Haematology

FOURTH EDITION
AN ILLUSTRATED COLOUR TEXT
tahir99-VRG & vip.persianss.ir
Content Strategist: Jeremy Bowes
Content Development Specialist: Fiona Conn
Project Manager: Srividhya Vidhya Shankar
Design Direction: Greg Harris
Illustration Manager: Jennifer Rose
tahir99-VRG & vip.persianss.ir
Martin R Howard
MBChB MD FRCP FRCPath
Consultant Haematologist
York Teaching Hospital NHS Foundation Trust
Clinical Senior Lecturer
Hull York Medical School
York, UK
Peter J Hamilton
MA BM BCh FRCP FRCPath (retired)
Formerly Consultant Haematologist
Royal Victoria Inrmary
Lecturer in Medicine
University of Newcastle-upon-Tyne
Newcastle-upon-Tyne, UK
Illustrated by Robert Britton and Antbits Ltd.
Haematology
AN ILLUSTRATED COLOUR TEXT
FOURTH EDITION
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2013
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2013 Elsevier Ltd. All rights reserved.
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
First edition 1997
Second edition 2002
Third edition 2008
Fourth edition 2013
ISBN 978-0-7020-5139-5
ebook ISBN 978-0-7020-5415-0
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Notices
Knowledge and best practice in this eld are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identied, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions.
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liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
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Printed in China
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This edition has been considerably
updated to acknowledge recent
developments in the understanding and
treatment of benign and malignant
diseases of the blood. The addition of a
section addressing Haematology in the
Elderly reects the increasing age of
the population. A number of case
histories have been added to allow the
enthusiastic student to test their
learning. These are intended to be
enjoyed. Although it can seem
complicated, haematology remains a
fascinating specialty which well repays
attempts at understanding.
MRH
The principles that guided the rst
edition of this book sixteen years ago
still apply. In the era of whole genome
sequencing and targeted therapies, the
proper clinical management of patients
with blood disorders relies very heavily
on traditional skills: history taking,
clinical examination and careful
selection of laboratory investigations.
Preface to the fourth edition
tahir99-VRG & vip.persianss.ir
Preface to the rst edition
that the format, with double page
spreads and extensive colour
illustration, will allow information
to be absorbed painlessly and with
enjoyment! The text is designed to be
suitable for medical students, junior
hospital doctors, general practitioners,
biomedical scientists, and nurses
with a special interest in haematology.
Those taking higher medical
examinations should nd it a
useful revision aid.
We have stressed recent advances in
technology in the laboratory and newer
treatment strategies on the ward.
However, if this book has a message it
is that best practice and management
of blood diseases still relies heavily on
traditional skills history taking,
clinical examination, and careful
selection of laboratory investigations.
MRH, PJH
Blood is a hot, temperate, red humour
whose ofce is to nourish the whole
body to give it strength and colour,
being dispersed by the veins through
every part of it, wrote Richard Burton
in 1628. Studying the red humour can
be hard work. Complex nomenclature
and classications make haematology
seem tedious and unintelligible to the
uninitiated. The object of this book is to
give a basic grounding in the biology
and diseases of the blood. We hope
tahir99-VRG & vip.persianss.ir
v
Acknowledgements
Saunders (Newcastle-upon-Tyne); Mr M
Cullen, Mrs H Dickinson, Dr D Norfolk,
Mrs S Ricketts, Dr A Scarsbrook
(Leeds); Prof D Grimwade, Dr E Letsky,
Dr J Marsh (London); Prof E Preston
(Shefeld); Dr P Bolton-Maggs, Mrs H
Jones (SHOT); Haematology
Laboratories at York Teaching Hospital
and The Royal Victoria Inrmary,
Newcastle-upon-Tyne; the Medical
Illustration Department at York
Teaching Hospital. Thanks to all
involved at Elsevier.
We are grateful to the following
colleagues for their advice and help
with illustrations: Dr A Anderson, Dr L
Bond, Dr A Clarke, Dr I N Reid, Dr R.
Mannion, Dr A Turnbull, Dr H
Wilkinson (York); Dr A Hall, Dr A
Lennard, Dr M Reid, Dr P W G
tahir99-VRG & vip.persianss.ir
2 1 ANATOMY AND PHYSIOLOGY
1 The bone marrow
detectable precursor cell creates granulocytes, erythrocytes,
monocytes and megakaryocytes and is thus called CFU
GEMM
.
HSCs may also be identied and separated from more com-
mitted progenitors by the use of ow cytometry as they have
a characteristic immunophenotype.
HSCs have the capacity for self-renewal as well as differen-
tiation and the system allows enormous amplication. A life-
time of human haematopoiesis with the generation of
incalculable numbers of mature cells may rely on only a few
thousand stem cells present at birth. These cells depend on
their micoenvironment, the niche, for regulation of self-
renewal and differentiation. Both haematopoietic and stromal
stem cells have the capacity to produce cells associated with
other tissues such as bone, liver, lung and muscle. This
concept of plasticity has therapeutic implications as stem
cells are used to repair a variety of damaged tissues.
Regulators of haematopoiesis
Control of haematopoiesis is mediated via regulatory mole-
cules (or growth factors Table 1.1). These are generally
glycoproteins produced by stroma and differentiated blood
cells. They may act on more than one cell lineage and fre-
quently show additive and synergistic interactions with each
In early fetal life, blood is produced in
the mesoderm of the yolk sac. During
the second to seventh months the liver
and spleen take over. Only in the last 2
months of fetal development does the
bone marrow become the predominant
site of blood formation. During child-
hood, marrow in the more peripheral
bones becomes gradually replaced by
fat, so that in adult life over 70% is
located in the pelvis, vertebrae and
sternum (Fig 1.1). This explains the sites
used for bone marrow sampling (see
p. 106).
The structure of the
bone marrow
A trephine biopsy allows a two-
dimensional view of the bone marrow
Fig 1.1 Sites of blood production in the fetus and after birth.
0
50
100
0 1 2 3 4 5 6 7 8 9 10 20 30 40 50 60 70
Prenatal (months) Postnatal (years)
Birth
B
l
o
o
d

p
r
o
d
u
c
t
i
o
n

(
%
)
Yolk sac
Liver
Spleen
Bone
marrow
Vertebrae
and pelvis
Sternum
Rib
Femur
Tibia
Fig 1.2 Normal bone marrow. Light microscopy of bone marrow
trephine biopsy.
down the light microscope (Fig 1.2). Haematopoietic cells of
varying lineage and maturity are packed between fat spaces
and bony trabeculae. Ultrastructural studies reveal clusters of
haematopoietic cells surrounding vascular sinuses which
allow eventual discharge of mature cells into the blood. Dif-
ferent lineages are compartmentalised; for example, the most
immature myeloid precursors lie deep in the marrow paren-
chyma while more mature forms migrate towards the sinus
wall. Lymphocytes tend to surround small radial arteries
while erythrocytes form islands around the sinus walls.
Blood precursor cells in the marrow exist in close proximity
to stromal cells. Stromal cells are those cells which do not
mature into the three main types of peripheral blood cells
thus they include macrophages, fat cells, endothelial cells and
reticulum cells.
Immature blood cells are attached to these stromal cells by
multiple cellular adhesion molecules (e.g. bronectin and col-
lagen). Adhesive molecules have specic receptors on stromal
and haematopoietic cells. As blood cells mature, the receptors
down-regulate and the cells become less adherent and com-
mence the journey through the sinus wall and into the
bloodstream.
Haematopoiesis: the stem cell hierarchy
Haematopoiesis means the formation of blood. A number of
transcription factors (e.g. GATA-1, MLL) are critical both for
stem cell formation and function and lineage-specic
differentiation.
The rst adult haematopoietic stem cells (HSCs) are gener-
ated in the aorto-gonad-mesonephros (AGM) region of the
embryo. The classical hierarchy diagram (Fig 1.3) where all
cells arise in orderly fashion from a HSC is helpful but simpli-
ed; in reality, HSCs are groups of cells with diverse potentials
depending on transcription factors and the local microenvi-
ronment. HSCs are not detectable by microscopic techniques
but their existence can be inferred from cell cultures. Culture
of these early cells on agar generates groups of more mature
and thus recognisable progenitor cells known as colony-
forming units (CFUs). For myeloid development the earliest
tahir99-VRG & vip.persianss.ir
3 The bone marrow
Fig 1.3 The stem cell hierarchy. LT-HSC, long-term haematopoietic stem cell; ST-HSC, short-term
haematopoietic stem cell; CMP, common myeloid progenitor; CLP, common lymphoid progenitor; MEP,
megakaryocyte/erythroid progenitor; GMP, granulocyte/macrophage progenitor; CFU, colony-forming
unit; BFU, burst-forming unit; G, granulocyte; E, erythroid; M, monocyte; Meg, megakaryocyte.
Mature
cells
CFU-Meg CFU-GM
CFU-G CFU-M
BFU-E
Megakaryocyte
CFU-E
Pre B Pre-T
CLP
MEP GMP
CMP
ST-HSC
LT-HSC
Self-renewal
Multipotent
progenitors
Committed
precursors
Pluripotent
stem cells
B-lymphocyte T-lymphocyte
Platelets
Monocyte Neutrophil Red
cell
Fig 1.4 Schematic view of action of regulator on haematopoietic
cell. Second messengers include protein kinase C and calcium ions.
Cell proliferation
Differentiation
Maturation
Change in functional
activity
Haematopoietic
regulator
Specific
membrane
receptor
2nd
messengers
Proteins
Gene
activation
Table 1.1 Key actions of some haematopoietic regulators
Growth factor Key actions
Interleukin-1 Mediates acute phase responses; cofactor for other growth factors
Interleukin-2 Growth factor for activated T-lymphocytes
Interleukin-3 Supports early haematopoiesis by promoting growth of stem cells
c-kit ligand (stem cell factor) Interacts with other factors to stimulate pluripotent stem cells
Erythropoietin Lineage-specic growth factor promoting production of red cells
GM-CSF Growth factor promoting production of neutrophils, monocytes, macrophages,
eosinophils, red cells and megakaryocytes
G-CSF Lineage-specic growth factor promoting production of neutrophils
M-CSF Lineage-specic growth factor promoting monocyte and macrophage production
Thrombopoietin (Mpl ligand) Lineage-specic growth factor promoting platelet production
CSF, colony-stimulating factor; G, granulocyte; M, macrophage.
other. Their actions are multiple, includ-
ing the promotion of proliferation, dif-
ferentiation and maturation, as well as
changing functional activity. Prolifera-
tive regulators alter the behaviour of
cells by interacting with specic recep-
tors on the cell surface (Fig 1.4).
Receptors for haematopoietic regula-
tors have been molecularly cloned and
many are related in structure (haemat-
opoietic receptor superfamily). The
combination of regulator and mem-
brane receptor leads to a structural
change in the receptor and the trigger-
ing of a complex sequence of biochemi-
cal events (signal transduction). The end
result is the generation of intracellular
regulators in the cell cytoplasm which
have the capacity to activate genes,
which in turn encode proteins essential
in cell activation.
Under normal circumstances regula-
tors circulate in the plasma at virtually
unidentiable levels. The activities of
many factors are likely to be localised
and transient so that systemic levels are
of limited signicance. For instance, in
the marrow, regulators acting at the ear-
liest stages of haematopoiesis (e.g. c-kit
ligand) are released from stromal cells
in close proximity to haematopoietic
precursor cells.
The colony-stimulating factors (CSFs)
were originally dened by their ability
to stimulate blood progenitor cells
while the interleukins (ILs) were dened
by their effects on mature lymphocytes.
Subsequent discoveries have rendered
this dual nomenclature unhelpful thus
IL-3 is a key stem cell growth factor. The
term cytokine incorporates all growth
factors.
The bone marrow
The bone marrow is the site of blood formation (haematopoiesis)
after birth.
The cells recognisable in the blood are ultimately all derived from
haematopoietic stem cells (HSCs) which reside in a bone marrow
niche.
Immature blood cells in the marrow are attached to stromal cells
by multiple cellular adhesion molecules. Maturing blood cells are
eventually released through vascular sinus walls into the
bloodstream.
Control of haematopoiesis is mediated via transcription factors and
haematopoietic regulators.
tahir99-VRG & vip.persianss.ir
4 1 ANATOMY AND PHYSIOLOGY
2 Red cells
The mature red cells of the blood transport the respiratory
gases, oxygen and carbon dioxide (CO
2
). Oxygen is carried
from the lungs to the tissues, where it is exchanged for CO
2
.
Red cells are equipped to perform this function for 120 days
during which they make a 300 mile journey around the
microcirculation.
Prior to discharge from marrow sinuses into the peripheral
blood, red cells shed their nuclei. This gives the advantages
of reduced weight and transformation into a biconcave disc
with increased deformability compared with the more rigid
spheroidal nucleated precursor (Fig 2.1).
The blood volume comprises the mass of red cells and the
plasma. Plasma volume is regulated by stretch receptors in
the heart and kidney which inuence secretion of antidiuretic
hormone (ADH) and aldosterone. Erythropoiesis is regulated
chiey by the growth factor erythropoietin.
Erythropoietin
Unlike other growth factors, erythropoietin is mainly synthe-
sised by the peritubular endothelial cells of the kidney. Pro-
duction is triggered by tissue hypoxia (lack of oxygen). Cells
can sense hypoxia via mediators such as the transcription
factor HIF (hypoxia-inducible factor). HIF activates genes vital
in the adaptive response to hypoxia including the erythropoi-
etin gene. Erythropoietin molecules bind to specic mem-
brane receptors on primitive erythroid cells in the bone
marrow and induce maturation. The increase in red cells
released into the blood stops when normal oxygen transport
is restored this feedback circuit is illustrated in Figure 2.2.
Structure
The mature red cell is around 7.8 m across and 1.7 m thick.
Its biconcave shape allows maximum exibility and an
umbrella shape is adopted to traverse the smallest capillaries
which have diameters of only 5 m. The ability of red cells
to recover from the recurrent stresses of the turbulent circula-
tion hinges on the design of the membrane.
The red cell membrane is composed of a collapsible lattice
of specialised proteins (the cytoskeleton) and an outer lipid
bilayer (Fig 2.3). The protein skeleton is responsible for main-
taining red cell shape while the lipid bilayer provides a hydro-
phobic skin. The main skeletal proteins are spectrin, actin,
proteins 4.1 and 4.2, and ankyrin. Spectrin is the most abun-
dant and consists of alpha and beta chains wound around
each other. Spectrin heterodimers can align at the ends to
form tetramers (i.e. four chains). Spectrin tetramers are joined
together by actin in association with protein 4.1. This exible
skeleton is attached to the rest of the membrane by ankyrin,
which interacts with protein 4.2 to link the spectrin beta chain
to the cytoplasmic end of the transmembrane protein band
3. The lipid bilayer consists mainly of a mixture of phospholi-
pids and cholesterol. Cholesterol molecules are inserted
between phospholipid molecules in such a way that they
stiffen the membrane while still allowing a degree of uidity
between the bilayers.
Defects of both the red cell membrane proteins and
lipids may lead to changes in red cell shape and premature
destruction.
Fig 2.1 Scanning electron microscope picture of mature red cells
showing clearly the characteristic biconcave shape. (Copyright Dennis
Kunkel Microscopy Inc.)
Fig 2.2 Feedback circuit in production of erythropoietin.
Red cell mass Erythropoietin
Erythroid
precursors
Stem
cells
Oxygen
sensor
Erythropoietin
production
Bone marrow
Kidney
Fig 2.3 The red cell membrane.
Band
3
Protein 4.1
Protein 4.2
Ankyrin Spectrin Actin
Cytoplasm
Glycophorin
Lipid bilayer
5 Red cells
Metabolism
Red cells require an energy source to
maintain their structure and also a
mechanism for detoxication of oxi-
dants. Energy is provided by the
EmbdenMeyerhof pathway, a sequence
of biochemical reactions in which
glucose is metabolised to lactate with
the generation of two molecules of ade-
nosine triphosphate (ATP). ATP main-
tains the osmotic pressure of the cell by
driving sodium and calcium pumps in
the membrane. It also provides energy
for the cytoskeletal changes needed for
recovery of cell shape. The Embden
Meyerhof pathway does not require
oxygen as a substrate but a small amount
of oxidative glycolysis occurs by the
hexose monophosphate shunt (pentose
phosphate pathway) in which glucose-6-
phosphate is metabolised to generate
nicotinamide adenine dinucleotide
phosphate (NADPH). The hexose
monophosphate shunt plays a vital role
in oxygen detoxication and when oxi-
dised substrates accumulate in the cell
it increases activity several fold. Inher-
ited deciencies of red cell enzymes in
either the EmbdenMeyerhof pathway
(e.g. pyruvate kinase) or the hexose
monophosphate shunt (e.g. glucose-6-
phosphate dehydrogenase) can lead to
shortened red cell survival and haemo-
lytic anaemia (see p. 29).
Haemoglobin and
oxygen transport
The key function of red cells, to carry
oxygen to the tissues and return CO
2

from the tissues to the lungs, depends
on the specialised protein haemoglobin
which is present in large amounts
in mature cells. The normal adult hae-
moglobin molecule (HbA) contains four
polypeptide chains (globin chains): the
two alpha chains and two beta chains
are often notated as
2

2
. Combined
with each of the polypeptide chains is a
haem molecule which contains ferrous
iron (Fe
2+
) and protoporphyrin (Fig 2.4).
The iron combines reversibly with
oxygen and thus haem forms the
oxygen-carrying part of the molecule.
Other globin chains are formed by the
fetus and the change from fetal to adult
haemoglobin occurs in the rst 36
months of life. However, the subunits
designated and persist into later life
and small amounts of fetal haemoglobin
(HbF;
2

2
) and HbA
2
(
2

2
) are found in
adults.
Haemoglobin is more than an inert
carrier molecule. The individual globin
chains interact with each other to facili-
tate the ofoading of oxygen at lower
oxygen saturations. The metabolite
2,3-diphosphoglyceride (2,3-DPG) gen-
erated in a side-arm of the Embden
Meyerhof pathway has an important
role in the process, which results in a
sigmoid-shaped oxygen dissociation
curve (Fig 2.5). In anatomical terms hae-
moglobin has a high afnity for oxygen
in the lungs and a much lower afnity
in the tissues. The oxygen dissociation
curve moves to the left when oxygen
afnity increases; this occurs when H
+

ion concentration is reduced or haemo-
globin F (which cannot bind 2,3-DPG)
raised. The curve moves to the right
when oxygen afnity decreases; for
instance when 2,3-DPG concentration
rises or the abnormal sickle haemo-
globin (HbS) is present. The P
50
level
is dened as the partial pressure of
oxygen at which haemoglobin is half
saturated.
Ageing and death
Beyond 100 days red cells start to show
features of ageing including a declining
rate of glycolysis, reduced levels of ATP
and membrane lipid, and a loss of ex-
ibility. The terminal event is unclear but
effete cells are removed from the circula-
tion by the macrophages of the liver and
spleen.
Most of the catabolised haemoglobin,
particularly the iron, is reused (see also
p. 24). The protoporphyrin of haem is
metabolised to the yellow pigment
bilirubin which is bound to albumin in
the plasma. Bilirubin is conjugated in
the liver to a water-soluble diglucuro-
nide that is converted to stercobilin and
stercobilinogen and excreted in the
faeces. Some stercobilin and sterco-
bilinogen are reabsorbed from the intes-
tine and excreted in the urine as urobilin
and urobilinogen.
Fig 2.5 The oxygen dissociation curve. The
P
50
is 3.6 kPa in normal red cells.
0
50
100
13 3.6
Oxygen tension (kPa)
Saturation (%)
Fig 2.4 The essential elements
of the haemoglobin molecule.
In reality each globin chain has a
complex helical structure. The
chain has 141 amino acids and the
chain 146. The haem molecule
consists of four pyrrole rings
arranged around a ferrous ion.
a
1
b
1
b
2
a
2
Haem
molecule
Globin
chain
Red cells
Erythropoiesis (the formation of red
cells) is regulated by the growth factor
erythropoietin.
Mature red cells have a biconcave disc
shape and no nucleus.
The red cell membrane consists of a
lattice of specialised proteins and an
outer lipid bilayer.
Red cells derive energy principally from
the metabolism of glucose to lactate
(EmbdenMeyerhof pathway).
Red cells contain a specialised protein,
haemoglobin, which allows carriage of
oxygen to the tissues and return of CO
2

from the tissues to the lungs.
6 1 ANATOMY AND PHYSIOLOGY
3 Neutrophils, eosinophils, basophils
and monocytes
actinmyosin assembly in the cell membrane, the latter medi-
ating the movement necessary for locomotion and phagocy-
tosis. Once the cell is at the target site the foreign antigen or
particle is recognised via cell surface receptors and engulfed
within a phagocytic vacuole. There are various methods of
killing; key mechanisms are the generation of nitric oxide and
antimicrobial proteins, and oxidative metabolism in which
antimicrobial oxidants are formed (the respiratory burst).
Cytokines such as G-CSF and GM-CSF (see p. 3) not only
increase neutrophil production but also promote chemotaxis
and phagocytosis.
In clinical practice an increase in neutrophils in the blood
(neutrophil leucocytosis or neutrophilia) is a common
The term white cells or leucocytes refers to the nucleated
cells of the blood the neutrophils, lymphocytes, monocytes,
eosinophils and basophils. All these cells play a role in defend-
ing the host against infection and other insults. Neutrophils,
monocytes, eosinophils and basophils are phagocytes. They
engulf and destroy foreign material and damaged cells. The
term granulocytes may be used to particularly describe neu-
trophils, eosinophils and basophils.
Neutrophils
The blood neutrophil (Fig 3.1a) is the end-product of an
orchestrated sequence of differentiation in the myeloid cells
of the bone marrow. The mature cell has a multi-lobed
nucleus and four different types of granules in the cytoplasm.
Neutrophils have a limited lifespan of around 56 days in the
blood. Approximately half the cells are included in a normal
blood count (the circulating pool), the remainder being in the
marginal pool. The essential function of all these cells is to
enter the tissues and combat infection. This requires both
migration to the site of infection or tissue injury (chemotaxis)
and the destruction of foreign material (phagocytosis). Normal
chemotaxis is dependent on the release of chemotactic factors
generated by bacteria and leucocytes already present at the
infection site. Neutrophils may migrate intravascularly as they
navigate healthy tissues to reach the site of tissue injury.
Neutrophil mobility is imbued both by the presence
of adhesion molecules on the cell surface and by an
Fig 3.1 Leucocytes in the blood. (a) Neutrophils; (b) neutrophil with phagocytosed bacteria; (c) eosinophil; (d) basophil; (e) monocyte.
(a)
(b)
(c)
(d)
(e)
7 Neutrophils, eosinophils, basophils and monocytes
accompaniment to infection and tissue
injury (Table 3.1). The strain on the neu-
trophil compartment often leads to
younger band forms being discharged
from the marrow into the bloodstream
and the appearance of toxic changes,
including coarsened granulation and
vacuolation. Occasionally, phagocytosed
bacteria are visible (Fig 3.1b).
Reduced neutrophils in the blood
(neutropenia) is seen in a wide range
of inherited and acquired disorders.
Serious infection is not seen regularly
until the count falls below 0.5 10
9
/L.
Neutropenia may be an isolated abnor-
mality or associated with a pancytope-
nia. Some causes of an isolated
neutropenia are listed in Table 3.2. In
general, neutropenia may be caused by
underproduction from the marrow (e.g.
leukaemia), reduced neutrophil lifespan
(e.g. immune neutropenia), or pooling
of neutrophils in a large spleen. It is
important to remember that drugs may
be responsible. The term chronic benign
neutropenia is generally used in patients
who have an isolated moderate neutro-
penia with no clear aetiology and a
benign course. There may be an associ-
ated monocytosis. There is some ethnic
variation in neutrophil counts with
black people having a lower normal ref-
erence range than white people. In the
rare genetic disorder cyclical neutrope-
nia, the neutrophil count falls every
1535 days and recurrent infections
occur.
In addition to quantitative abnormali-
ties, neutrophils can be functionally
abnormal. There are several rare inher-
ited diseases characterised by impaired
neutrophil adherence, chemotaxis or
bactericidal activity. In chronic granulo-
matous disease, neutrophils are able to
phagocytose but not kill catalase-positive
microorganisms. Inheritance is auto-
somal or X-linked and patients suffer
recurrent purulent infections and asso-
ciated granuloma formation. Diagnosis
is made in the nitroblue tetrazolium test
where the patients neutrophils fail to
reduce the dye.
Eosinophils
Eosinophils (Fig 3.1c) are characterised
by their two-lobed nucleus and red-
orange staining granules. They have sig-
nicant proinammatory and cytotoxic
activity and play a role in the pathogen-
esis of various allergic, parasitic and neo-
plastic disorders. Interleukin 5 is a key
mediator of eosinophil differentiation
and activation.
The most common causes of eosi-
nophilia in the Western world are allergic
disorders such as asthma, eczema and hay
fever. In developing countries, parasitic
infections are frequently implicated.
Other relatively common aetiologies are
drug hypersensitivity, malignancy, various
skin diseases and connective tissue disor-
ders. Hypereosinophilic syndrome is
characterised by a marked sustained eosi-
nophilia and associated tissue damage.
The disorder is very variable with several
subtypes. The myeloproliferative variant
is associated with a FIP1L1-PDGFRA
fusion gene and often responds to imat-
inib (see p. 45).
Basophils
Basophils are the least numerous of
the blood leucocytes. They are easily
recognised by their abundant dark
purple cytoplasmic granules (Fig 3.1d).
The granules contain mediators of acute
inammation, including heparin and
histamine. Basophils and their tissue
equivalent, mast cells, have receptors for
the Fc portion of IgE. They play a central
role in immediate hypersensitivity reac-
tions. Basophilia is usually associated
with myeloproliferative disorders (e.g.
chronic myeloid leukaemia). However, it
may be reactive to a range of systemic
diseases including inammatory bowel
disease and hypothyroidism. It some-
times occurs during the recovery phase
from acute infection.
Monocytes
Monocytes circulate in the blood
before entering the tissues where they
undergo transformation into macro-
phages. Monocyte colony-stimulating
factor (M-CSF) is vital for monocyte
and macrophage development and acti-
vation. The mononuclear phagocyte
system consisting of monocytes and
macrophages is a potentially confusing
concept as macrophages subserve differ-
ent functions and adopt discrete nomen-
clature in different tissues (e.g. osteoclasts
in bone, Kuppfer cells in liver). Macro-
phages are phagocytic cells but unlike
neutrophils are able to survive the
phagocytic event. They also act as acces-
sory cells in the immune response by
presenting antigens to T-lymphocytes
(see p. 8) and secreting a wide range of
cytokines involved in inammation,
immunity and haematopoiesis.
Blood monocytes typically have a
kidney-shaped nucleus (Fig 3.1e). A
monocytosis in the blood occurs in
chronic bacterial infections such as
tuberculosis and may accompany a wide
range of infective, inammatory and
malignant disorders. Monocytopenia is
less frequently noted but can be severe
in patients receiving corticosteroid
treatment.
Table 3.1 Causes of a neutrophil
leucocytosis
Physiological (e.g. pregnancy)
Bacterial infections
Inammatory diseases (e.g. vasculitis, inammatory
bowel disease)
Trauma/surgery
Malignancy
Acute haemorrhage
Severe metabolic disorders (e.g. diabetic
ketoacidosis)
Myeloproliferative diseases (e.g. chronic myeloid
leukaemia)
Iatrogenic (e.g. treatment with growth factors,
corticosteroids)
Table 3.2 Causes of an isolated
neutropenia
1
Drugs
2
Idiopathic/benign/constitutional
Congenital (Kostmanns syndrome)
Cyclical neutropenia
Autoimmune (sometimes with a connective tissue
disorder)
Infections (e.g. viral, typhoid, tuberculosis)
1
Most bone marrow diseases (e.g. leukaemia, aplastic anaemia)
cause a pancytopenia.
2
Some drugs are well-documented causes (e.g. penicillin,
co-trimoxazole, carbimazole, phenothiazines) but in practice any
agent the patient is taking should be viewed with suspicion.
Neutrophils, eosinophils,
basophils and monocytes
The white cells of the blood (leucocytes) play a key role in defending the host against
infection and other insults.
Neutrophils, monocytes, eosinophils and basophils are phagocytes.
These phagocytic cells may perform other functions; monocytes act as accessory cells
presenting antigens to T-lymphocytes.
Each cell has a characteristic morphological appearance in the blood lm.
Changes in leucocyte numbers (e.g. neutrophil leucocytosis) are common accompaniments
of various disease states.
8 1 ANATOMY AND PHYSIOLOGY
4 Lymphocytes
Lymphocytes are found in large numbers in blood, lymph
(the clear uid of the lymphatic vessels) and in lymphoid
organs such as the thymus, lymph nodes and spleen. They
are essential for immunity. B-lymphocytes produce antibody
against a specic antigen (humoral immunity) while
T-lymphocytes are the cells of the cell-mediated response.
Primary lymphoid organs (bone marrow, thymus) are the
sites of lymphoid development. In the secondary lymphoid
organs (lymph nodes, spleen), mature lymphocytes meet anti-
gens and the immune response is triggered.
Most mature lymphocytes appear under the light micro-
scope as cells with round nuclei and a thin rim of agranular
cytoplasm (Fig 4.1). Although B- and T-cells are not distin-
guishable by their morphology, there are major differences in
their mode of maturation and function.
T-lymphocytes
T-cells make up 75% of the lymphocytes of the blood and
form the basis of cell-mediated immunity. They are less auton-
omous than their B-cell companions, needing the cooperation
of antigen-presenting cells expressing self-histocompatibility
molecules (human leucocyte antigens (HLA)) for the recogni-
tion of the antigen by the T-cell receptor (TCR) (Fig 4.2).
T-cells originate in the marrow but many are destroyed in
subsequent processing by the thymus, the objective being to
select the minority of cells which will recognise self-HLA but
not react with self-tissue antigens. The maturation sequence
is characterised by changing patterns of cell surface molecules
(Fig 4.3). Mature T-cells are divisible into two basic types.
About two-thirds of blood T-cells are helper cells expressing
the surface marker CD4, while the remainder express CD8
and are mostly of cytotoxic type.
It appears that helper cells recognise the combination of
antigen and self-HLA class II molecules on the antigen-
presenting cell, and cytotoxic cells bind with antigen in con-
junction with HLA class I molecules on the target cell (Fig
4.2). TCR genes, like Ig genes, are subject to rearrangement
of germ-line DNA. Following triggering of T-cells by specic
antigen reacting with the TCR, the clonal proliferation of
activated T-cells is sustained by the secretion of cytokines.
Interleukin-2 is the main T-cell growth factor.
Fig 4.1 Mature lymphocytes in the blood.
Fig 4.2 Interaction of T-lymphocyte and antigen-presenting cells.
The T-cell receptor complex (TCR) recognises the combination of processed
antigen and major histocompatibility complex (MHC) molecule and the
immune response is initiated.
Differentiation
Ag infected cell
Ag presenting cell
Cell lysis
Class I MHC
CD8+
Cytotoxic T-cell
CD8+
Cytotoxic T-cell
CD4+
T helper cell
Recognition
TCR
Class II MHC
Growth
factors
B-cell
Plasma cell
Antigen (Ag)
Ag processed into
peptides and combined
with MHC molecules
Fig 4.3 Maturation of B- and T-lymphocytes. (a) B-lymphocyte maturation in the bone marrow. (b) T-lymphocyte development in the bone marrow
and thymus.
Stem
cell
Pre-B Early Mature Activated
PC
cell
Plasma
cell
B-cell
Antigen independent Antigen dependent
First Ig rearrangement (VDJ) Second Ig rearrangement (isotope switch)
Expression of selected CD markers
Tdt
cyt m
Surface Ig
CD10
CD19
CD20
PC : plasmacytoid Ig : immunoglobulin
(a)
Large
cortical
thymocyte
Small
cortical
thymocyte
Medullary
thymocyte
Pre-T cell
Stem
cell
Rearrangement of TCR genes
TCR : T-cell receptor
(b)
Tdt
CD7
Cyt CD3
CD2
CD1
CD4+8 / CD4 / CD8
Expression of selected CD markers
Bone
marrow
Thymus Blood,
lymph node,
spleen
Virgin
T-cell
B-lymphocytes
B-lymphocytes are responsible for humoral immunity. Fol-
lowing an appropriate antigenic stimulus they transform into
plasma cells and secrete antibody specic to that antigen.
B-cells are derived from the stem cells of the bone marrow.
Unlike T-cells it is not clear whether they are subject to further
9 Lymphocytes
processing at a site outside the marrow
in humans. The various stages of B-cell
maturation are illustrated in Figure 4.3.
Each cell can be dened by its expres-
sion of membrane and cytoplasmic
antigens in addition to the stage of
immunoglobulin gene rearrangement.
Within the lymphoid tissues, such as
the lymph nodes and spleen, mature
unactivated or virgin B-cells can be
stimulated by antigen to undergo a mor-
phological transformation into immu-
noblasts and, ultimately, plasma cells.
Stimulation of a single B-cell by
antigen combining with its cell surface
immunoglobulin variable region leads
to a sequence of proliferation and
differentiation resulting in a clone of
immunoglobulin-secreting plasma cells.
This adaptive immune response is
antigen-specic and is facilitated by
helper T-cells and cytokine-secreting
macrophages. Memories of particular
antigens are immortalised by memory
B-cells, allowing a prompt response
to reinfection. The immunoglobulins
secreted by lymphocytes and plasma
cells are heterogeneous proteins, each
designed to interact with a specic
antigen in the defence of the body
against infection (Fig 4.4). There are ve
subclasses of immunoglobulin (Ig),
dependent on the type of heavy chain
(IgG, IgA, IgM, IgD and IgE), with some
further division of subclasses (e.g.
IgG
14
). IgM is generally produced as the
initial response to infection, followed by
a more prolonged production of IgG.
IgA is found in secretions, while IgE
plays a role in delayed hypersensitivity
reactions.
The genes encoding the heavy and
light chains of immunoglobulin are rear-
ranged from their germ-line congura-
tion during early B-cell maturation. The
variable (V), diverse (D), joining (J) and
constant (C) region exons undergo a
complex sequence of DNA splicing, dele-
tions and juxtapositions. The rationale of
this frenetic activity prior to transcrip-
tion is to allow the totality of B-cells to
produce an enormously diverse popula-
tion of immunoglobulins (antibodies)
targeting a vast number of potential anti-
gens. Lymphocytes that can react against
self-molecules are usually functionally
inactivated or deleted so that the adap-
tive immune system normally only
targets foreign antigens (natural immu-
nological tolerance).
Natural killer (NK) cells
NK cells are a subset of lymphocytes
which share many of the characteristics
of cytotoxic T-cells. However, NK cells
do not rearrange or express TCR genes.
They particularly kill target cells that
poorly express class I MHC and are less
able to signal viral infection to cytotoxic
T-cells. NK cells express two classes of
receptors which either activate or inhibit
their killing role. Activating receptors
bind to a variety of ligands on the target
cell whereas the inhibitory receptors
generally bind to HLA class I molecules.
In the blood lm, NK cells appear as
large lymphocytes with abundant cyto-
plasmic granules.
Changes in disease
An increase in lymphocytes in the blood
(lymphocytosis) is generally a reaction
to infection or is part of a malignancy.
A polyclonal T-cell lymphocytosis is a
common response to viral infection,
particularly in childhood. Lymphocytes
may be morphologically abnormal with
variable changes including increased
size and cytoplasmic basophilia. These
heterogeneous atypical lymphocytes are
seen in numerous viral infections but
they are a particular feature of infectious
mononucleosis (see p. 97).
A number of lymphoid malignancies
are associated with lymphocytosis
(Table 4.1). In acute lymphoblastic leu-
kaemia and spill-over of non-Hodgkins
lymphoma cells into the blood, the
malignant lymphocytes are usually mor-
phologically distinctive and confusion
with a reactive lymphocytosis rarely
occurs. In chronic lymphocytic leukae-
mia (CLL), the lymphocytes often appear
unremarkable although the presence of
disrupted forms, termed smear cells, is
characteristic.
Lymphocyte counts are often tran-
siently low after surgery and trauma. A
more chronic lymphopenia is a feature
of ongoing cytotoxic drug treatment and
late HIV infection when CD4 counts fall
to low levels.
Fig 4.4 Basic immunoglobulin structure. The Fab portion is involved
in antigen binding and the Fc portion attaches to macrophages or
lymphocytes expressing the relevant Fc receptor.
V
L
C
L
V
H
C
H
C
H
C
H
V
L
C
L
V
H
C
H
C
H
C
H
Heavy
chains
Light
chain
Hinge
region
Heavy
chain
Fab
Fc
V = variable (antibody binding) region
C = constant region
Table 4.1 Common causes of a lymphocytosis
Infections Acute viral infections (e.g. pertussis, infectious mononucleosis,
rubella)
Chronic infections (e.g. tuberculosis, toxoplasmosis)
Malignancy Chronic lymphocytic leukaemia and variants
Non-Hodgkins lymphoma (minority)
Acute lymphoblastic leukaemia
Lymphocytes
Lymphocytes are essential for normal immunity.
B-lymphocytes respond to an appropriate antigen by transforming
into plasma cells and secreting specic antibody (humoral
immunity).
T-lymphocytes cooperate with antigen-presenting cells in the
recognition of antigen; recognition triggers a clonal proliferation of
activated T-cells (cell-mediated immunity).
The genes encoding immunoglobulin chains and the T-cell
receptor are subject to rearrangement of germ-line DNA.
Various disease states lead to an increase in blood lymphocyte
numbers (lymphocytosis): in those over 50 years, chronic
lymphocytic leukaemia is a common cause.
10 1 ANATOMY AND PHYSIOLOGY
5 The spleen
Although the spleen has been known
of since ancient times, its function
has remained obscure until relatively
recently. Hippocrates thought it was the
source of black bile. Galen suggested it
might be a lter, in view of its spongy
consistency. Our current understanding
of the spleen is dependent on a detailed
appreciation of its vascular supply and
the organisation of its main component
parts: the lymphoid white pulp, the
blood-containing red pulp and the inter-
vening marginal zone.
Structure
The spleen is derived from condensa-
tion of the mesoderm in the dorsal
mesogastrium of the embryo. It plays a
modest haematopoietic role in the
middle part of fetal life, but in the adult
haematopoiesis is usually only seen in
pathological states. An average adult
spleen weighs about 150 g and it has to
become enlarged to at least three times
its normal size before becoming palpa-
ble on clinical examination (p. 17).
The splenic artery penetrates the thick
capsule which invests the organ (Fig
5.1). Branches of the splenic artery are
surrounded by a highly organised aggre-
gate of lymphoid tissue which is termed
the white pulp (Fig 5.2). Intimate to the
central arteriole is the periarteriolar
lymphatic sheath an area mainly
populated by T-lymphocytes. Among
these T-lymphocytes are non-phagocytic,
antigen-presenting cells known as inter-
digitating cells. Spaced at intervals in
the periarteriolar lymphatic sheath are
lymphoid follicles (Malpighian bodies).
In an inactive state these follicles are
composed of recirculating B-lymphocytes
intertwined with cytoplasmic processes
of follicular dendritic cells. The latter
cells may play a role in long-term anti-
body production. When contact with
antigen stimulates B-cell activation, a
germinal centre of rapidly dividing cells
forms in the follicle. This is a key area
in the normal B-lymphocyte prolifera-
tive response and development of B-cell
memory (see p. 8 for discussion of
lymphocytes).
The periarteriolar lymphatic sheath
and B-lymphocyte follicles are separated
from the red pulp by a marginal zone
constituted mainly of non-circulating
B-cells. The marginal zone also contains
specialised macrophages able to take up
Fig 5.1 Structure of the spleen. The white pulp is composed of the periarteriolar lymphatic sheath
and lymphatic nodules. The red pulp contains the splenic cords and sinuses and is separated from the
white pulp by the marginal zone. See text for full discussion.
Marginal
zone
Capsule
Lymphatic
nodule
Periarterial
lymphatic
sheath
Central
artery
Splenic
sinuses in
red pulp
Splenic cords
in red pulp
Direct connection
between artery
and sinus
Trabecular
vein
Lymphatic
nodule
carbohydrate antigens. The red pulp is
composed of two alternating structures:
the splenic sinuses and the splenic cords
(the cords of Billroth). The cords are a
reticular meshwork packed with macro-
phages and antibody-secreting plasma
cells. The sinuses are broad channels
lined with fusiform endothelial cells.
Most of the central arterioles open into
the marginal zone. As alluded to already,
circulating T-lymphocytes move into
the periarteriolar lymphatic sheath and
B-lymphocytes migrate to the follicles.
Other blood cells move slowly through
the complex meshwork of the red pulp,
and cells which are sufciently deforma-
ble and compliant squeeze between the
endothelial cells in the sinus wall into
the lumen of the sinus and back into
the circulation. The organisation of the
spleen into the different compartments is
under the control of various cytokines
and adhesion molecules.
Function
The spleen has two key functions. It
removes older red cells, blood-borne
microorganisms and cellular debris
from the blood. It also plays a vital role
in the bodys response to bacterial and
fungal infections.
It clears unwanted red cells and parti-
cles from the blood in three ways.
Firstly, they can be removed by phago-
cytes. Bacteria, particularly encapsulated
organisms that are not opsonised by
antibodies and complement, are cleared
from the circulation. The spleen is prob-
ably the site of the initial immune
response to these organisms. Phago-
cytic cells in the spleen also remove red
cells coated with IgG antibody.
The second mechanism at work is the
removal of red cells which are not suf-
ciently deformable to pass through
the sinus wall. Pathological states where
red cells lose deformability and are
destroyed prematurely in the spleen
include sickle cell anaemia, hereditary
spherocytosis and malaria.
Finally, the spleen can remove debris
or organisms from within cells. Howell
Jolly bodies (fragments of nucleus) and
malarial parasites are removed when
most of the cell passes through the
inter-endothelial slit with the intracel-
lular particle abandoned on the cord
side.
The spleen has the capacity to mount
complex innate and adaptive immune
responses. Both types of response occur
in the marginal zone, rich in macro-
phages and marginal zone B-cells, while
the white pulp is limited to adaptive
immunity.
Abnormal splenic states
Asplenism and hyposplenism
Surgical removal of the spleen (splenec-
tomy) may be indicated in a variety of
haematological disorders and following
trauma. The spleen may also be absent
as a congenital anomaly, often associ-
ated with transpositions or malforma-
tions of the great vessels and viscera
(asplenia syndrome). Reduced splenic
function can result from splenic atrophy
in disorders such as sickle cell anaemia,
11 The spleen
adult coeliac disease and essential
thrombocythaemia (Table 5.1).
Hyposplenism leads to characteristic
changes in the blood lm (Fig 5.3).
Changes in red cell appearance include
the presence of HowellJolly bodies,
Pappenheimer (siderotic) granules and
target cells. Other less regular red cell
features are lipid-rich acanthocytes and
circulating nucleated cells. There is
often a moderate rise in the lymphocyte,
monocyte and platelet count. Approxi-
mately one-third of circulating platelets
are pooled in the normal spleen. The
increase in platelets post-splenectomy is
frequently impressive (greater than
1000 10
9
/L) but the count usually falls
to a lower level in the longer term.
Quantitation of splenic function is not
straightforward. Methods include the
measurement of the percentage of
pitted erythrocytes using interference
phase microscopy, various immunologi-
cal parameters and scintigraphy.
The clinical signicance of an absent
spleen is the associated increased risk of
life-threatening infection. The risk is
greatest in children under 5 years of age
and where there is a serious underlying
medical disorder such as Hodgkins lym-
phoma or thalassaemia. Most infections
occur within 2 years of splenectomy but
fulminating infection can strike at any
stage. In most cases infection is with
encapsulated bacteria, notably Strepto-
coccus pneumoniae, Haemophilus inuen-
zae and Neisseria meningitidis. In
temperate regions more than half of
serious infections are caused by the
pneumococcus, with high mortality.
Splenectomised patients have an
increased susceptibility to severe malaria.
Prophylaxis against such infections is
the best approach and recommenda-
tions for the management of asplenic
patients are shown in Table 5.2.
Fig 5.2 Light microscopy of the spleen clearly showing the
distribution of red and white pulp.
Table 5.1 Causes of hyposplenism
Congenital absence of spleen
Splenectomy
Sickle cell anaemia
Coeliac disease
Essential thrombocythaemia
Dermatitis herpetiformis
Inammatory bowel disease
Amyloidosis
Advanced age
Fig 5.3 The blood lm in hyposplenism. A HowellJolly body is seen
within a red cell. There are target cells and acanthocytes.
The spleen
The spleen is organised into three main components: the white pulp, the red pulp and the
intervening marginal zone.
The spleen acts as a lter, removing unwanted red cells and particles from the blood.
The spleen can mount complex adaptive immune responses.
An absent or poorly functioning spleen leads to characteristic blood changes and an
increased risk of overwhelming infection, including fulminating malaria.
An enlarged spleen (splenomegaly) may cause hypersplenism with reduced cell counts in
the blood.
Table 5.2 Management recommendations
in the asplenic patient
Immunisation
1
Pneumococcus, Haemophilus
inuenzae type B, group C
meningococcus, inuenza
Antibiotic
prophylaxis
2
Oral phenoxymethylpenicillin
or erythromycin
Prompt treatment
of infection
Patients need systemic
antibiotics and urgent
admission to hospital
Medicalert disc or
card
Detailing asplenic state and
medical contacts
Avoid travel to
high-risk malarial
areas
1
Where possible at least 2 weeks prior to splenectomy.
Reimmunisation is usually required, the timing determined by
measurement of specic antibody levels.
2
The duration of antibiotic prophylaxis is controversial but should
generally be lifelong.
Hypersplenism
Hypersplenism is usually dened as a
depression of one or more of the cell
counts in the blood which can be wholly
attributed to splenic enlargement. Other
criteria such as the presence of a normal
bone marrow, or correction of cytopenia
by splenectomy may be appended.
Although the denition only requires an
isolated anaemia, leucopenia or throm-
bocytopenia, there is frequently a mod-
erate pancytopenia.
Splenomegaly is not always associ-
ated with hypersplenism, and hyper-
splenism can occur irrespective of the
degree of splenic enlargement. Thus, it
may be seen in the modest splenomeg-
aly of liver cirrhosis.
The pancytopenia of hypersplenism is
probably induced by three contributory
mechanisms:

Hypervolaemia consequent upon a

disproportionately expanded plasma
volume lling the vascular space of
the enlarged spleen and the
splanchnic bed.

Intrasplenic pooling of red cells which

is increased from the normal 515%
to 40% in moderate splenomegaly.
This is accompanied by pooling of
neutrophils and platelets.

Premature destruction of circulating

blood cells.
12 1 ANATOMY AND PHYSIOLOGY
6 Haemostasis
10 days. They have no nucleus and no
capacity for DNA biosynthesis but do
have a complex infrastructure. Pores in
the trilaminar platelet membrane
connect with an open canalicular system
allowing transport of agonists in and
discharge of secretions out. The mem-
brane receptors for agonists include:

the glycoprotein (GP) Ia/IIa complex

(
2

1
integrin) and glycoprotein (GP)
VI which are receptors for collagen

the GPIb/IX/V complex, a receptor

for vessel wall von Willebrand factor
(vWF) and thrombin

the GPIIb/IIIa complex (

IIb

3

integrin), which is an agonist-induced
receptor for brinogen and vWF
(vWF is discussed in more detail on
p. 74).
In the platelet cytoplasm are organelles
including alpha granules (containing
brinogen, vWF, thrombospondin and
other proteins) and dense granules
(containing small molecules such as
ADP and calcium).
Platelet activation follows stimulation
by agonists such as ADP and thrombox-
ane A
2
interacting with surface recep-
tors, or by direct contact with the vessel
wall subendothelial matrix. Platelets
convert from a compact disc to a sphere,
surface receptors become activated, and
cytoplasmic granules secrete their con-
tents. The net effect is the mediation and
reinforcement of aggregation and adhe-
sion, and the promotion of further acti-
vation. Other circulating platelets adhere
to the initial layer and a loose platelet
plug is formed.
In addition to the formation of a phys-
ical barrier at the site of injury, platelets
have a procoagulant action. The coagu-
lation sequence described below com-
pletes much more rapidly in the
presence of platelets. Following activa-
tion, platelets rearrange their membrane
phospholipids and shed vesicles from
their surface. The platelet surface and
vesicles reveal binding sites for coagula-
tion proteins leading to the creation of
coagulation complexes (e.g. the pro-
thrombinase complex) which accelerate
formation of factor Xa and thrombin.
Coagulation
Although often loosely used to encom-
pass all aspects of clot formation, the
term coagulation more specically
refers to the mechanism directly leading
to the conversion of the soluble plasma
protein brinogen to the insoluble rigid
polymer brin. The formation of the
stable haemostatic plug composed of
enmeshed brin and platelets is the cul-
mination of a complex biochemical
cascade involving circulating coagulation
factors. This system allows extreme
amplication with a robust thrombus
arising from the initial stimulus of tissue
injury. Most activated coagulation factors
are proteolytic enzymes (serine pro-
teases) which in the presence of cofac-
tors cleave other factors in an ordered
sequence. Thus, prothrombin (factor II),
factor VII, factor IX and factor X are
proenzymes which are converted to
their active enzyme form (denoted by
the letter a) by cleavage of one or two
peptide bonds. Factors V and VIII are
procofactors which are converted to the
active cofactors (Va and VIIIa) also by
cleavage of peptide bonds. The blood
clotting proenzymes prothrombin and
factors VII, IX and X require vitamin K
for their activation (see pp. 76, 77).
The coagulation cascade, leading to
the generation of thrombin and the for-
mation of a brin thrombus, is classi-
cally divided into two parts: the intrinsic
and extrinsic pathways (Table 6.1).
In the intrinsic pathway factor XII is
activated by exposed collagen and other
negatively charged components of the
subendothelium. Activation of factor XII
leads to the sequential activation of
factors XI, IX, VIII (as cofactor), X and
prothrombin. In the extrinsic pathway
tissue factor complexes with factor VII
with sequential activation of factors VII,
X and prothrombin. Both intrinsic and
extrinsic pathways terminate in the nal
common pathway where activated factor
X, in association with the cofactor factor
Va in the presence of phospholipid and
calcium, converts prothrombin into
thrombin. Thrombin in turn converts
brinogen to brin by splitting the bri-
nopeptides A and B from the centre
domain to form brin monomers. These
monomers combine spontaneously into
dimers which assemble to form the
brin polymer. Factor XIII crosslinks
the brin polymer to consolidate the
thrombus. The conventional division
into two pathways is useful in the inter-
pretation of in vitro laboratory tests of
haemostasis. The prothrombin time
(PT) is a simple measure of the function
Blood clotting is a critical defence mech-
anism which, in conjunction with
inflammatory and general repair
responses, helps protect the integrity of
the vascular system after injury. The
complex sequence of events described in
detail below is activated within seconds
of tissue damage. It is easiest to divide
the description of normal haemostasis
into a platelet component, with forma-
tion of a loose platelet plug at the site of
injury, and a coagulation component,
where there is generation of a more
robust fibrin scaffold (thrombus)
around the platelets. This approach
facilitates understanding but in practice
the two mechanisms are inextricably
linked.
The role of platelets
Following damage to a blood vessel
there is immediate vasoconstriction to
slow blood ow and reduce the risk of
exsanguination. The break in the
endothelial cell barrier leads to the
recruitment of platelets from the circula-
tion to form an occlusive plug. Platelets
interact both with the vessel suben-
dothelial matrix (platelet adhesion) and
with each other (platelet aggregation)
(Fig 6.1). The rst step in this process,
adhesion, does not require platelet met-
abolic activity. It does, however, lead to
the activation of platelets.
Platelets are small disc-shaped parti-
cles produced in megakaryocyte cyto-
plasm which have a lifespan of around
Fig 6.1 Primary platelet adhesion, activation
and aggregation. vWF, von Willebrand factor.

1
IIb
3
IIb
3
Translocation
granule
Dense granule
GPIb/IX/V
Collagen
Tethering of
platelets
vWF
GPVI
Fibrinogen
Primary adhesion
and activation
Thromboxane
A2
ADP
Aggregation
13 Haemostasis
of the extrinsic pathway and the activated partial thrombo-
plastin time (APTT) monitors the intrinsic pathway (p. 20).
However, the physiological pathways at work in vivo are not
so simply dened (see Fig 6.2). It seems that the intrinsic
pathway is rarely relevant to coagulation in vivo patients
with hereditary deciency of factor XII have a prolonged
APTT but no bleeding disorder. The crucial protein in the
initiation of blood coagulation is tissue factor, an integral
membrane protein expressed on non-vascular cells. When a
blood vessel is damaged, circulating factor VII comes into
contact with tissue factor. The tissue factor/factor VIIa complex
activates not only factor X (the extrinsic pathway) but also
factor IX.
Regulation of coagulation
Blood coagulation is modulated by three major inhibitory
systems:

Anti-thrombin. This is the most important inhibitor of

the terminal proteins of the cascade, particularly factor Xa
and thrombin. Its activity is greatly increased by interaction
with heparin in the microvasculature and on the surface of
endothelial cells.

Proteins C and S. Protein C is a vitamin K-dependent

plasma protein which inactivates the cofactors Va and
VIIIa and stimulates brinolysis. Protein C is converted to
its active enzymic form by interaction with thrombin.
Protein S acts as a cofactor for protein C.

Tissue factor pathway inhibitor (TFPI). TFPI

inactivates factor Xa and then the TFPI/factor Xa complex
inhibits factor VIIa within the VIIa/tissue factor complex.
Fibrinolysis
Once damaged endothelium is repaired the brin thrombus
must be removed to restore normal blood ow. Thrombus
removal is facilitated by a brin-splitting serine protease,
plasmin. The brinolytic system is shown schematically in
Figure 6.3. Release of tissue plasminogen activator (t-PA) from
endothelial cells leads to conversion of the proenzyme plas-
minogen into plasmin. t-PA is most active when bound to
brin, thus maximising its action at the site of the thrombus.
Plasmin has the capacity to digest brin in addition to brino-
gen and a number of other proteins. Digestion of a cross-
linked thrombus by plasmin leads to the formation of
degradation products which themselves act as anticoagu-
lants. Fibrinolysis is under strict control; circulating plasmin
is inactivated by the protease inhibitor
2
-antiplasmin.
Table 6.1 The classic coagulation cascade
Intrinsic pathway
Factor XIIa + Kallikrein XIa IXa Xa Final common pathway
Extrinsic pathway Factor Xa Thrombin Fibrin
Factor VIIa Tissue factor Xa
Fig 6.2 Physiological pathways of blood coagulation. Green arrows
indicate the action of enzymes on substrates; red arrows indicate the
conversion of a protein from one functional state to another after the
cleavage of one or more peptide bonds. F, factor; TF, tissue factor; T,
thrombin; PT, prothrombin. Reprinted with permission from Furie B, Furie BC
2004 Role of platelet P-selectin and microparticle PSGL-1 in thrombus
formation. Trends in Molecular Medicine 10(4):171178.
FXIa FXI
FIXa FIX
FXa FX
T PT
FVIIIa FIXa FVIIIa FVIII
T
FVa FXa FVa FV
T
FVIIa FVII
FVIIa TF
T
Fibrinogen Fibrin
TF
Clot formation
Monocyte
Plasma
Haemostasis
The clotting of blood is a critical defence mechanism protecting
the integrity of the vascular system after injury.
Platelets form an occlusive plug at the site of tissue injury. They also
have procoagulant action.
The term coagulation describes the process by which brinogen is
converted to the insoluble rigid polymer brin; the nal thrombus
is formed of enmeshed brin and platelets.
The term coagulation cascade describes the sequential activation
of coagulation factors; in vivo the major initiator of coagulation is
tissue factor.
Fibrin generation is regulated by naturally occurring anticoagulants
and brin is ultimately removed by the brinolytic system.
Fig 6.3 The brinolytic system. Note that, unlike the other activators
listed, streptokinase is an exogenous activator derived from -haemolytic
streptococci.
Tissue plasminogen activator (t-PA)
Urokinase
Factor XIIa
Kallikrein
Streptokinase
Plasminogen
Fibrin(ogen) degradation
products
Plasmin
Fibrin(ogen)
Plasminogen activators
14 2 THE HAEMATOLOGY PATIENT
7 History taking
Abnormalities of the blood are associated with a wide range
of symptoms and these are discussed in detail under diagnos-
tic headings in subsequent sections. The intention of this
section is to give an overview of history taking in patients with
blood disorders. Despite the advent of sophisticated labora-
tory equipment to test blood, a thorough history remains
fundamental to accurate diagnosis. In practice the history may
precede and then follow the knowledge of a laboratory test
abnormality. Whatever the order of events, only by consider-
ing symptoms, physical signs and laboratory results in con-
junction can the correct conclusion be reached and the patient
be managed in the appropriate psychosocial setting (Fig 7.1).
History of the presenting complaint
Patients may be asymptomatic and have an unpredictable
abnormality detected on a routine blood count. Other patients
present to the doctor with complaints dependent on the
nature of the change in the blood. Some will have several
blood abnormalities and present with a large number of
symptoms. Despite this complexity it is possible to highlight
some common groups of symptoms (Table 7.1).
Symptoms attributable to anaemia (low
haemoglobin concentration)
Patients with anaemia have a reduced supply of oxygen to the
tissues. Symptoms include fatigue, weakness, dyspnoea, pal-
pitations, headaches, tinnitus and chest pain (due to exacerba-
tion of angina). The symptoms are affected not only by the
severity of the anaemia but by its speed of onset. Anaemia
which develops rapidly is usually less well tolerated and
patients are more debilitated.
Symptoms attributable to a low white cell
count (leucopenia)
It is usually a reduction in neutrophils (neutropenia) which
causes clinical problems. Patients are susceptible to infections,
the risk rising sharply at neutrophil counts below 0.5 10
9
/L.
Serious blood diseases such as acute leukaemia can present
as life-threatening infections or as apparently trivial infections
(e.g. a sore throat) which are unusually refractory to normal
treatment. Perineal sepsis can be a particular problem.
Symptoms attributable to a low platelet
count (thrombocytopenia)
Thrombocytopenia leads to a haemorrhagic tendency and
common presentations include epistaxes (nose bleeds), bleed-
ing from gums, menorrhagia (heavy periods) and excessive
bleeding after trauma or surgery. Patients may also complain
of easy bruising or a petechial rash. Spontaneous bleeding is
usually restricted to platelet counts below 20 10
9
/L. In disor-
ders of platelet function similar symptoms may occur even
when the count is normal.
Symptoms attributable to abnormal coagulation
Patients with a defect in the coagulation cascade (e.g. low
factor VIII level in haemophilia A) bleed easily after surgery
and trauma but the pattern of spontaneous haemorrhage is
normally different to that seen in platelet disorders. The com-
monest complaints are of bleeding into joints (haemarthroses)
Fig 7.1 The history, clinical examination and laboratory investigations
are all essential in the diagnosis of a disorder of the blood.
History Clinical examination
Laboratory
investigations
and muscles. Lifelong symptoms suggest an inherited abnor-
mality while recent onset is consistent with an acquired
aetiology.
Symptoms attributable to inltration
by malignancy
Malignant disorders of the blood such as leukaemias and
lymphomas have the capacity to invade tissues. Patients may
complain of lumps in the neck, axillae or groin caused by
lymphadenopathy or of abdominal pain or distension caused
by splenomegaly. Involvement of the nervous system may
manifest as headache, pain in dermatomal distribution or loss
of function.
The severity, quality and temporal characteristics of pain
may or may not be helpful in identifying an underlying blood
disorder. The pain of the vaso-occlusive crisis of sickle cell
anaemia is often distinctive whereas the chronic low back pain
of myeloma is all too easily dismissed.
Table 7.1 Common haematological abnormalities and associated
symptoms
Nature of abnormality
1
Commonly associated symptoms
Anaemia Fatigue, weakness, dyspnoea, palpitations,
headache, dizziness, tinnitus
Leucopenia (particularly neutropenia) Unusually severe or recurrent infections
Thrombocytopenia Easy bruising, excessive bleeding after
trauma, spontaneous bleeding from
mucous membranes
Defective coagulation (e.g. key factor
deciency)
Excessive bleeding after trauma,
spontaneous bleeds into joints and
muscles
Inltration by malignancy (e.g.
leukaemia, lymphoma)
Lumps caused by lymphadenopathy,
pain, neurological symptoms
1
The haematological abnormalities have many possible causes but will always tend to lead to the
symptoms shown.
15 History taking
Systemic enquiry
A thorough systemic enquiry is essential as blood abnormali-
ties are more often caused by a general systemic disorder than
by a specic blood disease. It can be difcult to establish
whether the primary problem is in the bone marrow or if the
blood is reacting to pathology elsewhere. One example is a
high platelet count (thrombocytosis). This may be caused by
the bone marrow disorder essential thrombocythaemia but
equally can be secondary to infection, inammation or malig-
nancy (reactive thrombocytosis). Only by excluding a non-
haematological aetiology can the diagnosis of essential
thrombocythaemia be condently made. On occasion the hae-
matological diagnosis prompts a return to a particular part of
the systemic enquiry. Thus the nding of unexplained iron
deciency necessitates an exhaustive enquiry for symptoms
of gastrointestinal disease associated with chronic blood loss.
Past medical history
It is important to elicit a history of diseases which may have
caused a haematological abnormality or which may affect the
management of a primary blood disorder such as leukaemia.
Where there is a known abnormality in the blood count it is
helpful to establish whether previous counts have been per-
formed. Where past results are available they will clarify
whether the problem is of recent onset or longstanding. For
patients presenting with easy bruising or bleeding, previous
surgical exposure is of particular interest. The lack of exces-
sive bleeding after surgery suggests that the bleeding tendency
is either of limited signicance or of more recent onset.
Drug history
Drugs can cause haematological problems some commoner
examples are listed in Table 7.2. A careful drug history (wher-
ever possible veried by checking tablets) may suggest a likely
offending agent. If the problem is of sufcient severity to
cause concern the drug should ideally be discontinued and
the blood count monitored to check resolution. It is as rele-
vant to obtain a history of allergy in haematology as in other
areas of medicine. Indeed, patients with haematological malig-
nancies are often given an unusually large number of chemo-
therapeutic and antimicrobial agents and possible reactions
have to be vigilantly documented to avoid repeat exposure.
Family history
As can be seen from Table 7.3, a number of blood diseases are
inherited. A knowledge of the mode of inheritance is useful in
diagnosis and essential in counselling the patient and family.
A simple question as to the presence of anaemia or a bleeding
problem in other family members can prevent unnecessary
investigation and delay in diagnosis.
Social history
With the growing reliance on technology for diagnosis and
treatment it can be surprisingly easy to forget that a blood
disorder is affecting a real person. An understanding of the
patients normal lifestyle is particularly important where a
chronic or serious disease is diagnosed. Many people develop-
ing haematological malignancies are elderly and need support
in the community, including, perhaps, visits by social workers
and nurses. Often such diseases are incurable and expert man-
agement of symptoms has to be complemented by an under-
standing of the patients need to sort out affairs and
communicate the news to family and friends. In working
adults the onset of diseases like leukaemia, with frequent clinic
visits and hospitalisation, can lead to unemployment and
marital and nancial difculties. In children chronic blood
disorders such as haemophilia and haemoglobinopathies may
cause time lost from school and create stresses for the whole
family. Good practice of clinical haematology requires consid-
eration of the far-reaching effects of the diagnosis and neces-
sary treatment on the patient.
Miscellaneous
Alcohol misuse can cause blood changes, the most common
being macrocytosis (enlarged red cells). A positive history will
prevent unnecessary investigation for other causes. Smoking is
a cause of moderate polycythaemia (elevated haematocrit/
haemoglobin level) and appears to be associated with an
increased incidence of acute myeloid leukaemia. Travel to
tropical areas raises the possibility of malaria and other tropi-
cal diseases which can affect the blood.
History taking
In the diagnosis of blood disorders, the history is complementary to
the clinical examination and laboratory testing.
Blood abnormalities such as anaemia, leucopenia and
thrombocytopenia lead to predictable groups of symptoms.
Blood abnormalities may be caused by systemic diseases, familial
disorders and drugs. A thorough systemic enquiry, past medical
history, drug history and family history should be elicited.
Serious and chronic blood diseases (e.g. leukaemia,
haemoglobinopathies, haemophilia) have major social implications
for children and adults; these should be explored not ignored.
Table 7.2 Possible haematological side-effects of drugs
Haematological abnormality Drugs
1
Marrow aplasia Chloramphenicol (idiosyncratic)
Cytotoxics (dose-related)
Haemolytic anaemia Cephalosporins
Penicillins
Leucopenia/agranulocytosis Phenothiazines
Sulphonamides
Thrombocytopenia Quinine
Thiazide diuretics
1
Many drugs have been implicated in all these abnormalities the examples shown are some of the
more common offenders.
Table 7.3 Some inherited blood disorders
Red cell disorders
Disorders of the membrane Hereditary spherocytosis and elliptocytosis
Disorders of haemoglobin Thalassaemias and sickle syndromes
Disorders of metabolism Glucose-6-phosphate dehydrogenase and pyruvate
kinase deciencies
Coagulation disorders
Factor deciency Haemophilia A and B
Combined factor and platelet
abnormality
von Willebrand disease
Platelet abnormality BernardSoulier syndrome (rare)
White cell disorders Rare functional disorders (e.g. chronic granulomatous
disease)
The mode of inheritance of these disorders is discussed in the relevant sections.
16 2 THE HAEMATOLOGY PATIENT
8 Examining the patient
universally performed but is crucial in a
patient with haemophilia.
Examination of the
lymph nodes
Lymph nodes may be enlarged in
primary blood disorders and systemic
diseases. Enlargement is referred to as
lymphadenopathy or just adenopathy.
The differential diagnosis differs in gen-
eralised and localised forms of lym-
phadenopathy (Table 8.2). In practice,
palpable lymphadenopathy is usually
limited to the cervical, axillary and
inguinal areas.
Enlargement of the cervical lymph
nodes is the most common cause of a
swelling in the neck and, if massive, may
be easily visible (Fig 8.1). Following
careful inspection of the neck, it is
easiest to examine the cervical nodes
from behind the seated patient, method-
ically palpating the anatomical areas
detailed in Figure 8.2. As for all lumps,
it is important to document not only the
size and location of enlarged nodes, but
also the shape, consistency and presence
of tenderness. Lymphadenopathy sec-
ondary to infection is more often tender
than that due to malignancy. Nodes
involved by carcinoma are characteristi-
cally stony hard while those involved by
lymphoma are more rubbery. The pres-
ence of cervical adenopathy should
always prompt a thorough examination
of the head and neck to detect a local
cause (e.g. malignancy or infection);
formal ear, nose and throat examination
is often indicated.
The axillary nodes are best examined
with the patient supine and the arm
supported by the side, the examiner
using the right hand to gently palpate
the left axilla and the left hand for the
right axilla. Anatomically, the nodes are
divided into medial, lateral, posterior,
central and apical groups. Examination
of inguinal nodes is most easily per-
formed while examining the abdomen.
Care must be taken not to confuse
inguinal adenopathy with an irreducible
femoral hernia. Enlarged abdominal
lymph nodes may cause an abnormal
fullness of the central abdomen on
palpation.
On occasion it is difcult to be certain
that nodes are pathologically enlarged.
Interpretation must take account of the
patients age and occupation. Large ton-
sillar glands are common in children,
while people exposed to repeated minor
injuries of the hands and feet often have
Abnormalities of the blood may arise as
a result of a primary disorder of the
bone marrow (e.g. leukaemia) or from
a wide range of systemic disorders. A
thorough clinical examination is vital
both to conrm a likely diagnosis and
to exclude coexistent problems. There is
not space here to detail all the elements
of clinical examination; we have concen-
trated on aspects of the examination
most relevant to patients with a primary
blood disorder.
Look at the patient!
It is easy to examine a patient carefully
without properly observing them. A
deliberate inspection of the patients
face while taking the history may reveal
vital clues even before the formal exami-
nation is commenced. Common exam-
ples include the pallor of iron deciency
anaemia, the lemon tint of megaloblas-
tic anaemia, the jaundice of a haemolytic
anaemia, and the plethora of polycythae-
mia. Before laying a hand on the patient,
a careful inspection of the mouth and
skin may also point to particular blood
abnormalities or disorders (Table 8.1).
The patients ethnic origin can be of rel-
evance. Sickle cell anaemia is an unlikely
diagnosis in a patient with white skin
while pernicious anaemia is equally
unlikely in a patient with black skin.
Children with chronic blood disorders
such as haemoglobinopathies are fre-
quently thinner and shorter than their
healthy peers.
General examination
Careful observation should be followed
by a methodical examination of the
major systems. The possible abnormali-
ties in each system which may be seen
in blood diseases are too numerous to
detail here. They are referred to in the
relevant sections describing each disease.
Although examination should be
ordered, in a busy clinical practice it is
often necessary to prioritise. Rectal
examination is not routine in all patients
with blood disorders but is denitely
indicated in unexplained iron deciency
to exclude an otherwise asymptomatic
rectal carcinoma; it is contraindicated in
patients with suspected leukaemia and
neutropenia. Similarly, an exhaustive
examination of the major joints is not
Table 8.2 Common causes of
lymphadenopathy
Localised
Local bacterial or viral infection
Lymphoma
Metastatic malignancy
Generalised
Systemic infection
bacterial (e.g. tuberculosis)
viral (e.g. EpsteinBarr, HIV)
Lymphoma
Other haematological malignancy (e.g. leukaemia)
Inammatory disease (e.g. connective tissue disorder,
sarcoid)
Disseminated malignancy
Fig 8.1 Massive cervical lymphadenopathy.
Table 8.1 Observation of the patient with
a blood disorder. Some common signs
and their possible clinical relevance
Clinical sign Possible haematological
abnormality
Face
Pallor Any anaemia
Lemon tint Megaloblastic anaemia
Jaundice Haemolytic anaemia
Plethora Polycythaemia
Mouth
Ulcers Neutropenia
Glossitis Megaloblastic anaemia
Iron deciency anaemia
Angular stomatitis Iron deciency anaemia
Candida (thrush) Immunosuppression
Skin
Pallor Any anaemia
Jaundice Haemolytic anaemia
Excessive bruising Coagulation disorder,
thrombocytopenia
Purpuric/petechial rash Thrombocytopenia
Leg ulcers Sickle cell anaemia
17 Examining the patient
some lymphadenopathy in the draining
areas. A period of observation can be
helpful. If serious doubt persists then a
surgical biopsy is indicated.
Examination of
the spleen
The spleen is enlarged in many blood
disorders and in some systemic diseases
(Table 8.3). The presence of a palpable
spleen and its characteristics often
narrows the differential diagnosis con-
siderably. Examination of the spleen is
frequently done badly. It is easy to miss
a slightly enlarged spleen which is just
palpable (tippable) and it is also embar-
rassingly easy to miss a spleen which is
massively enlarged. However, neither of
these mistakes is likely if the examina-
tion is conducted as below.
The patient should be examined on a
suitable examination couch or bed and
should be encouraged to relax. The
whole abdomen is exposed. The exam-
iner sits or kneels to allow palpation
with a (warm) hand with the forearm
horizontal to the abdomen. First, the
abdomen is inspected for a visible mass
and the patient is asked if they have any
abdominal tenderness. It is normal to
palpate the whole abdomen and then
examine the major organs in turn. The
spleen enlarges from below the tenth rib
along a line heading for the umbilicus
(Fig 8.3). Palpation for the spleen is com-
menced in the right lower quadrant of
the abdomen, otherwise massive
enlargement can be missed. The hand is
moved in stages towards the tip of the
left tenth rib while the patient takes
deep breaths. The edge of an enlarged
spleen connects with the tips of the
index and middle ngers during deep
inspiration. If the spleen is not palpable
using this technique, it is worth rolling
the patient slightly onto the right side
with the examiners left hand held
rmly behind the left lower ribs (Fig
8.4). This latter manoeuvre may lift
forward a slightly enlarged spleen and
make it palpable on deep inspiration.
The following features are typical of
an enlarged spleen:

It has a characteristic shape and

sometimes a palpable notch on its
upper edge.

You cannot get above it.

It moves with respiration.

It is dull to percussion.

