Oxford University Press makes no representation, express or implied, that

the drug dosages in this book are correct. Readers must therefore always

check the product information and clinical procedures with the most up-to-

date published product information and data sheets provided by the manu-

facturers and the most recent codes of conduct and safety regulations. The

authors and the publishers do not accept responsibility or legal liability for

any errors in the text or for the misuse or misapplication of material in this

work.

Except where otherwise stated (e.g. Paediatric Haematology), drug

doses and recommendations are for the non-pregnant adult who is

not breast-feeding.

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Foreword to the first edition

The Concise Oxford Dictionary defines a handbook as ‘a short manual or

guide’. Modern haematology is a vast field which involves almost every

other medical speciality and which, more than most, straddles the worlds

of the basic biomedical sciences and clinical practice. Since the rapidly pro-

liferating numbers of textbooks on this topic are becoming denser and

heavier with each new edition, the medical student and young doctor in

training are presented with a daunting problem, particularly as they try to

put these fields into perspective. And those who try to teach them are not

much better placed; on the one hand they are being told to decongest the

curriculum, while on the other they are expected to introduce large slices

of molecular biology, social science, ethics and communication skills, not

to mention a liberal sprinkling of poetry, music and art.

In this over-heated educational scene the much maligned ‘handbook’

could well stage a come-back and gain new respectability, particularly in

the role of a friendly guide. In the past this genre has often been viewed as

having little intellectual standing, of no use to anybody except the panic-

stricken student who wishes to try to make up for months of mis-spent

time in a vain, one-night sitting before their final examination. But given

the plethora of rapidly changing information that has to be assimilated, the

carefully prepared précis is likely to play an increasingly important role in

medical education. Perhaps even that ruination of the decent paragraph

and linchpin of the pronouncements of medical bureaucrats, the ‘bullet-

point’, may become acceptable, albeit in small doses, as attempts are

made to highlight what is really important in a scientific or clinical field of

enormous complexity and not a little uncertainty.

In this short account of blood diseases the editors have done an excel-

lent service to medical students, as well as doctors who are not specialists

in blood diseases, by summarising in simple terms the major features and

approaches to diagnosis and management of most of the blood diseases

that they will meet in routine clinical practice or in the tedious examina-

tions that face them. And in condensing this rapidly expanding field they

have, remarkably, managed to avoid one of the great difficulties and pitfalls

of this type of teaching; in trying to reduce complex issues down to their

bare bones, it is all too easy to introduce inaccuracies.

One word of warning from a battle-scarred clinician however. A précis

of this type suffers from the same problem as a set of multiple-choice

questions. Human beings are enormously complex organisms, and sick

ones are even more complicated; during a clinical lifetime the self-critical

doctor will probably never encounter a ‘typical case’ of anything. Thus the

outlines of the diseases that are presented in this book must be used as

approximate guides, and no more. But provided they bear this in mind,

students will find that it is a very valuable summary of modern haema-

tology; the addition of the Internet sources is a genuine and timely bonus.

D. J. WEATHERALL

April 1998

Preface to the second edition

Haematology has seen many changes since 1998 when the first edition of

this small book was written. Most notably, there are major advances in the

treatments of malignant blood disorders with the discovery of tyrosine

kinase inhibitors which have transformed the outlook for patients with

CML, the rediscovery of arsenic for AML and many other new therapies.

Progress has been slower in the non-malignant arena since there is still

limited evidence on which to base decisions. We have attempted to

update each section in the book in order to ensure that it reflects current

practice. Although molecular diagnostics have seen huge changes through

the Human Genome Project and other methodological developments, we

have not included these in great detail here because of lack of space. We

have attempted to focus more on clinical aspects of patient care.

This edition welcomes two new authors: Professor Sir John Lilleyman,

immediate Past-President of the Royal College of Pathologists, is a

Paediatric Oncologist at Barts and The London, Queen Mary’s School of

Medicine and Dentistry, University of London. John is a leading figure in

the world of paediatric haematology with an interest in both malignant

and non-malignant disease affecting children. He has extensively revised

the Paediatric section of the book, in addition to Immunodeficiency.

Dr Trevor Baglin, Consultant Haematologist at Addenbrookes Hospital,

Cambridge is Secretary of the British Committee for Standards in

Haematology Haemostasis and Thrombosis Task Force. Trevor is the

author of many evidence-based guidelines and peer-reviewed scientific

papers. He has rewritten the Haemostasis section of the book and

brought this in line with modern management.

Other features of this edition include the greater use of illustrations such

as blood films, marrows and radiological images which we hope will

enhance the text and improve readers’ understanding of the subject. We

have increased the number of references and provided URLs for key web-

sites providing easy access to organisations and publications.

There will doubtless be omissions and errors and we take full responsi-

bility for these. We are very keen to receive feedback (good or other-

wise!) since this helps shape future editions. If there is something you feel

we have left out please complete the Readers comment card.

CRJS

January 2004

Preface to the first edition

This small volume is intended to provide the essential core knowledge

required to assess patients with possible disorders of the blood, organise

relevant investigations and initiate therapy where necessary. By reducing

extraneous information as much as possible, and presenting key informa-

tion for each topic, a basic understanding of the pathophysiology is pro-

vided and this, we hope, will stimulate readers to follow this up by

consulting the larger haematology textbooks.

We have provided both a patient-centred and disease-centred

approach to haematological disease, in an attempt to provide a form of

‘surgical sieve’, hopefully enabling doctors in training to formulate a differ-

ential diagnosis before consulting the relevant disease-orientated section.

We have provided a full review of haematological investigations and

their interpretation, handling emergency situations, and included the com-

monly used protocols in current use on Haematology Units, hopefully

providing a unified approach to patient management.

There are additional sections relating to patient support organisations

and Internet resources for further exploration by those wishing to delve

deeper into the subject of blood and its diseases.

Obviously with a subject as large as clinical haematology we have been

selective about the information we chose to include in the handbook. We

would be interested to hear of diseases or situations not covered in this

handbook. If there are inaccuracies within the text we accept full respon-

sibility and welcome comments relating to this.

ASD

CRJS

AGS

1998

Acknowledgements

We are indebted to many of our colleagues for providing helpful sugges-

tions and for proofreading the text. In particular we wish to thank Dr

Helen McCarthy, Specialist Registrar in Haematology; Dr Jo Piercy,

Specialist Registrar in Haematology; Dr Tanay Sheth, SHO in

Haematology, Southampton; Sisters Clare Heather and Ann Jackson,

Haematology Day Unit, Southampton General Hospital; Dr Mike

Williams, Specialist Registrar in Anaesthetics; Dr Frank Boulton, Wessex

Blood Transfusion Service, Southampton; Dr Paul Spargo, Consultant

Anaesthetist, Southampton University Hospitals; Dr Sheila Bevin, Staff

Grade Paediatrician; Dr Mike Hall, Consultant Neonatologist; Dr Judith

Marsh, Consultant Haematologist, St George’s Hospital, London; Joan

Newman, Haematology Transplant Coordinator, Southampton; Professor

Sally Davies, Consultant Haematologist, Imperial College School of

Medicine, Central Middlesex Hospital, London; Dr Denise O’Shaughnessy,

Consultant Haematologist, Southampton University Hospitals NHS Trust;

Dr Kornelia Cinkotai, Consultant Haematologist, Barts and The London

NHS Trust; Dr Mansel Haeney, Consultant Immunologist, Hope Hospital,

Salford; Dr Simon Rule, Derriford Hospital, Plymouth; Dr Adam Mead,

Specialist Registrar Barts and The London; Dr Chris Knechtli, Consultant

Haematologist, Royal United Hospital, Bath. And finally, we would like to

thank Alastair Smith, Morag Chisholm and Andrew Duncombe for their

contributions to the first edition of the handbook.

Warm thanks are also extended to Oxford University Press, and in partic-

ular Catherine Barnes, commissioning editor for medicine. She has been a

calming influence throughout the reworking of the handbook. Kate Martin,

production manager, has helped immensely with artwork and matters of

book design. Our thanks also go to Georgia Pinteau, PA to Catherine,

who has facilitated throughout, chasing up electronic artwork and other

materials required for the book.

Typographical notes—the entire book was typeset using Quark Express™

4.11 on a Mac G4 minitower. Body text is a modified Gill Sans (designed

and very kindly supplied by Jonathan Coleclough) with headings/subhead-

ings in Frutiger and Gill Sans. Symbols comprise Universal Greek w. Math

Pi, Zapf Dingbats, Universal News w. Commercial Pi, and a modified

version of Murray Longmore’s OUP font

(modified by Jonathan

Coleclough).

Symbols and abbreviations

cross-reference

important

very important

decreased

increased

normal

9:3

male: female ratio

1°

primary

2°

secondary

2,3 DPG

2,3 diphosphoglycerate

2-CDA

2-chlorodeoxyadenosine

α2-M

alpha₂ microglobulin

6-MP

6-mercaptopurine

^99mTc-MIBI

^99mTc methoxyisobutyl-isonitride or ^99mTc-MIBI

scintigraphy

aplastic anaemia or reactive amyloidosis

antibody

ABVD

adriamycin (doxorubicin), bleomycin, vinblastine,

dacarbazine

ACD

acid-citrate-dextrose or anaemia of chronic disease

ACE

angiotensin converting enzyme

ACL

anticardiolipin antibody

ACML

atypical chronic myeloid leukaemia

ADA

adenosine deaminase

ADE

cytosine arabinoside (Ara-C) daunorubicin etoposide

ADP

adenosine 5-diphosphate

AFB

acid fast bacilli

antigen

AIDS

acquired immunodeficiency syndrome

AIHA

autoimmune haemolytic anaemia

AIN

autoimmune neutropenia

(primary) amyloidosis

ALB

serum albumin

ALG

anti-lymphocyte globulin

ALIPs

abnormal localisation of immature myeloid precursors

ALL

acute lymphoblastic leukaemia

ALS

advanced life support

ALT

alanine aminotransferase

AML

acute myeloid leukaemia

AMP

adenosine monophosphate

ANA

antinuclear antibodies

ANCA

anti-neutrophilic cytoplasmic antibody

ANAE

alpha naphthyl acetate esterase

APC

activated protein C

APCR

activated protein C resistance

APL

antiphospholipid antibody

APML

acute promyelocytic leukaemia

APS

antiphospholipid syndrome

APTR

activated partial thromboplastin ratio

APTT

activated partial thromboplastin time

APTT ratio

activated partial thromboplastin time ratio

ARDS

adult respiratory distress syndrome

ARF

acute renal failure

ARMS

amplification refractory mutation system

AST

aspartate aminotranferase

ASCT

autologous stem cell transplantation

AT (ATIII)

antithrombin III

ATCML

Adult-type chronic myeloid (granulocytic) leukaemia

ATG

anti-thymocyte globulin

ATLL

adult T-cell leukaemia/lymphoma

ATP

adenosine triphosphate

ATRA

all-trans retinoic acid

A-V

arteriovenous

BAL

broncho-alveolar lavage

B-CLL

B-cell chronic lymphocytic leukaemia

bis die (twice daily)

BEAC

BCNU, etoposide, cytosine & cyclophosphamide

BEAM

BCNU, etoposide, cytarabine (ara-C), melphalan

b₂-M

b₂-microglobulin

BFU-E

burst-forming unit-erythroid

BJP

Bence Jones protein

Burkitt lymphoma

bone marrow

BMJ

British Medical Journal

BMT

bone marrow transplant(ation)

BNF

British National Formulary

blood pressure

BPL

BioProducts Laboratory

BSS

Bernard-Soulier syndrome

Symbols and abbreviations

Bethesda Units

carcinoma

Ca²⁺

calcium

CABG

coronary artery by pass graft

cALL

common acute lymphoblastic leukaemia

CBA

collagen binding activity

CBV

cyclophosphamide, carmustine (BCNU), etoposide

(VP16)

CCF

congestive cardiac failure

CCR

complete cytogenetic response

cluster designation

CDA

congenital dyserythropoietic anaemia

cDNA

complementary DNA

CEL

chronic eosinophilic leukaemia

CGL

chronic granulocytic leukaemia

CHAD

cold haemagglutinin disease

CHOP

cyclophosphamide, adriamycin, vincristine, prednisolone

C/I

consolidation/intensification

CJD

Creutzfeldt-Jakob disease (v = variant)

Cl^-

chloride

CLD

chronic liver disease

CLL

chronic lymphocytic (‘lymphatic’) leukaemia

CMC

chronic mucocutaneous candidiasis

CML

chronic myeloid leukaemia

CMML

chronic myelomonocytic leukaemia

CMV

cytomegalovirus

CNS

central nervous system

COAD

chronic obstructive airways disease

COC

combined oral contraceptive

COMP

cyclophosphamide, vincristine, methotrexate,

prednisolone

complete remission

CRF

chronic renal failure

CRP

C-reactive protein

CRVT

central retinal renous thrombosis

CSF

cerebrospinal fluid

computed tomography

CTZ

chemoreceptor trigger zone

CVA

cerebrovascular accident

CVP

cyclophosphamide, vincristine, prednisolone; central

venous pressure

CVS

cardiovascular system

CXR

chest x-ray

CyA

cyclosporin A

CytaBOM

cytarabine, bleomycin, vincristine, methotrexate

day

DAGT

direct antiglobulin test

DAT

direct antiglobulin test; daunorubicin, cytosine (Ara-C),

thioguanine

dATP

deoxy ATP

DBA

Diamond-Blackfan anaemia

dyskeratosis congenita

DCS

dendritic cell system

DCT

direct Coombs’ test

DDAVP

desamino D-arginyl vasopressin

DEAFF

detection of early antigen fluorescent foci

DEB

diepoxy butane

DFS

disease-free survival

DHAP

dexamethasone, cytarabine, cisplatin

delayed intensification

DIC

disseminated intravascular coagulation

decilitre

DLBCL

diffuse large B-cell lymphoma

DLI

donor leucocyte/lymphocyte infusion

DMSO

dimethyl sulphoxide

DNA

deoxyribonucleic acid

DOB

date of birth

DPG

diphosphoglycerate

DRVVT

dilute Russell’s viper venom test

DTT

dilute thromboplastin time

DVT

deep vein thrombosis

DXT

radiotherapy

EACA

epsilon aminocaproic acid

EBV

Epstein-Barr virus

EBVP

etoposide bleomycin vinblastine prednisolone

ECG

electrocardiograph

ECOG

European Co-operative Oncology Group

EDTA

ethylenediamine tetraacetic acid

EFS

event-free survival

EGF

epidermal growth factor

Symbols and abbreviations

ELISA

enzyme-linked immunosorbent assay

EMU

early morning urine

Epo

erythropoietin

EPOCH

doxorubicin/epirubicin, vincristine, etoposide over 96h

IVI with bolus cyclophosphamide and oral prednisolone

EPS

electrophoresis

ESHAP

etoposide, methylprednisolone, cytarabine, platinum

ESR

erythrocyte sedimentation rate

essential thrombocythaemia or exchange transfusion

FAB

French-American-British

FACS

fluorescence-activated cell sorter

FBC

full blood count (complete blood count, CBC)

FCM

fludarabine, cyclophosphamide, melphalan

FDP

fibrin degradation products

FDG-PET

218 fluoro-D-2-deoxyglucose positron emission

tomography

iron

FEIBA

factor eight inhibitor bypassing activity

FEL

familial erythrophagocytic lymphohistiocytosis

FeSO₄

ferrous sulphate

FFP

fresh frozen plasma

FFS

failure-free survival

family history

FISH

fluorescence in situ hybridisation

FITC

fluorescein isothiocyanate

FIX

factor IX

femtolitre

follicular lymphoma

FNA

fine needle aspirate

FOB

faecal occult blood

α-FP

alpha-fetoprotein

FVIII

factor VIII

FVL

factor V Leiden

gram

G6PD

glucose-6-phosphate dehydrogenase

general anaesthetic

G-CSF

granulocyte colony stimulating factor

GIT

gastrointestinal tract

GM-CSF

granulocyte macrophage colony stimulating factor

glycoprotein

GPI

glycosylphosphatidylinositol

G&S

group, screen and save

GvHD

graft versus host disease

GvL

graft versus leukaemia

hour

HAV

hepatitis A virus

haemoglobin

HbA

haemoglobin A

HbA₂

haemoglobin A₂

HbF

haemoglobin F (fetal Hb)

HbH

haemoglobin H

HBsAg

hepatitis B surface antigen

HBV

hepatitis B virus

HCII

heparin cofactor II

HCD

heavy chain disease

HCG

human chorionic gonadotrophin

HCL

hairy cell leukaemia

HCO_3-

bicarbonate

Hct

haematocrit

HCV

hepatitis C virus

HDM

high dose melphalan

HDN

haemolytic disease of the newborn

HDT

high dose therapy

hereditary elliptocytosis

HELLP

haemolysis, elevated liver enzymes and low platelets

HES

hypereosinophilic syndrome

HHT

hereditary haemorrhagic telangiectasia

HIT(T)

heparin-induced thrombocytopenia (with thrombosis)

HIV

human immunodeficiency virus

Hodgkin’s lymphoma (Hodgkin’s disease)

HLA

human leucocyte antigen

HLH

haemophagocytic lymphohistiocytosis

H/LMW

high/low molecular weight

HMP

hexose monophosphate shunt

HMWK

high molecular weight kininogen

HPA

human platelet antigen

HPFH

hereditary persistence of fetal haemoglobin

HPLC

high performance liquid chromatography

HPP

hereditary pyropoikilocytosis

Symbols and abbreviations

HRT

hormone replacement therapy

hereditary spherocytosis

HTLV-1

human T-lymphotropic virus type 1

HUS

haemolytic uraemic syndrome

IAGT

indirect antiglobulin test

IAHS

Infection-associated haemophagocytic syndrome

ICE

ifosfamide, carboplatin, etoposide

ICH

intracranial haemorrhage

IDA

iron deficiency anaemia

involved field [radiotherapy]

IFA

intrinsic factor antibody

IFN-

interferon alpha

immunoglobulin

IgA

immunoglobulin A

IgD

immunoglobulin D

IgE

immunoglobulin E

IgG

immunoglobulin G

IgM

immunoglobulin M

IL-1

interleukin-1

intramuscular

IMF

idiopathic myelofibrosis

INR

International normalised ratio

inv

chromosomal inversion

IPI

International Prognostic Index

IPSS

International Prognostic Scoring System

intrathecal

ITP

idiopathic thrombocytopenic purpura

ITU

Intensive Therapy Unit

iu/IU

international units

IUT

intrauterine transfusion

intravenous

IVI

intravenous infusion

IVIg

intravenous immunoglobulin

JCMML

juvenile chronic myelomonocytic leukaemia

JML

juvenile myelomonocytic leukaemia

JVP

jugular venous pressure

kilogram

litre

lupus anticoagulant

LAP

leucocyte alkaline phosphatase (score)

light chain

LCH

Langerhans cell histiocytosis

LDH

lactate dehydrogenase

LFTs

liver function tests

LFS

leukaemia free survival

LGL

large granular lymphocyte

LLN

lower limit of normal

LMWH

low molecular weight heparin

lymph node(s)

lumbar puncture

LPD

lymphoproliferative disorder

LSCS

lower segment Caesarian section

M&P

melphalan and prednisolone

MACOP-B

methotrexate, doxorubicin, cyclophosphamide, vincristine,

bleomycin, prednisolone

MAHA

microangiopathic haemolytic anaemia

MALT

mucosa-associated lymphoid tissue

m-BACOD

methotrexate, bleomycin, adriamycin (doxorubicin),

cyclophosphamide, vincristine, dexamethasone

mast cell(s)

MCH

mean cell haemoglobin

MCHC

mean corpuscular haemoglobin concentration

MCL

mantle cell lymphoma

MCP

mitoxantrone, chlorambucil, prednisolone

MCR

major cytogenetic response

M-CSF

macrophage colony stimulating factor

MCV

mean cell volume

MDS

myelodysplastic syndrome

MetHb

methaemoglobin

myelofibrosis

milligram

MGUS

monoclonal gammopathy of undetermined significance

MHC

major histocompatibility complex

myocardial infarction

min(s)

minute(s)

multiple myeloma

MMC

mitomycin C

MNC

mononuclear cell(s)

month(s)

MoAb

monoclonal antibody

Symbols and abbreviations

MPD

myeloproliferative disease

MPO

myeloperoxidase

MPS

mononuclear phagocytic system

MPV

mean platelet volume

MRD

minimal residual disease

MRI

magnetic resonance imaging

mRNA

messenger ribonucleic acid

MRSA

methicillin-resistant Staphylococcus aureus

MSBOS

maximum surgical blood ordering schedule

Mst II

a restriction enzyme

MSU

midstream urine

mass: thoracic

MTX

methotrexate

MUD

matched unrelated donor (transplant)

Na⁺

sodium

NADP

nicotinamide adenine diphosphate

NADPH

nicotinamide adenine diphosphate (reduced)

