algorithm for the evaluation and treatment of adult patients with neutropenia. Christopher Gibson, and Nancy Berliner Blood 2014;124: by American Society of Hematology

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40 Serum electrophoresis normal B12/folate normal film essentially normal Sputum mycoplasma

41 Infection +/- antibiotic induced neutropenia Repeat neutrophil count normal 1-2 weeks later If it doesn t improve after 4 weeks or continues to get worse Haematology needed.

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