It cannot be felt bimanually or

balloted.
In practice an enlarged spleen is most
likely to be misidentied as an enlarged
left kidney. However, the kidney is not
dull to percussion (it is covered by the
colon) and it can be felt bimanually and
balloted. It is worth listening with a
stethoscope over an enlarged spleen as
inammation of the capsule may cause
an audible splenic rub. The spleen is
usually uniformly enlarged and it is not
generally possible to identify the under-
lying disorder by palpation alone. The
degree of enlargement does, however,
give a diagnostic clue (see Table 8.3).
Fig 8.2 Lymph nodes of the neck.
Posterior triangle
Upper deep cervical
(including tonsillar node)
Middle deep cervical
Lower deep cervical
Sternomastoid muscle
Clavicle
Suboccipital
Trapezius muscle
Supraclavicular
Fig 8.3 Schematic view of
splenic enlargement. The
notch is frequently not palpable.
The arrow shows the normal
direction of enlargement.
10th rib
Fig 8.4 Examination of the spleen.
Examining the patient
The clinical examination is an important part of the diagnosis of blood disorders.
It is helpful to carefully observe the patient prior to the formal examination of systems.
In routine clinical practice some aspects of examination are prioritised (e.g. rectal
examination in unexplained iron deciency).
Proper examination of the lymph nodes requires familiarity with the normal anatomical
groups and the causes of enlargement.
Examination of the spleen is frequently badly performed; with poor technique even
massive splenomegaly can be missed.
Table 8.3 Common causes of splenomegaly
Degree of
enlargement
Centimetres palpable
below costal margin
Causes
Slight 04 Various acute and chronic infections
(e.g. septicaemia, tuberculosis)
Moderate 48 Haemolytic anaemia
Infectious mononucleosis
Portal hypertension
Massive Greater than 8 Myelobrosis
Chronic myeloid leukaemia
Polycythaemia vera
Lymphoma
Malaria
Leishmaniasis
Note: The division by size is clinically helpful but disorders associated with massive splenomegaly may
also cause lesser degrees of enlargement.
18 2 THE HAEMATOLOGY PATIENT
9 Laboratory haematology I Blood and
bone marrow
light scattering method the cells deect a beam of light (often
a laser beam) and a detector converts the scatter into pulses
proportional to cell size. For sophisticated measurements such
as the differential white cell count the two methods can be
used together with the addition of other modalities reliant on
biochemical reactions and light absorbance.
Sophisticated though this technology is, automated cell
counters are ultimately no substitute for the trained human
eye. Results outside the machines numerical normal range or
the presence of unusual circulating cells (e.g. leukaemic cells)
should be agged as being abnormal. This alerts the operator
who will return to the original blood sample to make a lm.
The blood lm
A blood lm is simply made by smearing a drop of anticoagu-
lated venous blood onto a glass slide with a glass spreader
(Fig 9.2a). In larger laboratories lm spreading can be auto-
mated. Following drying, the lm is xed with methanol and
stained. Routine stains are based on Romanowskys method
commonly used variants are the MayGrnwaldGiemsa
(MGG) stain and Wrights stain. Constituent dyes include
methylene blue, azure B and eosin. Once stained, the blood
lm should be systematically studied under the light
Diagnosis of most blood disorders is possible from a combi-
nation of clinical history, clinical examination and relatively
routine laboratory tests. Haematology laboratories are heavily
dependent on complex electronic machinery. The ubiquitous
full blood count (FBC) is the archetypal haematological inves-
tigation and is performed by specialised automated cell
counters. However, despite the accessibility of modern tech-
nology, the more simple traditional techniques of blood and
bone marrow lm spreading, staining, and light microscopy
remain essential parts of the haematologists repertoire.
The blood count
Many of the diseases discussed in this book are rst suggested
by an abnormality in the blood count (often referred to as the
full blood count). The test is performed on a small specimen
of anticoagulated venous blood; the normal anticoagulant is
ethylene diamine tetra-acetic acid (EDTA). A typical report is
illustrated in Figure 9.1. As can be seen, it contains a large
amount of numerical information pertaining to the three cell
lines in the peripheral blood: red cells (and haemoglobin),
white cells (with a differential count of each specic cell type)
and platelets.
When interpreting the report it is sensible to initially focus
on the haemoglobin (Hb) concentration, total white cell count
(WBC) and platelet count most blood abnormalities of clini-
cal signicance are associated with a derangement of at least
one of these values. Much of the remaining information
details the nature of the red cells and their degree of haemo-
globinisation, and the precise make-up of the white cell count.
The former values are helpful in the diagnosis of anaemia,
and the latter in the diagnosis of a variety of diseases of white
cells (e.g. leukaemias) and reactions to systemic disease. To
understand the role of the automated blood count in clinical
practice, and particularly its limitations, it is helpful to under-
stand how the numerical values are generated.
Automated haematology counters
The two essential functions of the automated blood cell
counter are the measurement of Hb concentration in the
blood and the counting and sizing of blood cells.
Most counters use a modication of the traditional cyan-
methaemoglobin method to measure Hb concentration. In
essence, blood is diluted in a solution where Hb is converted
to cyanmethaemoglobin and then the Hb concentration
derived from the light absorbance (optical density) of the
resultant solution measured by a spectrophotometer. Auto-
mated machines have at least two channels for cell counting.
In one, red cells and platelets may be counted and in the other
red cells are lysed leaving white cells for analysis. Extra chan-
nels are often used for differential white cell and reticulocyte
counting.
There are two basic methods for cell counting and sizing:
electrical impedance and light scattering. The electrical imped-
ance method relies on blood cells being very poor conductors
of electricity. Thus, when the cells are passed in a stream
through a narrow aperture across which an electrical current
is maintained, the individual cells create an increase in electri-
cal impedance of a size proportional to the cell volume. In the
Fig 9.1 Typical blood count report.
HAEMATOLOGY YORK DISTRICT HOSPITAL TEL: (01904) 726802
Surname
Other names
Address
Consultant/GP
Hosp. No.
See handbook for paediatric ranges
NEDIFF, FBC
D.O.B.
Source
Lab. No.
NHS No.
Sex
Clinical
WBC
x109
Chest pain
Blood 04.09.09 13:32
4.46 29.8 33.5 0.397 89 133 7.1 246
Results validated and automatically authorised by computer
Accident & Emergency YDH 432 Run
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
4.2
2.3
0.5
0.1
0.0
x10
9
/L
x10
9
/L
x10
9
/L
x10
9
/L
x10
9
/L
( 2.0 - 7.5 )
( 1.0 - 4.5 )
( 0.2 - 1.2 )
( 0.1 - 0.6 )
( 0.0 - 0.2 )
HB
g/L /L
PLTS
x10
9
/L
RBC
x1012/L
MCV
fl
PCV
L/L
MCH
pg
MCHC
g/dL
ESR
mm/hr
M 130 - 180
F 115 - 165
M 4.5 - 5.8
F 4.2 - 5.4
M 1 - 10
F 1 - 15
M 0.40 - 0.50
F 0.37 - 0.47 4.0 - 11.0 77 - 99 27 - 32 30 - 35 150 - 400
Sample type Taken Received Date & Time printed
04.09.09 14:00 04/09.2009 14:58
Fig 9.2 Blood lm.
(a) Macroscopic;
(b) light microscopy.
(a)
(b)
19 Laboratory haematology I Blood and bone marrow
microscope the normal appearance of a lm stained by the
MGG method is illustrated in Figure 9.2b. Alternative stains
are sometimes needed. Visualisation of reticulocytes requires
the use of a dye such as methylene blue on live unxed cells
(supravital stain). Malarial parasites are most easily seen fol-
lowing staining at a specic pH.
The rst step in lm examination is a decision as to whether
the lm is of adequate quality. Either poor staining techniques
or prolonged storage of the specimen may make the lm
worthless. Any comment on the lm appearance is usually
appended to the blood count report. The nomenclature used
in lm reporting can appear obscure; some more commonly
used morphological terms are listed in Table 9.1. Microscopic
images of blood cells are now routinely photographed using
digital cameras. These images may increasingly be used to
create virtual slides or employed with cell recognition
systems for automated morphological screening.
Where the lm is signicantly abnormal, examination of
the bone marrow can give further diagnostic information.
Bone marrow examination
The clinical procedure for obtaining samples of bone marrow
is described on page 106. From the favoured site, the posterior
iliac crest, it is possible to obtain both a marrow aspirate
sample and a marrow trephine biopsy.
Aspirate
The aspirate is simply sucked through the needle and spread
onto a glass slide; the marrow particles are normally easily
visible (Fig 9.3a). The marrow is xed and stained as for a
blood lm and additionally stained by Perls method to dem-
onstrate iron. Microscopy and reporting is systematic with
reference to the overall cellularity, the appearance and number
of each normal cell line, possible inltration by malignant
cells, and any other pathological features. The advantage of
the aspirate specimen is that individual cells are well pre-
served and subtle morphological changes can be detected. The
major disadvantage is that the normal architecture of the
marrow is lost. In the investigation of haematological malig-
nancy (e.g. leukaemia) marrow aspirate samples are often also
used for immunophenotyping and cytogenetic and molecular
genetic testing.
Trephine biopsy
The trephine biopsy (Fig 9.4) is sectioned and normally
stained by haematoxylin and eosin (H&E) and Giemsa
methods. Silver impregnation can be used to demonstrate
marrow brosis and Perls stain to highlight iron. The tre-
phine is less good than the aspirate for identifying morpho-
logical abnormalities of individual cells but it is better for
detecting abnormalities of marrow architecture and inltra-
tion by solid malignancy. The two types of bone marrow
sample are thus complementary.
Fig 9.3 Bone
marrow aspirate.
(a) Macroscopic;
(b) light microscopy.
(a)
(b)
Fig 9.4 Bone
marrow trephine
specimen.
(a) Macroscopic;
(b) light microscopy.
(a)
(b)
Laboratory haematology I
blood and bone marrow
Many blood disorders are rst suggested by an abnormality in the
blood count particularly in the haemoglobin concentration, total
white cell count or the platelet count.
Automated haematology counters measure haemoglobin
concentration and count and size blood cells.
Where the blood count is abnormal, examination of the blood lm
often reveals morphological abnormalities undetectable by the
automated counter.
Signicant blood abnormalities can be further investigated by
examination of the bone marrow aspirate and trephine biopsy
specimens provide complementary information.
Table 9.1 Some morphological terms used in blood lm reports
Red cells
Hypochromia Pale staining of cells
Polychromasia Grey-blue tint to cells (usually reticulocytes)
Anisocytosis Variation in cell size
Poikilocytosis Variation in cell shape
Macrocytosis/microcytosis Increase/decrease in cell size
Spherocyte Small spherical densely stained cell
Burr cell Crimpled cell membrane
Target cell Increased staining in middle of area of central
pallor suggests increased surface area
Basophilic stippling Small basophilic inclusions in cytoplasm (RNA)
HowellJolly bodies Nuclear remnants in cytoplasm
Schistocyte Fragmented cell
White cells
Hypersegmented neutrophils Increased nuclear segmentation
Left-shifted neutrophils Reduced nuclear segmentation
Toxic granulation Increased neutrophil cytoplasmic granularity
Atypical lymphocytes Morphology variable; often seen in viral infections
Blasts Leukaemic cells
Platelets
Clumping Sticking together; can cause artefactually low count
Note: Causes of these morphological abnormalities are discussed in the disease sections.
20 2 THE HAEMATOLOGY PATIENT
10 Laboratory haematology II Coagulation and
the acute phase response
the acute phase response suggests a physical cause for symp-
toms. Possibilities include trauma, infections, neoplasia and
autoimmune disease. Serial measurements can be useful in
monitoring the effects of treatment. The most widely used
measurements of the acute phase response are the erythrocyte
sedimentation rate (ESR), the plasma viscosity, and C-reactive
protein.
ESR
In this simple and inexpensive test venous blood (in citrate
anticoagulant) is drawn up into a vertical tube (Fig 10.1) and
allowed to stand for 1 hour. The red cells settle out of suspen-
sion and the length of plasma cleared after the hour is meas-
ured. The normal values are less than 5 mm/hour in men and
less than 7 mm/hour in women, although values of up to
15 mm/hour are not infrequent in those over 60 years old.
The test mainly reects brinogen levels but is also inuenced
by
2
-macroglobulin, immunoglobulins and albumin. These
proteins buffer the electrostatic repellent forces on the red cell
membrane and allow the cells to come together and form
reversible aggregates or rouleaux which fall more quickly
through the plasma. The ESR result is affected by the haemo-
globin concentration with high values seen in anaemia and
low values in polycythaemia. A fresh sample must be pro-
cessed as the result also changes over time.
Simple tests of blood coagulation
Despite the complexity of haemostasis (p. 12), it is possible
to make a general assessment of coagulation with a few
relatively simple rst-line tests. As an initial screen of haemo-
static function the following tests should be combined with
a blood count and lm to determine platelet number and
appearance.
The prothrombin time (PT)
The test is performed by adding thromboplastin to the
patients platelet-poor plasma, warming, and then adding
calcium. The time to clot formation is recorded in seconds
and the PT may be expressed as the ratio of the patients time
to a normal control time. The thromboplastin used should
have been calibrated to allow this result to be converted to
the international normalised ratio (INR) the ratio which
would have been obtained if the international reference prep-
aration for thromboplastin had been used in the test (see p.
80). The PT is essentially a measure of the efciency of the
extrinsic clotting system (factor VII) in addition to the func-
tioning of factors V and X, prothrombin and brinogen.
Activated partial thromboplastin time (APTT)
This test is sometimes referred to as the partial thromboplas-
tin time with kaolin (PTTK) or the kaolin cephalin clotting
time (KCCT). Patient platelet-poor plasma is combined with
contact factors (kaolin, phospholipid) and calcium and the
time to clot formation recorded in seconds. The test measures
the overall efciency of the intrinsic pathway (i.e. factors VIII,
IX, XI, XII) as well as the function of factors V, X, pro-
thrombin and brinogen.
Quantitation of plasma brinogen
In most laboratories this has replaced the thrombin time as
a rst-line test. Several accurate methods are available for the
quantitative assay of plasma brinogen. Fibrinogen is an acute
phase reactant (see below) and is frequently elevated in sick
patients. Causes of low levels include disseminated intravas-
cular coagulation (DIC) and severe liver disease.
Common clinical causes of abnormal rst-line coagulation
tests are shown in Table 10.1. Second-line tests may be needed
for more precise diagnosis. In mixing experiments (or correc-
tion tests) patient plasma is mixed with normal or factor-
decient plasma prior to repeating rst-line tests. If a particular
coagulation factor is thought to be lacking, a quantitative
assay can then be performed. A circulating inhibitor of coagu-
lation is suggested by failure of the coagulation abnormality
to be corrected by the addition of normal plasma. Many
routine tests are now automated. Most coagulation instru-
ments rely on measurement of changes in optical density to
detect clot formation.
Measurement of the acute
phase response
In assessing patients with ill-dened symptoms it can be
helpful to measure activation of the acute phase response, the
bodys response to tissue damage. Evidence of activation of
Fig 10.1 Measurement of the ESR.
Table 10.1 Common causes of abnormal rst-line clotting tests
Test Prolonged
prothrombin time
Prolonged APTT Low brinogen
Common causes Warfarin Heparin
1
DIC
Liver disease Haemophilia Severe liver disease
Vitamin K deciency vWD
DIC DIC
Liver disease
Lupus anticoagulant
APTT, activated partial thromboplastin time; DIC, disseminated intravascular coagulation; vWD, von
Willebrand disease.
1
Unfractionated heparin.
21 Laboratory haematology II Coagulation and the acute phase response
Plasma viscosity
This test also measures the acute phase response indirectly,
the result correlating with brinogen and immunoglobulin
levels. The plasma viscosity has some advantages over the
ESR. The normal range is the same in males and females and
the result is independent of haemoglobin concentration. The
sample can be taken from the EDTA anticoagulated blood
count bottle and the test does not need to be performed
immediately. The normal range, which is temperature depend-
ent, is detailed in Table 10.2. Plasma viscosity measurement
has direct pathophysiological relevance in myeloma where
very high values are seen in the hyperviscosity syndrome.
C-reactive protein (CRP)
This easily measured protein is elevated in most types of
tissue injury. The CRP is usually increased within 68 hours
of the insult. The normal range is up to 10 mg/L with levels
of 1040 mg/L in severe viral infections, levels of 40300 mg/L
in bacterial infections and levels over 300 mg/L in severe
burns. CRP results are not inuenced by anaemia.
Other possible measures of the acute phase reaction include
quantitation of brinogen, haptoglobins, alpha-1-antitrypsin
and anti-chymotrypsin. These all rise following tissue damage
but some acute phase reactants (notably albumin and trans-
ferrin) actually fall.
Electrophoresis
Electrophoresis has two routine applications in haematology.
In the diagnosis of haemoglobinopathies (e.g. thalassaemia),
cellulose acetate electrophoresis at alkaline pH is used to
separate the abnormal haemoglobins. Citrate agar electro-
phoresis at a lower pH may be helpful in selected cases. In
the investigation of myeloma, serum and urine electrophore-
sis is performed to detect the monoclonal immunoglobulin
or light chains characteristic of the disease (Fig 10.2).
Flow cytometry
Flow cytometry is essentially the measurement of the charac-
teristics of cells passing in a uid stream through a detection
apparatus. The automated cell counters described in the previ-
ous section are the major application of the ow cytometry
principle in haematology but the technique also plays a key
role in the diagnosis of haematological malignancy. Leukae-
mic cells often have a particular immunophenotype a char-
acteristic pattern of detectable antigens on the cell surface and
in the cell cytoplasm (see also relevant disease sections). The
antigens are identied by cluster differentiation (CD) numbers
(e.g. CD13 is a myeloid antigen; see Appendix II). Cells from
peripheral blood or a bone marrow aspirate sample are incu-
bated with specic CD monoclonal antibodies which are
conjugated with a uorochrome, a molecule which emits light
at a specic wavelength when excited by a laser. The ow
cytometer is then used to detect populations of cells labelled
by the uorescent marker (Fig 10.3). Flow cytometry may be
used in conjunction with molecular methods for the detection
of minimal residual disease in leukaemia.
Fig 10.2 Urine electrophoresis. The highlighted sample demonstrates
proteinuria and the presence of Bence Jones (immunoglobulin light chain)
protein (red arrow) in a patient with myeloma and renal failure.
Fig 10.3 Flow cytometry. The use of a combination of myeloid and
lymphoid antibodies shows multiple different cell lines and maturation
stages each in a different colour.
Laboratory haematology II
coagulation and the acute
phase response
Despite the complexity of haemostasis the coagulation mechanism
can be assessed with a few relatively simple rst-line tests.
The term acute phase response describes the bodys response to
tissue damage; commonly used measures include the ESR, plasma
viscosity and C-reactive protein.
Electrophoresis is routinely used in the diagnosis of
haemoglobinopathies and in the investigation of myeloma.
Flow cytometry methodology is exploited in automated blood cell
counters and plays a key role in the characterisation of leukaemia.
Table 10.2 Clinical signicance of the plasma viscosity
Plasma viscosity (mPas)
measured at:
25C 37C
Normal range
1
1.501.72 1.151.35
Acute/chronic organic diseases
(malignancy, infection, etc.)
1.752.55 1.361.99
Need to exclude paraproteinaemias/
hyperviscosity syndrome
>2.55 >2.00
1
Slightly higher levels can be seen in normal older people.
22 3 ANAEMIA
11 Introduction and classication
have been performed, anaemia is more
common in women than in men. Par-
ticularly susceptible groups include
pregnant women, children under 5
years and the elderly. The majority of
cases in younger people are caused by
iron deciency. Anaemia is surprisingly
common in the elderly, affecting roughly
10% of people over 65 years. Up to a
third of these cases remain unexplained
(see p. 92). In developing countries,
factors inuencing the prevalence of
anaemia include climate, socioeconomic
conditions and, most importantly, the
incidence of coexistent diseases.
General features
In anaemia the bloods reduced oxygen-
carrying capacity can lead to tissue
hypoxia. The clinical manifestations of
signicant anaemia (see also p. 14) are
to a large extent due to the compensa-
tory mechanisms mobilised to counter-
act this hypoxia. Cardiac overactivity
causes palpitations, tachycardia and
heart murmurs. The dyspnoea of severe
anaemia may be a sign of incipient car-
diorespiratory failure. Pallor is due pri-
marily to skin vasoconstriction with
redistribution of blood ow to tissues
with higher oxygen dependency such as
the brain and myocardium.
Anaemia is one of the most common
clinical problems presenting in general
practice, in hospitals and in medical
examinations. Usually characteristic
symptoms and signs prompt a blood
count to conrm the diagnosis but on
occasion an unexpectedly low haemo-
globin estimation in a routine blood
count precedes the clinical consultation.
Whatever the sequence of events,
anaemia is not in itself an adequate diag-
nosis; further enquiry to establish the
underlying cause is essential.
A logical approach to anaemia
demands a clear understanding of both
its possible causes and its clinical and
laboratory features. There are two major
classications both have advantages
and they are best used together.
Classication
Morphological classication
As already discussed (p. 18), modern
electronic laboratory equipment can
provide estimations of red cell indices in
addition to haemoglobin concentration.
Abnormal red cell indices should be
conrmed by microscopic examination
of blood lms. The morphological clas-
sication is based on a correlation
between red cell indices and the under-
lying cause of anaemia. The most impor-
tant measurements are of red cell size
(mean cell volume or MCV) and red cell
haemoglobin concentration (mean cell
haemoglobin (MCH) or mean cell hae-
moglobin concentration (MCHC)).
Anaemias with raised, normal and
reduced red cell size (MCV) are termed
macrocytic, normocytic and microcytic,
respectively. Anaemias associated with
a reduced haemoglobin concentration
within red cells are termed hypochro-
mic and those with a normal MCH are
termed normochromic. Characteristic
combinations are of microcytosis and
hypochromia, and normocytosis and
normochromia. As can be seen in Figure
11.1, this terminology is helpful in nar-
rowing the differential diagnosis of
anaemia. It is perhaps least helpful in
normocytic anaemia as the possible
causes are numerous and diverse.
The value of the blood lm in diagno-
sis should not be underestimated. For
instance, combined iron deciency (a
cause of microcytosis) and folate de-
ciency (a cause of macrocytosis) may
cause an anaemia with a normal MCV.
However, inspection of the lm will
reveal a dual population of microcytic
hypochromic red cells and macrocytic
red cells.
Aetiological classication
Figure 11.2 illustrates a classication of
anaemia based on cause. It is less imme-
diately helpful than the morphological
classication in forming a differential
diagnosis but it does illuminate the
pathogenesis of anaemia. The funda-
mental division is between excessive
loss or destruction of mature red cells,
and inadequate production of red cells
by the marrow.
Loss of red cells occurs in haemor-
rhage and excessive destruction in
haemolysis. A normal bone marrow will
respond by increasing red cell produc-
tion with accelerated discharge of young
red cells (reticulocytes) into the blood.
Inadequate red cell production may
result from insufcient erythropoiesis
(i.e. a quantitative lack of red cell precur-
sors) or ineffective erythropoiesis (i.e.
Denition
The term anaemia refers to a reduction
of haemoglobin or red cell concentra-
tion in the blood. With the widespread
introduction of automated equipment
into haematology laboratories the hae-
moglobin concentration has replaced
the haematocrit (or packed cell volume)
as the key measurement. Haemoglobin
concentration can be determined accu-
rately and reproducibly and is probably
the laboratory value most closely cor-
related with the pathophysiological con-
sequences of anaemia. Thus, anaemia is
simply dened as a haemoglobin con-
centration below the accepted normal
range.
The normal range for haemoglobin
concentration varies in men and women
and in different age groups (Table 11.1).
The denition of normality requires
accurate haemoglobin estimation in a
carefully selected reference population.
Subjects with iron deciency (up to 30%
in some unselected populations) and
pregnant women must be excluded or
the lower level of normality will be mis-
leadingly low. Normal haemoglobin
ranges may vary between ethnic groups
and between populations living at differ-
ent altitudes.
Prevalence
The prevalence of anaemia and the aeti-
ologies vary in different populations. In
developed countries where most studies
Table 11.1 Normal haemoglobin
concentrations at different ages
Age Mean
haemoglobin
(g/L)
Lower limit
of normal
(g/L)
Birth (cord blood) 165 135
13 days (capillary) 185 145
1 month 140 100
26 months 115 95
6 months2 years 120 105
26 years 125 115
612 years 135 115
1218 years:
female 140 120
male 145 130
Adult:
female 140 115
male
1
155 135
1
Normal haemoglobin concentration probably slightly lower after
65 years.
23 Introduction and classication
defective erythrocytes destroyed in the
marrow). Examples of insufcient eryth-
ropoiesis include bone marrow hypo-
plasia, as in aplastic anaemia, and
inltration of the marrow by a leukae-
mia or other malignancy. Inefcient
erythropoiesis is seen in disorders such
as megaloblastic anaemia, thalassaemia
and myelodysplastic syndromes.
The above provides a useful frame-
work for thinking about anaemia. In
reality different mechanisms can operate
simultaneously. The anaemia of thalas-
saemia is caused by both ineffective
erythropoiesis and haemolysis.
Management
The treatment of specic types of
anaemia is discussed in subsequent sec-
tions. However, some general state-
ments can be made. Whenever possible,
the cause of anaemia should be deter-
mined before treatment is instituted.
Blood transfusion should only be used
where the haemoglobin is dangerously
low, where there is risk of a further dan-
gerous fall in haemoglobin (e.g. rapid
bleeding), or where no other effective
treatment of anaemia is available.
Prompt blood transfusion can be
life-saving in a profoundly anaemic
patient but it should be undertaken with
great caution as heart failure can be
exacerbated. Mild anaemia in the elderly
should not be overlooked as it is a fre-
quent cause of debility and has been
linked with increased mortality.
Fig 11.1 Classication of anaemia based on red cell measurement.
Blood loss (acute)
Haemolysis
1
Chronic disease
2
Marrow infiltration
MCV and MCH
normal
Normocytic
Normochromic
Megaloblastic
anaemias
MCV
raised
Macrocytic
Iron deficiency
Thalassaemia
MCV and MCH
low
Microcytic
Hypochromic
Common
examples
Red cell
indices
Anaemia
type
1
Occasionally macrocytic
2
Occasionally microcytic hypochromic
Fig 11.2 Classication of anaemia based on cause.
Dilution of red
cells by increased
plasma volume
(e.g. hypersplenism)
Failure of
production of red
cells by the
bone marrow
Increased
destruction
of red cells
(haemolytic anaemias)
Loss of red cells
due to bleeding
Nutritional deficiency
(e.g. iron, vitamin B
12
,
folate)
Reduced bone marrow
erythroid cells (e.g. aplastic
anaemia, marrow infiltration
by leukaemia or
malignancy)
Ineffective red cell
formation (e.g. chronic
inflammation,
thalassaemia, renal
disease)
Anaemia
Anaemia: introduction and
classication
Anaemia is dened as a haemoglobin concentration below the accepted normal range.
The normal range for haemoglobin is affected by sex, age, ethnic group and altitude.
The clinical features of anaemia are largely caused by compensatory measures mobilised to
counteract hypoxia.
Anaemia can be classied according to red cell morphology or aetiology.
Red cell indices and morphology correlate with the underlying cause of anaemia.
Wherever possible the cause of anaemia should be determined before treatment is started.
Blood transfusion is only required in a minority of cases.
24 3 ANAEMIA
12 Iron deciency anaemia
infection is the commonest cause of
iron deciency worldwide. Malabsorp-
tion and increased demand for iron, as
in pregnancy, are other possible causes.
Poor diet may exacerbate iron deciency
but is rarely the sole cause outside the
growth spurts of infancy and teenage
years.
Clinical features
These can be conveniently grouped into
three categories:

General symptoms and signs of

anaemia (see pp. 14 and 22).

Symptoms and signs specic to

iron deciency. Iron is required by
many tissues in the body, shortage
particularly affecting endothelial cells.
Patients with long-standing deciency
may develop nail attening and
koilonychia (concave nails), sore
tongues and papillary atrophy,
angular stomatitis (Fig 12.3),
dysphagia due to an oesophageal web
(PlummerVinson syndrome) and
gastritis. Many patients have none of
these and their absence is thus of
little signicance. Iron deciency in
young children can contribute to
psychomotor delay and behavioural
problems (see also p. 91).

Symptoms and signs due to the

underlying cause of iron
deciency. Patients may
spontaneously complain of heavy
periods, indigestion or a change in
bowel habit. Once the diagnosis of
iron deciency is known, it is often
useful to retake the history and
Iron
Iron is a constituent of haemoglobin
and rate limiting for erythropoiesis. The
metabolism of iron in the body is domi-
nated by its role in haemoglobin synthe-
sis (Fig 12.1). Normally, the total iron
content of the body remains within
narrow limits: absorption of iron from
food (usually up to 34 mg/day) must
replace any iron losses. Iron is not
excreted as such but is lost in desqua-
mated cells, particularly epithelial cells
from the gastrointestinal tract. Menstru-
ating women will lose an additional
highly variable amount of iron, and in
pregnant women the rate of iron loss is
about 3.5 times greater than in normal
men. The storage forms of iron, ferritin
and haemosiderin, constitute about 13%
of total body iron. The small peptide
hepcidin plays a key role in iron metab-
olism and absorption (see p. 36).
Iron deciency
Clinically signicant iron deciency is
characterised by an anaemia which can
usually be condently diagnosed on the
basis of the clinical history and simple
laboratory tests. It cannot be over-
stressed that the diagnosis of iron de-
ciency is not adequate in itself a cause
for the deciency must always be sought.
Causes
The likely cause will vary with the age,
sex and geographic location of the
patient (Table 12.1). Iron deciency is
usually caused by long-term blood loss,
most often gastrointestinal or uterine
bleeding and less commonly bleeding in
the urinary tract or elsewhere. Particu-
larly in elderly patients, deciency may
be the presenting feature of gastrointes-
tinal malignancy (Fig 12.2). Hookworm
Fig 12.1 The normal iron cycle. Iron is absorbed from the gut into plasma where it is transported to
the bone marrow for haemoglobin synthesis. Dying red cells are engulfed by macrophages in the
reticuloendothelial system, and iron is recycled into the plasma for reuse. Iron is transported in the
plasma bound to the glycoprotein, transferrin. Transferrin receptors exist on most cells in the body. Of
the total 45 g of iron in the body only about 0.1% is being recycled at any given time. The rest is in
tissue-specic proteins such as haemoglobin (66% of total body iron) and myoglobin, or stored in ferritin.
Red
blood cells
Macrophages
Spleen
Liver
Erythroid bone
marrow
Gut
Serum transferrin-Fe
Absorption Excretion
Fig 12.2 Carcinoma of the colon. A
53-year-old man presented to his doctor
complaining only of tiredness. A blood count was
consistent with iron deciency (Hb 76 g/L, MCV
69 ) and this was conrmed by a low serum
ferritin level. History and examination revealed no
obvious cause for his iron deciency.
Colonoscopy revealed a large bowel carcinoma
which was successfully resected.
Fig 12.3 Glossitis and angular stomatitis in
iron deciency.
Table 12.1 Causes of iron deciency
Very common
Bleeding from the gastrointestinal tract (e.g. benign
ulcer, malignancy, hookworm)
Menorrhagia
Other
Pregnancy
Malabsorption (e.g. coeliac disease, Helicobacter
pylori gastritis
1
)
Malnutrition
Bleeding from urinary tract
Pulmonary haemosiderosis
1
May also cause bleeding.
25 Iron deciency anaemia
re-examine the patient with a view to
detecting any clue of an underlying
disorder. Rectal examination should
be routine.
Diagnosis
The diagnosis may be suspected on the
basis of the history and examination but
laboratory investigations are required
for conrmation.
The blood count
Iron deciency causes a hypochromic
microcytic anaemia. The automated red
cell analyser generates a report with hae-
moglobin, MCV and MCH values below
the normal range (see p. 22). There is a
variation in red cell size (anisocytosis)
reected by a high red cell distribution
width (RDW). A blood lm will show
characteristic features (Fig 12.4).
Conrmatory tests
Further tests are helpful in conrming
the diagnosis (Table 12.2) and excluding
other causes of a hypochromic micro-
cytic anaemia (see p. 23). Measurement
of serum ferritin is probably the most
useful of these tests: a low level always
indicates iron deciency but a normal
level does not guarantee normal stores
as ferritin is increased in chronic inam-
mation and liver disease. In occasional
difcult cases (e.g. where the patient has
recently been transfused) a bone marrow
aspirate is helpful in showing absence
of iron stores. In practice the most likely
confusion is with the anaemia of chronic
disease (p. 36).
Management
This is divisible into investigations of the
underlying cause and the correction of
iron deciency.
Investigation of
underlying cause
Where the likely cause is apparent,
further investigations can be highly
selective. Thus in a young woman with
severe menorrhagia and no other symp-
toms it can be assumed that uterine
bleeding is the cause of iron deciency,
and investigation of the gastrointestinal
(GI) tract is not necessary. A gynaeco-
logical referral would be adequate. Com-
plaints of indigestion or a change in
bowel habit should prompt an endos-
copy or a colonoscopy or barium enema
as rst investigations. However, often
there are no symptoms suggesting a site
of blood loss. The GI tract is by far the
most common site in men and post-
menopausal women. Faecal occult blood
testing is inadequately sensitive to
exclude gastrointestinal bleeding and
therefore a reasonable approach to this
common problem is to commence with
colonoscopy and, if normal, to proceed
to upper GI endoscopy. If upper GI
endoscopy is performed rst in an
elderly patient and shows a benign
ulcerative lesion then assessment of the
lower GI tract should probably still be
performed as coexistent colonic neo-
plasms are found in a signicant minor-
ity of cases. Anti-tissue transglutaminase
(tTG-IgA) is a simple screening method
for coeliac disease. If the GI tract is
normal, rare causes of iron deciency
should be considered (see Table 12.1). In
20% of cases of iron deciency no cause
is found.
Correction of iron deciency
Oral iron is given to correct the anaemia.
The normal regimen is ferrous sulphate
200 mg three times a day (providing
195 mg elemental iron daily). Side-
effects, including nausea, epigastric pain,
diarrhoea and constipation, are best
managed by reducing the dosage rather
than changing the preparation. An ade-
quate response to oral iron is an increase
in haemoglobin of 20 g/L every 3 weeks.
Iron is given for at least 6 months to
ensure body stores are replete. There are
several possible causes of a failure to
respond to oral iron (Table 12.3).
Parenteral iron (intramuscular or intra-
venous) can be used where oral therapy
is unsuccessful because of poor tolera-
bility or compliance or where there is
continuing blood loss or malabsorption.
Preparations include iron dextran, iron
sucrose and ferric caboxymaltose. Ana-
phylactic reactions can occur and a test
dose may be indicated.
Fig 12.4 Blood lm from a patient with iron
deciency. The red cells are hypochromic (pale
staining) and microcytic.
Table 12.3 Failure to respond to oral iron
possible causes
Wrong diagnosis (i.e. other cause of anaemia)
Non-compliance
Malabsorption
Continued bleeding
Iron deciency anaemia
Iron is a constituent of haemoglobin and is essential for erythropoiesis.
Iron deciency is most often caused by long-term blood loss.
Iron deciency causes a hypochromic microcytic anaemia.
The anaemia is usually easily corrected with oral iron supplements.
It is important to establish the cause of iron deciency it may be the presenting feature
of gastrointestinal malignancy.
Table 12.2 Tests to conrm iron deciency
Test Result in iron
deciency
Comment
Ferritin Low Level increased in chronic inammation/liver disease
Transferrin saturation Low Low levels also in elderly and chronic disease
Serum iron Low Levels uctuate signicantly and low in chronic disease
Transferrin concentration
1
High Useful test as low in anaemia of chronic disease
Zinc protoporphyrin High Late nding only
BM iron Low Informative but invasive investigation
Serum transferrin receptor level High Also high in haemolysis
Percentage of hypochromic red cells High Limited availability
Reticulocyte haemoglobin content Low Limited availability
BM, bone marrow.
1
Total iron binding capacity (TIBC) may alternatively be used.
26 3 ANAEMIA
13 Megaloblastic anaemia
(ineffective haematopoiesis) or enter
the bloodstream as enlarged, misshapen
cells with a reduced survival time. In
clinical practice megaloblastic anaemia
is almost always caused by deciency of
vitamin B
12
(cobalamin) or folate (pter-
oylmonoglutamate). It is one of the
most common causes of a macrocytic
anaemia.
The megaloblastic anaemias are charac-
terised by delayed maturation of the
nucleus of red cells in the bone marrow
due to defective synthesis of DNA.
Red cells either die in the marrow
Why does deciency of vitamin B
12
or folate lead to megaloblastic anaemia?
Key characteristics of these essential
vitamins are summarised in Table 13.1.
Both folate and vitamin B
12
are neces-
sary for the synthesis of DNA (Fig 13.1).
Folate is needed in its tetrahydrofolate
form (FH
4
) as a cofactor in DNA synthe-
sis. Deciency of B
12
leads to impaired
conversion of homocysteine to methio-
nine causing folate to be trapped in
the methyl form. The resultant de-
ciency in methylene FH
4
deprives the
cell of the coenzyme necessary for DNA
formation.
All dividing cells in the body suffer
from the impaired DNA synthesis of B
12

and folate deciency. However, the
actively proliferating cells of the bone
marrow are particularly affected. As
RNA synthesis progresses unhindered
in the cytoplasm, the erythroid cells
develop nuclearcytoplasmic imbalance
with abundant basophilic cytoplasm and
enlarged nuclei. The chromatin pattern
in the nucleus is characteristically abnor-
mal; one author has described it as
resembling ne scroll work, another as
sliced salami (Fig 13.2). The slowed syn-
thesis of DNA leads to prolonged cell
cycling and the cells being discharged
into the blood without the normal quota
of divisions. Red cells are enlarged and
egg-shaped and the neutrophils hyper-
segmented due to retention of surplus
nuclear material (Fig 13.3).
Clinical syndromes
Vitamin B
12
deciency
Pernicious anaemia
This classic cause of vitamin B
12
de-
ciency is an autoimmune disorder. Most
patients have IgG autoantibodies tar-
geted against gastric parietal cells and
the B
12
transport protein intrinsic factor.
The precise pathogenesis, and particu-
larly the role of the autoantibodies, is
incompletely understood but B
12
de-
ciency ultimately arises from reduced
secretion of intrinsic factor (IF) by pari-
etal cells and, hence, reduced availability
of the B
12
IF complex which is absorbed
in the terminal ileum.
Fig 13.1 The cause of megaloblastic
anaemia. Both vitamin B
12
and folate (FH4) are
necessary for normal synthesis of DNA (see text).
Homocysteine Methionine
dUMP dTMP DNA
Methylene FH
4
FH
2
FH
4
Methyl FH
4
Vit. B
12
Fig 13.2 Bone marrow aspirate in
megaloblastic anaemia. The immature red cells
show nuclearcytoplasmic imbalance with
enlarged abnormal nuclei and basophilic
cytoplasm.
The clinical hallmarks of pernicious
anaemia are gastric parietal cell atrophy
and achlorhydria, a more generalised
epithelial cell atrophy and megaloblastic
anaemia. The disease is most common
in northern Europe in women greater
than 50 years of age and is familial.
Affected patients classically have prema-
ture greying of the hair and blue eyes
and may develop other autoimmune
disorders including vitiligo, thyroid
disease and Addisons disease. Slight
jaundice is caused by the haemolysis of
ineffective erythropoiesis.
Patients usually have symptoms of
anaemia and the generalised epithelial
abnormality can manifest as glossitis
(Fig 13.4) and angular stomatitis. The
archetypal neurological complication
subacute combined degeneration
arises from demyelination of the dorsal
and lateral columns of the spinal cord.
Patients most commonly complain of
an unsteady gait, and if B
12
deciency is
not corrected there can be progression
to irreversible damage of the central
nervous system with paralysis and
dementia. There is a possible increased
incidence of carcinoma of the stomach
and colorectal cancer in pernicious
anaemia.
Table 13.1 Vitamin B
12
and folate
Characteristic Vitamin B
12
Folate
Average dietary intake/day (g) 20 250
1
Minimum adequate intake/day (g) 12 150
1
Major food sources Animal produce only Liver, vegetables
Normal body stores Sufcient for several years Sufcient for a few months
Mode of absorption Combined with transport protein (IF) secreted
by gastric parietal cells then absorbed
through ileum via special receptors
Dietary folate converted to
methyl THF and absorbed in
duodenum and jejunum
THF: tetrahydrofolate; IF: intrinsic factor.
1
500 g daily required in pregnancy.
27 Megaloblastic anaemia
Diagnosis
1. Blood count and lm. There is a
macrocytic anaemia with the typical
lm appearance of megaloblastic
anaemia. There may be leucopenia
and thrombocytopenia.
2. Bone marrow aspirate. This is not
always necessary. It will conrm
megaloblastic anaemia but will not
illuminate the underlying cause.
3. Estimation of vitamin B
12
and folate
levels. In pernicious anaemia the
serum vitamin B
12
level is normally
very low but the assay is not
entirely reliable and a trial of
therapy may be justied where
clinical and blood features strongly
suggest deciency. Serum
methylmalonate and homocysteine
levels are raised in B
12
deciency but
their role in diagnosis is limited by
their being often increased in
normal people and a range of other
disorders. Serum folate may be
elevated and the red cell folate
reduced (folate is trapped in its
extracellular methyl FH
4
form see
Fig 13.1).
4. Autoantibodies. Parietal cell
antibodies are found more
commonly in the serum than IF
antibodies (90% vs 50%) but
whereas IF antibodies are almost
diagnostic of pernicious anaemia,
parietal cell antibodies occur in
about 15% of healthy elderly people.
5. Tests for vitamin B
12
absorption. The
urinary secretion (Schilling) test was
formerly much used but radioactive
cyanocobalamin is not available now
and the test is obsolete.
Treatment
Vitamin B
12
levels are usually replen-
ished by intramuscular injection of the
vitamin. Several injections of 1 mg
hydroxycobalamin are given over the
rst few weeks and then either one
injection every 3 months or daily oral
vitamin B
12
12 mg daily for life. The
increase in reticulocytes in the blood
peaks 67 days after the start of
treatment.
In practice, ill patients with megalob-
lastic anaemia are often started on both
B
12
and folate supplements after a blood
sample has been taken for assay of the
vitamins. When the results are known
the unnecessary vitamin can be stopped.
Blood transfusion is best avoided as it
may lead to circulatory overload where
judged necessary to correct hypoxia,
it is undertaken with extreme caution.
Platelet transfusion is used for bleeding
caused by severe thrombocytopenia but
this is unusual. Hypokalaemia occasion-
ally requires correction.
Other causes of vitamin B
12

deciency
These are mostly abnormalities of the
stomach and ileum (Table 13.2). As
normal body stores are sufcient for 2
years, clinically apparent deciency
from any cause will develop slowly.
Folate deciency
Folate deciency is caused by dietary
insufciency, malabsorption, excessive
utilisation or a combination of these
(Table 13.2). Patients may complain of
symptoms of anaemia or of an underly-
ing disease. The increased risk of
thrombosis is because of associated
hyperhomocysteinaemia (see p. 79).
There is a macrocytic anaemia and a
megaloblastic bone marrow. In signi-
cant deciency both serum and red cell
folate are usually low but the latter is
the better measure of tissue stores. In
addition to a thorough dietary history
patients may need investigations for
malabsorption (e.g. jejunal biopsy).
Folate deciency is treated with oral
folic acid 5 mg once daily. This is given
for several months at least, the precise
duration of therapy depending on the
underlying cause. Folate is prescribed
prophylactically in pregnancy (400 g
daily) with a reduction in neural tube
defects in the fetus and also in groups
of patients at high risk of deciency
(Table 13.2). Before folate is prescribed,
vitamin B
12
deciency must be excluded
(or corrected) as subacute combined
degeneration of the cord can be
precipitated.
Fig 13.3 Peripheral blood lm in
megaloblastic anaemia. There is a macrocytosis
and the neutrophils are hypersegmented.
Fig 13.4 Painful glossitis in pernicious
anaemia.
Table 13.2 The megaloblastic anaemias
Vitamin B
12
deciency
Deciency of gastric
intrinsic factor
Pernicious anaemia
Gastrectomy
Intestinal
malabsorption
Ileal resection/Crohns disease
Stagnant loop syndrome
Tropical sprue
Fish tapeworm
Congenital malabsorption
Dietary deciency
(rare)
Vegans
Folate deciency
Dietary deciency
Malabsorption Coeliac disease
Tropical sprue
Small bowel disease/resection
Increased
requirement
Pregnancy
Prematurity
Haemolytic anaemia
Myeloproliferative/malignant/
inammatory disorders
Other causes
Drug-induced
suppression of
DNA synthesis
Folate antagonists
Metabolic inhibitors
Nitrous oxide (prolonged use)
Inborn errors Hereditary orotic aciduria
Megaloblastic
anaemia
Megaloblastic anaemia is a common
cause of a macrocytic anaemia.
In clinical practice it is almost always
caused by deciency of vitamin B
12
or
folate.
Vitamin B
12
deciency normally arises
from malabsorption the classic
clinical syndrome is the autoimmune
disorder pernicious anaemia.
Folate deciency is more often due to
frank dietary deciency or increased
dietary requirements as in pregnancy.
Vitamin B
12
deciency should be
excluded or corrected before folate is
administered as subacute combined
degeneration of the cord can be
precipitated.
28 3 ANAEMIA
14 Haemolytic anaemia I General features and
inherited disorders
abnormalities including frontal bossing of
the skull.
Initial laboratory investigations of
haemolysis will include an automated
blood count, a blood lm and a reticulo-
cyte count. The blood count will show low
haemoglobin. Many cases of haemolysis
have normochromic normocytic red cell
indices although some are moderately
macrocytic. The latter observation is
caused by the increased number of large
immature red cells (reticulocytes) in the
peripheral blood following a compensa-
tory increase in red cell production by the
bone marrow. Reticulocytes have a charac-
teristic blue tinge with Romanowsky
stains and their presence in the lm
causes polychromasia. A reticulocyte
count is performed either manually on a
blood lm stained with a supravital stain
or by the automated cell counter.
Simple laboratory tests to detect
increased breakdown of red cells are also
useful indicators of haemolysis. In addi-
tion to moderately raised serum bilirubin
(often 3050 mol/L), there may be raised
levels of urine urobilinogen and faecal
stercobilinogen. Bilirubin itself is uncon-
jugated and therefore does not appear in
the urine. Haptoglobin, a glycoprotein
bound to free haemoglobin in the plasma,
is depleted in haemolysis. In intravascular
haemolysis, haemoglobin and haemosi-
derin can be detected in the urine.
Haemosiderin is present for several weeks
after a haemolytic episode and is simply
demonstrated by staining urine sediment
for iron.
General features of haemolysis
Table 14.1 Classication of the haemolytic anaemias
Inherited disorders
Red cell membrane Hereditary spherocytosis and hereditary elliptocytosis
Haemoglobin Thalassaemia syndromes and sickling disorders
Metabolic pathways Glucose-6-phosphate dehydrogenase and pyruvate kinase deciency
Acquired disorders
Immune Warm and cold autoimmune haemolytic anaemia
Isoimmune Rhesus or ABO incompatibility (e.g. haemolytic disease of newborn, haemolytic
transfusion reaction)
Non-immune and trauma Valve prostheses, microangiopathy, infection, drugs or chemicals, hypersplenism
Fig 14.1 Mild jaundice in a patient with
hereditary spherocytosis.
Fig 14.2 Hereditary spherocytosis.
Spherocytes in a blood lm.
Fig 14.3 Increased osmotic fragility in
hereditary spherocytosis. Spherocytes are
more fragile than normal red cells and lyse at
higher saline concentrations. The sensitivity of the
test is increased by incubating the cells at 37C.
100
Red cell
lysis (%)
Sodium chloride concentration
Normal
range
Curve in severe
hereditary spherocytosis
The term haemolytic anaemia describes
a group of anaemias of differing aetiology
that are all characterised by abnormal
destruction of red cells. The hallmark of
these disorders is reduced lifespan of the
red cells rather than underproduction by
the bone marrow.
In classication of the haemolytic
anaemias there are three main
considerations:

The mode of acquisition of the

disease: is it an inherited disorder or
a disorder acquired in later life?

The location of the abnormality: is

the abnormality within the red cell
(intrinsic) or outside it (extrinsic)?

The site of red cell destruction: red

cells may be prematurely destroyed
in the bloodstream (intravascular
haemolysis) or outside it in the
spleen and liver (extravascular
haemolysis).
The simple classication in Table 14.1
relies upon division of the main clinical
disorders into inherited and acquired
types. In general, it can be seen that inher-
ited disorders are intrinsic to the red cell
and acquired disorders extrinsic. The
inherited disorders can be subdivided
depending on the site of the defect within
the cell in the membrane, in haemo-
globin, or in metabolic pathways. Acquired
disorders (discussed in the next section)
are broadly divided depending on whether
the aetiology has an immune basis.
Diagnosis of a
haemolytic anaemia
Recognition of the general clinical and
laboratory features of haemolysis usually
precedes diagnosis of a particular clinical
syndrome. Where haemolysis leads to
signicant anaemia the resultant symp-
toms are as for other causes of anaemia.
However, the increased red cell break-
down of the haemolytic anaemias causes
an additional set of problems. Accelerated
catabolism of haemoglobin releases
increased amounts of bilirubin into the
plasma such that patients may present
with jaundice (Fig 14.1). Where the spleen
is a major site of red cell destruction there
may be palpable splenomegaly. Severe
prolonged haemolytic anaemia in child-
hood can lead to expansion of the
marrow cavity and associated skeletal
29 Haemolytic anaemia I General features and inherited disorders
In patients with milder disease folate supplements are consid-
ered but no other treatment is required. In more serious cases
the spleen is removed. This should ideally be performed after 6
years of age with counselling regarding the infection risk.
Hereditary elliptocytosis
This is generally a mild disorder with similarities to hereditary
spherocytosis. There is a variable deciency of spectrin tetram-
ers. Red cells are elliptical except in the rare subtype hereditary
pyropoikilocytosis when they are more distorted and heat labile.
Splenectomy may be indicated for severe haemolysis.
Abnormalities of haemoglobin
These disorders are referred to collectively as the haemoglobin-
opathies. Thalassaemia and sickle cell syndromes are discussed
in later sections.
Abnormalities of red cell metabolism
The red cell has metabolic pathways to generate energy and also
to protect it from oxidant stress (Fig 14.4). Loss of activity of key
enzymes may lead to premature destruction; there are two
common examples.
Glucose-6-phosphate dehydrogenase (G6PD) deciency
G6PD is a necessary enzyme in the generation of reduced glu-
tathione which protects the red cell from oxidant stress. De-
ciency is X-linked, affecting males; female carriers show half
normal G6PD levels. The disorder is most common in West
Africa, southern Europe, the Middle East and South-East Asia.
Patients are usually asymptomatic until increased oxidant stress
leads to a severe haemolytic anaemia, often with intravascular
destruction of red cells. Common triggers include fava beans,
drugs (many, including antimalarials and analgesics) and infec-
tions. The disease can alternatively present as jaundice in the
neonate. Diagnosis requires demonstration of the enzyme de-
ciency by direct assay this should not be done during acute
haemolysis as reticulocytes have higher enzyme levels than
mature red cells and a false normal level may result. Treatment
is to stop any offending drug and to support the patient. Blood
transfusion may be necessary.
Pyruvate kinase (PK) deciency
In this autosomal recessive disorder patients lack an enzyme in
the EmbdenMeyerhof pathway. Red cells are unable to generate
adequate ATP and become rigid. All general features of haemoly-
sis can be present, but clinical symptoms are often surprisingly
mild for the degree of anaemia as the block in metabolism leads
to increased intracellular 2,3-DPG levels facilitating release of
oxygen by haemoglobin. Splenectomy may help in reducing
transfusion requirements.
Fig 14.4 Schematic diagram of red cell metabolism. This shows the
key roles of pyruvate kinase in the EmbdenMeyerhof pathway (the cells
source of ATP) and glucose-6-phosphate dehydrogenase in the hexose-
monophosphate shunt (the cells protection from oxidant stress). The broken
line represents several intermediate steps.
NADPH+H
+
NADP
GSSG 2GSH
H
2
O O

Glucose
Glucose-6-P
Fructose-6-P
Lactate
2,3.DPG
6-PG
Ribulose 5-P
Glucose-6-phosphate
dehydrogenase
Pyruvate
kinase
EmbdenMeyerhof
pathway
Hexosemonophosphate
shunt
RapoportLuebering
shunt
Examination of the bone marrow is not usually necessary in
the work-up of haemolysis but, where performed, will show an
increased number of immature erythroid cells. Formal demon-
stration of reduced red cell survival by tagging of cells with radio-
active chromium (
51
Cr) and in vivo surface counting of
radioactivity to identify the site of red cell destruction are other
possible investigations infrequently performed in practice.
Inherited disorders
Disorders of the red cell membrane
Hereditary spherocytosis
This is the most common cause of inherited haemolytic disease
in northern Europeans. The disease is heterogeneous with a
variable mode of inheritance. There are many possible gene
mutations with alterations in spectrin, ankyrin and other mem-
brane proteins. In a blood lm the red cells are spheroidal
(spherocytes) with a reduced diameter and more intense stain-
ing than normal red cells (Fig 14.2). These abnormal red cells are
prone to premature destruction in the microvasculature of the
spleen.
The severity of haemolysis is variable and the disease may
present at any age. Fluctuating levels of jaundice and palpable
splenomegaly are common features. Occasionally, patients
develop severe anaemia associated with the transient marrow
suppression of a viral infection; this so-called aplastic crisis,
which may intervene in any form of chronic haemolysis, is often
caused by parvovirus B19. Prolonged haemolysis may lead to
bilirubin gallstones.
Diagnosis is facilitated by the presence of a family history. The
combination of general features of haemolysis and spherocytes
in the blood is suggestive of hereditary spherocytosis but not
diagnostic as spherocytes may also be seen in autoimmune
haemolysis. The two haemolytic disorders are distinguished by
the direct antiglobulin test, which is negative in hereditary sphe-
rocytosis and nearly always positive in immune haemolysis.
Useful screening tests for hereditary spherocytosis include
measurement of osmotic fragility (Fig 14.3) and ow cytometric
analysis of eosin-5-maleimide binding. In difcult cases, gel elec-
trophoretic analysis of red cell membranes is helpful.
Haemolytic anaemia I
general features and
inherited disorders
Haemolytic anaemias are caused by abnormal destruction of red
cells.
Most inherited haemolytic disorders have a defect within the red
cell while most acquired disorders have the defect outside the cell.
Haemolysis causes characteristic clinical features and laboratory
abnormalities. It may be intra- or extravascular.
Hereditary spherocytosis and hereditary elliptocytosis are
haemolytic disorders caused by a deciency in the red cell
membrane.
Glucose-6-phosphate dehydrogenase and pyruvate kinase are key
enzymes in red cell metabolism; inherited deciency leads to
haemolysis.
30 3 ANAEMIA
15 Haemolytic anaemia II Acquired disorders
a frequent examination nding in severe
cases. The most characteristic laboratory
abnormality in warm AIHA is a positive
direct antiglobulin test (DAT) sometimes
known as the Coombs test (p. 83). A
major priority in management is the iden-
tication and treatment of any causative
disorder. It is particularly important to
stop an offending drug cephalosporin
antibiotics are most commonly impli-
cated. Where the haemolysis itself requires
treatment, steroids are normally used (e.g.
prednisolone 12 mg/kg daily). In idio-
pathic AIHA most patients will respond
to steroids with a signicant rise in hae-
moglobin and diminished clinical symp-
toms. However, the disease is usually
controlled rather than cured and relapses
often occur when steroids are reduced or
stopped. Where refractoriness to steroids
develops, splenectomy is usually indi-
cated. Other immunosuppressive drugs
(e.g. azathioprine, ciclosporin), intrave-
nous immunoglobulin, cytotoxic agents
and the monoclonal antibody rituximab
may all be helpful in difcult cases.
Cold autoimmune
haemolytic anaemia
In cold AIHA the antibody is generally of
IgM type with specicity for the I red cell
antigen. It attaches best to red cells in the
peripheral circulation where the blood
temperature is lower. As is seen in Table
15.1, this kind of haemolysis can occur in
the context of a monoclonal (i.e. malig-
nant) proliferation of B-lymphocytes in
the so-called idiopathic cold haemaggluti-
nin syndrome or in a variety of lympho-
mas. The other major cause is infection.
The severity of haemolysis varies and
agglutination (clumping) of red cells (Fig
15.3) may cause circulatory problems
such as acrocyanosis, Raynauds phenom-
enon and ulceration. The haemolysis,
where longstanding, is often worse in the
winter. On occasion red cell destruction is
intravascular due to direct lysis by acti-
vated complement. Where this occurs free
haemoglobin is released into the plasma
(haemoglobinaemia) and may appear in
the urine (haemoglobinuria), giving it a
dark colour. Cold AIHA arising from
infection is usually self-limiting. Where it
is chronic the mainstay of treatment is
keeping the patient warm, particularly in
the extremities. In forms associated with
lymphoproliferative disorders, cytotoxic
drugs (e.g. chlorambucil) or rituximab
may be helpful. Steroids are generally
ineffective.
Isoimmune
haemolytic anaemia
Here alloantibodies (isoantibodies) cause
haemolysis as a result of transfusion or
Autoimmune
haemolytic anaemia
Autoimmune haemolytic anaemia
(AIHA) is an example of an acquired form
of haemolysis with a defect arising outside
the red cell. The bone marrow produces
structurally normal red cells and prema-
ture destruction is caused by the pro-
duction of an aberrant autoantibody
targeted against one or more antigens on
the cell membrane. Once an antibody has
attached itself to the red cell, the exact
nature of the haemolysis is determined
by the class of antibody and the density
and distribution of surface antigens.
IgM autoantibodies cause destruction by
agglutination or by direct activation of
serum complement. IgG class antibodies
generally mediate destruction by binding
of the Fc portion of the cell-bound immu-
noglobulin molecule by macrophages in
the spleen and liver. The disparate behav-
iour of different types of autoantibody
provides the explanation for a number of
different clinical syndromes.
Classication
Table 15.1 shows a simple approach to the
classication of autoimmune haemolytic
anaemia. The disease can be divided into
warm and cold types depending on
whether the antibody reacts better with
red cells at 37C or 05C. For each of
these two basic types of autoimmune
haemolysis there are a number of possible
causes and these can be incorporated into
the classication. A diagnosis of autoim-
mune haemolysis may precede diagnosis
of the causative underlying disease.
Clinical presentation and
management
Warm autoimmune
haemolytic anaemia
Warm AIHA (Figs 15.1 and 15.2) is the
most common form of the disease. The
red cells are coated with either IgG alone,
IgG and complement, or complement
alone. Premature destruction of these cells
usually takes place in the reticuloendothe-
lial system. Approximately half of all cases
are idiopathic but in the other half there
is an apparent underlying cause (Table
15.1). The autoantibody is produced by
polyclonal B-cells and is usually non-
specic with reactivity against basic mem-
brane constituents present on virtually all
red cells. Patients present with the clinical
and laboratory features of haemolysis dis-
cussed in the last section. Splenomegaly is
Table 15.1 Classication of the
autoimmune haemolytic anaemias
Warm AIHA (usually IgG)
Primary (idiopathic)
Secondary Lymphoproliferative
disorders
Other neoplasms
Connective tissue
disorders
Drugs
Infections
Cold AIHA (usually IgM)
Primary (cold
haemagglutinin
disease)
Secondary Lymphoproliferative
disorders
Infections (e.g.
mycoplasma)
Paroxysmal cold
haemoglobinuria
1
1
Caused by a biphasic polyclonal IgG antibody
(DonathLandsteiner).
Fig 15.1 Blood lm in warm AIHA.
Spherocytes and polychromasia are present.
Fig 15.2 Increased reticulocytes in warm
AIHA. The reticulocyte ribosomal RNA is stained
supravitally by brilliant cresyl blue.
31 Haemolytic anaemia II Acquired disorders
transfer across the placenta. These anti-
bodies are conventional antibodies spe-
cic for foreign antigens on incompatible
red cells. Haemolytic blood transfusion
reactions are discussed on page 84 and
haemolytic disease of the newborn on
page 90.
Microangiopathic
haemolytic anaemia
Collectively, microangiopathic haemolytic
anaemia (MAHA) is one of the most fre-
quent causes of haemolysis. The term
describes intravascular destruction of red
cells in the presence of an abnormal
microcirculation. There are many causes
of MAHA (Table 15.2) but common trig-
gers are the presence of disseminated
intravascular coagulation (DIC), abnor-
mal platelet aggregation and vasculitis.
Characteristic laboratory ndings include
red cell fragmentation in the blood lm
(Fig 15.4) and the coagulation changes
seen in DIC (see p. 79). Two specic syn-
dromes merit brief description.
Haemolytic uraemic
syndrome (HUS)
HUS mainly affects infants and children.
The three main features are MAHA, renal
failure and thrombocytopenia. The
disease can occur as seasonal epidemics
caused by Escherichia coli producing vero-
toxin; it is then preceded by bloody diar-
rhoea. Treatment is essentially supportive
with dialysis for renal failure. Mortality
ranges from 5 to 15%.
Thrombotic thrombocytopenic
purpura (TTP)
This rare congenital or acquired disorder
has many similarities to HUS. It is charac-
terised by MAHA, thrombocytopenia
(often severe), uctuating neurological
symptoms, fever and renal failure. Platelet
microvascular thrombi are mediated
by ultra-large von Willebrand factor
multimers which accumulate due to de-
ciency of a protease (ADAMTS 13). Daily
plasma exchange is the mainstay of treat-
ment; mortality rates are 1020%.
Other acquired
haemolytic anaemias
Haemolysis associated with red cell frag-
mentation may also occur due to the
mechanical effects of defective heart valves
or in long distance runners who effec-
tively stamp repeatedly on a hard surface
(march haemoglobinuria). Certain drugs
(e.g. dapsone and sulfasalazine) can cause
oxidative intravascular haemolysis in
normal people if taken in sufcient
dosage. Many infections can cause haemo-
lysis, either by direct invasion of red cells
or via the circulatory changes already dis-
cussed. The anaemia of malaria often has
a haemolytic component (pp. 9899).
Paroxysmal nocturnal haemoglob-
inuria (PNH) (Fig 15.5) is a rare example
of acquired haemolysis caused by an
intrinsic red cell defect. In this clonal dis-
order arising from a somatic mutation in
the PIG-A gene in a stem cell, the mature
blood cells have faulty anchoring of
several proteins to membrane glycophos-
pholipids containing phosphatidylinosi-
tol. Clinical features are highly variable
and include intravascular haemolysis,
pancytopenia and recurrent thrombotic
episodes, including portal vein thrombo-
sis. There is coexistent marrow damage
and PNH is often associated with aplastic
anaemia and may even terminate in acute
leukaemia. The traditional diagnostic test
exploited the cells unusual sensitivity to
complement lysis (Ham test). Flow cytom-
etry is now used to show the cells charac-
teristic lack of certain surface proteins
(CD55, CD59) and to quantitate the PNH
clone. Management is largely supportive
with blood transfusion and anticoagula-
tion. More recently, eculizumab, a mono-
clonal antibody blocking activation of
terminal complement, has been given to
reduce haemolysis and the risk of throm-
bosis. Allogeneic stem cell transplantation
is the only curative option but is used very
selectively (e.g. in severe marrow failure).
Fig 15.3 Cold agglutination in the blood
lm of a patient with cold autoimmune
haemolytic anaemia.
Fig 15.4 Blood lm in microangiopathic
haemolytic anaemia. Fragmented red cells and
thrombocytopenia.
Fig 15.5 Haemosiderinuria caused by
chronic intravascular haemolysis in PNH
(Perls reaction).
Table 15.2 Causes of microangiopathic
haemolytic anaemia
Haemolytic uraemic syndrome (HUS)
1
Thrombotic thrombocytopenic purpura (TTP)
1
Carcinomatosis
Vasculitis
Severe infections
Pre-eclampsia
Glomerulonephritis
Malignant hypertension
1
Some authorities believe that HUS and TTP are effectively a single
disorder TTP-HUS.
Haemolytic anaemia II
acquired disorders
Autoimmune haemolytic anaemia (AIHA) can be divided into warm and cold types
dependent on the temperature at which the antibody reacts optimally with red cells.
For each type of AIHA there are possible underlying causes which must be identied and
treated.
The term microangiopathic haemolytic anaemia (MAHA) describes the intravascular
destruction of red cells in the presence of an abnormal microenvironment. Clinical
syndromes associated with MAHA include haemolytic uraemic syndrome and thrombotic
thrombocytopenic purpura.
Paroxysmal nocturnal haemoglobinuria (PNH) is a rare example of acquired haemolysis
caused by an intrinsic red cell defect.
32 3 ANAEMIA
16 The thalassaemias
-Thalassaemias are autosomal reces-
sive disorders characterised by reduced
(
+
) or absent (
0
) production of
chains. The heterozygous (trait or
minor) form of the disease is usually
symptomless while homozygosity is
associated with the clinical disease
-thalassaemia major. Homozygous
mild (
+
) thalassaemia may, however,
lead to a less severe clinical syndrome
termed thalassaemia intermedia. The
-thalassaemias are very heterogeneous
at the molecular level the large major-
ity of mutations are single base substitu-
tions (point mutations) and insertions
or deletions of one to two bases.
Although molecular analysis may be
needed, diagnosis of the major syn-
dromes is normally possible from con-
sideration of the clinical features and
simple laboratory tests. The latter must
include a blood count and blood lm,
and haemoglobin electrophoresis with
quantication of the different types of
haemoglobin (i.e. HbA, HbA
2
, HbF).
Other structural Hb variants may
coexist with thalassaemias giving rise to
a wide range of clinical disorders. Only
the more common thalassaemia syn-
dromes are discussed here.
Clinical syndromes
-Thalassaemias
Hb-Barts hydrops syndrome ( / )
Here deletion of all four genes leads to
complete absence of -chain synthesis.
As the -globin chain is needed for fetal
haemoglobin (HbF) as well as adult hae-
moglobin (HbA) (see p. 5) the disorder
is incompatible with life and death
occurs in utero (hydrops fetalis).
HbH disease (/ )
This disorder arises from deletion of
three of the four -globin genes and is
found most commonly in South-East
Asia. The clinical features are variable
but there is often a moderate chronic
haemolytic anaemia (Hb 70110 g/L)
with splenomegaly and sometimes
hepatomegaly. Severe bone changes and
growth retardation are unusual. The
blood lm shows hypochromic micro-
cytic red cells with poikilocytosis, poly-
chromasia and target cells. The HbH
molecule is formed of unstable tetram-
ers of unpaired chains (
4
). It is best
detected by electrophoresis but may be
demonstrated as red cell inclusion
bodies in reticulocyte preparations.
-Thalassaemia traits
Deletion of a single -globin chain leads
only to a slight lowering of red cell
mean corpuscular volume (MCV) and
mean corpuscular haemoglobin (MCH)
and even deletion of two genes usually
only minimally lowers the haemoglobin
with a raised red cell count and
hypochromia and microcytosis. These
carrier states can be difcult to identify
in the routine laboratory as haemo-
globin electrophoresis is normal. Occa-
sional HbH bodies may be detected in
reticulocyte preparations. Denitive
diagnosis requires DNA analysis.
-Thalassaemias
-Thalassaemia major
The characteristic severe anaemia (Hb
less than 70 g/L) is caused by -chain
excess leading to ineffective erythropoi-
esis and haemolysis. Anaemia rst
becomes apparent at 36 months
when production of HbF declines. The
child fails to thrive and develops hepat-
osplenomegaly. Compensatory expan-
sion of the marrow space causes the
typical facies with skull bossing and
maxillary enlargement (Fig 16.1a). The
hair-on-end radiological appearance
of the skull (Fig 16.1b) is due to expan-
sion of bone marrow into cortical bone.
If left untreated further complications
can include repeated infections, bone
fractures and leg ulcers. Red cell mem-
brane abnormalities contribute to
hypercoagulability.
Laboratory testing should precede
blood transfusion. There is a severe
hypochromic microcytic anaemia with
a characteristic blood lm (Fig 16.2)
and Hb electrophoresis demonstrates
absence or near absence of HbA with
small amounts of HbA
2
and the remain-
der HbF (Fig 16.3).
With intense supportive therapy,
increasing numbers of patients in the
The thalassaemias are a heterogeneous
group of inherited disorders of haemo-
globin synthesis. They are characterised
by a reduction in the rate of synthesis of
either alpha or beta chains and are clas-
sied accordingly (i.e. -thalassaemia,
-thalassaemia). The basic haematologi-
cal abnormality in the thalassaemias is
a hypochromic microcytic anaemia of
variable severity. Unbalanced synthesis
of - and -globin chains can damage
red cells in two ways. Firstly, failure of
and chains to combine leads to
diminished haemoglobinisation of red
cells to levels incompatible with survival.
Even those hypochromic cells released
into the circulation transport oxygen
poorly. The second mechanism for
red cell damage is the aggregation of
unmatched globin chains the inclu-
sion bodies lead to accelerated apoptosis
of erythroid precursors in the bone
marrow (ineffective erythropoiesis) and
destruction of more mature red cells in
the spleen (haemolysis). In general,
the clinical severity of any case of thalas-
saemia is proportionate to the degree of
imbalance of - and -globin chain
synthesis.
Thalassaemias are among the most
common inherited disorders. Gene carri-
ers have some protection from falci-
parum malaria. Cases occur sporadically
in most populations but the highest tha-
lassaemia gene frequency is in a broad
geographical region extending from the
Mediterranean through the Middle East
and India to South-East Asia.
Classication
The classication illustrated in Table
16.1 is based on the mode of inheritance
of thalassaemia.
As the -globin chain gene is dupli-
cated on each chromosome there may
be total loss of -globin chain produc-
tion (termed
0
or /haplotype) or
partial loss of -chain production result-
ing from loss of only one gene (termed

+
or /haplotype).
The most important clinical syn-
dromes are haemoglobin (Hb)-Barts
hydrops syndrome ( / ), which is
incompatible with life, and Hb H disease
(/ ). At the molecular level the
-thalassaemias result from loss of -
gene function due to gene deletion
or non-deletional mutations; different
types of mutations may be co-inherited.
Table 16.1 Classication of thalassaemia
Type of
thalassaemia
Heterozygote Homozygote
-Thalassaemia
1

0
( /) Thal. minor Hydrops fetalis

+
(/) Thal. minor Thal. minor
-Thalassaemia

0
Thal. minor Thal. major

+
Thal. minor Thal. major or
intermedia
1
Compound heterozygosity ( /) leads to HbH disease.
33 The thalassaemias
developed world survive into adulthood.
Blood transfusion remains the mainstay
of management. Raising the haemo-
globin concentration both reduces tissue
hypoxia and suppresses endogenous
haematopoiesis which is largely ineffec-
tive. There is improved growth and
development and reduced hepat-
osplenomegaly. Transfusion is generally
given to maintain a haemoglobin level
of at least 90100 g/L. Splenectomy can
reduce the transfusion frequency. With
such regular transfusion iron chelation
is necessary to minimise iron overload.
Without chelation, accumulation of iron
damages the liver, endocrine organs and
heart with death in the second or third
decades. The most commonly used
regimen is subcutaneous desferrioxam-
ine given for 57 days per week. Compli-
ance may be problematic (especially in
teenagers) but where good there is a
considerably improved life expectancy.
Oral iron chelators (e.g. deferiprone,
deferasirox) are emerging as an accept-
able alternative. Endocrine disturbances
related to iron overload will require
appropriate therapy.
Allogeneic stem cell transplantation
is a serious option. In best risk patients
the probability of survival exceeds 90%.
Experimental therapies include drugs
designed to stimulate fetal haemoglobin
production (e.g. erythropoietin, hydroxy-
carbamide) and gene therapy (see p. 103).
Thalassaemia intermedia
Thalassaemia intermedia is a clinical
syndrome which may result from a
variety of genetic abnormalities (Table
16.2). The clinical features are less severe
than in -thalassaemia major as the /-
globin chain imbalance is less pro-
nounced. Patients usually present later
than is the case for -thalassaemia major
(often at 24 years), and have relatively
high haemoglobin levels (80100 g/L),
moderate bone changes and normal
growth. Transfusion may be required
but requirements are less than in
-thalassaemia major.
-Thalassaemia trait (minor)
Heterozygotes for
0
or
+
are usually
asymptomatic with hypochromic micro-
cytic red cells and slightly reduced hae-
moglobin levels. The red cell count is
elevated. The key diagnostic feature is a
raised HbA
2
level (47%). The disorder
may be confused with iron deciency
leading to unnecessary investigations. If
both parents have -thalassaemia trait
there is a 25% chance of a child having
-thalassaemia major.
Prenatal diagnosis
This depends on early identication of
couples at risk and sensitive counselling.
Adequate amounts of fetal DNA can be
obtained around the 10th week of gesta-
tion by chorionic villus sampling.
Current technologies allow reliable
identication of single point mutations
from very small DNA samples. Tech-
niques are being developed to analyse
fetal DNA obtained from maternal
plasma or peripheral blood.
Fig 16.1 -Thalassaemia major. (a) Typical facies; (b) skull X-ray showing hair-on-end appearance.
(a) (b)
Fig 16.2 Blood lm in -thalassaemia major.
Fig 16.3 Haemoglobin electrophoresis (cellulose acetate, pH 8.5). The patterns obtained in
normality and some common thalassaemia syndromes are shown. Other screening methods include
high-performance liquid chromatography and isoelectric focusing.
Normal b thal trait b thal major HbH disease
Hb type
H
A
F
A
2
Table 16.2 Possible causes of thalassaemia
intermedia
Mild defects of -globin chain production, e.g.
homozygous mild
+
-thalassaemia
Homozygosity or compound heterozygosity for
severe -thalassaemia with co-inheritance of
-thalassaemia or genetic factors enhancing -chain
production
Heterozygous -thalassaemia with co-inheritance of
additional -globin gene
-thalassaemia and hereditary persistence of fetal
haemoglobin
HbH disease
The thalassaemias
The thalassaemias are a heterogeneous group of inherited disorders where there is a
reduction in the rate of synthesis of haemoglobin chains (-thalassaemia) or chains
(-thalassaemia).
There may be both ineffective erythropoiesis and haemolysis. The basic haematological
abnormality is a hypochromic microcytic anaemia.
There are several clinical syndromes. In general the severity is proportionate to the degree
of imbalance of - and -globin chains.
-Thalassaemia major leads to severe anaemia requiring regular blood transfusion and iron
chelation.
Thalassaemia trait is a symptomless clinical disorder which should not be confused with
iron deciency. Genetic counselling is required in selected cases.
34 3 ANAEMIA
17 Sickle cell syndromes
Vascular-occlusive crises
Acute, episodic, painful crises are a
potentially disabling feature of sickle
cell anaemia. They may be triggered by
infection or cold. Patients complain of
musculoskeletal pain which may be
severe and require hospital admission.
Hips, shoulders and vertebrae are most
affected. Attacks are generally self-
limiting but infarction of bone can occur
and must be distinguished from salmo-
nella osteomyelitis. Avascular necrosis
of the femoral head is a crippling com-
plication. Other organs are vulnerable to
infarction; most serious is neurological
damage which may manifest as seizures,
transient ischaemic attacks (TIAs) and
strokes. Vaso-occlusion in infancy is
responsible for the handfoot syn-
drome, a type of dactylitis damaging the
small bones of hands and feet (Fig 17.3).
Sequestration crises
These arise from sickling and infarction
within particular organs. Specic syn-
dromes include acute chest syndrome
with occlusion of the pulmonary vascu-
lature, girdle sequestration caused by
occlusion of the mesenteric blood
supply, and hepatic and splenic
sequestration.
Other complications
These are multiple, usually caused by
vascular stasis and local ischaemia.