NAIT

neonatal alloimmune thrombocytopenia

NAP

neutrophil alkaline phosphatase

NBT

nitro blue tetrazolium

NEJM

New England Journal of Medicine

NHL

non-Hodgkin’s lymphoma

NRBC

nucleated red blood cells

non-secretory [myeloma]

NSAIDs

non-steroidal antiinflammatory drugs

NSE

non-specific esterase

OCP

oral contraceptive pill

omni die (once daily)

OPG

orthopantomogram

overall response

overall survival

pernicious anaemia

PAI

plasminogen activator inhibitor

PaO₂

partial pressure of O₂ in arterial blood

PAS

periodic acid-Schiff

peripheral blood

PBSC

peripheral blood stem cell

protein C

PCC

prothrombin complex concentrate

PCH

paroxysmal cold haemoglobinuria

PCL

plasma cell leukaemia

PCP

Pneumocystis carinii pneumonia

PCR

polymerase chain reaction

PCV

packed cell volume

PDGF

platelet-derived growth factor

PDW

platelet distribution width

pulmonary embolism

PEP

post-expoure prophylaxis

PET

pre-eclamptic toxaemia or position emission tomography

platelet factor

PFA

platelet function analysis

PFK

phosphofructokinase

PFS

progression-free survival

PGD2

prostaglandin D2

PGE1

prostaglandin E1

PGK

phosphoglycerate kinase

Philadelphia chromosome

PIG

phosphatidylinositol glycoproteins

PIVKA

protein induced by vitamin K absence

pyruvate kinase

PLL

prolymphocytic leukaemia

PML

promyelocytic leukaemia

PNET

primitive neuroectodermal tumour

PNH

paroxysmal nocturnal haemoglobinuria

per os (by mouth)

PPH

post-partum haomorrhage

PPI

proton pump inhibitor

PPP

primary proliferative polycythaemia

PRCA

pure red cell aplasia

PRN

as required

ProMACE

prednisolone, doxorubicin, cyclophosphamide, etoposide

PRV

polycythaemia rubra vera

protein S

PSA

prostate-specific antigen

prothrombin time

PTP

post-transfusion purpura

PUVA

phototherapy with psoralen plus UV-A

PVO

pyrexia of unknown origin

polycythaemia vera

QoL

quality of life

GM-CSF

granulocyte macrophage colony stimulating factor

glycoprotein

GPI

glycosylphosphatidylinositol

G&S

group, screen and save

GvHD

graft versus host disease

GvL

graft versus leukaemia

hour

HAV

hepatitis A virus

haemoglobin

HbA

haemoglobin A

HbA₂

haemoglobin A₂

HbF

haemoglobin F (fetal Hb)

HbH

haemoglobin H

HBsAg

hepatitis B surface antigen

HBV

hepatitis B virus

HCII

heparin cofactor II

HCD

heavy chain disease

HCG

human chorionic gonadotrophin

HCL

hairy cell leukaemia

HCO_3-

bicarbonate

Hct

haematocrit

HCV

hepatitis C virus

HDM

high dose melphalan

HDN

haemolytic disease of the newborn

HDT

high dose therapy

hereditary elliptocytosis

HELLP

haemolysis, elevated liver enzymes and low platelets

HES

hypereosinophilic syndrome

HHT

hereditary haemorrhagic telangiectasia

HIT(T)

heparin-induced thrombocytopenia (with thrombosis)

HIV

human immunodeficiency virus

Hodgkin’s lymphoma (Hodgkin’s disease)

HLA

human leucocyte antigen

HLH

haemophagocytic lymphohistiocytosis

H/LMW

high/low molecular weight

HMP

hexose monophosphate shunt

HMWK

high molecular weight kininogen

HPA

human platelet antigen

HPFH

hereditary persistence of fetal haemoglobin

HPLC

high performance liquid chromatography

HPP

hereditary pyropoikilocytosis

standard deviation

secondary erythrocytosis

SEP

extramedullary plasmacytoma

SLE

systemic lupus erythematosus

SLL

small lymphocytic lymphoma

SLVL

splenic lymphoma with villous lymphocytes

systemic mastocytosis

SmIg

surface membrane immunoglobulin

SOB

short of breath

SPB

solitary plasmacytoma of bone

SPD

storage pool deficiency

stat

statim (immediate; as initial dose)

sTfR

soluble transferrin receptor

SVC

superior vena cava

SVCO

superior vena caval obstruction

T° (4T°)

temperature (fever)

1/2

half-life

thyroxine

TAM

transient abnormal myelopoiesis

TAR

thrombocytopenia with absent radius

tuberculosis

TBI

total body irradiation

TCR

T-cell receptor

tds

ter die sumendum (to be taken 3 times a day)

TdT

terminal deoxynucleotidyl transferase

TEC

transient erythroblastopenia of childhood

TENS

transcutaneous nerve stimulation

tissue factor

TFT

thyroid function test(s)

TGF-b

transforming growth factor-b

TIAs

transient ischaemic attacks

TIBC

total iron binding capacity

tiw

three times in a week

TNF

tumour necrosis factor

topo II

topoisomerase II

TORCH

toxoplasmosis, rubella, cytomegalovirus, herpes simplex

TPA

tissue plasminogen activator

TPI

triphosphate isomerase

TPN

total parenteral nutrition

TPO

thrombopoietin

TPR

temperature, pulse, respiration

Symbols and abbreviations

TRAP

tartrate-resistant acid phosphatase

TRM

treatment related mortality

TSH

thyroid-stimulating hormone

thrombin time

TTP

thrombotic thrombocytopenic purpura

TXA

tranexamic acid

TXA2

thromboxane A2

U&E

urea and electrolytes

u/U

units

ulcerative colitis

UFH

unfractionated heparin

URTI

upper respiratory tract infection

USS

ultrasound scan

UTI

urinary tract infection

VAD

vincristine adriamycin dexamethasone regimen

VBAP

vincristine, carmustine (BCNU), doxorubicin

(adriamycin), prednisolone

VBMCP

vincristine, carmustine, melphalan, cyclophosphamide,

prednisolone

VIII:C

Factor VIII clotting activity

VDRL

screening test for syphilis (Venereal Disease Research

Laboratory)

ventricular fibrillation

Vit K

vitamin K

VMCP

vincristine, melphalan, cyclophosphamide, prednisolone

VOD

veno-occlusive disease

VTE

venous thromboembolism

vWD

von Willebrand’s disease

vWF

von Willebrand factor

vWFAg

von Willebrand factor antigen

WBC

white blood count or white blood cell

WCC

White cell count

Waldenström’s macroglobulinaemia

XDPs

cross-linked fibrin degradation products

X match

cross-match

µg

microgram

Foreword to the first edition by David Weatherall

Preface to the second edition

vii

Preface to the first edition

vii

Acknowledgements

viii

Symbols and abbreviations

Clinical approach

Red cell disorders

White blood cell abnormalities

133

Leukaemia

149

Lymphoma

193

Myelodysplasia

217

Myeloproliferative disorders

237

Paraproteinaemias

265

Transplantation

293

Haemostasis and thrombosis

343

Immunodeficiency

407

Paediatric haematology

421

Haematological emergencies

499

Supportive care

535

Protocols and procedures

543

Haematological investigations

631

Blood transfusion

643

Phone numbers and addresses

663

Haematology on-line

671

Charts and nomograms

677

Normal ranges

687

Index

693

History taking in patients with

haematological disease

Approach to patient with suspected haematological disease

An accurate history combined with a careful physical examination are fun-

damental parts of clinical assessment. Although the likely haematological

diagnosis may be apparent from tests carried out before the patient has

been referred, it is nevertheless essential to assess the clinical background

fully—this may influence the eventual plan of management, especially in

older patients.

It is important to find out early on in the consultation what the patient

may already have been told prior to referral, or what he/she thinks the

diagnosis may be. There is often fear and anxiety about diagnoses such as

leukaemia, haemophilia or HIV infection.

Presenting symptoms and their duration

A full medical history needs to be taken to which is added direct ques-

tioning on relevant features associated with presenting symptoms:

Non-specific symptoms such as fatigue, fevers, weight loss.

Symptoms relating to anaemia e.g. reduced exercise capacity, recent

onset of breathlessness and nature of its onset, or worsening of angina,

presence of ankle oedema.

Symptoms relating to neutropenia e.g. recurrent oral ulceration, skin

infections, oral sepsis.

Evidence of compromised immunity e.g. recurrent oropharyngeal infec-

tion.

Details of potential haemostatic problems e.g. easy bruising, bleeding

episodes, rashes.

Anatomical symptoms, e.g. abdominal discomfort (splenic enlargement

or pressure from enlarged lymph nodes), CNS symptoms (from spinal

compression).

Past medical history, i.e. detail on past illnesses, information on pre-

vious surgical procedures which may suggest previous haematological

problems (e.g. may suggest an underlying bleeding diathesis) or be

associated with haematological or other sequelae e.g. splenectomy.

Drug history: ask about prescribed and non-prescribed medications.

Allergies: since some haematological disorders may relate to chemicals

or other environmental hazards specific questions should be asked

about occupational factors and hobbies.

Transfusion history: ask about whether the patient has been a blood

donor and how much he/she has donated. May occasionally be a factor

in iron deficiency anaemia. History of previous transfusion(s) and their

timing is also critical in some cases e.g. post-transfusion purpura.

Tobacco and alcohol consumption is essential; both may produce sig-

nificant haematological morbidity.

Travel: clearly important in the case of suspected malaria but also rele-

vant in considering other causes of haematological abnormality,

including HIV infection.

Physical examination

This forms part of the clinical assessment of the haematology patient. Pay

specific attention to:

General examination —e.g. evidence of weight loss, pyrexia, pallor (not

a reliable clinical measure of anaemia), jaundice, cyanosis or abnormal

pigmentation or skin rashes.

The mouth —ulceration, purpura, gum bleeding or infiltration, and the

state of the patient’s teeth. Hands and nails may show features

associated with haematological abnormalities e.g. koilonychia in chronic

iron deficiency (rarely seen today).

Record —weight, height, T°, pulse and blood pressure; height and

weight give important baseline data against which sequential

measurements can subsequently be compared. In myelofibrosis, for

example, evidence of significant weight loss in the absence of symptoms

may be an indication of clinical progression.

Examination —of chest and abdomen should focus on detecting the

presence of lymphadenopathy, hepatic and/or splenic enlargement.

Node sizes and the extent of organ enlargement should be carefully

recorded.

Lymph node enlargement —often recorded in centimetres e.g. 3cm ¥

3cm ¥ 4cm; sometimes more helpful to compare the degree of

enlargement with familiar objects e.g. pea. Record extent of liver or

spleen enlargement as maximum distance palpable from the lower

costal margin.

Erythematous margins of infected skin lesions —mark these to monitor

treatment effects.

Bones and joints —recording of joint swelling and ranges of movement

are standard aspects of haemophilia care. In myeloma, areas of bony

tenderness and deformity are commonly present.

Optic fundi —examination is a key clinical assessment in the

haematology patient. May yield the only objective evidence of

hyperviscosity in paraproteinaemias

(

Emergencies p510) or

hyperleucocytosis ( Emergencies p510) such as in e.g. CML. Regular

examination for haemorrhages should form part of routine

observations in the severely myelosuppressed patient; rarely changes of

opportunistic infection such as candidiasis can be seen in the optic

fundi.

Neurological examination —fluctuations of conscious level and

confusion are clinical presentations of hyperviscosity. Isolated nerve

palsies in a patient with acute leukaemia are highly suspicious of

neurological involvement or disease relapse. Peripheral neuropathy and

long tract signs are well recognised complications of B₁₂ deficiency.

Splenomegaly

Many causes. Clinical approach depends on whether splenic enlargement

is present as an isolated finding or with other clinical abnormalities e.g.

jaundice or lymphadenopathy. Mild to moderate splenomegaly have a

much greater number of causes than massive splenomegaly.

Causes of splenomegaly

Infection

Viral

EBV, CMV, hepatitis

Bacterial

SBE, miliary tuberculosis, Salmonella, Brucella

Protozoal

Malaria, toxoplasmosis, leishmaniasis

Haemolytic

Congenital

Hereditary spherocytosis,

hereditary elliptocytosis

Sickle cell disease (infants), thalassaemia

Pyruvate kinase deficiency, G6PD deficiency

Acquired

AIHA (idiopathic or 2°)

Myeloproliferative

Myelofibrosis, CML, polycythaemia rubra vera

& leukaemic

Essential thrombocythaemia, acute leukaemias

Lymphoproliferative

CLL, hairy cell leukaemia, Waldenström’s,

SLVL, other NHL, Hodgkin’s disease,

ALL & lymphoblastic NHL

Autoimmune disorders &

Rheumatoid arthritis, SLE, hepatic cirrhosis

Storage disorders

Gaucher’s disease, histiocytosis X

Niemann-Pick disease

Miscellaneous

Metastatic cancer, cysts, amyloid,

portal hypertension, portal vein thrombosis,

tropical splenomegaly

Clinical approach essentially involves a working knowledge of the possible

causes of splenic enlargement and determining the more likely causes in

the given clinical circumstances by appropriate further investigation. There

are fewer causes of massive splenic enlargement, i.e. the spleen tip pal-

pable below the level of the umbilicus.

Massive splenomegaly

2 Myelofibrosis.

2 Chronic myeloid leukaemia.

2 Lymphoproliferative disease—CLL and variants including SLVL, HCL

and marginal zone lymphoma.

2 Tropical splenomegaly.

2 Leishmaniasis.

2 Gaucher’s disease.

2 Thalassaemia major.

Lymphadenopathy

Occurs in a range of infective or neoplastic conditions; less frequently

enlargement occurs in active collagen disorders. May be isolated, affecting

a single node, localised, involving several nodes in an anatomical lymph

node grouping, or generalised, where nodes are enlarged at different sites.

As well as enlargement in the easily palpable areas (cervical, axillary and

iliac) node enlargement may be hilar or retroperitoneal and identifiable

only by imaging. Isolated/localised lymphadenopathy usually results from

local infection or neoplasm. Generalised lymphadenopathy may result

from systemic causes, especially when symmetrical, as well as infection or

neoplasm. Rarely drug-associated (e.g. phenytoin).

Causes of lymphadenopathy

Infective

Bacterial

Tonsillitis, cellulitis, tuberculous infections & primary

syphilis usually produce isolated or localised node

enlargement

Viral

EBV, CMV, rubella, HIV, HBV, HCV

Other

Toxoplasma, histoplasmosis, chlamydia, cat-scratch

Neoplastic

Hodgkin’s disease (typically isolated or localised

lymphadenopathy), NHL isolated, generalised or

localised, CLL, metastatic carcinoma, acute

leukaemia (ALL especially, but occasionally AML)

Collagen and other

E.g. rheumatoid arthritis, SLE, sarcoidosis

systemic disorders

History and examination —points to elicit

2 Age.

2 Onset of symptoms, whether progressing or not.

2 Systemic symptoms, weight loss (>10% body weight loss in <6 months).

2 Night sweats.

2 Risk factors for HIV infection.

2 Local or systemic evidence of infection.

2 Evidence of systemic disorder such as rheumatoid arthritis.

2 Evidence of malignancy; if splenic enlargement present then lym-

phoreticular neoplasm is more likely.

2 Specific disease-related features e.g. pruritus and alcohol induced

lymph node pain associated with Hodgkin’s disease.

2 Determine the duration of enlargement ± associated symptoms,

whether nodes are continuing to enlarge and whether tender or not.

Distribution of node enlargement should be recorded as well as size of

node.

Investigations

1. FBC and peripheral blood film examination.

2. ESR or plasma viscosity.

3. Screening test for infectious mononucleosis and serological testing for

other viruses.

Unexplained anaemia

Evaluate with the combined information from clinical history, physical

examination and results of investigations.

History —focus on

2 Duration of symptoms of anaemia —short duration of dyspnoea and

fatigue etc. suggests recent bleeding or haemolysis.

2 Specific questioning on blood loss—include system-related questions

e.g. GIT and gynaecological sources, ask about blood donation.

2 Family history —e .g . in relation to hereditary problems such as HS or

ethnic Hb disorders such as thalassaemia or HbSS.

2 Past history —e . g. association of gastrectomy with later occurrence of

Fe and/or B₁₂ deficiency.

2 Drug history —including prescribed and non-prescribed medication.

2 Dietary factors —mainly relates to folate and Fe deficiency, rarely B₁₂

in vegans. Fe deficiency always occurs because Fe losses exceed intake

(it is extremely rare in developed countries for diet to be the sole

cause of Fe deficiency).

Examination

2 May identify indirectly helpful signs e.g. koilonychia in chronic Fe defi-

ciency (rare), jaundice in haemolytic disorders.

2 Lymphadenopathy suggesting lymphoreticular disease or viral infection.

2 Hepatosplenomegaly in lymphoproliferative or myeloproliferative disorders.

Full blood count

Laboratory investigation of anaemia is discussed fully in section 2. Anaemia

in adult 9 if Hb <13.0g/dL and in adult 3 if Hb <11.5g/dL.

MCV useful for initial anaemia evaluation

5 MCV (<76fL)

Fe deficiency

a & b thalassaemia, HbE, HbC

Anaemia of chronic disorders

Normal MCV (78-98fL) Recent bleeding

Anaemia of chronic disorders

Most non-haematinic deficiency causes

Combined Fe + B₁₂/folate deficiency

4 MCV (>100fL)

Folate or B₁₂ deficiency

Haemolytic anaemia

Liver disease

Marrow dysplasia & failure syndromes including

aplastic anaemia

2° to antimetabolite drug therapy e.g. hydroxyurea

The need for film examination, reticulocyte counting and additional tests

on the FBC sample such as checking for Heinz bodies is based on the

initial clinical and FBC findings. The findings from the initial FBC examina-

Patient with elevated haemoglobin

Finding a raised Hb concentration requires a systematic clinical approach

for differential diagnosis and further investigation. Initially it is essential to

check whether the result ties in with the known clinical findings —if unex-

pected the FBC should be re-checked to exclude a mix-up over samples

or a sampling artefact. Dehydration and diuretic therapy may 4 the Hct

and these should be excluded in the initial phase of assessment.

Having determined that the 4 Hb concentration is genuine the issue is

whether there is a genuine increase in red cell mass or not, and the expla-

nation for the elevated Hb.

Anoxia is a major stimulus to RBC production and will result in an

increase in erythropoietin with consequent erythrocytosis.

History and examination should assess

2 Recent travel and residence at high altitude (>3000m).

2 COAD, other hypoxic respiratory conditions, cyanotic congenital heart

disease, other cardiac problems causing hypoxia.

2 Smoking —heavy cigarette smoking causes 4 carboxyHb levels leading

to 4 RBC mass to compensate for loss of O₂ carrying capacity.

2 Ventilatory impairment 2° to gross obesity, alveolar hypoventilation

(Pickwickian syndrome).

2 Possibility of high-affinity Hb abnormalities arises if there is a FH of

polycythaemia, otherwise requires assessment through Hb analysis.

2 If obvious secondary causes excluded possibilities include:

Spurious polycythaemia —pseudopolycythaemia or Gaisbock’s syndrome,

associated features can include cigarette smoking, obesity, hypertension

and excess alcohol consumption; sometimes described as

‘stress

polycythaemia’.

Primary proliferative polycythaemia

(polycythaemia rubra vera) —

plethoric facies, history of pruritus after bathing or on change of

environmental temperature and presence of splenomegaly are helpful

clinical findings to suggest this diagnosis.

Inappropriate erythropoietin excess —occurs in a variety of benign and

malignant renal disorders. Rare complication of some tumours including

hepatoma, uterine fibroids and cerebellar haemangioblastoma.

Part of clinical assessment must also include an evaluation of thrombotic

risk; previous thrombosis or a family history of such problems increase the

urgency of investigation and appropriate treatment

p240-249.

Elevated WBC

Leucocytosis is defined as elevation of the white cell count >2 SD above

the mean. The detection of leucocytosis should prompt immediate

scrutiny of the automated WBC differential (generally accurate except in

leukaemia) and the other FBC parameters. Blood film should be examined

and a manual differential count performed. Important to evaluate leucocy-

tosis in terms of the age-related absolute normal ranges for neutrophils,

lymphocytes, monocytes, eosinophils and basophils (

p688, 690) and

the presence of abnormal cells: immature granulocytes, blasts, nucleated

red cells and ‘atypical cells’.

Leukaemoid reaction —leucocytosis >50

¥ 10⁹/L defines a neutrophilia

with marked ‘left shift’ (band forms, metamyelocytes, myelocytes and

occasionally promyelocytes and myeloblasts in the blood film).

Differential diagnosis is chronic granulocytic leukaemia (CGL) and in

children, juvenile CML. Primitive granulocyte precursors are also

frequently seen in the blood film of the infected or stressed neonate,

and any seriously ill patient e.g. on ITU.

