Approach in Hematology

Te & Chin
Contents 1. Anemia 2. Bleeding disorders 3. Thrombophilia 4. Pancytopenia 5. Approach to Hematologic malignancy 6. Splenomegaly 7. Lymphadenopathy 1. Anemia Acute / Subacute-Chronic Anemia or Pancytopenia Hemolytic / Non hemolytic MCV + RDW Provisional diagnosis Normal / Hypo- / Hyperproliferative marrow PBS : Monomorphic Microcytic anemia Hemolytic : TH Non hemolytic : IDA ACD SA Normocytic anemia Hct > 30 R/O IDA 1st CKD Hemolytic anemia IVH / EVH Intrinsic / Extrinsic Immune / Non-immune Non HA ACD / BM disease Macrocytic anemia MCV > 110 : AIHA / MGB MCV 100-110 PBS MGB B12 / Folic Non MGB Drugs + Alcohol Liver disease HypoTH BM dz. Other disease

2. Bleeding disorders Recognitions (7) Localized main cascade Screening coagulogram Congenital / Acquired Each detailed : low platelet / dysfunction / PT-PTT + Bleeding disorders that normal screening coagulogram 3. Thrombophilia Awareness setting Exclude other vasculopathy mimick Artery / Venous or Mixed Artery 5 + Physiologic / Pathologic Hereditary / Acquired Treatment 4. Pancytopenia Not complete SS 3 series Exclude Extra-marrow cause 1> S+++ 2> Obvious cause Active AI disease : SLE / RA(Felty) Dilutional effect 3> WBC > 2000 and PMN predominate 4> Normal PBS Marrow cause (4) Substrate B12 / Folic Stem cell AA / Drug / MDS Proliferatn Infection-Inflammation Severe sepsis Hypothyroidism Alcohol HIV Myelop(7) Malignancy H : ALKLK / LM NH: Metastatic CA Infection : TB-NTM / F / Brucella / Fibrosis : PMF Malignant myelosclerosis Infiltrative disease Bone disease Hemophagocytic syndrome

PBS : Blast / LkEr picture Cellularity ALK > LM > MM > CA > MDS-Drugs-MGB > PNH 5. Approach to Hematologic malignancy Acute < 1 mo. (Acute febrile illness) LN+ / BMF / PBS-Blast Acute Leukemia : M / L Leukemic phase of lymphoma LN++ / Med LN++ +Abn CBC Adult T cell lymphoma/leukemia (Young adult male) Hodgkin lymphoma Mantle cell lymphoma Lymphoma polyposis Lymphoblastic lymphoma LN+++ / Normal PBS Very AGG Lymphoma / Richters B-LbL /Burkitt /Plasma Lk/DLBL Hyperviscosity syndrome AML Monoblast-cyte > 50,000 AML Myeloid > 100,000 ALL Lymphocyte > 200,000 CML rarely > 500,000 Paraproteinemia Lymphoplasmocytic L Waldenstrom MGb Subacute 1-3 mo. (Prolong fever / FUO) DDX both acute and chronic dz. Chronic > 3 mo. (Prolong fever / FUO) LN++ / S++ / abnormal CBC Absolute Lymphocyte > 5000 CLL + AIHA / ITP Absolute Monocyte > 1500 Hairy cell HCL CD25 + Leukemic phase of lymphoma

CMMol

LN++ / Normal CBC Indolent lymphoma most common FL+CLL/SLL/HCL/MZL Chronic Asymptomatic L+S++++ MPD / Splenic MZL ass. HCV Spleen size relate WBC CML-philadelphia chromosome LN+ : BX R/O extramedullary blastic phase CML Spleen size not relate other PBS prominent tear drop cell : PMF/AMM Almost always anemia PBS normal Hct + MCV / JAK-2 gene High Hct + low MCV mostly PV > ET + Pattern recognition Abnormal Skin lesion : Mycosis fungoides / Sezary synd. CRAB + Plasmacytoma / Gb Plasma cell > 10 % in BM/ Amyloid / POEMs DCM echo finding : Sparking appearance : Multiple myeloma Small to Medium vasculopathy + LVR End organ ischemia+ HCV : Essential Mixed Cryoglobilinemia / WaldenSt Testicular mass : ALL / Lymphoma + Germ cell tumor Brain mass : Primary CNS lymphoma ass EBV Third space effusion : Primary effusion lymphoma Cavity based Sjogren with rapid LN++ / H.pylori and Hashimotos thyroiditis : MALT lymphoma Lymphoma in HIV (3) NHL can occur in any CD4 CD4 normal T or B cell CD4 low most common aggressive B cell Primary CNS lymphoma Primary effusion lymphoma Hypercalcemia : Lymphoma / MM

6. Splenomegaly Congestive PHT Rt. Sided heart failure Budd Chiari PHT most common cirrhosis Portal vein thrombosis Splenic vein thrombosis / obstruction Non congestive Increase function RE hyperfunction : Chronic EVH-Thal/HS Immune mediated Infection : Meliod / IM AIR : RA / SLE BE Extramedullary hematopoiesis : MPD Space occupying lesion Tumor Benign Malignant Splenic marginal lymphoma Metastasis : Melanoma Cyst Abscess : Pyogenic(+Melioid) Infiltrative disease Infection : TB / Meliod Malignancy : Lymphoma / Melanoma Other substance Glycogen-storage disease Hemochromatosis Amylodosis / Sarcoidosis Huge Splenomegaly (8) > 8 cm. / 1000 g MPD especially AMM Hairy cell leukemia / CLL CMMoL Splenic marginal lymphoma ass. HCV Chronic malaria Thalassemia Splenic vein thrombosis

7. Lymphadenopathy LN++ CLN 1 cm. Axilla 1.5 cm. Inguinal 2 cm. Localized / Generalized Localized disease of drainage organ Virchows Lungs / Breast / GI / Testis / Ovary Axilla Breast / Melanoma / UE Inguinal GU / Rectum / Melanoma / LE Intra-abd. Germ cell Reactive lymphadenitis most common !!! Infection Bacteria / Virus / TB NTM / Melioid Tumor LPD / Indolent Lymphoma rubbery Metastasis (drainage) hard-fixed Infiltrative : Amyloidosis / Sarcoidosis etc. Generalized Infection : Bacteria / Virus / TB NTM / F Systemic infection CNT disease Tumor Hematologic Leukemia Aggressive Lymphoma Metastasis (rare) Drugs Hydralazine / Allpurinol / Gold / CBZ / Diphenylhydrantoin Infiltrative disease Sarcoidosis / Amyloidosis / POEM Lipid storage dz. Gauchers / Niemann-Pick / Fabry / Tangier Kikuchis (Histiocytic necrotizing) Castlemans disease Others Kawasakis disease