Genitourinary. Papillary necrosis with

haematuria; loss of ability to
concentrate urine; nephrotic
syndrome; priapism.

Skin. Lower limb ulceration.

Eyes. Proliferative retinopathy;

glaucoma.

Hepatobiliary. Liver damage; pigment

gallstones.
Diagnosis
Diagnosis depends on the following:

Blood lm appearance (see Fig 17.2).

Screening tests for sickling. The blood

sample is deoxygenated (e.g. with
sodium metabisulphate) to induce
sickling.

Haemoglobin electrophoresis. In sickle

cell anaemia (HbSS) there is no HbA
detectable (Fig 17.4).
The sickle cell syndromes are a group of
haemoglobinopathies which primarily
affect the Afro-Caribbean population.
The common feature of these diseases
is inheritance of an abnormal haemo-
globin -chain gene the gene is desig-
nated
S
. Inheritance of two
S
genes
leads to a serious disorder termed sickle
cell anaemia. A similar syndrome can
result from inheritance of the
S
gene
with another abnormal gene such
as the haemoglobin C gene or
-thalassaemia gene. Inheritance of the

S
gene with a normal -chain gene (
A
)
causes the innocuous sickle cell trait
(Fig 17.1).
Pathophysiology
The abnormal
S
gene has a high inci-
dence in tropical and subtropical regions
as the abnormal haemoglobin produced
(HbS) gives some protection against fal-
ciparum malaria. HbS differs from
normal haemoglobin (HbA) in that
glutamic acid has been replaced by
valine at the sixth amino acid from the
N-terminus of the -globin chain. The
clinical features of sickle cell anaemia
arise from the propensity of red cells
containing haemoglobin S to undergo
sickling. In the deoxygenated state HbS
undergoes a conformational change
leading to the creation of haemoglobin
tetramers which aggregate to produce
large polymers. The red cell loses its
normal deformability and becomes
characteristically sickle-shaped (Fig 17.2).
Damage to the membrane leads to
increased rigidity and the ultimate
sequestration of the red cell in the retic-
uloendothelial system causing haemo-
lytic anaemia. The inexible sickle cells
also become lodged in the microcircula-
tion causing stasis and obstruction.
Clinical syndromes
Sickle cell anaemia (HbSS)
This classic form of sickle cell syndrome
is enormously variable in severity.
Haemolytic anaemia
The haemoglobin is generally in the
range 60100 g/L. Because HbS releases
oxygen more readily than HbA, the
symptoms of anaemia are often surpris-
ingly mild. Intercurrent infection with
parvovirus or folate deciency can block
erythropoiesis and cause a sudden fall
in haemoglobin the aplastic crisis.
Fig 17.1 Inheritance of sickle cell syndromes. Two pedigrees showing inheritance of sickle cell
syndromes. In the rst family one child is unaffected, one has sickle cell trait and one has sickle cell
anaemia. In the second family one child has inherited the abnormal sickle gene and the HbC gene; this
double heterozygosity leads to haemoglobin SC disease.
1. Both parents have sickle trait 2. One parent has sickle trait and the other
is heterozygous for HbC
S A S A
A A S A S S
Sickle trait
(AS)
Sickle cell
anaemia (SS)
Unaffected
S A C A
A A S A S C
Haemoglobin
SC disease
Fig 17.2 Blood lm in sickle cell anaemia.
Fig 17.3 Dactylitis in sickle cell anaemia.
(Reproduced with permission from Linch D C,
Yates A P 1996 Colour Guide Haematology
Churchill Livingstone, Edinburgh.)
35 Sickle cell syndromes
Management
General. Patients need support in the
community and easy access to centres
experienced in the management of
sickle cell anaemia. Prophylaxis is
important. Patients should avoid factors
known to precipitate crises, take folate
supplements (because of chronic
haemolysis) and be prescribed penicillin
and pneumococcal vaccine (because of
hyposplenism caused by infarction).
Infections require prompt treatment.
Transcranial Doppler ultrasonography
can identify children at high risk of
stroke. Annual retinal screening is
recommended.
Painful vascular-occlusive crises.
First-line treatment is rest, increased
uids and adequate oral analgesia. Con-
stitutional upset or pain not relieved by
oral analgesia necessitates hospital
admission with continued rest, warmth,
intravenous uids and opiate analgesia.
Psychological support is vital.
Blood transfusion. Acute or chronic
simple red cell transfusion may be given
to relieve severe anaemia and to reduce
the amount of circulating sickle haemo-
globin. Chronic transfusions are the
most effective intervention to prevent
recurrent cerebrovascular events. Other
indications for transfusion include com-
plications such as chest syndrome and
priapism. Blood transfusion is not
usually required for episodes of pain.
Exchange transfusion is preferred to
simple transfusion for rapid reduction
of HbS levels or where simple transfu-
sion would cause hyperviscosity or cir-
culatory overload. Blood is phenotypically
matched to reduce the chance of alloim-
munisation. Iron chelation may be
required.
Pregnancy and surgery. Transfu-
sion is not routinely indicated in an
uncomplicated pregnancy but may be
needed for severe anaemia or other
sickle-cell-related complications. During
surgery it is important to avoid hypoxia
and dehydration. Preoperative simple
transfusion or even exchange transfu-
sion may be appropriate for high-risk
procedures.
Hydroxycarbamide. Increasing the
level of fetal haemoglobin in red cells
with the antimetabolite hydroxycar-
bamide can reduce the severity of the
disease. Clinical trials have been encour-
aging with signicant reductions in
painful crises, major complications,
blood transfusion, hospital admissions
and mortality rates. It is important to
ensure compliance as clinical benet
may not be immediate. There are con-
cerns regarding the leukaemogenic and
teratogenic effects of hydroxycarbamide
but with cautious use and patient educa-
tion (e.g. appropriate contraception) the
risks appear to be low.
Stem cell transplantation. Alloge-
neic stem cell transplantation offers the
possibility of a cure in selected high risk
patients but it will not be more widely
applicable until the toxicity is reduced
(see p. 56).
Gene therapy. Gene therapy has the
potential to provide a cure without the
risks of allogeneic stem cell transplanta-
tion (see p. 103).
Prognosis
The risk of early death is inversely
related to fetal haemoglobin levels. The
most common causes of death are infec-
tion in infancy, cerebrovascular acci-
dents in childhood and adolescence and
respiratory complications in adult life.
Doubly heterozygous sickling
disorders
Here patients inherit the
S
gene and
another abnormal gene usually HbC
or -thalassaemia. HbSC disease is
similar to HbSS but there is a tendency
for fewer painful crises and a higher
incidence of proliferative retinopathy
and avascular necrosis. The severity of
sickle cell/-thalassaemia depends on
whether patients have the
+
or
0
geno-
type. The less common HbS/
0
form has
a similar clinical picture to HbSS.
Sickle cell trait (HbAS)
Sickle cell trait normally causes no clini-
cal problems as there is enough HbA in
red cells (approximately 60%) to prevent
sickling. However, haematuria occasion-
ally occurs as a result of renal papillary
necrosis and additional care is required
during pregnancy and anaesthesia. Diag-
nosis is by a sickling test and Hb elec-
trophoresis (see Fig 17.4). Life expectancy
is normal although there may be a
slightly increased risk of sudden death
during intense exercise in young adults.
Counselling and
prenatal diagnosis
Genetic counselling is needed by those
affected with either the homozygous
disease, compound heterozygosity or
the trait. Prenatal diagnosis is possible
using mutation analysis on PCR-
amplied DNA from chorionic villi (see
p. 100).
Screening strategies
Screening of all newborn babies for
sickle cell syndromes is recommended
to reduce the risk of early death from
infection. Preconception testing and
antenatal testing of pregnant women is
performed depending on individual risk
and the local prevalence of sickle cell
disease. A similar approach is adopted
prior to surgery.
Fig 17.4 Cellulose acetate electrophoresis to separate
haemoglobins A, F, S and C. Lane 4, control sample; Lanes 2, 3, 6, 7,
normal; Lane 1, sickle cell anaemia; Lane 5, sickle cell trait.
A
F
S
A
2
/C
Sickle cell syndromes
The sickle cell syndromes are a group of haemoglobinopathies
which primarily affect people of African origin.
Inheritance of two
S
genes leads to the serious clinical disorder
sickle cell anaemia (HbSS).
Clinical problems in sickle cell anaemia include chronic haemolytic
anaemia, vascular-occlusive crises, sequestration crises and
susceptibility to infection.
Routine management of sickle cell anaemia entails prophylactic
measures, supportive care during vascular-occlusive crises and the
selective use of blood transfusion and hydroxycarbamide.
Sickle cell trait (HbAS) is an innocuous clinical disorder but genetic
counselling is often needed.
36 3 ANAEMIA
18 Anaemia of chronic disease
questions remain. Key factors in aetiol-
ogy are summarised in Figure 18.2.
Inammatory cytokines such as tissue
necrosis factor (TNF) and interleukin-1
and -6 are implicated in all of these
processes.
There is a modest shortening of red
cell lifespan which leads to an increased
demand for bone marrow production.
The marrow struggles to respond ade-
quately as there is blunting of the
expected increase in erythropoietin
secretion and also diminished respon-
siveness of erythroid precursor cells to
erythropoietin. Hepcidin, a peptide
hormone, appears to be an important
mediator of ACD. This acute phase reac-
tant protein is released from the liver
following stimulation by interleukin-6.
Actions of hepcidin include inhibition of
microbial infection, macrophage iron
recycling and intestinal iron absorption.
Its role in iron balance and transport is
mediated via binding to ferroportin, the
major cellular iron efux protein.
Patients with inammation and anaemia
have elevated serum and urine levels of
hepcidin. Abnormalities of iron metabo-
lism are well documented in ACD.
These include:

reduced iron absorption from the

gastrointestinal tract

decreased plasma iron concentration

excessive retention of iron in

reticuloendothelial cells
(macrophages) with diminished
release to erythroid cells.
The high prevalence of ACD has
led to the suggestion that it may have
some benets for those with chronic
inammation. Perhaps withdrawal of
iron by increased storage in the
reticuloendothelial system limits its
availability to microorganisms or
tumour cells. Decreased haemoglobin
levels reduce the oxygen-carrying capac-
ity of the blood and might reduce the
oxygen supply to unwelcome microor-
ganisms and cells. Cell-mediated immu-
nity is probably strengthened by reduced
levels of metabolically active iron in the
circulation as iron inhibits the activity of
IFN-.
Diagnosis
Most patients will have a documented
chronic disorder and a moderate
anaemia. On occasion the anaemia is a
more dominant feature and the underly-
ing cause is not immediately apparent.
The anaemia is usually of normochro-
mic normocytic type although it can be
slightly hypochromic microcytic. The
blood lm appearance is often unre-
markable but there may be changes
reactive to the underlying disorder such
as a neutrophil leucocytosis, thrombocy-
tosis and rouleaux formation. There
is a reticulocytopenia. Inammatory
markers such as C-reactive protein
(CRP) and erythrocyte sedimentation
rate (ESR) are often raised. Serum iron
concentration and transferrin concen-
tration are usually reduced. The serum
ferritin level is normal or high (as an
acute phase reactant). In practice, ACD
is most commonly confused with mild
iron deciency anaemia, particularly if
the MCV and MCH are reduced.
However, the two forms of anaemia
should be distinguishable as in uncom-
plicated iron deciency the transferrin
concentration is elevated and the ferritin
level is low. In difcult cases the serum
Anaemia of chronic disease (ACD) is a
term used to describe a type of anaemia
seen in a wide range of chronic inam-
matory, infective and malignant diseases
(Table 18.1). The anaemia often becomes
apparent during the rst few months of
illness and then remains fairly constant
(Fig 18.1). It is rarely severe (haemo-
globin 90 g/L; packed cell volume
(PCV) 0.30) but there is some correla-
tion with the intensity of the underlying
illness. For instance, in infection the
anaemia is often more marked where
there is a persistent fever and in malig-
nancy where there is widespread dis-
semination. Patients may suffer no
symptoms from their anaemia or have
only slight fatigue. The importance of
this type of anaemia arises not from its
severity but from its ubiquity. It is widely
misunderstood (for such a common dis-
order) and ill patients are frequently
subjected to excessive haematological
investigation and unnecessary treat-
ment with haematinics. The term ACD
should not be used to describe other
causes of anaemia such as haemolysis or
bleeding which may also complicate
chronic disorders. It has been argued
that the designation ACD is inappropri-
ate but other suggested terms (e.g.
anaemia of inammation) appear even
less satisfactory. The anaemia of chronic
renal failure is variously referred to as
ACD although it has its own specic
features (see p. 96).
Incidence
Because its causes are common, ACD is
probably only second to iron deciency
as a cause of anaemia. It has been esti-
mated to account for approximately half
of all hospital cases of anaemia not
explained by blood loss.
Pathophysiology
The causation of the anaemia of chronic
disease has been extensively studied but
Table 18.1 Common causes of the anaemia
of chronic disease
Malignancy
Rheumatoid arthritis
Various connective tissue disorders
Chronic infection
Extensive trauma
Chronic renal failure
1
Chronic heart failure
1
See also page 96.
Fig 18.1 ACD in a
patient with chronic
infection. The rate of
development of anaemia
and its nal severity are
typical of ACD.
Months since onset of infection
Haemoglobin (g/L)
0
20
40
60
80
100
120
0 3 6 9 12
37 Anaemia of chronic disease
transferrin receptor concentration and the serum transferrin
receptor-ferritin index may be useful (Table 18.2). Measure-
ment of the percentage of hypochromic red cells or reticulo-
cyte haemoglobin content can be helpful in detecting
coexistent iron-restricted red cell production in a patient with
ACD. Reliable hepcidin assays are under development and are
likely to enter routine clinical practice. Bone marrow examina-
tion is not routinely required but where performed will show
normal or increased marrow iron stores with decreased
marrow sideroblasts (Fig 18.3).
It should be remembered that anaemia in a patient with a
chronic medical disorder may be of multifactorial origin. It is
important not to misdiagnose ACD as something else but
equally it cannot be assumed that every patient with long-
standing disease and a low haemoglobin has only ACD.
Management
As the anaemia is usually non-severe and not progressive, the
management is primarily that of the underlying disorder. The
rationale for treating the anaemia itself is to avoid immediate
deleterious effects (e.g. on the cardiovascular system), to
improve quality of life, and possibly to improve the prognosis
of the underlying condition.
Occasionally, patients cannot adequately compensate for
the anaemia and require blood transfusion. Recombinant
human erythropoietin and its derivatives can be effective in
relieving anaemia, particularly in rheumatoid arthritis and
malignancy. Their use is restricted by concerns of increased
risk of thromboembolic events and higher rates of tumour
recurrence; they should only be used selectively and in the
lowest effective dose. In the absence of coexistent iron de-
ciency, oral iron supplements are rarely helpful. Intravenous
iron may be benecial, especially if combined with erythro-
poietin, but there is limited experience outside the eld of
renal medicine. Further studies are needed to evaluate the
effect of amelioration of the anaemia on the course of the
underlying disease. Possible future therapies for ACD include
alternative stimulators of erythropoiesis, hepcidin antagonists
and novel anti-inammatory agents.
Fig 18.2 Overview of the aetiology of
ACD. Cytokines such as TNF, interleukin-1
and interleukin-6 and the peptide hepcidin
play key roles (see text).
ACD
Impaired red cell production
in marrow
Reduced red cell
survival
Inhibition of red cell
precursors
Blunted response to
erythropoietin
Impaired iron mobilisation
and utilisation
Fig 18.3 Bone marrow aspirate stained with Perls stain showing
increased reticuloendothelial iron stores in ACD.
Table 18.2 Comparison of clinical and laboratory ndings in ACD
and iron deciency anaemia
Characteristic ACD Iron deciency
Severity of anaemia Hb usually 90 g/L Very variable
Symptoms of anaemia Usually mild May be severe
Coexistent chronic disease Yes Variable
Red cell indices (MCV, MCH) Normochromic Hypochromic
Normocytic
1
Microcytic
Blood lm appearance Often normal or reactive
2
Hypochromia
Microcytosis
Poikilocytosis
Target cells
Serum iron Reduced Reduced
Transferrin concentration Reduced or normal Increased
Ferritin Normal or increased Reduced
3
Serum transferrin receptor Normal Increased
Serum transferrin
receptor-ferritin index
4
Low High
Marrow iron stores Normal or increased Reduced
1
May be slightly hypochromic microcytic.
2
Reactive changes in a blood lm may accompany the underlying disorder; possible abnormalities
include rouleaux formation, a neutrophil leucocytosis and thrombocytosis.
3
Unless there is a coexistent acute phase response when the ferritin level may be normal.
4
Transferrin receptor concentration divided by serum ferritin concentration (or log of plasma ferritin
concentration).
Anaemia of chronic disease
(ACD)
ACD is seen in a wide range of chronic malignant, inammatory
and infective disorders.
The pathogenesis of ACD is complex. There is a reduction in both
red cell production and survival. Hepcidin is likely to be a key
mediator.
The anaemia is usually of normochromic, normocytic type,
non-progressive and is rarely severe.
Treatment is primarily that of the underlying disorder. Blood
transfusion and erythropoietin may help in selected cases. Iron
supplementation has a limited role.
38 4 LEUKAEMIA
19 Introduction
incompletely understood, this protein causes deregulated
myeloid cell growth.
Chromosome deletions and additions
A chromosome may be completely or partly deleted, for
example monosomy 7 in acute myeloid leukaemia (AML).
Here a normal gene may be lost, allowing expression
of a recessive cancer gene. Conversely, an additional chromo-
some may be gained.
Submicroscopic mutations
A change in the base sequence of certain oncogenes may
predispose to leukaemia. The RAS oncogene which encodes
a protein vital in signal transduction is mutated in 50% of
cases of AML.
Epigenetic mechanisms
Epigenetic changes, where there is a change in gene function
(e.g. altered DNA methylation) but not structure, may play a
role in leukaemia.
The leukaemias are a heterogeneous group of malignant
blood disorders. In this introductory section, general charac-
teristics such as denitions, aetiology and classication are
discussed. Each of the more common types of leukaemia is
subsequently described in more detail.
Denition
Leukaemia is a type of cancer caused by the unregulated
proliferation of a clone of immature blood cells derived from
mutant haematopoietic stem cells. The disease is the result of
multiple acquired genetic and epigenetic events which can
vary widely between patients. Leukaemic transformation is
assumed to occur at or near the level of the leukaemic stem
cell prior to denite lineage commitment. The leukaemic cells
do not differentiate normally. They may avoid standard mech-
anisms of cell death (apoptosis) and they may also retain the
stem cell signature of self-renewal. This relentless proliferat-
ing clone of aberrant cells eventually squeezes out normal
cells from the bone marrow causing marrow failure and
death.
Incidence
Leukaemia is not a common disorder but it is a signicant
cause of death from cancer (Fig 19.1). There is a male prepon-
derance in most types of leukaemia. Geographic variations
exist; for instance, chronic lymphocytic leukaemia is the pre-
dominant form of leukaemia in the Western world but is
much less frequent in Japan, South America and Africa.
Aetiology
As for other malignancies, the evolution of leukaemia is likely
to be a multistep process. Thus, accumulated genetic muta-
tions corrupt normal cellular pathways controlling prolifera-
tion and differentiation and lead to the production of an
autonomous proliferating stem cell clone (clonal evolution).
It is easiest to think about the aetiology in terms of these
acquired genetic abnormalities and other more general pre-
disposing factors.
Genetic abnormalities
Cytogenetic analysis and particularly molecular genetic tech-
niques have revealed various acquired non-random chromo-
somal derangements which play a fundamental role in
leukaemogenesis (Fig 19.2). There are a number of different
types of possible chromosomal change.
Chromosomal translocations
One chromosome breaks and donates a fragment to another
chromosome which reciprocates by returning a fragment of
its own. Such translocations can result in the movement of
proto-oncogenes to new sites where they have the capacity to
cause leukaemic transformations. The classical example of a
balanced translocation is the Philadelphia chromosome,
found in 95% of cases of chronic myeloid leukaemia (CML),
where breakages in chromosomes 9 and 22 result in the crea-
tion of a new fusion gene (BCR-ABL) which encodes a novel
protein with intense tyrosine kinase activity. In a manner
Fig 19.1 Annual causes of death from malignancy in the year 2011
(estimated data from United States).
Lung
Colorectal
Breast
Pancreas
Non-Hodgkins
lymphoma
0 100000
Prostate
Leukaemia
157,000
49,000
40,000
37,000
34,000
22,000
19,000
Annual deaths
Fig 19.2 Fluorescence in situ hybridisation (FISH) study of a
complex karyotype (including t(8;16) ) in a patient with acute
myeloid leukaemia.
39 Introduction
Particular chromosome changes are
often associated with specic types of
leukaemia (e.g. the Philadelphia chro-
mosome in CML). However, few abnor-
malities are entirely specic the
Philadelphia chromosome can be found
in cases of acute leukaemia. It should
also be noted that not all cases of leu-
kaemia have a detectable cytogenetic
abnormality. The incidence of abnor-
mality is partly dependent on the labora-
tory expertise available.
Predisposing factors
In a small subpopulation of leukaemic
patients there is another obvious predis-
posing factor the more common of
these are listed in Table 19.1.
The incidence of acute leukaemia and
chronic myeloid leukaemia increases
with radiation dose exposure in all age
groups. Classic studies have included
people exposed to the atomic bombs in
Japan and patients receiving radiother-
apy for ankylosing spondylitis in the
middle years of the 20th century. Results
from studies of diagnostic radiation and
adult leukaemia are inconsistent and in
appropriate radiological procedures
the benet is likely to outweigh what
appears to be at most a very small risk.
Paternal preconception exposure to ion-
ising radiation has been associated with
an increased incidence of acute leukae-
mia in offspring.
Cytotoxic chemotherapy, particularly
with alkylating agents, leads to an
increased risk of leukaemia (Fig 19.3).
The risk appears to be greatest in older
patients also treated with radiotherapy.
The best established occupational leu-
kaemogenic exposure is undoubtedly to
benzene. A number of genetically deter-
mined diseases also predispose to leu-
kaemia. Here the liability to leukaemia
is probably caused by factors such as
increased chromosomal breakage (e.g.
Fanconis anaemia) and immunosup-
pression (e.g. ataxia telangiectasia).
Viruses are known to be the main
cause of leukaemia in many animals but
in humans the only well-proven associa-
tion is of the HTLV-1 virus with the rare
disorder T-cell leukaemia lymphoma
(Fig 19.4). Myelodysplastic syndromes
(pp. 5051) and myeloproliferative dis-
orders (pp. 6467) may transform to
acute myeloid leukaemia.
Classication
In such a potentially complex group of
disorders it is helpful to use a relatively
simple classication. The leukaemias
can most broadly be divided into acute
and chronic types depending on their
clinical course. The classication illus-
trated here (Table 19.2) further divides
leukaemias into their cell of origin (i.e.
myeloid or lymphoid) and refers to the
microscopic appearance (morphology)
of the leukaemic cells. The traditional
classication of the acute leukaemias is
that of the FAB group the abbreviation
being for the French, American and
British nationalities of the terminolo-
gists but this has been overtaken by
the World Health Organization (WHO)
system. Basic morphological techniques
(e.g. microscopic inspection of a blood
lm and bone marrow sample) remain
important in the initial diagnosis but
cytogenetic and molecular genetic tech-
niques are becoming increasingly
important in classication as acquired
genetic changes frequently have prog-
nostic signicance and can guide
treatment.
In the following pages are discussed
acute myeloid leukaemia, acute lym-
phoblastic leukaemia, chronic myeloid
leukaemia and chronic lymphocytic leu-
kaemia. Together these four diseases
constitute the overwhelming majority of
leukaemias in clinical practice. A few
rarer types of leukaemia are discussed
separately.
Fig 19.3 Peripheral blood lm in a young
woman with acute myeloid leukaemia.
She had received chemotherapy for
choriocarcinoma several years previously.
Fig 19.4 Bone marrow trephine appearance
in human T-cell leukaemia lymphoma. The
only human leukaemia with a known viral
causation.
Table 19.1 Factors predisposing
to leukaemia
Radiation exposure
Previous chemotherapy (particularly alkylating agents)
Occupational chemical exposure (e.g. benzene)
Some genetically determined disorders (e.g. Down
syndrome)
Viral infection (only HTLV-1 proven as a causative
factor)
Myelodysplastic and myeloproliferative disorders
Other possible (e.g. cigarette smoking)
Leukaemia: introduction
Leukaemia is a type of cancer caused by the unregulated
proliferation of a clone of immature blood cells.
Leukaemia is a heterogeneous group of clinical disorders classied
on the basis of their clinical course (acute or chronic) and their cell
of origin (myeloid or lymphoid).
The aetiology of leukaemia is likely to be multifactorial with known
predisposing factors such as radiation exposure present in only a
minority of cases. Acquired genetic and epigenetic abnormalities
play a fundamental role in leukaemogenesis with certain changes
associated with particular types of leukaemia.
Table 19.2 Classication of leukaemia
1
Acute leukaemia Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic leukaemia Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Other types Hairy cell leukaemia
Prolymphocytic leukaemia
T-cell leukaemia lymphoma
1
See specic disease sections for more detail.
40 4 LEUKAEMIA
20 Acute myeloid leukaemia

AML with t(15;17)(q22;q12) (M3,

M3V). More traditionally referred to
as acute promyelocytic leukaemia, this
disease is associated with a high
incidence of disseminated
intravascular coagulation (DIC) and a
high risk of spontaneous bleeding
into vital organs.
Tissue inltration is more common in
subtypes with monocytic morphology
and immunophenotypic features (i.e.
FAB M5) patients often present with
gum inltration (Fig 20.1), lymphaden-
opathy, skin deposits and hepatosplenom-
egaly. Central nervous system (CNS)
disease is rare in AML but most frequent
in monocytic/monoblastic leukaemia.
Diagnosis
Diagnosis depends on a logical sequence
of tests.
1. Blood count and lm. The white
cell count (WCC) is usually elevated
(up to 200 10
9
/L) but may be
normal or low. There is often
anaemia and thrombocytopenia.
Usually there are leukaemic blast
cells although occasionally these are
absent. There may be dysplastic
changes in other cells.
2. Bone marrow aspirate and
trephine. The bone marrow is
inltrated by leukaemic blast cells
(Fig 20.2). In more immature forms
of AML morphological
differentiation from acute
lymphoblastic leukaemia (ALL) can
be difcult.
3. Cytochemistry. Special stains are
used on bone marrow and blood
smears to help differentiate myeloid
and lymphoid blast cells. In AML
there is positivity with Sudan black
and myeloperoxidase these stains
are negative in ALL. AML with
Introduction
Acute myeloid leukaemia (AML) is a
malignant clonal disorder of haemat-
opoietic progenitor cells. Leukaemic
transformation usually occurs at a very
early stage of myeloid development,
probably at or near the haematopoietic
stem cell, but it may develop in a more
mature cell. The disease is heterogene-
ous. The malignant cells acquire genetic
alterations which upset their normal
mechanisms of self-renewal, prolifera-
tion and differentiation. Ultimately the
malignant clone causes marrow failure.
AML is rare in childhood and the inci-
dence increases with age; two-thirds of
cases occur in people aged over 60 years.
Classication
The WHO system has now largely
superseded the French-American-British
(FAB) classication. The newer classica-
tion reduces the bone marrow leukae-
mic blast cell percentage differentiating
AML from myelodysplastic syndrome
(see p. 50) from 30% to 20%. Other key
changes include the creation of specic
subtypes with non-random cytogenetic
or equivalent molecular abnormalities,
and the distinction of patients with mul-
tilineage dysplasia and also previous
chemotherapy. The major FAB subtypes
are included in the other category with
the exception of acute promyelocytic
leukaemia (previously FAB M3) which is
now in the recurrent translocations
group due to the inevitable presence of
t(15;17). It can be seen (Table 20.1) that
occasional cases of AML show meg-
akaryocytic or erythroid differentiation.
Gene mutations are likely to become
increasingly important in classication.
Clinical features
In practice there is little uniformity in
presentation. Some patients are remark-
ably asymptomatic while others are seri-
ously ill. Bone marrow inltration by
leukaemic blast cells usually leads to
anaemia, neutropenia and thrombocy-
topenia. Thus, patients often have
symptoms of anaemia, infection and
haemorrhage.
One subtype of AML deserves special
consideration as it must be treated as a
medical emergency:
Table 20.1 WHO classication of acute
myeloid leukaemia
AML with recurrent genetic abnormalities
1
AML with t(18;21)(q22;q22)
AML with inv (16)(p13;q22) or t(16;16) (p13.1;q22) (M4
Eo)
AML with t(15;17)(q22;q12) (M3:M3V)
AML with t(9;11) (p22;q23)
AML with t(6;9) (p23;q34)
AML with inv(3) (q21;q26.2) or t(3;3) (q21;q26.2)
AML (megakaryoblastic) with t(1;22) (p13;q13)
AML with myelodysplasia-related changes
Therapy related myeloid neoplasms
AML not otherwise specied
2
AML with minimal differentiation (M0)
AML without maturation (M1)
AML with maturation (M2)
Acute myelomonocytic leukaemia (M4)
Acute monoblastic/ monocytic leukaemia(M4/5)
Acute erythroid leukaemia (M6)
Acute megakaryoblastic leukaemia (M7)
Acute basophilic leukaemia
Acute panmyelosis with myelobrosis
Myeloid sarcoma
Myeloid proliferation related to Down syndrome
Blastic plasmacytoid dendritic cell neoplasm
1
See also Table 2 for genetic changes.
2
FAB equivalent is shown in parentheses.
Fig 20.1 Gum inltration in acute
monocytic (M5) leukaemia.
Fig 20.2 Bone marrow appearance in
different FAB subtypes of AML. (a) AML M2:
the leukaemic blast cells show some granulocytic
differentiation. (b) AML M3 (promyelocytic): the
leukaemic cells show marked cytoplasmic
granularity. (c) AML M4 (myelomonocytic): some
of the leukaemic cells have monocytic features.
(a)
(b)
(c)
41 Acute myeloid leukaemia
monocytic features will stain
positively with a non-specic
esterase stain.
4. Immunophenotyping. Both
surface and intracellular antigens
are analysed. Characteristic myeloid
antigens include CD13 and CD33
while CD34 positivity indicates a
particularly immature cell of origin.
Modern multicolour ow cytometry
techniques allow quantitation of
blast cells and correlate with both
morphology features and the
common balanced translocations.
5. Cytogenetics. A bone marrow
sample is sent for analysis.
Chromosome abnormalities are
associated with particular AML
subtypes and also give vital
prognostic information (see Tables
20.1 and 20.2).
6. Molecular biology. Molecular
techniques are increasingly
important in classication,
determining prognosis, and in
monitoring response of disease to
treatment (see p. 100). Sequential
RT-PCR monitoring (e.g. in patients
with the t(15;17) subtype in clinical
remission) can predict the
likelihood of relapse. Numerous
genetic abnormalities are being
identied mutation of the tyrosine
kinase receptor gene FLT3 is the
commonest nding in patients with
normal cytogenetics and carries a
poorer prognosis. Other genetic
mutations (e.g. nucleophosmin 1
(NPM1), two mutations of CEPPA
gene) can favourably inuence
prognosis.
Management
Supportive care
This includes red cell transfusion for
anaemia, platelet concentrates for
thrombocytopenia and broad-spectrum
intravenous antibiotics for infection.
An indwelling central venous catheter
facilitates support during and after
chemotherapy.
Chemotherapy and stem
cell transplantation
The rst objective of treatment with cyto-
toxic drugs is to achieve a complete
remission (CR) dened as less than 5%
blast cells in a normocellular bone
marrow. Initial cytotoxic drug treatment
is termed induction. A CR is followed
by a second sequence of drugs termed
consolidation. Induction and consolida-
tion take at least several months, but
longer-term maintenance treatment is
rarely given. The well tested combination
of an anthracycline (e.g. daunorubicin)
and cytosine arabinoside is standard
induction therapy. Higher doses of cyto-
sine are often used as consolidation
therapy. Acute promyelocytic leukaemia
(t(15;17)) is additionally treated with the
differentiating agent all-trans-retinoic
acid (ATRA), which reduces the risk of
early death from bleeding and improves
long-term survival compared with chem-
otherapy alone.
Autologous stem cell transplantation
(SCT) can be used to intensify chemo-
therapy but the benet has proved dif-
cult to quantify. Surprisingly, the
precise role of allogeneic SCT is also not
clear-cut most clinicians would con-
sider a transplant from an available
HLA-matched sibling in a younger
patient with high-risk (see below) or
relapsed disease. Novel molecular tar-
geted therapies under exploration
include anti-CD33 antibodies, FLT3
inhibitors and demethylating agents.
Prognosis
The major factors determining outcome
are age, initial response to treatment
and genetic abnormalities. Approxi-
mately 8090% of younger patients will
achieve a CR with conventional chemo-
therapy. Younger patients with standard
risk disease have 5-year survivals of
4045% with optimal therapy; this com-
pares with around 70% for good risk
and 20% for poor risk groups. Older
patients have a greater incidence of
adverse cytogenetics (Fig 20.3) and toler-
ate chemotherapy less well, and CR and
cure rates are much lower (see p. 93).
Indeed, it may be kinder not to use
chemotherapy in some elderly patients.
In children, intensive chemotherapy
gives 5-year survival rates of around
50%.
Fig 20.3 Relationship between age of presentation and characteristics of AML. Older patients
have a higher incidence of poor risk disease. (Reprinted with permission from Smith ML, Hills RK,
Grimwade D 2011 Independent prognostic variables in AML. Blood Reviews 25: 40.)
0-14 15-34 35-44 45-59 60+
100
90
80
70
60
50
40
30
20
10
0
Secondary
Favourable
Intermediate
Adverse
Acute myeloid leukaemia
AML arises out of the malignant transformation of a myeloid precursor cell.
The WHO classication emphasises the prognostic signicance of non-random
chromosome abnormalities.
Symptoms mainly result from anaemia, neutropenia and thrombocytopenia.
Prognosis largely depends on age, initial response to treatment, and genetic abnormalities.
Chemotherapy leads to CR rates of 8090% in younger patients but cure rates are lower,
around 45%. Allogeneic stem cell transplantation is considered in younger patients at high
risk of relapse.
Older patients tolerate chemotherapy less well and cure is rarely achievable.
Table 20.2 Common genetic abnormalities in AML
Abnormality Genes involved Associated subtype Prognosis
1
t(8;21) AML1-ETO (RUNX1
-RUNX1-T1)
M2 Good
t(15;17) PML-RAR M3 Good
inv 16 CBFB-MYH11 M4 Good
t(9;11) MLL M4/5 Poor
5 and 7 (various) Unknown Secondary AML
2
Poor
1
Compared with AML with no detectable genetic abnormality.
2
Antecedent events include chemotherapy, myelodysplastic syndrome and myeloproliferative disorders.
42 4 LEUKAEMIA
21 Acute lymphoblastic leukaemia
in ALL than in AML and patients can
present with symptoms of raised intrac-
ranial pressure (headache, vomiting) or
cranial nerve palsies (particularly VI and
VII). Examination ndings may include
pallor, haemorrhage into the skin and
mucosae, lymphadenopathy and mod-
erate hepatosplenomegaly. In males the
testes can be involved and should be
routinely examined.
Diagnosis
1. Blood count and lm
The white cell count may be raised,
normal or low. Only 20% have white cell
counts greater than 50 10
9
/L. Anaemia
and thrombocytopenia are common.
The proportion of blast cells in the
white cell count varies from 0% to 100%.
2. Bone marrow aspirate
and trephine
This is essential to conrm the diagnosis
and for classication.
3. Cytochemistry
Stains which classically show positivity
in AML Sudan black and myeloper-
oxidase are negative in ALL.
Cytochemistry is useful in distinguish-
ing precursor B and B-ALL from T-ALL.
Reactivity with the acid phosphatase
stain is seen in malignant T-lymphocytes
but not in B-cells which may show peri-
odic acid Schiff (PAS) block positivity.
4. Immunophenotyping
Useful reagents for establishing the
diagnosis and identifying the immuno-
logical subtype include antibodies to
CD19, CD79A and CD22 (found in most
B-lineage ALLs), CD10 (the common
ALL antigen), CD3 and CD7 (found in
T-lineage ALLs).
Acute lymphoblastic leukaemia (ALL) is a clonal malignancy
of lymphoid precursor cells. In over 80% of cases the malig-
nant cells are primitive precursors of B-lymphocytes and the
remainder are T-cell leukaemias. The abnormal cell may arise
at various stages of early lymphocyte differentiation (see p. 8).
ALL has a peak incidence in childhood with a gradual rise
in incidence in later years (Fig 21.1). The disease has distinct
characteristics in children and adults. Childhood ALL is often
curable by chemotherapy whereas cure is elusive in adult ALL.
Poorer outcome in adult ALL is due to a combination of a
greater frequency of high-risk leukaemia with more drug
resistance, and less effective treatment regimens.
Fig 21.1 Incidence of ALL at different ages.
10.0
8.0
6.0
4.0
2.0
0.0
80 70 60 50 40 30 20 10 0
Age (years)
Incidence rate
(per 100000 population)
Male
Female
Table 21.1 Classication of ALL
Morphological classication
1
L1 Small uniform blast cells with
scanty cytoplasm
L2 Large heterogeneous blast cells
with nucleoli and low
nuclearcytoplasmic ratio
L3 Basophilic vacuolated blast cells
Immunological classication
B-lineage ALL
Early pre-B
Pre-B ALL
B-cell
T-lineage ALL
Early
Cortical
Mature
1
See also Figure 21.2.
Fig 21.2 Morphology of ALL blast cells.
(a) L1 type; (b) L2 type; (c) L3 type. Note that
the L2 cells have more cytoplasm and more
prominent nucleoli than L1 cells. L3 type cells
have cytoplasmic vacuolation.
(a)
(b)
(c)
Classication
The French-American-British (FAB)
morphological classication is based on
characteristics of the blast cells, includ-
ing cell size, nuclearcytoplasmic ratio,
number and size of nucleoli and the
degree of cytoplasmic basophilia (Fig
21.2). Morphological classication is
now less important than that based on
immunophenotyping, cytogenetics and
molecular analysis (Table 21.1).
Denition of the immunological sub-
types of ALL depends on the presence
or absence of various cell surface and
cytoplasmic antigens. A commonly used
classication divides ALL into early
pre-B, pre-B, B-cell and T-cell subtypes.
Mature B-cell ALL typically has L3
morphology. The current WHO classi-
cation divides most ALL subtypes
into B- or T-lymphoblastic leukaemia/
lymphoma under the heading precur-
sor lymphoid neoplasms. Mature B-ALL
is included as Burkitt lymphoma.
In the selection of treatment it is
important to differentiate between three
broad groups; T-cell ALL, mature B-ALL
and all other types of B-lineage ALL.
Genetic abnormalities are becoming
increasingly important in classication
of ALL as they give vital prognostic
information (Table 21.2).
Clinical features
These can be very variable. Accumula-
tion of malignant lymphoblasts in the
marrow leads to a scarcity of normal
cells in the peripheral blood and symp-
toms may include those associated with
anaemia, infection and haemorrhage.
Other common complaints are anorexia
and back or joint pain. T-cell ALL is asso-
ciated with a large mediastinal nodal
mass and pleural effusions which result
in dyspnoea. Central nervous system
(CNS) involvement is more often seen
43 Acute lymphoblastic leukaemia
5. Cytogenetics
Cytogenetic analysis is doubly useful as
structural abnormalities correlate with
particular subtypes of ALL and both
structural and numerical abnormalities
give prognostic information (see Table
21.2). Varying patterns of cytogenetic
abnormality may partly explain the dif-
ferent prognosis in children and adults.
The Philadelphia chromosome, regarded
as a marker of incurability by chemo-
therapy, is found in 2030% of adult
cases but in only 2% of children.
6. Molecular techniques
Molecular analysis yields complemen-
tary and additional information to con-
ventional cytogenetics (see Table 21.2).
The cryptic t(12;21) creates a TEL-AML1
(ETV6-RUNX1) fusion gene this is
the commonest genetic rearrangement
in childhood ALL and it can only
be detected by molecular techniques.
Although not yet routinely available in
most laboratories, global gene expres-
sion proling reveals distinct patterns in
specic subtypes of ALL (see p. 100).
Management and
outcome
General principles
Patients with ALL require supportive
care. Chemotherapy is the mainstay of
treatment. Drug schedules vary but
remission induction classically relies on
three agents: vincristine, a glucocorticoid
(e.g. prednisolone) and asparaginase.
The anthracycline daunorubicin may be
included in the induction regimen and
other drugs, notably methotrexate, cyclo-
phosphamide and cytosine arabinoside,
then added in intensication (consoli-
dation) (see p. 54 for more detail of
individual drugs). The rationale for early
intensication of treatment is to reduce
the leukaemic cell population quickly
and reduce the likelihood of drug resist-
ance. Therapy is usually completed with
a period of maintenance using meth-
otrexate and mercaptopurine. The
greater chance of CNS disease in ALL
(than in AML) necessitates prophylactic
treatment to prevent CNS relapse. The
usual method is intrathecal and systemic
chemotherapy with the possible addi-
tion of cranial irradiation in those at
highest risk.
The ultimate choice of management
is inuenced by a number of prognostic
factors which have changed with
improving treatment (Table 21.3). Where
clinical and laboratory features predict a
poor response to chemotherapy alone,
more intensive treatments such as allo-
geneic stem cell transplantation (SCT)
are considered. Of all the prognostic
indices the most inuential is age.
ALL in children
The majority of children are curable
with current chemotherapy regimens.
The standard strategy is intensive induc-
tion therapy, CNS prophylaxis, and
maintenance treatment for 22.5 years.
In children receiving the most intensive
protocols, 5-year disease-free survivals of
nearly 90% are now achievable. Autolo-
gous and allogeneic SCT is best reserved
for relapse after chemotherapy or for
patients with poor prognostic features.
New methods for detecting minimal
residual disease during treatment (e.g.
after induction) allow early identica-
tion of patients at high risk of relapse.
Mature B-ALL is a special case best
treated with short-term fractionated
intensive chemotherapy. With improved
cure rates the long-term side-effects of
the drugs, including endocrine prob-
lems, secondary leukaemia and cardio-
toxicity, are becoming increasingly
relevant. Wherever feasible, the use of
agents with the safest proles is
desirable.
ALL in adults
The majority of adult patients enter
remission but are not curable with
chemotherapy alone and less than 40%
will become long-term survivors. Most
chemocurable patients are aged between
16 and 25 years with other good prog-
nostic features. This good risk sub-
group resembles childhood ALL and
chemotherapy alone is a reasonable
initial policy with cure rates of around
75%. For adults with higher-risk disease
the hope of cure is likely to depend on
even more intensive therapy with either
autologous or allogeneic SCT. Alloge-
neic SCT from an HLA-matched family
donor performed in rst remission gives
long-term survival of around 50%.
SCT using an unrelated HLA-matched
donor is more risky but can be success-
ful. In Philadelphia chromosome posi-
tive ALL the tyrosine kinase inhibitor
imatinib is useful adjunctive therapy
(see p. 45). Optimum management of
adult ALL has yet to be dened and
there is a need for careful consideration
of all the known prognostic factors in
each case. More elderly patients (over 60
years) tolerate chemotherapy less well
and cure rates are very low. In these
cases it is often kinder to concentrate on
palliation of symptoms and provision of
a short period of good quality life rather
than undertaking aggressive chemother-
apy with a negligible chance of success.
Table 21.2 Chromosomal abnormalities in ALL
Abnormality Prognostic signicance
Numerical change
High hyperdiploidy (over 50 chromosomes) Favourable
Hyperdiploidy (4750) Intermediate
Pseudodiploidy (46 with structural/numerical change) Intermediate
Hypodiploidy (less than 46) Poor
Structural abnormality Genes involved
Philadelphia chromosome, t(9;22)
1
BCR-ABL Poor
t(12;21)
2
TEL-AML1 (ETV6-RUNX1) Good
t(1;19) E
2
A-PBX1 Good
t(v;11q23) MLL-AF4, ENL-MLL Poor
t(8;14)
3
MYC Good
1
Must be distinguished from the lymphoid blast crisis of chronic myeloid leukaemia.
2
Occurs in 20% cases of childhood ALL. Not detectable by standard cytogenetics.
3
Seen in B-ALL with L3 morphology.
Table 21.3 Factors predicting poor
prognosis in ALL
Increasing age
1
High white cell count at presentation
Certain cytogenetic abnormalities (see Table 21.2)
Poor response to treatment
2
1
With the exception of children under 1 year who have a worse
prognosis than older children.
2
Assessed from the bone marrow appearance after 14 days of
chemotherapy.
Acute lymphoblastic leukaemia
ALL is a clonal malignancy of lymphoid precursor cells.
There is a peak incidence in childhood and a gradual rise in later years.
Accumulation of lymphoblasts in the bone marrow often leads to anaemia, infection and
haemorrhage. CNS involvement is more common than in acute myeloid leukaemia.
The majority of children are curable with standard chemotherapy regimens and CNS
prophylaxis.
In adults, cure by chemotherapy alone is much less frequent. Autologous or allogeneic
stem cell transplantation may be considered in high-risk cases.
tahir99-VRG & vip.persianss.ir
44 4 LEUKAEMIA
22 Chronic myeloid leukaemia
is usually associated with an insidious
deterioration in the patients health and
the need for more intense treatment to
control splenic size and white cell count.
Diagnosis and
monitoring
The major laboratory abnormality in
CP-CML is an elevated white cell count;
this often exceeds 100 10
9
/L. The blood
lm shows an increase in morphologi-
cally normal myeloid cells at all stages
of differentiation but with greatest
numbers of myelocytes and neutrophils
(Fig 22.3). There is usually an absolute
basophilia. Thrombocytosis and nucle-
ated red cells may be present.
The bone marrow appearance is less
informative than the blood lm; pro-
nounced hypercellularity and abnormal
myelopoiesis is characteristic but not
specic for CML. The key diagnostic
abnormality is the presence of the Ph
chromosome. Patients with apparent
CML with Ph chromosome negativity
need careful review as they may repre-
sent an atypical myeloproliferative or
myelodysplastic disorder.
The accelerated phase is characterised
by an increase in the number of imma-
ture cells in the peripheral blood and in
blast crisis the blood appearance is dom-
inated by the presence of myeloblasts
Chronic myeloid leukaemia (CML) is
a clonal myeloproliferative disorder
which results from an acquired genetic
change in a pluripotential stem cell. The
disease is characterised by a gross over-
production of neutrophils and their
precursors (Fig 22.1). It is unusual in
having three clinical phases: a relatively
benign chronic phase is followed by
an ominous accelerated phase and,
nally, an almost invariably fatal acute
leukaemic phase termed blast crisis.
The annual incidence of CML is
around one per 100 000 with presenta-
tion most common in the fth and sixth
decades of life. The diagnosis is increas-
ingly made in asymptomatic patients
having routine blood tests.
Pathogenesis
The hallmark of CML cells is the pres-
ence of a Philadelphia (Ph) chromosome
the t(9;22)(q34;q11) chromosomal
translocation. Over 95% of classical
CML cases are Ph positive. The Ph trans-
location causes the fusion of the ABL
proto-oncogene from chromosome 9 to
the interrupted end of the breakpoint
cluster region (BCR) of chromosome 22
(Fig 22.2). The chimeric BCR-ABL gene
created on the Ph chromosome (22q)
Fig 22.1 Blood sample (right) from a
patient with CML. Note the greatly increased
white cell component (buffy coat) compared
with the normal sample.
Fig 22.2 The Philadelphia chromosome. Chromosomal and molecular
abnormalities in chronic myeloid leukaemia. In a translocation between
chromosomes 9 and 22 (t(9;22) ) the oncogene ABL on chromosome 9 is
moved to the breakpoint cluster region (BCR) of chromosome 22. The
resulting BCR-ABL hybrid gene encodes a protein with high tyrosine kinase
activity.
Chimeric fusion
protein with tyrosine
kinase activity
BCR-ABL
chimeric RNA
? Mechanism
Proliferation
of myeloid cells
in bone marrow
Chromosome
9 9q+
ABL
SIS
3'BCR
22 22q-
SIS
ABL
5'BCR
5'
3'
BCR
BCR
22
ABL
9
5' 3' DNA
encodes a protein with considerably greater tyrosine kinase
activity than the normal counterpart. In chronic phase CML,
cells in the progenitor pool have increased proliferation due
to over-expression of BCR-ABL. The mechanism by which the
BCR-ABL oncogene affects stem cell kinetics is not well
understood. It presumably deregulates signalling pathways
involved in proliferation, apoptosis, cellular adhesion and
genomic stability. Progression to blast crisis with production
of leukaemic stem cells requires complex additional events
including increased proliferation and self-renewal capacity
avoidance of cell death, a block in differentiation and bypass-
ing of normal immune responses.
Clinical features
Patients usually present in chronic phase. Typical symptoms
are of anaemia, anorexia and weight loss. Splenomegaly is the
most common physical nding and is often marked, causing
pain, bloating and satiety. The occasional patient presents
with gout or hyperviscosity associated with a very high white
cell count. Neutropenia and thrombocytopenia are not nor-
mally features of chronic phase and infection and haemor-
rhage are rare.
After a period of stability in chronic phase, patients develop
blast crisis with symptoms typical of acute leukaemia. Between
chronic phase (CP) and blast crisis is an intervening period
of acceleration. The accelerated phase is poorly dened but
tahir99-VRG & vip.persianss.ir
45 Chronic myeloid leukaemia
(65% of cases) or lymphoblasts (35%).
The most widely used staging system,
devised by Sokal, is based on patient age,
spleen size, blood blast cell count
and platelet count. Monitoring of the
response to treatment is now central to
management. This involves examination
of the peripheral blood, bone marrow
metaphase cytogenetics and measure-
ment of BCR-ABL transcripts using real-
time quantitative polymerase chain
reaction (RQ-PCR). The results allow
the patients response to be dened at
key time points (see Table 22.1). Where
there is failure or a suboptimal response,
alternative therapy is considered.
Treatment
Recent advances have revolutionised the
management of chronic phase CML. It
has been transformed from a disease
with a very poor prognosis to a chronic
subclinical disorder controlled with oral
medication.
Chronic phase
Patients presenting with a very high
white cell count may have symptoms of
hyperviscosity and can benet from
leucapheresis.
Drug therapy. Hydroxycarbamide
can also be used to rapidly reduce an
initial high white cell count. Tyrosine
kinase inhibitors (TKIs) are the treat-
ment of choice. Imatinib at a dose of
400 mg daily orally is normally used
as rst-line. Patients achieving the
milestones shown in Table 22.1 have an
excellent prognosis, with long-term sur-
vival rates exceeding 90% and a very low
risk of transformation to accelerated
phase or blast crisis. For patients who
are unable to tolerate imatinib or who
become resistant, so-called second gen-
eration TKIs such as dasatinib and nilo-
tinib can be effective. Both these drugs
are more potent than imatinib and are
likely to be increasingly used as initial
treatment. Third generation agents (e.g.
bosutinib) are under investigation.
Stem cell transplantation (SCT).
Allogeneic SCT is at present the only
proven curative treatment for CML.
Patients have survived for more than 10
years after SCT with no detectable BCR-
ABL transcripts in blood or bone
marrow. The 5-year leukaemia-free sur-
vival after HLA- identical sibling SCT is
around 60%. Results have been best
when SCT has been performed in
chronic phase within 1 year of diagno-
sis. The use of low intensity condition-
ing prior to allogeneic transplantation
(see p. 57) potentially allows the proce-
dure in older patients. In younger
patients the use of an unrelated HLA-
matched donor is possible but results
are poorer than for sibling donor SCT.
Autologous stem cell transplantation
can induce Ph-negative haematopoiesis
but the therapeutic value is unproven.
Choice of treatment in chronic
phase. The number of allogeneic SCTs
performed for CP-CML has fallen
sharply in the imatinib era. TKI therapy
is now unquestionably the treatment of
choice in the vast majority of patients.
Allogeneic SCT still has a role in patients
who fail TKI therapy although it is not
currently clear how this failure should
be dened. Patients who do not respond
to two TKIs should probably receive
allogeneic SCT if feasible.
Advanced disease
In the accelerated phase and blast crisis,
options remain limited. Patients may be
helped by allogeneic SCT but results are
much inferior to those achieved in CP.
Blast crisis can be treated with the com-
bination chemotherapy regimens used
in acute leukaemia, and some patients
(particularly those with lymphoblastic
transformation) will initially respond
and return to chronic phase. Unfortu-
nately, such remissions are usually
short-lived. Imatinib can also give good
responses but these are rarely
sustained.
Fig 22.3 Blood lm in CML showing
myeloid cells of varying maturity.
Table 22.1 Evaluation of response to imatinib in chronic phase CML
Time after start of
treatment
Response
Optimal Suboptimal Failure
3 months CHR and at least minor CyR No CyR No CHR
6 months At least partial CyR Less than partial CyR No CyR
12 months CCyR Partial CyR Less than partial CyR
18 months MMR Less than MMR Less than CCyR
Any time Stable or improving MMR Loss of MMR. Presence of
BCR-ABL mutations
Loss of CHR. Loss of CCyR.
Clonal evolution
1
CHR: complete haematological remission; CyR: cytogenetic response; CCyR: complete cytogenetic response; MMR: major molecular response.
1
Additional chromosome abnormalities in Ph
+
cells.
Chronic myeloid leukaemia
CML is a clonal myeloproliferative disorder arising from an acquired genetic change in a
pluripotential stem cell.
The hallmark of CML cells is the Philadelphia chromosome (t(9;22) ) and the resultant
chimeric BCR-ABL gene.
There is gross overproduction of neutrophils and their precursors.
CML has an indolent chronic phase followed by a period of acceleration and a nal,
generally fatal, acute leukaemic phase.
Tyrosine kinase inhibitors (e.g. imatinib) have much improved the prognosis of CP-CML.
Allogeneic stem cell transplantation is the only well proven curative treatment but is
associated with signicant mortality.
tahir99-VRG & vip.persianss.ir
46 4 LEUKAEMIA
23 Chronic lymphocytic leukaemia
cells (Fig 23.2). Unexplained persisting
lymphocytosis in an elderly person
should always suggest CLL. The diagno-
sis is made by proving that the lym-
phocytosis is a proliferation of clonal
B-cells; this is most simply demon-
strated by using in situ or ow cytom-
etry techniques (see p. 21) to show that
the cells have characteristic B-lymphocyte
antigens and that a single immunoglob-
ulin light chain (kappa or lambda) exists
on the cell surface (i.e. it is a monoclonal
population). The bone marrow aspirate
shows increased numbers of small lym-
phocytes and a trephine biopsy is worth-
while as the pattern of lymphocyte
inltration gives prognostic informa-
tion. The blood lm appearance may
suggest autoimmune haemolysis or
autoimmune thrombocytopenia, both
of which can complicate CLL.
The term monoclonal B-cell lymphocy-
tosis is used where there are fewer than
5 10
9
/L monoclonal B-lymphocytes in
the blood in the absence of other disease
features such as lymphadenopathy.
In the majority of cases the
immunophenotye is identical to CLL
and some of these patients will progress
to CLL over time.
Staging
Staging is important in CLL as it helps
in making a rational decision as to
whether to commence treatment, and it
also gives useful prognostic informa-
tion. The easiest method is the Binet
adaptation of the previous Rai system
(Table 23.1); this is simple to apply and
correlates closely with survival.
Other variables are increasingly
important in predicting prognosis. As
gene sequencing is expensive and time-
consuming, expression of the signalling
molecule ZAP-70 can be used as a sur-
rogate marker for unmutated IgV
H

genes and a poor prognosis (Table 23.2).
Management
When to start treatment
There has to be a reason to start treat-
ment in CLL many patients with early
Chronic lymphocytic leukaemia (CLL)
is a disease characterised by a clonal pro-
liferation of antigen-stimulated mature
B-lymphocytes. It is the most frequent
form of leukaemia in the Western world
and is a disease of the elderly; almost all
patients are over 50 years old at diagno-
sis. Recent research has highlighted the
biological diversity of CLL. The disease
can be most broadly divided into two
types dependent on whether the leukae-
mic cells have a mutation of the immu-
noglobulin heavy chain variable region
(IgV
H
) gene. Patients with cells lacking
this mutation tend to have more aggres-
sive disease with shortened survival.
Clinical features
Many patients survive long periods with
minimal symptoms, while others have a
rapid demise with bone marrow failure,
bulky lymphadenopathy and hepat-
osplenomegaly. Fortunately, the former
group is in the majority. Indeed, the
diagnosis is increasingly made by chance
on a routine blood count. Elderly
patients with early CLL are very likely
to die from other causes.
Where problems do arise, patients
commonly complain of symptoms of
anaemia, lymphadenopathy, unusually
persistent or severe infections and
weight loss. The most frequent ndings
on examination are lymphadenopathy
and splenomegaly. In more advanced
cases other tissues such as skin, the gas-
trointestinal tract, the central nervous
system, lungs, kidneys and bone may be
inltrated by leukaemic cells. Occasion-
ally there is transformation into a poorly
differentiated large cell lymphoma
which carries a poor prognosis (Richter
syndrome). The immunodeciency in
CLL is caused mainly by hypogamma-
globulinaemia, which predisposes to
infections (Fig 23.1) and also accounts
for an increased incidence of other
malignancies.
Diagnosis
The diagnosis is suggested by a high
lymphocyte count conrmed by the
blood lm appearance. Lymphocyte
counts in CLL exceed 5 10
9
/L and may
reach levels of 500 10
9
/L or more. The
cells resemble normal mature lym-
phocytes but are often slightly larger
with a tendency to burst during prepara-
tion of blood lms, resulting in smear
Fig 23.1 CLL is a cause of acquired
immunosuppression. (a) Oral candidiasis;
(b) severe chickenpox.
(a)
(b)
Fig 23.2 Blood lm in CLL. The malignant
cells resemble mature lymphocytes but are prone
to burst during lm preparation leading to the
formation of smear cells.
Table 23.1 Binet staging system for CLL
Stage A No anaemia or thrombocytopenia
Fewer than three lymphoid areas
1
enlarged
Stage B No anaemia or thrombocytopenia
Three or more lymphoid areas enlarged
Stage C Anaemia (Hb less than 100 g/L) and/or
platelets less than 100 10
9
/L
1
Lymphoid areas are cervical, axillary and inguinal
lymphadenopathy (uni- or bilateral), spleen and liver.
tahir99-VRG & vip.persianss.ir
47 Chronic lymphocytic leukaemia
stage disease are completely well and
need reassurance as to its relatively
benign nature. Early treatment may
slow progress but does not improve sur-
vival and can lead to signicant side-
effects including other neoplasms, and
the emergence of resistant disease.
Choice of treatment
Treatment should be commenced when
the patient develops signicant symp-
toms, when the disease is progressing
rapidly or when it is already at an
advanced clinical stage. For many years,
oral chlorambucil (usually given inter-
mittently) has been the traditional rst-
line agent for treatment. Chlorambucil
is still useful in older patients and where
there is signicant comorbidity but it has
now been mostly replaced in rst-line
treatment by the more effective purine
analogue udarabine. The combination
of udarabine with other agents has
brought benets with higher levels of
complete remission (Fig 23.3) translat-
ing into a survival advantage; the current
favoured regimen is a combination of
udarabine, cyclophosphamide and the
monoclonal antibody rituximab (anti-
CD20). The alkylating agent bendamus-
tine is a promising new approach to
rst-line treatment. Steroids (e.g. pred-
nisolone) are best reserved for patients
with pancytopenia or autoimmune com-
plications such as haemolysis or immune
thrombocytopenia. Treatment decisions
are increasingly inuenced by risk
factors (see Table 23.2) in addition to
stage for instance, patients with 17p
deletions are known to respond poorly
to udarabine and may be considered
for more novel therapies such as alem-
tuzumab (anti-CD52) and ibrutinib.
Radiotherapy can be used as pallia-
tion, particularly where enlarged
lymph nodes or spleen cause compres-
sive problems. Splenectomy can be ben-
ecial for painful splenomegaly or
autoimmune cytopenia. In hypogamma-
globulinaemia and recurrent infection,
regular intravenous immunoglobulin
has been shown to be well tolerated and
quality of life is often improved.
None of the above drug regimens or
other treatment modalities will cure
CLL; the emphasis is on control of
symptoms and prolongation of life. In
the rare younger patient with CLL a
more aggressive approach to treatment
may be justied to try and eradicate
disease. Allogeneic stem cell transplan-
tation should be considered in younger
t patients with refractory CLL or with
very poor prognostic features (e.g. 17p
deletion).
Fig 23.3 Efcacy of udarabine in CLL. Fludarabine, usually in combination with other agents, is
now the favoured rst-line treatment. Its general superiority over chlorambucil is demonstrated in this
patient the chest infection is a reminder that udarabine is, however, more immunosuppressive than
chlorambucil.
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
10
50
Chlorambucil
(longstanding)
Treatment
Cervical
lymph nodes
Spleen
Lymphocyte
count
(x10
9
/L)
Fludarabine
(6 courses)
Months
Chest
infection
Fig 23.4 The
combination of
different agents as
rst-line treatment for
CLL leads to improved
response rates.
(Reproduced from Hallek
M 2009 State-of-the-art
treatment of chronic
lymphocytic leukaemia.
American Society of
Haematology Educational
Book). CR, complete
remission; OR, overall
response; Chl,
chlorambucil; F,
udarabine; C,
cyclophosphamide; R,
rituximab.
Chl F FC FCR
100
90
80
70
60
50
40
30
20
10
0
CR%
OR%
Table 23.2 Other prognostic factors in CLL
1
Factor Prognosis
Good Poor
Age Younger Older
Response to therapy (e.g. CR
2
) Yes No
Lymphocyte morphology Typical Atypical
Histopathology of marrow trephine Non-diffuse inltration Diffuse inltration
No. of lymphocytes in blood Low (e.g. <50 10
9
/L) High (e.g. >50 10
9
/L)
Lymphocyte doubling time Long (e.g. >12 months) Short (e.g. <12 months)
Immunophenotype FMC7 CD38 FMC7+ CD38+

2
-microglobulin Low High
Cytogenetics del 13q14 del 11q22, trisomy 12, del 17p13
3
Mutation IgV
H
genes Yes No
ZAP-70 expression No Yes
1
Factors not included in Binet staging system.
2
Complete remission.
3
p53 mutation/deletion.
Chronic lymphocytic leukaemia
CLL is the commonest form of leukaemia in the Western world. It is a disease of the elderly.
There is a clonal proliferation of B-lymphocytes.
Symptoms/signs include anaemia, recurrent infections, weight loss, lymphadenopathy and
hepatosplenomegaly.
The clinical course is often indolent but it can be more aggressive in advanced stages.
Chemotherapy is often not immediately needed in early CLL.
The combination of udarabine, cyclophosphamide and rituximab (FCR) is the initial
treatment of choice in most cases.
tahir99-VRG & vip.persianss.ir
48 4 LEUKAEMIA
24 Other leukaemias
of lymphoid cells with blood-lled
spaces lined by hairy cells (the pathog-
nomonic pseudosinuses of HCL).
There is no specic karyotypic
abnormality.
Management
A minority of patients (perhaps 10%)
are asymptomatic and in the rst
instance may require no intervention.
Treatment options are as follows.
Nucleoside analogues
Purine analogues are highly effective
treatment, producing a more complete
and durable response than other thera-
pies (Fig 24.3). Both cladribine and
pentostatin give excellent long-term sur-
vivals (9095% at 10 years) and death
from HCL is rare.
Interferon alfa
Although less effective than nucleosides,
interferon alfa may still be used in
patients with severe cytopenia or where
the myelosuppressive effects of nucleo-
sides are unacceptable. In the latter
patients, G-CSF may also be helpful.
Major side-effects of interferon alfa
include systemic symptoms such as
pyrexia, lethargy and depression. Fol-
lowing cessation, the disease normally
slowly relapses but it will often respond
to reintroduction of the drug.
Splenectomy
This produces improvement in symp-
toms and cytopenia but responses are
not particularly durable and it is now
less used than previously.
Prolymphocytic
leukaemia
Prolymphocytic leukaemia (PLL) may
be connected with chronic lymphocytic
leukaemia (p. 46), but it more often
presents de novo and is best regarded as
a distinct disease. The malignant cell is
usually of B-lineage and is more mature
than the B-CLL cell. Thus, in addition to
characteristic B-cell antigens, the cells
show a high density of surface immu-
noglobulin and clonal rearrangements
of both heavy and light chain immu-
noglobulin genes. TP53 mutations are
commonly found. Approximately 20%
of cases are of T-cell lineage.
Clinical features and diagnosis
PLL is very much a disease of the elderly
with a maximum incidence in the eighth
decade of life. The most common clini-
cal presentation of B-PLL is massive
splenomegaly. Lymphadenopathy is
usually not conspicuous. In T-PLL,
involvement of lymph nodes and other
tissues including liver and skin is more
common. The characteristic PLL blood
abnormality is a marked lymphocytosis
(normally greater than 100 10
9
/L).
Anaemia is normal but platelet numbers
are often well preserved. Prolym-
phocytes are large cells recognised by
their condensed nucleus with a single
prominent nucleolus surrounded by
abundant cytoplasm. B- and T-cell types
are not distinguishable by routine
microscopy.
Management
PLL has a poorer prognosis than chronic
lymphocytic leukaemia. The disease is
usually aggressive and the median sur-
vival is 3 years with an even bleaker
outlook in the T-cell variant. Most
patients are elderly and the disease is
frequently refractory to conventional
chemotherapy. Palliative options include
splenic irradiation, splenectomy and
leucapheresis to control the high white
cell count. Survival in B-PLL may be
improved by use of udarabine and
rituximab while alemtuzumab (anti-
CD52 monoclonal antibody) is emerg-
ing as rst-line treatment for T-PLL.
T-cell large granular
lymphocyte leukaemia
T-cell large granular lymphocyte leukae-
mia (T-LGL) is a clonal disorder
Hairy cell leukaemia
Hairy cell leukaemia (HCL) is a rare
chronic B-cell leukaemia characterised
by distinctive biological features and
unusual sensitivity to treatment. The
name of the disease is a reference to the
distinctive appearance of the malignant
cell (Figs 24.1 and 24.2).
Clinical features
Patients often have non-specic symp-
toms including fatigue and weight loss.
Infection, the main cause of morbidity
and mortality, and bleeding are other
possible presentations. The spleen is the
probable site of origin of the malignant
clone and splenomegaly is found in over
80% of cases. This may be massive and
is usually not accompanied by lymphad-
enopathy. The liver is enlarged in 50% of
patients.
Diagnosis
Most cases of HCL have a pancytopenia
and there may be circulating hairy cells
in the blood lm. Neutropenia and
monocytopenia are often particularly
marked, accounting for the frequency of
infection. Hairy cells strongly express
the markers of mature activated B-cells:
CD19, CD11c, CD20, CD22 and CD25
and CD103. The bone marrow is nor-
mally difcult to aspirate because of
increased brosis; the trephine will
show a variable number of inltrating
hairy cells. Where splenectomy is per-
formed, the sinuses and cords are seen
to be inltrated by a uniform population
Fig 24.1 Normal lymphocyte and hairy cell.
Fig 24.2 Hairy cells seen with electron
microscopy.
tahir99-VRG & vip.persianss.ir
49 Other leukaemias
of cytotoxic T-lymphocytes. It is often
associated with autoimmune disorders
such as rheumatoid arthritis. The most
common blood manifestation is severe
chronic neutropenia although anaemia
and thrombocytopenia may also occur.
Patients can suffer from recurrent infec-
tions, B symptoms such as fever and
weight loss, and hepatosplenomegaly.
Although the disorder is unequivocally
a leukaemia rather than a reactive
process, it is generally indolent with
responses to immunosuppressive
treatment.
Adult T-cell
leukaemia lymphoma
Adult T-cell leukaemia lymphoma
(ATLL) is a malignant disorder of rela-
tively mature T-lymphocytes. It is rare
but of great interest as it is conclusively
caused by a virus. The majority of
patients with ATLL have antibodies to
HTLV-1 and denitive evidence for the
aetiological role of this retrovirus has
come from studies showing monoclonal
integration of proviral DNA in the leu-
kaemic cells.
The disease is mostly seen in areas
endemic for HTLV-1, notably in parts of
Japan and in the islands of the Carib-
bean. There is a long latent period from
infection to overt disease and less than
5% of infected people actually develop
ATLL. Patients most commonly present
in the fth decade and, as its name sug-
gests, ATLL may behave as a leukaemia
or a lymphoma. In the most acute form
presentation is with a frank leukaemia.
The malignant cells in the blood are
pleomorphic but often have very irregu-
lar polylobulated nuclei. Even within the
leukaemic group there is great heteroge-
neity with chronic and smouldering
forms. In 25% of cases the disease is
better described as a lymphoma as there
is no demonstrable blood involvement.
Despite the variability of the pathology
there are well-dened clinical and labo-
ratory features which should prompt
consideration of the diagnosis, particu-
larly in a person from an HTLV-1
endemic area (Table 24.1). In practice,
lymphoma-type ATLL may be confused
with other forms of T-non-Hodgkins
lymphoma. Leukaemic ATLL must be
distinguished from Sezary syndrome,
a lymphoproliferative disorder with
circulating T-cells and skin changes
including erythroderma and exfoliative
dermatitis.
Diagnosis
This requires morphological examina-
tion and immunophenotyping of blood
lymphocytes or a lymph node biopsy.
HTLV-1 positivity is established by sero-
logical testing and by DNA analysis of
affected tissue where available. Chromo-
some abnormalities are found in up to
90% of cases but are not specic for
ATLL.
Management
Therapy is offered to patients with
acute, lymphomatous or unfavourable
prognosis chronic type ATLL while
patients with typical chronic or smoul-
dering disease are normally rst
observed. Treatment is unsatisfactory
and the median survival in aggressive
disease is less than 1 year. The lym-
phoma type of ATLL has a slightly better
outlook than the leukaemia type. Acute
forms are frequently resistant to conven-
tional lymphoma chemotherapy proto-
cols (e.g. CHOP) and more intensive
regimens with central nervous system
prophylaxis are generally recom-
mended. The combination of interferon
alfa and the antiviral agent zidovudine
may give responses where chemother-
apy has failed. Allogeneic stem cell
transplantation can be considered in
younger patients with a suitable donor.
The chronic and smouldering leukae-
mia forms can run a protracted course
but eventually transform to an acute
phase. Skin lesions may be helped by
extracorporeal photochemotherapy.
Fig 24.3 Response of hairy cell leukaemia to treatment with cladribine (2-CDA). Bone marrow
examinations 1 and 2 showed numerous hairy cells, and bone marrow 3 a remission.
0
White cells
(X 10
9
/L)
Total count
Hairy cells
10 9 8 7 6 5 4 3 2 1 0
Platelets
(x 10
9
/L)
Haemoglobin
(g/L)
1
2
4
5
6
10
50
100
140
70
80
90
100
110
130
140
150
120
3
Bone marrow
Months from diagnosis
Interferon 2-CDA
1 2 3
Table 24.1 Common clinical and
laboratory features in ATLL
Clinical
Lymphadenopathy
Skin lesions
Splenomegaly
Hepatomegaly
Pulmonary lesions
Laboratory
High white cell count
Anaemia
Thrombocytopenia
Hypercalcaemia
Other leukaemias
Hairy cell leukaemia (HCL) is a malignant proliferation of B-cells with a characteristic hairy
appearance. Pancytopenia and splenomegaly are common. Nucleoside analogue drugs are
usual rst-line treatment and the prognosis is good.
Prolymphocytic leukaemia is a B-cell (or less often a T-cell) malignancy typied by
presentation in the elderly, a high white cell count, splenomegaly and a poor prognosis.
T-cell LGL leukaemia most commonly manifests as chronic severe neutropenia.
Adult T-cell leukaemia lymphoma is a malignant disorder of T-lymphocytes associated with
infection by the HTLV-1 virus. It may present as leukaemia or lymphoma.
tahir99-VRG & vip.persianss.ir
50 4 LEUKAEMIA
25 The myelodysplastic syndromes
common in the subtypes with increased blast cells. CMML,
like the acute monocytic leukaemias, has specic features
including splenomegaly (rare in other forms of MDS), skin
inltration and serous effusions.
Diagnosis
Morphology
The diagnosis of MDS depends on careful morphological
examination of the blood lm and bone marrow aspirate and
trephine specimens (Fig 25.2). Common abnormalities
include:

Peripheral blood. Red cells anisopoikilocytosis,

macrocytosis. Neutrophils hypogranulation, pseudo-
Pelger forms. Platelets giant forms.