Leucoerythroblastic blood film —contains myelocytes, other primitive

granulocytes, nucleated red cells and often tear drop red cells, is due to

bone marrow invasion by tumour, fibrosis or granuloma formation and

is an indication for a bone marrow biopsy. Other causes include

anorexia and haemolysis.

Leucocytosis due to blasts —suggests diagnosis of acute leukaemia and is

an indication for cell typing studies and bone marrow examination.

FBC, blood film, white cell differential count and the clinical context in

which the leucocytosis is detected will usually indicate whether this is due

to a 1° haematological abnormality or reflects a 2° response.

It is clearly important to seek a history of symptoms of infection and

examine the patient for signs of infection or an underlying haematological

disorder.

Neutrophilia

2 2° to acute infection is most common cause of leucocytosis.

2 Usually modest (uncommonly >30

¥ 10⁹/L), associated with a left shift

and occasionally toxic granulation or vacuolation of neutrophils.

2 Chronic inflammation causes less marked neutrophilia often associated

with monocytosis.

2 Moderate neutrophilia may occur following steroid therapy, heatstroke

and in patients with solid tumours.

2 Mild neutrophilia may be induced by stress (e.g. immediate postopera-

tive period) and exercise.

2 May be seen in the immediate aftermath of a myocardial infarction or

major seizure.

2 Frequently found in states of chronic bone marrow stimulation (e.g.

chronic haemolysis, ITP) and asplenia.

2 Primary haematological causes of neutrophilia are less common. CML

is often the cause of extremely high leucocyte counts (>200

¥ 10⁹/L),

predominantly neutrophils with marked left shift, basophilia and occa-

Clinical approach

sional myeloblasts. A low LAP score and the presence of the Ph chro-

mosome on karyotype analysis are usually helpful to differentiate CGL

from a leukaemoid reaction.

2 Less common are juvenile CML, transient leukaemoid reaction in

Down syndrome, hereditary neutrophilia and chronic idiopathic neu-

trophilia.

Bone marrow examination is rarely necessary in the investigation of a

patient with isolated neutrophilia. Investigation of a leukaemoid reaction,

leucoerythroblastic blood film and possible CGL or juvenile CML are firm

indications for a bone marrow aspirate and trephine biopsy. Bone marrow

culture, including culture for atypical mycobacteria and fungi, may be

useful in patients with persistent pyrexia or leucocytosis.

Lymphocytosis

2 Lymphocytosis >4.0

¥ 10⁹/L.

2 Normal infants and young children <5 have a higher proportion and

concentration of lymphocytes than adults.

2 Rare in acute bacterial infection except in pertussis (may be >50

10⁹/L).

2 Acute infectious lymphocytosis also seen in children, usually associated

with transient lymphocytosis and a mild constitutional reaction.

2 Characteristic of infectious mononucleosis but these lymphocytes are

often large and atypical and the diagnosis may be confirmed with a het-

erophil agglutination test.

2 Similar atypical cells may be seen in patients with CMV and hepatitis A

infection.

2 Chronic infection with brucellosis, tuberculosis, secondary syphilis and

congenital syphilis may cause lymphocytosis.

2 Lymphocytosis is characteristic of CLL, ALL and occasionally NHL.

Where primary haematological cause suspected, immunophenotypic

analysis of the peripheral blood lymphocytes will often confirm or exclude

a neoplastic diagnosis. BM examination is indicated if neoplasia is strongly

suspected and in any patient with concomitant neutropenia, anaemia or

thrombocytopenia.

Reduced WBC

Although not entirely synonymous, it is uncommon for absolute leu-

copenia (WBC <4.0

¥ 10⁹/L) to be due to isolated deficiency of any cell

other than the neutrophil though in marked leucopenia several cell lines

are often affected.

Neutropenia

Defined as a neutrophil count <2.0

¥ 10⁹/L. The risk of infective complica-

tions is closely related to the absolute neutrophil count. More severe

when neutropenia is due to impaired production from chemotherapy or

marrow failure rather than to peripheral destruction or maturation arrest

where there is often a cellular marrow with early neutrophil precursors

and normal monocyte counts. Type of infection determined by the degree

and duration of neutropenia. Ongoing chemotherapy further increases the

risk of serious bacterial and fungal opportunistic infection and the pres-

ence of an indwelling intravenous catheter increases the incidence of

infection with coagulase-negative staphylococci and other skin commen-

sals. Patients with chronic immune neutropenia may develop recurrent

stomatitis, gingivitis, oral ulceration, sinusitis and peri-anal infection.

Neutrophil count

Risk of infection

1.0-1.5

¥ 10⁹/L

No significant increased risk of infection.

0.5-1.0

¥ 10⁹/L

Some increase in risk; some fevers can be treated as

an outpatient.

<0.5

¥ 10⁹/L

Major increase in risk; treat all fevers with broad

spectrum IV antibiotics as an inpatient.

The history and physical examination provide a guide to the subsequent

management of a patient with neutropenia. Simple observation is appro-

priate initially for an asymptomatic patient with isolated mild neutropenia

who has an unremarkable history and examination. If there has been a

recent viral illness or the patient can discontinue a drug which may be the

cause, follow-up over a few weeks may see resolution of the abnormality.

Investigations

BM examination —if there is concomitant anaemia or thrombocytopenia,

if there is a history of significant infection or if lymphadenopathy or

organomegaly are detected on examination. Usually unhelpful in patients

with an isolated neutropenia >0.5

¥ 10⁹/L. However, if neutropenia per-

sists, bone marrow aspiration, biopsy, cytogenetics and serology for col-

lagen diseases, anti-neutrophil antibodies, HIV and immunoglobulins

should be performed.

Differential diagnoses

Isolated neutropenia may be the presenting feature of myelodysplasia,

aplastic anaemia, Fanconi’s anaemia or acute leukaemia but these

Clinical approach

conditions will usually be associated with other haematological

abnormalities.

Post-infectious

(most usually post-viral) neutropenia may last several

weeks and may be followed by prolonged immune neutropenia.

Severe sepsis particularly at the extremes of life.

Drugs —cytotoxic agents, and many others, notably phenothiazines,

many antibiotics, NSAIDs, anti-thyroid agents and psychotropic agents.

Recovery of neutrophils usually starts within a few days of stopping the

offending drug.

Autoimmune neutropenia due to anti-neutrophil antibodies may occur

in isolation or in association with haemolytic anaemia, immune

thrombocytopenia or SLE.

Felty's syndrome neutropenia is accompanied by seropositive

rheumatoid arthritis, and splenomegaly.

Chronic benign neutropenia of infancy and childhood is associated with

fever and infection but resolves by age 4, probably also has an immune

basis.

Benign familial neutropenia is a feature of rare families and of certain

racial groups, notably negroes, is associated with mild neutropenia but

no propensity to infection.

Chronic idiopathic neutropenia is a diagnosis of exclusion, associated

with severe neutropenia but often a benign course.

Cyclical neutropenia is a condition of childhood onset and dominant

inheritance characterised by severe neutropenia, fever, stomatitis and

other infections occurring with a periodicity of ~4 weeks.

Hereditary causes

(less common) include Kostmann syndrome (

p459), Shwachman-Diamond-Oski syndrome (

p459), Chediak-

Higashi syndrome (

p465), reticular dysgenesis and dyskeratosis

congenita.

Management

Febrile episodes should be managed according to the severity of the neu-

tropenia (see table) and the underlying cause (bone marrow failure is

associated with more life-threatening infections). Broad spectrum IV

antibiotics may be required and empirical systemic antifungal therapy may

be required in those who fail to respond to antibiotics. Prophylactic antibi-

otic and antifungal therapy may be helpful in some patients with chronic

neutropenia as may G-CSF. Antiseptic mouthwash is of value and regular

dental care is important.

Lymphopenia

Lymphopenia (<1.5

¥ 10⁹/L) may be seen in acute infections, cardiac

failure, pancreatitis, tuberculosis, uraemia, lymphoma, carcinoma, SLE and

Elevated platelet count

Thrombocytosis is defined as a platelet count >450

¥ 10⁹/L. May be due

to a primary myeloproliferative disorder (MPD) or a secondary reactive

feature. If the platelet count is markedly elevated a patient with a myelo-

proliferative disorder has a risk of haemorrhage (due to the production of

dysfunctional platelets), or thrombosis, or both. The patient’s history may

reveal features of the condition to which the elevated platelet count is

secondary. Clinical examination may provide similar clues or reveal the

presence of palpable splenomegaly which suggests a myeloproliferative

disorder. FBC may provide useful information: marked leucocytosis with

left shift (in the absence of a history of infection), basophilia or an elevated

haematocrit and red cell count are highly suggestive of a myeloprolifera-

tive disorder when associated with thrombocytosis. Unusual for reactive

thrombocytosis to cause a platelet count >1000

¥ 10⁹/L. Note: platelet

counts below this may occur in myeloproliferative disorders.

Differential diagnosis

Myeloproliferative disorders

Disorders associated with 4 platelets

Primary thrombocythaemia

Haemorrhage

Polycythaemia rubra vera

Trauma

Chronic granulocytic leukaemia

Surgery

Idiopathic myelofibrosis

Iron deficiency anaemia

Malignancy (ca lung, ca breast,

Hodgkin’s disease)

Acute & chronic infection

Inflammatory disease e.g. rheumatoid

arthritis, UC

Post-splenectomy

Investigation

2 BM aspirate may show megakaryocyte abnormalities in MPD.

2 BM trephine biopsy may show clusters of abnormal megakaryocytes

and increased reticulin or fibrosis in MPD.

Management

2 In reactive thrombocytosis treat the underlying condition.

2 Unusual for treatment to 5 the platelet count to be necessary in a

patient with reactive thrombocytosis.

2 Consider low dose aspirin (or if contraindicated, dipyridamole).

2 Reactive thrombocytosis is generally transient.

2 If secondary to iron deficiency —review FBC after iron therapy: the

platelet count normalises if thrombocytosis was due to iron deficiency.

2 Iron deficiency may have masked PRV—this will be revealed by iron

therapy.

2 If impossible to define the cause of thrombocytosis then a watch-and-

wait policy should be followed in an asymptomatic patient.

2 If MPD is suspected — Essential thrombocythaemia, p250.

Reduced platelet count

Thrombocytopenia is defined as platelet count <150

¥ 10⁹/L. Although

there is no precise platelet count at which a patient will or will not bleed,

most patients with a count >50

¥ 10⁹/L are asymptomatic. The risk of

spontaneous haemorrhage increases significantly <20

¥ 10⁹/L. Purpura is

the most common presenting symptom and is usually found on the lower

limbs and areas subject to pressure. May be followed by bleeding gums,

epistaxis or more serious life-threatening haemorrhage. A patient with

newly diagnosed severe thrombocytopenia with or without purpura is a

medical emergency and should be admitted for further investigation and

treatment.

Confirm low platelet count by examination of the blood sample for clots

and the blood film for platelet aggregates (causing pseudothrombocy-

topenia). History and examination will determine the clinical severity of

the thrombocytopenia and should also reveal the duration of symptoms,

presence of any prodromal illness, causative medication or underlying

disease.

Determine whether the cause of thrombocytopenia is failure of produc-

tion or increased consumption. FBC may be helpful as the mean platelet

volume (MPV) is often elevated in the latter group (large platelets may

also be seen on the blood film). May also reveal additional haematological

abnormalities (normocytic anaemia or neutropenia) suggestive of a bone

marrow disorder. A coagulation screen should also be performed.

Examination of the bone marrow is the definitive investigation in all

patients with moderate or severe thrombocytopenia—may reveal normal

megakaryocytes or compensatory hyperplasia in peripheral destruction

syndromes or marrow hypoplasia or infiltration. Tests for platelet anti-

bodies are unreliable but an autoimmune screen may be helpful to

exclude lupus.

Management

Treat underlying condition. Most patients with a platelet count >30

10⁹/L require no specific therapy. Avoid aspirin. In the event of life-threat-

ening haemorrhage platelet transfusion should be administered to throm-

bocytopenic patients with the exception of those with heparin-induced

thrombocytopenia and TTP.

Easy bruising

Evaluation of a patient who complains of easy bruising involves a detailed

history, physical examination with particular attention to any current

haemorrhagic lesions and the performance of basic haemostatic investiga-

tions. More common in 3 and often difficult to evaluate. Also a frequent

complaint in the elderly.

History

Careful attention to the history is essential to the diagnosis of all the

haemorrhagic disorders and one must attempt to define the nature of the

bruising in a patient with this complaint. Note: many normal healthy people

believe that they have excessive bleeding or bruising. Conversely some

people with haemorrhagic disorders and abnormal bleeding histories will

not volunteer the information unless asked directly or indeed may con-

sider their bleeding to be normal. Remember that excessive bruising may

be a manifestation of a blood vessel disorder rather than a coagulopathy

or platelet disorder.

Ask about

Presenting complaint—How long and how frequently has easy bruising

occurred? Is it ecchymoses or purpura? How extensive are bruises? Are

they located in areas subject to trauma (e.g. limbs) or pressure (e.g. waist

band)? Do petechiae occur? Are bruises painful? Is there a palpable knot

or cord? How long to resolution? How many currently?

Associated symptoms

Has there been gum bleeding? Has the patient experienced prolonged

bleeding after skin trauma, dental extraction, childbirth or surgery? Has

there been any other form of haemorrhage e.g. epistaxis, menorrhagia,

joint or soft tissue haematoma, haematemesis, melaena, haemoptysis or

haematuria? Is there a history of poor wound healing?

Family history

Has any other family member a history of excessive bleeding or bruising?

Drug history

Is the patient on any medication (remember self-medication of vitamins

and food supplements), most notably aspirin, anticoagulant therapy?

Systematic enquiry

Is there evidence of a disorder associated with a haemorrhagic tendency

e.g. hepatic or renal failure, malabsorption, leukaemia, connective tissue

disorder or amyloid?

Physical examination

Haemorrhagic skin lesions are likely to be present in a patient with a

serious problem and their distribution will often indicate the extent to

which they are likely to be related to trauma. Senile purpura is almost

invariably on the hands and forearms. True purpura is easily differentiated

from erythema and telangiectasis by pressure. Petechiae are highly sugges-

tive of a platelet or vascular disorder whilst palpable purpura is associated

with anaphylactoid purpura. In addition there may be other physical find-

ings which may indicate an underlying disorder e.g. splenomegaly or lym-

Clinical approach

phadenopathy in leukaemia, signs of hepatic failure, telangiectasia in

Osler-Rendu-Weber syndrome or hyperextensible joints and paper-thin

scars in Ehlers-Danlos syndrome.

Basic haemostatic investigations

All patients should be investigated except those in whom history and

examination has given strong grounds for believing that they are normal

and in whom there is a history of a normal response to a haemostatic

challenge e.g. surgery or dental extraction.

Screening tests

2 FBC and blood film.

2 APTT.

2 PT.

2 Thrombin clotting time and/or fibrinogen.

2 Bleeding time (a largely obsolete investigation, of dubious utility).

If these investigations are normal there is no indication for further haemo-

static investigations unless the history provides strong grounds for

believing that there is indeed a haemostatic disorder. The appropriate

further investigation of the haemostatic mechanism is discussed in Section

10.

Differential diagnoses

2 Common diagnoses

- Simple easy bruising (purpura simplex).

- Trauma (including non-accidental injury in children).

- Senile purpura.

2 Haemostatic defects

- Thrombocytopenia.

- Platelet function defects.

- Coagulation abnormalities (rarely).

2 Vascular defects

- Corticosteroid excess.

- Collagen diseases.

- Uraemia.

- Dysproteinaemias.

- Anaphylactoid purpura.

- Ehlers-Danlos syndrome.

- Scurvy.

- Vasculitis.

Recurrent thromboembolism

A hypercoagulable state should be suspected in all patients with recurrent

thromboembolic disease, family history of thrombosis, thrombosis at a

young age or at an unusual site (in addition to recurrent thromboem-

bolism) associated with inherited thrombophilia. Further important

aspects of the history are precipitating factors at the time of thrombosis

and lifestyle considerations e.g. smoking, exercise and obesity. Clin-

ical examination may reveal signs suggestive of an associated underlying

condition.

Hypercoagulable states

Inherited

Activated protein C resistance (factor V Leiden)

Protein C deficiency

Protein S deficiency

Prothrombin gene mutation

Hyperhomocysteinaemia

Sickle cell disease

Antithrombin deficiency and some very rare abnormalities

of fibrinogen, plasminogen and plasminogen activator

Acquired

Immobilisation

Oral contraceptive or oestrogen therapy

Postpartum

Old age

Postoperative

Malignancy (notably Ca pancreas)

Nephrotic syndrome

Myeloproliferative disorders

Hyperhomocysteinaemia

Antiphospholipid syndrome (lupus anticoagulant)

Hyperviscosity

Paroxysmal nocturnal haemoglobinuria

Thrombotic thrombocytopenic purpura

Heparin-induced thrombocytopenia

Laboratory Investigation

Thrombophilia p394.

Pathological fracture

Fracture in a bone compromised by the presence of a pathological

process resulting in fracture occurring following relatively minor trauma.

Most commonly due to local neoplastic involvement or osteoporosis.

Haematological causes

2 Local bony damage.

2 Myelomatous deposits.

2 Lymphoma.

2 Metastatic carcinoma (± marrow infiltration); breast, prostate and lung

are commoner primary sites.

2 Gaucher’s disease.

2 Sickle cell anaemia.

2 Homozygous thalassaemia.

2 Osteoporosis from prolonged corticosteroid therapy e.g. for autoim-

mune disease.

Clinically

Presentation as local pain, discomfort and restriction of mobility.

Diagnosis

Confirmed by x-ray or other imaging.

Management

2 Awareness of risk/possibility and early diagnosis.

2 Analgesia.

2 Orthopaedic—immobilisation and support as appropriate for nature

and site of injury, surgical intervention including pinning or other

fixation.

2 Radiotherapy—local management of fracture 2° to local malignancy.

2 Mobilisation—physiotherapy.

2 Treatment of underlying condition predisposing to fracture.

Raised ESR

The ESR remains an established, empirical test clinically useful as a method

for identifying and monitoring the acute phase response. It is influenced by

changes in fibrinogen, a-macroglobulins and immunoglobulins which

enhance red cell aggregation in vitro.

Plasma viscosity is also an effective measure of acute phase reactants

and can be used as an alternative to the ESR in clinical practice;

increases in ESR and plasma viscosity generally parallel each other.

Normal ranges

2 0-10mm/h for 9 18-65 years.

2 1-20mm/h for 3 18-65 years.

2 Upper limits of normal increase by 5-10mm/h for patients >65 years.

2 Other factors e.g. Hct influence the ESR.

2 Should be regarded as semiquantitative.

2 Marked elevations are clinically significant.

2 Modest elevations can be more problematic to interpret.

The main advantages to the ESR are its low cost and technical simplicity

allied to the absence of a more accurate, inexpensive and technically

simple alternative.

Causes of raised ESR

Pregnancy

Increases in pregnancy; maximal in 3rd trimester

Infections

Acute and chronic infections, including TB

Note: 4 ESR also occurs in HIV infection

Collagen disorders

Rheumatoid, SLE, polymyalgia rheumatica,

vasculitides etc. (including temporal arteritis); ESR

useful as non-specific monitor of disease activity

Other inflammatory Inflammatory bowel disease, sarcoidosis, post-MI

processes

Neoplastic conditions Carcinomatosis, NHL, Hodgkin’s disease and

paraproteinaemias (benign & malignant)

Investigations

Given the wide range of situations in which a raised ESR can arise, further

investigation depends on a carefully conducted history and examination. In

the absence of likely causes from these, simple initial laboratory and radi-

ology assessments to include urinalysis, full blood count and film examina-

tion, urea, electrolytes, plasma protein electrophoresis, an autoimmune

profile and CXR should represent a practical and pragmatic primary diag-

nostic screen.

p632.

Serum or urine paraprotein

Differential diagnosis

Common

2 Monoclonal gammopathy of undetermined significance (MGUS).

2 Myeloma.

2 Solitary plasmacytoma.

2 Lymphoproliferative disorders e.g. CLL, NHL, Waldenström’s.

Less common

2 Autoimmune disorders e.g. rheumatoid arthritis, SLE.

2 Polymyalgia rheumatica.

Rare

2 AL amyloid (primary amyloid).

2 Plasma cell leukaemia.

2 Heavy chain disease.

Discriminating clinical features

MGUS —no symptoms or signs, normal FBC and biochemical profile,

paraprotein level <30g/L and stable, no immuneparesis (rarely present),

BM plasma cells <10%, no lytic lesions.

Plasmacytoma —localised bone pain, low paraprotein level, isolated

bony lesion.

Myeloma —symptoms and signs of anaemia or hyperviscosity

(

p510); bone pain or tenderness, raised Ca²⁺, creatinine, urate; high b-2

microglobulin and low albumin; immuneparesis; paraprotein >30g/L of

IgG or >20g/L of IgA or heavy BenceJones proteinuria; BM >10%

plasma cells; lytic bone lesions on x-ray. Minimum diagnostic criteria

are at least 2 of emboldened items.

Plasma cell leukaemia —as myeloma but fulminant history. Plasma cells

seen on blood film.

Heavy chain disease —rare, characterised by a single heavy chain only in

serum or urine electrophoresis. Presence of any light chain excludes.

Amyloid —myriad clinical features. Diagnosis on biopsy of affected site

or, if inaccessible, by BM or rectal biopsy —characteristic fibrils stain

with Congo Red and show green birefringence in polarised light.

CLL and NHL —systemic symptoms e.g. fever, night sweats, weight loss.

Lymphadenopathy or hepatosplenomegaly likely. Confirm on BM or

node biopsy.

Waldenström’s —as for CLL but with symptoms or signs of

hyperviscosity (

p284).

Autoimmune disorders —suggested by joint pain, skin rashes,

multisystem disease. Confirm on autoimmune profile including

rheumatoid factor, ANA, ANCA.

p272.

Anaemia in pregnancy

Physiological changes in red cell and plasma volume occur during

pregnancy.

2 Red cell mass 4 by ≤30%.

2 Plasma volume 4 ≤60%.

2 Net effect to 4 blood volume by ≤50% with lowering of the normal

Hb concentration to 10.0-11.0g/dL during pregnancy. MCV increases

during pregnancy.

2 Iron deficiency is a common problem and cause of anaemia in pregnancy.

Cause of 4 requirements

Amount of additional Fe

4 Red cell mass

~500mg

Fetal requirements

~300mg

Placental requirements

~5mg

Basal losses over pregnancy (1.0-1.5mg/d)

~250mg

These result in a total requirement of ≤1000mg Fe requiring an average

daily intake of 3.5-4.0mg/d. Average Western diet provides <4.0mg Fe/d

so that balance is marginal during pregnancy. Diets with Fe mainly in non-

haem form (e.g. vegetables) provide less Fe available for absorption. Thus

a high risk of developing Fe deficiency anaemia which is exacerbated if pre-

conception Fe stores are reduced.

Folate requirements are increased during pregnancy because of

increased cellular demands; folate levels tend to drop during pregnancy.

Prophylaxis recommendation to give 40-60mg elemental Fe/d which

will increase availability of dietary absorbable Fe and protect against

chronic Fe deficiency; debated whether supplements required by all

pregnant women or only for those in at-risk socio-economic and

nutritionally deficient groups. Folate supplementation is recommended

for all and also appears to reduce incidence of neural tube defects.

2 Dilutional anaemia —Hb seldom <10.0g/dL (requires no therapy).

2 Fe deficiency —may occur with normal MCV because of 4 MCV associ-

ated with pregnancy; check serum ferritin and give Fe replacement;

assess and treat the underlying cause.

2 Blood loss —sudden 5 in Hb may signify fetomaternal bleeding or

other forms of concealed obstetric bleeding.

2 Folate deficiency —macrocytic anaemia in pregnancy almost invariably

will be due to folate deficiency (B₁₂ deficiency is extremely rare during

pregnancy).

2 Microangiopathic haemolysis/DIC may be seen in eclampsia or fol-

lowing placental abruption or intrauterine death. HELLP syndrome

(p34) is rare but serious cause of anaemia.

2 Anaemia may also arise during pregnancy from other unrelated causes

and should be investigated.

Thrombocytopenia in pregnancy

A normal uncomplicated pregnancy is associated with a platelet count in

the normal range though up to 10% of normal deliveries may be associ-

ated with mild thrombocytopenia (>100

¥ 10⁹/L). Detection of thrombo-

cytopenia in a pregnant patient requires consideration not only of the

diagnoses listed in the previous section but also the conditions associated

with pregnancy which cause thrombocytopenia. An additional important

consideration is the possible effect on the fetus and its delivery.

If thrombocytopenia is detected late in pregnancy, most women will have

a platelet count result from the booking visit (at 10-12 weeks) for com-

parison. Mild thrombocytopenia (100-150

¥ 10⁹/L) detected for the first

time during an uncomplicated pregnancy is not associated with any risk to

the fetus nor does it require special obstetric intervention other than hos-

pital delivery.

Non-immune thrombocytopenia

2 Thrombocytopenia may develop in association with pregnancy-induced

hypertension, pre-eclampsia or eclampsia. Successful treatment of

hypertension may be associated with improvement in thrombocy-

topenia which is believed to be due to consumption. Treatment of

hypertension, pre-eclampsia or eclampsia may necessitate delivery of

the fetus who is not at risk of thrombocytopenia.

l HELLP syndrome (haemolysis, elevated liver enzymes and low

platelets) may occur in pregnancy.

2 A number of obstetric complications, notably retention of a dead fetus,

abruptio placentae and amniotic fluid embolism, are associated with

DIC ( p512).

Immune thrombocytopenia may occur in pregnancy and women with

chronic ITP may become pregnant. Therapeutic considerations must

include an assessment of the risk to the fetus of transplacental passage

of antiplatelet antibody causing fetal thrombocytopenia and a risk of

haemorrhage before or during delivery. There is no reliable parameter

for the assessment of fetal risk which, although relatively low, is most

significant in women with pre-existing chronic ITP. Note: the severity of

the mother’s ITP has no bearing on the fetal platelet count.

Women with a platelet count <20

¥ 10⁹/L due to ITP should receive

standard prednisolone therapy or IVIg (

p388). If prednisolone fails

or is contraindicated, IVIg should be administered and may need to be

repeated at 3 week intervals. Splenectomy should be avoided (high rate

of fetal loss). Enthusiasm has waned for assessing the fetal platelet

count during pregnancy by cordocentesis followed by platelet

transfusion. Fetal scalp sampling in early labour is unreliable and

hazardous. Delivery should occur in an obstetric unit with paediatric

support and the neonate’s platelet count should be monitored for

several days as delayed falls in the platelet count occur.

BCSH Guidelines (2003) Guidelines for the investigation and management of idiopathic thrombo-

cytopenic purpura in adults, children and in pregnancy. Br J Haematol, 120, 574-596.

Prolonged bleeding after surgery

Prolonged bleeding following surgery often requires urgent haematolog-

ical opinion and investigation. Usually the cause of the bleeding is surgical,

i.e. due to local factors, and not a reflection of any underlying systemic

bleeding disorder.

History and clinical assessment

2 Past history in relation to previous haemostatic challenges e.g. previous

surgery, dental extractions. Ask specific questions about whether

blood transfusion was required.

2 Presence of specific clinical problems e.g. impaired liver or renal function.

2 Recent drug history —especially aspirin or NSAIDs which can affect

platelet function. Also enquire about cytotoxic drugs and anticoagulants.

2 Family history of bleeding problems especially after surgery.

2 Nature of the surgery and intrinsic haemorrhagic risks of procedure.

2 Whether surgery was elective or emergency (in emergency surgery

known risk factors are less likely to have been corrected).

2 Check case record or ask surgeon/anaesthetist for information on

intraoperative bleeding, technical problems etc.

2 Whether surgery involves a high risk of triggering DIC e.g. pancreatic

or major hepatobiliary surgery.

2 Detailed physical examination is not usually practical but bruising,

ecchymoses or purpura should be assessed especially if remote from

the site of surgery.

2 What blood products have been used and over how long? Transfusion

of several units of RBCs over a short period of time will dilute avail-

able clotting factors.

2 Review preoperative investigation results and other information avail-

able in the record on past procedures and/or investigations.

Investigation

2 Ensure samples not taken from heparinised line.

2 FBC with platelet count and blood film examination.

2 PT, APTT and fibrinogen.

With normal platelets and coagulation screen bleeding is usually sur-

gical and the patient should be supported with blood and urgent sur-

gical re-exploration undertaken. Platelet function abnormalities may

occur with aspirin/NSAIDs, uraemia or extracorporeal circuits.

Prolongation of both PT and APTT suggests massive bleeding and inad-

equate replacement, DIC, underlying liver disease or oral anticoagu-

lants. Disproportionate, isolated increases in either PT or APTR are

more likely to indicate previously undiagnosed clotting factor deficien-

cies. A low platelet count may reflect dilution and consumption from

bleeding or DIC if platelets were known to be normal preoperatively.

Treatment

2 Low platelets or platelet function abnormalities:

Give 1-2 adult doses of platelets stat.

2 DIC—give 2 adult doses of platelets are 4 units FFP (10-20 units of

cryoprecipitate if fibrinogen low) and recheck PT, APTT and FBC.

2 Anticoagulant effect:

heparin—reverse with protamine sulphate.

Positive sickle test (HbS solubility test)

The decreased solubility of deoxyHbS forms the basis of this test. Blood is

added to a buffered solution of a reducing agent e.g. sodium dithionate.

HbS is precipitated by the solution and produces a turbid appearance.

Note: does not discriminate between sickle cell trait and homozygous

disease.

Use

This is a quick screening test (takes ~20 mins), often used preoperatively

to detect HbS.

Action if sickle test +ve

2 Delay elective operation until established whether disease or trait.

2 Ask about family history of sickle cell anaemia or symptoms of SCA.

2 FBC and film.

FBC and film features of sickle trait vs. disease

Sickle cell trait

FBC— normal or 5 MCV & MCH, no anaemia

Film normal (may be microcytosis or target cells)

Sickle cell disease

FBC—Hb~7-8g/dL (range ~4-11g/dL)

Film—sickled RBCs, target cells, polychromasia,

basophilic stippling, NRBC (hyposplenic features in

adults)

2 Hb electrophoresis.

2 Group and antibody screen serum.

False +ve results

2 Low Hb.

2 Severe leucocytosis.

2 Hyperproteinaemia.

2 Unstable Hb.

False -ve results

2 Infants <6 months.

2 HbS <20% (e.g. following exchange blood transfusion).

Sickle test not recommended as a screening test in pregnancy as it will not

detect other Hb variants that interact with HbS e.g. b thalassaemia trait.

Standard Hb electrophoresis of at-risk groups should be performed (and

of all pregnant women if a high local ethnic population).

Red cell disorders

The peripheral blood film in anaemias

Anaemia in renal disease

Anaemia in endocrine disease

Anaemia in joint disease

Anaemia in gastrointestinal disease

Anaemia in liver disease

Iron deficiency anaemia

Vitamin B₁₂ deficiency

Folate deficiency

Other causes of megaloblastic anaemia

Anaemia in other deficiency states

Haemolytic syndromes

Genetic control of haemoglobin production

Sickling disorders

HbS - new therapies

Sickle cell trait (HbAS)

Other sickling disorders

Other haemoglobinopathies

Unstable haemoglobins

Thalassaemias

a thalassaemia

b thalassaemia

Other thalassaemias

Hereditary persistence of fetal haemoglobin

Hb patterns in haemoglobin disorders

Non-immune haemolysis

Hereditary spherocytosis

Hereditary elliptocytosis

100

Glucose-6-phosphate dehydrogenase deficiency

102

Pyruvate kinase deficiency

104

Other red cell enzymopathies

106

Drug-induced haemolytic anaemia

108

Methaemoglobinaemia

110

Microangiopathic haemolytic anaemia (MAHA)

112

Acanthocytosis

114

Autoimmune haemolytic anaemia

116

Cold haemagglutinin disease (CHAD)

118

Leucoerythroblastic anaemia

120

Aplastic anaemia

122

Paroxysmal nocturnal haemoglobinuria

124

Pure red cell aplasia

126

Iron overload

128

Transfusion haemosiderosis

130

The peripheral blood film in anaemias

Morphological abnormalities and variants

Microcytic RBCs

Fe deficiency, thalassaemia trait & syndromes, congenital

sideroblastic anaemia, anaemia of chronic disorders

Macrocytic RBCs

Alcohol/liver disease (round macrocytes), MDS, pregnancy and

newborn, haemolysis, B12 or folate deficiency, hydroxyurea and

antimetabolites (oval macrocytes), acquired sideroblastic anaemia,

hypothyroidism, chronic respiratory failure, aplastic anaemia

Dimorphic RBCs

Fe deficiency responding to iron, mixed Fe and B12/folate

deficiency, sideroblastic anaemia, post-transfusion

Polychromatic RBCs

Response to bleeding or haematinic Rx, haemolysis, BM infiltration

Spherocytes

HS, haemolysis e.g. warm AIHA, delayed transfusion

reaction, ABO HDN, DIC and MAHA, post-splenectomy

Pencil/rod cells

Fe deficiency anaemia, thalassaemia trait & syndromes, PK deficiency

Elliptocytes

Hereditary elliptocytosis, MPD and MDS

Fragmented red cells

MAHA, DIC, renal failure, HUS, TTP

Teardrop RBCs

Myelofibrosis, metastatic marrow infiltration, MDS

Sickle cells

Sickle cell anaemia, other sickle syndromes (not sickle trait)

Target cells

Liver disease, Fe deficiency, thalassaemia, HbC syndromes.

Crenated red cells

Usually storage or EDTA artifact. Genuine RBC crenation

may be seen post-splenectomy and in renal failure

Burr cells

Renal failure

Acanthocytes

Hereditary acanthocytosis, a-b-lipoproteinaemia, McLeod red

cell phenotype, PK deficiency, chronic liver disease (esp. Zieve’s)

Bite cells

G6PD deficiency, oxidative haemolysis

Basophilic stippling

Megaloblastic anaemia, lead poisoning, MDS, haemoglobinopathies

Rouleaux

Chronic inflammation, paraproteinaemia, myeloma

4 Reticulocytes

Bleeding, haemolysis, marrow infiltration, severe hypoxia,

response to haematinic therapy

Heinz bodies

Not seen in normals (removed by spleen), small numbers

seen post-splenectomy, oxidant drugs, G6PD deficiency,

sulphonamides, unstable Hb (Hb Zurich, Köln)

Howell-Jolly bodies

Made of DNA, generally removed by the spleen, dyserythropoietic

states e.g. B12 deficiency, MDS, post-splenectomy, hyposplenism

H bodies

HbH inclusions, denatured HbH (b4 tetramer), stain with

methylene blue, seen in HbH disease (- -/- a), less

prominent in a thalassaemia trait, not present in normals

Hyposplenic blood film

Howell-Jolly bodies, target cells, occasional nucleated RBCs,

lymphocytosis, macrocytosis, acanthocytes

Anaemia in renal disease

Anaemia is consistently found in the presence of chronic renal failure.

Severity generally relates to the degree of renal impairment. The domi-

nant mechanism is inadequate production of erythropoietin. Other con-

tributory factors include (i) suppressive effects of uraemia and (ii) 5 in

RBC survival. Uraemia impairs platelet function leading to blood loss and

Fe deficiency. Small amounts of blood are inevitably left in the tubing fol-

lowing dialysis so that blood loss and Fe deficiency are further contribu-

tory factors in dialysis patients. Folate is lost in dialysis and

supplementation is required to avoid deficiency. Aluminium toxicity (from

trace amounts in dialysis fluids) and osteitis fibrosa from hyperparathy-

roidism are rare contributory factors.

Laboratory features

2 Hb typically 5.0-10.0g/dL.

2 MCV 6.

2 Blood film — mostly normochromic RBCs; schistocytes and acantho-

cytes present. No specific abnormalities in WBC or platelets.

2 Microangiopathic haemolytic changes present in vasculitic collagen dis-

orders with renal failure and classically in HUS and TTP.

Management

2 Short term treatment with RBC transfusion, based on symptoms (not Hb).

2 Correction of Fe and folic acid deficiencies.

2 Erythropoietin (Epo) will correct anaemia in most patients.

Start at 50-100units/kg SC ¥ 3/week. Give IV iron at same time.

Response apparent <10 weeks; reduced doses required as mainte-

nance. Renal Association guidelines have been produced for applica-

tion and monitoring of Epo therapy. Although expensive it improves

quality of life and avoids transfusion dependency and iron overload.

Side effects of Epo

2 4 BP.

2 Pure red cell aplasia.

2 Thrombotic tendency.

Blood film: chronic renal failure with burr (irregular shaped) cells.

www.nephronline.org/standards3/

Anaemia in endocrine disease

Anaemia and other haematological effects occur in various endocrine dis-

orders. The abnormalities will usually correct as the endocrine abnor-

mality is corrected.

Pituitary disorders

Deficiency/hypopituitarism is associated with normochromic, normo-

cytic anaemia; associated leucopenia may also occur. Abnormalities

correct as normal function is restored, by replacement therapy.

Thyroid disorders

Hypothyroidism may produce a mild degree of anaemia; MCV usually 4

but may be normal. Corrects on restoration of normal thyroid function.

Menorrhagia occurs in hypothyroidism and can result in associated Fe

deficiency. B₁₂ levels should be checked because of the association with

other autoimmune disorders (e.g. pernicious anaemia).

Thyrotoxicosis may be associated with mild degrees of normochromic

anaemia in 20% of cases which corrects as function is normalised.

Erythroid activity is increased but a disproportionate increase in plasma

volume means either no change in Hb concentration or mild anaemia.

Haematinic deficiencies occur and should be excluded.

Adrenal disorders

Hypoadrenalism results in normochromic, normocytic anaemia; the

plasma volume is 5 which masks the true degree of associated anaemia.

The abnormalities are corrected by replacement mineralocorticoids.

Hyperadrenalism (Cushing’s) results in erythrocytosis with a typical net

increase in Hb (by 1-2g/dL). Occurs whether Cushing’s is primary or

iatrogenic. Mechanism is unclear.

Parathyroid disorders —hyperparathyroidism may be associated with

anaemia from impairment of erythropoietin production, or in some

cases from secondary marrow sclerosis.

Sex hormones —androgens stimulate erythropoiesis and are

occasionally used to stimulate red cell production in aplastic anaemia.

The influence of androgens explains the higher Hb in adult 9 cf. 3.

Diabetes mellitus when poorly controlled may be associated with

anaemia; however, the majority of haematological abnormalities in

diabetes mellitus result from secondary disease related complications

e.g. renal failure.

Anaemia in joint disease

Rheumatoid arthritis, psoriatic arthropathy and osteoarthritis may be

complicated by anaemia. Various factors contribute to anaemia, com-

monly more than one is present, especially in rheumatoid arthritis. Some

of the mechanisms that give rise to anaemia in rheumatoid also apply in

other connective tissue disease, e.g. SLE, polyarteritis nodosa, etc.

Anaemia of chronic disorders (ACD)

ACD is a cytokine-driven suppression of red cell production. The clinical

problem is to being able to recognise the presence of other contributory

factors in pathogenesis of the anaemia. Bone marrow macrophages fail to

pass their stored iron to developing RBCs and a lower than expected rise

in erythropoietin suggesting some inhibition in its pathway. Marrow also

appears less responsive to Epo. 4 IL-1 has been identified. Detailed studies

suggest a synergistic effect of IL-1 with T-cells to produce IFN-g which can

suppress erythroid activity. May also be 4 levels of TNF-a which inhibits

erythropoiesis through release of IFN-b from marrow stromal cells.

Typical features of ACD

2 Hb range 7.0-11.0g/dL.

2 MCV is usually 6 but when longstanding the

MCV is moderately 5 (may look like iron deficiency).

2 Ferritin usually 6 but may be 4.

2 Serum iron 6 or 5, TIBC 6 or 5.

2 Serum transferrin receptor levels normal.

2 Bone marrow Fe stores plentiful.

Additional mechanisms of anaemia in rheumatoid disease

Autoimmune phenomena

Warm antibody AIHA in association with

rheumatoid and other collagen disorders; film

will show reticulocytosis and +ve DAT

Red cell aplasia

Drug related problems

Chronic blood loss (caused by medication)

Drug side effects e.g. macrocytosis from

antimetabolite immunosuppressives, e.g.

azathioprine and methotrexate, oxidative

haemolysis secondary to dapsone or

sulfasalazine (occurs in normal individuals as

well as those with G6PD deficiency)

Anaemia secondary to gold therapy for

rheumatoid arthritis

Idiosyncratic reactions, unexplained or

unforeseeable reactions such as marrow aplasia

Rare autoimmune haemolysis due to mefenamic

acid, diclofenac or ibuprofen

2° to other organ problems Hypersplenism, Felty’s syndrome in rheumatoid,

renal failure in SLE or polyarteritis

Anaemia in gastrointestinal disease

Anaemia occurs in GIT disorders through mechanisms of blood loss,

anaemia of chronic disease (ACD), specific disease-related complications

or drug side effects/idiosyncrasy occurring singly or in various combina-

tions.

Blood loss in gastrointestinal disease

Acute

Immediately following acute haemorrhage—RBC

indices usually normal

Normochromic anaemia

Acute on chronic

RBC indices show low normal or marginally 5,

especially MCV

Film shows mixture of normochromic &

hypochromic RBCs (‘dimorphic’)

Chronic

RBC indices show established chronic Fe deficiency

features 5 MCV, MCH, platelets often 4

Anaemia in GIT disorders can be simply considered against some of the

commoner problems arising through the GIT:

Oesophageal —bleeding from peptic oesophagitis, association of

oesophageal web and chronic Fe deficiency.