Bone marrow. Erythroid cells multinuclearity, nuclear

budding, ring sideroblasts. Myeloid cells hypogranularity,
increased blast cells. Megakaryocytes giant forms or
micromegakaryocytes.
Where there are changes in all three lines the term triline-
age dysplasia is used. The bone marrow trephine biopsy
usually conrms marrow hypercellularity, although brosis
and even hypocellularity may occur.
Genetics
Around 50% of cases of MDS show cytogenetic abnormali-
ties. Common changes include monosomy 7 or 7q, trisomy
8, monosomy 5 or 5q, and loss of the Y chromosome. The
incidence of chromosome abnormalities increases with the
severity of the disease and risk of leukaemic transformation.
Work is ongoing to better characterise the complex molecu-
lar basis of MDS. Mutations of genes encoding cell surface
receptors (e.g. KIT), signal transduction proteins (e.g. RAS),
transcription factors (e.g. AML1), epigenetic modiers (e.g.
MLL) and protein degradation pathways (e.g. CBL) have been
identied.
Prognostic factors
The outcome is closely linked to the classication and the risk
of transformation to leukaemia. The International Prognostic
Scoring System (IPSS) based on the number of blood cyto-
penias, percentage of bone marrow blasts and karyotype is
a simple prognostic tool which can be used to direct
The myelodysplastic syndromes (MDS) are a group of clonal
disorders of the bone marrow. Their common feature is bone
marrow failure as a result of ineffective haematopoiesis rather
than reduced haematopoietic activity. A hypercellular marrow
and peripheral blood cytopenia with characteristic dysplastic
morphological abnormalities form the basis for diagnosis. In
early disease there is increased apoptosis of marrow progeni-
tors causing peripheral blood cytopenia but in later MDS
there is actually decreased apoptosis with characteristic gene
mutations, enhanced survival of myeloblasts and potential
expansion of a leukaemic clone. Patients may develop frank
acute myeloid leukaemia (AML; see p. 40). Increased marrow
angiogenesis and autoimmunity also occur.
MDS is predominantly a disease of the elderly, although it
may affect all ages. It can arise de novo or follow previous
chemotherapy or radiotherapy for another malignancy. It
seems to be increasing in incidence.
Classication
This is not straightforward. The French-American-British
(FAB) classication divides MDS into ve subtypes depending
on morphological features and particularly the number of
blood and marrow leukaemic blast cells. The more recent
WHO system (Table 25.1) divides MDS into unilineage or
multilineage dysplasia, refractory anaemia with ring siderob-
lasts and dysplasia with excess blasts. The FAB entity chronic
myelomonocytic leukaemia (CMML) is now included in the
overlap MDS with myeloproliferative disorder category. It is
likely that cytogenetic and molecular abnormalities will be
increasingly incorporated into the classication; a current
example is 5q syndrome, a distinct subtype of MDS associ-
ated with a response to novel therapy and a good
prognosis.
Clinical features
The diagnosis may follow a routine blood count in an asymp-
tomatic patient. Where symptoms do occur they range from
a mild anaemia to the consequences of severe marrow failure
with profound anaemia, leucopenia and thrombocytopenia
(Fig 25.1). Abnormal haematopoiesis can cause functional
abnormalities of cells, and infection and haemorrhage may be
more severe than would be predicted from the degree of
cytopenia. Pronounced symptoms are predictably more
Fig 25.1 Purpuric rash in myelodysplastic syndrome. The patient was
thrombocytopenic.
Table 25.1 WHO classication of myelodysplastic syndrome
Refractory anaemia with unilineage dysplasia
Refractory anaemia (RA)
Refractory neutropenia (RN)
Refractory thrombocytopenia (RT)
Refractory anaemia with ring sideroblasts (RARS)
Refractory cytopenia with multilineage dysplasia (RCMD)
Refractory anaemia with excess blasts (RAEB)
1
MDS with isolated del (5q)
MDS, unclassiable
Myelodysplastic/myeloproliferative neoplasms (MDS/MPN)
Chronic myelomonocytic leukaemia (CMML)
Atypical chronic myeloid leukaemia
Refractory anaemia with ring sideroblasts and thrombocytosis (RARST)
1
Dened as 510% blasts in bone marrow.
tahir99-VRG & vip.persianss.ir
51 The myelodysplastic syndromes
treatment (Table 25.2). Median survivals
vary from 6 years in the low risk group
to less than a year in patients at higher
risk. Patients with low risk disease have
an average period of 10 years before the
onset of AML whereas for high risk
patients this is only a few months.
Treatment
Supportive care
In patients with signicant marrow
failure, supportive care is crucial to
ameliorate symptoms and prolong life.
Regular blood transfusion is often nec-
essary to control symptoms of anaemia,
and haemorrhage is managed with
platelet transfusions. Patients receiving
multiple blood transfusions can benet
from iron chelation therapy. This may
reduce not just iron overload but also
transfusion dependency. Infections
require swift intervention with broad-
spectrum antibiotics.
Specic treatments
Treatment needs to be individualised
according to the type of disease and age
of the patient.
Low-risk MDS
In patients with low-risk MDS, the
main goal of treatment is to improve
cytopenias. Anaemia may respond to
erythropoietin alone or combined with
G-CSF. Immunosuppression with anti-
thymocyte globulin (ALG) can give
good results in younger patients with
marrow hypocellularity. The immu-
nomodulatory agent lenalidomide is
particularly effective in patients with del
(5q), often leading to resolution of
anaemia and transfusion independence.
After a long period when low-risk MDS
patients received only supportive care, it
is likely that many will now receive at
least a trial of growth factors or a novel
agent.
High-risk MDS
In high-risk MDS (e.g. RAEB; see
Table 25.1), the primary aim is to
prolong survival and delay transforma-
tion to AML. In younger patients,
AML-type chemotherapy and allogeneic
stem cell transplantation, the only
potentially curative treatment, are pos-
sible options. The hypomethylating
agent azacitidine has shown efcacy
in higher risk subgroups with signi-
cantly prolonged survivals and delay of
onset of AML. It is given subcutaneously
as outpatient therapy and is generally
well tolerated.
Fig 25.2 Myelodysplastic syndromes. Morphological changes in the blood lm and bone marrow aspirate. (a) Pseudo-Pelger neutrophil with bilobed
nucleus. (b) Dysplastic megakaryocyte in the bone marrow. (c) Iron stain of the bone marrow showing ring sideroblasts.
(a) (b) (c)
Table 25.2 The International Prognostic Scoring System for Primary MDS
Score Value
Prognostic variable 0 0.5 1 1.5 2 Risk group Score
Bone marrow blasts (%) <5 510 1120 2130 Low 0
Int-1 0.51
Karyotype Good
1
Intermediate Poor
2
Int-2 1.52
Cytopenias 0/1 2/3 High 2
Int: Intermediate
1
E.g. normal, del (5q).
2
E.g. complex or chromosome 7 abnormalities.
The myelodysplastic syndromes
MDS is a heterogeneous group of clonal disorders of the bone marrow; the abnormal clone
differentiates ineffectively, leading to a hypercellular marrow and blood cytopenia.
MDS may affect all ages but is predominantly a disease of the elderly.
Diagnosis depends on the presence of characteristic morphological changes in the blood
and marrow.
Classication into subtypes relies on bone marrow morphology and cytogenetics.
Prognosis is highly variable.
Supportive care remains crucial but growth factors and other specic therapeutic agents
(e.g. lenalidomide, azacitidine) are increasingly used. Chemotherapy and stem cell
transplantation may be considered in younger patients with high-risk disease
tahir99-VRG & vip.persianss.ir
52 4 LEUKAEMIA
26 Aplastic anaemia
very short telomeres. This is also
observed in 1015% of patients with
acquired AA.
Infections known to predispose to AA
include viral hepatitis and parvovirus
infection. Exposure to chemicals, drugs
and radiation can damage stem cells.
Drugs may depress haematopoiesis idi-
osyncratically or predictably (Table
26.2). In roughly two-thirds of patients,
no cause is apparent and AA is termed
idiopathic. Improved haematopoiesis
following immunosuppression (see
below) suggests that in at least some
cases the abnormal stem cell compart-
ment is further compromised by poorly
dened immune phenomena.
Clinical features
Patients with marrow failure predictably
present with anaemia, unusually
frequent or severe infections (caused
by neutropenia) and a haemorrhagic
tendency (caused by thrombocytope-
nia). The onset may be gradual or fulmi-
nant. Symptoms or signs of an
underlying systemic disorder (e.g. Fan-
conis) or possible trigger (e.g. hepatitis)
may be present. An exhaustive history,
including drug and occupational expo-
sure, and a thorough examination are
mandatory.
Diagnosis
There are really two questions. Is the
pancytopenia due to aplastic anaemia?
Is this idiopathic AA or aplasia second-
ary to an identiable cause (Table 26.3)?
A reasonable sequence of investiga-
tions is as follows:
1. Blood count and lm
There is a pancytopenia and reticulocy-
topenia. To dene AA there must be at
least two of the following: (1) haemo-
globin less than 100 g/L; (2) neutrophils
less than 1.5 10
9
/L; (3) platelets less
than 50 10
9
/L. There are no abnormal
cells in the blood lm.
2. Bone marrow aspirate
and trephine
This is the key diagnostic test. The
marrow aspirate can be highly sugges-
tive of aplasia with grossly hypocellular
The term aplastic anaemia is a misno-
mer in that the disorder so described is
characterised by a pancytopenia arising
from failure of production of all the
normal cells of peripheral blood. The
underlying cause is a reduction in
the number of pluripotential stem cells.
This decit may be exacerbated by an
abnormality in the marrow microenvi-
ronment or an autoimmune reaction
against the abnormal haematopoietic
tissue.
Aplastic anaemia is rare (approxi-
mately 25 cases/million/year world-
wide) and affects all ages. It must be
emphasised that it is not a subtype of
leukaemia. However, the diseases pre-
senting clinical characteristics, the man-
agement problems of marrow failure
(including fulminating septicaemia and
haemorrhage) and the possible evolu-
tion to a clonal marrow disorder dictate
its inclusion in this section.
Classication and
aetiology
Aplastic anaemia (AA) may be part of a
congenital syndrome, be secondary to
well-dened insults to the bone marrow,
or arise apparently spontaneously with
no identiable cause. A simple classica-
tion is shown in Table 26.1. The most
common congenital disorder is Fanco-
nis anaemia. Affected children suffer
from defective DNA repair and the
aplasia often coexists with skeletal
deformities, skin pigmentation (Fig
26.1) and renal abnormalities. To date,
fteen genes (termed FANC) have been
identied. Dyskeratosis congenita,
another form of constitutional aplasia, is
distinguished by a later onset, nail dys-
trophy, leukoplakia of mucosal surfaces
and a high incidence of epithelial
tumours. There is defective telomere
maintenance and patients usually have
Fig 26.1 Fanconis anaemia. (a) Digital abnormalities in brothers with the syndrome. (b) Skin pigmentation.
(a) (b)
Table 26.1 Classication of
aplastic anaemia
1. Idiopathic AA
2. Congenital AA Fanconis anaemia
Dyskeratosis congenita
3. Secondary AA Drugs idiosyncratic or
dose-related
Chemicals
Ionising radiation
Infection
Table 26.3 Causes of pancytopenia
Marrow failure or inltration
Aplastic anaemia
Myelodysplastic syndrome
Leukaemia
Myelobrosis
Inltration by other malignancy (e.g. lymphoma,
carcinoma)
Infection (e.g. tuberculosis)
Megaloblastic anaemia
Prolonged starvation
Hypersplenism
Portal hypertension
Felty syndrome (rheumatoid arthritis)
Storage disorders
Table 26.2 Drugs associated with aplastic
anaemia
1
Predictable Cytotoxic agents
Idiosyncratic Chloramphenicol
Sulfonamides
Phenylbutazone
Indometacin
Gold salts
Penicillamine
Carbamazepine
Phenytoin
Carbimazole
1
This is a selective list of more commonly implicated agents.
tahir99-VRG & vip.persianss.ir
53 Aplastic anaemia
particles but a trephine biopsy is neces-
sary to conrm the diagnosis and quan-
tify the degree of hypocellularity (Fig
26.2). Aplasia may be patchy and if the
trephine is surprisingly cellular in the
context of the blood count, then further
samples should be obtained. In practice
the only likely confusion is with hypocel-
lular myelodysplastic syndrome (see p.
50) or an atypical presentation of acute
leukaemia, the latter particularly in
childhood.
3. Tests for an underlying cause
These include liver function tests, viral
titres, vitamin B
12
and folate levels and
tests for paroxysmal nocturnal haemo-
globinuria (see p. 31) and the inherited
bone marrow failure syndromes.
Cytogenetic analysis of the hypocellular
bone marrow is often problematic but
will reveal abnormal cytogenetic clones
in some patients.
Measurement of severity
This is crucial as the severity dened
from peripheral blood and bone marrow
measurements predicts the response to
treatment and survival (Table 26.4). The
median survival of untreated severe AA
is 36 months with only 20% of patients
surviving longer than 1 year.
Management
Removal of cause
Where an agent such as a drug or a
chemical is implicated this should be
removed.
Supportive care
Blood and platelet transfusion may be
life-saving but should be used judi-
ciously as patients with AA have intact
cellular and humoral immunity and can
become sensitised to histocompatibility
antigens. Iron chelation therapy may be
required. Infection in neutropenic
patients requires prompt expert man-
agement (see p. 87).
Restoring normal
haematopoiesis
There are two major options: immu-
nosuppression and stem cell
transplantation.
Immunosuppression
AA is thought to be at least in part an
autoimmune disease and immunosup-
pressive agents provide worthwhile
responses and prolonged survival in
6080% of patients with 5-year survival
around 75%. Responses are poorer in
younger patients and in severe aplastic
anaemia (SAA). The best regimen is a
combination of antithymocyte globulin
(ATG) and ciclosporin. Both drugs are
potentially toxic ATG can produce
pyrexia, rashes and hypotension while
ciclosporin may cause nephrotoxicity
and hypertension. Complete or partial
responses to immunosuppressive
treatment can take several months.
Other immunosuppressive drugs
which may be considered include
cyclophosphamide and the anti-CD52
monoclonal antibody alemtuzumab. As
further discussed below, there is concern
that immunosuppression may stimulate
haematopoiesis but not necessarily cure
the disease.
Stem cell transplantation (SCT)
The object of allogeneic SCT is to repop-
ulate the patients marrow with normal
stem cells from a healthy compatible
donor. Transplantation from an HLA-
identical sibling donor in younger
patients (less than 45 years) produces
long-term survival (possibly cure) in
about 7590% of cases. It is important
to transplant early in the course of the
disease as multiple transfusions lead to
sensitisation and an increased chance of
graft rejection. Minimal-intensity condi-
tioning regimens (see p. 57) are being
explored.
Immunosuppression or SCT?
Younger patients (less than 30 years)
with SAA and a matched sibling donor
should be transplanted. In VSAA (see
Table 26.4) in this age group, the lack of
a family donor should prompt a search
for an HLA-matched unrelated donor.
In patients 3040 years with SAA,
sibling SCT and immunosuppression
produce similar survivals over 25 years.
However, a signicant proportion of
patients receiving immunosuppression
alone, approximately 25% at 10 years,
evolve to clonal marrow diseases such
as paroxysmal nocturnal haemoglob-
inuria, myelodysplastic syndrome and
acute myeloid leukaemia. Thus in this
group matched sibling SCT probably
gives a better long-term prognosis. In
older patients with SAA, and patients
with non-severe AA, immunosuppres-
sion is generally the treatment of choice.
Growth factors
Growth factors cannot rectify the stem
cell defect and are therefore not rou-
tinely used in AA. G-CSF may be useful
in severe infection.
Fig 26.2 Bone marrow trephine in severe
aplastic anaemia. The cellularity is markedly
reduced. (Compare with normal bone marrow
appearance, p. 2.)
Table 26.4 Severity of aplastic anaemia
AA is dened as non-severe (NSAA) unless it is:
1. Severe (SAA). Requires two of three peripheral
blood criteria:
Neutrophils less than 0.5 10
9
/L
Platelets less than 20 10
9
/L
Reticulocytes less than 20 10
9
/L
Within the bone marrow:
Less than 25% haematopoietic cells, or 2550%
haematopoietic cells and less than 30% cellularity
2. Very severe (VSAA). Requires a neutrophil count
less than 0.2 10
9
/L in the presence of at least one
other peripheral blood criterion and the bone
marrow features given for SAA
Aplastic anaemia
AA is characterised by a pancytopenia arising from the failure of production of normal cells
by the bone marrow.
There is a reduction in the number of pluripotential stem cells; there may also be an
abnormal marrow microenvironment and ill-dened autoimmunity.
AA can be congenital, secondary to well-dened insults (e.g. drugs) or idiopathic.
Prognosis relates to severity, which is dened from blood and bone marrow indices.
Evolution to a clonal marrow disorder such as leukaemia may occur.
Good supportive care is vital.
Major treatment modalities are immunosuppression and SCT the choice of treatment is
based on patient age, disease severity and availability of a stem cell donor.
tahir99-VRG & vip.persianss.ir
54 4 LEUKAEMIA
27 Chemotherapy and related treatments
some antimetabolic activity. The main
toxic effect of the group is myelosup-
pression. Fludarabine is signicantly
immunosuppressive.
Topoisomerase poisons
and inhibitors
This broad class of drugs includes the
anthracyclines (doxorubicin, daunoru-
bicin, mitoxantrone, idarubicin) and the
epipodophyllotoxins (etoposide). The
anthracyclines are cell cycle non-specic
drugs. The acute dose-limiting toxicity is
bone marrow suppression but the
cumulative dosage is limited by cardio-
toxicity. Etoposide is a phase-specic
drug (active in G
2
) with myelosuppres-
sion the major toxicity.
Spindle poisons
Key agents in this group are the two
vinca alkaloids, vincristine and vinblast-
ine. They are cell-cycle phase-specic,
exerting a cytotoxic effect by binding to
cellular microtubular protein and inhib-
iting mitosis. Vincristines major adverse
effects are mixed motor-sensory and
autonomic neuropathies (patients
usually initially complain of pins and
needles in the ngers or toes and
constipation); vinblastine is less neuro-
toxic but causes more bone marrow
suppression.
Side-effects of
conventional
cytotoxic drugs
Some toxic effects are common to many
cytotoxic drugs and must be discussed
with all patients receiving a relevant
single agent or combination chemother-
apy (Table 27.1). Myelosuppression and
alopecia are often unavoidable. However,
nausea and vomiting can usually be
minimised or even completely avoided
by modern antiemetic protocols. The
probability of infertility is inuenced by
the agents used, the total dosage, the
duration of administration and the age
and sex of the patient. Strategies to mini-
mise infertility include prechemother-
apy storage of germ cells (unfortunately,
fertility is often abnormal at presenta-
tion) or choice of regimens which are
relatively non-sterilising. Gonadal failure
occurs more commonly in women and
may be managed by hormone replace-
ment therapy; androgens are used
in men. Chemotherapy is associated
with an increased risk of secondary
malignancy including leukaemia and
solid tumours. Alkylating agents are
particularly leukaemogenic.
Multi-drug resistance
The major problem in the treatment of
leukaemia and other haematological
malignancies is the emergence of cells
resistant to chemotherapy. Genes
capable of conferring resistance to cyto-
toxic drugs have been characterised. Of
particular note is the P-glycoprotein or
multi-drug resistance gene (MDR1), as
its over-expression can lead to resistance
to many of the agents used in the treat-
ment of leukaemia. The MDR1 gene
encodes a membrane protein which
acts as an ATP-dependent efux pump
transporting organic compounds out of
the cell. Elevated MDR1 levels appear
to predict a poor prognosis in acute
myeloid leukaemia. A number of MDR-
reversing agents (e.g. ciclosporin, PSC-
833, zosuquidar) have been given in
conjunction with normal chemotherapy
in AML but so far with little benet.
Other treatments for
haematological
malignancy
Conventional chemotherapy currently
plays the major role in the treatment of
most haematological malignancies but,
General principles
The life cycle of the normal cell is shown
schematically in Figure 27.1. Conven-
tional anti-leukaemic and lymphoma
cytotoxic drugs can be broadly divided
into those agents active during only one
phase of the cell cycle (phase-specic)
and those acting at all stages (phase
non-specic). In practice, most anti-
leukaemic drugs act predominantly
against proliferating cells and therefore
affect a fraction of the malignant cell
population. Thus, if in advanced acute
leukaemia the total number of malig-
nant cells is 10
10
, a single course of chem-
otherapy could be expected to kill
between 2 and 5 log of cells, leaving
between 10
5
and 10
8
residual leukaemic
cells. It can be seen that the chance of
eradication of the disease by chemother-
apy is favoured by early treatment when
the leukaemic mass is small and by
repeated courses of cytotoxic drugs. It is
also logical to combine different agents
to maximise the anti-leukaemic activity
and exploit different toxicities (combi-
nation chemotherapy).
Major classes
of conventional
cytotoxic drugs
Alkylating agents
Despite their variable structure, all
alkylating agents appear to have a
common mechanism with cross-linking
of DNA the principal cytotoxic action.
Agents commonly used in haematologi-
cal practice include melphalan, chloram-
bucil, cyclophosphamide, busulfan and
bendamustine. These are toxic to rapidly
proliferating cells and the dose-limiting
toxicity is myelosuppression. Other
side-effects include infertility, haemor-
rhagic cystitis (cyclophosphamide)
and an increased risk of secondary
malignancy.
Antimetabolites
These drugs are compounds which
interfere with the utilisation of a natural
metabolite by virtue of the similarity of
their chemical structure. Most are ana-
logues of nucleic acid precursors. Com-
monly used examples are the folinic
acid analogue methotrexate, the purine
analogues 6-mercaptopurine and
udarabine, and the pyrimidine ana-
logue cytosine arabinoside. The alkylat-
ing agent bendamustine also has
Fig 27.1 The cell cycle.
G
1
period
(preparation)
G
2
period
(DNA repair)
S phase
(DNA synthesis)
Mitosis
(division)
Table 27.1 Common adverse effects of
cytotoxic drugs
Short-term effects Long-term effects
Myelosuppression Infertility
Nausea and vomiting Secondary malignancy
Alopecia
Mucositis
Note: If extravasated from the vein some drugs can cause severe
tissue injury.
55 Chemotherapy and related treatments
as these selected examples demonstrate,
there is increasing emphasis on more
targeted therapies which exploit particu-
lar characteristics of tumour cells and
cause fewer systemic side-effects.
Differentiating agents
In most cases, attempts to induce matu-
ration of malignant cells have been dis-
appointing. One notable exception is
the drug all-trans-retinoic acid (ATRA)
in acute promyelocytic leukaemia (asso-
ciated with t(15;17)). At pharmacological
concentrations ATRA overcomes the
suppressive effect of the PML-RAR
fusion protein, allowing leukaemic pro-
myelocytes to differentiate into neu-
trophils. Addition of ATRA to normal
chemotherapy reduces the severity of
APL-related coagulopathy and gives a
signicantly better survival than chemo-
therapy alone. The major side-effect is
ATRA syndrome where a rising white
blood cell count accompanies systemic
upset with cardiopulmonary and renal
problems.
Monoclonal antibodies
Monoclonal antibodies (MoAbs)
promise tumour-targeted therapy with
minimal toxicity. They may be unconju-
gated or conjugated to a toxin or radio-
isotope. One potential target is the
CD20 antigen which is present in over
90% of B-cell lymphomas. An unconju-
gated chimeric human-mouse anti-
CD20 MoAb (rituximab) is widely used
in association with chemotherapy in
follicular and diffuse large B-cell non-
Hodgkins lymphomas. Newer anti-
CD20 agents (e.g. ofatumumab) are
being investigated. The linking of a radi-
onucleotide to anti-CD20 may improve
efcacy. Other MoAbs in clinical prac-
tice include anti-CD52 (alemtuzumab)
in chronic lymphocytic leukaemia, anti-
CD33 (Mylotarg) in acute myeloid leu-
kaemia and anti-CD30 (brentuximab) in
Hodgkins lymphoma.
Tyrosine kinase inhibitors (TKIs)
Imatinib mesilate (Glivec), a specic
small molecule inhibitor of BCR-ABL, is
very effective drug therapy for chronic
myeloid leukaemia (CML) (see also p.
45). In patients who develop resistance
to imatinib more potent BCR-ABL
inhibitors (e.g. dasatinib, nilotinib) can
give good responses. Other TKIs
entering clinical practice include JAK2
inhibitors (e.g. ruxolitinib) in myelo-
proliferative neoplasms and FLT3 inhibi-
tors in acute myeloid leukaemia.
Proteosome inhibitors
The proteosome is an enzyme complex
that plays a crucial part in cell-cycle
control and gene expression by regu-
lating cellular protein degradation.
Inhibition of the proteosome ulti-
mately results in cell death. Bortezomib
(Velcade) is a proteosome inhibitor that
is able to kill tumour cells selectively. It
is effective in myeloma and it also has
activity in non-Hodgkins lymphomas.
The most troublesome side-effect is
peripheral neuropathy.
Epigenetic therapies
The term epigenetics refers to heritable
changes in gene expression which are
not coded in the DNA sequence. Epige-
netic mechanisms, including DNA and
histone modications, are potentially
reversible. The hypomethylating agents
azacitidine and decitabine have activity
in myelodysplastic syndrome and acute
myeloid leukaemia.
Anti-angiogenic agents
Myeloma is known to be associated
with increased angiogenesis in the bone
marrow. The anti-angiogenic agents tha-
lidomide and lenalidomide now play
key roles in the treatment of this malig-
nancy. Both drugs have other mecha-
nisms of action including alteration of
tumour cell cycle progression and
immunomodulation.
Interferon alfa
Interferon alfa is an antiviral protein
with immunomodulatory and
anti-cancer activities. It has been exten-
sively used in CML and hairy cell leu-
kaemia but is now being largely
supplanted by more effective and better
tolerated agents.
Haematopoietic growth
factor therapy
Several haematopoietic growth factors
are routinely used in clinical haematol-
ogy. Their main use is in haematological
malignancy.
Supportive care in patients with
blood cytopenia
G-CSF (see p. 2) is most commonly
used to accelerate the production of
neutrophils following chemotherapy or
stem cell transplantation. The shortened
period of neutropenia reduces the inci-
dence of infections and the length of
stay in hospital. It can also help main-
tain the dose intensity of chemotherapy.
Erythropoietin is mainly used to treat
the anaemia of renal failure but may
ameliorate anaemia in selected patients
with myelodysplastic syndrome and
myeloma. Early trials of thrombopoietin-
like agents to treat thrombocytopenia
were unsuccessful due to the develop-
ment of neutralising antibodies. Throm-
bopoietin receptor agonists are used in
immune thrombocytopenia (see p. 69)
but they have no denite role in throm-
bocytopenia due to marrow failure.
Stem cell mobilisation
G-CSF is used in conjunction with
chemotherapy to mobilise stem cells
from the bone marrow to the blood
prior to harvesting (see also p. 56).
Chemotherapy and related
treatments
There are several classes of conventional cytotoxic drugs with different mechanisms of
action.
In leukaemia and lymphoma it is usual to combine cytotoxic drugs in repeated courses to
maximise anti-tumour activity and exploit different toxicities.
Cytotoxic drugs have predictable short-term and long-term side-effects.
Conventional chemotherapy is increasingly being supplemented, or even replaced, by
therapies targeting particular characteristics of tumour cells (e.g. tyrosine kinase inhibitors
in CML).
Erythropoietin may be used to treat anaemia in selected patients with haematological
malignancy.
G-CSF is used to shorten the duration of neutropenia after intensive chemotherapy and to
mobilise stem cells for harvesting.
56 4 LEUKAEMIA
28 Stem cell transplantation
family size in the Western world, only
around 30% of patients will have an
HLA-identical sibling. Transplants from
HLA-haploidentical relatives have been
associated with a high rate of morbidity
and mortality. An alternative strategy is
to search for an unrelated volunteer
donor who is a phenotypic HLA match.
From the worldwide databases of 18
million HLA-typed volunteers, around
50% of Caucasian patients can be found
a suitable donor. Success rates are lower
in other ethnic groups. Use of a HLA-
mismatched donor leads to an increase
in the incidence and severity of the
adverse effects of SCT. Weaker trans-
plant reactions result from mismatch
for minor histocompatibility antigens,
single peptides derived from polymor-
phic proteins which may differ between
donor and recipient.
After conditioning treatment there is a
period of about 3 weeks before engraft-
ment during which the patient is
severely pancytopenic and immunosup-
pressed and requires intensive support-
ive care with blood products and
aggressive treatment of any infection.
Major adverse events include graft failure
with rejection arising from a failure to
immunosuppress the patient adequately,
and graft-versus-host disease (GVHD).
GVHD is a potentially life-threatening
disorder predominantly affecting the
skin (Fig 28.2), gastrointestinal tract and
liver which may occur early after trans-
plantation (acute GVHD) or after a few
months (chronic GVHD). GVHD results
from donor immunocompetent cells
attacking antigens in the recipient and
can be abrogated by removal of
T-lymphocytes from the donor stem
cells. Such lymphocyte depletion may
lead to an increased risk of relapse of the
underlying malignancy, conrming that
much of the curative potential of alloge-
neic SCT is due to the presence of immu-
nologically active donor cells rather than
the preparative regimen (see also non-
myeloablative SCT). The profound and
prolonged immunosuppression of allo-
geneic SCT renders the patient vulnera-
ble to life-threatening fungal and viral
(e.g. cytomegalovirus) infections. Causes
of late death include relapse of disease,
chronic GVHD and secondary cancers
related to previous chemotherapy and
SCT conditioning. Peripheral blood
stem cells are now used more often than
bone marrow for allogeneic procedures.
For related donors, PBSC give quicker
engraftment and probably reduced
disease relapse and improved survival
although there is some increase in
GVHD. Common indications for alloge-
neic SCT include acute leukaemia and
chronic myeloid leukaemia.
Autologous SCT
The procedure is outlined in Figure 28.1.
High-dose chemotherapy, and some-
times radiotherapy, is followed by rein-
fusion of previously stored patient stem
cells. Autologous SCT has less toxicity
than allogeneic SCT and therefore can
be performed in older patients. It also
has the advantage that the patient is the
The term stem cell transplantation
(SCT) is used to describe a number of
different procedures. In allogeneic SCT
the haematopoietic stem cells are pro-
vided by another individual, either a
family member or an unrelated donor.
In autologous SCT the patients own
stem cells are used to re-establish hae-
matopoiesis. For many years bone
marrow (BM) harvested from the pelvis
was the only source of stem cells but
now they are more commonly harvested
from the peripheral blood (PB) by
leucapheresis.
Allogeneic and syngeneic
(twin) SCT
The allogeneic procedure is outlined in
Figure 28.1. The patients own haemat-
opoietic stem cells, immune system and
residual tumour cells are conventionally
destroyed by conditioning treatment
with high-dose chemotherapy and
(usually) radiotherapy prior to intrave-
nous infusion of stem cells harvested
from the healthy donor. The ideal
patient has a disease curable by alloge-
neic SCT but not by less toxic treatment
and is young (less than 40 years old).
The ideal donor, excepting the rare pres-
ence of a twin, is a sibling genotypically
matched with the recipient for HLA-A,
B and DR. The genes for HLA are found
on chromosome 6 and so inheritance
follows the rules of simple Mendelian
inheritance; two siblings have a one in
four chance of sharing the same two
HLA haplotypes. With relatively small
Fig 28.1 Stem cell transplantation.
High-dose chemotherapy
irradiation
High-dose chemotherapy
irradiation
additional
immunosuppression
Patient
Stem cells given
intravenously
Very intensive
supportive care and
GVHD prophylaxis
Donor
(usually HLA-matched sibling)
Patient
Stem cells given
intravenously
Moderately intensive
supportive care
(a) Allogeneic
(b) Autologous
Storage of stem
cells 'purging'
Harvest of stem cells
Harvest of stem cells
Possible lymphocyte depletion
57 Stem cell transplantation
donor and therefore donor unavailabil-
ity and GVHD are not issues. The main
disadvantage of autologous SCT com-
pared with allogeneic SCT is an
increased incidence of relapse of malig-
nant disease. It is not clear whether this
arises from resistance to the condition-
ing treatment or infusion of residual
tumour cells in the graft. The purging
of tumour cells from grafts does not
appear to alter survival. Peripheral blood
stem cells (PBSC) have now largely
replaced the use of bone marrow in
autologous procedures. PBSC can be
harvested from the patients blood by
leucapheresis during the recovery phase
from moderate doses of chemotherapy
(Fig 28.3). The growth factor G-CSF is
often used to facilitate the mobilisation
of stem cells. Compared with the tradi-
tional bone marrow autologous trans-
plant, PBSCT gives more rapid recovery
of a normal blood count with fewer
infections, less intensive supportive care
and shortened hospital stay. PBSCT is
currently widely used as a convenient
and relatively safe method of escalating
the dose of chemotherapy in patients
with acute leukaemia, lymphoma and
myeloma. Its role in the treatment of
non-haematopoietic solid tumours
and autoimmune disorders is less
established.
Recent developments
Non-myeloablative allogeneic
SCT (reduced intensity)
As allogeneic SCT has evolved it has
become increasingly apparent that its
curative potential is not simply due to
the killing of tumour cells by intensive
conditioning regimens. The major ther-
apeutic component of allogeneic SCT is
thought to be donor T-lymphocytes
mediating graft versus tumour (GVT)
or graft versus leukaemia (GVL) effects.
The rationale of reduced intensity SCT
is to avoid potentially harmful intensive
pre-transplant conditioning and to
instead harness the anti-leukaemic (or
other tumour) effects of the donor allo-
reactive T-lymphocytes. These cells are
capable of killing leukaemic stem cells
and other tumour cells resistant to con-
ventional chemotherapy. Patients are
given moderate doses of chemotherapy
and immunosuppressive drugs to
engender a state of host versus graft tol-
erance before the infusion of allogeneic
donor stem cells. As the procedure is of
relatively low toxicity it allows alloge-
neic SCT in older patients. There is,
however, still a signicant risk of acute
and chronic GVHD. Reduced intensity
conditioning regimens are being devel-
oped to try and minimise the toxicity
and to maximise GVT activity. Donor
lymphocyte infusions (DLIs) are another
form of allogeneic cell therapy. In
patients with leukaemia relapsed after
allogeneic SCT, a simple infusion of
lymphocytes from the original donor
may induce a further remission.
Umbilical cord blood
transplantation
Umbilical cord blood (UCB) is an
important source of haematopoietic
stem cells now being used for transplan-
tation. UCB is readily available and large
banks of stored frozen UCB are signi-
cantly extending the application of SCT.
Immunocompetent cells in CB are less
mature than the T- and B-lymphocytes
in an adult and there is a lower risk of
inducing GVHD, allowing the possibil-
ity of HLA-mismatched UCB transplan-
tation. A cord blood unit provides a
relatively low stem cell dose leading to
slower haematopoietic and immune
recovery. Results are better where higher
cell doses are available. Emerging strate-
gies include the use of double cord
blood transplants and in vitro tech-
niques to increase the number of
haematopoietic stem cells. UCB trans-
plantation has been mainly used in chil-
dren. In adults it is considered when
other donor cells are unavailable or not
quickly accessible.
Fig 28.2 Acute GVHD of the skin after
allogeneic SCT.
Fig 28.3 Peripheral blood stem cells being harvested by leucapheresis.
Stem cell transplantation
Stem cell transplantation (SCT) procedures may be undertaken using an HLA-matched
family donor or unrelated donor (allogeneic SCT), an identical twin donor (syngeneic SCT)
or the patients own stored stem cells (autologous SCT).
Stem cells may be sourced from the bone marrow but are now more commonly derived
from peripheral blood (PBSC).
Allogeneic SCT is a more effective anti-leukaemic treatment than autologous SCT but is
associated with greater toxicity including graft rejection and graft versus host disease.
The greater curative potential of allogeneic SCT in leukaemia is largely due to a graft versus
leukaemia (GVL) effect mediated by donor T-lymphocytes.
More recent developments include reduced intensity conditioning regimens exploiting
GVL effects and alternative sources of stem cells (e.g. umbilical cord blood).
58 5 LYMPHOMA AND MYELOMA
29 Hodgkins lymphoma
nodes usually gradually enlarge but may
uctuate in size. Patterns of disease
suggest contiguous spread via the lym-
phatic chain. Mediastinal involvement is
a particular feature of the nodular scle-
rosing histological subtype (Fig 29.2).
Splenomegaly and hepatomegaly occur
but massive enlargement is rare.
Signicant systemic upset affects a
minority of patients (2030%) at presen-
tation. This includes fever, sweating
(often at night), weight loss, pruritus
and fatigue.
Lymphocyte predominant
nodular Hodgkins lymphoma
Most cases present with cervical aden-
opathy and early stage disease. The
disease is more indolent than classical
HL with long survivals common.
However, late relapse and transforma-
tion to diffuse large B-cell NHL can
occur. Treatment of advanced disease is
similar to that used for classical HL (see
below).
Diagnosis and staging
Diagnosis
The key investigation is biopsy of
a lymph node for histological
The lymphomas are malignant disor-
ders of lymphoid tissue subdivided into
two broad groups Hodgkins lym-
phoma (HL) and non-Hodgkins lym-
phoma (NHL).
Hodgkins disease was rst described
by Thomas Hodgkin in 1832. In devel-
oped countries there is a bimodal age
distribution with peak incidences in
young adults (1535 years) and the
more elderly (over 50 years). The disease
is commoner in men.
Aetiology
Hodgkins lymphoma is an unusual
malignancy in that the malignant cells,
termed ReedSternberg cells (Fig 29.1),
and mononuclear Hodgkins cells form
only a minority of the tumour. The
remainder is composed of very variable
numbers of other cells including lym-
phocytes, granulocytes, broblasts and
plasma cells. This inammatory cell
inltrate presumably reects an immune
response by the host against the malig-
nant cells. ReedSternberg (RS) cells
appear to originate from germinal-centre
B-lymphocytes. In classical HL the RS
cells are crippled germinal-centre B-cells
incapable of secreting immunoglobu-
lins, while in lymphocyte predominant
nodular HL RS cells the coding regions
of the immunoglobulin genes are intact
and potentially functional.
EpsteinBarr virus (EBV) may play
a role in classical Hodgkins lym-
phoma, particularly the mixed cellular-
ity subtype. When the disease occurs in
patients with HIV infection and after
solid organ transplantation it is often
EBV-associated. There is no specic
chromosomal translocation associated
with Hodgkins lymphoma.
Classication
It is acknowledged in the World Health
Organization (WHO) classication (see
also p. 60) that Hodgkins disease com-
prises two distinct Hodgkins lympho-
mas with different clinical features:
classical HL and lymphocyte predomi-
nant nodular HL (Table 29.1).
Clinical presentation
Classical Hodgkins lymphoma
Asymmetrical and painless lymphaden-
opathy, most often in the cervical region,
is the most common presentation. The
Fig 29.1 ReedSternberg cells in a lymph node biopsy. This giant cell is binucleated or
multinucleated with large inclusion-like nucleoli and abundant cytoplasm.
Table 29.1 WHO classication of Hodgkins lymphoma
Histological subtype Histological pattern Immunophenotype
Lymphocyte predominant
nodular
Polylobulated ReedSternberg (RS) cells
Nodular growth pattern
CD30
CD20+
CD45+
Classical
Lymphocyte-rich
Nodular sclerosis
Mixed cellularity
Lymphocyte depletion
Classical or lacunar type. RS cells in
inammatory cell background. In nodular
sclerosis type are often brous bands
CD15+
CD30+
CD45
Fig 29.2 Chest X-ray showing mediastinal
lymphadenopathy in nodular sclerosing
Hodgkins lymphoma.
examination. This is needed to distin-
guish Hodgkins lymphoma from other
causes of lymphadenopathy.
Staging
Optimal treatment is determined by
the stage of disease (Fig 29.3), which
is derived from the following
investigations:
1. Blood count and bone marrow
investigation. A mild normochromic
59 Hodgkins lymphoma
or microcytic anaemia and blood
eosinophilia may be present. Bone
marrow aspiration and trephine
biopsy to detect inltration by
disease is necessary in more
advanced cases.
2. Imaging. A whole body computed
tomography (CT) scan is the central
staging procedure. In difcult cases
this may be supplemented by
magnetic resonance imaging (MRI).
Positron emission topography (PET)
scanning is increasingly used in
staging and also to assess response
during and after treatment (Fig
29.4). Clinical trials are needed to
better dene its role.
Management of classical
Hodgkins lymphoma
The challenge is to improve current
high cure rates while reducing the inci-
dence of the serious late complications
of radiotherapy and chemotherapy.
Early stage disease
Patients with stage I or II disease who
lack adverse features (Table 29.2) have
been traditionally treated with radio-
therapy alone. This is given over an
extended eld using a linear accelerator.
Nodes above the diaphragm are treated
using the mantle eld (like the mantle
on a suit of armour) while the inverted
Y eld includes all nodes below the
diaphragm.
Radiotherapy alone fails to cure
disease in 2030% of patients and there
is now more widespread use of chemo-
therapy in early stage disease either
alone or in combination with radiother-
apy. Chemotherapy may be used in
shorter courses (than for advanced
disease) and the radiation eld may be
more restricted when combined with
chemotherapy. There are various chem-
otherapy protocols but most common is
ABVD (doxorubicin, bleomycin, vinblas-
tine, dacarbazine), which is given intra-
venously as 4-weekly cycles.
Advanced stage disease
All patients with stage III or IV disease
require chemotherapy with possible
addition of radiotherapy for bulky
disease or palliation of symptoms.
ABVD is the regimen of choice for most
patients. This is being compared in clini-
cal trials with alternating or hybrid
regimens containing a larger number of
drugs. Autologous stem cell transplanta-
tion is the best choice for younger
patients who fail induction chemother-
apy or who have early relapse. Novel
targeted therapies under investigation
include the anti-CD30 monoclonal
antibody-drug conjugate brentuximab
vedotin.
Prognosis and late effects
of treatment
Survival rates are closely linked to
stage although within each stage other
prognostic factors inuence outcome
(see Table 29.2). Cure rates for early
stage disease are around 90% while even
more advanced disease is curable in up
to 80% of patients with optimal manage-
ment. As in other haematological
malignancies, elderly patients tolerate
chemotherapy less well and cure rates
are more modest. In long-term survivors
there is a risk of secondary malignancy.
Young women receiving mediastinal
irradiation are at particularly high risk
of breast cancer. Other possible late
effects of treatment include cardiac
disease, lung damage, sterility and endo-
crine dysfunction.
Fig 29.3 Staging of Hodgkins lymphoma. Stage I, node involvement in single lymph
node area (e.g. cervical); II, two or more lymph node areas on one side of diaphragm; III,
nodal involvement above and below diaphragm; IV, involvement outside node areas
(e.g. liver, bone marrow). The stage is followed by the letter A (absence) or B (presence)
pertaining to signicant systemic symptoms (one or more of: unexplained fever above 38C,
night sweats, loss of more than 10% body weight in 6 months). A single extranodal site is
designated E.
Stage I Stage II Stage III Stage IV
Fig 29.4 PET scan appearance in Hodgkins
lymphoma.
Table 29.2 Factors predicting
a poor prognosis
Advanced stage (most important)
B symptoms
Increased tumour bulk
Increased sites of disease
Advanced age
Extranodal disease
Poor response to chemotherapy (e.g. after two
cycles)
Early relapse
Elevated erythrocyte sedimentation rate (ESR)
Lymphopenia
Anaemia
Hodgkins lymphoma
The term Hodgkins lymphoma describes a group of lymphomas distinct from the
non-Hodgkins lymphomas.
The presumed malignant cells, ReedSternberg and mononuclear Hodgkins cells, compose
a minority of tumour cells.
Common clinical presentations are palpable lymphadenopathy and constitutional
symptoms.
Prognosis is largely determined by the stage of the disease.
Chemotherapy leads to high cure rates even in advanced disease. The late side-effects of
such treatment (e.g. secondary malignancy) are signicant.
60 5 LYMPHOMA AND MYELOMA
30 Non-Hodgkins lymphoma
clinical course but are often curable.
Low-grade tumours are composed of
smaller, better differentiated cells. They
are more indolent clinically but have a
tendency to repeatedly relapse.
The current WHO classication
avoids the overly simplistic high-grade/
low-grade split and divides lymphomas
into more specic subtypes based on
clinical features, morphology, immu-
nophenotype, karyotype and molecular
characteristics. In addition to NHL and
Hodgkins lymphoma the WHO scheme
contains a number of other lymphoid
neoplasms occurring mainly at extran-
odal sites that are discussed elsewhere
(e.g. myeloma, hairy cell leukaemia).
Some of the major entities are shown in
Table 30.1.
Clinical presentation
NHL is essentially a disease of lymph
nodes but it has a more diverse presen-
tation than Hodgkins lymphoma with
more irregular spread and a higher
incidence of extranodal involvement. It
may be an indolent disorder, perhaps
requiring no immediate treatment, or an
aggressive, rapidly fatal malignancy.

Nodal involvement. Painless

lymphadenopathy (Fig 30.1), often in
the cervical region, is the most
common presentation of NHL.
Enlarged nodes may cause
complications such as superior vena
cava syndrome and hydronephrosis.

Extranodal involvement. Intestinal

lymphoma can present with vague
abdominal pain, anaemia (caused by
bleeding) or dysphagia. CNS disease
frequently leads to headache and
cranial nerve palsies and may cause
spinal cord compression. Lymphoma
may arise in the skin (e.g. mycosis
fungoides). Bone marrow
involvement is more common in
low-grade lymphomas and can result
in pancytopenia.

Systemic symptoms. Sweating and

signicant weight loss occur in less
than a quarter of patients and, where
present, usually indicate advanced
disease. Occasionally, patients present
with metabolic complications such as
hyperuricaemia, renal failure and
hypercalcaemia.
Diagnosis and staging
Diagnosis depends on obtaining a
tissue biopsy, usually a lymph node, for
Malignant solid tumours of lymphoid
tissue which are not Hodgkins lym-
phoma are termed non-Hodgkins
lymphomas (NHL). This group of lym-
phomas is even more heterogeneous
than Hodgkins lymphoma. The disease
is the most common haematological
malignancy and is currently the fth
most common cancer in the Western
world. It appears to be increasing in inci-
dence. NHL may occur at any age but
the median age of presentation is 5560
years.
Aetiology
The cause of the majority of cases of
NHL is obscure. However, specic chro-
mosomal translocations are closely
associated with particular histological
types. Thus, the majority of Burkitts
lymphoma cases demonstrate the t(8;14)
abnormality in which the MYC onco-
gene on chromosome 8 is moved next
to the immunoglobulin heavy chain
region on chromosome 14. Almost
90% of follicular low-grade lymphomas
are characterised by t(14;18) where the
BCL2 gene on chromosome 18 is moved
to the immunoglobulin heavy chain
region. This leads to excessive expres-
sion of BCL2, an oncogene known
to inhibit apoptosis (programmed cell
death). It is likely that such chromo-
some rearrangements require further
events perhaps co-expression of a
second proto-oncogene or antigenic
stimulus to produce the clonal malig-
nant cell. Possible triggering antigens
include Helicobacter pylori in gastric
MALT lymphoma and hepatitis C in
marginal zone lymphoma. The aggres-
sive extranodal lymphomas seen in
AIDS are likely to result from a combi-
nation of immunosuppression (due
to the HIV virus), deregulation of a
proto-oncogene (MYC) and secondary
viral infection (EpsteinBarr virus).
Similar tumours may follow organ
transplantation.
Classication
This is complex and ever-changing with
a real risk of heart-sink for the uniniti-
ated. In simplest terms NHL can be
divided into high-grade and low-grade
types. High-grade tumours are com-
posed of large poorly differentiated
lymphoid cells. They have an aggressive
Table 30.1 The WHO classication of
lymphoid malignancy
1
With respect to NHL, approximately 90% of cases are
of B-cell type and 10% of T-cell type. The commonest
NHL entities are follicular (2025% of all cases) and
diffuse large B-cell (3035%)
B-cell neoplasms
Precursor B-cell neoplasms
Precursor B-lymphoblastic lymphoma/leukaemia
Mature B-cell neoplasms
Chronic lymphocytic leukaemia/small lymphocytic
lymphoma
Lymphoplasmacytic lymphoma
Hairy cell leukaemia
Plasma cell myeloma/plasmacytoma
Marginal zone lymphoma
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma
Burkitts lymphoma
B-cell proliferations of uncertain malignant
potential
T-cell and putative NK-cell neoplasms
Precursor T-cell neoplasms
Precursor T-lymphoblastic lymphoma/leukaemia
Mature T-cell and NK-cell neoplasms
T-cell prolymphocytic leukaemia
T-cell large granular lymphocyte leukaemia
Adult T-cell lymphoma/leukaemia
Mycosis fungoides/Sezarys syndrome
Enteropathy-type T-cell lymphoma
Angioimmunoblastic T-cell lymphoma
Peripheral T-cell lymphoma unspecied
Anaplastic large cell lymphoma
Hodgkins lymphoma (see p. 58)
1
See text for discussion.
Fig 30.1 Axillary lymphadenopathy in
non-Hodgkins lymphoma.
61 Non-Hodgkins lymphoma
histological examination (Fig 30.2).
Immunophenotyping is used to identify
the degree of maturation of the malig-
nant cell and determine whether it is of
B- or T-cell origin. B-cell antigenic
markers include CD19, 20 and 22 and
T-cell markers CD2, 3, 5 and 7. Gene
rearrangement studies also aid identi-
cation. B-cell lymphomas have their
immunoglobulin genes clonally rear-
ranged while in T-cell lymphomas there
is clonal rearrangement of the T-cell
receptor genes. Molecular techniques
(see p. 100) are being increasingly used
to detect chromosome abnormalities
and to derive prognostic information.
The staging system is similar to that
used in Hodgkins lymphoma. Patients
are staged with CT scanning (Fig 30.3),
MRI or PET, and a bone marrow aspi-
rate and trephine. However, in NHL the
stage plays a more modest role in man-
agement than in Hodgkins lymphoma.
The histological type of the tumour is
more closely related to the likely clinical
course and other factors impinge upon
prognosis. An international prognostic
index (IPI), based on age, stage, bulk of
disease, performance status and serum
lactate dehydrogenase (LDH) level, is
commonly used (see Appendix III).
Management and
prognosis
Only some of the commoner NHL sub-
types will be discussed.
Follicular lymphoma
Follicular lymphoma is usually a low-
grade tumour. There is typically dis-
seminated disease at presentation, an
initial good response to therapy, but
then recurrent relapses at decreasing
intervals. Median survival is between
10 and 15 years. Patients may initially
require no treatment. Local disease
(unusual) may be treated with radio-
therapy. For disseminated disease
requiring intervention there is a wide
range of possibilities. There is a move
towards rituximab (anti-CD20 mono-
clonal antibody)-containing regimens
(e.g. R-CVP: rituximab, cyclophospha-
mide, vincristine, prednisolone) but oral
agents such as chlorambucil and udara-
bine are still widely used. For relapsed
disease in younger patients either
autologous or allogeneic stem cell trans-
plantation should be considered. Radio-
immunotherapy (the combination of a
monoclonal antibody with a radioiso-
tope) is a promising alternative. Rituxi-
mab maintenance therapy for 2 years
after induction treatment appears to
improve survival but cure remains
elusive.
Diffuse large B-cell lymphoma
This is the commonest type of high-
grade NHL, the classic presentation
being a rapidly enlarging nodal mass. A
few cases will have transformed from
previous follicular NHL. Localised
disease is generally treated with a com-
bination of shortened chemotherapy
and local radiotherapy. Disseminated
disease requires full course chemother-
apy and an anthracycline-based regimen
combined with rituximab (R-CHOP;
cyclophosphamide, doxorubicin, vinc-
ristine, prednisolone) is the standard.
Approximately 7080% of patients will
achieve remission and 60% will be
cured. In patients with high-risk disease
(based on IPI or genetic abnormalities)
or relapse, use of more intensive chemo-
therapy with or without stem cell
support can potentially improve the
prognosis.
Selected other
lymphoma subtypes
Mantle cell lymphoma is heterogene-
ous but is typically disseminated with
marrow involvement and a poor
response to treatment. Median survival
is only 4 years. Marginal zone lym-
phoma is indolent and includes extran-
odal tumours of mucosa-associated
lymphoid type (MALT). MALT lym-
phoma of the stomach is associated with
Helicobacter pylori and antibiotic treat-
ment to eliminate the bacterium may
lead to lymphoma regression. Burkitts
lymphoma is treated with intensive
combination chemotherapy with a good
chance of cure in younger patients.
There is a high risk of tumour lysis syn-
drome. Peripheral T-cell lymphomas
have a high incidence of extranodal
disease and, overall, a worse prognosis
than B-cell NHL. The CHOP regimen
is commonly used but in view of
the disappointing results a number
of experimental agents are under
investigation.
Fig 30.2 Section of a cervical lymph node
showing extensive inltration with large
poorly differentiated lymphoid cells typical
of diffuse large B-cell non-Hodgkins
lymphoma.
Fig 30.3 CT scan of the abdomen showing
enlargement of lymph nodes in a patient
with non-Hodgkins lymphoma.
Non-Hodgkins lymphoma
The term NHL encompasses solid tumours of lymphoid tissue which are not Hodgkins
lymphoma.
Histological classication is complex. There is great clinical heterogeneity with indolent and
aggressive types of disease.
Indolent (e.g. follicular) NHL often initially responds well to chemotherapy but cure is
elusive.
Aggressive (e.g. diffuse large B-cell) NHL may be cured with conventional chemotherapy
combined with rituximab (R-CHOP); autologous stem cell transplants are increasingly used
for high-risk and relapsed disease.
62 5 LYMPHOMA AND MYELOMA
31 Myeloma
myeloma requires evidence of such impairment; typically
increased calcium, renal insufciency, anaemia, or bone
lesions (Table 31.1 and Fig 31.3). Bony disease is increasingly
assessed by MRI scanning in addition to traditional X-rays
(skeletal survey) (Fig 31.4). Patients who have a paraprotein
in the serum but who do not meet the criteria for myeloma
are diagnosed as having MGUS. They have a rate of progres-
sion to myeloma of 1% per year. Monoclonal gammopathy is
associated with other diseases such as lymphoma, non-
haematopoietic malignancies and connective tissue disorders
but it is also quite common in healthy elderly people (approxi-
mately 5% over 70 years of age).
The prognosis of myeloma can be predicted from present-
ing clinical and laboratory features (Table 31.2). The combina-
tion of a high
2
-microglobulin level and a low albumin level
Introduction
Multiple myeloma is a malignant disorder in which there is an
uncontrolled proliferation of clonal plasma cells in the bone
marrow. Secretion of a variety of proteins by the malignant
cells leads to characteristic symptoms and signs. Myeloma
constitutes 1015% of all haematological malignancies and is
essentially a disease of the elderly only 2% of cases are diag-
nosed in patients less than 40 years old.
Basic biology
The initial step in the development of myeloma is the appear-
ance of a small number of clonal plasma cells (the clinical
syndrome is monoclonal gammopathy of uncertain signi-
cance (MGUS) ). Approximately 50% of patients with MGUS
have translocations involving the immunoglobulin heavy
chain locus on chromosome 14q32. With progression to frank
myeloma, more complex genetic events occur in the neoplas-
tic plasma cells. Changes in the bone marrow microenviron-
ment include the induction of angiogenesis, the suppression
of cell-mediated immunity and increased secretion of
interleukin-6, a powerful growth factor for myeloma cells.
Bone lesions result from osteoclast activation. Myeloma cells
secrete a monoclonal immunoglobulin or immunoglobulin
fragments (M-proteins or paraproteins) composed of a
single heavy chain class and a single light chain class, kappa
or lambda. Most myelomas produce IgG or IgA but light
chains alone are produced in over 10% of cases. Free light
chain appearing in the urine is termed Bence Jones protein.
Occasionally myeloma is non-secretory with no detectable
M-protein. Localised plasma cell tumours in the absence of
systemic myeloma are termed plasmacytomas.
Clinical features
More than two-thirds of patients have bone pain at presenta-
tion. Pain is most common in the back and chest and may be
attributed to arthritis. More advanced bone disease can lead
to pathological fractures or vertebral collapse with loss of
height. Inltration of the bone marrow by plasma cells may
lead to symptoms of anaemia or bleeding due to thrombocy-
topenia. Infections are common due to immune paresis (low
level of normal immunoglobulins) and other complications
which may lead to symptoms include hypercalcaemia, amy-
loidosis and renal failure. The major cause of the nephropathy
is deposition of obstructive tubular casts composed of immu-
noglobulin light chains other possible factors include dehy-
dration, infection and amyloid.
Diagnosis and staging
Myeloma is an easy malignancy to miss as the early symp-
toms such as malaise and backache are common in the popu-
lation. The combination of backache and a high erythrocyte
sedimentation rate (ESR) should be taken seriously as it may
indicate myeloma or another metastatic malignancy.
In asymptomatic (smouldering) myeloma there is gener-
ally a serum monoclonal protein >30 g/L and/or bone marrow
clonal plasma cells >10% but no related organ or tissue
impairment (Figs 31.1 and 31.2). A diagnosis of symptomatic
Fig 31.1 The blood lm in myeloma. There is marked rouleaux
formation and increased background staining.
Fig 31.2 The bone marrow in myeloma. The malignant plasma cells
show varying degrees of maturity.
Fig 31.3 Electrophoretic strip showing serum paraprotein bands.
Patient 1 has an IgM paraprotein (Waldenstrms macroglobulinaemia),
patient 2 IgA myeloma and patient 3 IgG myeloma.
63 Myeloma
carries a particularly poor prognosis.
Cytogenetic and molecular genetic pro-
les of the malignant cells also predict
myeloma behaviour. Hyperdiploid and
t(11;14) mutations dene standard risk
disease while non-hyperdiploid, t(4;14),
del(17p) and del(13q) mutations indi-
cate inferior outcome.
Management and
outcome
Myeloma may be diagnosed by chance
on laboratory screening in patients with
limited disease and no symptoms. In
this group, about 20% of all patients,
the disease may remain stable for
several years and there is no advantage
in early intervention. Where treatment
is required this generally entails drug
therapy, management of specic com-
plications, and palliation.
Drug therapy
Myeloma remains incurable with
current standard treatment but there
has been recent progress with the intro-
duction of novel therapeutic agents
targeting myeloma cells and their micro-
environment. Treatment algorithms are
evolving rapidly but the immunomodu-
latory agent thalidomide is frequently
used in rst-line regimens (often com-
bined with dexamethasone and cyclo-
phosphamide). In younger tter patients
(<6570 years) induction therapy is gen-
erally followed by stem cell harvesting
and intensication of treatment with
high dose melphalan and autologous
stem cell transplantation. This strategy
gives a median survival of 5 years.
Other agents increasingly used in
induction and maintenance therapy
include lenalidomide, pomalidomide
and the proteosome inhibitor borte-
zomib (Velcade). All patients should
(see p. 94). Additional bisphosphonate
therapy is helpful in hypercalcaemia,
and anaemia can respond to erythropoi-
etin. Renal failure often responds to
rehydration and chemotherapy but
haemodialysis may be required.
Palliative treatment
a team approach
Particular emphasis is placed on pain
relief and the maintenance of independ-
ence (see pp. 9495).
Waldenstrms
macroglobulinaemia
This disease is a form of indolent lym-
phoma. It is appropriately considered
with myeloma as the malignant cells,
which show features of lymphocytes
and plasma cells, secrete an IgM para-
protein. Patients may complain only of
fatigue, but high IgM levels can lead to
the hyperviscosity syndrome, with con-
fusion and neurological symptoms. In
these cases retinal examination reveals
engorged veins, haemorrhages, exudates
(Fig 31.5) and rarely papilloedema.
Other possible physical signs include
lymphadenopathy and hepatosplenom-
egaly. Where treatment is required,
options include chemotherapy (e.g.
chlorambucil or udarabine) and mono-
clonal antibodies (e.g. rituximab).
Signicant hyperviscosity requires
plasmapheresis.
Table 31.2 Myeloma: poor prognostic factors
Low haemoglobin
High calcium
High M-protein or Bence Jones protein level
Multiple lytic lesions on X-ray
High creatinine (i.e. renal failure)
High
2
-microglobulin
Low albumin
Poor response to chemotherapy
Adverse cytogenetics (e.g. del(17p) )
Table 31.1 Diagnostic criteria for
symptomatic myeloma
Monoclonal protein in serum and/or urine (Fig 31.3)
Bone marrow clonal plasma cells
1
or plasmacytoma
(Fig 31.2)
Related organ or tissue impairment (end organ
damage including bone lesions)
1
If ow cytometry is performed most plasma cells (>90%) will show a
neoplastic phenotype.
Fig 31.4 X-rays of the skull (a) and left
radius and ulna (b) in a patient with
myeloma. Numerous lytic lesions are seen.
(a)
(b)
additionally receive a bisphosphonate.
In the very elderly or in patients with
signicant comorbidity, a gentler
approach (e.g. low dose melphalan and
prednisolone) may be justied. In the
rare very t young patient allogeneic
stem cell transplantation is a potentially
curative but very toxic option.
Management of complications
The pain of bone disease may require
local radiotherapy in addition to analge-
sia. In spinal compression, radiotherapy
and high-dose steroids usually obviate
the need for laminectomy. Spinal
pain may be alleviated by vertebroplasty
Fig 31.5 The fundus in hyperviscosity
syndrome complicating Waldenstrms
macroglobulinaemia.
Myeloma
Myeloma is a malignant proliferation of plasma cells.
Diagnostic features include an M-protein in the serum and/or urine, osteolytic bone
lesions and inltration of the bone marrow by malignant plasma cells.
Bone pain is the most common presenting symptom.
Complications include renal failure, hypercalcaemia and amyloidosis.
Commonly used agents include thalidomide, lenalidomide and bortezomib. Autologous
stem cell transplantation is performed in younger tter patients.
Good palliative care, especially pain relief, is crucial.
Waldenstrms macroglobulinaemia is a form of indolent lymphoma with secretion of an
IgM paraprotein and possible hyperviscosity.
64 6 MYELOPROLIFERATIVE NEOPLASMS
32 Polycythaemia
hypercellularity but there may be no
pathognomonic features. Testing for the
JAK2 V617F mutation is now central to
the diagnosis of PV (Table 32.1). Around
95% of patients with PV are positive. In
the rare negative PV cases, mutations in
exon 12 of JAK2 have been found. It is
likely that other genetic events (e.g.
MPL, TET2 mutations) are required for
disease development.
Management. The dual purpose of
treatment is to relieve symptoms and to
reduce the risk of complications such as
thrombotic disease and bleeding. Aspirin
(75 mg/day) should be given unless
Introduction
In simple terms, polycythaemia (or
erythrocytosis) means an increase in red
cell count, haemoglobin and packed cell
volume (PCV) above the normally
accepted levels. Polycythaemia due to an
absolute increase in red cell mass may
occur as a myeloproliferative neoplasm
(polycythaemia vera (PV) ) or secondary
to hypoxia or an abnormal focus of
erythropoietin secretion. In apparent
polycythaemia the raised haemoglobin
and PCV are not accompanied by a sig-
nicantly raised red cell mass; usually
the plasma volume is relatively reduced
(Fig 32.1).
An approach to the
patient with
polycythaemia
The initial decision to investigate further
is taken on the basis of a persisting
raised PCV (haematocrit) or haemo-
globin level. If true polycythaemia is
conrmed by measurement of red cell
mass and plasma volume then the next
step is to determine whether this is
primary or secondary. The full sequence
of investigations is not required in all
cases. For example, in a patient with
known respiratory disease causing
chronic hypoxia, a degree of polycythae-
mia is predictable and does not require
investigation (Fig 32.2).
Clinical syndromes
Polycythaemia vera (PV)
PV is a myeloproliferative neoplasm;
other diseases in this category are essen-
tial thrombocythaemia and myelobro-
sis (see p. 66). In PV a pluripotential stem
cell is mutated. Almost all patients with
the disease (and some with essential
thrombocythaemia and myelobrosis)
have an identical acquired point muta-
tion in the Janus kinase 2 (JAK2) gene.
Clinical features. The raised red cell
mass and total blood volume with asso-
ciated hyperviscosity causes the symp-
toms and signs of the disease. Common
complaints include headaches, dizziness,
lethargy, sweating and pruritus (the
latter particularly after a hot bath). Most
importantly, there is an increased risk of
arterial and venous thrombosis, particu-
larly strokes. Paradoxically, a combina-
tion of hyperviscosity and platelet
Fig 32.1 Red cell mass and plasma volume in normality, true polycythaemia and apparent
polycythaemia. (a) Normal red cell mass (RCM) and plasma volume (PV). (b) True polycythaemia:
there is a signicant increase in RCM and total blood volume. (c) Apparent polycythaemia: RCM and PV
are at the upper and lower limits of the normal range with a resultant increased haematocrit.
Upper limit
red cell mass
(a) (b) (c)
Plasma
volume (PV)
Red cell
mass (RCM)
Fig 32.2 Approach to the patient with polycythaemia.
1
If there is any doubt as to the secondary aetiology, investigations for polycythaemia vera (e.g. JAK2
testing) should still be performed.
Raised packed
cell volume
Male > 0.52
Female > 0.48
Polycythaemia
Apparent
polycythaemia
Secondary
polycythaemia
Polycythaemia
vera
Raised red cell mass
No
No
No
Yes
Yes
Yes
Causes of secondary polycythaemia
present
1
(see Table 32.2)
Diagnostic criteria for polycythaemia
vera present (see Table 32.1)
Idiopathic erythrocytosis
dysfunction may cause a bleeding ten-
dency. The increased cell turnover can
lead to gout (Fig 32.3). Patients are char-
acteristically plethoric and may have
rosacea (Fig 32.4). Palpable splenomeg-
aly may be present.
Diagnosis. The diagnostic challenge
is to differentiate PV from a secondary
polycythaemia. Splenomegaly and ele-
vated white cell and platelet counts are
suggestive of PV. Increased erythropoi-
esis can lead to iron deciency. Erythro-
poietin estimation by radioimmunoassay
is normal or low. The bone marrow
aspirate and trephine in PV show
65 Polycythaemia
contraindicated. The PCV is reduced
below 0.45 by venesections (up to
450 mL of blood removed) which may
initially be required twice weekly. In
more severe disease the need for vene-
section can become intolerable and
cytotoxic drugs are used to suppress
erythropoiesis. Hydroxycarbamide is
the usual choice. Interferon alfa can be
useful in younger patients and in preg-
nancy. Busulfan is effective given inter-
mittently but is best limited to older
patients as there is a signicant risk of
secondary malignancy. Drug treatment
is particularly important when there is
a need to control coexistent thrombocy-
tosis or progressive splenomegaly. JAK2
inhibitors are under investigation.
PV is a relatively benign disorder and
if well controlled is compatible with a
median survival of greater than 10 years.
However, it is a clonal disease and a few
patients eventually transform to mye-
lobrosis (10%) or even acute leukaemia
(5%). The risk of the latter is increased
by treatment with alkylating agents.
Secondary polycythaemia
This is due to either a physiological
response to hypoxia or an inappropriate
secretion of erythropoietin. Causes are
numerous and are listed in Table 32.2
(and see Fig 32.5). Treatment is
essentially that of the underlying cause,
although cases with very high PCVs
may benet from venesection.
Idiopathic erythrocytosis
This is a small heterogeneous group of
patients who have an absolute poly-
cythaemia without features of either PV
or secondary polycythaemia. Venesec-
tion may be required.
Apparent polycythaemia
This condition has accumulated several
names including spurious, stress or rela-
tive polycythaemia, pseudopolycythae-
mia and Gaisbocks syndrome. The
usual cause is an increase in red cell
mass and a decrease in plasma volume
within the normally accepted limits (see
Fig 32.1). Patients are most frequently
male and middle-aged. Other common
characteristics are excess weight, hyper-
tension, diuretic use and signicant con-
sumption of alcohol and tobacco. The
adoption of a healthier lifestyle often
leads to resolution of polycythaemia.
Venesection is not routine but is consid-
ered where there are thrombotic risk
factors.
Fig 32.3 Gout complicating severe PV.
Fig 32.4 The face is a diagnostic clue in
polycythaemia vera. Patients are frequently
plethoric and may have rosacea.
Table 32.1 Diagnostic criteria for
polycythaemia vera (PV)
1
The diagnosis of PV requires (1) both major criteria and
one minor or (2) the rst major and two minor criteria.
Major criteria
Signicantly raised haematocrit
2
Presence of JAK2 mutation
Minor criteria
1. Bone marrow trephine biopsy showing
hypercellularity for age and other features of
myeloproliferation
2. Low serum erythropoietin level
3. Endogenous erythroid colony formation
1
World Health Organization 2008.
2
Haemoglobin level or red cell mass may also be used.
Fig 32.5 Clubbing in a patient with
cyanotic congenital heart disease and
secondary polycythaemia.
Table 32.2 Causes of secondary
polycythaemia
Hypoxia High altitude
Hypoxic lung disease
Cyanotic congenital heart
disease (Fig 32.5)
Smoking
Abnormal Hb with increased
O
2
afnity
Inappropriate
secretion of
erythropoietin
Renal disease (e.g. tumours,
cysts, hydronephrosis)
Hepatoma
Cerebellar haemangioblastoma
Phaeochromocytoma
Uterine broids
Other Androgens
Neonatal polycythaemia
Hypertransfusion
Note: In practice hypoxia is by far the commonest cause. Renal
tumours are a rare cause but important to exclude. Neonatal
polycythaemia is discussed on page 90.
Polycythaemia
Polycythaemia means an increase in haemoglobin and PCV above normally accepted limits.
Polycythaemia can be absolute (with an increased red cell mass) or apparent (with a
normal red cell mass). The absolute form can be primary or secondary.
Polycythaemia vera is a myeloproliferative neoplasm associated with mutations in the JAK2
gene. Secondary polycythaemia arises from a physiological response to hypoxia or
inappropriate secretion of erythropoietin.
Management of PV is by venesection alone or with cytotoxic drugs.
Treatment of secondary polycythaemia is essentially that of the underlying cause.
Apparent polycythaemia may respond to adoption of a healthier lifestyle.
66 6 MYELOPROLIFERATIVE NEOPLASMS
33 Essential thrombocythaemia and myelobrosis
ET as opposed to a reactive thrombocy-
tosis. Even where there is an acquired
JAK2 gene mutation, other myeloprolif-
erative disorders must be excluded.
Bone marrow examination is worth-
while to exclude chronic myeloid
leukaemia (absence of Philadelphia
chromosome), myelobrosis or myelo-
dysplasia, and to check iron stores.
Patients with polycythaemia vera may
have thrombocytosis, while patients
with ET can have an increased red cell
mass. In practice such patients are better
diagnosed as having myeloproliferative
neoplasms rather than forced into either
category. Only about 5% of all raised
platelet counts are due to ET, but per-
sistence of the count above 1000, par-
ticularly with coexistence of thrombosis
or haemorrhage, makes it the likely
diagnosis. Abnormal platelet function
tests suggest ET rather than a reactive
thrombocytosis.
Management
Management is not straightforward.
The decision whether to treat at all must
follow consideration of the patients age,
the degree of thrombocytosis and the
presence or perceived risk of signicant
thrombotic or haemorrhagic events.
Any clinical benet must be weighed
against potential toxicity of cytotoxic
drugs. In a patient of more advanced age
(>60 years) or with a very high platelet
count (>1500) or a history of throm-
boembolic disease, the treatment of
choice is hydroxycarbamide and low-
dose aspirin. Anagrelide or interferon
alfa may be preferred where hydroxy-
carbamide is not tolerated. The objective
of treatment is to maintain the platelet
count in the normal range and prevent
thrombosis and haemorrhage. Low-
dose aspirin alone is a reasonable option
in patients at lower risk of these compli-
cations. Interferon is the usual drug of
choice in pregnancy.
Myelobrosis
Primary myelobrosis is a myeloprolif-
erative neoplasm characterised by bone
marrow brosis and splenomegaly. It
may develop de novo or in the setting of
polycythaemia vera or essential throm-
bocythaemia. Most patients are over 50
years.
Myelobrosis is a neoplastic clonal
disorder originating in a single
pluripotential stem cell. Abnormal meg-
akaryocytes are produced in increased
numbers and it is these cells which
release cytokines such as platelet-derived
growth factor (PDGF) and transforming
growth factor-, which stimulate brob-
last proliferation and build-up of colla-
gen in the bone marrow. The scarred
marrow is unable to function normally
and haematopoietic stem cells move to
the spleen and liver (extramedullary
haematopoiesis).
Essential
thrombocythaemia
Essential thrombocythaemia (ET) is
a chronic myeloproliferative neoplasm
characterised by a persistent increase in
platelet count. It is thought to be a clonal
stem cell disorder although recent
studies suggest that it is heterogeneous.
Almost half of ET patients are positive
for the JAK2 V617F mutation (see p. 64).
They appear to have distinct clinical fea-
tures including a closer link to poly-
cythaemia vera and a higher incidence
of thrombosis. ET may be associated
with either thrombotic or haemorrhagic
complications, the latter caused by
abnormal platelet function. The average
age of presentation is around 60 years.
The prognosis is generally good
although there is a risk of transforma-
tion to myelobrosis, polycythaemia
and acute myeloid leukaemia.
Clinical features
ET may be asymptomatic and discov-
ered accidentally on routine blood
testing. Symptoms commonly arise
from disturbances of the microcircula-
tion. Patients may complain of burning
sensations in the soles and palms, cold
peripheries and varied neurological
symptoms including headache and
dizziness. Arteriolar occlusion can cause
ischaemia, gangrene or acrocyanosis.
Thrombosis of large arteries is of even
greater concern. Haemorrhagic prob-
lems are less common but include
ecchymoses, epistaxis, menorrhagia and
bleeding into the mouth and gut.
Splenomegaly is unusual at least in part
because of splenic infarction, which can
be painful.
Diagnosis
Platelet counts can be as high as
2000 10
9
/L and usually exceed 450
10
9
/L (the normal range is 150400
10
9
/L) (Fig 33.1). In practice, there is no
single test to specically identify ET
diagnosis is often a process of exclusion.
As thrombocytosis may accompany a
wide range of disorders including infec-
tions, inammatory conditions, malig-
nancy and iron deciency, a thorough
history and examination is mandatory.
The lack of a measurable acute phase
response (i.e. normal erythrocyte sedi-
mentation rate, plasma viscosity and
brinogen) increases the likelihood of
Fig 33.1 Blood lm in essential
thrombocythaemia showing increased
numbers of platelets of varying size.
Fig 33.2 Blood lm in myelobrosis
showing a myelocyte and nucleated red cell
(i.e. leucoerythroblastic lm) and tear-drop
poikilocytes.
67 Essential thrombocythaemia and myelobrosis
Clinical features
The disease is often insidious in onset with fatigue and weight
loss. Splenomegaly is present in all cases and massive in 10%
(Fig 33.4). Splenic pain is common and a bulky spleen may
lead to portal hypertension, bleeding varices and ascites.
Hepatomegaly is seen in two-thirds of cases.
Diagnosis
Anaemia is almost universal and the blood lm shows tear-
drop poikilocytes and a leucoerythroblastic picture (Fig 33.2).
In the early stages, thrombocytosis and neutrophilia may
occur but in more advanced disease low counts are the rule.
Bone marrow aspiration characteristically results in a dry tap
(i.e. only peripheral blood aspirated), and a marrow trephine
showing dense reticulin bres on silver staining, brosis and
osteosclerosis is needed for diagnosis (Fig 33.3). There is
usually megakaryocytic hyperplasia. The JAK2 gene mutation
is present in approximately 50% of cases. X-rays often show
bone sclerosis. The major differential diagnosis is from other
myeloproliferative disorders and myelodysplastic syndromes
which may be associated with a degree of marrow brosis.
Systemic causes of marrow brosis such as marrow inltra-
tion by carcinoma or lymphoma and disseminated tubercu-
losis should also be considered.
Prognosis and management
Average survival is 47 years but this is very variable. Manage-
ment is increasingly guided by prognostic scoring systems.
Leukaemic transformation occurs in about 15% of patients.
Asymptomatic patients may require no treatment. For anaemia
a trial of a corticosteroid, androgen or erythropoietin is worth-
while but regular transfusion is usually needed. Oral chemo-
therapeutic agents such as hydroxycarbamide may improve
quality of life by reducing systemic upset and shrinking the
spleen. There is abnormal bone marrow angiogenesis in mye-
lobrosis and the anti-angiogenic agents thalidomide and
lenalidomide can improve blood counts and reduce splenom-
egaly with some durable responses. The JAK2 inhibitor rux-
olitinib is a promising new agent. Its major benets are
reduced splenomegaly and constitutional symptoms. Other
JAK2 inhibitors are under investigation.
Splenic irradiation can alleviate splenic pain. Splenectomy
must not be undertaken lightly as it is associated with con-
siderable mortality (around 510%). However, it is considered
for painful splenomegaly, unacceptable transfusion require-
ments, life-threatening thrombocytopenia, profound cachexia
or complications of portal hypertension.
Allogeneic stem cell transplantation is the only potentially
curative procedure. Use of reduced intensity conditioning
regimens (see p. 57) may allow its wider application.
Fig 33.3 Bone marrow trephine biopsy in myelobrosis. (a) Marked
brosis and osteosclerosis. (b) Increased reticulin bres (stained by silver
impregnation).
(a)
(b)
Fig 33.4 Massive splenomegaly in myelobrosis.
Essential thrombocythaemia
and myelobrosis
ET is a chronic myeloproliferative neoplasm characterised by a
persistent increase in platelet count.
Patients with ET may be asymptomatic or have either thrombotic
or haemorrhagic complications.
Patients with ET at high risk of complications are usually treated
with hydroxycarbamide and low-dose aspirin.
Myelobrosis is a myeloproliferative neoplasm characterised by
bone marrow brosis and splenomegaly.
Common symptoms in myelobrosis are fatigue, weight loss and
splenic pain.
Treatment of myelobrosis is problematic. Regular transfusion is
often needed for anaemia. Cautious chemotherapy, splenic
irradiation and splenectomy can relieve symptoms in some
patients. JAK2 inhibitors show promise.
68 7 HAEMOSTASIS AND THROMBOSIS
34 Thrombocytopenia
menorrhagia are all relatively common, with haematuria and
melaena less frequent. Intracranial bleeding is of serious
import but, thankfully, is rare. Possible examination ndings
include purpura and more extensive petechial haemorrhages
involving the skin and mucous membranes (Fig 34.2). The
retina should be routinely inspected for haemorrhages.
Clinical syndromes
Immune thrombocytopenia (ITP)
ITP is a disease characterised by immune thrombocytopenia
mediated by platelet antibodies that accelerate platelet destruc-
tion and inhibit their production. It is a heterogeneous
disorder but it is conventional to divide it into two discrete
entities: acute ITP and chronic ITP (Table 34.2). This division
is convenient for discussion of pathogenesis and apt for most
patients, but in real life there is overlap between the two
syndromes.
Acute ITP
The acute form of the disease is usually seen in childhood. It
typically has an abrupt onset a week or so following a trivial
viral illness. It is likely that in post-viral cases IgG antibody
attaches to viral antigen absorbed onto the platelet surface.
The resultant sudden fall in platelet count (often to below
20 10
9
/L) can lead to all the symptoms and signs quoted
above. Despite this, serious complications such as intracranial
bleeding are very rare and the disease is self-limiting in around
90% of cases. Often only observation is required, but where
the bleeding tendency is unusually severe, oral corticosteroids
or intravenous immunoglobulin can be given as in chronic
ITP (see below). A few children go on to develop chronic
thrombocytopenia, but even here the disease is relatively
benign and may eventually spontaneously remit.
Thrombocytopenia can be simply dened as a blood platelet
count of below 150 10
9
/L. With the routine measurement of
platelet number by automated cell counters it is a relatively
common laboratory nding. Before initiating further investi-
gations it is important to conrm that a low platelet count is
genuine by careful inspection of the blood sample and lm.
Either a small clot in the sample or platelet clumping (Fig
34.1) can cause artefactual thrombocytopenia.
Causes
Major causes of thrombocytopenia are listed in Table 34.1.
Many of the diseases and syndromes are discussed
elsewhere.
In general terms there are four possible processes leading
to thrombocytopenia:

Failure of marrow production. The bone marrow failure of

haematological disease (e.g. aplastic anaemia, leukaemia)
usually causes pancytopenia. However, thrombocytopenia
may be the only sign of intrinsic marrow disease or
marrow suppression associated with infection or
chemotherapy.