Gastric —pernicious anaemia and B₁₂ deficiency, late effects of partial or

total gastrectomy producing B₁₂ and/or Fe deficiency. Microangiopathic

haemolytic anaemia from metastatic adenocarcinoma.

Small bowel—malabsorption states e.g. Fe and/or folate deficiency 2° to

coeliac disease, malabsorption from other problems including

inflammatory bowel disease; hyposplenism secondary to coeliac with or

without 4 platelets.

Large bowel —blood loss anaemia from inflammatory bowel disorders.

Note: these may also be associated with ACD. Rare occurrence of

autoimmune haemolysis associated with ulcerative colitis.

Pancreas —anaemia of chronic disease associated with carcinoma or

chronic pancreatitis, DIC associated with acute pancreatitis.

Liver —see p54.

Drug related anaemia arises through

2 Upper GIT irritation causing blood loss —aspirin, NSAIDs, corticos-

teroids.

2 Bleeding due to specific drugs e.g. warfarin and heparin.

2 Drug-induced haemolysis e.g. oxidative (Heinz body) haemolysis due

to sulphasalazine or dapsone.

2 Production impairment e.g. aplasia secondary to mesalazine.

Anaemia in liver disease

Anaemia is common in chronic liver disorders. There are several possible

causes including:

2 Anaemia of chronic disease—part of marrow response to chronic

inflammatory processes.

2 Macrocytosis ± anaemia: specific effects on membrane lipids cause

4 MCV.

2 Alcohol—direct suppressive effect on erythropoiesis with 4 MCV.

2 Folate deficiency: seen in alcoholic liver disease7nutritional deficiency

and/or direct effect of alcohol on folate metabolism.

2 Blood loss from oesophageal varices7acute or chronic anaemia.

2 Hypersplenism—portal hypertension can produce marked splenic

enlargement leading to hypersplenism.

2 Haemolytic anaemias e.g.

- Autoimmune haemolytic anaemia in association with chronic active

hepatitis.

- Zieve’s syndrome (hypertriglyceridaemia + self-limiting haemolysis

due to acute alcohol excess).

- Viral hepatitis may provoke oxidative haemolysis in those with

G6PD deficiency.

- Acute liver failure—DIC and MAHA may occur.

- Acanthocytosis: acute haemolytic anaemia with acanthocytosis

(spur cell anaemia). Rare. Usually late stage liver disease, with poor

prognosis.

Iron deficiency anaemia

Microcytic anaemia is common and the commonest cause is chronic iron

deficiency.

Iron physiology and metabolism

Normal (Western) diet provides @15mg of iron/d, of which 5-10% is

absorbed in duodenum and upper jejunum. Ferrous (Fe²⁺) iron is better

absorbed than ferric (Fe³⁺) iron. Total body iron store @ 4g. Around 1mg

of iron/d lost in urine, faeces, sweat and cells shed from the skin and GIT.

Iron deficiency is commoner in 3 of reproductive age since menstrual

losses account for

~20mg Fe/month and in pregnancy an additional

500-1000mg Fe may be lost (transferred from mother7fetus).

Causes of iron deficiency

Reproductive system Menorrhagia

GI tract

Oesophagitis, oesophageal varices, hiatus hernia

(ulcerated), peptic ulcer, inflammatory bowel

disease, haemorrhoids, carcinoma: stomach,

colorectal, (rarely angiodysplasia, hereditary

haemorrhagic telangiectasia)

Malabsorption

Coeliac disease, atrophic gastritis (note: may also

result from Fe deficiency), gastrectomy

Physiological

Growth spurts, pregnancy

Dietary

Vegans, elderly

Genitourinary system Haematuria (uncommon cause)

Others

PNH, frequent venesection e.g. blood donation

Worldwide

Commonest cause is hookworm infestation

Assessment

Clinical history—review potential sources of blood loss, especially GIT

loss.

Menstrual loss— quantitation may be difficult; ask about number of

tampons used per day, how often these require changing, and duration.

Other sources of blood loss e.g. haematuria and haemoptysis (these are

not common causes of iron deficiency). Ask patient if he/she has been a

blood donor —regular blood donation over many years may cause

chronic iron store depletion.

Drug therapy e.g. NSAIDs and corticosteroids may cause GI irritation

and blood loss.

Past medical history e.g. previous gastric surgery (7malabsorption).

Ask about previous episodes of anaemia and treatments with iron.

Red cell disorders

In patients with iron deficiency assume underlying cause is blood loss until

proved otherwise. In developed countries pure dietary iron lack causing

iron deficiency is almost unknown.

Examination

2 General examination including assessment of mucous membranes (e.g.

hereditary haemorrhagic telangiectasia).

2 Seek possible sources of blood loss.

2 Abdominal examination, rectal examination and sigmoidoscopy mandatory.

2 Gynaecological examination also required.

Laboratory tests

2 Hb 5.

2 5 MCV (<76FLz) and 5 MCHC (note: 5 MCV in thalassaemia and

ACD).

2 Red cell distribution width (RDW): 4 in iron deficiency states with a

greater frequency than in ACD or thalassaemia trait.

2 Serum ferritin (measurement of iron/TIBC generally unhelpful).

Ferritin assay preferred —a low serum ferritin identifies the presence of iron

deficiency but as an acute phase protein it can be 4, masking iron deficiency.

5 iron and 4 TIBC indicates iron deficiency.

2 The soluble transferrin assay (sTfR) is useful in cases where 4 ESR.

sTfR is 4 in iron deficiency but 6 in anaemia in presence of 4 ESR

(e.g. rheumatoid, other inflammatory states). This assay is not univer-

sally available at present.

2 % hypochromic RBCs—some modern analysers provide this para-

meter. 4% hypo RBCs are seen in iron deficiency but also thalassaemia,

CRF on Epo where insufficient iron given.

2 Zinc protoporphyrin (ZPP)—in the absence of iron, zinc is incorpo-

rated into protoporphyrin and can be measured.

2 Examination of BM aspirate (iron stain) is occasionally useful.

2 Theoretically FOB testing may be of value in iron deficiency but results

can be misleading. False +ve results seen in high dietary meat intake.

Blood film in iron deficiency anaemia: note pale red cells with pencil cell (top left).

Treatment of iron deficiency

Simplest, safest and cheapest treatment is oral ferrous salts, e.g. FeSO₄(Fe

gluconate and fumarate equally acceptable). Provide an oral dose of ele-

mental iron of 150-200mg/d. Side effects in 10-20% patients (e.g. abdom-

inal distension, constipation and/or diarrhoea) —try 5 the daily dose to bd

or od. Liquid iron occasionally necessary, e.g. children or adults with swal-

lowing difficulties. Increasing dietary iron intake has no routine place in the

management of iron deficiency except where intake is grossly deficient.

Response to replacement

A rise of Hb of 2.0g/dL over 3 weeks is expected. MCV will 4 concomi-

tantly with Hb. Reticulocytes may 4 in response to iron therapy but is not

a reliable indicator of response.

Duration of treatment

Generally ~6 months. After Hb and MCV are normal continue iron for at

least 3 months to replenish iron stores.

Failure of response

2 Is the diagnosis of iron deficiency correct?

- Consider anaemia of chronic disorders or thalassaemia trait.

2 Is there an additional complicating illness?

- Chronic infection, collagen disorder or neoplasm.

2 Is the patient complying with prescribed medication?

2 Is the preparation of iron adequate in dosage and/or formulation?

2 Is the patient continuing to bleed excessively?

2 Is there malabsorption?

2 Are there other haematinic deficiencies (e.g. B₁₂ or folate) present?

2 Reassess patient: ?evidence of continued blood loss or malabsorption.

Parenteral iron

Occasionally of value in genuine iron intolerance, if compliance is a

problem, or if need to replace stores rapidly e.g. in pregnancy or prior to

major surgery. Note: Hb will rise no faster than with oral iron.

Intravenous iron Iron may be administered IV as iron hydroxide sucrose

complex.

Intramuscular iron e.g. iron sorbitol citrate. Usually ~10-20 IM

injections over several week period (note: injections painful and lead to

long-term skin discoloration at the injection site). Best avoided.

Andrews, N.C. (1999) Disorders of iron metabolism. N Engl J Med, 341, 1986-1995; Kuhn, L.C. &

Hentze, M.W. (1992) Coordination of cellular iron metabolism by post-transcriptional gene regu-

lation. J Inorg Biochem, 47, 183-195; Tapiero, H., Gate, L. & Tew, K.D. (2001) Iron: deficiencies

and requirements. Biomed Pharmacother, 55, 324-332.

Vitamin B₁₂ deficiency

B₁₂deficiency presents with macrocytic, megaloblastic anaemia ranging

from mild to severe (Hb <6.0g/dL). Symptoms are those of chronic

anaemia, i.e. fatigue, dyspnoea on effort, etc. Neurological symptoms may

also be present —classically peripheral paraesthesiae and disturbances of

position and vibration sense. Occasionally neurological symptoms occur

with no/minimal haematological upset. If uncorrected, the patient may

develop subacute combined degeneration of the spinal cord7perma-

nently ataxic.

Pathophysiology

B₁₂ (along with folic acid) is required for DNA synthesis; B₁₂ is also

required for neurological functioning. B₁₂ is absorbed in terminal ileum

after binding to intrinsic factor produced by gastric parietal cells. Body

stores of B₁₂ are 2-3mg (sufficient for 3 years). B₁₂is found in meats, fish,

eggs and dairy produce. Strictly vegetarian (vegan) diets are low in B₁₂

although not all vegans develop clinical evidence of deficiency.

Presenting haematological abnormalities

2 Macrocytic anaemia (MCV usually >110fL). In extreme cases RBC

anisopoikilocytosis can result in MCV values lying just within normal

range.

2 RBC changes include oval macrocytosis, poikilocytosis, basophilic stip-

pling, Howell-Jolly bodies, circulating megaloblasts.

2 Hypersegmented neutrophils.

2 Leucopenia and thrombocytopenia common.

2 Bone marrow shows megaloblastic change; marked erythroid hyper-

plasia with predominance of early erythroid precursors, open atypical

nuclear chromatin patterns, mitotic figures and ‘giant’ metamyelocytes.

2 Iron stores usually 4.

2 Serum B₁₂ 5.

2 Serum/red cell folate usually 6 or 4.

2 LDH levels markedly 4 reflecting ineffective erythropoiesis.

2 Autoantibody screen in pernicious anaemia: 80-90% show circulating

gastric parietal cell antibodies, 55% have circulating intrinsic factor anti-

bodies. Note: parietal cell antibodies are not diagnostic since found in

normals; IFA is only found in 50% of patients with PA but is diagnostic.

Causes of B₁₂ deficiency

Pernicious anaemia

Commonest, due to autoimmune gastric

atrophy resulting in loss of intrinsic

factor production required for absorp-

tion of B₁₂. Incidence increases >40

years and often associated with other

autoimmune problems, e.g. hypothy-

roidism.

Following total gastrectomy May develop after major partial gastrec-

tomy.

Ileal disease

Resection of ileum, Crohn’s disease.

Red cell disorders

Blind loop syndromes

E.g. diverticulae or localised inflamma-

tory bowel changes allowing bacterial

overgrowth which then competes for

available B₁₂.

Fish tapeworm

Diphyllobothrium latum.

Malabsorptive disorders

Tropical sprue, coeliac disease.

Dietary deficiency

E.g. vegans.

Management of B₁₂ deficiency

Identify and correct cause if possible.

Above investigations are undertaken and a test of B₁₂ absorption is

carried out (e.g. Schilling test). Urinary excretion of a test dose of B₁₂

labelled with trace amounts of radioactive cobalt is compared with

excretion of B₁₂ bound to intrinsic factor*; the test is done in two

parts. B₁₂ malabsorption corrected by intrinsic factor is diagnostic of

pernicious anaemia (in absence of previous gastric surgery).

Management —hydroxocobalamin 1mg IM and folic acid PO should be

given immediately.

Supportive measures —bed rest, O₂ and diuretics may be needed

while awaiting response. Transfusion is best avoided but 2 units of con-

centrated RBCs may be used for patients severely compromised by

anaemia (risk of precipitating cardiac failure); hypokalaemia is occasion-

ally observed during the immediate response to B₁₂ and serum [K⁺]

should be monitored.

Response apparent in 3-5d with reticulocyte response of

>10%;

normoblastic conversion of marrow erythropoiesis in 12-24h. Patients

frequently describe a subjective improvement within 24h.

B₁₂

replacement therapy —initially hydroxocobalamin

¥ 1mg IM

should be given during the first 2 weeks, thereafter maintenance injec-

tions are needed 3-monthly.

If dietary deficiency seems likely and B₁₂ deficiency mild, worth trying

oral B₁₂ (cyanocobalamin 50-150mg or more, daily between meals)

Long term follow-up depends on the primary cause. Pernicious

anaemia patients require lifelong treatment and should be checked

annually with a full blood count and thyroid function; the incidence of

gastric cancer is twice as high in these patients compared to the

normal population.

Broad spectrum antibiotics should be given to suppress bacterial over-

growth in blind loop syndrome ± local surgery if appropriate. Long

term IM B₁₂ may be the pragmatic solution if blind loop cannot be cor-

rected.

*Worldwide shortage of intrinsic factor at present, due to worries about human prion disease.

This means that only part I Schilling test available in most centres.

Guidelines on the investigation and diagnosis of cobalamin and folate deficiencies. A publication of

the British Committee for Standards in Haematology. BCSH General Haematology Test Force

(1994). Clin Lab Haematol, 16, 101-115; Toh, B.H., van Driel, I.R. & Gleeson, P.A. (1997)

Pernicious anemia. N Engl J Med, 337, 1441-1448.

Folate deficiency

Folate deficiency represents the other main deficiency cause of mega-

loblastic anaemia; haematological features indistinguishable from those of

B₁₂ deficiency. Distinction is on basis of demonstration of reduced red cell

and serum folate.

Megaloblastic anaemia patients should never receive empirical treat-

ment with folic acid alone. If they lack B₁₂, folic acid is potentially

capable of precipitating subacute combined degeneration of the

cord.

Pathophysiology

Adult body folate stores comprise 10-15mg; normal daily requirements

are 0.1-0.2mg, i.e. sufficient for 3-4 months in absence of exogenous

folate intake. Folate absorption from dietary sources is rapid; proximal

jejunum is main site of absorption. Main dietary sources of folate are liver,

green vegetables, nuts and yeast. Western diets contain ~0.5-0.7mg

folate/d but availability may be lessened as folate is readily destroyed by

cooking, especially in large volumes of water. Folate coenzymes are an

essential part of DNA synthesis, hence the occurrence of megaloblastic

change in deficiency.

Diagnosis

Haematological findings are identical to those seen in B₁₂ deficiency —

macrocytic, megaloblastic anaemia. Other findings also similar to B₁₂

except parietal cell and intrinsic factor autoantibodies usually

-ve.

Reduced folate levels —serum folate levels reflect recent intake, red cell

folate levels give a more reliable indication of folate status.

Causes of folate deficiency

5 intake

Poor nutrition, e.g. poverty, old age, ‘skid

row’ alcoholics.

4 requirements/losses

Pregnancy, 4 cell turnover, e.g. haemol-

ysis, exfoliative dermatitis, renal dialysis.

Malabsorption

Coeliac disease, tropical sprue, Crohn’s

and other malabsorptive states.

Drugs

Phenytoin, barbiturates, valproate, oral

contraceptives, nitrofurantoin may

induce folate malabsorption.

Antifolate drugs

Methotrexate, trimethoprim, pentami-

dine antagonise folate cf. induce defi-

ciency.

Alcohol

Poor nutrition plus a direct depressant

effect on folate levels which can precipi-

tate clinical folate deficiency.

Management

1. Treatment and support of severe anaemia as for B₁₂ deficiency.

Red cell disorders

2. Folic acid 5mg/d PO (never on its own —see above), unless patient

known to have normal B₁₂ level.

3. Treatment of underlying cause e.g. in coeliac disease folate levels and

absorption normalize once patient established on gluten-free diet. Long

term supplementation advised in chronic haemolysis e.g. HbSS or HS.

4. Prophylactic folate supplements recommended in pregnancy and other

states of increased demand e.g. prematurity.

Blood film: normal neutrophil: usually has <5 lobes. This one has 3 lobes.

Hypersegmented neutrophils with 7-8 lobes: found in B₁₂ or folate deficiency. Note:

blood films and marrow appearances are identical in B₁₂ and folate deficiencies.

Other causes of megaloblastic

anaemia

Megaloblastic anaemia not due to actual deficiency of either B₁₂ or folate

is uncommon, but may occur in the following situations.

Congenital

2 Transcobalamin II deficiency —absence of the key B₁₂ transport

protein results in severe megaloblastic anaemia (will correct with par-

enteral B₁₂).

2 Congenital intrinsic factor deficiency —autosomal recessive, results in

failure to produce intrinsic factor. Presents as megaloblastic anaemia

up to age of 2 years and responds to parenteral B₁₂.

2 Inborn errors of metabolism —errors in folate pathways, also occurs in

orotic aciduria and Lesch-Nyhan syndrome.

2 Megaloblastosis commonly present in the congenital dyserythropoietic

anaemias ( p450).

Acquired

2 MDS —often present in sideroblastic anaemia (RARS).

2 Acute leukaemia —megaloblastic-like erythroid dysplasia in AML M6.

2 Drug induced —secondary to antimetabolite drugs including 6-mercap-

topurine, cytosine arabinoside, zidovudine and hydroxyurea.

2 Anaesthetic agents —transient megaloblastic change after nitrous

oxide.

2 Alcohol excess —may result in megaloblastic change in absence of

measurable folate deficiency.

2 Vitamin C deficiency —occasionally results in megaloblastic change.

Anaemia in other deficiency states

Iron, folate or vitamin B₁₂ deficiencies account for the majority of clinically

significant deficiency syndromes resulting in anaemia. Anaemia is recog-

nised as a complication in other vitamin deficiencies and in malnutrition.

Vitamin A deficiency

Produces chronic disorder like iron deficiency anaemia with 5 MCV and

MCH.

Vitamin B₆ (pyridoxine) deficiency

Can produce hypochromic microcytic anaemia; sideroblastic change may

occur. Pyridoxine is given to patients on antituberculous therapy with iso-

niazid which is known to interfere with vitamin B₆ metabolism and cause

sideroblastic anaemia.

Vitamin C deficiency

Occasionally associated with macrocytic anaemia (± megaloblastic change

in 10%); since the main cause of vitamin C deficiency is inadequate diet or

nutrition there may be evidence of other deficiencies.

Vitamin E deficiency

Occasionally seen in the neonatal period in low birth weight infants —

results in haemolytic anaemia with abnormal RBC morphology.

Starvation

Normochromic anaemia ± leucopenia occurs in anorexia nervosa; fea-

tures are not associated with any specific deficiency; bone marrow is typi-

cally hypocellular.

Haemolytic syndromes

Definition

Any situation in which there is a reduction in RBC life-span due to 4 RBC

destruction. Failure of compensatory marrow response results in anaemia.

Predominant site of RBC destruction is red pulp of the spleen.

Classification —3 major types

Hereditary vs. acquired

Immune vs. non-immune

Extravascular vs. intravascular

Hereditary cause suggested if history of anaemia refractory to treatment

in infancy ± FH e.g. other affected members, anaemia, gallstones, jaundice,

splenectomy. Acquired haemolytic anaemia is suggested by sudden onset

of symptoms/signs in adulthood. Intravascular haemolysis —takes place

in peripheral circulation cf. extravascular haemolysis which occurs in RES.

Hereditary

2 Red cell membrane disorders e.g. HS and hereditary elliptocytosis.

2 Red cell enzymopathies e.g. G6PD and PK deficiencies.

2 Abnormal Hb e.g. thalassaemias and sickle cell disease, unstable Hbs.

Acquired-immune

Alloimmune

Autoimmune

2 HDN

2 Warm AIHA-1° or 2° to SLE, CLL, drugs

2 RBC transfusion incompatibility

2 Cold-Mycoplasma or EBV infection,

2 Cold haemagglutinin disease (CHAD)

2 Lymphoproliferative disorders

2 Paroxysmal cold haemoglobinuria (PCH)

Acquired-non-immune

2 MAHA

2 TTP/HUS

2 Hypersplenism

2 Prosthetic heart valves

2 March haemoglobinuria

2 Sepsis

2 Malaria

2 Paroxysmal nocturnal haemoglobinuria

Clinical features

Symptoms of anaemia e.g. breathlessness, fatigue. Urinary changes e.g. red

or dark brown of haemoglobinuria. Symptoms of underlying disorder.

Confirm haemolysis is occurring

2 Check FBC.

2 Peripheral blood film —polychromasia, spherocytosis, fragmentation

(schistocytes), helmet cells, echinocytes.

2 4 reticulocytes.

2 4 serum bilirubin (unconjugated).

2 4LDH.

Red cell disorders

2 Low/absent serum haptoglobin (bind free Hb).

2 Schumm’s test (for intravascular haemolysis).

2 Urinary haemosiderin (implies chronic intravascular haemolysis e.g.

PNH).

Discriminant diagnostic features

Establish whether immune or non-immune —check DAT

?Immune if DAT +ve check IgG and C₃ specific reagents —suggest warm

and cold antibody respectively. Screen serum for red cell alloantibodies.

?Cold antibody present —examine blood film for agglutination, check

MCV on initial FBC sample and again after incubation at 37°C for 2h.

High MCV at room temperature due to agglutinates falls to normal at

37°C. Check anti-I and anti-i titres for confirmation. Check Mycoplasma

IgM and EBV serology, and for presence of Donath Landsteiner antibody

(cold reacting IgG antibody with anti-P specificity).

?Warm antibody present —IgG +ve DAT only suggestive —examine

film for spherocytes (usually prominent), lymphocytosis or abnormal

lymphs to suggest LPD. Examine patient for nodes.

?Intravascular haemolysis —check for urinary haemosiderin, Schumm’s

test.

?Sepsis —check blood cultures.

?Malaria —examine thick and thin blood films for parasites.

?Renal/liver abnormality —examine for hepatomegaly, splenomegaly,

LFTs and U&E.

?Low platelets —consider TTP/HUS.

?Haemoglobinopathy —check Hb electrophoresis.

?Red cell membrane abnormality —check family history and perform

red cell fragility test.

?Red cell enzyme disorder —check family history and do G6PD and PK

assay. Note: enzymes may be falsely normal if reticulocytosis.

?PNH —check immunophenotyping for CD55 + CD59 (Ham’s acid lysis

test now largely obsolete).

Treatment

Treat underlying disorder. Give folic acid and iron supplements if low.

Gehrs, B.C. & Friedberg, R.C. (2002) Autoimmune hemolytic anemia. Am J Hematol, 69, 258-271.

Genetic control of haemoglobin

production

Hb comprises 4 protein subunits (e.g. adult Hb = 2

¥ a+2

¥ b chains,

a₂b₂) each linked to a haem group. Production of different globin chains

varies from embryo7adult to meet the particular environment at each

stage. Globin genes are located on chromosomes 11 and 16. All globins

related to a globin are located on chromosome 16; all those related to b

globin are on chromosome 11. The sequence in which they are produced

during development reflects their physical order on chromosomes such

that z is the first a-like globin to be produced in life. After z expression

stops, a production occurs (z7a switch). On chromosome 11 the

arrangement of b-like globin genes follows the order (from left7right)

e7g7d7b mirroring the b-like globin chains produced during devel-

opment. As embryo develops into fetus, z production stops and a is pro-

duced. The a globin combines with g chains and produces a₂g₂ (fetal Hb,

HbF). After birth g production 5 and d and b chains are produced. Adults

have predominantly HbA (a₂b₂) although small amounts of HbA₂ (a₂d₂)

and HbF are produced.

Hb switching is physiological but the mechanism is unclear. HbF (a₂g₂)

binds O₂ more tightly than adult haemoglobin, ensuring adequate O₂

delivery to the fetus which must extract its O₂ from mother’s circulation.

After birth the lungs expand and the O₂ is derived from the air, with b

production replacing that of g, leading to an increase in adult haemoglobin

(a₂b₂).

Haemoglobin

Globin chains

Amount

Embryo

Hb Gower 1

z₂e₂

42%*

Hb Gower 2

a₂e₂

24%*

Hb Portland

z₂g₂

*by 5th week

Fetus

HbF

a₂g₂

85%

HbA

a₂b₂

5-10%

Adult

HbA

a₂b₂

97%

HbA₂

a₂d₂

2.5%

HbF

a₂g₂

0.5%

Haemoglobin abnormalities

Fall into 2 major groups: structural abnormalities of Hb due to alterations in

DNA coding for the globin protein leading to an abnormal amino acid in

the globin molecule, e.g. sickle haemoglobin (b^S). Second group of Hb dis-

orders results from imbalanced globin chain production—globins pro-

Red cell disorders

duced are structurally normal but their relative amounts are incorrect and

lead to the thalassaemias.

Haemoglobinopathies result in significant morbidity and mortality on a

world-wide scale. Patients with these disorders are also seen in Northern

Europe and the UK, especially in areas with significant Greek, Italian, Afro-

Caribbean and Asian populations.

a-like genes on chromosome 16

yz ya2

a2 a1

-like genes on chromosome 11

Gg Ag

Arrangement of a-like and b-like globin genes (y indicates pseudogene)

a globin switching

yz ya2 ya1

a2 a1

b globin switching

Gg Ag

Globin gene switching during development

Sickling disorders

Sickle cell anaemia (homozygous SS, b^Sb^S), HbSC (b^Sb^C), HbS/b⁺ or b°

thalassaemia, and HbSD (b^Sb^D) all produce significant symptoms but

homozygous sickle cell anaemia is generally the most severe. The gene has

remained at high frequency due to conferred resistance to malaria in het-

erozygotes. Inheritance is autosomal recessive.

Sickle cell anaemia (SCA, HbSS)

Pathogenesis

Widespread throughout Africa, Middle East, parts of India and

Mediterranean. Single base change in b globin gene, amino acid

(glu7val). In UK Afro-Caribbean population gene is found in ~1:10.

RBCs containing HbS deform (elongate) under conditions of reduced oxy-

genation, and form characteristic sickle cells —do not flow well through

small vessels, and are more adherent than normal to vascular endothe-

lium, leading to vascular occlusion and sickle cell crises. Patients with SCA

are the offspring of parents both of whom are carriers of the b^Sgene, i.e.

they both have sickle cell trait, and homozygotes for the abnormal b^S gene

demonstrate features of chronic red cell haemolysis and tissue infarction.

Clinical features

Highly variable. Many have few symptoms whilst others have severe and

frequent crises, marked haemolytic anaemia and chronic organ damage.

HbF level plays role in ameliorating symptoms (4 HbF7fewer and milder

crises). History may reveal a +ve family history or past history of crises.

2 Infancy —newborns have higher HbF level than normal adult, pro-

tected during first 8-20 weeks of life. Symptoms start when HbF level

falls. SCA often diagnosed <1 year.

2 Infection —high morbidity and mortality due to bacterial and viral

infection. Pneumococcal septicaemia (Streptococcus pneumoniae) well

recognised. Other infecting organisms: meningococcus (Neisseria menin-

gitidis), Escherichia coli and Haemophilus influenzae (hyposplenic).

2 Anaemia —children and adults often severely anaemic (Hb ~6.0-9.0

g/dL). Anaemia is chronic and patients generally well-adapted until

episode of decompensation (e.g. severe infection) occurs.

Sickle crises

2 Vaso-occlusive —dactylitis, chest syndrome and girdle syndrome.

Patients complain of severe bone, joint and abdominal pain. Bone pain

affects long bones and spine, and is due to occlusion of small vessels.

Triggers: infection, dehydration, alcohol, menstruation, cold and tem-

perature changes - often no cause found.

2 Dactylitis —mainly children. Metacarpals, metatarsals, backs of hands

and feet swollen and tender (small vessel occlusion and infarction).

Recurrent, can result in permanent radiological abnormalities in bones

of the hands and feet (rare).

2 Acute chest syndrome —common cause of death. Chest wall pain,

sometimes with pleurisy, fever and SOB. Resembles infection, infarc-

tion or embolism. Requires prompt and vigorous treatment. Transfer

to ITU if pO₂ cannot be kept >70 mmHg on air. 10% mortality. Treat

infection vigorously, often due to S pneumoniae, H influenzae,

Mycoplasma, Legionella.

Red cell disorders

Aplastic crises —sudden 5 in marrow production (esp. red cells).

Parvovirus B19 infection is cause (invades developing RBCs). Mostly

self-limiting and after 1-2 weeks the marrow begins to function nor-

mally. Top-up transfusion may be needed.

Haemolytic crises —uncommon; markedly reduced red cell lifespan.

May be drug-induced, 2° to infection (e.g. malaria) or associated G6PD

deficiency.

Sequestration crises —mainly children (30%). Pooling of large

volumes of blood in spleen and/or liver. Severe hypotension and pro-

found anaemia may result in death.

Other problems

- Growth retardation: common in children, but adult may have

normal height (weight tends to be lower than normal). Sexual mat-

uration delayed.

- Locomotor: Avascular necrosis of the head of the femur or

humerus, arthritis and osteomyelitis (Salmonella infection). Chronic

leg ulceration is complication of many haemoglobinopathies

including sickle cell anaemia. Ischaemia is main cause.

- Genitourinary: Renal papillary necrosis7haematuria and renal

tubular defects. Inability to concentrate urine. Priapism in ~60%

males. Less common if HbF4. Frequent UTIs in women, CRF in

adults.

- Spleen: Severe pain (infarction of splenic vessels). Spleen may

enlarge in early life but after repeated infarcts diminishes in size

(7hyposplenism by 9-12 months of age). Splenic function is

impaired.

- Gastrointestinal: Gallstones common (2° to chronic haemolysis).

Derangement of LFTs (multifactorial).

- CVS: Murmurs (anaemia), tachycardia.

- Eye: Proliferative retinopathy (in 30%), blindness (esp. HbSC),

retinal artery occlusion, retinal detachment.

- CNS: Convulsions, TIAs or strokes, sensory hearing loss (usually

temporary).

- Psychosocial: Depression, socially withdrawn.

Laboratory features

Anaemia usual (Hb ~6.0-9.0 g/dL in HbSS although may be much lower;

HbSC have higher Hb). Reticulocytes may be 4 (to ~10-20%) reflecting

intense bone marrow production of RBCs. Anaemic symptoms usually

mild since HbS has reduced O₂ affinity. MCV and MCH are normal, unless

also thalassaemia trait (25% cases). Blood film shows marked variation in

red cell size with prominent sickle cells and target cells; basophilic stip-

pling, Howell-Jolly bodies and P appenheimer bodies (hyposplenic fea-

tures after infancy). Sickle cell test (e.g. sodium dithionate) will be positive.

Does not discriminate between sickle cell trait and homozygous disease.

Serum bilirubin often 4 (due to excess red cell breakdown).

Blood film in homozygous sickle cell disease. Note the elongated (sickled) red cells.

Confirmatory tests

Haemoglobin electrophoresis shows 80-99% HbS with no normal HbA.

HbF may be elevated to about 15%. Parents will have features of sickle cell

trait.

Screening

In at-risk groups pregnant woman should be screened early in pregnancy.

If both parents of fetus are carriers offer prenatal/neonatal diagnosis.

Affected babies should be given penicillin daily and be immunised against S.

pneumoniae, H influenzae type b, and Neisseria meningitidis.

Prenatal diagnosis

May be carried out from first trimester (chorionic villus sampling from 10

weeks gestation) or second trimester (fetal blood sampling from umbilical

cord or trophoblast DNA from amniotic fluid). DNA may be analysed

using restriction enzyme digestion with Mst II and Southern blotting, RFLP

analysis assessing both parental and fetal DNA haplotypes, oligonucleotide

probes specific for sickle globin point mutation, or PCR amplification fol-

lowed by restriction enzyme digestion of amplified DNA. ARMS (amplifi-

cation refractory mutation system) PCR is useful in ambiguous cases. In

late pregnancy fetal blood sampling may be used to confirm diagnosis.

Management

General

Lifelong prophylactic penicillin 250mg bd PO with folate replacement.

Pneumovax II vaccination advisable.

Management during pregnancy and anaesthesia

Anaesthesia should be carried out by experienced anaesthetist who is

aware of complications of SCA. If the patient is unwell consider transfu-

sion to Hb of 10g/dL, but generally transfusion not necessary.

Management of crises

Haematological Emergencies: Sickle Crisis p532.

www.bcshguidelines.com/pdf/SICKLE.V4_0802.pdf

HbS—new therapies

Agents that elevate HbF levels

It has been recognised for some time that 4 HbF levels ameliorate b tha-

lassaemia and sickle cell disease. HbF reduces HbS polymerisation and

hence sickling. HbF level of >10% reduces episodes of aseptic necrosis;

levels >20% HbF are associated with fewer painful crises.

Hydroxyurea —several studies have shown that baboons treated with

cytosine arabinoside showed

4 HbF. Similar results obtained with

hydroxyurea which has advantages over other cytotoxics e.g. low risk

of secondary malignancy with prolonged use. Hydroxyurea has been

evaluated in a large number of clinical trials. Effects are dose-dependent

and the highest elevation of HbF is seen at myelosuppressive doses.

Erythropoietin —leads to 4 HbF but not widely used in the management

of haemoglobinopathies. Evidence suggests that rHuEPO provides an

additive effect when alternated with hydroxyurea. Dose required is high

(1000-3000iu/kg ¥ 3d/week) with co-administration of Fe supplements.

5-azacytidine —inhibitor of methyltransferase, enzyme responsible for

methylation of newly incorporated cytosines in DNA. Preventing

methylation of the g globin gene leads to 4 HbF.

Risk of developing

2° malignancy.

Short chain fatty acids —butyrate analogues are potent inducers of

haematopoietic differentiation. Elevated concentrations of butyrate and

other fatty acids in diabetic mothers is responsible for the persistently

elevated HbF in the neonates born to such mothers. Initial studies

involving the use of butyrate to increase HbF levels in patients with

sickle cell anaemia appeared promising but subsequent studies have

been disappointing.

Bone marrow transplantation —sibling donor transplants for sickle cell

disease have been carried out in a number of centres. Since the

mortality from sickle cell disease has dropped over recent years from

15%71%, and with the advent of hydroxyurea therapy, there is a less

compelling argument for BMT in sickle cell disease.

Gene therapy —potentially curative but experimental. Globin gene

transfer has been attempted with variable results. Expression of

exogenous gene has been at levels too low to be of benefit.

Charache, S. et al (1995) Effect of hydroxyurea on the frequency of painful crises in sickle cell

anemia. Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell Anemia. N Engl J

Med, 332, 1317-1322; Platt, O.S. et al. (1994) Mortality in sickle cell disease. Life expectancy and

risk factors for early death. N Engl J Med, 330, 1639-1644.

Sickle cell trait (HbAS)

Asymptomatic carriers have one abnormal b^S gene and one normal b gene

(with 30 million carriers worldwide).

Clinical features

2 Carriers are not anaemic and have no abnormal clinical features.

2 Sickling rare unless O₂ saturation falls <40%. Crises have been

reported with severe hypoxia (anaesthesia, unpressurised aircraft).

2 Occasional renal papillary necrosis, haematuria and inability to concen-

trate the urine in adults.

Laboratory features

2 Hb, MCV, MCH and MCHC normal (unless also a thalassaemia trait).

2 HbS level 40-55% (if <40% then also a thalassaemia trait).

2 Film may be normal or show microcytes and target cells.

2 Sickle cell test will be +ve (HbSS and HbAS).

Carrier detection

Neither FBC nor film can be used for diagnostic purposes. Detection of

the carrier state relies on haemoglobin electrophoresis (HbA ~50%; HbS

~50%).

Care needed during anaesthesia (avoid hypoxia).

Other sickling disorders

HbSC

Milder than sickle cell anaemia but resembles it. Patients have fewer and

milder crises. Retinal damage (microvascular, proliferative retinopathy)

and blindness are major complications (30-35%). Arrange regular oph-

thalmological review by specialist. Aseptic necrosis of femoral head and

recurrent haematuria are common. Increased risk of splenic infarcts and

abscesses.

Beware thrombosis and PE especially in pregnancy.

Clinical

Mild anaemia (Hb 8-14g/dL) and splenomegaly common. Less haemolysis,

fewer painful crises, fewer infections and less vaso-occlusive disease than

SCA. Growth and development normal. Lifespan normal.

Pregnancy may be hazardous.

Film

Prominent target cells with fewer NRBC than seen in SCA. Howell-Jolly

and Pappenheimer bodies (hyposplenism). Occasional C crystals may be

seen.

Diagnosis

Hb electrophoresis and family studies. MCV and MCH are much lower

than in HbSS.

HbSD, HbSO_Arab

Milder than HbSS. Both rare. Interactions of these globins with HbS

results in reduced polymerisation. HbDPunjab(b121 glu7gln) and HbOArab(b121

glu7lys)

cause little disease on their own although there may be mild

haemolysis in the homozygote. These haemoglobins cause sickle cell

disease when present with HbS.

HbSa thalassaemia

Common in Black individuals. Lessens severity of SCA by reducing the

concentration of Hb in red cells.

HbSb thalassaemia

Caused by inheritance of b^S from one parent and b thalassaemia from the

other. Sickle/b° thalassaemia is severe since no normal b globin chains are

produced. Sickle/b⁺ thalassaemia is much milder having b globin in 5-15%

of their Hb. Microcytosis and splenomegaly are characteristic. Family

screening will confirm microcytosis and 4 HbA₂ in one of the parents.

Management

Essentially as for HbSS with prompt treatment of crises (see above).

Other haemoglobinopathies

HbC disease (b6 glu7lys)

West Africa. Patients have benign compensated haemolysis. Development

is normal, splenomegaly is common. Gallstones are recognised complica-

tion. The Hb may be mildly 5. MCV and MCH 5 and reticulocytes 4. Blood

film shows prominent target cells and occasional HbC crystals. Hb elec-

trophoresis shows mainly HbC with some HbF. HbA is absent. Red cells

said to be ‘stiff’. Care with anaesthesia.

HbC trait (b6 glu7lys)

Asymptomatic. Hb is 6. Film may be normal or show presence of target

cells. HbC 30-40%.

HbD disease (e.g. D_Punjab b121 glu 7gln)

Found in North West India, Pakistan and Iran. Film shows target cells.

HbD trait (e.g. D_Punjab b121 glu7gln)

Of little consequence other than interaction with HbS. Hb and MCV 6.

Film normal or shows target cells.

HbE disease (b26 glu7lys)

South East Asia (commonest Hb variant), India, Burma and Thailand. This

Hb is moderately unstable when exposed to oxidants. May produce tha-

lassaemic syndrome when mRNA splice mutants. There is mild anaemia,

MCV and MCH 5, reticulocytes 6. Film shows target cells, hypochromic

and microcytic red cells. There are few symptoms; underlying compen-

sated haemolysis, mild jaundice. Liver and spleen size are normal.

Treatment is not usually required.

HbE trait (b26 glu7lys)

Asymptomatic. Indices similar to b thalassaemia trait. Hb usually 6.

Unstable haemoglobins

Congenital Heinz body haemolytic anaemia caused by point mutations in

globin genes. Hb precipitates in red blood cells7Heinz bodies. In normal

Hb there are non-covalent bonds maintaining the Hb structure; loss of

bonds leads to Hb denaturation and precipitation. Production of Heinz

bodies leads to less deformable red cells with reduced lifespan.

Predominantly autosomal dominant; most patients are heterozygotes.

Mainly affects b globin chain e.g. HbHammersmith (mutation involves

amino acid in contact with haem pocket); HbBristol (replacement of non-

polar by polar amino acid with distortion of protein).

Clinical features

2 Well compensated haemolysis.

2 Hb may be 6 if unstable Hb has high O₂ affinity.

2 Haemolysis exacerbated by infection and oxidant drugs.

2 Jaundice and splenomegaly are common.

2 Some Hbs are unstable in vitro but show little haemolysis in vivo.

Investigation

2 Hb 6 or 5.

2 MCV often 5.

2 Film shows hypochromic RBCs, polychromatic RBCs, basophilic stip-

pling.

2 Heinz bodies seen post-splenectomy.

2 Reticulocytes are 4.

2 Demonstrate unstable Hb using e.g. heat or isopropanol stability tests.

2 Brilliant cresyl blue will stain Heinz bodies.

2 Estimation of P₅₀ may be helpful.

2 DNA analysis of value in some cases.

Management

Most cases run benign course. Treatment seldom required. Gallstones

common. Recommend regular folic acid supplementation. Splenectomy

of value in some patients. Avoidance of precipitants of haemolysis

advised.

Thalassaemias

Arise as a result of diminished or absent production of one or more globin

chains. Net result is imbalanced globin chain production. Globin chains in

excess precipitate within RBCs leading to chronic haemolysis in bone

marrow and peripheral blood. Occur at high frequency in parts of Africa,

the Mediterranean, Middle East, India and Asia. Found in high frequency in

areas where malaria is endemic and thalassaemia trait probably offers

some protection.

Named after affected gene e.g. in a thalassaemia the a globin gene is

altered in such a way that either a globin synthesis is reduced (a⁺) or abol-

ished (a°) from RBCs. Severity varies depending on type of mutation or

deletion of the a or b globin gene.

a thalassaemia

Two a globin genes on each chromosome 16, with total of 4 a globin

genes per cell (normal person is designated aa/aa). Like sickle cell

anaemia, patients can either have mild a thalassaemia (a thalassaemia trait)

where one or two a globin genes are affected or may have severe a tha-

lassaemia if three or four of the genes are affected. a thalassaemia is gen-

erally the result of large deletions within a globin complex.