Shortened lifespan. Platelets can be destroyed in the

circulation. The most common mechanism is an
immunological reaction in clinical syndromes such as
immune thrombocytopenia.

Sequestration. Splenomegaly can cause low platelet counts

because of pooling in the enlarged organ. The spleen is
not necessarily massively enlarged.

Dilution. Normal platelets are diluted by massive blood

transfusion.
Clinical presentation
Patients with thrombocytopenia are particularly prone to
bleeding from mucous membranes. It should be emphasised
that spontaneous bleeding is usually only seen with platelet
counts of less than 1020 10
9
/L, although patients with
associated platelet dysfunction may bleed at higher counts.
Conjunctival haemorrhage, nose and gum bleeding and
Fig 34.1 Blood lm showing clumping of platelets. This phenomenon
causes an artefactual thrombocytopenia in the automated blood count.
Table 34.2 Comparison of classic acute and chronic ITP
Characteristic Acute ITP Chronic ITP
Age Childhood Adult life
Previous viral infection Frequent Unusual
Platelet count ( 10
9
/L) Often <20 Variable
Onset Sudden Insidious
Duration Few weeks Years/lifelong
Spontaneous remission Around 90% Rare
ITP, immune thrombocytopenia.
Table 34.1 Causes of thrombocytopenia
Pathogenesis Disease examples
Failure of production Leukaemia, myelodysplasia, aplastic anaemia,
megaloblastic anaemia, myelobrosis, malignant
inltration, infection, drugs
1
Shortened lifespan
Immune ITP, drugs
1
, connective tissue disorders, antiphospholipid
antibody syndrome, infection, post-transfusion
purpura, neonatal alloimmune thrombocytopenia
Non-immune DIC, thrombotic thrombocytopenic purpura
Sequestration Hypersplenism, cardiopulmonary bypass surgery
Dilution Massive blood transfusion
1
See Table 34.3.
ITP, immune thrombocytopenia; DIC, disseminated intravascular coagulation.
69 Thrombocytopenia
Chronic ITP
There has been recent change in our
understanding of the pathophysiology
of chronic ITP. Antibodies that mediate
platelet destruction also impact platelet
production by damaging megakaryo-
cytes and/or blocking the release of
proplatelets. A few cases may not
be antibody-mediated and will not
respond to standard immunosuppres-
sive therapies.
Chronic ITP is most common in adult
life. Patients may be asymptomatic or
have insidious onset of bleeding prob-
lems. Serious spontaneous bleeding is
generally limited to platelet counts
below 10 10
9
/L and even then it is
unusual. Fatigue is common. Paradoxi-
cally, it appears that the disorder may
have a pro-thrombotic element where
platelet counts are restored to normal.
A palpable spleen suggests a diagnosis
other than ITP.
The blood lm conrms thrombocy-
topenia; often the platelets are increased
in size (Fig 34.3). There is no single spe-
cic test for ITP. A bone marrow aspirate
and trephine biopsy will show increased
megakaryocytes but it is often not neces-
sary if other features are typical. Further
investigations are designed to exclude
other causes of isolated thrombocytope-
nia such as connective tissue disorders
and antiphospholipid antibody syn-
drome. Apparent primary ITP may be
secondary to subclinical viral infections
such as hepatitis C, cytomegalovirus,
HIV and Helicobacter pylori. In younger
patients congenital thrombocytopenias
may be confused with ITP. A thorough
drug history is essential.
Patients with asymptomatic mild
thrombocytopenia can be merely
observed. It is difcult to state a platelet
count below which treatment is manda-
tory. In practice, serious bleeding is rare
even at lower platelet counts and drug
side-effects are common so treatment
should generally be reserved for patients
who have symptoms or signs. The
normal rst-line treatment is pred-
nisolone (1 mg/kg body weight). About
two-thirds of patients have a signicant
increase in platelet count within weeks
but subsequent dose reduction often
leads to relapse. Where there is no
response to steroids, immunoglobulin
(IVIg) can be efcacious. Platelet trans-
fusions are seldom indicated as the
platelets are rapidly destroyed but
they may be considered in severe
haemorrhage.
If the platelet count cannot be ade-
quately maintained on non-toxic doses
of corticosteroid then splenectomy is
considered. About two-thirds of patients
have a good response. The management
of severe/symptomatic thrombocytope-
nia post-splenectomy is improving as
new agents are introduced. The mono-
clonal antibody rituximab may give
durable responses. Second-generation
thrombopoietin receptor (TPO-R) ago-
nists stimulate platelet production via
megakaryocyte proliferation and matu-
ration. Two TPO-R agonists in current
use are romiplostim and eltrombopag.
There remains a need for other
approaches including relatively non-
toxic doses of corticosteroids (e.g. pred-
nisolone 10 mg), pulsed high dose
corticosteroids, intermittent IVIg,
danazol, vinca alkaloids, ciclosporin, aza-
thioprine and mycophenolate. All give
some responses reecting the heteroge-
neity of the disease.
Drug-induced thrombocytopenia
Many drugs have been linked with iso-
lated thrombocytopenia (Table 34.3).
The mechanism is usually the forma-
tion of antiplatelet antibodies. General
management is withdrawal of the
offending drug and platelet transfusion
for signicant bleeding.
Heparin-induced thrombocytopenia
(HIT) is an immune-mediated disorder
caused by the development of antibod-
ies to platelet factor 4 and heparin.
The thrombocytopenia is typically
non-severe and occurs 510 days after
starting heparin. Unlike other drug-
induced thrombocytopenias, HIT leads
to increased risk of thromboembolism.
Heparin should be stopped and an alter-
native anticoagulant substituted.
Post-transfusion purpura
In this very rare syndrome severe throm-
bocytopenia develops approximately 1
week after a blood transfusion. In most
cases the patients platelets are negative
for the platelet antigen HPA-1a and the
transfused platelets are HPA-1a positive.
In a way incompletely understood an
anti-HPA-1a isoantibody destroys the
patients own platelets. Bleeding may be
severe. IVIg is an effective treatment.
Fig 34.2 Purpuric rash in a patient with
acute ITP.
Fig 34.3 Blood lm in ITP. The platelets are
reduced in number and increased in size.
Table 34.3 Some drugs associated
with thrombocytopenia
Heparin Penicillin
Quinine/quinidine Diazepam
Gold salts Tolbutamide
Sulphonamides Aspirin
Thiazides Cephalosporins
Rifampicin Ranitidine
Thrombocytopenia
Thrombocytopenia (a low platelet count) is a relatively common laboratory nding. It is
important that it is conrmed by inspection of a blood lm.
In general thrombocytopenia can be caused by failure of marrow production, shortened
platelet lifespan, sequestration in the spleen and dilution by massive blood transfusion.
Immune thrombocytopenia (ITP) is a heterogeneous disease characterised by platelet
antibodies which accelerate platelet destruction and inhibit their production.
Acute ITP is usually seen in childhood and is typically self-limiting. Chronic ITP classically
occurs in adult life. There is often an initial response to steroid treatment but splenectomy
may ultimately be required. Newer agents include rituximab and thrombopoietin receptor
agonists.
70 7 HAEMOSTASIS AND THROMBOSIS
35 Disorders of platelet function and
vascular purpuras
Inherited disorders of
platelet function
The commonest inherited platelet func-
tion and coagulation disorder, von Wil-
lebrand disease, is described on page 74.
BernardSoulier syndrome
This is a rare autosomal recessive bleed-
ing disorder. There is a combination of
platelet dysfunction, thrombocytopenia
and abnormal platelet morphology.
The mild thrombocytopenia is probably
caused by reduced platelet survival. The
functional platelet defect arises from
mutation in the polypeptides of the
glycoprotein (GP) Ib/IX/V complex. This
complex is crucial for the initial adhe-
sion of platelets to exposed subendothe-
lium at high shear ow and for binding
of platelets to von Willebrand factor.
In platelet aggregation studies there is
failure to aggregate with ristocetin.
Bleeding can be severe and particularly
complicates other predisposing events
such as peptic ulcers and pregnancy.
Patients require platelet transfusion for
severe bleeding and prior to surgery.
Antibrinolytic agents and DDAVP (see
p. 73) are useful in some cases.
Glanzmanns thrombasthenia
This rare autosomal recessive disease is
also caused by loss or dysfunction of a
platelet glycoprotein complex GP IIb/
IIIa. This normally acts as a receptor for
adhesive proteins such as brinogen
and von Willebrand factor. Platelet
numbers and morphology are normal
but the platelets fail to aggregate with all
agonists except ristocetin (see Fig 35.1).
Clinical manifestations are variable but
there is typically onset in the neonatal
period and subsequent cutaneous and
gastrointestinal bleeding, and menor-
rhagia. Platelet transfusions are indi-
cated where local haemostatic measures
fail. If there is platelet refractoriness,
recombinant factor VIIa can be used.
Other disorders
Hereditary diseases of platelet function
may also result from deciency of plate-
let storage organelles (storage pool dis-
orders) or release defects where there is
failure to successfully release granule
contents upon platelet activation. These
disorders usually cause only mild bleed-
ing problems.
Acquired disorders of
platelet function
These disorders are common. Causes
include foods, drugs, systemic disorders
and diseases of the blood (Table 35.1).
Aspirin
Many drugs can affect platelet function
but aspirin is the best documented and
the most frequently prescribed. At lower
doses aspirin selectively acetylates and
irreversibly inactivates the enzyme
cyclooxygenase-1 (COX-1), preventing
the production of thromboxane A
2
from
arachidonic acid and inhibiting aggrega-
tion for the remainder of the platelets
lifespan. Responses are variable but
aspirin can dramatically prolong the
bleeding time and cause haemorrhage
Platelet dysfunction should be consid-
ered wherever there are the clinical
symptoms and signs of thrombocytope-
nia (p. 14) in the presence of a normal
or only moderately reduced platelet
count. Disorders of platelet function can
be divided into inherited disorders
which are rare but well characterised in
the laboratory, and acquired disorders
which are much more common but
often of obscure aetiology. Bleeding
problems may also arise in a number of
inherited and acquired disorders of the
vasculature and its supporting connec-
tive tissue the vascular purpuras.
Laboratory testing of
platelet function
Ideally, blood samples for testing of
platelet function should be taken from
fasting and resting subjects who have
not smoked, ingested caffeine or drugs
known to affect platelet function. A
blood count and blood lm are rou-
tinely performed. The bleeding time,
where a small incision is made in the
forearm skin and the time to cessation
of bleeding recorded, is now less used
as it is subjective and has poor reproduc-
ibility. A number of dedicated platelet
function instruments (e.g. PFA-100)
allow screening tests but the results
must be interpreted with caution as they
are not diagnostic or sensitive for mild
platelet disorders.
Platelet aggregation studies assess
the ability of platelets to aggregate in
response to the addition of a variety of
agonists (e.g. ADP, adrenaline (epine-
phrine), collagen, arachidonic acid, ris-
tocetin). The tracings produced (Fig
35.1) require expert interpretation. The
methodology remains the gold standard
with the response to agonists giving
characteristic patterns in inherited disor-
ders. Other tests of platelet function
include ow cytometry for the quantita-
tion of glycoprotein receptor density,
and the measurement of total and/or
released adenine nucleotides. The latter
tests may conrm the ndings from
platelet aggregation studies (e.g. in
BernardSoulier syndrome) or reveal
abnormalities where aggregation studies
are normal or equivocal (e.g. in a storage
pool disease or release defect).
Fig 35.1 Platelet aggregation studies. When compared with the normal control it can be seen
that in Glanzmanns thrombasthenia there is loss of aggregation with all the agonists used.
ADP Collagen Adrenaline
O
p
t
i
c
a
l

d
e
n
s
i
t
y
I
n
c
r
e
a
s
i
n
g

l
i
g
h
t

t
r
a
n
s
m
i
s
s
i
o
n
Addition
of agonist
Normal platelets Glanzmann's thrombasthenia
71 Disorders of platelet function and vascular purpuras
in patients with thrombocytopenia or
other coexistent bleeding problems.
Chronic renal failure
Uraemia can lead to multiple platelet
defects. Elevated levels of nitric oxide
may inhibit platelet adhesion, activation
and aggregation. Anaemia contributes
to uraemic bleeding as fewer red cells
mean that fewer platelets are displaced
towards an injured vessel wall. Dialysis
reduces haemorrhagic symptoms. This
can be supplemented by correction of
severe anaemia, DDAVP and platelet
transfusions.
Cardiopulmonary bypass
Platelets are activated and degranulated
in the extracorporeal circuit, impairing
their effectiveness in vivo. This may be
exacerbated by hypothermia and large
doses of heparin. Excessive bleeding is
uncommon but where this happens
platelet transfusion is efcacious.
Haematological diseases
Platelet function is impaired in a number
of blood diseases, including acute
myeloid leukaemia, myelodysplastic
syndromes, myeloproliferative disorders
and myeloma.
Vascular purpuras
A bleeding tendency caused by a local
or general vascular abnormality is
referred to as a vascular purpura (Table
35.2). Diagnosis of these diseases is
made mainly on clinical grounds with
laboratory exclusion of other haemo-
static defects.
Inherited disorders
Hereditary haemorrhagic
telangiectasia (HHT)
The hallmark of this rare autosomal
dominant disease is the development of
multiple ateriovenous malformations
(AVMs). Small AVMs are referred to as
telangiectasia. Close to the surface of the
skin and mucous membranes, they
often rupture and bleed. Two mutated
genes, endoglin and ALK1, have been
implicated. Clinical problems include
recurrent epistaxes (90% of cases), gas-
trointestinal haemorrhage, haematuria
and larger pulmonary arteriovenous
malformations (PAVMs). Chronic bleed-
ing from the gut causes iron deciency
anaemia. On examination there are the
characteristic telangiectasia (Fig 35.2).
Management includes local control of
bleeding (e.g. laser treatment of tel-
angiectasia), iron supplements and
embolisation of PAVMs.
Inherited diseases of
connective tissue
Several rare inherited disorders of con-
nective tissue predispose to bleeding.
The mechanism is either a general
failure of support of blood vessels or
defective interaction between platelets
and abnormal collagen. Specic diseases
include EhlersDanlos syndrome, pseu-
doxanthoma elasticum and Marfan
syndrome.
Acquired disorders
This is a very heterogeneous group.
HenochSchnlein purpura is a syn-
drome usually seen in childhood where
an itchy purpuric rash typically follows
an infection. Spontaneous remission is
the rule but renal failure may result.
Other causes of acquired purpuric
rashes include infections, drug reac-
tions, scurvy, trauma, prolonged steroid
therapy and simple old age (senile
purpura, Fig 35.3).
Table 35.1 Causes of abnormal
platelet function
Inherited BernardSoulier syndrome
Glanzmanns thrombasthenia
Storage pool disorders
Release defects
Other (e.g. von Willebrand disease)
Acquired Drugs (e.g. aspirin)
Foods (e.g. garlic)
Chronic renal failure
Cirrhosis
Cardiopulmonary bypass surgery
Blood diseases: acute myeloid
leukaemia, myelodysplastic syndromes,
myeloproliferative disorders, myeloma
Various systemic disorders
1
1
These include disseminated intravascular coagulation (DIC) and
thrombotic thrombocytopenic purpura (TTP).
Table 35.2 The vascular purpuras
Inherited Hereditary haemorrhagic telangiectasia
1
Connective tissue diseases
EhlersDanlos syndrome
Pseudoxanthoma elasticum
Marfan syndrome
Acquired HenochSchnlein purpura
Various infections
Drug reactions (allergic purpuras)
Senility
Prolonged corticosteroid treatment
Scurvy
Mechanical
1
Sometimes known as RenduOslerWeber disease.
Fig 35.2 Telangiectasia in hereditary
haemorrhagic telangiectasia.
Fig 35.3 Senile purpura.
Disorders of platelet function
and vascular purpuras
Platelet dysfunction should be considered where there are the clinical features of
thrombocytopenia in the presence of a normal or only moderately reduced platelet count.
Laboratory testing of platelet function normally includes a blood count, a blood lm and
platelet aggregation studies. Careful collection of the sample is crucial.
Inherited disorders of platelet function are generally well characterised but rare (e.g.
BernardSoulier syndrome), whereas acquired disorders are more frequent but often of
obscure aetiology.
Aspirin is a common cause of acquired platelet dysfunction.
A vascular purpura is a disorder with a bleeding tendency caused by a local or general
vascular abnormality. Diseases may be inherited (e.g. hereditary haemorrhagic
telangiectasia) or acquired (e.g. HenochSchnlein purpura).
72 7 HAEMOSTASIS AND THROMBOSIS
36 Haemophilia
can compress adjacent nerves and
vessels with serious consequences (Fig
36.2). Haematuria is not unusual and,
until recently, intracranial bleeding was
the most common cause of death in
haemophilia.
Complications of treatment
In afuent countries, factor VIII replace-
ment treatment as described below has
been enormously benecial in allowing
early control of bleeding and the avoid-
ance of chronic joint damage. Unfortu-
nately, most haemophiliac patients
treated before 1985 became infected
with pathogenic viruses contaminating
factor VIII concentrate, notably HIV
and hepatitis C. There are now improv-
ing therapies for both HIV and hepatitis
C infection and younger patients receiv-
ing only virus-free factor products have
avoided these complications. Approxi-
mately 25% of patients with severe hae-
mophilia will develop antibodies to
factor VIII (inhibitors). They tend to
appear in childhood but may occur after
years of treatment.
Diagnosis
Haemophilia is associated with a pro-
longed activated partial thromboplastin
time (APTT) in the routine clotting
screen. The diagnosis is conrmed by a
factor VIII assay. In the presence of a
family history there are usually few
problems in diagnosis. Tests can be
performed on umbilical cord blood. In
the absence of a family history the
disease may present in a young child
with bruising and a swollen joint and be
mistakenly regarded as non-accidental
injury. Mild haemophilia may only
cause problems after trauma or surgery.
All patients with bleeding or bruising of
a severity disproportionate to the trauma
sustained should be investigated to
exclude a bleeding disorder.
Management
Treatment of haemophilia is complex,
and severe disease is best managed in
haemophilia centres where an experi-
enced team of doctors, nurses, physio-
therapists and social workers can help
patients and their families to lead a rela-
tively normal life.
Treatment of bleeding
Most haemophiliac patients require
replacement therapy with factor VIII
concentrate and this is often self-
administered at home when a bleed
occurs (on demand treatment). The
Haemophilia is an inherited disorder of
coagulation. The general term haemo-
philia is usually taken to mean haemo-
philia A, a deciency of factor VIII, but
a smaller number of cases are caused by
a deciency of factor IX (haemophilia
B).
Haemophilia A
Haemophilia A is transmitted as an
X-linked recessive disorder. Thus, all
males with the defective gene have hae-
mophilia, all sons of haemophiliac men
are normal, all daughters are obligatory
carriers and daughters of carriers have a
50% chance of also being carriers. The
disease prevalence is 1 in 10 000 people.
The gene for factor VIII is situated at the
tip of the long arm of the X chromo-
some. A wide variety of mutations of the
gene can lead to underproduction of
factor VIII and the clinical syndrome of
haemophilia. In about half of haemo-
philia families an unusual molecular
genetic abnormality involving inversion
of the factor VIII gene at intron 22 has
been found. A family history is not inevi-
tably present, as up to 30% of all new
cases of haemophilia are due to recent
sporadic mutations.
Clinical features
As factor VIII is a critical component of
the blood coagulation pathway (see p.
12), low levels predispose to recurrent
bleeding. The likelihood of bleeding can
be roughly predicted from the factor
VIII level, which may be expressed as
units/dL or as percentage activity (Table
36.1).
Bleeding in haemophilia
The disease usually becomes apparent
when the child begins to crawl. Severely
affected patients not receiving prophylac-
tic treatment experience 3050 bleeding
episodes each year. The most common
problems are spontaneous bleeds into
joints, often elbows or knees, although
any joint can be involved. Patients may
develop particular target joints which
bleed frequently. They often have an
innate feeling that a bleed has started
prior to any objective signs. Recurrent or
inadequately managed joint bleeds lead
to chronic deformity of the joint with
swelling and pain (Fig 36.1).
Bleeding may also afict deep-seated
muscles, often the exor muscle groups.
If ignored, the enlarging haematoma
Table 36.1 Factor VIII level and clinical
severity of haemophilia
Factor VIII level Clinical severity
Less than 2 units/dL Severe: frequent spontaneous
bleeds into joints and muscles
25 units/dL Moderate: some spontaneous
bleeds, bleeding after minor
trauma
545 units/dL Mild: bleeding only after
signicant trauma or surgery
Fig 36.1 Chronic knee damage in severe haemophilia A. (b) Shows bilateral osteoporosis,
narrowing of the joint space and joint deformity.
(a) (b)
Fig 36.2 Psoas muscle bleed in haemophilia
A. There was sensory loss in the outlined area
caused by pressure on the femoral nerve.
73 Haemophilia
dose and duration of treatment depends
on the patients size and the locality and
magnitude of the bleed. One unit of
factor VIII is the amount contained in
1 mL of normal plasma. For spontane-
ous haemarthroses it is sufcient to
raise the factor VIII level to 30% of
normal; in a 70 kg man this entails a
dose of around 1000 units. More serious
bleeding or surgery requires levels of
70100% maintained until the risk sub-
sides (Fig 36.3). Factor VIII products
undergo processing to maximise quality,
purity and viral safety. Plasma-derived
factor VIII is being increasingly replaced
by recombinant factor VIII. Third-
generation recombinant factor VIII is
free of any animal or human protein.
Prophylactic (alternate day) recom-
binant factor VIII treatment in children
eradicates bleeding and improves quality
of life. Periods of secondary prophylaxis
may be considered in older patients
with problematic joint bleeds.
Treatment of inhibitors is highly spe-
cialised. Acute bleeds can be treated with
recombinant factor VII
a
or a concentrate
of activated vitamin K derived clotting
factors (FEIBA). Eradication of the inhib-
itor may be achieved by immune toler-
ance regimens where factor VIII is given
regularly in high doses with or without
immunomodulatory agents.
In patients with mild disease, 1-amino-
8-D-arginine vasopressin (DDAVP),
given intravenously or by nasal spray,
mobilises factor VIII from stores and
may avoid the need for concentrate. The
antibrinolytic agent tranexamic acid
can also be used to reduce bleeding it
should, however, be avoided in haema-
turia where it can induce clot colic.
Likely advances in haemophilia drug
therapy are pegylated recombinant
factor VIII allowing less frequent admin-
istration and novel approaches includ-
ing non-peptide haemostatic agents
which reduce reliance on replacement
coagulation factor.
Treatment of viral infection
Haemophiliac patients with HIV infec-
tion require state-of-the-art manage-
ment of the physical and social problems
which can arise. Hepatitis C infection
carries a long-term risk of cirrhosis (20
30%) and hepatocellular cancer. The
combination of pegylated interferon
and ribavirin eradicates the virus in 50
80% of cases dependent on the viral
genotype.
Gene therapy
Gene therapy is a potentially curative
treatment for haemophilia and is dis-
cussed on page 103.
The carrier state and
genetic counselling
Female carriers are generally asympto-
matic but some will have low enough
levels of factor VIII (1030%) to cause
excessive bleeding after trauma. In fami-
lies with inversion of the factor VIII
gene (see above), rst-generation molec-
ular biology methods have been used in
carrier and prenatal diagnosis (Fig 36.4).
The more recent development of
polymerase chain reaction (PCR)-based
screening and sequencing technology
has allowed identication of the muta-
tion in nearly all patients with haemo-
philia A. Large databases of the known
mutations are freely available.
Haemophilia B
Haemophilia B is an X-linked recessive
bleeding disorder in which there is a
deciency of factor IX. There are many
clinical similarities to haemophilia A
severely affected patients suffer recur-
rent spontaneous joint bleeds. However,
inhibitors (antibodies to factor IX) are
less common than in haemophilia A.
Earlier factor IX concentrates were asso-
ciated with thromboembolic complica-
tions but safer high purity preparations
and recombinant products are now
available for treatment. The half-life of
infused factor IX is around 18 hours and
thus it can often be given just once daily
to maintain levels after spontaneous
bleeding or surgery. Prophylactic treat-
ment can be given once or twice weekly.
Fig 36.4 Southern blotting illustrating the
factor VIII gene inversion. Lane 1, normal male;
Lane 2, female heterozygous for proximal
inversion; Lane 3, male with distal inversion; Lane
4, female heterozygous for distal inversion; Lane
5, normal female.
Fig 36.3 Typical response to factor VIII infusion in a patient with severe haemophilia.
An infusion of 3500 units will increase the level to around 100% in a 70 kg man. As factor VIII has a
half-life of 12 hours, the level falls to 50% at this time an infusion of 1750 units increases the level
from 50 to 100%.
0
0
20
40
60
80
100
12 24 Hours
Plasma factor VIII
level (%)
3500 u
Factor VIII
1750 u
Factor VIII
Haemophilia
Haemophilia A is an X-linked recessive disorder characterised by deciency of factor VIII.
Severely affected patients suffer recurrent spontaneous bleeds, most often into joints.
Replacement therapy with factor VIII concentrate is needed in
all but mild cases; previous contamination of plasma-derived concentrates has led to HIV
and hepatitis C infection.
DDAVP and tranexamic acid can help control bleeding in mild disease.
The management of choice in severely affected children is prophylactic treatment with
genetically engineered recombinant factor VIII.
Haemophilia B is characterised by deciency of factor IX; inheritance and clinical features
are similar to haemophilia A.
74 7 HAEMOSTASIS AND THROMBOSIS
37 Von Willebrand disease and other inherited
coagulation disorders
Von Willebrand disease
Von Willebrand disease (vWD) is the most common inherited
bleeding disorder. The prevalence of symptomatic vWD is
approximately 0.01%. Identication of milder forms is com-
plicated by the broad range of von Willebrand factor (vWF)
levels in the normal population; it is important to recognize
that the diagnosis of vWD requires the presence of bleeding
symptoms (see Fig 37.1).
All vWD is caused by mutations in the gene for vWF. vWF
is an adhesive glycoprotein secreted by endothelium and meg-
akaryocytes (see also p. 12). It is a multimeric protein with a
characteristic normal distribution of multimer sizes in plasma.
vWF has two key functions: promotion of platelet adhesion
to damaged endothelium and other platelets (Fig 37.2) and the
transport and stabilisation of factor VIII. Thus, the clinical
disorder of vWD is associated with excessive bleeding due to
abnormal platelet function and low factor VIII activity. The
relationship between the risk of bleeding and vWF level is not
strong until the level is very low. The clinical and laboratory
heterogeneity of vWD necessitates the denition of several
subtypes.
Classication (Table 37.1 and Fig 37.3)
The current classication of vWD depends on electrophoretic
analysis of vWF multimers. In type 1 vWD, the multimers
appear to be normal in structure and function but decreased
in concentration. In type 2 vWD there is a qualitative de-
ciency of vWF divisible into four subtypes. In type 2A there
is an absence of high molecular weight vWF multimers and
markedly reduced vWF binding to platelets. 2B refers to a
variant where defective platelet adhesion results, paradoxi-
cally, from increased binding of vWF to platelets. In 2M there
is decreased platelet-dependent vWF function despite a rela-
tively normal multimer pattern while 2N is characterised by
failure of vWF to bind factor VIII. In the rare type 3 form,
there is an almost complete deciency of vWF and the factor
VIII level is markedly decreased.
There is correlation between the subtype and the mode of
inheritance. Type 1 vWD is the most common form of the
disease (80% of cases) and inheritance is often autosomal
dominant. Type 2 vWD (15% of cases) may be dominant or
recessive and the type 3 variant is recessive. Because inherited
deciencies of vWF function are common the accidental
co-inheritance of otherwise recessive vWD alleles may occur
(compound heterozygosity). There is currently no genotypic
classication of vWD. More than 250 mutations of all
types have been identied. These include large and small
deletions, nonsense and missense mutations and splicing
abnormalities.
Clinical features
Severe vWD is characterised by spontaneous bleeding, par-
ticularly epistaxes, gum bleeding and menorrhagia. Easy
bruising is also common but (with the exception of type 3)
haemarthroses and muscle haematomas are rare. Milder
disease often presents with excessive bleeding following
trauma or surgical procedures and the diagnosis can easily be
Fig 37.1 One approach to vWD diagnosis. In practice, this has to be
individualised (see text). vWD, von Willebrand disease; vWF, von Willebrand
factor; FVIIIc, factor VIII; RIPA, ristocetin-induced platelet aggregation.
1
In children should have lower threshold for measuring vWF levels.
Not VWD
1
Evaluate for other
bleeding disorders
Patient evaluation and
bleeding score
Suspected VWD
Low
Bleeding score
abnormal
Normal
Measurement of
VWF levels
e.g. abnormal coagulation screen,
family history of VWD,
bleeding symptoms
Probable VWD
further testing: e.g. FVIIIc, RIPA,
multimers, DDAVP infusion test
Bleeding score normal
Fig 37.2 The role of von Willebrand factor in platelet adhesion.
Following vessel wall injury, large multimers of vWF bind to subendothelial
microbrils and also to glycoprotein (Gp) Ib on the platelet membrane thus
mediating platelet adhesion. A secondary binding site with platelet Gp IIb/
IIIa promotes further adhesion.
Platelet
Membrane
Vessel
wall
Collagen
Subendothelial
microfibrils
vWF
GP
Ib
GP
IIb
GP
IIIa
Fig 37.3 SDSPAGE multimer analysis of von Willebrand factor.
Typical multimer patterns in normal plasma and types 1, 2A, 2B and 3 vWD
are shown diagrammatically.
Normal Type 1 Type 2A Type 2B Type 3
Large
multimers
Intermediate
multimers
Small
multimers
missed. A thorough history is crucial and must include assess-
ment of the severity of recent bleeding, the existence of previ-
ous bleeding problems (particularly after surgery, dental
extractions and childbirth) and the presence of a family
75 Von Willebrand disease and other inherited coagulation disorders
history of easy bleeding. A standard
questionnaire can be used to generate a
quantitative bleeding score. Death from
bleeding is rare but it may follow
massive gastrointestinal haemorrhage.
Laboratory diagnosis
Diagnosis can be complicated and tests
often have to be repeated. It is not clear
which laboratory measurement best
correlates with the severity of bleeding.
1. Blood count. The platelet count is
normal except for a moderate
reduction in some cases of type 2B
disease.
2. Activated partial thromboplastin
time (APTT). Usually prolonged
due to low factor VIII : C levels. The
prothrombin time (PT) is normal.
3. Quantitative immunoassay for
vWF antigen.
4. Functional assay of vWF. The
commonest methodology is the
ristocetin cofactor assay. Collagen
binding assays are also used.
5. Factor VIII : C assay. Often low.
May be borderline or normal in
mild type 1 disease.
6. Multimer analysis. The multimer
composition of circulating VWF is
assessed by either crossed
immunoelectrophoresis or sodium
dodecyl sulphate electrophoresis
(see Fig 37.3).
7. Platelet aggregation studies.
Ristocetin (an obsolete antibiotic)
induces platelet aggregation in
normal plasma but not in severe
vWD. An exception is the type 2B
variant where platelets aggregate at
unusually low concentrations of
ristocetin.
8. Blood group. Normal plasma vWF
levels tend to be lower in group O
individuals.
9. General tests of primary
haemostasis. The bleeding time is
bleeding include factor XI concentrate
and recombinant factor VIIa.
Factor VII deciency
This is inherited as an autosomal reces-
sive disorder. The bleeding tendency is
very variable with central nervous system
haematoma a real risk in severe cases.
The diagnosis is conrmed by factor VII
assay and recombinant factor VII con-
centrate is available for treatment.
Factor V deciency
This is a very rare autosomal recessive
condition. Bleeding episodes are treated
with virally inactivated fresh frozen
plasma.
Factor XIII deciency
Another rare autosomal recessive disor-
der, factor XIII deciency causes a
severe haemorrhagic tendency and poor
wound healing. Most sufferers present
early in life, often with profuse bleeding
from the umbilical cord, and death may
result from intracranial haemorrhage.
Screening coagulation tests are normal.
Diagnosis requires the laboratory dem-
onstration of solubility of patient plasma
clots in urea (there is defective cross-
linking of brin). Factor XIII concen-
trate is available for treatment.
Abnormalities of brinogen
Inherited disorders of brinogen are
broadly divisible into quantitative
deciencies (abrinogenaemia and
hypobrinogenaemia) and qualitative
abnormalities (dysbrinogenaemia).
Abrinogenaemia is an autosomal
recessive disease in which blood fails
to clot in all coagulation screening
tests and plasma brinogen is barely
detectable by radioimmunoassay. The
bleeding tendency can be severe with
spontaneous haemorrhage and exces-
sive blood loss after surgery. Fibrinogen
concentrate is the treatment of choice.
Many patients with hypobrinogenae-
mia and dysbrinogenaemia are
asymptomatic.
Table 37.1 Summary of classication
of vWD
Type 1 vWD is a partial quantitative deciency of
vWF
Type 2 vWD is a qualitative deciency of vWF
Type 3 vWD is a virtually complete deciency of
vWF
Type 2A vWD is a qualitative variant with an
absence of high molecular weight vWF multimers
Type 2B vWD is a qualitative variant with increased
afnity of vWF for platelet glycoprotein lb (reduced
in other types)
Type 2M vWD is a qualitative variant not caused by
absence of high molecular weight multimers
Type 2N vWD is a qualitative variant with reduced
afnity of vWF for factor VIII
Note: Mixed phenotypes may be caused by compound
heterozygosity.
now little used. The PFA-100 (see p.
70) is a useful screening test but is
also abnormal in other platelet
disorders.
Management
Very mild bleeding problems may
require little intervention, perhaps just
local measures and the prescription of
an antibrinolytic drug such as tran-
examic acid. More signicant bleeding
generally responds to an infusion or
intranasal spray of DDAVP (desmo-
pressin) which stimulates release of
vWF from stores. DDAVP is predictably
most effective in patients with a partial
quantitative impairment of vWF (type
1). It is less effective in most type 2 vari-
ants and is generally contraindicated in
type 2B. Patients with type 3 disease do
not respond to DDAVP as they lack any
capacity to secrete vWF. Where DDAVP
is ineffective or contraindicated, then
selected plasma-derived factor VIII con-
centrates containing sufcient vWF are
used. An unusually sustained rise in
factor VIII levels can be obtained as the
vWF in the concentrate prolongs sur-
vival of the patients own factor VIII.
Recombinant vWF is under develop-
ment. Patients with vWD normally
require treatment with either DDAVP or
factor VIII concentrate prior to surgery.
Effective genetic counselling in
vWD demands a full understanding
of the disease subtype and mode of
inheritance.
Other inherited
coagulation disorders
Factor deciencies
Factor VIII and factor IX deciencies
See section on haemophilia (pp. 7273).
Factor XI deciency
This bleeding disorder occurs most
commonly in Ashkenazi Jews. There is
a variable relationship between the
factor XI level and the bleeding ten-
dency. Treatment options for signicant
Von Willebrand disease and
other inherited coagulation
disorders
vWD is a relatively common and very heterogeneous inherited bleeding disorder.
Deciency of von Willebrand factor (vWF) causes abnormal platelet function and low factor
VIII activity.
Classication of vWD relies on electrophoretic analysis of vWF multimers.
Mild bleeding problems in vWD require little intervention. More signicant bleeding is
treated with either DDAVP or factor VIII concentrates containing vWF.
There are various other inherited coagulation factor deciencies. In most there are specic
concentrates available for treatment.
Inherited disorders of brinogen include quantitative deciencies (abrinogenaemia and
hypobrinogenaemia) and qualitative abnormalities (dysbrinogenaemia).
76 7 HAEMOSTASIS AND THROMBOSIS
38 Acquired disorders of coagulation
can also increase the haemorrhagic
risk by its anticoagulant action. Its use
should be considered where thrombosis
predominates. Recombinant activated
protein C may be benecial in patients
with severe sepsis and DIC.
Vitamin K deciency
Vitamin K in the body is derived from
dietary vegetables and intestinal ora.
Once absorbed it is stored in the liver
and following further metabolism it acts
as a cofactor for -glutamyl carboxyla-
tion of coagulation factors II, VII, IX and
X and proteins C and S. Vitamin K de-
ciency is probably the most common
acquired coagulation disorder encoun-
tered in hospital patients. The vitamin K
antagonist effect of warfarin is discussed
on page 80 and the vitamin K deciency
of liver disease later in this section.
Disseminated intravascular
coagulation (DIC)
DIC is a complex clinical syndrome which complicates many
serious illnesses (Table 38.1). It is characterised by intravascular
deposition of brin and accelerated degradation of brin and
brinogen caused by excess activity of proteases, notably
thrombin and plasmin, in the blood (Fig 38.1). DIC is hetero-
geneous both in its pathophysiology and clinical manifestations.
In most cases it probably begins when circulating blood is
exposed to tissue factor released from damaged tissues, malig-
nant cells or injured endothelium. This in turn leads to genera-
tion of thrombin which causes formation of soluble brin,
activation of circulating platelets, and secondary brinolysis.
DIC can cause bleeding, large vessel thrombosis and haem-
orrhagic tissue necrosis (Fig 38.2). The coagulation defect
arises from consumption of coagulation factors and platelets
and increased brinolytic activity. In clinical practice acute
DIC usually presents as widespread bleeding in an ill patient.
Oozing of blood from cannulation sites is characteristic.
Microthrombus formation can lead to irreversible organ
damage; the kidney, lungs and brain are frequent targets. DIC
is not necessarily a fulminant syndrome; more chronic forms
may be seen particularly in association with malignancy (e.g.
prostatic carcinoma).
Table 38.1 Common causes of DIC
Infections particularly septicaemia
Malignancy disseminated carcinoma or acute
leukaemia
Obstetric emergencies septic abortion, abruptio
placentae, etc. (see p. 89)
Shock surgical trauma, burns
Severe haemolytic transfusion reaction
Liver disease
Fig 38.1 Pathophysiology of DIC. A simplication of the complex
interactions.
Thrombosis
Trigger
Tissue factor
release
Cytokine
release
Plasminogen
activator release
Tissue
necrosis
Thrombin
generation
Plasmin
generation
Bleeding
Thrombocytopenia
Platelet
activation
Fibrinolysis
Fibrin
Fig 38.2 Haemorrhagic bullae and
gangrene in severe DIC.
Diagnosis depends on the laboratory
demonstration of accelerated brinoly-
sis accompanied by falling levels of
coagulation factors in an ill patient. The
following combination of laboratory test
abnormalities is typical:

reduced platelet count

prothrombin time (PT) prolonged

and activated partial thromboplastin
time (APTT) usually prolonged

thrombin time prolonged

brinogen level reduced

high levels of brin(ogen)

degradation products (FDPs) and
cross-linked brin degradation
products (D-dimers).
The cornerstone of management of DIC
is the treatment of the underlying
disease. Patients are more likely to die
from this than from thrombosis or
bleeding. However, specic treatment of
DIC may be life-saving and if bleeding
occurs support with blood products is
indicated. Platelets, fresh frozen plasma
(FFP a source of coagulation factors)
and cryoprecipitate (a source of brino-
gen) may all be used. Wherever possible
the choice of blood products should be
guided by the platelet count and coagu-
lation tests. More controversial is the
use of pharmacological inhibitors of
coagulation and brinolysis. Although
heparin can reduce clotting factor con-
sumption and secondary brinolysis, it
Fig 38.3 Spontaneous bruising in acquired
haemophilia.
77 Acquired disorders of coagulation
Dietary deciency
Normal dietary requirements for vitamin K are low (0.10.5 g/
kg) and thus patients must be considerably malnourished
before overt deciency occurs. This most commonly occurs
in patients receiving intensive medical care, particularly where
broad-spectrum antibiotics are used. Deciency is suggested
clinically by excessive bleeding and in the laboratory by a
prolonged prothrombin time. Supplemental vitamin K should
ideally be given before bleeding problems occur.
Malabsorption
Malabsorptive conditions such as coeliac disease and tropical
sprue may lead to vitamin K deciency. Vitamin K can also
be lost in chronic biliary obstruction due to failure of bile salts
necessary for fat absorption to reach the bowel.
In the newborn
Vitamin K deciency may arise in the rst weeks or months
of life, most commonly in breast-fed, full-term and otherwise
healthy babies. Contributory factors include low placental
transfer of vitamin K, low concentrations of vitamin K in
breast milk, low intake of milk and a sterile gut. The time of
onset is variable but haemorrhage most commonly occurs on
the 2nd to 4th day. A coagulation screen is abnormal with the
prothrombin time and APTT both prolonged. In most coun-
tries prophylactic vitamin K (1 mg intramuscular injection) is
given to newborn babies. Affected babies respond to parenteral
vitamin K but fresh frozen plasma or prothrombin complex
concentrate may be needed for severe haemorrhage.
Liver disease
The liver is vital to normal haemostasis. It produces all the
factors of the intrinsic and extrinsic coagulation pathway and
clears potentially damaging products of coagulation such as
brin degradation products and activated clotting factors. In
advanced liver disease there are often multiple haemostatic
abnormalities including reduced synthesis of clotting factors,
increased consumption of clotting factors (DIC), qualitative
and quantitative platelet abnormalities, qualitative brinogen
abnormalities and accelerated clot lysis. Where bleeding
occurs, therapy is guided by the dominant haemostatic prob-
lems. Possible interventions include parenteral vitamin K,
fresh frozen plasma, cryoprecipitate and platelet infusions.
Acquired haemophilia
Antibodies (inhibitors) that block the action of coagulation
factors may appear in patients who have no hereditary disor-
der of coagulation. Such autoantibodies most commonly
target factor VIII and the clinical syndrome is termed acquired
haemophilia. Acquired haemophilia may be associated with
a number of conditions including rheumatoid arthritis and
other autoimmune disorders, skin disorders, malignancy,
drug therapy (particularly penicillin) and pregnancy. However,
the most common presentation is in an elderly patient with
no associated condition. Possible clinical problems include
haemorrhage into soft tissues and muscles (Fig 38.3), haema-
turia, haematemesis and prolonged bleeding postpartum or
postoperatively. Bleeding can be difcult to control and death
occurs in approximately 10% of cases.
In the laboratory, the diagnosis of acquired haemophilia is
suggested by a prolonged APTT worsening with incubation
and not corrected by the addition of normal plasma, and a
low factor VIII level. Laboratory assay of the inhibitor is based
on the ability of the patients plasma to neutralise the activity
of a known amount of factor VIII.
Management is complex and controversial but can be
divided into the treatment of the acute bleeding episode and
subsequent attempts to eliminate the autoantibody by immu-
nosuppressive treatment. Possible approaches to the acute
episode include activated prothrombin complex concentrate
(such as FEIBA, which contains activated factors VII, IX, and
X) and recombinant factor VIIa. Immunosuppressive strate-
gies include intravenous immunoglobulin and plasmapher-
esis in the acute episode and longer-term steroids or
cyclophosphamide. The usual approach is summarised in
Figure 38.4.
Fig 38.4 The management of acquired haemophilia. APCC, activated
prothrombin complex concentrate; Ig, immunoglobulin; a, activated.
1
In refractory cases other immunosuppressive agents such as ciclosporin or
rituximab (anti-CD20) may be considered.
Bleeding patient
Acute treatment
of bleeding
APCC or
recombinant factor VIIa
Immunosuppression
Steroids
Cyclophosphamide
Intravenous Ig
Plasmapheresis
Short term
Longer term
1
Acquired disorders
of coagulation
Disseminated intravascular coagulation (DIC) is a complex clinical
syndrome which complicates serious illness. It causes both
haemorrhage and thrombosis. Laboratory tests are needed to
conrm the diagnosis.
Treatment of DIC is essentially that of the underlying cause. Blood
products are often indicated where bleeding occurs.
Vitamin K deciency is a common acquired coagulation disorder.
Advanced liver disease can cause multiple haemostatic
abnormalities.
Acquired haemophilia is generally caused by an autoantibody
targeted against factor VIII. It may be idiopathic or associated with
other autoimmune diseases, malignancy, pregnancy or drug
treatment.
78 7 HAEMOSTASIS AND THROMBOSIS
39 Thrombophilia
early age or to develop recurrent thrombotic problems.
Venous thrombosis predominates with the chance of throm-
bosis increased by the coexistence of other risk factors.
Thrombophilia can be inherited or acquired.
Patients who are predisposed to thrombosis generally either
have a disorder of the blood or an abnormality of the vessel
wall. Where enhanced coagulation is the major mechanism,
the disorder is referred to as thrombophilia. Patients with
thrombophilia either tend to have thrombosis at an unusually
Table 39.1 Characteristics suggesting possibility of thrombophilia
Venous thrombosis in patient less than 40 years old
Recurrent venous thrombosis or thrombophlebitis
Venous thrombosis in unusual site
Arterial thrombosis in patient less than 30 years old
Strong family history of venous thrombosis
Recurrent fetal loss
Skin necrosis in patient receiving warfarin
Purpura fulminans
Table 39.2 Major risk factors for thrombosis
Venous Arterial
Increasing age Increasing age
Immobility Smoking
Obesity Male sex
Oral contraceptive pill Hypertension
Trauma/surgery Strong family history
Thrombophilia (see text) Hyperlipidaemia
Pregnancy Diabetes mellitus
Malignancy Raised brinogen
Fig 39.1 Actions of proteins C and S. Thrombin and protein C bind to
thrombomodulin (TM), an endothelial membrane protein (steps 1 and 2).
Protein S then binds to this complex and also endothelial phospholipid (PL)
(step 3). The resulting complex proteolytically degrades activated factors V
and VIII (step 4). Protein C is activated by proteolytic cleavage by thrombin.
In APCR, factor V is relatively resistant to inactivation by the protein C
complex.
Endothelium
Plasma
Thrombin
Thrombin
TM
Thrombin
Protein
TM
Thrombin
TM
S
Protein
PL
Active
factors
V or VIII
Inactive
C
C
C
1 2 3
S
4
Which patients should be investigated for thrombophilia?
Testing for heritable thrombophilia is not indicted in unse-
lected patients presenting with venous thrombosis. Table 39.1
summarises factors which should prompt consideration of
thrombophilia. Accurate history taking is essential; particular
attention should be given to the nature of the recent throm-
botic event, the presence of known risk factors (Table 39.2), a
previous history of thrombosis and the family history. Deni-
tion of a positive family history of thrombosis is problematic.
If we use the simple denition of a history of deep vein
thrombosis (DVT) or pulmonary embolus (PE) in a rst or
second degree relative, then approximately 25% of all patients
will have a positive family history. Even among those with a
strong family history only a small minority will have a cause
of inherited thrombophilia identied.
Basic investigations of thrombophilia should include a
blood count (to exclude polycythaemia and other myelopro-
liferative disorders) and a coagulation screen. Further labora-
tory testing is dictated by the possible causes of familial and
acquired thrombophilia detailed below. Testing for throm-
bophilia should not be undertaken during an acute episode
of venous thromboembolism when low levels of coagulation
inhibitors are routinely found. Systemic disorders such as
liver disease or disseminated intravascular coagulation (DIC)
can depress the levels of coagulation inhibitors and thus
simulate the laboratory abnormalities found in familial
thrombophilia.
Familial thrombophilia
In theory, familial thrombophilia could be caused by any
genetically determined defect of the coagulation or brinolytic
systems that causes accelerated thrombin formation or
impaired brin dissolution. In practice, the well-dened causes
are associated with accelerated thrombin formation either due
to a shortage or failure of activation of one of a number of
circulating inhibitors of coagulation (Fig 39.1). Inherited
thrombophilia defects are only important in venous
thrombosis.
Factor V Leiden (FVR506Q)
The anticoagulant property of activated protein C (APC) lies
in its capacity to inactivate the activated cofactors Va and VIIIa
by limited proteolysis. Inherited resistance to the anticoagu-
lant action of APC (APCR) is an important cause of throm-
bophilia. In most cases resistance is caused by a single point
mutation in the factor V gene (factor V Leiden) with replace-
ment of Arg
506
with Gln. Arg
506
is located at one of the APC
cleavage sites in factor Va and the mutated Va is less sensitive
than normal Va to APC-mediated inactivation.
APCR has an autosomal dominant mode of inheritance and
is the most common known cause of familial thrombophilia.
The increased risk of venous thrombosis in APCR has been
estimated as 48-fold in heterozygotes and 50100-fold in
homozygotes. The prevalence of the disorder in Western
Europe is 37% with an incidence of around 15% in
unselected cases of venous thrombosis. The risk of venous
thrombosis is highest in patients homozygous for the muta-
tion or in heterozygotes with other risk factors.
Prothrombin G20210A
This prothrombin gene polymorphism is the second most
common known cause of familial thrombophilia. It is found
in approximately 4% of unselected patients with DVT. Both
APCR and the prothrombin gene polymorphism are associ-
ated with a small increased risk of recurrent fetal loss.
Protein C and S deciencies
Hereditary deciency of protein C is an autosomal dominant
disorder found in 25% of patients with thromboembolic
disease. An acquired deciency of protein C can occur in liver
disease, DIC and warfarin treatment. Familial protein C
79 Thrombophilia
deciency manifests as an increased
incidence of venous thromboembolism.
Thrombotic events vary from a super-
cial thrombophlebitis to DVT and PE.
They may be spontaneous or triggered
by other factors such as surgery or preg-
nancy. In the rare homozygous form, the
infant can be born with undetectable
levels of protein C and quickly develop
DIC and skin necrosis due to microv-
ascular thrombosis of subcutaneous
vessels (purpura fulminans). Protein S is
the non-enzymatic cofactor of protein C.
Hereditary deciency has similar clinical
features to protein C deciency.
Antithrombin deciency
Antithrombin (AT) is the major physi-
ological inhibitor of thrombin and clot-
ting factors IXa, Xa, XIa and XIIa.
Deciency can be inherited in an auto-
somal dominant manner. Its prevalence
is unclear but AT deciency probably
contributes to venous thrombosis in
around 25% of younger patients.
The risk of thrombosis varies between
disease subtypes, being greater for an
abnormality affecting the reactive
(thrombin binding) site than for an
abnormality affecting the heparin
binding site. Overall, it seems that the
risk of venous thrombosis is larger in
heterozygotes for AT deciency than for
those with APCR, protein C or protein
S deciency. The risk increases with age,
with up to 80% developing venous
thrombosis by 55 years.
Other forms of
familial thrombophilia
High levels of the amino acid homo-
cysteine are associated with atheroscle-
rosis and venous thrombosis and high
factor VIII concentrations have been
linked with an increased risk of venous
thrombosis. The mechanisms involved
and the degree to which they are geneti-
cally determined is unclear. Other can-
didates for familial thrombophilia status
include the dysbrinogenaemias (p. 75)
and factor XII deciency.
Management of
familial thrombophilia
The precise role of laboratory throm-
bophilia testing in clinical decision
making remains unclear.
Acute venous thrombosis
This should be treated with heparin
and warfarin as in patients without her-
itable thrombophilia (p. 80). Patients
with protein C (and occasionally protein
S) deciency can rarely develop warfarin-
associated skin necrosis; this may be
caused by an initial rapid fall in protein
C levels after warfarin commencement
leading to a hypercoagulable state and
thrombosis in the subcutaneous circu-
lation. The risk can be minimised by
ensuring full heparinisation before
introducing warfarin. Protein C concen-
trates have been given to treat purpura
fulminans in homozygous disease.
Other situations
Case nding of asymptomatic relatives
with low risk thrombophilia (e.g. factor
V Leiden) is not indicated. Asympto-
matic patients with familial throm-
bophilia detected on laboratory tests
do not usually need anticoagulation.
Patients with recurrent thrombosis or a
single thrombosis with a high risk of
recurrence (e.g. multiple thrombophilic
defects) should be considered for long-
term anticoagulation. Management of
thrombophilia in pregnancy is complex.
Warfarin is potentially teratogenic and
subcutaneous low molecular weight
heparin is given where anticoagulation
is necessary.
Counselling
Counselling is frequently not straight-
forward. Any doubts relating to diagno-
sis and the probability of thrombosis in
asymptomatic family members must be
acknowledged. Known acquired risk
factors such as immobility, obesity and
the oestrogen-containing oral contra-
ceptive should be avoided wherever
possible. There is a two to four times
increased risk of venous thromboembo-
lism in women receiving hormone
replacement therapy (HRT).
Acquired forms
of thrombophilia
Antiphospholipid
antibody syndrome
Diagnosis of this syndrome requires
either venous and/or arterial throm-
boembolism or adverse outcomes in
pregnancy in the presence of a persist-
ing antiphospholipid antibody (Table
39.3). The syndrome can be primary,
where the patient has no obvious
autoimmune disease, or secondary if
the patient also has systemic lupus ery-
thematosus (SLE) or a lupus-like disease.
About half of all patients have the
primary form of the disorder. Up to 2%
of the general population have detecta-
ble antiphospholipid antibodies the
probability of clinical problems is great-
est where the antibody titre is high.
The cause of thrombophilia in
antiphospholipid antibody syndrome is
not entirely understood. Antiphospholi-
pid antibodies have been shown to play
a direct role in the development of
thrombosis in experimental animal
models. Management must be individu-
alised. Where there has been an episode
of major thrombosis, warfarin appears
to offer the best protection against
recurrent thrombosis. Aspirin may give
additional benet in arterial thrombosis.
Women with a history of morbidity in
pregnancy are best treated in future
pregnancies with a combination of
aspirin and heparin.
Other acquired forms
of thrombophilia
Myeloproliferative disorders are dis-
cussed elsewhere (pp. 6467). Increased
levels of plasma brinogen, and
D-dimers may be predictors for coro-
nary artery disease. Whether these and
other haemostatic abnormalities are
constitutional changes predisposing to
coronary atherosclerosis and thrombo-
sis or whether they are markers of pre-
existing inammation and endothelial
dysfunction is unclear.
Table 39.3 Clinical and laboratory criteria
for a diagnosis of antiphospholipid
antibody syndrome (at least one clinical
and one laboratory feature must
be present)
Clinical features
Vascular thrombosis
Pregnancy morbidity (e.g. unexplained late fetal death,
prematurity due to placental insufciency/eclampsia,
recurrent rst trimester spontaneous abortion)
Laboratory tests
Antiphospholipid
antibodies:
lupus anticoagulant and/or
anticardiolipin/2-
glycoprotein 1 antibodies
Thrombophilia
The term thrombophilia describes a predisposition to thrombosis caused by abnormally
enhanced coagulation. Patients often have venous thrombosis at an early age or develop
recurrent thrombotic problems.
Classic familial thrombophilia disorders are deciencies of the naturally occurring inhibitors
of coagulation, protein C, protein S and antithrombin.
Factor V Leiden is a thrombophilia disorder caused by an inherited mutation in the factor V
gene. Heterozygosity is common (37% in Western European population).
The clinical role of laboratory thrombophilia testing is not well dened.
Antiphospholipid antibody syndrome is an acquired disorder characterised by laboratory
identication of antiphospholipid antibodies and clinical features including thrombophilia
and morbidity in pregnancy.
80 7 HAEMOSTASIS AND THROMBOSIS
40 Anticoagulation and thrombolytic therapy
prophylaxis. They appear to have superior efcacy, a better
safety prole and to be more cost-effective than unfraction-
ated heparin. LMW heparins cause less bleeding and a lower
incidence of thrombocytopenia and osteoporosis. The more
predictable dose response precludes the need for routine
monitoring and the long half-life allows once or twice daily
subcutaneous administration. Where monitoring is indicated
(e.g. in renal failure), the anti-Xa effect is measured. LMW
heparin treatment allows outpatient management of uncom-
plicated DVT.
Fondaparinux is a synthetic form of the heparin pentasac-
charide molecule with a specic anti-Xa effect. It has similar
indications to LMW heparin.
Warfarin
Oral anticoagulant drugs are derived from 4-hydroxycoumarin
and the standard agent is warfarin. Warfarin works by antago-
nising vitamin K, which is needed for the gamma carboxyla-
tion of certain glutamic acid residues that facilitate calcium
binding of coagulation factors II, VII, IX and X (Fig 40.2).
Some indications for warfarin are shown in Table 40.1.
Where rapid anticoagulation is required a reasonable starting
regimen is a single 10 mg dose and then protocol-guided
adjustment according to the international normalised ratio
(INR). A coagulation screen should always be checked before
Two major classes of drugs are commonly used in the man-
agement of thromboembolic disease. The anticoagulants
heparin and warfarin are used to prevent thrombosis and
limit the extension of an established clot, while thrombolytic
agents such as streptokinase are used to dissolve thrombus.
Anticoagulation
Heparin
Unfractionated heparin is a naturally occurring gly-
cosaminoglycan produced by mast cells. Low molecular
weight (LMW) heparin is prepared by controlled depolymeri-
sation of the unfractionated form. Both unfractionated and
LMW heparin exert their anticoagulant properties by binding
to antithrombin (AT) and potentiating its activity. AT is a
normal circulating anticoagulant which inhibits the actions of
factor Xa and thrombin. LMW heparin differs from unfrac-
tionated heparin in having a relatively greater anti-Xa than
antithrombin activity.
Unfractionated heparin
Standard unfractionated heparin may be used therapeutically
to treat established thrombosis (usually intravenously at
higher dosage) or prophylactically to prevent thrombosis
(usually subcutaneously at lower dosage). Most common
indications for therapeutic use are deep vein thrombosis
(DVT) and pulmonary embolism (PE) (Fig 40.1). A typical
regimen is an intravenous loading dose of 5000 units followed
by an infusion of 10002000 units/hour. The anticoagulant
response varies as the drug binds non-specically to plasma
and cellular proteins. Laboratory monitoring using the APTT
(see p. 20) is required; the therapeutic range is usually 1.52.5,
these values being the ratio of the patients APTT to a control
sample. As the half-life is short, high APTTs are managed by
stopping the heparin but in the event of bleeding (in up to
7% of cases) the antidote protamine can be given. When the
APTT is too low the heparin dose should be promptly
increased. Heparin is normally continued until oral anticoagu-
lation is therapeutic.
Prophylactic heparin is most commonly given to prevent
DVT and PE in patients undergoing surgery. It is particularly
indicated in patients with known risk factors for venous
thrombosis (see p. 78) and in major procedures. A typical
Fig 40.1 Large pulmonary embolus at the bifurcation of the main
pulmonary trunk.
Fig 40.2 The vitamin K cycle and the action of warfarin. The major site of warfarin action is not a
direct effect on the carboxylation step needed for coagulation factor activation but on steps needed for
resynthesis of active vitamin K from its epoxide form.
Vitamin K
-quinone
Dietary
vitamin K
Vitamin
K-H2
Vitamin K
reductase
Vitamin K
epoxide
reductase
Vitamin K-2,3
epoxide
O
2
g- glutamyl
carboxylase
g-carboxylated (active)
coagulation factors
II, VII, IX, X
Inactive coagulation
factors II, VII, IX, X
prophylactic regimen is 5000 units sub-
cutaneously preoperatively and 5000
units 8- to 12-hourly after surgery, for 7
days or until the patient is mobile. No
laboratory monitoring is necessary in
routine cases where required anti-X
a