Silent a thalassaemia (- a/aa)

One gene deleted. Asymptomatic. 5 MCV and MCH in minority.

a thalassaemia trait (aa/- - or - a/- a)

Asymptomatic carrier—recognised once other causes of microcytic

anaemia are excluded (e.g. iron deficiency). Hb may be 6 or minimally 5.

MCV and MCH are 5. Absence of splenomegaly or other clinical findings.

Requires no therapy.

Haemoglobin H disease (- -/- a)

Three a genes deleted; only one functioning copy of the a globin

gene/cell. Clinical features variable. May be moderate anaemia with Hb

8.0-9.0g/dL. MCV and MCH are 5. Hepatosplenomegaly, chronic leg

ulceration and jaundice (reflecting underlying haemolysis). Infection, drug

treatment and pregnancy may worsen anaemia.

Blood film shows hypochromia, target cells, NRBC and increased reticulo-

cytes. Brilliant cresyl blue stain will show HbH inclusions (tetramers of b

globin, b₄, that have polymerised due to lack of a chains). Hb pattern con-

sists of 2-40% HbH (b₄) with some HbA, A₂ and F.

Treatment

Not usually required but prompt treatment of infection advisable. Give

regular folic acid especially when pregnant. Splenectomy of value in some

patients with HbH disease. Needs monitoring and may require blood

transfusion.

Red cell disorders

Haemoglobin Bart’s hydrops fetalis (- - /- -)

Common cause of stillbirth in South East Asia. All 4 a globin genes

affected. g chains form tetramers (HbBart’s, g₄) which bind oxygen very

tightly, with resultant poor tissue oxygenation. Fetus is either stillborn (at

34-40 weeks gestation) or dies soon after birth. They are pale, distended,

jaundiced and have marked hepatosplenomegaly and ascites.

Haemoglobin is ~6.0g/dL and the film shows hypochromic red cells, target

cells, increased reticulocytes and nucleated red cells. Haemoglobin

analysis shows mainly HbBart’s (g₄) with a small amount of HbH (b₄);

HbA, A₂ and F are absent.

b thalassaemia

There are only 2 copies of b globin gene per cell. Abnormality in one b

globin gene results in b thalassaemia trait; if both b globin genes are

affected the patient has b thalassaemia major or b thalassaemia intermedia.

Unlike a thalassaemia, most b thalassaemias are due to single point muta-

tions. Results in reduced b globin synthesis (b⁺) or absent b globin pro-

duction (b°). In b thalassaemia major, patients have severe anaemia

requiring lifelong support with blood transfusion (with resultant iron over-

load). There is ineffective erythropoiesis. Not obvious at birth due to

presence of HbF (a₂g₂) but as g chain production diminishes and b globin

production increases effects of the mutation become obvious. Children

fail to thrive, and development is affected. Hepatosplenomegaly (due to

production and destruction of red cells by these organs) is typical.

Children also develop facial abnormalities as the flat bones of the skull and

other bones attempt to produce red cells to overcome the genetic defect.

Skull radiographs show ‘hair on end’ appearances reflecting the intense

marrow activity in the skull bones.

Investigation and management

b thalassaemia trait

2 Carrier state.

2 Hb may be 5 but is not usually <10.0g/dL.

2 MCV 5 to ~63-77fL.

2 Blood film: microcytic, hypochromic RBCs; target cells often present.

Basophilic stippling especially in Mediterraneans.

2 RCC 4.

2 HbA₂ (a₂d₂) 4—provides useful diagnostic test for b thalassaemia trait.

2 Occasionally confused with iron deficiency anaemia, however, in thalas-

saemia trait the serum iron and ferritin are normal (or 4) whereas in

IDA they are 5.

Blood film in thalassaemia trait

Treatment

Not usually required. Usually detected antenatally or on routine FBC pre-

op.

Red cell disorders

b thalassaemia intermedia

2 Denotes thalassaemia major not requiring regular blood transfusion;

more severe than b thalassaemia trait but milder than b thalassaemia

major.

2 May arise through several mechanisms e.g.

- Inheritance of mild b thalassaemia mutations (e.g. homozygous b⁺ tha-

lassaemia alleles, compound heterozygote for two mild b⁺ thalas-

saemia alleles, compound heterozygotes for mild plus severe b⁺

thalassaemia alleles).

- Elevation of HbF.

- Coinheritance of a thalassaemia.

- Coinheritance of b thalassaemia trait with e.g. HbLepore.

- Severe b thalassaemia trait.

Clinical

2 Present with symptoms similar to b thalassaemia major but with only

moderate degree of anaemia.

2 Hepatosplenomegaly.

2 Iron overload is a feature.

2 Some patients are severely anaemic (Hb ~6g/dL) although not

requiring regular blood transfusion, have impaired growth and devel-

opment, skeletal deformities and chronic leg ulceration.

2 Others have higher Hb (e.g. 10-12g/dL) with few symptoms.

Management

Depends on severity. May require intermittent blood transfusion, iron

chelation, folic acid supplementation, prompt treatment of infection, as for

b thalassaemia major.

b thalassaemia major (Cooley’s anaemia)

Patients have abnormalities of both b globin genes. Presents in childhood

with anaemia and recurrent bacterial infection. There is extramedullary

haemopoiesis with hepatosplenomegaly and skeletal deformities.

Clinical

2 Moderate/severe anaemia (Hb ~3.0-9.0g/dL).

2 MCV and MCHC 5.

2 Reticulocytes 4.

2 Blood film: marked anisopoikilocytosis, target cells and nucleated red

cells.

2 Methyl violet stain shows RBC inclusions containing precipitated a

globin.

2 Hb electrophoresis shows mainly HbF (a₂g₂). In some b thalassaemias

there may be a little HbA (a₂b₂) if some b globin is produced.

2 HbA₂ may be 6 or mildly elevated.

b thalassaemia major: note bizarre red cells with marked anisopoikilocytosis

Management

2 Regular lifelong blood transfusion (every 2-4 weeks) to suppress inef-

fective erythropoiesis and allow normal growth and development in

childhood.

2 Iron overload (transfusion haemosiderosis) is major problem —damages

heart, endocrine glands, pancreas and liver. Desferrioxamine reduces

iron overload (by promoting iron excretion in the urine and stool), and

is given for 8-12h per day SC for 5 days/week. Compliance may be dif-

ficult, especially in younger patients. Complications of desferrioxamine

include retinal damage, cataract and infection with Yersinia spp.

2 Splenectomy may be of value (e.g. if massive splenomegaly or

increasing transfusion requirements) but best avoided until after the

age of 5 years due to 4 risk of infection. Infective episodes should be

treated promptly with intravenous antibiotics.

2 Bone marrow transplantation has been carried out using sibling donor

HLA-matched transplants with good results in young patients with b

thalassaemia major. The procedure carries a significant procedure-

related morbidity and mortality, along with GvHD ( BMT section

p324-326).

Screening

Screen mothers at first antenatal visit. If mother is thalassaemic carrier,

screen father. If both carriers for severe thalassaemia offer prenatal diag-

nostic testing. Fetal blood sampling can be carried out at 18 weeks gesta-

tion and globin chain synthesis analysed. Chorionic villus sampling at 10+

weeks gestation provides a source of fetal DNA that can be analysed in a

variety of methods: Southern blotting, oligonucleotide probes or RFLP

analysis may determine genotype of fetus. Moving towards PCR based

techniques; likely to improve carrier detection.

Weatherall, D.J. & Provan, A.B. (2000) Red cells I: inherited anaemias. Lancet, 355, 1169-1175.

Other thalassaemias

Heterozygous db thalassaemia

Produces a picture similar to b thalassaemia trait with 4 HbF (5-20%) and

microcytic RBCs; HbA₂ is 6 or 5.

Homozygous db thalassaemia

Homozygous condition is uncommon. There is failure of production of

both d and b globins. Milder than b thalassaemia major, i.e. b thalassaemia

intermedia. Represents a form of thalassaemia intermedia. Hb 8-11g/dL.

Absence of HbA and HbA₂; only HbF is present (100%).

Heterozygous b thalassaemia/db thalassaemia

Similar to b thalassaemia major (but less severe). Hb produced is mainly

HbF with small amount of HbA₂.

gdb thalassaemia

Homozygote is not viable. Heterozygous condition is associated with

haemolysis in neonatal period and thalassaemia trait in adults with

6 HbF and HbA₂.

HbLepore

This abnormal Hb is the result of unequal crossing over of chromosomes.

Affects b and d globin genes with generation of a chimeric globin with d

sequences at NH₂ terminal and b globin at COOH terminal. Production

of db globin is inefficient; there is absence of normal d and b globins. The

phenotype of the heterozygote is thalassaemia trait; the homozygote

picture is thalassaemia intermedia.

BCSH haemoglobinopathy diagnosis guidelines

www.bcshguidelines.com/pdf/bjh809.pdf

Red cell disorders

Hereditary persistence of fetal

haemoglobin

Heterogeneous groups of disorders caused by deletions or cross-overs

involving b and g chain production, or non-deletional forms due to point

mutations upstream of the g globin gene, with high levels of HbF produc-

tion in adult life. There is 5 d and b chain production with enhanced g

chain production. Globin chain imbalance is much less marked than in b

thalassaemia, resulting in milder disorder. There are few clinical effects.

May be pancellular (very high levels of HbF haemoglobin synthesis with

uniform distribution in RBCs) or heterocellular (increased numbers of F

cells).

Mechanism

Like db thalassaemia, HPFH frequently arises from deletions of DNA,

which remove or inactivate the b globin gene (note: heterocellular HPFH

may be result of mutations outside the b globin gene).

Heterozygous HPFH

Anaemia may be mild or absent. Haematological indices are normal.

There is balanced a/non-a globin chain synthesis. HbF level ~25%.

Hb patterns in haemoglobin disorders

% Haemoglobin

Other

Normal

2-3

b thalassaemia trait

80-95

1-5

3-7

b thalassaemia intermedia

30-50

50-70

0-5

b thalassaemia major

0-20

80-100

0-13

HPFH (Black heterozygote) 60-85

15-35

1-3

HPFH (Black homozygote)

100

a thalassaemia trait

85-95

Bart’s 0-10% at birth

HbH disease

60-95

H 5-30%

Bart’s 20-30% at birth

HbBart’s hydrops

Bart’s 80-90%

HbE trait

60-65

1-2

2-3

E 30-35

HbE disease

5-10

E 95

HbE/b thalassaemia

30-40

E 60-70

HbE/a thalassaemia

E 80

HbD trait

50-65

1-5

1-3

D 45-50

HbD disease

1-5

1-3

D 90-95

HbD/b thalassaemia

0-7

1-7

D 80-90

HbC trait

60-70

C 30-40

HbC disease

slight 4

C 95

Sickle trait

55-70

30-45

Sickle cell anaemia

Sickle/b⁺ thalassaemia

5-30

5-15

60-85

Sickle/b^o thalassaemia

5-30

4-8

70-90

Sickle/D

1-5

D 50%

Sickle/C

50-65

C 50%

HbLepore trait 80-90

1-3

2-2.5

Lepore 9-11%

HbLepore disease

70-90

Lepore 8-30%

HbLepore/b thalassaemia

70-90

2.5

Lepore 5-15%

Non-immune haemolysis

4 major groups

2 Infections.

2 Vascular (mechanical damage).

2 Chemical damage.

2 Physical damage.

Infection

Malaria —especially falciparum. Causes anaemia through marrow

suppression, hypersplenism and RBC sequestration. In addition there is

haemolysis due to destruction of parasitised RBCs by RES and

intravascular haemolysis when sporozoites released from infected RBCs.

Blackwater fever refers to severe acute intravascular haemolysis with

haemoglobinaemia, 5 Hb, haemoglobinuria and ARF.

Babesiosis —Babesia (RBC protozoan). Rapid onset of vomiting,

diarrhoea, rigors, jaundice, 4T°. Haemoglobinaemia, haemoglobinuria,

ARF and death.

Clostridium perfringens —septicaemia and acute intravascular

haemolysis.

Viral —especially viral haemorrhagic fevers e.g. dengue, yellow fever.

Mechanical

Cardiac —turbulence and shear stress following mechanical valve

replacement. General feature of haemolysis: 4 reticulocytes, LDH, plasma

Hb, with 5 haptoglobins ± platelets. Urinary haemosiderin +ve.

MAHA —see p112.

HUS/TTP —see p530.

March haemoglobinuria —with severe strenuous exercise e.g. running.

Destruction of RBCs in soles of feet. Worse with hard soles and uneven

hard ground. Mild anaemia. No specific features on film. May be

associated GIT bleeding and 5 ferritin (lost in sweat).

Chemical & physical

Oxidative haemolysis —chronic Heinz body intravascular haemolysis

with dapsone or salazopyrine in G6PD deficient people or unstable Hb

(and normals if dose high enough). Film: bite cells (RBC). Heinz bodies

not prominent if intact spleen. Haemolysis well compensated.

MetHb —see p110.

Lead poisoning —moderate 5 RBC lifespan. Anaemia mainly due to

block in haem synthesis although lead also inhibits 5' nucleotidase (NT).

Basophilic stippling on film. Ring sideroblasts in BM.

Red cell disorders

O₂ —haemolysis in patients treated with hyperbaric O₂.

Insect bites —e . g . spider, bee-sting (not common with snake bites).

Heat —e . g . burns7severe haemolysis due to direct RBC damage.

Liver disease —reduced RBC lifespan in acute hepatitis, cirrhosis, Zieve’s

syndrome is an uncommon form of haemolysis —intravascular associated

with acute abdominal pain (

p54).

Wilson’s disease —autosomally inherited disorder of copper

metabolism, with hepatolenticular, hepatocerebral degeneration.

PNH —see p124.

Hereditary acanthocytosis —a-b-lipoproteinaemia. Rare, inherited.

Associated with retinitis pigmentosa, steatorrhoea, ataxia and mental

retardation.

Hereditary spherocytosis

Most common inherited RBC membrane defect characterised by variable

degrees of haemolysis, spherocytic RBCs with 4 osmotic fragility.

Pathophysiology

Abnormal RBC cytoskeleton: partial deficiency of spectrin, ankyrin, band 3

or protein 4.2 (leads to 5 binding to band 4.1 protein and ankyrin). Loss of

lipid from RBC membrane7spherical (cf. biconcave) RBCs with reduced

surface area7get trapped in splenic cords and have reduced lifespan.

RBCs use more energy than normal in attempt to maintain cell shape.

RBC membrane has 4 Na⁺permeability (loses intracellular Na⁺) and

energy required to restore Na⁺ balance. Red cells are less deformable

than normal.

Epidemiology

In Northern Europeans 1:5000 people are affected. In most cases inheri-

tance is autosomal dominant although autosomal recessive inheritance has

been reported.

Clinical features

Presents at any age. Highly variable from asymptomatic to severely

anaemic, but usually there are few symptoms. Well-compensated haemol-

ysis; other features of haemolytic anaemia may be present e.g.

splenomegaly, gallstones, mild jaundice. Occasional aplastic crises occur,

e.g. with parvovirus B19 infection.

Diagnosis

2 Positive family history of HS in many cases.

2 Blood film shows 44 spherocytic RBCs.

2 Anaemia, 4 reticulocytes, 4 LDH, unconjugated bilirubin, urinary

urobilinogen with 5 haptoglobins. DAT -ve.

Osmotic fragility test —RBCs incubated in saline at various

concentrations. Results in cell expansion and eventually rupture. Normal

RBCs can withstand greater volume increases than spherocytic RBCs.

Positive result (i.e. confirms HS) when RBCs lyse in saline at near to

isotonic concentration, i.e. 0.6-0.8g/dL (whereas normal RBCs will simply

show swelling with little lysis). Osmotic fragility more marked in patients

who have not undergone splenectomy, and if the RBCs are incubated at

37°C for 24h before performing the test.

Autohaemolysis test —since spherocytic RBCs use more glucose than

normal RBCs (to maintain normal shape) red cells incubated in buffer or

serum for 48h show lysis and release of Hb into solution, which can be

measured. In HS RBCs release greater amounts of Hb cf. normal RBCs

(3% vs. 1% in normal).

Complications

2 Aplastic crisis (e.g. parvovirus B19 infection, but may be any virus); see

temporary 55 reticulocytes, Hb and Hct.

2 Megaloblastic changes in folate deficiency.

2 4 haemolysis during intercurrent illness e.g. infections.

2 Gallstones (in 50% patients; occur even in mild disease).

Red cell disorders

2 Leg ulceration.

2 Extramedullary haemopoiesis.

2 Iron overload if multiply transfused.

Exclude

Other causes of haemolytic anaemia e.g. immune-mediated, unstable Hbs

and MAHA, which can give rise to spherocytic RBCs.

Treatment

Supportive treatment is usually all that is required, e.g. folic acid (5mg/d).

In parvovirus crisis Hb drops significantly and blood transfusion may be

required. Splenectomy is ‘curative’ but is reserved for patients who are

severely anaemic or who have symptomatic moderate anaemia. Best

avoided in patients <10 years old due to risk of 4 fatal infection post-

splenectomy.

Remember pre-splenectomy vaccines and post-splenectomy antibiotics

(

p582).

100

Patient

Control

Normal range

% RBC

lysis

0.2

0.4

0.6

0.8

1.0

% Saline

Osmotic fragility assay: note control red cells (red) lyse at lower % saline since they

are able to take up more water than spherocytic red cells before lysis occurs.

Blood film in hereditary spherocytosis: note large numbers of dark spherical red

cells.

Hereditary elliptocytosis

Heterogeneous group of disorders with elliptical RBCs.

3 major groups

2 Hereditary elliptocytosis.

2 Spherocytic HE.

100

2 South East Asian ovalocytosis.

Pathophysiology

Mutations in a or b spectrin. There may be partial, complete deficiency, or

structural abnormality of protein 4.1, or absence of glycophorin C.

Epidemiology

In Northern Europeans 1:2500 are affected. Inheritance is autosomal

dominant. More common in areas where malaria is endemic.

Clinical features

Most are asymptomatic. Well-compensated haemolysis. A few patients

have chronic symptomatic anaemia. Homozygote more severely affected.

Diagnosis

2 May have positive family history.

2 Blood film shows 44 elliptical or oval RBCs.

2 Anaemia, 4 reticulocytes, 4 LDH, unconjugated bilirubin, urinary

urobilinogen with 5 haptoglobins. DAT is -ve.

2 Osmotic fragility usually normal (unless spherocytic HE).

2 Transient increase in haemolysis if intercurrent infection.

Complications

Usual complications of haemolytic anaemia e.g. gallstones, folate defi-

ciency, etc.

Treatment

Supportive care: folic acid (5mg/d). Most patients require no treatment. In

more severe cases consider splenectomy. Remember pre-splenectomy

vaccines and post-splenectomy antibiotics (

p582).

Spherocytic HE

Elliptical and spherical ‘sphero-ovalocytes’ in peripheral blood. Haemolysis

and 4 osmotic fragility distinguish it from common hereditary elliptocy-

tosis. Molecular basis is unknown.

Southeast Asian ovalocytosis

Caused by abnormal band 3 protein. RBCs are oval with 1-2 transverse

ridges. Cells have 4 rigidity and 5 osmotic fragility. RBCs are more resis-

tant to malaria than normal RBCs.

Glucose-6-phosphate dehydrogenase

deficiency

G6PD is involved in pentose phosphate shunt 7generates NADP,

NADPH and glutathione (for maintenance of Hb and RBC membrane

integrity, and reverse oxidant damage to RBC membrane and RBC compo-

102

nents). G6PD deficiency is X-linked and clinically important cause of oxidant

haemolysis. Affects 9 predominantly; 3 carriers have 50% normal G6PD

activity. Occurs in West Africa, Southern Europe, Middle East and South

East Asia.

Features:

2 Haemolysis after exposure to oxidants or infection.

2 Chronic non-spherocytic haemolytic anaemia.

2 Acute episodes of haemolysis with fava beans (termed favism).

2 Methaemoglobinaemia.

2 Neonatal jaundice.

Mechanism Oxidants7denatured Hb7methaemoglobin7Heinz

bodies7RBC less deformable7destroyed by spleen.

2 main forms of the enzyme: normal enzyme is G6PD-B, most prevalent

form worldwide; 20% of Africans are type A. A and B differ by one amino

acid. Mutant enzyme with normal activity = G6PD A(+), find only in Black

individuals. G6PD A(-) is main defect in African origin; 5 stability of

enzyme in vivo; 5-15% normal activity. 400+ variants but only 2 are rele-

vant clinically: type A(-)

= Africans

(10% enzyme activity) and

Mediterranean (with 1-3% activity).

Drug-induced haemolysis in G6PD deficiency

2 Begins 1-3d after ingestion of drug.

2 Anaemia most severe 7-10d after ingestion.

2 Associated with low back and abdominal pain.

2 Urine becomes dark (black sometimes).

2 Red cells develop Heinz body inclusions (cleared later by spleen).

2 Haemolysis is typically self-limiting.

2 Implicated drugs shown in table (next page).

2 But heterogeneous; variable sensitivity to drugs.

2 Risk and severity are dose related.

Haemolysis due to infection and fever

2 1-2d after onset of fever.