assays are used.
Apart from haemorrhage, patients on
heparin may develop thrombocytopenia
(see p. 69) and prolonged use can cause
osteoporosis. It should be prescribed
cautiously where there is any bleeding
tendency.
LMW heparin
LMW heparins are now preferred
for treatment of DVT and PE and
81 Anticoagulation and thrombolytic therapy
warfarin is prescribed. The maintenance
dose is usually between 3 and 9 mg.
Laboratory monitoring depends on the
prothrombin time (see p. 20). As throm-
boplastin reagents used in this test vary,
their sensitivity is labelled with an inter-
national sensitivity index (ISI) which
permits reporting as an INR such that
INR = (prothrombin time)
ISI
.
As it takes several days for warfarin to
become therapeutic, the conventional
treatment of established thrombosis is
to start heparin and warfarin simultane-
ously and only to stop heparin when the
desired INR has been achieved. Warfa-
rin should be used with caution in
patients with a bleeding tendency. The
most common side-effect is haemor-
rhage, the risk of serious bleeding cor-
relating with the height of the INR. Poor
control of anticoagulation and bleeding
may arise from poor prescribing or
compliance, intercurrent illness and
interaction with a potentiating drug
(Table 40.2). A prolonged INR in a non-
haemorrhagic patient may only require
withdrawal of the drug for a few days.
Where there is haemorrhage, warfarin
can be reversed within hours by oral/
intravenous vitamin K (0.55 mg) and
instantly by infusion of a concentrate of
prothrombin complex. Guidelines are
complex and signicant warfarin over-
dosage should be discussed with a hae-
matologist. The duration of warfarin
treatment depends on the indication.
Anticoagulation may be needed for only
3 months in a patient with a limited
DVT and reversible risk factors (e.g.
post-surgery). Longer periods are indi-
cated in idiopathic venous thrombosis,
and lifelong warfarin treatment may be
justied following recurrent episodes of
venous thrombosis or where there is a
known ongoing thrombotic risk such as
a prosthetic heart valve, atrial brillation
or a thrombophilic state.
Community and outpatient warfarin
treatment is best monitored in specialist
clinics where control is audited and
technologies such as computerisation
exploited.
New oral anticoagulant agents
There is a need for oral anticoagulant
agents with more predictable pharma-
cokinetics than warfarin. A number of
new drugs have been tested in clinical
trials and are now entering clinical prac-
tice for both prophylaxis and treatment
of thromboembolic disease. Examples
include the direct thrombin inhibitor
dabigatran exilate and the factor X
inhibitor rivaroxaban. This is a fast
moving area of medicine and new anti-
coagulants are further discussed on
page 102.
Thrombolytic therapy
Thrombolytic agents dissolve fresh clots
and therefore restore vascular patency
more quickly than anticoagulants. The
commonly used agents streptokinase,
urokinase and tissue plasminogen acti-
vator (alteplase) work by activating the
brinolytic system (see p. 13 and Fig
40.3). They convert plasminogen, the
inactive proenzyme of the system, to the
proteolytic enzyme plasmin. Thrombo-
lytic drugs are indicated in any patient
with acute myocardial infarction in
which the benet is likely to outweigh
the risk of treatment. Early administra-
tion gives the best results. Other possi-
ble uses for this class of drugs include
treatment of complicated venous throm-
bosis, acute ischaemic stroke and the
unblocking of occluded venous cathe-
ters. The major side-effect is excessive
bleeding.
Table 40.1 Warfarin: common indications
and recommended INRs
Indication Target INR
1
Deep vein thrombosis 2.5
Pulmonary embolus 2.5
Atrial brillation 2.5
Mural thrombosis 2.5
Cardioversion 2.5
Mechanical prosthetic heart valves 2.53.5
2
Recurrent venous thromboembolism
on warfarin therapy
3.5
Thrombosis in antiphospholipid
antibody syndrome
2.5
1
An INR within 0.5 units of the target is usually satisfactory.
2
Depending on valve.
Table 40.2 Drugs interacting
with warfarin
1
Potentiating Antagonising
Alcohol Oral contraceptives
Cimetidine Spironolactone
Allopurinol Antihistamines
Quinine Barbiturates
Amiodarone Rifampicin
Co-trimoxazole Sucralfate
Metronidazole Anti-epileptics
Tricyclics
Aspirin and salicylates
Anabolic steroids
Thyroxine
Sulnpyrazone
1
These are some commonly implicated agents this is not a
comprehensive list.
Fig 40.3 Action of thrombolytic agents.
Plasmin
Fibrin
degradation
Plasminogen
Intrinsic activation
from vessel wall
Extrinsic activation
(e.g. tPA)
Thrombolytic
agents
Anticoagulation and
thrombolytic therapy
The anticoagulant drugs heparin and warfarin are used to prevent
thrombosis and limit the extension of an established clot.
Unfractionated heparin is given intravenously and low molecular
weight heparin, now generally preferred, is given subcutaneously.
Warfarin is given orally and acts by inhibiting vitamin K.
Therapeutic treatment with both unfractionated heparin and
warfarin requires careful laboratory monitoring.
New oral anticoagulant drugs (e.g. dabigatran, rivaroxaban) are
entering clinical practice.
Thrombolytic agents are used to dissolve thrombus. They act by
converting plasminogen to the proteolytic enzyme plasmin.
82 8 BLOOD TRANSFUSION
41 Blood groups and blood testing
disease (CJD) infection are not suitable
donors.
The objective of routine testing of
donated blood is to provide blood which
can be selected for likely compatibility
with a patient and which contains no
identiable infectious agent (Table 41.2).
Antibody testing (e.g. for HIV and hepa-
titis C) is now supplemented by molecu-
lar techniques sensitive enough to trace
the virus in the blood before the devel-
opment of antibodies (i.e. during the
window period).
Testing before transfusion
Most incompatible transfusions are
caused not by errors in the transfusion
laboratory but by giving blood to the
wrong patient (i.e. not the patient
whose serum was tested prior to the
transfusion). The source of such mis-
takes is usually inaccurate documenta-
tion on forms and specimens or
inadequate procedures for identifying
patients prior to transfusion (see also
p. 84).
If tests on donor and recipient blood
conrm matching for ABO and Rhesus
groups, the transfusion will be compat-
ible in around 98% of cases. The
sequence of tests prior to transfusion
The blood groups
Blood group antigens exist on the
surface of the red cell membrane (see
also p. 4). There are numerous blood
group systems encoded by genes on dif-
ferent chromosomes. They are highly
variable in their polymorphism and
clinical signicance.
The most important blood group is
the ABO system. The genes encoding
the ABO antigens are located on chro-
mosome 9 and are inherited in an auto-
somal dominant fashion. Each antigen
is a sugar residue made by a specic
glycosyl transferase. The ABO system is
crucial in clinical blood transfusion as
there are naturally occurring IgM anti-
bodies in the serum targeted against the
non-present ABO antigens (Table 41.1).
These antibodies necessitate the use
of ABO compatible blood for transfu-
sion. For example, the administration of
incompatible group A blood to a group
B patient would engender a potentially
fatal haemolytic transfusion reaction
due to the destruction of the donors
group A red cells by the recipients
anti-A antibody.
In other blood group systems natu-
rally occurring antibodies are rare.
However, immune antibodies, usually
of IgG type, may be induced by transfu-
sion of blood expressing different blood
group antigens or maternal exposure to
fetal red cell antigens. Where such
immune antibodies are present, trans-
fused blood must be matched for the
relevant blood group system in addition
to ABO. Maternal formation of immune
antibodies against antigens of the
Rhesus (Rh) blood group system, par-
ticularly the strongest antigen D,
accounts for most cases of haemolytic
disease of the newborn (p. 90).
The testing of blood
Donor blood
The safety of blood transfusion is max-
imised by careful selection of donors. All
donors should be in good health and,
wherever possible, unpaid volunteers.
Particular care is taken to exclude poten-
tial donors who may harbour infective
diseases which are transmissible by
blood transfusion thus people with
recent jaundice (? hepatitis), a history of
recent travel to malarial areas or risk
factors for HIV or CreutzfeldtJakob
Table 41. 2 Routine testing of
donated blood
ABO group
Rhesus group
Red cell antibody screen
Hepatitis B surface antigen, HBV DNA
Antibody to syphilis
Anti-HIV-1 and anti-HIV-2, HIV-1 antigen, HIV RNA
Anti-Hepatitis C, HCV RNA
Anti-HTLV
Fig 41.1 ABO blood grouping on a microplate.
Fig 41.2 Blood grouping using a gel system. (a) ABO and RhD grouping. (b) Rh and Kell grouping.
Unagglutinated red cells pass through the gel (after centrifugation) whereas agglutinated cells do not.
(a) (b)
Most incompatible blood
transfusions arise from clerical
errors and mistaken patient
identity.
includes antibody screening of the
patients serum and crossmatching to
ensure compatibility in the remaining
2%.
Blood grouping
The recipients red cells are tested for
ABO and Rhesus antigens and the
Table 41.1 The occurrence of ABO
antigens and antibodies
ABO blood group
O A B AB
Antigens on red cells None A B A+B
Antibody in serum Anti-A+B Anti-B Anti-A None
Frequency (%)
1
47 42 8 3
1
In the United Kingdom.
Incidences vary greatly in different populations.
83 Blood groups and blood testing
serum tested for naturally occurring
antibodies to conrm the ABO group.
Blood grouping tests traditionally rely
on the visual identication of agglutina-
tion of red cells induced by the presence
of antibodies against antigens present
on the cell surface (Fig 41.1). Gel technol-
ogy (see Fig 41.2) is widely used and
increasingly automated. DNA-based
tests may be employed as an adjunct to
haemagglutination but they are not cur-
rently indicated for routine ABO and Rh
group testing.
Antibody screening
The patients serum is tested against
three standard sets of screening red cells
of known antigenic type. This is to
detect immune or atypical antibodies
(i.e. non-ABO) which might destroy
donor red cells. Clinically relevant anti-
bodies are generally reactive at 37C. A
sensitive indirect antiglobulin test tech-
nique is used (see Fig 41.3). If an anti-
body is detected by this screen then a
larger panel of red cells is tested to
indentify it. The blood selected for the
patient must be negative for the relevant
antigen.
Crossmatching
The nal compatibility check is to mix
the patients serum with red cells from
each donor unit. The aim is to highlight
any earlier errors in grouping or anti-
body screening and to identify the pres-
ence of antibodies against rare antigens
not present on the screening cells. The
minor crossmatch mixing of donor
serum with patient red cells is not
routinely performed. With the integra-
tion of sophisticated computer systems
into laboratories, the serological cross-
match is being selectively replaced by
electronic crossmatching. This relies on
a combination of repeat group and anti-
body testing, specialised software and
stringent standard operating procedures
to detect any incompatibility.
Practicalities of
blood ordering
Where blood transfusion is required
and adequate time is available, tests
proceed as above and compatible units
are issued. In emergencies, blood is
sometimes needed more quickly than
this routine testing allows. Normal pro-
cedures may be adapted to speed up
issue of group specic blood. If there is
insufcient time to determine the
patients ABO group, then group O
Rhesus-negative blood may be used.
The bulk of blood is crossmatched for
use in elective surgical procedures.
Where there is only a small chance (less
than 10%) that transfusion will be
required it is reasonable to limit wastage
by adopting a group and save policy.
The patients blood group is determined
and the serum screened for atypical
antibodies. Provided the screen is nega-
tive, blood is not routinely crossmatched.
Most hospitals have implemented a
formal surgical blood order schedule
with guidelines for common operations
(Table 43.3). Such guidelines are gener-
alisations and special provision is made
for unusually difcult procedures or
patients who are judged to be at a higher
than average risk of haemorrhage. Elec-
tronic crossmatching is very rapid and
its introduction potentially reduces the
number of operations for which blood
is issued in advance.
Fig 41.3 The antiglobulin test. In the direct test red cells are sensitised in vivo, in the indirect test they are sensitised in vitro.
Agglutination
Positive test
Washing to
remove unbound
antibodies
Addition of
anti-human
globulin
Sensitised red cells
Anti-human globulin Red cell antibody Red cell antigen
Blood groups and blood testing
The blood group antigens exist on the surface of the red cell membrane. Blood groups are
highly variable in their polymorphism and clinical signicance.
The ABO system is crucial in blood transfusion as there are naturally occurring IgM
antibodies in the serum targeted against non-present ABO antigens this necessitates the
use of ABO compatible blood.
Blood donors are carefully selected and donor blood tested to exclude transmissible
infections.
Testing of donor and recipient blood for ABO and Rhesus groups, antibody screening and
crossmatching are routinely performed before transfusion to ensure compatibility.
Most incompatible blood transfusions arise from clerical errors and mistaken patient
identity.
Table 43.3 Possible guidelines for blood
ordering in a few common operations
Protocols vary between hospitals and should be based
on previous blood usage and local transfusion
laboratory practice
Procedure Recommendation
1
Cholecystectomy Group and save
Colectomy/hemicolectomy 2
Breast biopsy Group and save
Heart valve replacement 8
Resection of abdominal aortic
aneurysm
8
Abdominal hysterectomy Group and save
Total hip replacement 3
Transurethral resection of
prostate
Group and save
1
Figures refer to the number of units of red cells crossmatched prior
to surgery.
84 8 BLOOD TRANSFUSION
42 Clinical practice
haemoglobin can be expected from each
unit. Red cells are infused via specially
designed sterile giving sets which
contain 170 m lters. Careful monitor-
ing is particularly important during the
rst 10 minutes of each unit.
Complications of red
cell transfusion
Immediate
Haemolytic transfusion reactions.
These potentially fatal reactions arise
from the transfusion of incompatible
blood (usually for ABO). Symptoms
often occur within minutes and may
include chest, abdominal and loin pain,
vomiting, a burning skin, dyspnoea and
headache. Common signs are fever,
tachycardia and hypotension. Renal
failure and disseminated intravascular
coagulation (DIC) can follow. Once a
haemolytic reaction is suspected, the
transfusion should be stopped and the
venous access used to give crystalloid.
The transfused unit should be checked
(is another patient about to get a wrong
unit due to a mix up?) and the blood
bank informed. Initial investigations
must include blood samples from the
patient for a blood count and lm,
blood group, antibody screen and direct
antiglobulin test. The blood bank will
also repeat tests on the donated unit.
Management of complications will
require senior advice and often intensive
care. The overall mortality of ABO
incompatible transfusion is approxi-
mately 10%.
Non-haemolytic transfusion reac-
tions. The majority of adverse reactions
to blood are febrile reactions caused by
antileucocyte antibodies in the patient.
Uncomplicated febrile reactions are
simply managed by slowing the transfu-
sion and giving paracetamol. Routine
leucodepletion of red cells reduces such
reactions. Occasionally patients develop
allergic reactions with urticaria, wheez-
ing and (rarely) anaphylaxis.
Transfusion associated circula-
tory overload (TACO). Care must
be taken not to transfuse too rapidly,
especially in elderly patients with heart
disease.
Transfusion-related acute lung
injury (TRALI). This is an acute syn-
drome occurring within 6 hours of
transfusion and characterised by respi-
ratory distress, hypoxia, bilateral pulmo-
nary inltrates and a fever. Donor
antibodies to HLA class I and II antigens
and/or granulocyte-specic antigens
have been implicated in pathogenesis.
Mortality is around 10%.
Delayed
Infection. Bacteria, viruses and para-
sites may all be transmitted via blood
transfusion. Blood is screened for the
relevant agents and in practice the great-
est risk is of bacterial contamination. To
help reduce the chance of transmission
of the abnormal prion associated with
variant CreutzfeldtJakob disease (vCJD)
red cell donations are leucodepleted and
plasma is increasingly imported from
countries with no bovine spongiform
encephalopathy (BSE). The signicance
of transmission of infection from blood
can depend on the status of the recipi-
ent. Thus, cytomegalovirus (CMV) is of
little relevance in healthy adults but
potentially life-threatening in a patient
receiving an allogeneic stem cell trans-
plant or in a low birthweight premature
infant.
Red cell transfusion
Two questions need to be answered
before transfusion of red cells is
undertaken:
1. Is it indicated?
2. If it is indicated, which red cell
preparation should be used?
Some general indications for red cell
transfusion are listed in Table 42.1.
Whole blood is now rarely used.
Haemorrhage requires transfusion of
uids to maintain blood volume and red
cells to raise the haemoglobin level. For
correction of anaemia not responsive to
other measures red cells stored in
optimal additive solution are used.
There are few indications for red cells
stored in plasma.
Practicalities of red
cell transfusion
All those involved in the prescription
and administration of blood should
follow local guidelines with respect to
patient identication and the checking
of the compatibility and viability of the
transfused units. Critical information is
contained on the blood bag and the
attached compatibility label (Fig 42.1).
No discrepancies are permissible. Most
serious adverse transfusion reactions
are due to transfusion of the wrong
blood to the patient (Fig 42.2). Errors
can be reduced by newer technologies
such as bar coding and radiofrequency
chips these generally rely on machine
readable data on patient wristbands.
In shocked patients blood is trans-
fused rapidly, the precise rate dependent
on the monitoring of vital signs such as
pulse, blood pressure and urine output.
Transfusion for correction of anaemia
is usually a more elective process. Units
of red cells are typically given over 24
hours and a rise of around 10 g/L of
Table 42.1 Major indications for red
cell transfusion
To replace blood loss
Trauma
Surgery
Other haemorrhage (e.g. gastrointestinal bleed)
To correct anaemia
Marrow failure (e.g. aplastic anaemia, leukaemia)
Haemoglobinopathies (e.g. thalassaemia, sickle cell
disease)
Chronic disorders (e.g. renal failure, malignancy)
Severe haemolysis (e.g. haemolytic disease of the
newborn)
The nal decision to transfuse requires consideration of the patients
age, clinical state, and haemoglobin concentration.
Fig 42.1 Unit of red cells.
Fig 42.2 Serious hazards of transfusion,
United Kingdom 19922010 (data with
permission of SHOT). IBCT, incorrect blood
transfused; ATR, acute transfusion reactions; HSE,
handling and storage errors; I and U,
inappropriate/unnecessary/delayed transfusions;
HTR, haemolytic transfusion reactions; TRALI,
transfusion-related acute lung injury; TACO,
transfusion-associated circulation overload; TTI,
transfusion-transmitted infections.
IBCT (35%)
I and U
(6%
)
HSE (12%)
Anti-D
(12%)
ATR (21%)
Other (3%)
TRALI (3%)
TTI (1%)
TACO (1%)
HTR (6%)
85 Clinical practice
Delayed transfusion reactions.
These occur approximately 510 days
after transfusion and are caused by a
previously undetected antibody being
boosted by transfusion of incompatible
cells. Characteristic features include
fever, jaundice and a falling haemo-
globin. They are only rarely fatal.
Iron overload. A unit of blood con-
tains around 250 mg of iron. Iron is
only lost from the body in small
amounts and repeated transfusion can
lead to accumulation and toxic effects
identical to those seen in haemochro-
matosis. Where repeated transfusion is
predictable in a younger person (e.g. in
thalassaemia), chelation of iron limits
overload and prolongs life.
Massive blood transfusion
Massive transfusion is dened as replace-
ment of the patients whole blood
volume by stored allogeneic blood in
less than 24 hours. There have been
recent changes in practice driven by the
military experience of trauma with
increased early use of plasma and plate-
lets. Problems can still arise in part due
to the inevitable deciencies of stored
blood. Shortage of clotting factors and
platelets in transfused blood may exac-
erbate haemorrhage. It is important to
monitor haemostasis by checking the
basic coagulation screen and replacing
components accordingly. Metabolic dis-
turbances are less common but include
hyperkalaemia, hypocalcaemia, acidosis
and citrate toxicity. Rapid transfusion
can cause hypothermia; this can be min-
imised by carefully controlled blood
warming.
Alternatives to allogeneic
blood transfusion
Use of the patients own blood for trans-
fusion rather than allogeneic blood
minimises the risk of infection. Selected
patients awaiting elective surgery can
pre-deposit blood in the weeks prior to
the operation. An alternative approach,
now more favoured, is to use specially
designed equipment to salvage blood
lost during surgery and reinfuse it back
into the patient. Other strategies to
reduce blood transfusion include the
active treatment of anaemia, strict appli-
cation of transfusion triggers, anaes-
thetic measures or drugs (e.g. tranexamic
acid) to reduce blood loss and biological
agents such as erythropoietin. Ques-
tions remain regarding optimal transfu-
sion practice and there is a need for
more randomized controlled trials. Pos-
sible future developments include man-
ufactured haemoglobin solutions and
platelet substitutes.
Transfusion of platelets
and granulocytes
Platelet transfusion
This is used to treat or prevent haemor-
rhage in patients with signicant throm-
bocytopenia. It is more useful where
platelets are low due to underproduc-
tion (i.e. marrow failure) or dilution
than where thrombocytopenia is due to
immune destruction as in immune
thrombocytopenia (ITP). Platelets are
collected either from routine blood
donations or from a single donor by
plasmapheresis. They should ideally be
matched with the patient for ABO and
Rhesus. The standard dose for an adult
is either a single plasmapheresis dona-
tion or 46 pooled standard donations.
Where repeated platelet transfusions
are given, patients can become sensi-
tised against class I HLA antigens
absorbed onto the platelet surface with
the result that they derive a lower incre-
ment in platelet count than would be
predicted (platelet refractoriness). In
these cases, platelet donors matched
with the recipients HLA class I type can
be selected. Platelet transfusion can
cause non-haemolytic reactions and can
transmit infection as for red cells.
Granulocyte (neutrophil)
transfusion
Granulocyte transfusion is infrequently
used in neutropenia and the indications
are uncertain.
Transfusion of plasma
and plasma products
A wide range of plasma products is
available for therapeutic use:

Fresh frozen plasma (FFP). Plasma is

collected from whole blood or
derived from plasmapheresis prior to
rapid freezing. FFP contains the full
range of coagulation factors and
indications for use are shown in
Table 42.2. The normal dose in an
adult is one litre. FFP can transmit
infection and cause immunological
reactions it is not suitable for
volume expansion alone.

Cryoprecipitate. This is prepared from

FFP by slow thawing and separation
of the resultant precipitate. It is rich
in brinogen and may be useful in
the treatment of DIC and
management of massive blood
transfusion.

Factor VIII and IX concentrate. See

pages 7273.

Albumin. This is produced by

fractionation of pooled plasma.
Solutions for clinical use include
human albumin 4.5/5%, human
albumin 20% and plasma protein
fraction (PPF). Albumin solutions are
used for the treatment of severe
hypoproteinaemia, particularly when
associated with a low plasma volume.
Concentrated solutions can help
produce a diuresis in hypo-
albuminaemia (e.g. in hepatic
cirrhosis).

Immunoglobulins. These can be

specic and used in passive
prophylaxis against a range of
infections (e.g. varicella zoster,
tetanus) or to prevent haemolytic
disease of the newborn (anti-Rhesus
D). Non-specic immunoglobulins
are used for passive prophylaxis
against hepatitis A, treatment of
hypogammaglobulinaemia and in
selected autoimmune disorders (e.g.
ITP).
Table 42.2 Possible indications for use of
fresh frozen plasma
Disseminated intravascular coagulation (DIC)
Severe liver disease (e.g. prior to liver biopsy)
Coagulopathy of massive blood transfusion
Replacement therapy of some rare congenital factor
deciencies
Bleeding in haemorrhagic disease of newborn/
malabsorption vitamin K
Thrombotic thrombocytopenic purpura (with plasma
exchange)
Depletion of coagulation factors following
thrombolysis
Blood transfusion
clinical practice
Before red cell transfusion is undertaken the indication should be conrmed and the
optimal red cell preparation selected.
Red cell transfusion can cause both immediate complications (e.g. haemolytic transfusion
reaction) and delayed complications (e.g. infection, iron overload).
Platelet transfusion may be helpful in the management of thrombocytopenia.
A wide range of plasma products is available for transfusion. Selection of the appropriate
product requires an understanding of the therapeutic benet and possible side-effects.
There are alternatives to allogeneic blood transfusion (e.g. erythropoietin) which should be
considered in selected patients.
86 9 SPECIAL SITUATIONS
43 The immunosuppressed patient
Bacterial infection in neutropenic
patients may be overt for instance a
chest infection with a productive cough
or the presence of infected skin lesions
(Fig 43.1). However, bacterial sepsis can
equally present with non-specic
malaise and a pyrexia. In the latter case
extensive cultures including blood, nose,
throat, stool and urine are indicated.
Fungi
The incidence of invasive fungal infec-
tions is increasing and they are a
major cause of morbidity and mortal-
ity in patients with haematological
malignancy.
The most widespread fungal patho-
gen is Candida. Oral and colonic car-
riage of the organism is common in
healthy people. Invasive Candida infec-
tion is most likely in neutropenic
patients with indwelling catheters and
severe mucositis. Disseminated candi-
diasis usually presents with a persistent
fever and no diagnostic clinical features.
Possible organ involvement includes the
kidney, lung, heart and liver. Cutaneous
emboli may lead to a nodular skin erup-
tion while exudative retinal lesions can
be seen through the ophthalmoscope.
Candida spp. are grown from blood cul-
tures in only 20% of patients with inva-
sive candidiasis. The addition of candida
PCR signicantly improves detection
rates.
Aspergillus species, particularly
Aspergillus fumigatus, are potentially
deadly fungal pathogens. Infection is
usually via the inhalation of airborne
spores and is mainly pulmonary. A chest
X-ray may show pneumonia and cavita-
tion (Fig 43.2) but it is an insensitive
diagnostic method. Other infected sites
can include the paranasal sinuses, skin,
central nervous system and eye. Even in
disseminated disease, blood and sputum
cultures are rarely positive. Thirty per
cent of cases of invasive aspergillosis
remain undiagnosed and untreated at
death. Strategies for earlier diagnosis
include regular galactomannan antigen
testing, aspergillus PCR, and CT scan-
ning of the chest.
Pneumocystis jiroveci (previously
Pneumocystis carinii) is a fungus which
causes a potentially fatal bilateral pneu-
monia in patients with depressed cell-
mediated immunity. In haematological
practice it mostly affects patients receiv-
ing intensive chemotherapy regimens or
stem cell transplantation and patients
infected with the HIV virus. Bronchoal-
veolar lavage is useful in diagnosis.
Viruses
Most viral infection in immunosup-
pressed patients is caused by reactiva-
tion of latent organisms. Patients with
decient cell-mediated immunity (e.g.
acute lymphoblastic leukaemia (ALL),
stem cell transplantation, chronic lym-
phocytic leukaemia) are particularly sus-
ceptible. Important pathogens include
herpes simplex, varicella zoster and
cytomegalovirus (CMV). Clinical mani-
festations range from relatively trivial
mouth ulcers attributable to herpes
simplex through herpes zoster
Many patients with blood disorders
are immunosuppressed. Patients with
aggressive haematological malignancies
such as leukaemia and non-Hodgkins
lymphoma have their immune function
initially compromised by the disease and
then further depressed by chemother-
apy. Others have more subtle decien-
cies. Patients with benign diseases such
as immune thrombocytopenia (ITP) and
hereditary spherocytosis who have had
splenectomy performed are also at
increased risk of infection.
An increased susceptibility to infec-
tion can arise from multiple factors
(Table 43.1). Neutropenia and neutrophil
dysfunction are probably the most
important causes of infectious complica-
tions in patients with leukaemia. Unlike
many other forms of immunosuppres-
sion, neutropenia is easy to quantify
the risk of infection rises appreciably at
counts below 0.5 10
9
/L and is greatest
where the count is below 0.1. Lympho-
penia and lymphocyte dysfunction are
seen in lymphoid malignancy and after
chemo- and radiotherapy. Defects in
humoral immunity are particularly seen
in patients with chronic lymphoid
malignancies and in myeloma. The like-
lihood of infection is related to the sever-
ity of hypogammaglobulinaemia.
Other common immunosuppressive
factors are the loss of mucosal or skin
integrity due to damage from disease or
treatment, and the presence of indwell-
ing venous catheters.
Types of infection
Bacteria
Bacterial infections in neutropenic
patients are often caused by the spread
of commensal ora to previously sterile
sites. Fatal septicaemia can result from
Gram-negative bacilli such as Pseu-
domonas aeruginosa, E. coli, Klebsiella
spp. and Enterobacter spp. Gram-positive
cocci currently cause the majority of
documented bacteraemias. The skin
pathogen Staphylococcus epidermidis
often colonises indwelling venous cath-
eters. The use of broad-spectrum antibi-
otics can lead to the emergence of
toxin-producing Clostridium difcile in
the stools. Methicillin-resistant Staph.
aureus (MRSA) and bacteria produc-
ing extended-spectrum beta-lactamases
(ESBLs) leading to antibiotic resistance
are becoming increasingly problematic
in hospitals.
Table 43.1 Possible factors predisposing
to infection in haematology patients
Cellular defects
Neutropenia and neutrophil dysfunction
Lymphopenia and lymphocyte dysfunction
Humoral defects
Reduced antibody production
Anatomic defects
Reduced mucosal barriers (e.g. mucositis)
Indwelling venous catheters
Splenectomy (see p. 10)
Fig 43.1 Skin infection caused by
Streptococcus faecalis in a neutropenic
patient.
Fig 43.2 Aspergillosis complicating
prolonged neutropenia.
87 The immunosuppressed patient
(shingles) (Fig 43.3) with the risk of dis-
semination to the potentially fatal CMV
pneumonitis which complicates alloge-
neic stem cell transplantation. Measles
can be a fatal illness in children with
ALL. There may be no specic diagnos-
tic features of viral infection and it must
be considered as a possible cause of a
febrile illness in the immunosuppressed
patient. PCR-based diagnosis may allow
earlier therapy of CMV infection after
allogeneic stem cell transplantation.
Prevention of infection in
the immunosuppressed
patient
Neutropenia
General measures include the isolation
of the patient, laminar airow rooms,
strict hygiene and avoidance of possible
contaminants (e.g. uncooked food).
Simple precautions such as hand
washing by staff are crucial in reducing
infection rates.
Antimicrobial prophylaxis may reduce
the incidence of infection but there are
well-dened adverse effects. For instance,
quinolone antibiotic prophylaxis reduces
the number of bacterial infections
in patients with chemotherapy and
transplant-induced neutropenia but this
must be balanced against the side-effects
of the drug and the potential emergence
and dissemination of antimicrobial-
resistant organisms. Increased use of
antimicrobial agents increases the vul-
nerability of patients to nosocomial
infections (e.g. Clostridium difcile) and
community-acquired infections. Prophy-
laxis also complicates the treatment of a
subsequent episode of febrile neutrope-
nia. It appears that the best way to
exploit the benets of prophylaxis is to
restrict its use to patients at highest risk
such as those with a previous history of
neutropenic fever. Similar considera-
tions apply to the use of prophylaxis
against fungal infections.
Depressed cell-mediated
immunity and
hypogammaglobulinaemia
Impaired cell-mediated immunity leads
to an increased risk of Pneumocystis
jiroveci (carinii) pneumonia and viral
infections. Standard prophylaxis against
Pneumocystis is oral co-trimoxazole or
nebulised pentamidine where this is not
tolerated. Aciclovir is effective in reduc-
ing the incidence of viral infections. The
more toxic drug ganciclovir can be used
after stem cell transplantation to give
additional protection against CMV.
Patients with low-grade lymphoprolif-
erative disorders and myeloma can have
signicant hypogammaglobulinaemia
and suffer recurrent infection. Regular
infusions of immunoglobulin may be
helpful in these cases.
Post-splenectomy
See page 10.
Treatment of infection
The pyrexial neutropenic patient
A common clinical problem in haema-
tology is the management of the patient
with neutropenia who becomes unwell
and/or develops a pyrexia. A subgroup
of very carefully dened low-risk
patients may require only oral broad-
spectrum antibiotics but high-risk
patients can rapidly succumb to bacte-
rial infection and need prompt inpatient
empirical treatment with broad-
spectrum intravenous antibiotics even
before the infectious pathogen is identi-
ed. Blood and other cultures are taken
prior to starting antibiotics and a chest
X-ray is helpful: investigations, however,
should not substantially delay treat-
ment. A microbiological diagnosis is
made in only half of these cases.
The empirical antibiotic regimens are
designed to provide protection against
commonly implicated organisms, par-
ticularly those causing life-threatening
infection (e.g. Pseudomonas). Regimens
are constantly changing the major
groups of drugs are summarised in
Table 43.2.
Monotherapy (e.g. meropenem)
may be used but in patients at highest
risk a combination (e.g. piperacillin/
tazobactam and gentamicin) is usually
preferred.
Persistent pyrexia or clinical deteriora-
tion on rst-line antibiotics is a difcult
management problem. Often the infec-
tious agent is unknown. The usual
approach is to continue investigations
while making a change in the antibiotic
regimen. A lack of response prompts
consideration of empirical antifungal
treatment. To limit drug exposure,
entirely empirical therapy can be replaced
by a pre-emptive strategy where only
patients with probable fungal infection
(e.g. suggested by CT of chest) are treated
with antifungal agents. Growth factors
(e.g. G-CSF) may be given to shorten the
period of neutropenia.
Treatment of specic infections
Liposomal amphotericin B has generally
been the drug of choice for treatment of
established Aspergillus infection and in
the empirical antifungal role outlined
above, but voriconazole and caspofun-
gin are reasonable alternatives. Azoles,
particularly uconazole, are commonly
used in the treatment of Candida infec-
tion. Herpes simplex and varicella zoster
infections are best treated with aciclovir.
Ganciclovir or foscarnet is used for
CMV infection after allogeneic stem cell
transplantation. Pneumocystis jiroveci
(carinii) pneumonia is effectively treated
by either high-dose co-trimoxazole or
pentamidine.
Fig 43.3 Herpes zoster following allogeneic
stem cell transplantation.
Table 43.2 Groups of antibiotics used in
the empirical treatment of infection in
neutropenia
Group Examples
Antipseudomonal
penicillins
Azlocillin, piperacillin
Aminoglycosides Gentamicin, amikacin
Cephalosporins Ceftazidime
Quinolones Ciprooxacin
Carbapenems Meropenem, imipenem
Glycopeptides Teicoplanin, vancomycin
The immunosuppressed patient
Many patients with blood disorders are immunosuppressed. Possible factors predisposing
to infection include neutropenia, lymphopenia, reduced antibody levels and anatomical
defects.
Bacteria, fungi and viruses can all cause severe systemic infection in an immunosuppressed
patient.
Measures to prevent infection in the immunosuppressed patient include isolation of the
patient, strict hygiene and selective prophylactic use of antimicrobial agents.
Infection in a neutropenic patient generally requires empirical treatment with broad-
spectrum antibiotics. Persisting fever or clinical deterioration necessitates a change in
antibiotics and/or antifungal treatment.
88 9 SPECIAL SITUATIONS
44 Pregnancy
The other major type of anaemia in
pregnancy is megaloblastic anaemia.
This usually results from deciency of
folate. As for iron, folate requirements
are increased during pregnancy and
the diet is frequently inadequate to meet
this demand. Megaloblastic anaemia
most often presents as a macrocytic
anaemia in the third trimester or post-
partum. It is normal practice to give
folate supplements in pregnancy. The
amount of folate routinely administered
orally should be large enough to avoid
megaloblastic anaemia but not so large
as to risk masking pernicious anaemia
with vitamin B
12
deciency which does
occasionally occur in pregnancy. Folate
deciency in pregnancy has been linked
with an increased incidence of neural
tube defects in the fetus and recommen-
dations for planned pregnancies are the
use of folate supplements (400 g daily)
prior to conception and then particu-
larly in the rst 12 weeks. Larger doses
of folate are recommended where
women are at high risk of conceiving a
child with a neural tube defect (e.g. pre-
viously affected pregnancy). There is
no justication for the prescription of
multi-ingredient vitamin preparations
in pregnancy but a combined iron and
folate tablet of adequate dosage may be
prescribed.
It should be remembered that not all
anaemia in pregnancy is caused by de-
ciency states. Other blood disorders
may present in pregnancy and chronic
blood diseases such as sickle cell
anaemia can be especially difcult to
manage at this time.
Thrombocytopenia
in pregnancy
After anaemia, thrombocytopenia is the
most common haematological disorder
in pregnancy, occurring in 610% of all
pregnant women. A few women have
an obvious systemic disorder such as
pre-eclampsia; disseminated intravascu-
lar coagulation (DIC) in pregnancy is
further discussed below. However, the
majority of women are systemically well
with an apparently normal pregnancy.
In these cases thrombocytopenia can be
divided into two categories, with differ-
ing clinical implications for the mother
and fetus.
Incidental (gestational)
thrombocytopenia
Incidental thrombocytopenia is the
most common cause of thrombocytope-
nia in pregnancy accounting for around
75% of cases. Thrombocytopenia is mild
to moderate (70150 10
9
/L) and the
woman is otherwise well. There is no
past history suggesting a cause for the
low platelet count and particularly no
history of immune thrombocytopenia
(ITP). The disorder is not associated
with maternal haemorrhage or fetal or
neonatal thrombocytopenia. As there is
no diagnostic test it is often difcult to
distinguish gestational thrombocytope-
nia from mild ITP until a non-pregnancy
platelet count is available.
ITP in pregnancy
The management of pregnancy in a
woman with known chronic ITP can be
problematic as severe thrombocytope-
nia may be a threat to the mother and
there is also a risk of the child becoming
thrombocytopenic. The latter complica-
tion arises as the causative IgG antiplate-
let autoantibody in the mother freely
crosses the placenta and can target fetal
platelets. Fortunately, the majority of
babies escape severe thrombocytope-
nia (less than 50 10
9
/L) occurs in
around 10% of neonates and mortality
Haematological changes
Several haematological changes occur in
normal pregnancy (Fig 44.1). Beginning
in the sixth week there is an increase in
plasma volume accompanied by an
increase in red cell mass. The plasma
volume expansion peaks at around 24
weeks when it is approximately 40%
greater than in a non-pregnant woman.
As the increase in red cell mass is more
modest (1525%) a dilutional anaemia is
inevitable. In practice the haematocrit
and haemoglobin level start to fall at 68
weeks and reach a trough at around 20
weeks. It is unusual for the haemoglobin
level to fall below 100 g/L and if this
happens another cause for anaemia
should be sought. Negative iron balance
can be regarded as routine in pregnancy
and as discussed below frank iron de-
ciency commonly occurs.
The other major changes which may
be regarded as a physiological conse-
quence of pregnancy affect the coagula-
tion system. There are increases in the
levels of the coagulation factors VII, VIII
and X and a marked increase in plasma
brinogen. The resulting hypercoagula-
bility is helpful in limiting the likeli-
hood of life-threatening bleeding at
delivery but it does lead to an increased
risk of thromboembolism. The platelet
count falls about 10% during an uncom-
plicated pregnancy. Later in pregnancy
there may also be an increase in mean
platelet volume (MPV).
Anaemia in pregnancy
There are several causes of anaemia in
pregnancy. The most common scenario
is an exacerbation of the usual dilutional
anaemia by deciency of iron and/or
folate. Erythropoietin levels increase
less than in anaemic non-pregnant
women, possibly suppressed by hormo-
nal changes.
The identication of iron deciency
relies upon normal laboratory tests (p.
25). However, even in women with no
overt clinical deciency there is a pro-
gressive fall in serum iron through preg-
nancy. Routine dietary supplementation
with modest amounts of iron (e.g.
ferrous sulphate 200 mg daily) leads to
a signicant increase in haemoglobin
level at term compared with women
receiving no supplements. Parenteral
iron is contraindicated in the rst
trimester.
Fig 44.1 Common haematological changes in normal pregnancy.

1525% increase
red cell mass
40% increase
plasma volume
Dilutional
anaemia
Factors VII, VIII, X
Platelets
(late pregnancy)
Number
Volume
Normal pregnancy Fe
Fibrinogen
89 Pregnancy
from intracranial bleeding in those
affected is less than 1%. All manage-
ment decisions must thus acknowledge
that fetal thrombocytopenia is uncom-
mon and fetal mortality very rare. In
this context, aggressive treatment of all
mothers with ITP with corticosteroids
and/or intravenous immunoglobulin
and routine delivery by caesarean
section are not justied. The fetal plate-
let count is not routinely measured.
A conservative approach with normal
delivery and an immediate neonatal
cord blood platelet count is gaining
support. If the babys count is low or
falling, intravenous immunoglobulin
can be given. In more severe thrombo-
cytopenia, transcranial ultrasound can
be performed to exclude intracranial
haemorrhage. Because of its low inci-
dence of side-effects, intravenous
immunoglobulin is probably the treat-
ment of choice for severe maternal
thrombocytopenia.
Coagulation
abnormalities in
pregnancy
Thromboembolism and
anticoagulant therapy
Pulmonary embolism (PE) remains a
major cause of maternal death. Approxi-
mately half of fatal PEs occur antepar-
tum and half postpartum, the majority
of the latter in the rst 2 weeks of the
puerperium. About 70% of women who
develop venous thromboembolism in
pregnancy and the puerperium have
major risk factors. These include increas-
ing age, caesarean section, obesity, previ-
ous thrombotic problems and familial
thrombophilia. Hereditary throm-
bophilia (see p. 78) has also been linked
with recurrent fetal loss, intrauterine
growth restriction, pre-eclampsia and
placental abruption.
Both the anticoagulants commonly
used in clinical practice, heparin and
warfarin, require special consideration
in pregnancy.

Heparin. Neither unfractionated

standard heparin nor low molecular
weight heparin (LMWH) cross the
placenta. LMWH is widely used and
is both safe and effective in the
prevention and treatment of venous
thromboembolism in pregnancy,
with signicant bleeding, usually
from primary obstetric causes, in less
than 2% of cases. Anti-factor X
a
levels
can be monitored but the optimal
therapeutic range is unclear.

Warfarin. Warfarin is not signicantly

secreted in breast milk and treatment
is safe during lactation. However, it
readily crosses the placenta and is a
known teratogen, producing a
specic warfarin embryopathy at
around 612 weeks (approximately
5% incidence). Thus, heparin should
be substituted for warfarin in the rst
trimester. There may be a risk of fetal
haemorrhage secondary to warfarin
throughout pregnancy, particularly if
anticoagulant control is poor, and the
risk to mother and fetus becomes
unacceptable in the antepartum
period. It should therefore be
discontinued at 36 weeks and
heparin substituted until after
delivery. Current practice is to avoid
use of oral anticoagulants in
pregnancy wherever possible. There
is currently no place for the newer
oral anticoagulants (i.e. direct
thrombin and anti-X
a
inhibitors) due
to concerns regarding toxicity.
DIC in pregnancy
DIC is associated with a wide variety of
situations in pregnancy (Fig 44.2). The
chief characteristics and pathogenesis of
DIC are discussed on page 76. In preg-
nancy, DIC may manifest as a chronic
compensated state or as life-threatening
haemorrhage. The latter is a frightening
medical emergency and there should be
a planned regimen of management with
input from an obstetrician, haematolo-
gist, physician, anaesthetist and nurse
(Table 44.1). It is imperative that the
source of bleeding is identied and
addressed as soon as possible. It is often
shock which triggers DIC with a result-
ant increase in bleeding.
HELLP syndrome
HELLP is an acronym for microangio-
pathic haemolysis (H), elevated liver
enzymes (EL) and low platelets (LP).
The syndrome complicates less than
1% of all pregnancies but develops in
10% of women with pre-eclampsia.
Both disorders generally remit within
several days after delivery and delivery
of the fetus is therefore central to
management.
Fig 44.2 Causes of DIC in pregnancy.
Abruptio placentae
Amniotic fluid embolism
Septic abortion and intrauterine infection
Retained dead fetus
Hydatiform mole
Placenta accreta
Pre-eclampsia and eclampsia
Table 44.1 General guidelines for the
management of acute obstetric
haemorrhage
Secure venous access and insert a central line to
measure central venous pressure (CVP)
Seek additional (preferably senior) medical help
Collect samples for urgent blood count,
crossmatching and coagulation screen; liaise with
haematology laboratory
Restore blood volume may have to use
unmatched blood of patients ABO and Rh group
(preferred to group O Rh negative)
Address source of bleeding
Blood product replacement as necessary
Pregnancy
Normal pregnancy is accompanied by a modest dilutional anaemia.
Deciency of iron and/or folate frequently exacerbates the normal dilutional anaemia.
Thrombocytopenia is most often incidental and of little signicance. Immune
thrombocytopenia (ITP) may require treatment but a normal delivery is usual and severe
neonatal thrombocytopenia is rare.
There is a hypercoagulable state in pregnancy and pulmonary embolism remains a major
cause of maternal death. Low molecular weight heparin is generally the preferred
anticoagulant for treatment or prevention of thrombosis.
Disseminated intravascular coagulation (DIC) can complicate pregnancy and cause
life-threatening haemorrhage.
90 9 SPECIAL SITUATIONS
45 Paediatric haematology
against HDN due to RhD incompatibility
(see below), the most common cause of
the disorder is the formation of immune
antibodies against ABO; most cases are
associated with only mild haemolysis.
Diagnosis
Severe HDN can result in intrauterine
death. In the newborn child the presenta-
tion is entirely dependent on the degree of
haemolysis but common features include
anaemia, jaundice, oedema and hepat-
osplenomegaly. High levels of circulating
unconjugated bilirubin may lead to high
frequency deafness or deposition in the
basal ganglia with spasticity and other
neurological symptoms and signs (ker-
nicterus). Further investigation of the
anaemia reveals features typical of haemo-
lysis (Fig 45.1) with a positive direct anti-
globulin test (DAT). In HDN due to RhD
incompatibility the baby is RhD positive
and the mother RhD negative with a high
level of anti-D.
Management
Management of HDN is complex, requir-
ing close liaison between the haematol-
ogy laboratory and obstetrician. In RhD
alloimmunisation, if maternal anti-D
levels are high and paternal testing
indicates RhD heterozygosity, the fetal
Rh genotype can be determined non-
invasively by applying PCR technology
to a maternal blood sample. Another
advance is velocimetry of the fetal middle
cerebral artery during an affected preg-
nancy. High peak systolic velocities predict
severe fetal anaemia and allow the selec-
tive use of more invasive techniques such
as fetal blood sampling and intrauterine
transfusion. Newborns may experience
ongoing anaemia and require exchange
transfusion. Later anaemia may respond
to erythropoietin therapy. With optimal
management, a healthy child is the
outcome in more than 90% of cases.
RhD prophylaxis in RhD-negative
mothers
The breakthrough in the prevention of
HDN has been the introduction of proph-
ylaxis (Fig 45.2). A dose of Rh anti-D
immunoglobulin (Ig) is given to all
RhD-negative mothers who deliver a
RhD-positive infant. A larger than average
feto-maternal haemorrhage necessitates
a greater dose of anti-D Ig. It is most
likely that anti-D administration prevents
HDN by a negative modulation of the
primary immune response rather than
by simple removal of fetal RhD-positive
cells. General recommendations for Rh
prophylaxis are shown in Table 45.2.
As some women undoubtedly become
sensitised earlier in a normal pregnancy,
routine antenatal prophylaxis is widely
recommended.
Anaemia of prematurity
The haemoglobin concentration falls after
birth in all babies but in premature infants
it falls faster and to a lower level. At 13
months of age haemoglobin concentra-
tions of less than 70 g/L are common and
in babies born at less than 32 weeks gesta-
tion this anaemia is often associated with
inadequate adaptive responses including
tachycardia, tachypnoea and apnoeic
attacks. The anaemia is due in part to
shortened red cell lifespan and the effects
of rapid growth but the fundamental
problem appears to be a poor erythropoi-
etin response. Erythropoietin levels are
highest in premature infants with the
most severe anaemia and hypoxia but
even in these cases levels are inadequate
compared to those achieved in anaemic
adults. Recombinant erythropoietin is of
benet in some infants.
Polycythaemia in the neonate
Polycythaemia in the neonate is most
simply dened as a packed cell volume
(PCV) exceeding 0.65. Causes include
Many of the blood disorders encountered
in children have been discussed in the
preceding pages. For instance, acute lym-
phoblastic leukaemia is the most common
leukaemia of childhood, haemophilia is
usually diagnosed in infancy and the hae-
moglobinopathies are a signicant cause
of ill health in children worldwide.
Chronic and severe diseases of the blood
pose particular problems in childhood
and usually are best managed by a
paediatrician with a special interest in
haematology or in a combined paediatric/
haematology clinic. The childs growth
and development, and educational needs
often require special attention. In this
section we discuss some haematological
disorders encountered in paediatric prac-
tice which are not addressed elsewhere.
Normal values
It is important to appreciate that the
normal ranges for many haematological
tests vary with age. Table 45.1 illustrates
reference values for the total white cell
count (WCC) and the differential count in
children. More detailed listings of normal
ranges of laboratory tests in childhood
can be found in specialised paediatric hae-
matology texts.
Neonatal disorders
Haemolytic disease of
the newborn
Haemolytic disease of the newborn
(HDN) is a disease of the fetus and
newborn child. The haemolysis is caused
by maternal IgG antibodies traversing the
placenta and attaching to fetal red cells
which are destroyed in the childs reticu-
loendothelial system. The antibodies are
directed against a fetal red cell antigen not
shared by the mother. Incompatibility for
one of a large number of different red cell
blood group systems can cause HDN but
most cases of clinically signicant disease
affect a Rhesus (Rh)D-positive child where
the mother is RhD negative. Sensitisation
of the mother (i.e. the formation of anti-D)
occurs following the haemorrhage of fetal
red cells into the maternal circulation.
This usually occurs at parturition follow-
ing a normal pregnancy but may also
arise earlier in pregnancy or following
abortion. ABO incompatibility between
mother and fetus gives some protection
against sensitisation to RhD as fetal red
cells are quickly destroyed by the mothers
naturally occurring anti-A or anti-B anti-
bodies. Unfortunately, in most cases baby
and mother are ABO compatible. With
the considerable success of prophylaxis
Fig 45.1 Peripheral blood lm in a newborn
child with severe HDN. Note the numerous
nucleated red cells and polychromasia.
Table 45.1 Normal white cell counts in children ( 10
9
/L)
Age White cell count Neutrophils Lymphocytes
Birth (full term) 18 8 513 310
Day 3 15 8 35 28
1 month 12 7 39 316
26 months 12 6 1.59 410
26 years 10 5 1.58 69
612 years 9 4 28 15
Note: Normal haemoglobin values in childhood are shown on page 22, Table 1. The normal platelet count is the same in children and adults
(150400 10
9
/L).
91 Paediatric haematology
placental transfusion (e.g. delayed clamp-
ing of the cord), intrauterine hypoxia,
endocrine disorders (e.g. maternal diabe-
tes) and genetic disorders (e.g. trisomy 21).
Polycythaemia is often well tolerated but
if severe it may cause hyperviscosity with
congestive heart failure, respiratory dis-
tress, neurological disturbances and even
gangrene. Partial exchange transfusion
using a crystalloid solution to reduce the
haematocrit is indicated where a high
PCV is associated with symptoms and
signs of hyperviscosity.
Thrombocytopenia in
the neonate
Some causes of thrombocytopenia in
neonates are listed in Table 45.3. In prac-
tice the major divide is between seriously
ill infants where the low platelet count is
caused by disseminated intravascular
coagulation (DIC), and relatively well
infants where thrombocytopenia is most
often of immune aetiology or occurs sec-
ondary to a specic inherited syndrome.
Immune thrombocytopenia (ITP) may be
seen in infants born to mothers with ITP
where there is passive transfer of IgG
across the placenta. Alloimmune throm-
bocytopenia arises where the healthy
mother becomes sensitised against a fetal
platelet antigen in a manner analogous to
HDN; the platelet antigen HPA-1a is most
commonly implicated.
Iron deciency in infancy
Iron deciency has already been discussed
(p. 24) but some aetiological factors in
infancy are unique to this period of life.
Blood loss may still be the major cause
of deciency but other factors worthy of
consideration are decreased total body
iron at birth (e.g. prematurity, feto-
maternal haemorrhage, twins), the impact
of growth with increased demands for
iron, and dietary inadequacy (e.g. exces-
sive dependence on unsupplemented
cows milk).
Red cell aplasia
in childhood
and adolescence
Pure red cell aplasia (PRCA) is character-
ised by anaemia, reticulocytopenia and
reduced or absent erythroid precursor
cells in the bone marrow. There are many
causes of PCRA including infection
(e.g. parvovirus B19), connective tissue
disorders, and malignancies (e.g.
thymoma). However, two types of
PCRA are unique to childhood:
DiamondBlackfan anaemia and tran-
sient erythroblastopenia.
DiamondBlackfan anaemia
This is a rare heterogeneous disorder
caused by defects in structured ribosomal
proteins. The majority of cases are spo-
radic but various patterns of inheritance
have been documented. An anaemia with
the features of red cell aplasia usually
presents within the rst 12 months of
life. This runs a chronic course and can
be combined with developmental abnor-
malities. There is an increased risk of
haematological malignancy and other
cancers. Beyond blood transfusion, thera-
peutic options include corticosteroids,
ciclosporin and allogeneic stem cell
transplantation.
Transient erythroblastopenia
of childhood
This is a transient form of red cell aplasia
of probable immune origin which must
be distinguished from DiamondBlackfan
anaemia. It generally affects older children
(14 years) and may be diagnosed simul-
taneously in siblings or in seasonal clus-
ters. In over half of cases there is a previous
viral illness. The normocytic anaemia may
be accompanied by mild neutropenia. Full
recovery within 48 weeks is the rule.
Congenital
dyserythropoietic
anaemias (CDAs)
This is a group of rare inherited anaemias.
There are various subtypes but common
features include ineffective erythropoiesis
and multi-nucleated erythroblasts. The
white cell and platelet counts are normal.
Anaemia is usually rst diagnosed in
infancy or childhood. It may be of normo-
cytic or macrocytic type. Transfusion is
required in more severe cases.
Fig 45.2 Perinatal deaths/1000 births caused by HDN. (From Derrick
Tovey, LA 1992 Haemolytic disease of the newborn and its prevention. In:
Contreras, M (ed) ABC of Transfusion. BMJ Publishing.)
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
1950 1960 1970 1980
Year
E
x
c
h
a
n
g
e

t
r
a
n
s
f
u
s
i
o
n
P
r
e
m
a
t
u
r
e

d
e
l
i
v
e
r
y
A
m
n
i
o
c
e
n
t
e
s
i
s
I
n
t
r
a
u
t
e
r
i
n
e
t
r
a
n
s
f
u
s
i
o
n
R
h

I
g

p
r
o
p
h
y
l
a
x
i
s
Improved obstetric
and neonatal care
Deaths/
1000 births
Table 45.3 Some causes of
thrombocytopenia in the neonate
DIC in various severe systemic disorders
Intrauterine infection (e.g. rubella, cytomegalovirus)
Platelet antibodies:
autoimmune (maternal ITP)
alloimmune
drugs
Hereditary/congenital disorders:
WiskottAldrich syndrome
thrombocytopenia with absent radii (TAR)
syndrome
Post exchange transfusion
Neonatal leukaemia
Giant haemangioma
Table 45.2 Recommendations for
Rh prophylaxis
1
Rh prophylaxis after delivery
Anti-D (usually 500 IU) is given within 72 hours in
RhD-negative mothers where the infant is RhD positive
(or group undetermined). If there is a large
feto-maternal haemorrhage (assessed in a Kleihauer
test) additional anti-D is given
Rh prophylaxis and abortions
In RhD-negative mothers anti-D is given after all
therapeutic abortions and after spontaneous or
threatened abortions later than 1213 weeks
gestation and in selected cases of threatened abortion
before 12 weeks (usual dose 250 IU before 20 weeks
and 500 IU after 20 weeks)
Rh prophylaxis during pregnancy
Anti-D is given after possible sensitising events in
RhD-negative women. These include: amniocentesis,
chorionic villus sampling, abdominal trauma, external
cephalic version, antepartum haemorrhage, ectopic
pregnancy (usual dose of anti-D is 250 IU before 20
weeks and 500 IU after 20 weeks). Anti-D (500 IU)
should be given to non-sensitised RhD-negative
mothers at 28 and 34 weeks
1
United Kingdom guidelines.
Paediatric haematology
Chronic and severe blood disorders in children are usually best
managed by a paediatrician with a special interest in haematology
or in a combined paediatric/haematology clinic.
In haemolytic disease of the newborn (HDN), haemolysis is caused
by maternal IgG antibodies crossing the placenta and attaching to
fetal red cells. Most clinically signicant cases affect a RhD-positive
fetus or newborn child where the mother is RhD negative.
RhD prophylaxis has much reduced the incidence of severe HDN.
Prematurity is associated with a particular type of anaemia.
In pure red cell aplasia in children it is important to distinguish
between DiamondBlackfan anaemia and the more benign
transient erythroblastopenia of childhood.
92 9 SPECIAL SITUATIONS
46 Haematology in the elderly
mainly due to a combination of age-
related suppression of erythroid colony
formation, insensitivity to erythropoie-
tin and impaired iron utilisation.
Whatever its aetiology, anaemia in the
elderly is a relevant nding. It is associ-
ated with reduced physical and cogni-
tive functioning, an increased chance of
falls, an aggravation of comorbidity such
as cardiac and neurological disease, and
reduced survival. A low haemoglobin
level should not be readily dismissed as
part of normal ageing.
Where the anaemia has an explained
cause (e.g. iron deciency), treatment is
specic for that disorder. Erythropoeitin
may be used in chronic renal failure.
Blood transfusion is needed in only a
minority of cases (e.g. for the sympto-
matic anaemia of myelodysplastic syn-
drome), and in the very elderly and frail
must be undertaken cautiously to avoid
uid overload and the exacerbation of
cardiac failure. The treatment of unex-
plained anaemia in the elderly remains
controversial with no clear guidelines.
Thrombosis and
anticoagulation
Old age is a relatively hypercoagulable
state. Ageing leads to increased plasma
levels of brinogen and various clotting
factors and delayed brinolysis. The
incidence of both arterial and venous
thrombosis increases with age (Fig 46.2).
Advanced age is not in itself a contrain-
dication to the use of anticoagulant
therapy older patients may derive the
greatest benefit but there are
particular considerations. Patients over
60 years usually require lower doses of
vitamin K antagonists to maintain a
therapeutic range than younger patients.
Some studies have suggested an
increased risk of adverse events such as
bleeding in older patients on anticoagu-
lants. It is not clear whether this is
related to age alone or the presence of
comorbidity. It is sensible to monitor
elderly patients more frequently. It is
likely that the newer oral anticoagulants
(see p. 102) will also have to be used
cautiously in this group of patients.
Haemophilia and
other inherited
bleeding disorders
Haemophilia is not generally thought of
as a disease of the elderly. Recent
changes in management such as the
prophylactic use of coagulation factors
have focused on children and young
adults. However, at least in the West,
regular coagulation factor replacement
means that life expectancy is now
Average life expectancy is increasing.
Elderly people (>65 years) are likely to
make up more than 20% of the worlds
population by 2050. This effect is par-
ticularly marked in the developed world
where in some countries the population
over 65 years already outnumbers those
below 20 years. An ageing population
has implications for the practice of clini-
cal haematology. There are signicant
age-related changes in haematopoiesis
and haemostasis. Many blood diseases,
especially malignant disorders, are more
common in older people. The manage-
ment of blood diseases in the elderly is
often complicated by frailty, comorbid-
ity and a need for extra care in the hos-
pital and community.
Haematopoiesis
and ageing
There is an age-associated decline in
haematopoietic stem cells and haemat-
opoietic cell function. The reasons for
this are unclear and much of our knowl-
edge is derived from studies of mouse
models rather than humans. It is prob-
able that this decline arises from a com-
bination of accumulated genetic and
epigenetic changes, alterations in the
marrow microenvironment and sys-
temic effects such as inammation. Prac-
tical consequences of these biological
changes include reduced immune func-
tion, an increased incidence of cancer,
and a lesser tolerance of haematopoietic
stress (e.g. chemotherapy). Stem cells
from older donors are less efcient at
reconstituting haematopoiesis in trans-
plant recipients.
Fig 46.1 Causes of anaemia in the elderly.
Nutritional
deficiency
Anaemia of
chronic disease
Anaemia
unexplained
Fig 46.2 The incidence of venous thrombosis increases
exponentially with age.
20 40 60 80
500
I
n
c
i
d
e
n
c
e

r
a
t
e

p
e
r

1
0
0
,
0
0
0
/
y
e
a
r
1
400
300
200
100
0
0
Age (years)
1
New episodes of venous thromboembolism
Anaemia
Anaemia is a common clinical problem in the elderly. The
prevalence rises rapidly after 50 years and approaches 20% in
people aged over 80 years. In general, one third of cases will
have an identiable nutritional deciency (iron, vitamin B
12
or
folate) (Fig 46.1). Where iron deciency is the cause of anaemia
it is often secondary to gastrointestinal blood loss, and under-
lying bowel pathology (e.g. colonic carcinoma) should be
excluded. Another third of cases have the anaemia of chronic
disease. These patients have an obvious chronic inammatory
condition (see p. 36) and will often have a measurable acute
phase response (e.g. elevated C-reactive protein). In the nal
third of elderly patents, there is no clear cause for the anaemia
(sometimes termed anaemia unexplained). This entity is a
diagnosis of exclusion and has been the focus of much recent
interest. A few cases may be explained by myelodysplastic
syndrome or other rarer causes of anaemia but it is probably
93 Haematology in the elderly
approaching that of the whole male
population. This means that older
patients increasingly present with both
the clinical problems of haemophilia
(e.g. joint arthropathy and pain, blood-
borne infections) and age-related ill-
nesses such as cancer and cardiovascular
disease. The treatment of such comor-
bidities routinely involves invasive prac-
tical procedures and drugs which further
derange haemostasis, and patients will
often need intensive coagulation factor
replacement to counter the increased
risk of bleeding. The same considera-
tions apply to other inherited bleeding
disorders.
Haematological
malignancy and
chemotherapy
Haematological malignancy can occur at
any age but most types are more
common in the elderly. The median age
at diagnosis for all blood neoplasms
combined is around 70 years (Fig 46.3).
There is a male excess except for over 80
years when more women are diagnosed.
This may be because of greater female
life expectancy. Some haematological
malignancies in the elderly are diag-
nosed incidentally, are indolent, and
require little or no intervention. Exam-
ples are described in other sections and
include monoclonal gammopathy of
undetermined signicance (MGUS),
monoclonal B-cell lymphocytosis and
early stage chronic lymphocytic leukae-
mia. Other neoplasms are aggressive
and will reduce quality of life and shorten
life expectancy in the absence of effective
treatment.
Older patients tolerate chemotherapy
less well than younger patients and they
are less likely to be cured of their malig-
nancy (Table 46.1). Changes in pharma-
codynamics account for part of this
reduced effectiveness and increased tox-
icity. Reducing the dose of chemother-
apy drugs to minimise side-effects will
reduce cure rates. Other factors leading
to poorer outcomes in the elderly are
increased comorbidity and adverse
disease characteristics. For example,
elderly patients with acute myeloid leu-
kaemia have a higher incidence of poor
risk cytogenetic changes compared with
younger patients. They also have an
increased number of signicant chemo-
therapy side-effects including more pro-
found myelosuppression, neurotoxicity
and cardiotoxicity.
In the very elderly (>80 years), it may
be judged that intensive chemotherapy
is contraindicated. This might also apply
to younger patients with very signicant
comorbidity. Where chemotherapy is
undertaken, this should follow a careful
assessment of the benet and risk to the
individual patient. A formal geriatric
assessment should be considered in
patients 70 years and older. This can
identify potential reversible conditions
which might exacerbate the complica-
tions of treatment including anaemia,
depression, poor nutrition and a lack of
available care and social support. Other
practical steps to reduce the complica-
tions of chemotherapy are dose adjust-
ment for renal dysfunction (based on
the glomerular ltration rate), the pro-
phylactic use of growth factors (e.g.
granulocyte colony-stimulating factor
(G-CSF)) to shorten the period of mye-
losuppression and the selection of drug
regimens with relatively low toxicity. An
example of the latter is the avoidance of
anthracycline drugs in patients with
cardiac failure. Targeted therapies (e.g.
imatinib in chronic myeloid leukaemia)
are particularly attractive in the elderly
as they potentially combine high levels
of efcacy with fewer side-effects than
conventional chemotherapy.
Population studies show lower sur-
vival rates for older people with all types
of haematological malignancy. This
group of patients is generally under-
represented in formal clinical trials
of chemotherapy. Many are excluded
because of multiple comorbidities.
Where older patients are entered into
such trials the results must be inter-
preted cautiously as the selective nature
of trial entry means that the results may
not be applicable to the whole elderly
population.
Fig 46.3 Median ages of presentation of haematological malignancies.
Chronic lymphocytic leukaemia
Hodgkins lymphoma
Age (years)
Non-Hodgkins lymphoma
Myelodysplastic syndrome
Myeloma
Chronic myeloid leukaemia
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
67
13
65
72
38
66
69
76
0 80 70 60 50 40 30 20 10 90 100
Table 46.1 Guidelines for the management
of chemotherapy in older cancer patients
Geriatric assessment for patients over 70 years
Adjust doses to individual GFR in patients over 65
years
Prophylactic use of G-CSF in patients over 65 years
receiving regimens comparable to CHOP
1
Maintenance of haemoglobin level around 120 g/L
Use of drugs with low toxicity where feasible
GFR: glomerular ltration rate; G-CSF: granulocyte colony-
stimulating factor.
1
See page 61.
Haematology in the elderly
An ageing population has implications for the practice of clinical haematology. Many blood
disorders (e.g. malignant diseases) are commoner in the elderly.
There are signicant age-related changes in haematopoiesis and haemostasis.
Anaemia is a common clinical problem in the elderly; in a third of cases there is no clear
cause.
Old age is a relatively hypercoagulable state.
Older people tolerate chemotherapy less well than younger people and are less likely to be
cured of their haematological malignancy.
tahir99-VRG & vip.persianss.ir
94 9 SPECIAL SITUATIONS
47 Palliative care in haematological malignancy
likely to require an opiate analgesic given at an appropriate
dose and interval, possibly in combination with a specic
co-analgesic dependent on the nature of the pain. There is no
one optimal opiate dose and the correct dose must be achieved
by proactive titration so that the patient is pain free without
unacceptable toxicity. For most patients with chronic cancer
pain, the oral route is preferable but parenteral, transdermal
and rectal preparations are also widely employed. Pain pre-
vention must be complemented by management of drug side-
effects patients on opiates will generally need laxatives and
antiemetics. Particular care is necessary when analgesics are
changed. This requires an understanding of their relative
strengths and durations of action.
Opiates may be combined with co-analgesics to maximise
their effect. Examples in haematological practice include the
use of corticosteroids (usually dexamethasone) to tackle
symptoms of raised intracranial pressure or nerve inltration
secondary to lymphoma and the prescription of NSAIDs and
bisphosphonates to optimise control of bone pain in myeloma.
Tricyclic antidepressants can be a useful adjunct in neuro-
pathic pain.
Control of non-pain symptoms
Fatigue. In the haematology clinic, many patients with leu-
kaemia, lymphoma and myeloma complain of demoralising
fatigue. This is usually of multifactorial aetiology with a
mixture of physiological and psychosocial factors, the latter
including anxiety and sleep disruption. Anaemia is the most
common reversible physical cause and regular administration
The World Health Organization denes palliative care as an
approach that improves the quality of life of patients and their
families facing the problems associated with life-threatening
illness, through the prevention and relief of suffering by
means of early identication and impeccable assessment and
treatment of pain and other problems, physical, psychosocial
and spiritual. As the modern specialty of palliative medicine
was born in the hospice movement, there has been a tendency
to regard it as an end-of-life intervention, an option only when
disease-modifying cancer treatments have been exhausted. It
is more correctly viewed as being entirely complementary to
ongoing anti-tumour treatment for instance, a patient with
myeloma presenting with refractory bone pain is likely to
benet from expert symptom control early in their illness (Fig
47.1). Good palliative care requires a multidisciplinary team
approach with staff expert in communication and control of
symptoms and with the organisational skills to coordinate
care. Patients commonly derive palliative care input from
diverse sources (Fig 47.2). There is not space here to compre-
hensively review all aspects of palliative care but a number of
applications with particular relevance to patients with haema-
tological malignancy will be discussed.
Palliative chemotherapy
and radiotherapy
Chemotherapy and radiotherapy are primarily employed as
disease-modifying treatments but they may also be used in a
palliative context to relieve symptoms and improve quality of
life. Any side-effects of such treatment must be carefully
weighed against the likely symptom control. Chemotherapy
may thus be used to limit the degree of troublesome lym-
phadenopathy in advanced lymphoma or to reduce the sys-
temic upset from a high malignant cell burden in end-stage
leukaemia. Similarly, attenuated radiotherapy can give local
relief from tumour inltration in lymphoma and can reduce
pain from myeloma bone lesions (Fig 47.3). Surgical interven-
tions are used more sparingly but lymphomatous pleural
effusions can be drained and the severe pain of myelomatous
spinal disease can be ameliorated by the operation of verte-
broplasty where the vertebrae are reinforced with a cement-
like substance.
Management of cancer pain
Pain is a common symptom of cancer, particularly in patients
with advanced or refractory disease. The means are available
to give the great majority of patients good quality pain relief
but, in practice, this goal may be compromised by the time,
skill and commitment required of the medical team. Before
initiating therapy, it is important to fully assess the severity
(pain scales are available) and nature of the pain visceral
pain is often described as a dull ache, somatic pain may be
sharp and postural, while neuropathic pain can be burning
or numbing.
Pharmacological therapy is the mainstay of pain manage-
ment in patients with haematological malignancy. Patients
experiencing mild pain on no analgesia may be commenced
on an oral non-opiate agent (e.g. paracetamol, nonsteroidal
anti-inammatory drug (NSAID)) but more severe pain is
Fig 47.1 Current model of cancer management.
Focus
of care
Presentation
Palliative care
Death
Bereavement
care
Disease-modifying/
curative treatment
Time
Fig 47.2 Schematic view of a patients access to palliative care
services.
Patient
Home/
primary care
Hospital
outpatient
Hospital
inpatient
Home/hospice
Hospice
inpatient
tahir99-VRG & vip.persianss.ir
95 Palliative care in haematological malignancy
of subcutaneous erythropoietin
improves haemoglobin levels and
quality of life in selected patients with
myeloma, lymphoma and other cancers.
Nausea and vomiting. These symp-
toms are common, both due to tumour
inltration and as a side-effect of chemo-
therapy and analgesics. It is crucial
to identify the cause. A centrally acting
antiemetic drug (e.g. ondansetron) is
indicated for drug-induced nausea
whereas a pro-kinetic agent (e.g.
metoclopramide) is more appropriate
for gastric stasis or functional bowel
obstruction. In more difcult cases, it is
important to combine antiemetics logi-
cally and to consider alternative routes
of administration.
Anorexia and cachexia. Patients
with loss of appetite and weight loss
need expert dietary assessment and
advice. Oral corticosteroids can improve
appetite and lead to weight gain. Poor
nutrition may be exacerbated by drug-
induced mucositis, painful neutropenic
mouth ulcers and oral infections such as
candida and herpes simplex. This can be
minimised by good mouth care and
early recognition of infections.
Dyspnoea. Lymphoma can cause
dyspnoea because of bulky mediastinal
lymphadenopathy or lung inltration.
Patients with advanced leukaemia more
commonly develop the symptom during
fulminant respiratory infections or after
bleeds into the lung parenchyma. Once
correctable causes of dyspnoea have
been excluded, other options include
the selective administration of oxygen,
opiates and sedation to minimise the
subjective sensation of breathlessness.
Care at of the end of life. In patients
with advanced disease and refractory
symptoms in the nal days of life, seda-
tion may be used in the form of continu-
ous drug infusions via portable syringe
drivers (Fig 47.4). Strict criteria must be
used for patient selection and fully
informed consent must be obtained
from the patient (where possible) and
their family. Such measures should only
be resorted to after consultation with
the palliative care team.
Psychosocial oncology
It is important (but not always easy) to
distinguish the inevitable emotional
upset following a diagnosis of a life-
threatening disease such as leukaemia
from a more severe disturbance that
meets the criteria for a mental disorder.
In practice, there is a need for a multidis-
ciplinary strategy with the involvement
of specialist haematology/oncology
nurses, psychologists, psychiatrists and
social workers. High quality communi-
cation between the patient and their
physician and other members of
the caring team is crucial to blunt the
distress caused by setbacks and the
toxicity of treatment. Psychotherapeutic
approaches may be on an individual or
group basis and have been shown to
diminish any sense of isolation and to
boost optimism. The provision of good
quality information, exploiting the
internet and other new technologies, is
complementary to this process. Where
there is signicant anxiety and depres-
sion and correctable causes have been
excluded anxiolytics and antidepres-
sants can be benecial. Support must
also be given to the patients family, par-
ticularly at the time of bereavement.
Complementary therapy
Patients may turn to complementary
and alternative medicine. Staff specialis-
ing in traditional cancer medicine may
be ignorant of and even threatened by
such modalities. However, they should
not hesitate to advise against any unor-
thodox intervention which is likely to
lead to harm. There is some evidence for
the use of hypnosis in pain relief, for
acupuncture in the management of
drug-induced nausea and vomiting, and
for massage and meditation techniques
in decreasing distress and improving
sense of well-being. Centres specialising
in the treatment of haematological
malignancy are increasingly offering
these therapies to their patients.
Fig 47.3 The need for palliative care in a
patient with myeloma. An MRI scan of the
spine in a patient with myeloma showing
vertebral collapse. Back pain is a common
symptom in this disease.
Fig 47.4 A syringe driver used to give continuous drug infusions.
Palliative care in
haematological malignancy
Palliative care is designed to improve the quality of life of patients and their families it is
complementary to ongoing anti-cancer treatment.
Optimal provision of palliative care requires a multidisciplinary team with specialist skills.
Good communication is a vital therapeutic tool.
Chemotherapy and radiotherapy may be used to palliate symptoms.
Pain is a common symptom of haematological malignancy and is often poorly treated.
Patients with advanced disease may require an actively titrated opiate analgesic and an
appropriate co-analgesic.
Normal emotional distress following the diagnosis of a haematological cancer must be
distinguished from mental disorders requiring specic treatment.
tahir99-VRG & vip.persianss.ir
96 9 SPECIAL SITUATIONS
48 Systemic disease
worsen bleeding by interfering with the
normal interaction between platelets
and vascular endothelium.
Liver disease and alcohol
Signicant liver disease is associated
with haemostatic problems (see p. 77)
and red cell abnormalities including
macrocytosis and target cells. Excessive
alcohol consumption commonly causes
macrocytosis and thrombocytopenia.
Malignancy
Anaemia is seen in around half of
patients with non-haematological malig-
nant tumours. The anaemia of chronic
disease is the most common aetiology
(p. 36) but other causes include chemo-
therapy, blood loss, haemolysis and
marrow inltration. Invasion of the
bone marrow by solid tumours can
result in a pancytopenia and a character-
istic leucoerythroblastic blood picture
with circulating nucleated red cells and
myelocytes (Fig 48.2a). Clumps of malig-
nant cells may be seen in a bone marrow
aspirate but a bone marrow trephine is
a more reliable way of demonstrating
solid malignancy (Fig 48.2b).
Malignancy can be associated both
with a hypercoagulable state and a
bleeding tendency. The presence of
hypercoagulability was rst suggested
by the increased incidence of deep vein
thrombosis and pulmonary embolism
seen in cancer patients. The mechanism
is thought to be activation of the normal
clotting system with low-grade intravas-
cular coagulation and secondary bri-
nolysis. In the laboratory, common
ndings are elevated levels of clotting
factors and a shortened prothrombin
time and activated partial thromboplas-
tin time. It is presumed that cancer cells
secrete thromboplastin which initiates
clot formation. Treatment of venous
thrombosis in malignancy is difcult, as
anticoagulant control is often poor. Low
molecular weight heparin is generally
preferred to warfarin.
Disseminated intravascular coagula-
tion (DIC) can complicate malignancy.
It may be an acute haemorrhagic state
but is more often a chronic low-grade
disorder with no bleeding. It is particu-
larly likely to accompany carcinomas of
the prostate, stomach, colon, breast,
ovary, lung, gallbladder and melanoma.
DIC is further discussed on page 76.
Connective tissue
disorders
Systemic disorders such as rheumatoid
arthritis, systemic lupus erythematosus
(SLE) and mixed connective tissue
disease often lead to abnormal blood
counts. In practice the most common
finding, particularly in rheumatoid
arthritis, is the anaemia of chronic
disease. Immune thrombocytopenia is
more often seen in SLE and this hetero-
geneous disorder may also be compli-
cated by the presence of the lupus
anticoagulant (p. 79). Neutropenia can
arise in several connective tissue disor-
ders; the triad of long-standing rheuma-
toid arthritis, splenomegaly and
neutropenia is termed Felty syndrome.
There may be a small increased risk
of haematological malignancy in
patients with rheumatoid arthritis. In
Sjgrens syndrome there is a substan-
tially increased risk of non-Hodgkins
lymphoma.
Clinical haematologists spend a consid-
erable part of their time investigating
blood abnormalities in patients with dis-
eases of other organ systems. Some of
the more common diagnostic chal-
lenges are discussed here.
Renal disease
Diseases of the kidney are associated
with a remarkably wide range of possi-
ble haematological abnormalities (Table
48.1).
Anaemia is almost inevitable in
chronic renal failure. The pathogenesis
is complex but impaired erythropoietin
production is the principal cause. Other
possible contributory factors include the
release of inhibitors of erythropoiesis,
mild haemolysis and iron deciency.
The anaemia of renal failure is typically
normocytic and normochromic. A char-
acteristic nding in the blood lm is the
presence of burr cells (Fig 48.1). The best
treatment of anaemia is resolution of
the underlying renal problem (e.g. by
transplantation), but where this is not
feasible, recombinant erythropoietin is
the treatment of choice. Intermittent
bolus administration generally leads to
a marked improvement in anaemia and
transfusion independence. A failure of
the anaemia to respond to erythropoie-
tin should prompt a search for other
aetiologies such as iron deciency.
Paradoxically, some forms of renal
disease can lead to increased red cell
production and clinical polycythaemia
(see Table 48.1). This arises either from
inappropriate secretion of erythropoie-
tin by a kidney tumour or from local
renal hypoxia promoting erythropoietin
release from normal cells. Polycythae-
mia can be the presenting feature of
renal carcinoma and rapid identication
of the malignancy may allow curative
surgical treatment. Benign diseases such
as polycystic disease and hydronephro-
sis probably cause polycythaemia by
inducing renal ischaemia. The poly-
cythaemia of renal disease is not an
appropriate physiological response and
patients with high haematocrits can
derive benet from regular venesection.
Chronic renal failure is also associated
with a large number of possible platelet
and coagulation abnormalities. The
increased risk of bleeding in these
patients is generally caused by the
complex interaction of abnormalities
shown in Table 48.1. Anaemia tends to
Table 48.1 Haematological changes in renal disease
Abnormality Clinical association
Red cells Anaemia Chronic renal failure
Polycythaemia Renal carcinoma, cystic disease, hydronephrosis, parenchymal
disease, Bartters syndrome, renal transplantation
Burr cells Renal failure
Haemostasis Abnormal platelet function Renal failure
Thrombocytopenia
Disordered coagulation
1
1
The complex coagulation abnormalities of renal failure usually lead to a bleeding tendency but nephrotic syndrome is associated with an
increased incidence of thrombosis.
Fig 48.1 Burr cells in the blood in renal
failure.
tahir99-VRG & vip.persianss.ir
97 Systemic disease
Infections
Infections are probably the most
common cause of abnormal blood
counts in a typical haematology labora-
tory. Different infections are associated
with different abnormalities but it is
possible to make some generalisations.
Bacterial infections commonly cause a
neutrophil leucocytosis. The neutrophils
are classically left-shifted (i.e. reduced
nuclear segmentation) with increased
cytoplasmic granulation (toxic granula-
tion). Very severe bacterial infections
such as disseminated tuberculosis can
induce a leukaemoid reaction with
immature myeloid cells appearing in
the blood.
Viral infections most commonly cause
a transient lymphocytosis with reactive
changes in the cells. Two types of viral
infection merit more detailed descrip-
tion: infectious mononucleosis and HIV
infection.
Infectious mononucleosis
Infectious mononucleosis (or glandular
fever) is a disorder caused by the
EpsteinBarr virus (EBV). It predomi-
nantly affects adolescents and young
adults. Clinical features often include
malaise, fever, pharyngitis, lymphaden-
opathy, splenomegaly and hepatitis.
There is a small risk of splenic rupture.
The haematological hallmark of the
disease is the presence of numerous
atypical lymphocytes in the blood (Fig
48.3). These lymphocytes are mainly
activated T-cells produced as an immu-
nological response to EBV-infected
B-lymphocytes. Other possible blood
changes are neutropenia, thrombocyto-
penia and a cold-type autoimmune
haemolytic anaemia. The differential
diagnosis is essentially other viral dis-
eases, but where the blood abnormali-
ties are severe the disease may be
confused with acute lymphoblastic leu-
kaemia. The diagnosis is supported by
positive PaulBunnel or Monospot tests
which rely on the detection of heter-
ophile antibodies that appear in the
serum. If these tests are negative and
there remains clinical suspicion of the
disorder then EBV-specic serodiagnos-
tic tests should be performed. Treat-
ment of infectious mononucleosis
is essentially symptomatic, although
corticosteroids can be helpful in unusu-
ally difcult cases.
HIV infection
Progressive HIV infection has many
possible haematological consequences
(Table 48.2). These result from a combi-
nation of a direct effect of the virus,
opportunistic infection and side-effects
from the drugs used in treatment. The
blood changes are often similar to those
seen in other viral infections but a
chronic decline in the lymphocyte count
is a particular feature. Examination of
the bone marrow often reveals non-
specic features such as changes in
cellularity, brosis, trilineage myelodys-
plasia, increased plasma cells and prom-
inent haemophagocytosis. The presence
of granulomas can signify infection by
atypical mycobacteria or other oppor-
tunistic pathogens. In clinical practice
the major haematological problems
associated with HIV infection are
immune thrombocytopenia (ITP) and
lymphomas. The latter are typically
aggressive B-cell malignancies with
extranodal involvement.
Fig 48.2 Patient with prostatic carcinoma and invasion of the bone marrow. (a) Leucoerythroblastic blood picture: note the nucleated red cell and
myelocyte. (b) Bone marrow trephine specimen showing replacement of normal haematopoiesis by carcinoma.
(a) (b)
Fig 48.3 Atypical lymphocyte in infectious
mononucleosis.
Table 48.2 Possible haematological
changes in HIV infection
Blood Lymphopenia
Anaemia
Neutropenia
Thrombocytopenia
Atypical lymphocyte morphology
Anisopoikilocytosis
Macrocytosis
1
Bone marrow Variable changes in cellularity
Dysplasia
Increased plasma cells
Increased brosis
Haemophagocytosis
Opportunistic infection (e.g.
granulomas)
Lymphoid aggregates
Lymphoma
Other Positive direct antiglobulin test (DAT)
Lupus anticoagulant
1
Particularly in patients receiving the drug zidovudine.
Systemic
disease
Renal disease can cause anaemia,
polycythaemia and abnormalities in
platelets and coagulation.
Malignancy often causes anaemia.
Invasion of the bone marrow by solid
tumour is a cause of a
leucoerythroblastic blood picture.
Bacterial and viral infections are
common causes of abnormal blood
counts.
Infectious mononucleosis is a disease
caused by the EpsteinBarr virus.
Numerous atypical lymphocytes are
seen in the blood.
The many possible blood changes of
HIV infection result from a combination
of a direct viral effect, opportunistic
infection and drugs used in treatment.
tahir99-VRG & vip.persianss.ir
98 9 SPECIAL SITUATIONS
49 The developing world
some very ill patients with malaria initially have no detectable
parasites in the blood as there is sequestration of parasite-
laden red cells in the tissues. It is beyond the scope of this
book to make a detailed comparison of the four species but
some typical appearances are shown in Figure 49.2. Supple-
mentary methods of parasite detection include antigen and
antibody detection and DNA-based techniques.
Clinical features
Malaria has a different clinical presentation in non-immune
and immune patients.
Non-immune patient
The interval between the mosquito bite and the onset of
symptoms is typically 12 weeks. Common symptoms are
rigors, sweats, headache, vomiting, diarrhoea and muscle
pains. P. vivax and P. ovale are classically associated with
bouts of fever on alternate days and P. malariae on every third
day. Possible clinical signs include a rising temperature, tachy-
cardia, herpes labialis, jaundice, dehydration and splenomeg-
aly. P. falciparum infection is the most dangerous form of
malaria. The onset can be insidious and the fever has no
particular pattern. Life-threatening complications such as cer-
ebral malaria (with development of coma), acute renal failure
and blackwater fever (rapid intravascular haemolysis), can
suddenly develop in a patient previously not particularly ill.
Children are particularly at risk of a sudden demise.
The term developing world is used to describe the majority
of tropical countries which are hot, humid and poor. An
alternative term is the less economically sound nations, as
these countries are often advanced in human and cultural
resources. Haematological practice is different to that in most
developed countries. Genetic diseases such as the haemoglob-
inopathies and red cell enzymopathies are frequent in many
tropical regions. Deciency anaemia and haemolytic anaemia
are often secondary to infections such as ancylostomiasis
(hookworm) and malaria. Medical treatment regarded as
routine in the developed countries is commonly unavailable.
For instance, only about 20% of the worlds haemophiliac
population has access to factor VIII replacement therapy.
With the ever-increasing availability of exotic holidays and
regular foreign travel within immigrant populations, doctors
in the developed world are seeing more tropical diseases. In
the patient with unexplained symptoms such as malaise and
fever, or signs such as splenomegaly, a history of travel should
not be overlooked.
Malaria
Malaria is a protozoal disease, the infectious agent being Plas-
modium falciparum, P. vivax, P. ovale or P. malariae. Mortality
from the disease has fallen over the last decade but it remains
a serious health risk throughout the tropics and subtropics
where insecticide resistance of anopheline mosquitoes and
multiple drug resistance of malarial parasites make control
and treatment challenging. According to the World Health
Organization, there were 216 million cases of malaria and an
estimated 655 000 deaths in 2010. Most deaths occur in chil-
dren living in Africa where the disease accounts for 20% of
all childhood mortality.
Pathogenesis
The life cycle of the malaria parasite is illustrated in Figure
49.1. When taking a meal of blood an infected mosquito initi-
ates human infection by the inoculation of malarial sporo-
zoites. These rapidly pass to the liver where they enter
hepatocytes and divide. After several days, enormously
increased numbers of parasites (merozoites) depart the liver
and invade red cells. Here the merozoites develop via ring
forms and trophozoites into schizonts. Rupture of the sch-
izont releases 1220 merozoites back into the blood, thus
perpetuating the cycle. The duration of the blood cycle varies
between malarial species, explaining the different periodicity
of fever in each type. A further mosquito becomes infected
when it feeds on blood containing gametocytes, the sexual
form of the parasite.
Diagnosis
Although malarial parasites may be detected in normal blood
lms, their identication is generally easier in Leishmann or
Giemsa stain at a higher pH. A thick lm is best for detection
and a thin lm for determination of the species. Prolonged
inspection of the lm is sometimes necessary to spot malarial
parasites as there can be a low level of parasitaemia. Where
malaria is suspected on clinical grounds repeated samples
may be needed to make or exclude the diagnosis. P. falciparum
is often associated with higher parasite counts. Paradoxically,
Fig 49.1 Life cycle of the malarial parasite.
Female gametocyte
being fertilised by
male gamete
Maturation
of female
gamete
Exflagellating
male gametocyte
Zygote
Stomach
wall
Young
oocyst
Segmenting
oocyst
Ruptured
oocyst
Sporozoites
invading
salivary glands
Hypnozoite
Trophozoite
Schizont
Immature
gametocytes
Male and female
gametocytes
Merozoites
Ring form
Merozoites
Ookinete
tahir99-VRG & vip.persianss.ir
99 The developing world
Endemic malaria
In indigenous populations, malaria
presents variably depending on the
degree of endemicity, the age of the
patient and the development of immu-
nity. Thus in hyperendemic areas where
there are seasonal variations, adults
develop considerable immunity, malaria
causing only short episodes of fever and
a palpable spleen. In holoendemic areas
there is infection through the year and
usually the disease manifests as a tran-
sient low parasitaemia with no symp-
toms. In hypoendemic areas, epidemics
occur and the disease resembles that in
the non-immune. Tropical splenomegaly
syndrome is the development of massive
splenomegaly in adults in hyperen-
demic areas. The patient has a low para-
sitaemia with an exaggerated immune
response and very high levels of IgM.
Treatment and prophylaxis
Ill patients should be rested and rehy-
drated. A rational choice of drug treat-
ment requires knowledge of both the
clinical syndrome and the likelihood of
drug resistance. The mainstay of treat-
ment of severe malaria is quinine. This is
given intravenously. The dosage must be
carefully calculated to avoid under-
treatment or toxicity. Recent trials have
suggested that artesunate, a derivative of
the plant compound artemisin, is both
easier to give and more effective than
quinine in severe malaria. Its use in
Africa may be limited by its cost. Special-
ist advice should be sought in difcult
cases.
Chemoprophylaxis is advised for non-
immune travellers entering malarial
areas. Specic recommendations depend
on the risk of exposure to malaria, the
extent of drug resistance, the efcacy of
drugs, drug side-effects and patient-
related criteria (e.g. pregnancy, renal
impairment). Drugs used include chlo-
roquine, proguanil, meoquine and
doxycycline. Where there is doubt,
expert advice should be sought. Simple
preventative measures such as protec-
tive clothes, mosquito nets and insect
repellent creams also help reduce the
risk of infection. The recently discovered
red cell surface receptor which allows P.
falciparum to invade may provide a
target for a future vaccine.
Visceral leishmaniasis
(kala-azar)
This protozoal disease is transmitted by
sandies and caused by the organism
Leishmania donovani. It is a cause of
massive splenomegaly. The organism
may be detected in a blood lm within
monocytes or neutrophils but bone
marrow aspiration is more sensitive.
Other parasitic diseases
detectable in the blood
These include the following:

Filariasis. Microlariae are released

into the blood during an acute attack
of disease. As the organisms are
motile, examination of a wet
preparation is useful.

Babesiosis. This tick-borne disease

only occasionally affects humans.
Trophozoites which resemble small
ring-forms of P. falciparum can be
found in red cells.

Trypanosomiasis. The parasites are

extracellular and motile.
Iron deciency in
hookworm infection
Hookworms infect approximately a
billion people worldwide. They are a
major cause of gastrointestinal blood
loss and iron deciency anaemia in trop-
ical regions. Worms attach to the upper
small intestine and remove blood from
the host; the daily loss can be as great
as 250 mL. Management of anaemic
patients should include both treatment
of worms with an effective anti-
helminthic agent and oral iron supple-
ments to replenish stores.
Endemic Burkitts
lymphoma
Endemic Burkitts lymphoma is an
aggressive B-lymphoblastic lymphoma
which is found particularly in African
children. In areas where malaria is
holoendemic it is the most common
childhood cancer. The disease is associ-
ated with EpsteinBarr virus (EBV)
infection and the chromosomal rear-
rangement t(8;14). The classic clinical
presentation is with a massive tumour
of the jaw or other extranodal disease.
Cure rates exceeding 90% are possible
with combination chemotherapy.
Fig 49.2 Malarial parasites in the blood. (a) Ring-forms in P. falciparum malaria. (b) Schizonts in P. ovale malaria. (c) Gametocytes in P. vivax malaria.
(a) (b) (c)
The developing world
The incidence of many haematological disorders and the availability of treatment is
different in the developing world and developed countries.
Malaria is a protozoal disease transmitted to humans by anopheline mosquitoes. It is a
major health problem in tropical and subtropical regions.
Laboratory diagnosis of malaria depends on the identication of parasites in thick and thin
blood lms.
Optimum drug treatment of established malaria and the best choice of prophylaxis require
expert knowledge of clinical syndromes and possible drug resistance.
Hookworm infection is a major cause of iron deciency in tropical areas.
tahir99-VRG & vip.persianss.ir
100 10 RECENT ADVANCES IN HAEMATOLOGY
50 Molecular biology
complex gene expression data generated requires powerful
statistical analysis. Microarrays are enhancing our under-
standing of haematological malignancy (see below and Fig
50.2).
Molecular techniques now play a central role in the diagnosis
and management of blood disorders, particularly haemato-
logical malignancies. This is a rapidly changing eld and the
following is a summary of some of the most commonly used
and newest technologies and applications.
Selected techniques used in the analysis
of DNA
Polymerase chain reaction (PCR)
The object of PCR is to amplify a preselected sequence of
DNA many times over. This amplication greatly facilitates
subsequent analysis of the DNA sequence for point mutations
and polymorphisms, and often allows direct analysis of the
product by gel electrophoresis without the use of probes.
The method can only be briey described here. Essentially
two specic oligonucleotide primers are added to the DNA.
These have sequences matching the regions anking the
region of interest. A DNA polymerase is added and the
mixture heated, causing the DNA to dissociate into two single
strands. Following cooling the single strands bind to the oli-
gonucleotides which are in excess. The oligonucleotide then
acts as a primer for DNA polymerase and is extended to form
a new double-stranded molecule. With each repeat of the
cycle the amount of DNA is doubled. Generally about 30
cycles are used and amplication of approximately 10
6
can be
achieved.
Fluorescence in situ hybridisation (FISH)
FISH describes the hybridisation of specic DNA or RNA
sequences in situ to cellular targets attached to microscope
slides. The most popular probes are chromosome-specic
DNA sequences which generate a brilliant signal in both
metaphase and interphase nuclei. The technique is particu-
larly useful in the demonstration of chromosomal mono-
somies or trisomies but chromosome translocations (Fig
50.1), deletions and amplication of specic genes can also be
detected. The results of FISH may be further improved by
image processing.
Comparative genomic hybridisation
This technique is designed to detect regions in the genome
which are undergoing quantitative changes. Different tumours
show distinct genomic hybridisation patterns of gains and
losses. The method is especially useful in the analysis of
leukaemias.
Microarrays/gene proling
Microarray technology allows the simultaneous proling of
tens of thousands of genes thus painting a molecular portrait
of a tumour cell. Several methods are available for analysis of
a large number of RNA transcripts. These include comple-
mentary DNA microarrays, oligonucleotide microarrays and
serial analysis of gene expression (SAGE). The most com-
monly used platforms are the two microarray technologies
in which each experiment reveals the expression levels of over
20 000 genes. cDNA fragments and oligonucleotides can be
spotted onto glass slides. The DNA arrayed on the slide is
generally referred to as the probe and the cDNA or cRNA
derived from the sample is referred to as the target. The
Fig 50.1 Use of FISH in a case of chronic myeloid leukaemia (CML).
Probes for BCR and ABL are used juxtaposition of the two probes (giving a
yellow signal as in cell lower right) indicates the BCRABL rearrangement
seen in Ph+ CML.
Fig 50.2 Subgroups of diffuse large B-cell non-Hodgkins lymphoma
(DLBCL) according to gene expression proles. In the top panel each
column represents a single DLBCL and each row a single gene. Red areas
indicate increased expression and green areas reduced expression. Survival
after chemotherapy is different in the three groups. (Reprinted with
permission from Margalit O et al 2005 Micro-array based gene expression
proling of hematologic malignancies: basic concepts and clinical
applications. Blood Reviews 19: 226.)
Germinal-centre
B-cell like
Type 3
Activated
B-cell like
G
e
n
e
s
1.0
0.0
0.5
0 2 4 6 8 10
Overall survival (yr)
P
r
o
b
a
b
i
l
i
t
y
Germinal-centre B-cell like
Type 3
Activated B-cell like
tahir99-VRG & vip.persianss.ir
101 Molecular biology
Haematological malignancy
Diagnosis and classication
Leukaemias and lymphomas were origi-
nally diagnosed and classied on the
basis of their morphological appear-
ance. As is discussed in the disease sec-
tions, optimum management of these
disorders now requires the supplemen-
tation of traditional clinical and mor-
phological information with detail of
immunophenotypic, karyotypic and
molecular characteristics. Molecular
analysis allows the conrmation of spe-
cic disease markers (e.g. BCR-ABL in
chronic myeloid leukaemia) and also
reveals key prognostic information
(e.g. Ig gene mutation in chronic lym-
phocytic leukaemia). Microarray-based
gene expression and next-generation
Fig 50.3 Whole genome sequencing for detection of mutations in chronic lymphocytic
leukaemia. For each tumour genome, copy number (solid lines), density of mutations per 5-Mb
window (bars) and protein-coding mutations (dots) are shown. The shaded rectangle indicates the
location of the 13q14 deletion present in three of the four cases. Chromosome numbers are listed
below the four proles. (Reprinted by permission from Macmillan Publishers Ltd: Puente XS et al 2011,
Whole genome sequencing identies recurrent mutations in chronic lymphocytic leukaemia. Nature
475: 101105.)
Fig 50.4 The detection of minimal residual disease. The greater
sensitivity of PCR and immunological marker analysis compared with
traditional morphological techniques in the detection of residual leukaemic
cells can be seen. (Reproduced with permission of JJM van Dongen,
Department of Immunology, Erasmus University, Rotterdam, and Medicultura
International B.V.)
Relative frequency
of leukaemic cells
I-Rx = induction chemotherapy; M-Rx = maintenance chemotherapy
0
0 1 2 3 4
Follow-up in years
1
10
-1
10
-2
10
-3
10
-4
10
-5
10
-6
10
-7
M-Rx I-Rx
Detection limit of
immunological
marker analysis and
PCR techniques
Detection limit
morphological
techniques
'Cure'
Next-generation sequencing
Massively parallel sequencing (also termed next- or second-
generation sequencing) results in the simultaneous genera-
tion of millions of short DNA sequences. In studies of
haematological malignancy, it is important to sequence both
the tumour cells and normal tissue (e.g. skin) from the patient
to identify relevant acquired (somatic) mutations. In whole
genomic sequencing (Fig 50.3), the object is to sequence the
entire genome. More specic next-generation techniques
include exome and transcriptome sequencing.
Application of molecular biology
in haematology
Carrier detection and antenatal detection in
genetic disorders
Molecular techniques are crucial in antenatal diagnosis and
genetic counselling in genetic disorders of the blood. For
instance, PCR technology to detect DNA point mutations or
deletions in chorionic villus samples, enabling rst trimester
testing for thalassaemia. Extraction of fetal cells or DNA from
maternal blood may allow less invasive prenatal diagnosis.
Molecular biology
Molecular biology techniques routinely used in haematology
include the polymerase chain reaction (PCR), uorescence in situ
hybridisation (FISH) and comparative genomic hybridisation.
Molecular techniques play a key role in carrier detection and
antenatal detection in genetic disorders such as thalassaemia and
haemophilia.
In haematological malignancy, molecular techniques rene
diagnosis and classication, and improve detection of minimal
residual disease (MRD) after therapy.
Recent developments include microarray-based gene expression
proling and whole genome sequencing of haematological
malignancies.
sequencing studies, described above, provide novel insights
into the biology of leukaemia, lymphoma and myeloma. Sim-
plication of this expensive research technology is likely to
permit its eventual use in the hospital laboratory.
Minimal residual disease
Traditional denitions of remission in leukaemia have relied
on crude morphological criteria. Many patients in remission
subsequently relapse, implying the existence of occult neo-
plastic cells undetectable by normal morphological or cytoge-
netic methods so-called minimal residual disease (MRD) (Fig
50.4). Reliable detection of MRD potentially allows improved
management with escalation of therapy for patients with per-
sistent disease and the avoidance of excessive treatment in
patients showing a good response to previous intervention.
Detection of MRD relies upon the presence of disease markers
that can be targeted (e.g. PML-RAR in acute promyelocytic
leukaemia). In childhood and adolescent ALL the tandem
application of ow cytometry and PCR can be used to study
MRD in almost all patients and this information is being
employed in clinical trials. In CML quantitative PCR assay of
BCR-ABL transcripts is routinely used to direct management.
Very low levels of BCR-ABL mRNA predict a good clinical
outcome.
Stem cell transplantation
Molecular techniques can be used both to monitor MRD
post-transplant and to improve the level of HLA matching
between unrelated donors and recipients.
tahir99-VRG & vip.persianss.ir
102 10 RECENT ADVANCES IN HAEMATOLOGY
51 Potential advances in treatment
include immunomodulating drugs such
as lenalidomide. Such considerations
may also apply in other haematological
malignancies. For instance, encouraging
clinical results have been obtained in
chronic lymphocytic leukaemia follow-
ing the targeting of the tumour cells
with genetically modied autologous
T-cells.
New oral
anticoagulant drugs
Anticoagulant drugs are used both in the
treatment and prevention of throm-
boembolic disease (see pp. 8081). Con-
ventional heparin and warfarin were
discovered over 60 years ago while low
molecular weight heparin is a more
recent addition. All of these drugs have
disadvantages, none fullling all the cri-
teria for an ideal anticoagulant, namely
a high efcacy to safety index, a predict-
able dose response with no need for
laboratory monitoring, administration
by parenteral and oral routes, a rapid
onset of action, a safe antidote, freedom
from non-anticoagulant side-effects and
minimal interaction with other drugs.
Any new agent must aspire to meet as
many of these requirements as possible
without being prohibitively expensive.
Attempts to develop better anticoagu-
lants have focused on specic steps or
enzymes in the coagulation pathway.
Agents under evaluation include inhibi-
tors of the factor VIIIc/tissue factor
pathway, factor Xa inhibitors, activated
protein C and soluble thrombomodulin
and direct thrombin inhibitors (Fig 51.2).
Direct thrombin inhibitors and direct
factor X
a
inhibitors are now entering
clinical practice and their use is likely to
change the current practice of antico-
agulation. Dabigatran etexilate is a
prodrug. It is rapidly absorbed and
converted in the liver to the active
form dabigatran which acts as a direct
thrombin inhibitor binding both free
and clot-bound thrombin. The drug is
administered orally and no therapeutic
monitoring (i.e. laboratory testing of
drug levels or activity) is required.
Rivaroxaban is a direct inhibitor acti-
vated X (factor X
a
) and is also given
orally without the need for routine
monitoring. Apixaban and edoxaban
are other oral factor X
a
inhibitors under
This section addresses some potential
advances in the treatment of blood dis-
orders only briey alluded to in the
coverage of specic diseases. Inevitably
any such listing of advances is subjec-
tive. Most clinicians would expect an
expanding role for the targeting of the
microenvironment in haematological
malignancy, the wider use of new oral
anticoagulant agents, and the introduc-
tion of gene therapy for single-gene
disorders such as haemophilia and
thalassaemia.
Targeting the
microenvironment
in haematological
malignancy
The tumour microenvironment is cur-
rently thought to play a crucial role in
cancer biology. A better understanding
of the complex interactions between
tumour and non-malignant cells is likely
to translate into better characterization
of tumour pathophysiology and novel
approaches to therapy. In haematologi-
cal malignancy, follicular lymphoma
(see also p. 61) provides an excellent
model for the study of the microenvi-
ronment. This disease accounts for
approximately a quarter of all cases
of non-Hodgkins lymphoma. Modern
treatment with a combination of chemo-
therapy agents and the anti-CD20
monoclonal antibody rituximab has
improved overall survival but cure is
elusive. Better therapeutic strategies are
needed. Technologies such as immuno-
cytochemistry, functional cytotoxicity
assays and 3-D confocal imaging have
improved our understanding of the role
Fig 51.1 A schematic view of the
microenvironment in follicular lymphoma.
Cytotoxic CD8+ lymphocytes exert anti-tumour
effects (red arrows) while tumour cells seek
self-preservation (green arrows) by stimulating
CD4+ T-cells to secrete favourable cytokines,
inhibiting cytotoxic T-cells, and erecting a
tumour barrier.
Tumour cell
Non-malignant cells
(e.g. T-cells, macrophages)
Fig 51.2 Possible new anticoagulants. See text for discussion.
Coagulation pathway Possible anticoagulant
Tissue factor pathway
inhibitors
Protein C pathway
(e.g. activated protein C)
Xa inhibitors
(e.g. rivaroxaban)
Thrombin inhibitors
(e.g. dabigatran)
Initiation
Thrombin
generation
Thrombin
activity
Tissue factor / VIIa
IX
X
IXa, VIII a
Xa, Va
II
Thrombin
Fibrin
of the microenvironment in this disease and offered the pros-
pect of new treatments which tip the balance against the
tumour cells. The various interactions are complex (Fig 51.1)
but it is clear that CD8+ cytotoxic lymphocytes play an active
role and have the potential to be employed in the treatment
of follicular lymphoma. Most simplistically, a higher content
of T-cells appears to confer a better prognosis while pro-
tumour macrophages may worsen the outlook. Follicular lym-
phoma cells can manipulate the microenvironment to their
own advantage. Stimulation of CD4+ T-cell cytokine release
promotes tumour cell growth and survival. The tumour cells
also employ mechanisms to block entry of cytotoxic T-cells
into the tumour site and to inhibit recruitment and trafcking
of previously healthy T-cells. The challenge is to nd ways of
supplementing current immunotherapy regimens (e.g. rituxi-
mab and chemotherapy) by tipping the balance in the tumour
microenvironment towards enhanced T-cell anti-tumour
activity and away from immunosuppression. Possible agents
tahir99-VRG & vip.persianss.ir
103 Potential advances in treatment
development. The indications for all
these agents are gradually increasing as
they are tested in clinical trials. There
are still questions regarding long-term
safety. Also, there are no specic anti-
dotes to reverse the anticoagulant effects.
Fortunately, the drugs have a short half-
life and the bleeding risk is relatively
low.
Gene therapy
Gene therapy is potentially a very pow-
erful therapeutic tool applicable to a
wide range of diseases including several
blood disorders. After years of failure,
there have been recent successes in the
treatment of infants with immunode-
ciency and in selected patients with
malignancy. The basis of the technique
is the insertion of a new functional gene
into a cell (Fig 51.3). The gene is intro-
duced into the target cell by use of a
vector. Disabled viruses are commonly
used as vectors because they can under-
take tasks necessary for successful gene
transfer such as binding to the target cell
and delivering the viral genome to the
nucleus for transcription. Non-viral
vectors based on plasmid DNA pro-
duced in bacteria and combined with
lipids are also used. The optimum vector
and delivery method is likely to vary
depending on the disease under treat-
ment. Early protocols mainly involved
an ex vivo approach where the gene was
inserted into cells taken from the patient.
However, more recently the vector is
normally given directly to the patient (in
vivo approach). The problems have been
numerous and have included difculties
in characterising and accessing the
target cells, poor efcacy of gene trans-
fer, short-lived expression of the newly
introduced gene, and safety issues. The
latter especially relate to viral vectors
which have caused clinical symptoms of
infection and induced massive immuno-
logical responses. Two children cured of
their immunodeciency by gene therapy
subsequently developed leukaemia as a
result of insertional mutagenesis.
As single-gene disorders, both haemo-
philia and thalassaemia are good
candidates for cure by gene therapy.
Haemophilia is a particularly attractive
target disease as only a very small sus-
tained increase in factor VIII or IX levels
(12%) signicantly reduces the bleed-
ing tendency. A variety of methods for
transferring genes for factor VIII and IX
are under investigation. No single tech-
nique has emerged as being denitely
superior. Animal studies with viral-
derived vectors suggest that it is possible
to provide sustained therapeutic levels
of the clotting factors. Allowing the pos-
sibility that gene therapy for haemo-
philia may involve unforeseen risks, a
number of carefully designed clinical
studies in consenting patients are under
way. In an early trial, a small number
of patients with severe haemophilia B
were treated using a non-pathogenic,
non-integrating adeno-associated virus
(AAV) as a DNA carrier. An intravenous
schedule with gradually increased doses
was used. Patients achieved increased
factor IX levels with sustained clinical
benet, some being able to stop prophy-
lactic factor IX treatment. In thalassae-
mia initial efforts at gene therapy have
been directed against diseases of the
-globin gene. The therapeutic strategy
involves insertion of a normally func-
tioning -globin or -globin gene into
the patients haematopoietic stem cells.
At the time of writing, one patient with
-thalassaemia has been rendered trans-
fusion independent following gene
therapy but it is unclear if this was for-
tuitous or if this success can be repro-
duced in larger trials.
Gene therapy is also likely to have a
role in malignant disorders. Leukaemia
is essentially a genetic disease and, in
theory, gene therapy could eventually be
used to correct the abnormality in the
malignant cell and cure the patient with
minimal side-effects. Alternatively, gene
therapy might be used to augment the
patients own immune response against
malignant cells.
Fig 51.3 The essential steps necessary for
successful gene therapy in haemophilia A.
Patient cells with
normal factor VIII gene inserted
Obtain adequate levels of factor VIII
synthesis over a prolonged period
to 'cure' the disease
4
Factor
VIII
Haemophilia A is a sex-linked inherited
disorder. The gene is on the
X chromosome
Normal
factor VIII gene-vector
Design a suitable vector for the
insertion of the normal factor VIII
gene into patient cells
3
Patient cells
(e.g. hepatocytes)
Factor VIII gene
Haemophilia A is caused by a mutation of
the factor VIII gene. The normal factor
VIII gene has been identified
and cloned
2
Deletion
Establish the
genetic aetiology of the disease
1
Potential advances in treatment
The tumour microenvironment plays a crucial role in some haematological malignancies
(e.g. follicular lymphoma). It is likely to be increasingly targeted.
New anticoagulant agents are under active development. Oral thrombin and factor Xa
inhibitors potentially give safe anticoagulation without laboratory monitoring.
The enormous promise of gene therapy is likely to be soon translated into clinical benets.
There is a real prospect of successful treatment of haemophilia.
tahir99-VRG & vip.persianss.ir
104 11 PRACTICAL PROCEDURES
52 Venepuncture and venous access
vacuum is released. It is important to understand how the
system works before undertaking venepuncture.
Precautions
Blood should not be taken from a vein proximal to an intra-
venous infusion as the sample can be diluted. Neither should
eczematous or infected areas be used for venepuncture. If
patients are known to have a blood-transmissible infection
(e.g. hepatitis B or C, HIV) or are at increased risk of such an
infection this must be indicated on the specimen bottle and
request form. Due care must be taken as this is sensitive
information labels stating an infective risk are generally
available. In view of the possibility of needle-stick injuries,
those performing venepuncture should be vaccinated against
hepatitis B.
Common problems
Venepuncture is not always easy. If blood is not aspirable fol-
lowing perceived entry of the vein it is worth withdrawing the
needle slowly with suction applied as the vein may have been
transxed. If a vein cannot be located in the antecubital fossa
it is permissible to use veins at the wrist or on the dorsum of
the hand. If two attempts fail a more experienced colleague
Obtaining a sample of venous blood from a patient is the
most commonly performed practical procedure in haematol-
ogy. The technique is apparently straightforward but poorly
performed venepuncture can both upset the patient and com-
promise the quality of the sample. Gaining venous access for
the delivery of uids, blood or drugs is also fundamental to
good haematological practice. This section is an overview of
venepuncture and venous cannulation. These skills are best
learnt by practice with expert supervision.
Taking a venous blood
specimen (venepuncture)
The patient should be the correct patient check their iden-
tity! Most serious haemolytic transfusion reactions arise from
careless identication of patients and incorrect form labelling.
Patients should sit or lie comfortably in such a way that no
serious injury could result from a faint. The operator washes
his hands and wears plastic gloves insist on gloves that t
properly. The procedure is explained to the patient and the
necessary consent obtained. The presence of a little transient
pain when the needle is inserted should be acknowledged but
not exaggerated.
Under normal circumstances blood is most easily taken
from a vein in the antecubital fossa; the median cubital vein
is preferred (Figs 52.1 and 52.2). It is considerate to ask
whether the patient is left- or right-handed and then to choose
the non-dominant arm. A tourniquet is applied well proximal
to the site. This should cause distension of the veins but not
discomfort. Gentle palpation is the best method of identifying
a vein and checking its patency. If a suitable vein proves
elusive it may help to gently tap the area or to warm the arm
in water. The skin over the chosen vein is thoroughly cleaned
with antiseptic solution. Usually a 21- or 22-gauge needle is
used but a smaller size (e.g. 23) can be used where the veins
are fragile, or in children. The syringe should be adequate for
the sample where larger blood samples necessitate more
than one syringe a buttery needle may be preferred to a
conventional venepuncture needle. The needle is inserted
bevel uppermost along the line of the vein at an angle of
around 20. There is a distinctive give as the vein is entered.
Blood is aspirated into the syringe slowly to avoid haemolysis.
The tourniquet is released and the needle withdrawn after a
dry swab has been held to the site. Pressure should be applied
by the patient or an assistant with the arm held straight or
slightly elevated. The needle is removed from the syringe
not resheathed and placed directly into a sharps container.
The specimen is expelled gently from the syringe into the
relevant bottles. Mixing with anticoagulant is best achieved by
gently inverting the bottle several times violent shaking will
damage the sample. An adhesive plaster can be applied to the
venepuncture site (check for allergy) when bleeding has
stopped.
The above describes the procedure for a conventional
needle and syringe. Increasingly, venepuncture is performed
using closed evacuated container systems where a double-
ended venepuncture needle is screwed into a holder and the
evacuated tube inserted into the holder following entry of the
vein. Blood is automatically aspirated into the tube as the
Fig 52.1 Veins at the antecubital fossa. The median cubital vein is
preferred for routine venepuncture.
Left arm
anterior view
Cephalic
vein
Median
cubital vein
Fig 52.2 Taking blood from a vein in the antecubital fossa.
105 Venepuncture and venous access
should be sought. As a last resort a sample can be taken from
the femoral vein. The operator must be familiar with the
anatomy of the femoral region as the vein lies close to the
femoral artery and nerve.
Children
In babies and infants a blood sample is often more easily
obtained from a stab wound made with a lancet (capillary
blood). The usual site is the heel, although ngers and ear-
lobes can be used. Venepuncture may also be from scalp
veins.
protected with a sterile dressing and the
cannula secured with a bandage or
adhesive tape.
The most common problem is failure
to locate a vein in the favoured sites. A
more experienced operator may be suc-
cessful. Where problems persist in expe-
rienced hands, other veins such as those
in the region of the ankle or the subcla-
vian, jugular or saphenous veins may be
cannulated. Regular inspection of the
drip site and careful hygiene will mini-
mise the chance of infection. Where
there is local inammation or an other-
wise unexplained bacteraemia, the
cannula should be removed and another
site used.
Central venous cannulation
Insertion of wide-lumen silicon rubber
catheters (generally referred to as
Hickman catheters) is routinely under-
taken in clinical haematology where
recurrent intravenous access is required.
Examples include:

patients with haematological

malignancy receiving intensive
chemotherapy

patients with thalassaemia having

regular blood transfusions

children with haemophilia A on

prophylactic factor VIII treatment.
The catheter is normally inserted into
the subclavian vein and the location of
the distal tip checked on X-ray (Fig 52.4).
The proximal end of the catheter can be
tunnelled under the skin with an exit
site on the anterior chest wall. A catheter
cuff within the tunnel promotes the for-
mation of brous tissue which helps
secure the device. The procedure is
usually performed in the operating
theatre by a surgeon or anaesthetist.
Once in place the catheter may be used
for several months. Strict aseptic tech-
nique is necessary as infection with
coagulase-negative staphylococci is the
most common complication.
Fig 52.3 A large gauge plastic cannula.
Venous access
Peripheral venous cannulation
Almost all haematology patients admit-
ted to hospital require a drip to infuse
uids, blood products or drugs. Before
inserting a cannula into a vein, an appro-
priate giving set should be prepared in
accordance with instructions and the
bag or bottle containing the infusion
uid inverted and hung on the drip
stand. The set should be properly
primed and all bubbles excluded. The
operator must wash hands and wear
gloves. It is vital to ensure that the
patient is comfortable and fully under-
stands the procedure and that necessary
consent is obtained. The choice of
cannula depends both on the quality
of the veins and the duration and type
of infusion. For short-term infusions or
small veins a winged metal cannula
(buttery needle) is often suitable. In
other circumstances a larger gauge
plastic cannula is used (Fig 52.3). In
adults, 1820-gauge catheters provide
good ow rates without too much dis-
comfort for the patient.
The best site is the non-dominant
forearm or the dorsum of the hand. The
antecubital fossa is best avoided as it is
uncomfortable to have the elbow immo-
bilised. A tourniquet is applied and the
skin cleaned as for venepuncture. The
skin at the site may be stretched slightly
to immobilise the vein. The cannula
assembly (metal needle and surround-
ing plastic cannula) is introduced
through the skin and into the vein. Once
blood enters the cannula chamber or is
easily drawn into a syringe, the tourni-
quet is released and the metal needle
withdrawn from the plastic cannula
which may be advanced further into the
vein. The pre-prepared giving set is
attached to the cannula and uid
allowed to enter the vein while the inser-
tion site is carefully inspected for
possible extravasation. The needle is
promptly disposed of in a sharps recep-
tacle. To minimise the chance of the drip
being infected or dislodged the site is
Fig 52.4 Chest X-ray showing a central
venous catheter in situ.
Intravenous administration of
cytotoxic drugs (chemotherapy)
should only be undertaken
following appropriate training
in the use of these agents.
Venepuncture and
venous access
Obtaining a venous blood sample (venepuncture) is a commonly performed practical
procedure in haematology; poor technique can upset the patient and ruin the sample.
In babies and infants, capillary blood sampling is often easier than venepuncture.
Peripheral venous cannulation is commonly performed to infuse uids, blood products and
drugs.
Where there is serious difculty in locating a vein for venepuncture or cannulation, more
experienced help should be sought.
For recurrent venous access, insertion of an indwelling central venous catheter can be
helpful.
106 11 PRACTICAL PROCEDURES
53 Bone marrow aspiration and trephine biopsy
Marrow aspirate smears must be
made promptly at the bedside before
the marrow clots. If a larger volume is
needed for tests such as cytogenetics
and immunophenotyping, it is best to
use a second syringe as large samples
dilute the marrow with peripheral blood
and reduce the quality of the morpho-
logical preparations. If it proves difcult
or impossible to aspirate marrow it is
worth replacing the stylet and carefully
advancing or retracting the needle a
short distance before repeating aspira-
tion. It is important to remember that a
dry tap can result from marrow pathol-
ogy (particularly brosis or solid malig-
nancy) and is not always caused by poor
technique.
Once the aspirate needle is with-
drawn, rm pressure is applied to the
site for a few minutes and then a sterile
dressing or plaster used as protection.
The patient lies on his back for 15
minutes to ensure a period of recupera-
tion and that further light pressure is
The indications for performing bone marrow aspiration and
trephine biopsy procedures have previously been discussed
(p. 19). In this section the practical aspects of obtaining these
samples are outlined. More detailed accounts can be found in
books of practical procedures, but ultimately the only way to
perfect techniques is to practise under expert supervision.
Although the anterior iliac crest is occasionally preferred,
most operators get the best specimens from the posterior iliac
crest. The sternum is now rarely used. This is, in part, due to
the small risk of causing catastrophic damage to the mediasti-
num, but mainly because it is not possible to obtain a trephine
biopsy. Only the posterior iliac crest approach is described
here.
Bone marrow aspiration
As for all procedures the sequence of events should be
explained to the patient, reassurance given and consent
obtained. A degree of discomfort should be acknowledged but
it should be emphasised that this is transitory. In most adults,
local analgesia is adequate but sedation is considered where
patients are unusually anxious. A general anaesthetic is the
Fig 53.1 Anatomy of the posterior iliac crest. Possible sites for marrow
sampling are indicated in red.
norm in children. A clean, no touch
technique is mandatory and operators
should wear gloves. Stringent asepsis is
needed in immunosuppressed cases.
The patient lies in the left or right
lateral position and the skin over the
posterior iliac crest is cleaned with anti-
septic prior to screening with sterile
drapes. The crucial next stage is to prop-
erly identify the bony landmarks (Fig
53.1). This is straightforward in most
patients but can be problematic in obese
subjects. If there are real difculties in
locating the posterior iliac crest then the
anterior crest or the sternum may be
considered or the procedure may be
performed under CT guidance. A local
anaesthetic is inltrated into the skin
and then down to the periosteum.
Before use it should be checked that the
marrow aspirate needle stylet is easily
withdrawn and the guard is removed
(this is only required for sternal aspi-
rates). The needle (Fig 53.2) is inserted
through the skin and subcutaneous
tissues at the site of local anaesthetic
inltration until the periosteum is
encountered. It is pushed through the
periosteum with a deliberate screwing
motion (alternating clockwise and anti-
clockwise) a give is felt as the marrow
cavity is entered. The stylet is withdrawn
and a syringe attached to the needle (Fig
53.3). Approximately 0.5 mL of marrow
is aspirated into the syringe. The patient
should be warned that this stage often
causes pain but that it is momentary.
Fig 53.2 Bone marrow aspirate needle.
Fig 53.3 Aspiration of bone marrow from
the posterior iliac crest.
applied to the puncture site. Outpatients
should probably be observed for at least
an hour before being allowed home
(more if sedated). Troublesome haemor-
rhage from the site is rare but it is sen-
sible to correct a severe coagulation
defect before undertaking the proce-
dure. Thrombocytopenia alone is gener-
ally not a problem.
Patients often ask how quickly the
results will be available. Aspirate slides
can be processed for microscopy (see
107 Bone marrow aspiration and trephine biopsy
p. 19) within a few hours but most ancil-
lary tests (Table 53.1) take longer.
Bone marrow
trephine biopsy
In practice the trephine procedure is
usually performed immediately follow-
ing the aspirate at the same site. It is
helpful to enlarge the aspiration punc-
ture site slightly with a scalpel blade.
There is sometimes more prolonged dis-
comfort than in the aspirate procedure
and sedation is indicated in anxious
adults, and a general anaesthetic is nec-
essary in children. A number of different
disposable needles are available the
Jamshidi type is illustrated in Figure
53.4. Smaller needles are available for
paediatric use.
It is important to ensure that the
device is complete and that the stylet
can be easily withdrawn. The trephine
needle is inserted in a similar fashion to
the aspirate needle through the perios-
teum and approximately 0.5 cm into
the cortex (Fig 53.5a) when properly
inserted the needle should easily support
its own weight. The stylet is removed
prior to advancing the needle 23 cm
using the same oscillatory movement.
The needle is aimed towards the anterior
iliac crest. The method for breaking off
the biopsy varies with the needle used.
Some have devices designed to grip the
biopsy and ensure its retention. The
needle is then withdrawn taking care not
to catch the skin and lose the biopsy in
subcutaneous tissue. A special blunt
probe is provided to push the biopsy out
of the needle. The probe is inserted (with
great care to avoid injury to the operator)
at the sharp end of the needle so as not
to traumatise the sample.
If the aspirate is a dry tap it is
worthwhile gently dabbing the trephine
Fig 53.4 Bone marrow trephine needle.
Fig 53.5 Obtaining a trephine biopsy from
the posterior iliac crest. (a) Insertion of the
needle. (b) CT guidance is useful in obese
patients.
(a)
(b)
Table 53.1 Ancillary tests which may be
performed on bone marrow
aspirate samples
Cytochemistry
Cytogenetics
Immunophenotyping
Molecular studies
Microbiological culture
Cell culture studies
Drug resistance studies
Bone marrow aspiration and
trephine biopsy
The optimal site for both bone marrow aspiration and trephine biopsy procedures is the
posterior iliac crest.
Local analgesia is often adequate but nervous adults require sedation and children
normally require a general anaesthetic.
Marrow aspiration smears may be stained for microscopy immediately after the procedure
whereas trephine biopsies are processed over several days.
Serious side-effects from posterior iliac crest aspiration and trephine biopsy are very rare.
Occasionally there can be excessive haemorrhage or local infection at the site.
Bone marrow can be harvested from the iliac crests in patients (for autologous stem cell
transplantation) or healthy donors (for allogeneic stem cell transplantation).
biopsy onto a glass slide before putting
it into histological xative. This touch
preparation is not useful for subtle mor-
phological diagnosis but can permit
rapid identication of malignant inltra-
tion. It usually takes several days to
process the trephine biopsy. Aftercare is
the same as for the aspirate, although as
it is a slightly more invasive procedure
the patient also having a trephine may
require a longer period of recuperation.
Nevertheless, trephine biopsies are rou-
tinely performed in the outpatient clinic.
Bone marrow harvesting
Bone marrow can be harvested from a
patient (for autologous stem cell trans-
plantation) or from a donor (for alloge-
neic stem cell transplantation). The
procedure is performed under a general
anaesthetic, the marrow being collected
from the iliac crests using multiple
punctures with specialised harvest
needles. Normally, approximately 1 litre
is harvested from an adult in under
an hour. Donors are hospitalised for
around 48 hours. Serious side-effects are
rare but some short-lived discomfort
over the aspiration sites is common. The
procedure is now undertaken less often
as peripheral blood stem cells are more
commonly used than bone marrow in
both autologous and allogeneic trans-
plants (see page 56).
108 APPENDICES
Appendices
Appendix I: Reference ranges in normal adults
These gures are for guidance only. Normal reference ranges vary in different
populations and in different laboratories. Patient results should always be
compared with local reference ranges.
Blood count
Haemoglobin Male 130180 g/L Female 115165 g/L
Packed cell volume Male 0.400.52 Female 0.370.47
Red cell count Male 4.55.9 10
12
/L Female 3.85.2 10
12
/L
MCV 8096
MCH 2732 pg
MCHC 315345 g/L
Reticulocytes 50100 10
9
/L (0.52.5%)
White cell count 4.012.0 10
9
/L
Neutrophils 2.007.50 10
9
/L
Lymphocytes 1.504.00 10
9
/L
Monocytes 0.201.00 10
9
/L
Eosinophils 0.020.40 10
9
/L
Basophils 0.020.20 10
9
/L
Platelet count 150400 10
9
/L
MCV, mean corpuscular volume; MCH, mean corpuscular haemoglobin; MCHC, mean corpuscular haemoglobin concentration.
Acute phase response
Other
Ferritin Male 21300 g/L Female 15150 g/L
Serum iron 1332 mol/L
TIBC 4570 mol/L
Transferrin 1.22.0 g/L
Serum vitamin B
12
160760 ng/L
Serum folate 320 g/L
Red cell folate 160640 g/L
TIBC, total iron binding capacity.
ESR
1
Male 05 mm/h Female 07 mm/h
Plasma viscosity 1.501.72 mPas (25C)
C-reactive protein 010 mg/L
1
Higher levels (up to 15 mm/h) may be seen in the elderly.
ESR, erythrocyte sedimentation rate.
109 Appendices
Appendix II: Selected immunophenotypic
(cell surface) markers
Appendix III: International prognostic index (IPI) for
non-Hodgkins lymphoma (NHL)
The IPI was initially designed for predicting the outcome of diffuse large B-cell
lymphoma (see non-Hodgkins lymphoma section for further discussion of IPI).
However, it has been shown to also have validity in other types of NHL. Patients
in the higher risk groups have poor outcomes with conventional chemotherapy
regimens.
Pretreatment criteria Score 0 Score 1
Age (years)
1
60 or under Over 60
Stage (Ann Arbor) I or II III or IV
Number of extranodal sites of disease 1 or less Greater than 1
Performance status (ECOG/WHO scale
2
) 0 or 1 2 or greater
Serum lactate dehydrogenase (LDH) Low or normal High
These ve scores are added to dene the risk group as follows:
Low 0 or 1
Low intermediate 2
High intermediate 3
High 4 or 5
1
An age-adjusted model for patients less than 60 years is also available.
2
The ECOG/WHO performance status scale is dened as follows: (0) able to carry out all normal activities without restriction; (1) restricted in
physically strenuous activity but ambulatory and able to carry out light work; (2) ambulatory and capable of all self-care but unable to carry
out any work; up and about more than 50% of waking hours; (3) capable of only limited self-care; conned to bed or chair for more than 50%
of waking hours; (4) completely disabled; cannot undertake any self-care; totally conned to bed or chair; (5) dead.
Cluster differentiation (CD)
designation
Normal reactivity/Comments
CD2 T-lymphocytes
CD3 T-lymphocytes
CD4 Helper/inducer T-lymphocytes
CD5 T-lymphocytes, B-lymphocyte subset (expressed in B-CLL)
CD7 T-lymphocytes
CD8 Cytotoxic/suppressor T-lymphocytes
CD10 Precursor B-lymphocytes (expressed in common ALL)
CD11c Monocytes, granulocytes, NK cells, activated T-lymphocytes, hairy cells
CD13 Monocytes, granulocytes (expressed in AML)
CD14 Monocytes
CD19 B-lymphocytes
CD20 B-lymphocytes (except pre-B)
CD22 B-lymphocytes
CD33 Monocytes, myeloid cells (expressed in AML)
CD34 Haematopoietic stem cells
CD36 Platelets, monocytes (platelet GP IIIa)
CD38 Plasma cells, some lymphocytes
CD41 Platelets (GP IIb)
CD42a/b Platelets (GP Ib)
CD45 Leucocytes
CD55 Broad (decay accelerating factor
1
)
CD56 NK cells
CD57 NK cells
CD59 Broad (membrane inhibitor of reactive lysis
1
)
CD61 Platelets (GP IIIa)
CD68 Macrophages, neutrophils
CD75 B-lymphocytes
CD79 B-lymphocytes
CD103 Hairy cells
CD114 Granulocytes, monocytes
CD117 (expressed in AML) Mast cells, plasma cells, expressed in AML
1
Decient in paroxysmal nocturnal haemoglobinuria.
CLL, chronic lymphocytic leukaemia; ALL, acute lymphoblastic leukaemia; NK, natural killer; AML, acute myeloid leukaemia; GP, glycoprotein.
110 CASE HISTORIES
Case histories
vital to exclude gastrointestinal
bleeding despite the lack of
gastrointestinal symptoms. Clinical
examination should include rectal
examination. A colonoscopy
revealed a large bowel carcinoma
which was successfully resected.
Case 2 [pp. 2829]
A 15-year-old girl presents to her
primary care practitioner. According to
her parents, she is constantly pale and
tired. They have also noticed occasions
when her eyes are a little yellow. She
eats a normal diet and there is nothing
else of note in the remainder of the
history. The mother has had life-long
similar symptoms but these have been
only mild and never investigated. She
thinks other members of her family
might also be affected. The doctor
decides to check a full blood count as
he suspects anaemia:
Haemoglobin 94 g/L
MCV 92
MCH 31 pg
White cell count 8.3 10
9
/L
Platelet count 301 10
9
/L
1. What type of anaemia is this?
2. The mother and other family
members have similar symptoms
so this might be an inherited form
of anaemia. Do you know of any
causes of inherited anaemia?
3. What further simple blood tests can
be performed in the haematology
laboratory to help elucidate the
cause of the anaemia in this girl?
Notes to Case 2
1. This is a normocytic normochromic
anaemia.
2. Inherited causes of anaemia include
the haemoglobinopathies (e.g.
thalassaemias, sickle cell
syndromes), disorders of the red
cell membrane (e.g. hereditary
spherocytosis) and abnormalities of
red cell metabolism (e.g. glucose-6-
phosphate dehydrogenase
deciency). A thorough family
history is very important in the
diagnosis of these disorders. In
them all, the anaemia is at least
in part due to haemolysis. The
patients history of intermittent
jaundice also supports a diagnosis
of haemolytic anaemia.
3. Simple blood tests to clarify the
cause of the anaemia should include
a reticulocyte count and inspection
of a blood lm. Her reticulocyte
count was raised at 9% and the
blood lm revealed large numbers
of spherocytes (see p. 28, Fig. 14.2).
A diagnosis of hereditary
spherocytosis was made and was
later also conrmed in the mother.
In the Haemolytic anaemia II
section, you should be able to nd
an acquired form of haemolytic
anaemia which is also a cause of
spherocytes in the blood lm.
Case 3 [pp. 4041]
A previously well 26-year-old man
presents to the accident and
emergency department of his local
hospital with a 24 hour history of
spontaneous bruising and bleeding
from his gums. He has also felt
unusually tired for the last few weeks.
On examination he is pale with
numerous small bruises and a
scattered petechial rash. The accident
and emergency doctor suspects
that this might be a blood disorder
and he takes blood samples for a
full blood count and some tests of
coagulation:
Haemoglobin 84 g/L
MCV 95
MCH 31 pg
White cell count 25.4 10
9
/L
Platelet count 62 10
9
/L
Prothrombin time 22 seconds (912)
Activated partial
thromboplastin
time
58 seconds
(2636)
Fibrinogen level 1.1 g/L (1.74.5)
The automated haematology analyser
does not generate a white cell
differential count but the biomedical
scientist in the haematology laboratory
has inspected a blood lm and reports
that the white cell count is increased
because of numerous leukaemic
blast cells with marked cytoplasmic
granularity. An urgent request for
specialist clinical haematology advice
is made.
1. What is the most likely
diagnosis?
2. How urgent is the treatment of this
blood disorder?
These case histories and the attached
questions are designed to illustrate
themes discussed in the main text.
They are in no particular order. For
Case 1, there is an obvious clue in one
of the anaemia sections to help you get
started. For the subsequent cases, you
will have to dig a little deeper into the
book for the answers. Relevant page
numbers are shown is square brackets
next to each case number. Where not
appended, the normal ranges for the
laboratory test results are listed in
Appendix I.
Good luck!
Case 1 [pp. 2425]
A 53-year-old Caucasian man attends
his primary care practitioner
complaining of gradually increasing
fatigue and shortness of breath on
exertion. He has also noted a few
kilograms weight loss but there are no
other symptoms. His doctor decides to
check a full blood count, the results of
which are summarised:
Haemoglobin 75 g/L
MCV 69
MCH 24 pg
White cell count 9.2 10
9
/L
Platelet count 460 10
9
/L
1. What type of anaemia is this?
2. What is the most likely cause in
this man? What simple blood
investigation would conrm this?
3. If you conrm the anaemia
aetiology you suspect, are further
investigations necessary?
Notes to Case 1
1. This is a microcytic hypochromic
anaemia.
2. The most likely cause in a
Caucasian man of this age is iron
deciency. Measurement of serum
ferritin is a simple test to conrm
the diagnosis. It is usually reliable.
A low level always indicates iron
deciency but a normal level does
not guarantee normal stores as
ferritin is increased in chronic
inammation and liver disease. The
result here was 7 g/L. This low
level conrms the presence of iron
deciency. This may also be the
cause of the slight thrombocytosis.
3. A cause for iron deciency must
always be sought. In this man, it is
111 Case histories
Notes to Case 3
1. The combination of the symptoms,
the blood count, the coagulation test
results and the appearance of the
leukaemic blast cells strongly
suggest that this is acute myeloid
leukaemia with t (15;17) (q22;q12)
(M3:M3v). This subtype of the
disease is also known as acute
promyelocytic leukaemia. It is
associated with a high incidence
of disseminated intravascular
coagulation and a high risk of
spontaneous bleeding into vital
organs. The blood lm is shown
on page 40 as Figure 20.2b.
2. Very urgent. Immediate treatment
with the differentiating agent
all-trans retinoic acid (ATRA)
reduces the risk of early death from
bleeding. Tests to make a more
denitive diagnosis (e.g. molecular
testing to detect the genetic
abnormality) should not delay the
initiation of this treatment where
there is clinical suspicion of the
disorder.
Case 4 [pp. 4647]
A 72-year-old woman has a full blood
count checked as part of the routine
monitoring of her diabetes. She is
feeling very well and wonders whether
her doctor really needs to take these
blood samples. The full blood count
is surprisingly abnormal, as follows:
Haemoglobin 121 g/L
MCV 88
MCH 30 pg
White cell count 30.4 10
9
/L
Neutrophils 2.4
Lymphocytes 21.5
Monocytes 0.8
Eosinophils 0.2
Basophils 0.1
Platelet count 262 10
9
/L
Inspection of the blood lm reveals
the increased lymphocytes to resemble
normal lymphocytes but they are
perhaps a little larger. Numerous
smear cells are noted. Flow cytometry
of the cells conrms a diagnosis of
chronic lymphocytic leukaemia. The
blood lm is illustrated in the chronic
lymphocytic leukaemia section (Fig.
23.2). Subsequent examination of the
patient is normal with no palpable
lymphadenopathy or
hepatosplenomegaly.
1. What is the stage of the disease?
2. What is your treatment plan for this
lady?
Notes to Case 4
1. The lack of symptoms, absence of
palpable lymphadenopathy and the
normal haemoglobin level and
platelet count are consistent with
stage A disease.
2. This is an entirely incidental
diagnosis of early stage chronic
lymphocytic leukaemia in an elderly
person. The prognosis is very good
and there is no immediate need
for treatment. The patient can be
reassured and periodically followed
up in the haematology outpatient
clinic.
Case 5 [pp. 7273]
A 10-month-old male infant is brought
to the accident and emergency
department by his very anxious
parents. They report that he has had
more bruising than his older siblings
and that over the previous 2 days he
has developed swelling of the left knee
which he is now reluctant to bend.
There is no history of trauma and he
has been otherwise well with normal
development. There is no family
history of a similar problem. On
examination, the baby is irritable. He
is conrmed to have multiple small
ecchymoses and a swollen left knee.
The doctor decides to check a full
blood count and some rst-line
coagulation tests. The blood count is
normal but the coagulation screen is
abnormal as follows:
Prothrombin time 11 seconds (912)
Activated partial
thromboplastin
time
82 seconds
(2636)
Fibrinogen level 3.1 g/L (1.74.5)
1. Suggest a possible diagnosis.
2. What further blood test would you
request to conrm this diagnosis?
Notes to Case 5
1. The presence of multiple bruises
and joint swelling in a baby raises
the possibility of non-accidental
injury. It is important to remember
that a bleeding disorder can lead
to a very similar presentation. In
this case, the combination of the
symptoms and the very prolonged
activated partial thromboplastin
time (APTT) is very suggestive of
haemophilia. The lack of a family
history does not rule out this
diagnosis as up to 30% of all new
cases of haemophilia are due
to recent sporadic mutations.
Symptoms may only become
apparent after 6 months when the
baby begins to crawl.
2. The most common form of
haemophilia is haemophilia
A which is characterised by a
deciency of factor VIII. A factor
VIII assay was performed and this
revealed a very low level (1 unit/dL)
of the coagulation factor consistent
with severe disease.
Case 6 [pp. 6869]
A 62-year-old woman is admitted to
hospital with a chest infection. She has
no history of any blood disorder and a
normal blood count. Her infection is
treated with intravenous antibiotics.
She is also prescribed a daily
subcutaneous dose of low molecular
weight heparin as prophylaxis against
thromboembolism. After a week in
hospital she is feeling much better
with improvement in her pneumonia
but the medical team notice that her
platelet count is starting to fall. By day
10 of her admission it is 65 10
9
/L. She
has no symptoms of bleeding. On the
following day, she develops a swollen
left lower leg.
1. What is the most likely cause of the
thrombocytopenia?
2. What is the most likely cause of the
leg swelling?
Notes to Case 6
1. This patients isolated
thrombocytopenia (her
haemoglobin level and white cell
count were normal) occurred
following her admission to
hospital. A diagnosis of immune
thrombocytopenia (ITP) is possible
but the timing is suspicious of some
other cause. She is not obviously ill
enough for the low platelet count
to be a sign of disseminated
intravascular coagulation (DIC)
but it would be sensible to check
rst-line coagulation tests. The most
likely cause is a newly commenced
drug and heparin is the obvious
candidate. The drug chart should
be carefully scrutinised to exclude
other agents which might be
responsible (see p. 69, Table 34.3).
2. Heparin induced thrombocytopenia
(HIT) is a distinct syndrome
characterised by the development of
antibodies to platelet factor 4 and
heparin. The thrombocytopenia is
typically non-severe and occurs
510 days after starting heparin.
112 CASE HISTORIES
potential long-term side-effects of
chemotherapy (e.g. increased risk of
second malignancy, sterility, cardiac
disease, lung damage, endocrine
dysfunction) should be fully
acknowledged.
Case 9 [pp. 7879]
A 27-year-old woman presents to the
hospital accident and emergency
department complaining of a days
history of a swollen right lower leg.
This developed shortly after a long
ight. An ultrasound scan of the leg
conrms a deep vein thrombosis. The
patient tells the doctor that she has
a strong family history of venous
thrombosis and that she has previously
tested positive as being heterozygous
for the factor V Leiden mutation. This
is conrmed in her hospital notes
other thrombophilia tests were
normal. She is otherwise entirely well
and has had no previous episode of
thrombosis.
1. What is the increased risk of venous
thrombosis in people with the
factor V Leiden mutation?
2. Was it the correct decision to screen
her for this mutation?
3. How will the presence of
heterozygosity for the factor V
Leiden mutation alter the immediate
clinical management?
Notes to Case 9
1. Heterozygosity for the factor V
Leiden mutation gives a 48-fold
increase in risk for venous
thrombosis. This is a relatively small
risk and thrombosis often only
occurs where there are coexistent
risk factors (e.g. prolonged
immobility). Homozygosity carries
a much greater venous thrombotic
risk, around 50100-fold.
2. We must presume that she was
screened because one or more of
her relatives tested positive for the
factor V Leiden mutation and/or
other thrombophilia abnormalities
after an episode of venous
thrombosis. Testing strategies for
thrombophilia are controversial
but there is generally no indication
for case nding of asymptomatic
relatives with low risk
thrombophilia (such as factor V
Leiden heterozygosity). Her testing
was very likely unnecessary.
3. Patients with heritable
thrombophilia should have a deep
vein thrombosis treated with
Unlike other drug-induced
thrombocytopenias, HIT leads to an
increased risk of thromboembolism.
This patient had developed a deep
vein thrombosis; an ultrasound
of the affected leg ruled out a
haematoma and conrmed this
diagnosis. Heparin was discontinued
and an alternative anticoagulant
substituted.
Case 7 [pp. 8687]
A 42-year-old man is diagnosed as
having stage IV diffuse large B-cell
non-Hodgkins lymphoma. He is treated
with the RCHOP chemotherapy
regimen. Two weeks after the rst
cycle, he presents to the haematology
outpatient clinic complaining of
general malaise. There are no more
specic symptoms. He is initially
reviewed by the clinic nursing staff
who report him to appear pale and
unwell. He has a pyrexia, a slight
tachycardia and a normal blood
pressure. A blood sample is taken for
investigations including a full blood
count:
Haemoglobin 115 g/L
MCV 83
MCH 31 pg
White cell count 0.8 10
9
/L
Neutrophils 0.1
Lymphocytes 0.6
Monocytes 0.1
Platelet count 132 10
9
/L
1. You are asked for your opinion?
What diagnosis do you suspect?
2. What is your management plan?
Notes to Case 7
1. This man has severe neutropenia
following chemotherapy. His
malaise and pyrexia are very likely
due to neutropenic sepsis. It is
common for the symptoms of
infection in these patients to be
vague with no localisation.
2. Suspected neutropenic sepsis is a
medical emergency. A signicant
delay in the empirical
administration of intravenous
broad-spectrum antibiotics leads to
increased mortality. He should have
blood and other relevant cultures
performed prior to starting
antibiotics but investigations should
never signicantly delay antibiotic
treatment. The antibiotics can be
commenced in the clinic before
transfer to the haematology ward.
The empirical antibiotic regimens
are designed to provide protection
against commonly implicated
organisms (see p. 87, Table 43.2).
Case 8 [pp. 5859]
A previously well 32-year-old
man presents to his primary care
practitioner complaining of a 12 week
history of malaise, anorexia, weight
loss and drenching night sweats. It is
calculated that he has lost 15% of his
normal body weight. He has also
found a lump in his left neck which
the doctor identies as a 3 cm
enlarged non-tender cervical lymph
node. On more general examination,
he has similar enlarged nodes in the
axillary and inguinal regions but
nothing else. He is urgently referred
to the local hospital where a cervical
lymph node biopsy conrms the
suspected diagnosis of classical
Hodgkins lymphoma (nodular
sclerosing histological subtype). A
blood count reveals moderate anaemia
and an eosinophilia. A CT scan of the
neck, chest and abdomen conrms the
enlarged cervical, axillary and inguinal
nodes and also shows signicant
mediastinal and intra-abdominal
lymphadenopathy. The liver and spleen
are normal. Bone marrow examination
is also normal.
1. What is the stage of this mans
Hodgkins lymphoma?
2. Suggest a treatment plan.
3. What is the prognosis?
Notes to Case 8
1. He has lymph node involvement
above and below the diaphragm but
no evidence of disease outside nodal
areas (e.g. liver, bone marrow). He
has night sweats and signicant
weight loss. This is stage IIIB
disease (see p. 59, Fig. 29.3).
2. Stage IIIB disease is advanced stage
disease. He should receive a full
course of chemotherapy with the
possible addition of radiotherapy for
bulky disease. The ABVD regimen is
most commonly used. Alternating
or hybrid regimens containing a
larger number of drugs are under
investigation. The role of PET
scanning in staging and assessment
of response to treatment is also
under review.
3. In younger patients, the prognosis
of Hodgkins lymphoma is generally
good with cure rates of 80%
achievable even in advanced disease.
With such high cure rates, the
113 Case histories
level and packed cell volume (also
known as the haematocrit).
2. This is secondary polycythaemia
caused by the hypoxia of chronic
lung disease. The clinical history,
low oxygen saturation and raised
erythropoietin level are all
supportive of this diagnosis. In this
patient, further investigations for
the cause of polycythaemia, such as
screening for the JAK2 mutation
and bone marrow examination, are
unnecessary (p. 64, Fig. 32.2).
3. The management of secondary
polycythaemia is essentially that of
the underlying cause. This mans
polycythaemia is likely to improve
if he stops smoking and if his
respiratory function can be
improved. The role of venesection
in this situation is not well dened.
It may be helpful where the
haematocrit is very high (e.g. greater
than 0.55).
Case 12 [pp. 5051, 8485]
A 62-year-old woman with
myelodysplastic syndrome receives
regular blood (red cell) transfusions to
improve her haemoglobin level and
relieve symptoms of anaemia. She has
received these without problems every
34 weeks for the previous 6 months.
On this occasion, the nurses on the
hospital haematology day unit inform
the duty doctor that the patient has
become suddenly unwell only a
few minutes after the start of the
transfusion of the rst unit of red cells.
She is complaining of chest and loin
pain and has become acutely short
of breath. Her clinical observations,
normal before the start of the
transfusion, now show pyrexia,
tachycardia and hypotension. The
doctor is alarmed.
1. What diagnosis should he suspect?
2. What immediate action should he
take?
Notes to Case 12
1. The doctor should strongly suspect
a potentially fatal haemolytic
transfusion reaction. The acute onset
of the symptoms within minutes of
starting the red cell transfusion and
the changes in temperature, pulse
and blood pressure are all highly
suggestive of this.
2. He should immediately stop the
transfusion and maintain the
venous access with crystalloid. The
transfused unit should be checked
heparin and warfarin as in patients
without heritable thrombophilia.
Thus, the presence of the factor V
mutation does not affect her
immediate management. The
precise role of thrombophilia testing
in clinical decision making remains
nuclear.
Case 10 [pp. 5253]
A 25-year-old man presents to his
primary care practitioner with a 6
week history of increasing fatigue and
shortness of breath on exertion. He
has also noticed an intermittent sore
throat and that he has been bruising
more easily than usual. He has
been previously well and is on no
medication. On examination, he
appears pale and there are a few small
ecchymoses. His doctor suspects
anaemia and decides to perform a full
blood count:
Haemoglobin 64 g/L
MCV 94
MCH 30 pg
Reticulocyte count 0.1%
White cell count 0.9 10
9
/L
Neutrophils 0.1
Lymphocytes 0.7
Monocytes 0.1
Platelet count 9 10
9
/L
On receipt of the blood count result,
the doctor makes an urgent referral
to the local hospital haematology
department. Here, the blood count is
repeated and the result conrmed.
There are no abnormal cells in the
blood lm. A bone marrow aspirate
and trephine procedure is performed.
This shows a grossly hypocellular
bone marrow appearance with no
abnormal cells.
1. How could you describe the
abnormal blood count in one word?
2. What is the likely diagnosis?
3. What is the severity of this
disorder?
4. Suggest a treatment plan.
Notes to Case 10
1. Pancytopenia. There is reduction in
haemoglobin level, white cell count
and platelet count.
2. The marked hypocellularity of the
bone marrow is consistent with
aplastic anaemia. There are no
abnormal cells to suggest inltration
by leukaemia or another malignant
disorder. Possible causes of
secondary aplastic anaemia such as
drugs and viral infections must be
excluded (p. 52, Tables 26.1 and
26.2). This man had idiopathic
aplastic anaemia.
3. The blood results are consistent
with very severe aplastic anaemia
(p. 53, Table 26.4).
4. In a young t person with very
severe aplastic anaemia, the best
denitive therapy is likely to be
an allogeneic stem cell transplant
from an HLA-matched sibling or
unrelated donor. In the meantime,
he will need judicious use of red
cell and platelet transfusions to
manage symptoms arising from
anaemia and thrombocytopenia. If
he develops a systemic infection, he
will need prompt broad-spectrum
antibiotic treatment in view of his
severe neutropenia.
Case 11 [pp. 6465]
A 74-year-old man presents to his
primary care practitioner complaining
of a weeks history of cough and
increased dyspnoea. His medical
records reveal that he is a smoker and
that he has a history of chronic lung
disease. The doctors initial diagnosis
of a chest infection is conrmed by a
chest X-ray and he prescribes a course
of oral antibiotics. As the patient has
also complained of more longstanding
fatigue he decides to check some blood
tests including a full blood count:
Haemoglobin 196 g/L
Packed cell volume
(haematocrit)
0.54
MCV 95
MCH 31 pg
White cell count 9.8 10
9
/L
Platelet count 182 10
9
/L
In view of this abnormal result, the
patient is referred to the haematology
department at the local hospital. More
investigations are performed including
the following:
Oxygen saturation 89% (95100)
Serum erythropoietin level 28 mU/mL
(220)
1. What is the abnormality in the
blood count?
2. What is the most likely cause of this
abnormality?
3. What is the best treatment of the
blood abnormality?
Notes to Case 11
1. Polycythaemia. This is indicated by
the signicantly raised haemoglobin
114 CASE HISTORIES
the level of fetal haemoglobin in red
cells.
Case 15 [pp. 7677]
A 55-year-old woman is admitted to
hospital with a chest infection. Despite
prompt antibiotic treatment she
deteriorates and develops the
symptoms and signs of severe sepsis.
She is transferred to the intensive care
unit. Here it is noted that she has
oozing of blood from her cannulation
sites. The medical team request a full
blood count and coagulation tests:
Haemoglobin 102 g/L
MCV 81
MCH 30 pg
White cell count 9.2 10
9
/L
Platelet count 31 10
9
/L
Prothrombin time 26 seconds (912)
Activated partial
thromboplastin
time
58 seconds
(2636)
Fibrinogen level 0.8 g/L (1.74.5)
Fibrin degradation
products (FDPs)
Increased
1. What is the likely cause of the
patients bleeding?
2. How should this acquired bleeding
disorder be managed?
Notes to Case 15
1. The combination of
thrombocytopenia, prolonged
prothrombin time (PT) and
activated partial thromboplastin
time (APTT), reduced brinogen
level and increased brin
degradation products (or D-dimers)
in a very ill patient with widespread
bleeding is characteristic of
disseminated intravascular
coagulation (DIC).
2. The cornerstone of management
of DIC is the treatment of the
underlying disorder in this case
sepsis. In addition, bleeding may
be reduced by the transfusion of
platelets, fresh frozen plasma (FFP
a source of coagulation factors)
and cryoprecipitate (a source of
brinogen). Careful monitoring of
the bleeding symptoms and
repeated blood counts and
coagulation tests are vital to guide
the appropriate use of these blood
products. Recombinant activated
protein C may be of benet in DIC
associated with sepsis and could be
considered here.
(is another patient about to get a
wrong unit due to a mix-up?) and
the blood bank informed. Urgent
measures to resuscitate the patient
should be undertaken as necessary.
If an ABO incompatible transfusion
is conrmed, or even suspected,
senior medical advice should be
quickly sought to ensure proper
investigation, to guide the
management of complications
(e.g. renal failure, disseminated
intravascular coagulation) and to
establish the need for intensive care
input.
Case 13 [pp. 6263]
A previously well 59-year-old man
presents with a 3 month history of
persistent increasingly severe back and
rib pain. He also complains of loss of
energy. There is nothing diagnostic on
examination although he appears pale
and unwell. The doctor decides to
arrange some investigations including
blood tests. These show the patient
to have a moderate normocytic
normochromic anaemia with a blood
lm reported as rouleaux formation.
The biochemical tests reveal mild renal
failure and hypercalcaemia.
1. This man has a haematological
malignancy. What is the likely
diagnosis?
2. Suggest further investigations to
conrm the suspected diagnosis.
3. Suggest a treatment plan.
Notes to Case 13
1. The combination of chronic severe
back and rib pain, normocytic
normochromic anaemia, rouleaux
formation in the blood lm, renal
failure and hypercalcaemia is highly
suggestive of myeloma.
2. Vital tests to establish the diagnosis
of myeloma include serum and
urine electrophoresis to detect a
monoclonal protein and bone
marrow examination (aspirate and
trephine biopsy) to assess the
number of clonal plasma cells.
The degree of bone disease can be
determined with a combination of
traditional X-rays (skeletal survey)
and MRI scanning.
3. The above tests conrmed myeloma
with numerous bony lesions in the
ribs and spine. In a younger tter
patient such as this man, induction
chemotherapy (see p. 63) is
generally followed by stem cell
harvesting and intensication of
treatment with high dose melphalan
and autologous stem cell
transplantation. He should also
receive bisphosphonate therapy.
Case 14 [pp. 3435]
A 25-year-old man with sickle cell
anaemia (Hb SS) presents to the
casualty department of his local
hospital with a 24 hour history of
increasing back and shoulder pain
unresponsive to oral analgesics. He has
had numerous episodes of similar pain
in the past, some of which have led to
admission to hospital. He is clearly in
distress with severe pain but the doctor
can elicit no other symptoms.
His medication includes a folate
supplement, penicillin and
hydroxycarbamide. His full blood count
is as follows:
Haemoglobin 72 g/L
MCV 90
MCH 32 pg
White cell count 9.8 10
9
/L
Platelet count 365 10
9
/L
1. Why does the patient not have
more obvious symptoms from his
signicant anaemia?
2. Explain the aetiology of his pain.
3. How would you manage his
symptoms?
4. What is the mechanism of action of
hydroxycarbamide in this disease?
Notes to Case 14
1. When anaemia is chronic as in
sickle cell disease the symptoms are
often less pronounced than when
anaemia of similar severity (i.e.
similar haemoglobin level) develops
acutely. Also, because HbS releases
oxygen more readily than HbA, the
symptoms of anaemia are often
surprisingly mild.
2. He has a vaso-occlusive crisis. This
is caused by polymerisation of
deoxygenated HbS leading to
inexible sickle cells becoming
lodged in small vessels. This in turn
leads to oxygen deprivation of
tissues and avascular necrosis of the
bone marrow. Over 90% of hospital
admissions for patients with sickle
cell disease are for a painful crisis.
3. Management should include rest,
warmth, intravenous uids, opiate
analgesia and reassurance. Patients
who are ill should be referred
urgently for more specialist care.
4. Hydroxycarbamide can reduce the
severity of the disease by increasing
115
Index
lymphocytosis, 9
management and outcome, 43
poor prognosis, factors
predicting, 43t
subtypes, 42
Acute monocytic leukaemia, 40f
Acute myeloid leukaemia (AML)
and acute lymphoblastic
leukaemia, 40
age of presentation and AML
characteristics, 41f
allogeneic stem cell
transplantation, 56
and aplastic anaemia, 53
blood count and lm, 40
bone marrow aspirate and
trephine, 40
chemotherapy, 41
chromosome deletions and
additions, 38
classication, 40
clinical features, 40
common genetic abnormalities,
41t
cytochemistry, 4041
cytogenetics, 41
diagnosis, 4041
epigenetic therapies, 55
essential thrombocythaemia,
progression from, 66
FLT3 inhibitors, 55
uorescence in situ
hybridisation, 38f
immunophenotyping, 41
management, 41
molecular biology, 41
monoclonal antibodies, 55
multi-drug resistance, 54
and myelodysplastic syndromes,
39, 50
and myeloproliferative disorders,
39
peripheral blood lm, 39f
platelet function disorders, 71
polycythaemia, 65
prognosis, 41
smoking, 15
stem cell transplantation, 41
supportive care, 41
tyrosine kinase inhibitors, 55
Acute obstetric haemorrhage, 89t
Acute phase response
in elderly people, 92
lack of, in essential
thrombocythaemia, 66
measurement, 2021
Acute promyelocytic leukaemia,
4041
Acute venous thrombosis, 79
Adaptive immune response, 9
Adeno-associated virus (AAV),
103
Adenopathy, 16
Adenosine triphosphate (ATP), 5
Adhesion molecules
bone marrow structure, 2
neutrophils, 6
splenic structure, 10
Adult T-cell leukaemia lymphoma
(ATLL), 39f, 49
Abrinogenaemia, 75
Afro-Caribbean population, sickle
cell anaemia, 34
Agglutination, cold (cold
autoimmune haemolytic
anaemia), 31f
AIHA see Autoimmune haemolytic
anaemia (AIHA)
Albumin, 20, 85
Alcohol misuse, 15, 96
Aldosterone, 4
Alemtuzumab, 48, 53, 55
ALK1 (gene mutation), 71
Alkylating agents, 54
ALL see Acute lymphoblastic
leukaemia (ALL)
Allergic disorders, 7, 15
Alloantibodies, 3031
Allogeneic stem cell
transplantation
acute lymphoblastic leukaemia,
43
adult T-cell leukaemia
lymphoma, 49
aplastic anaemia, 53
bone marrow harvesting, 107
chronic lymphocytic leukaemia,
47
chronic myeloid leukaemia, 45
dened, 56
herpes zoster following, 87f
myelodysplastic syndromes, 51
non-myeloablative (reduced
intensity), 57
and syngeneic SCT, 56
thalassaemias, 33
Alloimmune thrombocytopenia,
91
All-trans-retinoic acid (ATRA), 41,
55
Alpha-1-antitrypsin, acute phase
response, 21
Alpha-2-macroglobulin, 20
Alteplase, 81
AML see Acute myeloid leukaemia
(AML)
Anaemia
acute lymphoblastic leukaemia,
42
acute phase response, 20
aetiological classication,
2223
aplastic see Aplastic anaemia
(AA)
blood count, 18
of chronic disease see Anaemia
of chronic disease (ACD)
classication, 2223, 23f
congenital dyserythropoietic
anaemias, 91
denition, 22
DiamondBlackfan, 91
dilutional, in pregnancy, 88
in elderly people, 2223, 92
Fanconis anaemia, 52
general features, 22
Page numbers ending in b, f and t refer to Boxes, Figures and Tables respectively
A
AA see Aplastic anaemia (AA)
Abdomen, examination, 17
Abdominal lymph nodes,
examination, 16
Abnormalities
blood count, 15
clotting tests, rst-line, 20t
coagulation see Coagulation
disorders
common haematological, 14t
brinogen, 75
genetic see Genetic
abnormalities
haemoglobin, 29
lymphocytes, 9
neutrophils, 7
red cells
indices, 22
metabolism, 29
splenic, 1011
stomach and ileum (vitamin B
12

deciency), 27
ABO blood grouping, 8283
neonatal disorders, 84, 90
platelet transfusion, 85
ABVD (doxorubicin, bleomycin,
vinblastine, dacarbazine)
chemotherapy protocol, 59
Aciclovir, 87
Acidosis, 85
Acrocyanosis, 30
Actin, 4
Actinmyosin assembly, cell
membrane, 6
Activated partial thromboplastin
time (APTT)
acquired haemophilia, 77
disseminated intravascular
coagulation, 76
haemostasis, 1213
and heparin, 80
laboratory haematology, 20
prolonged, in haemophilia, 72
vitamin K deciency, 77
Von Willebrand disease, 75
see also Prothrombin time (PT)
Activated protein C (APC), 78, 102
Activating receptors, natural killer
(NK) cells, 9
Acupuncture, 95
Acute graft-versus-host disease, 56
Acute immune thrombocytopenia
(ITP), 68, 68t, 69f
Acute lymphoblastic leukaemia
(ALL)
and acute myeloid leukaemia,
40
in adults, 43
allogeneic stem cell
transplantation, 56
in children, 43
classication, 42
clinical features, 42
diagnosis, 4243
incidence, at different ages, 42f
haemolytic see Haemolytic
anaemia
hypersplenism, 11
iron deciency see Iron
deciency anaemia
macrocytic, 22, 25, 27
management, 23
megaloblastic see Megaloblastic
anaemia
microcytic, 22
morphological classication, 22
myelodysplastic syndromes, 50
myelobrosis, 67
myeloma, 62
normochromic, 22
normocytic, 22
packed cell volume, 22
pernicious, 16, 2627, 88
platelet function disorders, 71
in pregnancy, 22, 88
of prematurity, 90
prevalence, 22
prolymphocytic leukaemia, 48
symptoms attributable to, 14
T-cell large granular lymphocyte
leukaemia, 4849
unexplained, in elderly people,
92
see also Haemoglobin; Red cells
Anaemia of chronic disease (ACD),
3637
Anagrelide, 66
Anaphylaxis, 25
Angiogenesis, bone marrow
abnormality, 67
Angular stomatitis, 24f, 26
Ankyrin, 4
Anopheline mosquitoes, 98
Anorexia, malignant disease, 95
Antecubital fossa, veins at, 104
Anterior iliac crest, 106107
Anthracycline, 41, 54
Anti-angiogenic agents, 55
Antibiotic treatment, 87, 87t
Antibodies
antileucocyte, 84
HTLV-1, 49
immune, 8283
isoantibodies, 3031
monoclonal, 55
naturally occurring, 82
Antibody screening, 8283
Anti-CD33 (Mylotarg), 55
Anti-chymotrypsin, acute phase
response, 21
Anticoagulation
in elderly people, 92
heparin, 80
new agents, 81
new drugs, 102103
in pregnancy, 89
thrombolytic therapy, 81
warfarin, 8081, 80f
Anti-D immunoglobulin (Ig), 90
Antidiuretic hormone (ADH), 4
Antiemetics, 95
Antibrinolytic agents, 70, 73
Antigen-presenting cells, 8f, 10
116 INDEX
Antiglobulin test, 83f
Anti-helminthic agents, 99
Antileucocyte antibodies, 84
Anti-leukaemic drugs, 54
Antimetabolites, 54
Antimicrobial prophylaxis, 87
Antiphospholipid antibody
syndrome, 79
Antithrombin (AT), 13, 7980
Antithymocyte globulin (ATG), 51,
53
Anti-tissue transglutaminase, 25
Aorto-gonad-mesonephros (AGM)
region, embryo, 2
APCR (activated protein resistance
ratio), 7879
Apixaban, 102103
Aplastic anaemia (AA)
aetiology, 52
classication, 52
clinical features, 52
diagnosis, 5253
immunosuppression, 5253
management, 53
removal of cause, 53
restoring normal
haematopoiesis, 53
severity measurement, 53
Apoptosis, 38, 60
Arteriovenous malformations
(AVMs), 71
Ashkenazi Jews, factor VI
deciency, 75
Aspergillus fumigatus, 8687
Aspirate, bone marrow
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
advantages and disadvantages,
19
aplastic anaemia, 5253
aspiration procedure, 106107
chronic lymphocytic leukaemia,
46
examination procedure, 19
hairy cell leukaemia, 48
increased reticuloendothelial
iron stores in anaemia of
chronic disease, 37f
iron deciency anaemia, 25
in megaloblastic anaemia, 26f
needle, 106f
pernicious anaemia, 26
polycythaemia, 64
systemic disease, 96
thrombocytopenia, 69
Aspirin
essential thrombocythaemia, 66
platelet function disorder caused
by, 7071
polycythaemia, 6465
Asplenia syndrome, 1011
Asplenism, 1011, 11t
ATG see Antithymocyte globulin
(ATG)
ATRA see All-trans-retinoic acid
(ATRA)
Autoantibodies, 27, 30
Autoimmune haemolysis, 46
Autoimmune haemolytic anaemia
(AIHA), 30
Autoimmune thrombocytopenia,
46
Autologous stem cell
transplantation, 5657
acute lymphoblastic leukaemia,
41, 43
bone marrow harvesting, 107
Hodgkins lymphoma, 59
myeloma, 63
Automated haematology counters,
18
Axillary lymphadenopathy,
lymphoma, 60f
Axillary nodes, examination, 16
Azacitidine, 55
Azathioprine, 30
Azoles, 87
B
Babesiosis, 99
Backache, myeloma, 62
Bacterial infection, 86, 97
see also Antibiotic treatment
Basophils, 7
B-cell lymphomas, 55, 97
BCL2 gene, non-Hodgkins
lymphoma, 60
BCR-ABL oncogene, 38
chronic myeloid leukaemia,
4445
molecular biology, 101
treatments, 55
Bence Jones protein, myeloma,
62
Bendamustine, 47, 54
BernardSoulier syndrome, 70
Biliary obstruction, vitamin K
deciency, 77
Bilirubin, 5
Biopsy
lymph node
Hodgkins lymphoma, 58, 58f
non-Hodgkins lymphoma,
6061
trephine see Trephine biopsy,
bone marrow
Bisphosphonate, myeloma, 63, 94
Black people, neutrophil counts, 7
Blast cells
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
morphology, 42f
Blast crisis, chronic myeloid
leukaemia, 4445
Bleeding
disseminated intravascular
coagulation, 76
haemophilia A, 7273, 72f
intracranial see Intracranial
bleeding
liver disease, 77
myeloma, 62
thrombocytopenia, 14, 68
tranexamic acid, 73
Von Willebrand disease, 7475
Bleeding time, 7071
Bleomycin, 59
Blood
clotting of see Clotting of blood
lymphocytes, mature, 8f
ordering practicalities, 83
peripheral see Peripheral blood
see also Blood count; Blood
groups; Blood tests; Blood
transfusion; Plasma; Platelet
function disorders; Platelets
Blood count
abnormalities, past medical
history, 15
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
aplastic anaemia, 52
Hodgkins lymphoma, 5859
iron deciency anaemia, 25
laboratory haematology, 18
lymphocytes, 9, 46
neutrophils, 6
pernicious anaemia, 24
report, 1819
Von Willebrand disease, 75
Blood lms
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 39f,
40
anaemia of chronic disease,
3637
aplastic anaemia, 52
chronic lymphocytic leukaemia,
46, 46f
chronic myeloid leukaemia, 44,
45f
cold autoimmune haemolytic
anaemia, cold agglutination
in, 31f
essential thrombocythaemia, 66f
haemolytic disease of the
newborn, 90f
hereditary spherocytosis, 29
hyposplenism, 11f
iron deciency, 25f
making, 1819
megaloblastic anaemia, 27f
microangiopathic haemolytic
anaemia, 31f
morphological terms, 19t
myelobrosis, 66f
myeloma, 62f
pernicious anaemia, 24
sickle cell anaemia (HbSS), 34f
thalassaemias, 33f
thrombocytopenia, 68f69f
warm autoimmune haemolytic
anaemia, 30f
Blood groups
ABO group, 8285, 90
gel system, using, 82f, 83
incompatibility, 82, 90
tests, 8283
Von Willebrand disease, 75
Blood tests
antibody screening, 83
antiglobulin, 83f
blood grouping, 8283
chronic myeloid leukaemia, 44f
crossmatching, 83
donor blood, 82
prior to transfusion, 8283
see also Venepuncture; Venous
access
Blood transfusion
acute myeloid leukaemia, 41
allogeneic, alternatives to, 85
anaemia, 23
aplastic anaemia, 53
complications, 8485
delayed complications, 8485
in elderly people, 92
granulocytes, 85
haemolytic reactions, 84
immediate complications, 84
incompatibility, 82
infection, 84
massive, 85
myelodysplastic syndromes, 51
non-haemolytic reactions, 84
platelets, 71, 85
practicalities, 84
red cells, 8485, 84t
safety factors, 82
sickle cell anaemia (HbSS), 35
testing before, 8283
transfusion associated
circulation overload, 84
transfusion-related acute lung
injury, 84
see also under Platelets; Stem cell
transplantation (SCT)
B-lymphocytes, 89
antigen-stimulated mature, in
CLL, 46
cold autoimmune haemolytic
anaemia, 30
germinal-centre, in HL, 58
splenic structure, 10
Bone disease, myeloma, 6263
Bone marrow
acute myeloid leukaemia
subtypes, appearance in,
40f
angiogenesis, 67
aspirate see Aspirate, bone
marrow
examination, 19
failure of production, in
thrombocytopenia, 68
haematopoiesis, 23, 3f
harvesting, 107
normal, 2f
prostatic carcinoma, 97f
regulators, haematopoiesis, 23,
3f
specic conditions, effects
Hodgkins lymphoma, 5859
myelodysplastic syndromes,
50
myelobrosis, 66
myeloma, 62, 62f
stem cell hierarchy, 2, 3f
structure, 2
trephine appearance, in human
T-cell leukaemic lymphoma,
39f
Bortezomib, 55, 63
Bovine spongiform
encephalopathy (BSE), 84
Brentuximab, 55, 59
Bronchoalveolar lavage, 86
Bruising, acquired haemophilia,
76f
Bullae, haemorrhagic, 76f
Burkitts lymphoma, 42, 6061
endemic, 99
Burr cells, renal failure, 96
Busulfan, 54
Buttery needle, venepuncture,
104
117 Index
C
Cachexia, malignant disease, 95
Cancer see Malignant disease
Candida infection, 86
Cannulation, 105
Carbon dioxide, transport, 4
Cardiac overactivity, anaemia, 22
Cardiopulmonary bypass, platelet
function disorders, 71
Caspofungin, 87
CD4 surface marker
HIV/AIDS, 9
and T-lymphocytes, 8
treatment advances, 102
CD8 surface marker, 8
CD20 antigen, 55
Cell cycle, 54
Cellulose acetate electrophoresis,
35f
Central nervous system (CNS)
disease
acute lymphoblastic leukaemia,
42
monocytic/monoblastic
leukaemia, 40
non-Hodgkins lymphoma, 60
Central venous cannulation, 105
Cerebral malaria, 98
Cervical lymph nodes,
enlargement, 16
Chemotaxis, 6
Chemotherapy
acute myeloid leukaemia, 41
combination, 54, 99, 102
consolidation, 41
elderly people see under Elderly
people
general principles, 54
high-dose, in stem cell
transplantation, 5657
Hodgkins lymphoma, 59
immunosuppression in, 86
induction, 41
major classes of conventional
drugs, 54
multi-drug resistance, 54
myelodysplastic syndromes, 51
palliative, 94
phase-specic and phase
non-specic, 54
and Philadelphia chromosome,
43
related treatments, 5455
Children see Paediatric
haematology
Chlorambucil, 54
chronic lymphocytic leukaemia,
47
follicular lymphoma, 61
myeloma, 63
Chloroquine, 99
Cholesterol, 4
CHOP regimen, diffuse large
B-cell lymphoma, 61
Chromosomal abnormalities see
Genetic abnormalities
Chromosome deletions and
additions, leukaemia, 38
Chronic benign neutropenia, 7
Chronic graft-versus-host disease,
56
Chronic granulomatous disease, 7
Chronic immune
thrombocytopenia (ITP),
68t, 69
Chronic lymphocytic leukaemia
(CLL)
clinical features, 46
diagnosis, 46
in elderly people, 46, 93
humoral immunity defects, 86
incidence, 38
lymphocytosis, 9
management, 4647, 47f
monoclonal antibodies, 55
prognosis, 47t
staging, 46
whole genome sequencing,
101f
Chronic myeloid leukaemia
(CML)
accelerated phase, 4445
advanced disease, 45
allogeneic stem cell
transplantation, 56
chronic phase, 4445
clinical features, 44
diagnosis and monitoring,
4445
drug therapy, 45, 45t, 55, 93
and essential thrombocythaemia,
66
uorescence in situ
hybridisation, 100f
pathogenesis, 44
Philadelphia (Ph) chromosome,
3839, 44, 44f
predisposing factors, 39
treatment, 45, 55
Chronic myelomonocytic
leukaemia (CMML), 50
Chronic renal failure
platelet function disorders, 71
systemic disease, 96
Chronic thrombocytopenia, 68
Ciclosporin, 30, 53
Circulating pool, neutrophils, 6
Cirrhosis, hepatitis risk, 73
Citrate agar electrophoresis, 21
Citrate toxicity, massive blood
transfusion, 85
Cladribine (2-CDA), 48, 49f
CLL see Chronic lymphocytic
leukaemia (CLL)
Clostridium difcile, 86
Clotting of blood, 12
rst-line tests, 20t
prothrombin time test, 20
Clubbing of nails, polycythaemia,
65f
Cluster differentiation (CD), 21
CML see Chronic myeloid
leukaemia (CML)
CMV see Cytomegalovirus
(CMV)
Coagulation
abnormal, symptoms
attributable to, 14
disorders see Coagulation
disorders
physiological pathways, 1213,
13f
regulation of, 13
tests, 20
Coagulation cascade
defects, 14
haemostasis, 12, 13t
Coagulation disorders
acquired, 7677
chronic renal failure, 96
disseminated intravascular
coagulation see
Disseminated intravascular
coagulation (DIC)
factor deciencies, 75
brinogen abnormalities, 75
haemophilia, acquired, 76f, 77
history taking, 14
hypercoagulability in malignant
disease, 96
liver disease, 77
in pregnancy, 89
vitamin K deciency, 7677
Coagulation factors, 12
Coeliac disease, splenic atrophy,
1011
Cold autoimmune haemolytic
anaemia, 30
Collagen receptors, 12
Colon carcinoma, iron deciency
anaemia, 24f
Colonoscopy, iron deciency,
25
Colony-forming units (CFUs), 2
Colony-stimulating factors (CSFs),
3
Combination chemotherapy, 54,
99, 102
Comparative genomic
hybridisation, 100
Complementary therapy, 95
Complete remission (CR), acute
myeloid leukaemia, 41
Computed tomography (CT) scan,
59, 61
Congenital dyserythropoietic
anaemias (CDAs), 91
Connective tissue disease, 71, 96
Coombs test, autoimmune
haemolytic anaemia, 30
Cords of Billroth, 10
Coronary atherosclerosis, 79
Corticosteroid treatment
anorexia and cachexia, in
malignancy, 95
monocytopenia, 7
pain relief, 94
in pregnancy, 89
see also Prednisolone; Steroid
treatment
Co-trimoxazole, 87
Counselling see Genetic
counselling
C-reactive protein (CRP), 21,
3637
Creutzfeldt-Jakob disease (CJD), as
contradiction to blood
donation, 82
Crossmatching, blood tests, 83
Cryoprecipitate
acquired coagulation disorders,
7677
transfusion, 85
Crystalloid solution, 84, 91
CT scans see Computed
tomography (CT) scan
Cultures, cell, 2
Cyanmethemoglobin method,
automated haematology
counters, 18
Cyanotic congenital heart disease,
65f
Cyclical neutropenia, 7
Cyclooxygenase-1 (COX-1), 7071
Cyclophosphamide, 54
acute lymphoblastic leukaemia,
43
aplastic anaemia, 53
chronic lymphocytic leukaemia,
47
diffuse large B-cell lymphoma, 61
follicular lymphoma, 61
myeloma, 63
Cytochemistry, 4042
Cytogenetics, 41, 43
Cytokines, 6, 10, 66
Cytomegalovirus (CMV)
pneumonitis, 87
red cell transfusion
complications, 84
thrombocytopenia, 68
Cytopenia, supportive care, 55
Cytoplasm, platelets, 12
Cytosine arabinoside, 54
acute lymphoblastic leukaemia,
43
acute myeloid leukaemia, 41
Cytoskeleton, 4
Cytotoxic drugs
major classes, 54
side-effects, 54
see also Chemotherapy
D
Dabigatran etexilate, 102103
Dacarbazine, 59
Dactylitis, sickle cell anaemia, 34f
Dasatinib, 45, 55
Daunorubicin, 54
acute lymphoblastic leukaemia,
43
acute myeloid leukaemia, 41
DDAVP (desmopressin) see
Desmopressin (DDAVP)
Decitabine, 55
Deep vein thrombosis (DVT), 78,
89
Desferrioxamine, subcutaneous, 32
Dendritic cells, follicular, 10
Desmopressin (DDAVP)
haemophilia, 73
platelet function disorders,
7071
Von Willebrand disease, 75
Developing world, diseases
affecting, 7, 22, 9899
Dexamethasone, 63, 94
Dialysis, 71
DiamondBlackfan anaemia, 91
DIC see Disseminated
intravascular coagulation
(DIC)
Diet
malabsorption see
Malabsorption
vitamin B
12
deciency see
Vitamin B
12
deciency
and vitamin K deciency, 77
118 INDEX
Differential white cell count, 18
Differentiating agents, 55
Diffuse large B-cell lymphoma
(DLBCL), 61, 100f
Direct antiglobulin test (DAT), 30,
90
Disseminated intravascular
coagulation (DIC)
acute myeloid leukaemia, 40
bleeding, 76
diagnosis and management, 76
brinogen, quantitation, 20
haemolytic transfusion reactions,
84
haemorrhagic bullae and
gangrene, 76f
malignant disease, 96
pathophysiology, 76f
in pregnancy, 8889
protein C and S deciencies,
7879
thrombocytopenia in neonate, 91
and thrombophilia, 78
DNA analysis techniques, 83,
100101
DNA synthesis, megaloblastic
anaemia, 24
Donor blood, 82
Donor lymphocyte infusions
(DLIs), 57
Doxorubicin, 54
diffuse large B-cell lymphoma,
61
Hodgkins lymphoma, 59
Doxycycline, malaria, 99
Drug history, 15, 69
Drug-induced conditions
aplastic anaemia, 52t
glucose-6-phosphate
dehydrogenase (G6PD)
deciency, 29
nausea and vomiting, 95
platelet function disorders,
7071
thrombocytopenia, 69
Drug treatment
anticoagulant therapy see
Anticoagulation
side-effects see Side-effects
specic conditions
chronic myeloid leukaemia,
45, 45t, 93
leukaemia, 54
malaria, 99
myeloma, 63, 94
nausea and vomiting, 95
polycythaemia, 6465
syringe drivers, continuous
infusions, 95
see also Chemotherapy;
Treatment of conditions;
specic drugs
Dry tap, bone marrow aspiration,
106
Dyes, blood lm, 1819
Dysbrinogenaemia, 75, 79
Dyskeratosis congenita, 52
Dyspnoea, 22, 95
E
Edoxaban, 102103
EhlersDanlos syndrome, 71
Elderly people
anaemia, 2223, 92
anticoagulation, 92
chronic lymphocytic leukaemia
in, 46, 93
essential thrombocythaemia, 66
haematopoiesis, 92
haemophilia and other inherited
blood disorders, 77, 9293
iron deciency, 24, 92
malignant disease, 9293, 93t
chemotherapy
contraindications, 41, 43, 93
chronic lymphocytic
leukaemia, 46
prolymphocytic leukaemia, 48
thrombosis, 92, 92f
vitamin K supplementation, 92
Electrical impedance, cell counting
and sizing, 18
Electronic crossmatching, 83
Electron microscopy, 48f
Electrophoresis, 21
cellulose acetate, 35f
electrophoretic strip, myeloma,
62f
sickle cell anaemia, 34, 35f
thalassaemias, 33f
EmbdenMeyerhof pathway, 5, 29
Endemic Burkitts lymphoma, 99
Endemic malaria, 99
End of life care, 95
Endoglin (gene mutation), 71
Endoscopy, iron deciency, 25
Endothelial cell barrier, 12
Enterobacter spp., 86
Eosinophils, 7
Epigenetics, 3839, 55
Epipodophyllotoxins, 54
EpsteinBarr virus (EBV)
endemic Burkitts lymphoma,
99
Hodgkins lymphoma, 58
mononucleosis, 97
non-Hodgkins lymphoma, 60
Erythrocyte sedimentation rate
(ESR)
acute phase response,
measurement, 20
anaemia of chronic disease,
3637
myeloma, 62
Erythropoiesis, 2223, 64
Erythropoietin, 4, 55
anaemia of chronic disease, 37
myelodysplastic syndromes, 51
myeloma, 63
in pregnancy, 88
radioimmunoassay, estimation
by, 64
renal failure, in elderly, 92
Escherichia coli (E. coli), 31, 86
ESR see Erythrocyte sedimentation
rate (ESR)
Essential thrombocythaemia (ET)
clinical features, 66
diagnosis, 66
management, 66
polycythaemia, 64
splenic atrophy, 1011
systemic enquiry, 15
Ethnic origin
disorder type, 16
factor VI deciency, 75
neutrophil counts, black people,
7
sickle cell anaemia, 34
Ethylene diamine tetra-acetic acid
(EDTA), 18, 21
Etoposide, 54
Examination
blood lms, 1819
bone marrow, 19
of patient, 1617
Exsanguination, 12
Extended spectrum beta-
lactamases (ESBLs), 86
Extracorporeal
photochemotherapy, adult
T-cell leukaemia lymphoma,
49
Extrinsic pathway, platelets, 1213,
13f
Eyes, sickle cell anaemia, 34
F
FAB (French-American-British)
classication, 39
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
myelodysplastic syndromes,
50
Factor II, 12
Factor V
activated partial thromboplastin
time, 20
coagulation disorders,
deciencies in, 75
platelets, 1213
prothrombin time test, 20
Factor Va, 12
Factor V Leiden (FVR506Q),
familial thrombophilia, 78
Factor VII
platelets, 1213
pregnancy, increase in, 88
prothrombin time test, 20
Factor VIIa, 1213
factor VI deciency, 75
platelet function disorders, 70
Factor VIII
activated partial thromboplastin
time, 20
C assay, 75
haemophilia, 7273, 73f
clinical severity of
haemophilia A and factor
VIII level, 14, 72t
see also Haemophilia A
platelets, 1213
pregnancy, increase in, 88
Factor VIIIa, 1213
Factor VIIIc/tissue factor pathway
inhibitors, 102
Factor IX
activated partial thromboplastin
time, 20
haemophilia B, 73
platelets, 1213
Factor X
activated partial thromboplastin
time, 20
platelets, 1213
pregnancy, increase in, 88
prothrombin time test, 20
Factor Xa, 12
Factor XI
activated partial thromboplastin
time, 20
coagulation disorders,
deciencies in, 75
platelets, 1213
Factor XII
activated partial thromboplastin
time, 20
coagulation disorders,
deciencies in, 75
platelets, 1213
Factor XIII, 1213, 75
Familial thrombophilia, 7879
Family history, 15
haemophilia A, 72
Fanconis anaemia, 52
Fatigue, in malignant disease,
9495
Felty syndrome, 96
Fetus, sites of blood production in,
2f
Fibrinogen, plasma
abnormalities, 75
acute phase response, 21
pregnancy, increase in, 88
quantitation, 20
Fibrinolysis/brinolytic system, 13
Fibroblasts, Hodgkins lymphoma,
58
Filariasis, 99
Flow cytometry
acute myeloid leukaemia, 41
haematopoiesis, 2
laboratory haematology, 21
platelet function disorders, 70
FLT3 inhibitors, acute myeloid
leukaemia, 55
Fluconazole, 87
Fludarabine, 54
chronic lymphocytic leukaemia,
47
follicular lymphoma, 61
myeloma, 63
prolymphocytic leukaemia, 48
Fluorescence in situ hybridisation
(FISH), 38f, 100
Folate deciency
megaloblastic anaemia, 2627
in pregnancy, 88
Follicular lymphoma, 61, 102, 102f
Fondaparinux, 80
French-American-British
classication see FAB
(French-American-British)
classication
Fresh frozen plasma (FFP)
acquired coagulation disorders,
7677
indications for use, 85t
Full blood count (FBC), 18
Functional assay, vWF antigen, 75
Functional cytotoxicity assays,
102
Fungal infection, 8687
G
Gaisbocks syndrome, 6465
Gametocytes, 98
Ganciclovir, 87
Gangrene, 76f
tahir99-VRG & vip.persianss.ir
119 Index
G-CSF see Granulocyte colony-
stimulating factor (G-CSF)
Gel technology, blood grouping,
82f, 83
Gene proling, 100
General anaesthesia, bone marrow
aspiration in children, 106
General examination, 16
Gene therapy
haemophilia A, 73
sickle cell anaemia (HbSS), 35
treatment advances, 103
Genetic abnormalities
17p deletions, in CLL, 47
adult T-cell leukaemia
lymphoma, 48
antenatal detection, 101
aplastic anaemia, 52
-chain gene, in sickle cell
syndromes, 3435
carrier detection, 101
haemophilia A, 72
leukaemia, 3839, 41t
acute lymphoblastic
leukaemia, 42, 43t
acute myeloid leukaemia, 41
adult T-cell leukaemia
lymphoma, 49
chronic myeloid leukaemia,
4445
myelodysplastic syndromes, 50
myeloma, 6263
non-Hodgkins lymphoma, 60
Philadelphia chromosome see
Philadelphia (Ph)
chromosome
platelet function disorders, 71
polycythaemia, 64
in tropical regions, 98
see also Cytogenetics;
Epigenetics
Genetic counselling
haemophilia A, 73
sickle cell syndromes, 35
thrombophilia, 79
Von Willebrand disease, 75
Genitourinary complications,
sickle cell anaemia, 34
Gentamicin, 87
Germ cells, prechemotherapy
storage, 54
Gestational thrombocytopenia, 88
Giemsa stain, 1819, 98
Glanzmanns thrombasthenia, 70
Globin chains, 5
Glossitis
iron deciency, 24f
pernicious anaemia, 26, 27f
Glucose-6-phosphate
dehydrogenase (G6PD)
deciency, 29
Glycoprotein (GP) la/Ha complex,
12
Glycoprotein (GP) lb/IX/V
complex, 12, 70
Glycoprotein (GP) llb/IIIa
complex, 12, 70
Gonadal failure, chemotherapy
treatment, 54
Gout, 64, 65f
Graft-versus-host disease (GVHD),
56, 57f
Graft-versus-leukaemia (GVL)
effects, 57
Graft-versus-tumour (GVT) effects,
57
Gram-negative bacilli, 86
Granulocyte colony-stimulating
factor (G-CSF), 93
chemotherapy and related
treatments, 55
stem cell transplantation, 5657
Granulocytes
blood transfusion, 85
dened, 6
Hodgkins lymphoma, 58
see also Basophils; Eosinophils;
Neutrophils
Growth factors
aplastic anaemia, 53
and bone marrow, 23
haematopoietic growth factor
therapy, 55
neutropenia, 87
H
Haem, protoporphyrin of, 5
Haemarthroses (bleeding into
joints), 14
Haematoma, haemophilia, 72
Haematopoiesis
and ageing, 92
aplastic anaemia, restoring in, 53
bone marrow, 23, 3f
myelodysplastic syndromes,
abnormalities in, 50
splenic structure, 10
Haematopoietic growth factor
therapy, 55
Haematopoietic stem cells (HSCs),
2
Haematoxylin and eosin (H&E)
stain, 19
Haemoglobin
abnormalities, 29
blood count, 18
cellulose acetate electrophoresis,
to separate, 35f
high concentration in
polycythaemia, 64
low concentration see Anaemia
molecule, essential elements, 5f
normal concentrations, 22, 22t
transport, 5
Haemoglobinaemia, 30
Haemoglobin molecule (HbA), 5
Haemoglobinopathies
in children, 1516
electrophoresis, 21
see also specic conditions, such
as thalassaemia
Haemoglobinuria, 30
Haemolysis
autoimmune, 46
autoimmune haemolytic
anaemia, 30
chronic lymphocytic leukaemia,
4647
general features, 2829
Haemolytic anaemia
acquired disorders, 3031
autoimmune, 30
classication, 28t
diagnosis, 2829
general features and inherited
disorders, 2829
isoimmune, 3031
microangiopathic, 31, 31f
and sickle cell anaemia, 34
Haemolytic disease of the
newborn (HDN), 90, 90f
blood group incompatibility, 82,
90
Haemolytic transfusion reactions,
84
Haemolytic uraemic syndrome
(HUS), 31
Haemophilia
acquired, 76f, 77
in children, 15
on demand treatment, 7273
in elderly people, 77, 9293
gene therapy, 103
joint examination, 16
see also Haemophilia A;
Haemophilia B
Haemophilia A
access to therapy, 98
bleeding, 7273, 72f
carrier state and genetic
counselling, 73
clinical features, 72
clinical severity and factor VIII
level, 14, 72t
diagnosis, 72
treatment complications, 72
Haemophilia B, 73, 103
Haemophilia centres, 72
Haemophilus inuenzae, 11
Haemorrhage
acute obstetric, 89t
coagulation disorders, 14
brinogen abnormalities, 75
thrombocytopenia, 14, 68
see also Bleeding
Haemorrhagic bullae, 76f
Haemosiderin, 28
Haemosiderinuria, 31f
Haemostasis, 1213
complexity, 20
primary tests, 75
Hairy cell leukaemia (HCL), 48,
55
Ham test, paroxysmal nocturnal
haemoglobinuria, 31
Haptoglobins, 21, 28
Hb-Bart hydrops syndrome, 32
HbH disease, 32
HDN see Haemolytic disease of
the newborn (HDN)
Helicobacter pylori, 60, 68
HELLP syndrome (haemolysis,
elevated liver enzymes and
low platelets), 89
Helper cells, 8
HenochSchnlein purpura, 71
Heparin
acute venous thrombosis, 79
cardiopulmonary bypass, 71
low molecular weight (LMW),
7980, 89, 102
in pregnancy, 89
unfractionated, 80, 89
Heparin-induced
thrombocytopenia (HIT),
69
Hepatitis
aplastic anaemia, 52
as contradiction to blood
donation, 82
haemophilia, 7273
marginal zone lymphoma, 60
thrombocytopenia, 68
venepuncture precautions, 104
Hepatobiliary complications, sickle
cell anaemia, 34
Hepatocellular cancer, 73
Hepatomegaly, 67
Hereditary elliptocytosis, 29
Hereditary haemorrhagic
telangiectasia (HHT), 71
Hereditary pyropoikilocytosis, 29
Hereditary spherocytosis, 28f, 29,
86
Hereditary thrombophilia, 89
Herpes simplex, 87
Herpes zoster, 87f
Hexose monophosphate shunt
(pentose phosphate
pathway), 5
Hickman catheters, 105
History taking
common haematological
abnormalities, 14t
presenting complaint, 14
systemic enquiry, 15
thrombophilia, 78
Von Willebrand disease, 7475
HIV/AIDS
CD4 count, 9
as contradiction to blood
donation, 82
haemophilia, 7273
and Hodgkins lymphoma, 58
immunosuppression, 86
systemic disease, 97
thrombocytopenia, 68
Hodgkins lymphoma (HL)
advanced stage disease, 59
aetiology, 58
age distribution, 58
classical, 58
classication, 58
clinical presentation, 58
diagnosis, 58
early stage disease, 59
late effects of treatment, 59
lymphocyte predominant
nodular, 58
management, 59
monoclonal antibodies, 55
prognosis, 59
spleen, absent, 11
staging, 5859, 59f
Hormone replacement therapy
(HRT), 79
HowellJolly bodies, 1011
HPA-1a (platelet antigen), 69
HTLV-1 antibodies, adult T-cell
leukaemia lymphoma, 49
Human leucocyte antigens (HLA),
8
platelet transfusion, 85
stem cell transplantation, 56
Humoral immunity, 8
defects, 86
Hydronephrosis, 60
Hydroxycarbamide
essential thrombocythaemia, 66
myelobrosis, 67
polycythaemia, 6465
sickle cell anaemia (HbSS), 35
Hypercoagulability, in malignant
disease, 96
tahir99-VRG & vip.persianss.ir
120 INDEX
Hyperdiploid mutations, myeloma,
6263
Hypereosinophilic syndrome, 7
Hyperhomocysteinaemia, 27
Hyperkalaemia, 85
Hypersensitivity reactions, 7
Hypersplenism, 11
Hyperviscosity syndrome, 21,
6364
Hypervolaemia, 11
Hypnosis, 95
Hypocalcaemia, 85
Hypocellular myelodysplastic
syndrome, 5253
Hypochromia, 22
Hypobrinogenaemia, 75
Hypogammaglobulinaemia, 46, 87
chronic lymphocytic leukaemia,
47
immunosuppression, 87
Hyposplenism, 1011, 11f, 11t
Hypothermia, 71, 85
Hypoxia-inducible factor (HIF), 4
I
Ibrutinib, 47
Idarubicin, 54
Idiopathic aplastic anaemia, 52
Idiopathic erythrocytosis, 65
Idiopathic venous thrombosis, 81
Ileum abnormalities, vitamin B
12

deciency, 27
Imaging
computed tomography (CT)
scan, 59, 61
magnetic resonance imaging, 59,
61
positron emission tomography
(PET) scans, 59, 61
Imatinib
chronic myeloid leukaemia, 45,
55, 93
hypereosinophilic syndrome, 7
Immune antibodies, 8283
Immune neutropenia, 7
Immune thrombocytopenia (ITP),
6869, 68t, 69f
chronic lymphocytic leukaemia,
47
haematopoietic growth factor
therapy, 55
and HIV/AIDS, 97
paediatric haematology, 91
in pregnancy, 8889
systemic disease, 96
see also Thrombocytopenia
Immunochemistry, 102
Immunodeciency, in chronic
lymphocytic leukaemia, 46
Immunoglobulins
acute phase response, 20
basic structure, 9f
and B-lymphocytes, 9
intravenous, 30, 89
thrombocytopenia, 69
transfusion, 85, 87
Immunological tolerance, natural,
9
Immunophenotyping
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 41
ow cytometry, 21
non-Hodgkins lymphoma, 61
Immunosuppression
allogeneic stem cell
transplantation, 56
see also Allogeneic stem cell
transplantation
antibiotic treatment, 87, 87t
aplastic anaemia, 5253
bone marrow aspiration, 106
and chemotherapy, 86
chronic lymphocytic leukaemia,
46f
depressed cell-mediated
immunity, 87
infection types, 8687
neutropenia, 87, 87t
prevention of infection, 87
treatment of infection, 87
see also Infection
Infection
and anaemia of chronic disease,
36f
aplastic anaemia, 52
bacterial, 86, 97
blood transfusion, 84
chronic lymphocytic leukaemia,
47
fungal, 8687
history taking, 14
HIV/AIDS, 97
hookworm, 99
immunosuppression, 8687
lymphadenopathy secondary to,
16
lymphocytosis, 9
mononucleosis, 97, 97f
neutropenia, 7
parasitic, 7, 9899
prevention, 87
red cell transfusion
complications, 84
systemic disease, 97
systemic enquiry, 15
treatment, 87
viral see Viral infection
Infertility, chemotherapy
treatment, 54
Inammation, systemic enquiry, 15
Inguinal nodes, examination, 16
Inherited blood disorders
connective tissue disease, 71
in elderly people, 9293
examples, 15t
familial thrombophilia, 78
haemolytic anaemia, 29
platelet function, 7071
sickle cell syndromes, 34f
vascular purpuras, 71
see also Genetic abnormalities;
Haemophilia
Inhibitory receptors, 9
Interference phase microscopy,
splenic function
quantitation, 11
Interferon alfa, 55
essential thrombocythaemia, 66
hairy cell leukaemia, 48
polycythaemia, 6465
Interleukin 5, eosinophils, 7
International normalised ratio
(INR), 20, 8081
International prognostic index
(IPI), 61
International Prognostic Scoring
System for Primary MDS
(IPSS), 5051, 51t
International sensitivity index
(ISI), 81
Intracranial bleeding
haemophilia A, 72
thrombocytopenia, 68
Intrinsic factor (IF), megaloblastic
anaemia, 2425
Intrinsic pathway, platelets, 1213,
13f
Iron
denition/role, 24
malabsorption, 2425
normal cycle, 24f
oral, failure to respond to, 25t
overload, 85
reuse of, 5
Iron chelation therapy
aplastic anaemia, 53
myelodysplastic syndromes, 51
thalassaemias, 33
Iron deciency
anaemia see Iron deciency
anaemia
characteristics, 24
correction, 25
in elderly people, 24, 92
erythropoiesis, 64
hookworm infection, 99
identication in pregnancy, 88
in infancy, 91
unexplained, 16
Iron deciency anaemia
and anaemia of chronic disease,
37t
causes, 2425
clinical features, 2425
conrmatory tests, 25
diagnosis, 25
investigation of underlying
cause, 25
management, 25
Isoantibodies, 3031
Isoimmune haemolytic anaemia,
3031
J
Janus kinase 2 (JAK2) gene
mutations
essential thrombocythaemia, 66
myelobrosis, 67
polycythaemia, 64
Janus kinase 2 (JAK2) inhibitors
myelobrosis, 67
myeloproliferative disorders,
55
polycythaemia, 65
Joints
bleeding into, 14
examination, 16
haemophilia, effects on, 72
K
Kaolin cephalin clotting time
(KCCT), 20
Kidney enlargement, 17
see also Renal disease; Renal
failure
Klebsiella spp., 86
Knee damage, haemophilia A, 72f
L
Laboratory haematology
blood and bone marrow, 1819
blood lms see Blood lms
coagulation and acute phase
response, 2021
Lactate dehydrogenase (LDH), 61
Leishmania donovani, 99
Leishmann stain, 98
Lenalidomide, 55
myelobrosis, 67
myeloma, 63
Leucocytosis, 67, 7t, 97
Leucopenia
hypersplenism, 11
myelodysplastic syndromes, 50
symptoms attributable to, 14
Leukaemia
acute lymphoblastic see Acute
lymphoblastic leukaemia
(ALL)
acute monocytic, 40f
acute myeloid see Acute myeloid
leukaemia (AML)
adult T-cell leukaemia
lymphoma, 39f, 49
aetiology, 3839
annual causes of death, 38f
anti-leukaemic drugs, 54
blood count, 18
chronic lymphocytic see Chronic
lymphocytic leukaemia
(CLL)
chronic myeloid see Chronic
myeloid leukaemia (CML)
classication, 39
denition, 38
dyspnoea in, 95
gene therapy, 103
genetic abnormalities, 3839
hairy cell, 48
history taking, 14
immunophenotype, cells, 21
immunosuppression, 86
incidence, 38
minimal residual disease, 21
predisposing factors, 39
prolymphocytic, 48
social history, 15
T-cell large granular lymphocyte,
4849
Leukapheresis, peripheral blood
stem cells harvested by, 56,
57f
Leukocytes, listed, 6
see also White cell count (WBC)
Light microscopy, spleen, 11f
Light scattering, cell counting and
sizing, 18
Lipid bilayer, red cells, 4
Liver disease
and alcohol, 96
coagulation disorders, 20, 77
hepatitis see Hepatitis
protein C and S deciencies,
7879
tahir99-VRG & vip.persianss.ir
121 Index
sickle cell anaemia, 34
and thrombophilia, 78
Liver function tests, 53
Local anaesthesia, bone marrow
aspiration, 106
Low molecular weight (LMW)
heparin, 7980, 89, 102
Lumps, examination, 16
Lymph, location of lymphocytes
in, 8
Lymphadenopathy
chronic lymphocytic leukaemia,
46
dened, 16
history taking, 14
Hodgkins lymphoma, 48f
infection, 16
massive cervical, 16f
mediastinal, in HL, 48f
non-Hodgkins lymphoma, 60
Lymph nodes
biopsy, 58, 58f, 6061
examination, 1617
location of lymphocytes in, 8
neck, 17f
Lymphocyte predominant nodular
Hodgkins lymphoma, 58
Lymphocytes, 89
atypical, infectious
mononucleosis, 97f
B-lymphocytes see
B-lymphocytes
changes in disease, 9
count, 9, 46
depletion, 56
donor lymphocyte infusions,
57
dysfunction, 86
hairy cell leukaemia, 48f
Hodgkins lymphoma, 58
mature, in blood, 8f
mononucleosis, infectious, 97
natural killer (NK) cells, 9
T-lymphocytes see
T-lymphocytes
see also Chronic lymphocytic
leukaemia (CLL)
Lymphocytosis
chronic lymphocytic leukaemia,
46, 93
common causes, 9t
infection, 9
Lymphoid follicles, splenic
structure, 10
Lymphoid organs, 89
Lymphoma
axillary lymphadenopathy, 60f
B-cell, 55, 97
Burkitts see Burkitts lymphoma
diffuse large B-cell, 61, 100f
dyspnoea in, 95
follicular, 61, 102, 102f
and HIV/AIDS, 97
Hodgkins lymphoma see
Hodgkins lymphoma (HL)
mantle cell, 61
marginal zone, 61
mucosa-associated lymphoid
type, 61
non-Hodgkins see Non-
Hodgkins lymphoma
pain management, 94
peripheral T-cell, 61
poorly differentiated large cell,
46
T-cell leukaemic see Adult T-cell
leukaemia lymphoma
Lymphopenia, 86
M
Macrocytic anaemias, 22, 25, 27
Macrocytosis, alcohol misuse, 15,
96
Macrophages, 7, 10
Magnetic resonance imaging
(MRI), 59, 61
Malabsorption
folate, 27
iron, 2425
vitamin K, 77
Malaria, 9899
history taking, 15
removal of malarial parasites, 10
Malignant disease
chemotherapy see
Chemotherapy
colon cancer, 24f
current management model, 94f
in elderly people see under
Elderly people
end of life care, 95
hypercoagulability in, 96
lymphocytosis, 9
median ages of presentation, 93f
microarrays/gene proling, 100
microenvironment, targeting,
102
minimal residual disease, 21, 101
molecular biology applications,
101
non-pain symptoms, control,
9495
pain management, 14, 94
palliative treatment see Palliative
treatment
prostatic carcinoma, bone
marrow invasion, 97f
psychosocial oncology, 95
rectal, 16
renal carcinoma, 96
secondary, mediastinal
irradiation, 59
staging
chronic lymphocytic
leukaemia, 46
Hodgkins lymphoma, 5859,
59f
myeloma, 6263
non-Hodgkins lymphoma,
6061
stem cell transplantation, 101
symptoms attributable to, 14
and systemic disease, 96
systemic enquiry, 15
see also Hepatocellular cancer;
Leukaemia; Lymphoma;
Myeloma
Malpighian bodies, 10
MALT (mucosa-associated
lymphoid type) lymphoma,
6061
Mantle cell lymphoma, 61
Marfan syndrome, 71
Marginal pool, neutrophils, 6
Marginal zone, spleen, 10
Marginal zone lymphoma, 61
Massive cervical lymphadenopathy,
16f
Mast cells, 7
MayGrnwaldGiemsa (MGG)
stain, 1819
MDR1 (multi-drug resistance
gene), 54
Mean cell haemoglobin (MCH),
22, 25, 3637
Mean cell haemoglobin
concentration (MCHC), 22
Mean cell volume (MCV), 22, 25,
3637
Mean corpuscular haemoglobin
(MCH), 32
Mean corpuscular volume (MCV),
32
Medical history, 15
Meoquine, 99
Megakaryocytes, increased in
thrombocytopenia, 69
Megaloblastic anaemia
B
12
deciency, 2627
bone marrow aspirate in, 26f
clinical syndromes, 2627
diagnosis, 27
folate deciency, 2627
in pregnancy, 88
treatment, 27
Melphalan, 54, 63
Memory B-cells, 9
Menstruation, iron deciency,
2425
Mercaptopurine, 43, 54
Merozoites, 98
Metabolism, red cell see Red cell
metabolism
Methicillin-resistant Staphylococcus
aureus (MRSA), 86
Methotrexate, 43, 54
Methylene blue stain, blood lm,
1819
Microangiopathic haemolytic
anaemia (MAHA), 31, 31f
Microarrays/gene proling, 100
Microcytic anaemias, 22
Microcytosis, 22
Microthrombus formation, in DIC,
76
Minimal residual disease (MRD),
haematological malignancy,
21, 101
Mitoxantrone, 54
Molecular biology
acute lymphoblastic leukaemia,
43
acute myeloid leukaemia, 41
application in haematology, 101
blood tests, 82
DNA analysis techniques,
100101
Monoclonal antibodies (MoAbs),
55
Monoclonal B-cell lymphocytosis,
46
in elderly people, 93
Monoclonal gammopathy of
uncertain signicance
(MGUS)
elderly people, 93
myeloma, 62
Monocyte colony-stimulating
factor (M-CSF), 7
Monocytes, 7
Monocytopenia, 7, 48
Mononuclear phagocyte system, 7
Mononucleosis, infectious, 97
Monospot test, mononucleosis, 97
M-proteins, myeloma, 62
MRI scans see Magnetic resonance
imaging (MRI)
Mucosa-associated lymphoid type
(MALT) lymphoma, 6061
Multi-drug resistance, 54, 98
Multimer analysis, Von Willebrand
disease, 74f, 75
Multiple myeloma see Myeloma
Mutations see Genetic
abnormalities
MYC oncogene, non-Hodgkins
lymphoma, 60
Myelodysplastic syndromes (MDS)
and acute myeloid leukaemia,
39, 50
and aplastic anaemia, 5253
classication, 50
clinical features, 50
diagnosis, 50
in elderly people, 92
epigenetic therapies, 55
genetic factors, 50
high-risk, 51
hypocellular, 5253
low-risk, 51
morphology, 50
and myelobrosis, 67
platelet function disorders, 71
prognosis, 5051
treatment, 51
Myelobrosis
characteristics, 6667
clinical features, 67
diagnosis, 67
essential thrombocythaemia,
progression from, 66
management, 67
polycythaemia, 6465
prognosis, 67
Myeloid antigens, 41
Myeloma
asymptomatic (smouldering),
62
biology, 62
bisphosphonate, 63, 94
clinical features, 62
complications, 63
diagnosis, 6263
humoral immunity defects, 86
hypogammaglobulinaemia, 87
management and outcome, 63
palliative treatment, 63, 95f
platelet function disorders, 71
proteasome inhibitors, 55
staging, 6263
Waldenstrms
macroglobulinaemia, 63
Myeloperoxidase
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 4041
Myeloproliferative disorders
and acute myeloid leukaemia,
39
basophilia, 7
tahir99-VRG & vip.persianss.ir
122 INDEX
chronic myeloid leukaemia, 44
JAK2 inhibitors, 55
and myelobrosis, 67
platelet function disorders, 71
and thrombophilia, 79
Myocardial infarction,
thrombolytic therapy, 81
N
Natural killer (NK) cells, 9
Naturally occurring antibodies, 82
Nausea and vomiting, malignant
disease, 95
Neck, lymph nodes, 17f
Neisseria meningitidis, 11
Neonates/neonatal disorders see
Newborns
Neural tube defects, 88
Neutropenia
antibiotic treatment, 87t
aspergillosis, 86f
bacterial infection, 86
growth factors, 87
haematopoietic growth factor
therapy, 55
hairy cell leukaemia, 48
history taking, 14
immunosuppression, 86
infection, 7
isolated, causes of, 7t
prevention of infection, 87
pyrexial neutropenic patient, 87
systemic disease, 96
T-cell large granular lymphocyte
leukaemia, 4849
Neutrophilia/neutrophil
leucocytosis, 67
Neutrophils, 67
dysfunction, 86
transfusion, 85
Newborns
anaemia of prematurity, 90
haemolytic disease of the
newborn, 90
iron deciency in, 91
polycythaemia in, 9091
RhD prophylaxis in RhD-
negative mothers, 90
sites of blood production in, 2f
thrombocytopenia, 91
venepuncture, 105
vitamin K deciency, 77
see also Paediatric haematology;
Pregnancy
Next-generation sequencing, 101
Nicotinamide adenosine
dinucleotide phosphate
(NADPH), 5
Nilotinib, 45, 55
Nitroblue tetrazolium test, chronic
granulomatous disease, 7
Non-haemolytic transfusion
reactions, 84
Non-Hodgkins lymphoma
aetiology, 60
classication, 60
clinical presentation, 60
diagnosis, 6061
high- and low-grade tumours, 60
immunosuppression, 86
lymphocytosis, 9
management, 61
monoclonal antibodies, 55
nodal involvement, 60
proteasome inhibitors, 55
Sjgrens syndrome, 96
staging, 6061
see also Hodgkins lymphoma
(HL); Lymphoma
Nonsteroidal anti-inammatory
drugs (NSAIDs), 94
Normochromic anaemias, 22
Normocytic anaemias, 22
Normocytosis, 22
Nose bleeds, thrombocytopenia,
14
Nucleoside analogues, hairy cell
leukaemia, 48
O
Observation of patient, 16
Ofatumumab, 55
Oligonucleotide microarrays, 100
Ondansetron, 95
Opiate analgesia, 94
Organelles, platelets, 12
Osmotic fragility, hereditary
spherocytosis, 28f
Oxygen, transport, 45
Oxygen dissociation curve, 5f
P
P
50
level, haemoglobin and oxygen
transport, 5
Packed cell volume (PCV), 22,
9091
Paediatric haematology
acute lymphoblastic leukaemia,
43
anaemia, 22
bone marrow aspiration, general
anaesthesia, 106
congenital dyserythropoietic
anaemia, 91
DiamondBlackfan anaemia, 91
haemoglobinopathies, 1516
haemophilia, 15
iron deciency in infancy, 91
neonatal disorders, 9091
normal values, 90
red cell aplasia in children and
adolescents, 91
sickle cell syndromes, 35
spleen, absent, 11
transient erythroblastopenia of
childhood, 91
umbilical cord blood (UCB)
transplantation, 57
venepuncture, 105
Pain
bone, in myeloma, 62
malignant disease, 14, 62
management of in palliative
care, 94
splenic, 14, 67
vascular-occlusive crises, 35
Palliative treatment
chemotherapy and radiotherapy,
94
complementary therapy, 95
myeloma, 63, 95f
non-pain symptoms, control,
9495
pain management, 94
psychosocial oncology, 95
see also Malignant disease
Pallor, anaemia, 22
Pancytopenia
aplastic anaemia, 52
chronic lymphocytic leukaemia,
47
hairy cell leukaemia, 48
hypersplenism, 11
and leukocytes, 7
myelodysplastic syndromes, 52f
non-Hodgkins lymphoma, 60
Pappenheimer (siderotic) granules,
11
Paracetamol, 94
Parallel sequencing, 101
Paraproteins, myeloma, 62
Parasitic infection, 7
malaria, 9899
Paroxysmal nocturnal
haemoglobinuria (PNH)
aplastic anaemia, 53
haemolytic anaemia, 31
Partial exchange transfusion, 91
Partial thromboplastin time with
kaolin (PTTK), 20
Parvovirus, aplastic anaemia, 52
PaulBunnel test, mononucleosis,
97
Pentamidine, 87
Pentostatin, hairy cell leukaemia,
48
Periarteriolar lymphatic sheath, 10
Periodic acid Schiff (PAS), acute
lymphoblastic leukaemia, 42
Peripheral blood
blood lm, in AML, 39f
myelodysplastic syndromes, 50
Peripheral blood stem cells
(PBSC), 5657
Peripheral T-cell lymphomas, 61
Peripheral venous cannulation,
105
Perls stain, 19, 31f
Pernicious anaemia, 2627, 27f
ethnic origin of patient, 16
in pregnancy, 88
Petechial haemorrhage,
thrombocytopenia, 68
PET scans see Positron emission
tomography (PET) scans
PFA-100 (platelet function
instrument), 70
P-glycoprotein, 54
Phagocytes, 6, 10
Phagocytosis, 6
Philadelphia (Ph) chromosome
acute lymphoblastic leukaemia,
43
chronic myeloid leukaemia,
3839, 44, 44f
Phospholipids, red cells, 4
Piperacillin, 87
Plasma
brinogen see Fibrinogen,
plasma
transfusion, 85
viscosity, 21
volume expansion, in pregnancy,
88
see also Fresh frozen plasma
(FFP)
Plasmacytomas, 62
Plasma-derived factor VIII, 7273
Plasma protein fraction (PPF), 85
Plasmin, 13
Plasmodium falciparum, 9899
Plasmodium malariae, 98
Plasmodium ovale, 98
Plasmodium vivax, 98
Plasticity concept, 2
Platelet-derived growth factor
(PDGF), 66
Platelet function disorders
acquired, 7071
causes of abnormal function, 71t
essential thrombocythaemia, 66
history taking, 14
inherited, 7071
vascular purpuras, 71
Platelet function instruments, 70
Platelets
in acquired coagulation
disorders, 7677
activation, 10, 12
adhesion, 12
role of vWF in, 74f
aggregation, 12, 70f
Von Willebrand disease, 75
blood transfusion, 71, 85
chronic renal failure,
abnormalities in, 96
clumping of, in
thrombocytopenia, 68f
count, 6869
cytoplasm, 12
destruction, in
thrombocytopenia, 68
dilution, in thrombocytopenia,
68
essential thrombocythaemia, 66
hyposplenism, 11
intrinsic and extrinsic pathways,
1213, 13f
laboratory testing of function, 70
loose plug, 12
low count see
Thrombocytopenia
organelles, 12
procoagulant action, 12
pro-thrombinase complex, 12
role, 12
transfusion of, 27, 85
and vasoconstriction, 12
PlummerVinson syndrome,
2425
Pneumocystis jiroveci (carinii)
pneumonia, 8687
PNH see Paroxysmal nocturnal
haemoglobinuria (PNH)
Polycythaemia
acute phase response, 20
apparent, 6465
approach to patient with, 64
clinical syndromes, 6465
essential thrombocythaemia,
progression from, 66
in newborn, 9091
renal disease, 96
secondary, 65, 65f
smoking, 15
Polycythaemia vera (PV), 6466,
65f
tahir99-VRG & vip.persianss.ir
123 Index
Polymerase chain reaction (PCR),
73, 90, 100101
real-time quantitative
polymerase chain reaction
(RQ-PCR), 45
Polymorphism, prothrombin gene,
78
Positron emission tomography
(PET) scans, 59, 61
Posterior iliac crest, 106f107f
Post-transfusion purpura,
thrombocytopenia, 69
Precursor lymphoid neoplasms, 42
Prednisolone
diffuse large B-cell lymphoma,
61
follicular lymphoma, 61
myeloma, 63
thrombocytopenia, 69
warm autoimmune haemolytic
anaemia, 30
see also Steroid treatment
Pre-eclampsia, 8889
Pregnancy
acute obstetric haemorrhage, 89t
anaemia in, 22, 88
antenatal detection of genetic
disorders, 101
coagulation abnormalities in, 89
common haematological
changes, 88f
disseminated intravascular
coagulation in, 8889
essential thrombocythaemia, 66
haematological changes, 88
HELLP syndrome, 89
sickle cell anaemia (HbSS), 35
thrombocytopenia in, 8889
thrombophilia in, 79
see also Newborns; Paediatric
haematology
Prematurity, anaemia of, 90
Prenatal diagnosis, 33, 35
Procoagulant action, platelets, 12
Proguanil, malaria, 99
Prolymphocytes, 48
Prolymphocytic leukaemia (PLL),
48
Prostatic carcinoma, bone marrow
invasion, 97f
Protein C
coagulation regulation, 13
deciency, familial
thrombophilia, 7879
Protein S
coagulation regulation, 13
deciency, familial
thrombophilia, 7879
Proteolytic enzymes, 12
Proteasome inhibitors, 55
Prothrombin, 1213
Pro-thrombinase complex,
platelets, 12
Prothrombin complex concentrate,
77
Prothrombin G20210A, familial
thrombophilia, 78
Prothrombin time (PT)
disseminated intravascular
coagulation, 76
haemostasis, 1213
laboratory haematology, 20
vitamin K deciency, 77
and warfarin, 81
see also Activated partial
thromboplastin time
(APTT)
Pseudomonas aeruginosa, 86
Pseudopolycythaemia, 6465
Pseudoxanthoma elasticum, 71
Psoas muscle bleed, haemophilia
A, 72f
Pulmonary arteriovenous
malformations (PAVMs), 71
Pulmonary embolism (PE)
main pulmonary trunk, 80f
in pregnancy, 89
thrombophilia, 78
Pure red cell aplasia (PRCA), 91
Purine analogues, hairy cell
leukaemia, 48
Purpura fulminans, 79
Purpuric rash
myelodysplastic syndrome, 50f
thrombocytopenia, 68, 69f
Pyruvate kinase (pk) deciency, 29
Q
Quantitative immunoassay, vWF
antigen, 75
Quinine, 99
Quinolone antibiotic, 87
R
Radioimmunoassay, erythropoietin
estimation by, 64
Radioimmunotherapy, follicular
lymphoma, 61
Radiotherapy
chronic lymphocytic leukaemia,
47
follicular lymphoma, 61
Hodgkins lymphoma, 59
myeloma, 63
palliative, 94
stem cell transplantation, 5657
Rai system, Binet adaptation, 46
Rashes, purpuric
myelodysplastic syndrome, 50f
thrombocytopenia, 68, 69f
Raynauds phenomenon, 30
Real-time quantitative polymerase
chain reaction (RQ-PCR), 45
Recombinant activated protein C,
acquired coagulation
disorders, 76
Recombinant vWF, 75
Rectal examination, 16
Red cell aplasia, 91
Red cell distribution width (RDW),
25
Red cell indices, 22
Red cell metabolism, 5
abnormalities, 29
schematic diagram, 29f
Red cells, 45
ageing and death, 5
blood count, 18
characteristic biconcave shape, 4f
enlarged (macrocytosis), 15, 24
erythropoietin, 4
haemoglobin and oxygen
transport, 5
high concentration in
polycythaemia, 64
intrasplenic pooling, in
hypersplenism, 11
membrane, 4f
disorders, 29
normochromic normocytic
indices, 28
premature destruction, in
hypersplenism, 11
removal, where unwanted, 10
renal disease, increased
production in, 96
structure, 4
transfusion, 8485, 84t
Red pulp, spleen, 10, 11f
ReedSternberg cells, lymph node
biopsy, in HL, 58f
Regulatory molecules see Growth
factors
Renal disease, 96
Renal failure
Burr cells, 96f
chronic, 71, 96
in elderly people, 92
haemolytic transfusion reactions,
84
platelet function disorders, 71
Resistance, multi-drug, 54
malaria, 98
Respiratory burst, phagocytosis, 6
Reticulocytes
haemolytic anaemia, 28
increased, in warm AIHA, 30f
Reticulocytopenia, aplastic
anaemia, 52
Rhesus (Rh) blood group system,
8283
clinical practice, 85
paediatric haematology, 90
Rheumatoid arthritis, 37, 96
Richter syndrome, 46
Ristocetin, failure to aggregate
with, 70
Rituximab, 55
chronic lymphocytic leukaemia,
47
diffuse large B-cell lymphoma,
61
follicular lymphoma, 61
prolymphocytic leukaemia,
48
treatment advances, 102
warm autoimmune haemolytic
anaemia, 30
Rivaroxaban, 81, 102103
Romanowskys stain, 1819, 28
Ruxolitinib, 55, 67
S
Schilling test, vitamin B
12

absorption, 27
Schizonts, 98
Scintigraphy, 11
Screening strategies, sickle cell
syndromes, 35
SDSPAGE multimer analysis, vW
factor, 74f
Sedation, bone marrow aspiration
and trephine biopsy,
106107
Senile purpura, 71f
Sepsis, 14, 76
Septicaemia, 86
Sequestration, 34, 68
Serial analysis of gene expression
(SAGE), 100
Severe aplastic anaemia (SAA),
53
Szary syndrome, 49
Shock, blood transfusion, 84
Sickle cell syndromes
counselling, 35
dactylitis, 34f
doubly heterozygous sickling
disorders, 35
inheritance, 34f
pathophysiology, 34
sickle cell anaemia (HbSS),
3435, 34f
ethnic origin of patient, 16
in pregnancy, 88
splenic atrophy, 1011
sickle cell trait (HbAS), 35
Side-effects
bone marrow harvesting, 107
cytotoxic drugs, 54
interferon alfa, 48
possible haematological, 15t
Signal transduction, 3
Silver impregnation, trephine
biopsy, 19
Sjgrens syndrome, 96
Skin disorders
infection, 86f
sickle cell anaemia, 34
Smear cells, chronic lymphocytic
leukaemia, 46
Smears, marrow aspirate, 106
Smoking, history taking, 15
Social history, 15
Southern blotting, factor VIII gene
inversion in haemophilia,
73f
Spectrin, 4
Spectrophotometer, automated
haematology counters, 18
Spindle poisons, 54
Spleen
abnormal states, 1011
absent, 1011
and B-lymphocytes, 9
enlargement, schematic view,
17f
examination, 17, 17f
function, 10
HowellJolly bodies, 1011
light microscopy, 11f
location of lymphocytes in, 8
red and white pulp, 10, 11f
structure, 10
Splenectomy, 1011
chronic lymphocytic leukaemia,
47
hairy cell leukaemia, 48
hereditary elliptocytosis, 29
pyruvate kinase (pk) deciency,
29
thrombocytopenia, 69
warm autoimmune haemolytic
anaemia, 30
Splenic artery, 10
Splenic cords, 10
Splenic sinuses, 10
tahir99-VRG & vip.persianss.ir
124 INDEX
Splenomegaly
chronic lymphocytic leukaemia,
46
chronic myeloid leukaemia, 44
common causes, 17t
hypersplenism, 11
myelodysplastic syndromes, 50
myelobrosis, 6667, 67f
pain in, 14
polycythaemia, 64
prolymphocytic leukaemia, 48
thrombocytopenia, 68
tropical splenomegaly syndrome,
99
Staging of malignant disease
chronic lymphocytic leukaemia,
46
Hodgkins lymphoma, 5859,
59f
myeloma, 6263
non-Hodgkins lymphoma,
6061
Stains and dyes, blood lms, 1819
see also specic stains, such as
Sudan black stain
Staphylococcus epidermidis, 86
Stem cell hierarchy,
haematopoiesis, 2, 3f
Stem cell mobilisation, 55
Stem cell transplantation (SCT)
acute myeloid leukaemia, 41
allogeneic see Allogeneic stem
cell transplantation
aplastic anaemia, 53
autologous see Autologous stem
cell transplantation
chronic myeloid leukaemia, 45
graft-versus-host disease, 56, 57f
haematological malignancy, 101
immunosuppression, 8687
leukapheresis, peripheral blood
stem cells harvested by, 56,
57f
non-myeloablative (reduced
intensity) allogeneic, 57
sickle cell anaemia (HbSS), 35
syngeneic, 56
twin (allogeneic and syngeneic),
56
umbilical cord blood, 57
see also Blood transfusion
Stercobilinogen, faecal, 28
Steroid treatment
chronic lymphocytic leukaemia,
47
myeloma, 63
thrombocytopenia, 69
warm autoimmune haemolytic
anaemia, 30
see also Prednisolone
Stomach abnormalities, vitamin
B
12
deciency, 27
Storage pool disorders, 70
Streptococcus faecalis, skin
infection, 86f
Streptococcus pneumoniae, 11
Streptokinase, 81
Stromal cells, 2
Stylet, bone marrow aspiration
and trephine biopsy,
106107
Subacute combined degeneration,
26
Submicroscopic mutations,
leukaemia, 38
Sudan black stain, 4042
Superior vena cava syndrome, 60
Supplementation
folic acid, 27
iron, 88
vitamin K, 77, 81
Supportive care
acute myeloid leukaemia, 41
aplastic anaemia, 53
haematopoietic growth factor
therapy, 55
myelodysplastic syndromes, 51
Supravital stain, blood lm, 1819
Surgery
sickle cell anaemia (HbSS), 35
splenectomy see Splenectomy
5q-syndrome, 50
Syngeneic stem cell
transplantation, and
allogeneic SCT, 56
Syringe drivers, continuous drug
infusions, 95
Systemic disease
basophilia, 7
blood count, 18
connective tissue, 71, 96
infection, 97
liver, 96
malignancy, 96
non-Hodgkins lymphoma, 60
renal, 96
and thrombophilia, 78
see also Infection; Liver disease;
Malignant disease
Systemic lupus erythematosus
(SLE), 79, 96
T
Tazobactam, 87
T-cell large granular lymphocyte
leukaemia (T-LGL), 4849
T-cell receptor (TCR), 8
Tear-drop poikilocytes,
myelobrosis, 67
Telangiectasia, 71
Telomeres, in aplastic anaemia, 52
Thalassaemias
classication, 32
clinical syndromes, 3233
gene therapy, 103
prenatal diagnosis, 33
spleen, absent, 11
-Thalassaemias, 32
-Thalassaemia intermedia, 33
-Thalassaemia major, 3233
-Thalassaemia trait (minor), 33
Thalidomide, 55
myelobrosis, 67
myeloma, 63
Third-generation recombinant
factor VIII, 7273
3-D confocal imaging, 102
Thrombin, 1213
inhibitors, 102103
Thrombocytes see Platelets
Thrombocytopenia
acute lymphoblastic leukaemia,
42
alcohol misuse, 96
alloimmune, 91
autoimmune, 46
bleeding, 14, 68
bone marrow aspiration, 106
causes, 68
clinical presentation, 68
clinical syndromes, 6869
heparin use, 80
hypersplenism, 11
incidental (gestational), 88
myelodysplastic syndromes, 50
myeloma, 62
in newborn, 91
in pregnancy, 8889
symptoms attributable to, 14
T-cell large granular lymphocyte
leukaemia, 4849
see also Immune
thrombocytopenia (ITP)
Thrombocytosis, systemic enquiry,
15
Thromboembolism, anticoagulant
therapy, 89
Thrombolytic therapy, 81
Thrombomodulin inhibitors, 102
Thrombophilia
acquired forms, 79
acute venous thrombosis, 79
familial, 7879
genetic counselling, 79
patients to be investigated, 78
in pregnancy, 79
Thromboplastin, prothrombin
time test, 20
Thrombopoeitin receptor (TPO-R),
second generation agonists,
69
Thrombosis
in elderly people, 92, 92f
large vessel, in DIC, 76
polycythaemia, risk in, 64
Thrombotic thrombocytopenic
purpura (TTP), 31
Thymus
destruction of T-lymphocytes by,
8
location of lymphocytes in, 8
Tissue factor pathway inhibitor
(TFPI), 13
Tissue hypoxia, anaemia, 22
Tissue necrosis, haemorrhagic, 76
Tissue plasminogen activator
(t-PA), 13, 81
T-lymphocytes, 8
acute lymphoblastic leukaemia,
42
adult T-cell leukaemia
lymphoma, 49
interaction with antigen-
presenting cells, 8f
removal in stem cell
transplantation, 56
splenic structure, 10
Topoisomerase poisons/inhibitors,
54
Tourniquets, 104105
Tranexamic acid, bleeding, 73
Transcranial Doppler
ultrasonography, sickle cell
syndromes, 35
Transcription factors, 2
Transforming growth factor-, 66
Transfusion see Blood transfusion
Transfusion associated circulation
overload (TACO), 84
Transfusion-related acute lung
injury (TRALI), 84
Transient erythroblastopenia of
childhood, 91
Treatment of conditions
advances in, 102103
bleeding, in haemophilia A,
7273
chronic lymphocytic leukaemia,
4647, 47f
chronic myeloid leukaemia, 45,
55
infection, 87
megaloblastic anaemia, 27
myelodysplastic syndromes, 51
viral, 73
see also Chemotherapy; Drug
treatment; Surgery
Trephine biopsy, bone marrow
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
aplastic anaemia, 5253
chronic lymphocytic leukaemia,
46
examination procedure, 19
hairy cell leukaemia, 48
human T-cell leukaemic
lymphoma, 39f
myelobrosis, 67f
polycythaemia, 64
procedure, 107
staining, 19
and structure of bone marrow, 2
systemic disease, 96
thrombocytopenia, 69
uses, 19
Tricyclic antidepressants, pain
management, 94
Trilaminar platelet membrane, 12
Trophozoites, 9899
Tropical splenomegaly syndrome,
99
Twin (allogeneic and syngeneic)
stem cell transplantation, 56
Tyrosine kinase inhibitors (TKIs),
55
acute myeloid leukaemia, 55
chronic myeloid leukaemia, 45
Tyrosine kinase receptor gene
mutation, acute myeloid
leukaemia, 41
U
Ulceration, cold autoimmune
haemolytic anaemia, 30
Ultrastructural studies, 2
Umbilical cord blood (UCB)
transplantation, 57
Unfractionated heparin, 80, 89
Uraemia, 71
Urobilin, 5
Urobilinogen, 5, 28
Urokinase, 81
V
Variant Creutzfeldt-Jakob disease
(vCJD), 84
tahir99-VRG & vip.persianss.ir
125 Index
Varicella zoster, 87
Vascular-occlusive crises, sickle cell
anaemia, 3435
Vascular purpuras, 71
Velocimetry, fetal middle cerebral
artery, 90
Venepuncture, 104105
Venesection, polycythaemia, 65
Venous access, 105
Venous thrombosis
acute, 79
in elderly people, 92f
Factor V Leiden (FVR506Q), 78
idiopathic, 81
malignant disease, 96
see also Deep vein thrombosis
(DVT)
Vertebroplasty, myeloma, 63
Very severe aplastic anaemia
(VSAA), 53
Vinblastine, 54
Hodgkins lymphoma, 59
Vincristine, 54
diffuse large B-cell lymphoma,
61
follicular lymphoma, 61
Viral infection
adult T-cell leukaemia
lymphoma, 49
aplastic anaemia, 52
haemophilia A, 73
hepatitis see Hepatitis
immunosuppression, 8687
systemic disease, 97
thrombocytopenia, 68
Visceral leishmaniasis (kala-azar),
99
Vitamin B
12
deciency
intramuscular injection, 2425
megaloblastic anaemia, 2627
in pregnancy, 88
Vitamin K
deciency, 7677
intravenous, 81
platelets, 12
supplementation, 77, 81, 92
and warfarin, 76, 80f
Vitamin K derived clotting factor,
73
Von Willebrand disease (vWD)
classication, 74
clinical features, 7475
diagnosis, 74f
laboratory diagnosis, 75
management, 75
types 1 and 2, 74
Von Willebrand factor (vWF)
platelet function disorders,
70
range of levels, 74
role in platelet adhesion, 74f
thrombotic thrombocytopenic
purpura, 31
Voriconazole, 87
W
Waldenstrms
macroglobulinaemia, 63
Warfarin
indications for use, 8081
method of action, 80
in pregnancy, 89
protein C and S deciencies,
7879
side-effects, 79
and vitamin K, 76, 80f
Warm autoimmune haemolytic
anaemia, 30, 30f
White cell count (WBC)
acute myeloid leukaemia, 40
chronic myeloid leukaemia, 44
laboratory haematology, 18
reference values, 90
see also Leukocytes
White cells, low count see
Leucopenia
White pulp, spleen, 10, 11f
World Health Organization
(WHO) classication
systems
acute lymphoblastic leukaemia,
42
acute myeloid leukaemia, 40
Hodgkins lymphoma, 58
non-Hodgkins lymphoma, 60
Wrights stain, 1819
Z
ZAP-70 (signalling molecule), 46
Zidovudine, 49
tahir99-VRG & vip.persianss.ir