2 Mild anaemia develops.

2 Commonly seen in pneumonic illnesses.

Favism

2 Hours/days after ingestion of fava beans (broad beans).

2 Beans contain oxidants vicine and convicine7free radicals7oxidise

glutathione.

2 Urine becomes red or very dark.

2 Shock may develop —may be fatal.

Red cell disorders

Risk of haemolysis in G6PD deficient individuals

Definite risk

Possible risk

103

Antimalarial drugs

Aspirin (1g/d acceptable in most cases)

Primaquine

Chloroquine

Pamaquine (not available in UK)

Probenecid

Quinine & quinidine (acceptable in

acute malaria)

Analgesic drugs

Aspirin

Phenacetin

Others

Dapsone

Methylthioninium chloride (methylene blue)

Nitrofurantoin

4-quinolones (e.g. ciprofloxacin, nalidixic acid)

Sulphonamides (e.g. cotrimoxazole)

Neonatal jaundice

2 May develop kernicterus (possible permanent brain damage).

2 Rare in A(-) variants.

2 More common in Mediterranean and Chinese variants.

Laboratory investigation

2 In steady state (i.e. no haemolysis) the RBCs appear normal.

2 Heinz bodies in drug-induced haemolysis (methyl violet stain).

2 Spherocytes and RBC fragments on blood film if severe haemolysis.

2 4 reticulocytes.

2 4 unconjugated bilirubin, LDH and urinary urobilinogen.

2 5 haptoglobins.

2 DAT -ve.

Diagnosis

Demonstrate enzyme deficiency. In suspected RBC enzymopathy, assay

G6PD and PK first, then look for unstable Hb. Diagnosis is difficult during

haemolytic episode since reticulocytes have 44 levels of enzyme and may

get erroneously normal result; wait until steady state (~6 weeks after

episode of haemolysis). Family studies are helpful.

Management

2 Avoid oxidant drugs —see BNF.

2 Transfuse in severe haemolysis or symptomatic anaemia.

2 IV fluids to maintain good urine output.

2 ± exchange transfusion in infants.

2 Splenectomy may be of value in severe recurrent haemolysis.

2 Folic acid supplements (?proven value).

2 Avoid iron unless definite iron deficiency.

Pyruvate kinase deficiency

Congenital non-spherocytic haemolytic anaemia, caused by deficiency of

PK enzyme (involved in glycolytic pathway), leading to unstable enzyme

with reduction in ATP generation in RBCs. O₂ curve is shifted to the right

due to 4 2,3-DPG production.

104

Epidemiology

Autosomal recessive. Affected persons are homozygous or double het-

erozygotes.

Clinical features

Variable, with chronic haemolytic syndrome. May be apparent in neonate

(if severe) or may present in later life.

Diagnosis

2 Variable anaemia.

2 Reticulocytes 44.

2 DAT -ve.

2 LDH 4.

2 Serum haptoglobin 5.

2 Definitive diagnosis requires assay of PK level.

Complications

Aplastic crisis may be seen in viral infection (e.g. parvovirus B19).

Treatment

Dependent on severity. General supportive measures include daily folic

acid (5mg/d). Transfusion may be required. Splenectomy may be of value

if high transfusion requirements. In aplastic crisis

(e.g. viral infection)

support measures should be used.

Zanella, A. & Bianchi, P. (2000) Red cell pyruvate kinase deficiency: from genetics to clinical mani-

festations. Baillieres Best Pract Res Clin Haematol, 13, 57-81.

Other red cell enzymopathies

Glycolytic pathway

2 Hexokinase deficiency.

2 Glucose phosphate isomerase deficiency.

2 Phosphofructokinase deficiency.

106

2 Aldolase deficiency.

2 Triosephosphate isomerase deficiency.

2 Phosphoglycerate kinase deficiency.

Epidemiology

Incidence <1 in 10⁶. Inheritance is autosomal recessive (most double

heterozygote) except for phosphoglycerate kinase deficiency (X-linked

recessive).

Clinical features

Similar to PK deficiency although most are more severely affected for the

degree of anaemia (glycolytic block results in 5 2,3-DPG and left shift of

O₂ dissociation curve). PFK deficiency is associated with myopathy. TPI

and PGK deficiencies are associated with progressive neurological deteri-

oration.

Diagnosis

2 See pyruvate kinase deficiency (p104).

2 Non-specific morphology with anisocytosis, macrocytosis and

polychromasia.

2 Definitive diagnosis requires assay of deficient enzyme (7reference lab).

Complications

2 See pyruvate kinase deficiency (p104).

Treatment

Folic acid (5mg/d). Transfusion may be required (beware Fe overload if

high transfusion requirement). Role of splenectomy controversial.

Natural history

Similar to pyruvate kinase except TPI and PGK-TPI present in childhood

and cause progressive paraparesis, most die <5 years old due to cardiac

arrhythmias. PGK can cause exertional rhabdomyolysis and consequential

renal failure. Those affected show progressive neurological deterioration.

Nucleotide metabolism—pyrimidine 5' nucleotidase deficiency

Epidemiology

Autosomal recessive. Note: lead poisoning causes acquired pyrimidine 5'

nucleotidase deficiency.

Clinical features

2 Moderate anaemia (Hb ~10g/dL).

2 4 Reticulocytes.

2 4 bilirubin.

2 Splenomegaly.

Drug-induced haemolytic anaemia

Large number of drugs shown to cause haemolysis of RBCs. Mechanisms

variable. May be immune or non-immune.

Some drugs interfere with lipid component of RBC membrane.

Oxidation and denaturation of Hb: seen with e.g. sulphonamides, espe-

108

cially in G6PD deficient subjects, but may occur in normal subjects if

drugs given in large doses e.g.

- Dapsone.

- Sulfasalazine.

Hapten mechanism describes the interaction between certain drugs

and the RBC membrane components generating antigens that stimu-

late antibody production. DAT +ve.

- Penicillins.

- Cephalosporins.

- Tetracyclines.

- Tolbutamide.

Autoantibody mediated haemolysis is associated with warm anti-

body mediated AIHA. DAT +ve.

- Cephalosporins.

- Mefenamic acid.

- Methyldopa.

- Procainamide.

- Ibuprofen.

- Diclofenac.

- IFN-a.

Innocent bystander mechanism occurs when drugs form immune

complexes with antibody (IgM commonest) which then attach to RBC

membrane. Complement fixation and RBC destruction occurs.

- Quinine.

- Quinidine.

- Rifampicin.

- Antihistamines.

- Chlorpromazine.

- Melphalan.

- Tetracycline.

- Probenecid.

- Cefotaxime.

Laboratory features

As for autoimmune haemolytic anaemia, Hb 5, reticulocytes 4, etc.

Differential diagnosis

2 Warm/cold autoimmune haemolytic anaemia.

2 Congenital haemolytic disorders, e.g. HS, G6PD deficiency, etc.

Treatment

2 Discontinue offending drug.

2 Choose alternative if necessary.

2 If DAT +ve with methyldopa no need to stop unless haemolysis.

2 Corticosteroids generally unnecessary and of doubtful value.

2 Transfuse in severe or symptomatic cases only.

2 Outlook good with complete recovery usual.

Methaemoglobinaemia

The normal O₂ dissociation curve requires iron to be in the ferrous form

(i.e. reduced, Fe²⁺). Hb containing the ferric

(oxidised, Fe³⁺) form is

termed methaemoglobin (MetHb). MetHb binds O₂ tightly leading to

poor tissue oxygenation. May be congenital or acquired.

110

Methaemoglobinaemia

Congenital

HbM

a or b globin mutation in vicinity of Fe

Fe becomes stabilised in Fe³⁺ form

Heterozygote has 25% HbM

MetHb reductase def.

Due to deficiency of NADH-cytochrome b₅

reductase. Autosomal recessive inheritance;

symptoms mainly in homozygote

Clinical features

Cyanosis from infancy. PaO₂ is normal

General health is good

Acquired

Occurs when RBCs are exposed to oxidising agents,

producing HbM. Implicated agents include:

phenacetin, local anaesthetics (e.g. lignocaine),

inorganic nitrates (NO₂). Patients may experience

severe tissue hypoxia. HbM binds O₂ tightly and

fails to release to tissues

HbM ≥60% requires urgent medical attention.

Diagnosis

May be history of exposure to oxidant drugs or chemicals.

Spectrophotometry or haemoglobin electrophoresis will demonstrate

HbM. Assays for MetHb reductase are available.

Treatment

In patients with congenital symptomatic HbM give ascorbate or methylth-

ioninium chloride (methylene blue). In acquired disorder remove oxidant,

if present, and administer methylthioninium chloride (methylene blue).

If severely affected consider exchange blood transfusion.

Microangiopathic haemolytic anaemia

(MAHA)

Definition

Increased RBC destruction caused by mechanical red cell deformation.

112

Caused by trauma or vascular endothelial abnormalities.

Causes

2 TTP/HUS see p468, 530.

2 PET/HELLP (haemolysis, elevated liver enzymes and low platelets).

2 Malignant tumour circulations.

2 Renal abnormalities e.g. acute glomerulonephritis, transplant rejection,

cyclosporin.

2 Vasculitides e.g. Wegener’s, PAN, SLE.

2 DIC.

2 Prosthetic heart valves.

2 March haemoglobinuria.

2 A-V malformations.

2 Burns.

Clinical

2 Varying degree of anaemia —most severe in DIC, TTP/HUS and HELLP.

2 Often associated with 5 platelets.

2 Blood film shows marked RBC fragmentation, stomatocytes and

spherocytes.

2 Reticulocytosis often very marked.

2 Signs of underlying disease should be sought.

Treatment

2 Diagnose and treat underlying disease.

2 Give folic acid and iron supplements if deficient.

Antman, K.H. et al. (1979) Microangiopathic hemolytic anemia and cancer: a review. Medicine

(Baltimore), 58, 377-384.

Acanthocytosis

Abnormal RBC shape (thorn-like surface protrusions) seen in a number of

conditions, inherited or acquired, affecting RBC membrane lipid structure.

RBCs develop normally in marrow but once in plasma adopt characteristic

shape. RBCs lose membrane and become progressively less elastic.

114

Inherited conditions resulting in significant acanthocytosis

2 A-b-lipoproteinaemia.

2 McLeod phenotype (lacking Kell antigen).

2 In(Lu) phenotype.

2 In association with abnormalities of band 3 protein.

2 Hereditary hypo-β-lipoproteinaemia.

Acquired conditions resulting in significant acanthocytosis

2 Severe liver disease.

2 Myelodysplastic syndromes.

2 Neonatal vitamin E deficiency.

Inherited conditions resulting in mild acanthocytosis

2 McLeod phenotype heterozygote.

2 Pyruvate kinase deficiency.

Acquired conditions resulting in mild acanthocytosis

2 Post-splenectomy and hyposplenic states.

2 Starvation including anorexia nervosa.

2 Hypothyroidism.

2 Panhypopituitarism.

A-b-lipoproteinaemia

Autosomal recessive. Congenital absence of b apolipoprotein.

Cholesterol:phospholipid ratio

4. RBC precursors normal. Usually

obvious in early life with associated malabsorption of fat (including vita-

mins A, D, E and K). Sphingomyelin accumulates.

Haematological abnormalities

2 Mild haemolytic anaemia.

2 50-90% circulating RBCs are acanthocytic.

2 Reticulocytes mildly 4.

McLeod phenotype

2 5 expression of Kell antigen on RBC.

2 Mild (compensated) haemolytic anaemia.

2 10-85% acanthocytic RBCs in peripheral blood.

Autoimmune haemolytic anaemia

RBCs react with autoantibody ± complement7premature destruction of

RBCs by reticuloendothelial system.

Mechanism

RBCs opsonised by IgG, recognized by Fc receptors on RES

116

macrophages7phagocytosis. If phagocytosis incomplete remaining

portion of RBC continues to circulate as spherocyte (note: phagocytosis

usually complete if complement involved).

Seen in

2 Haemolytic blood transfusion reactions.

2 Autoimmune haemolytic anaemia.

2 Drug-induced haemolysis (some).

Warm antibody induced

Idiopathic

2° to lymphoproliferative disease e.g.

CLL, NHL

2° to other autoimmune diseases e.g. SLE

Cold antibody induced

Idiopathic

Cold haemagglutinin disease (CHAD)

2° to Mycoplasma infection

Infectious mononucleosis

Lymphoma

Paroxysmal cold

Idiopathic

haemoglobinuria

2° to viral infection

Congenital or tertiary syphilis

Warm antibody induced haemolysis

Extravascular RBC destruction by RES mediated by warm-reacting anti-

body. Most cases are idiopathic with no underlying pathology, but may be

2° to lymphoid malignancies e.g. CLL, or autoimmune disease such as SLE.

Epidemiology

Affects predominantly individuals >50 years of age.

Clinical features

2 Highly variable symptoms, asymptomatic or severely anaemic.

2 Chronic compensated haemolysis.

2 Mild jaundice common.

2 Splenomegaly usual.

Diagnosis

2 Anaemia.

2 Spherocytes on peripheral blood film.

2 Reticulocytes are 44.

2 Neutrophilia common.

2 RBC coated with IgG, complement or both (detect using DAT).

2 Autoantibody —often pan-reacting but specificity in 10-15% (Rh,

mainly anti-e, anti-D or anti-c).

Red cell disorders

2 LDH 4.

2 Serum haptoglobin 5.

2 Exclude underlying lymphoma (BM, blood and marrow cell markers).

117

2 Autoimmune profile—to exclude SLE or other connective tissue dis-

order.

Treatment

Prednisolone 1mg/kg/d PO tailing off after response noted (usually 1-2

weeks). If no response consider immunosuppression e.g. azathioprine

(suitable for elderly but not younger patients —risk of 2° leukaemia) or

cyclophosphamide. Splenectomy should be considered in selected cases.

IVIg (0.4g/kg/d for 5d) useful in refractory cases, or where rapid response

required. Rituximab (anti-CD20) is emerging as a useful agent for a range

of refractory autoimmune disorders, including AIHA. Regular folic acid

(5mg/d) is advised.

Gehrs, B.C. & Friedberg, R.C. (2002) Autoimmune hemolytic anemia. Am J Hematol, 69, 258-271.

Cold haemagglutinin disease (CHAD)

Describes syndrome associated with acrocyanosis in cold weather due to

RBC agglutinates in blood vessels of skin. Caused by RBC antibody that

reacts most strongly at temperatures

<32°C. Complement is acti-

vated 7RBC lysis7haemoglobinaemia and haemoglobinuria. May be

118

idiopathic (1°) or 2° to infection with Mycoplasma or EBV (infectious

mononucleosis).

Clinical features

2 Elderly.

2 Acrocyanosis (blue discoloration of extremities e.g. fingers, toes) in

cold conditions.

2 Chronic compensated haemolysis.

2 Splenomegaly usual.

Diagnosis

2 Anaemia.

2 Reticulocytes are 44.

2 Neutrophilia common.

2 Positive DAT —C₃ only.

2 ± Autoantibodies —IgG or IgM

- Monoclonal in NHL.

- Polyclonal in infection-related CHAD.

2 IgM antibodies react best at 4°C (thermal amplitude 4-32°C).

2 Specificity

- Anti-I (Mycoplasma).

- Anti-i (infectious mononucleosis)—causes little haemolysis in adults

since RBCs have little anti-i (cf. newborn i >> I).

2 LDH 4.

2 Serum haptoglobin 5.

2 Exclude underlying lymphoma (BM, blood and marrow cell markers).

2 Autoimmune profile to exclude SLE or other connective tissue dis-

order.

Treatment

2 Keep warm.

2 Corticosteroids generally of little value.

2 Chlorambucil or cyclophosphamide (greatest value when there is

underlying B-cell lymphoma, occasionally helpful in 1° CHAD).

2 Plasma exchange may help in some cases.

2 If blood transfusion required use in-line blood warmer.

2 Splenectomy occasionally useful (note: liver is main site of RBC seques-

tration of C3b-coated RBCs).

2 Infectious CHAD generally self-limiting.

Natural history

Prolonged survival, spontaneous remissions not unusual, with periodic

relapses.

Leucoerythroblastic anaemia

Definition

A form of anaemia characterised by the presence of immature white and

red blood cells in the peripheral blood. Mature white cells and platelets

are also often reduced.

120

Causes

Marrow infiltration by

2 2° malignancy: commonly breast, lung, prostate, thyroid, kidney, colon.

2 Myelofibrosis (a primary myeloproliferative disorder, see p256).

2 Other haematological malignancy e.g. myeloma and Hodgkin’s disease.

2 Rarely, severe haemolytic or megaloblastic anaemia.

Marrow stimulation by

2 Infection, inflammation, hypoxia, trauma (common in ITU patients).

2 Massive blood loss.

When due to marrow infiltration, there is often associated neutropenia

± thrombocytopenia. Marrow stimulative causes often have neutrophilia

and thrombocytosis.

Investigations

2 FBC and blood film. Typical film appearances are of increased poly-

chromasia due to reticulocytosis, nucleated RBCs, poikilocytosis (tear

drop forms common in infiltrative causes), myelocytes and band forms,

occasionally even promyelocytes and blast cells.

2 Clotting screen —where cause is 2° malignancy or infective, DIC may

occur.

Bone marrow is usually diagnostic

2 Hypercellular BM with normal cell maturation, typical of marrow stim-

ulation causes.

2 Infiltration with neoplastic cells of a 2° malignancy may be identified as

abnormal clumps with characteristic morphology —immunohistochem-

istry may identify the primary source e.g. PSA for prostate.

2 Increase in reticulin fibres running in parallel bundles identifies fibrotic

infiltrative cause —usually myelofibrosis, but may occur with other

haematological malignancy.

Treatment

2 Diagnose and treat underlying cause if possible.

2 Supportive transfusions as required, management of bone marrow

failure (see p562).

Oster, W. et al. (1990) Erythropoietin for the treatment of anemia of malignancy associated with

neoplastic bone marrow infiltration. J Clin Oncol, 8, 956-962.

Aplastic anaemia

Definition

A gross reduction or absence of haemopoietic precursors in all 3 cell lin-

eages in bone marrow resulting in pancytopenia in peripheral blood.

Although this encompasses all situations in which there is myelosuppres-

122

sion, the term is generally used to describe those in which spontaneous

marrow recovery is unusual.

Incidence

Rare ~5 cases per million population annually. Wide age range, slight

increase around age 25 years and >65 years. 10¥ more common in

Orientals.

Causes

Divided into categories where aplasia is regarded as:

2 Inevitable

- TBI dose of >1.5Gy (note: >8Gy always fatal in absence of graft

rescue).

- Chemotherapy e.g. high dose busulfan.

2 Hereditary

- Fanconi syndrome—stem cell repair defect resulting in abnormali-

ties of skin, facies, musculo-skeletal system and urogenital systems.

- BM failure often delayed until adulthood.

2 Idiosyncratic

- Chronic benzene exposure.

- Drug-induced, but not dose related—mainly gold, chloramphenicol,

phenylbutazone, NSAIDs, carbamazepine, phenytoin, mesalazine.

- Genetic predisposition demonstrated for chloramphenicol.

2 Post-viral

- Parvoviral infections—classically red cell aplasia but may be all ele-

ments. Devastating in conjunction with chronic haemolytic anaemia

e.g. aplastic sickle crisis.

- Hepatitis viruses A, B and C, CMV and EBV.

2 Idiopathic

- Constitute the majority of cases.

Classification

2 According to severity most clinically useful.

2 Defines highest risk groups.

Classification of severity in aplastic anaemia

Severe

2 of the following:

neutrophils

<0.5

¥ 10⁹/L

platelets

<20

¥ 10⁹/L

reticulocytes <1%

Very severe

neutrophils

<0.2

¥ 10⁹/L,

and infection present

Red cell disorders

Clinical features

Reflects the pancytopenia. Bleeding from mucosal sites common, with

purpura, ecchymoses. Infections, particularly upper and lower respiratory

123

tracts, skin, mouth, peri-anal. Bacterial and fungal infections common.

Anaemic symptoms usually less severe due to chronic onset.

Diagnosis and investigation

2 FBC and blood film show pancytopenia, MCV may be 4, film mor-

phology unremarkable.

2 Reticulocytes usually absent.

2 BM aspirate and trephine show gross reduction in all haemopoietic

tissue replaced by fat spaces —important to exclude hypocellular MDS

or leukaemia —the main differential diagnoses.

2 Flow cytometry using anti-CD55 and anti-CD59 will show lack of both

membrane proteins. Ham’s acid lysis test is now largely obsolete.

2 Specialised cytogenetics on blood to exclude Fanconi syndrome (see

p456).

Complications

2 Progression to more severe disease.

2 Evolution to PNH —occurs in 7%.

2 Transformation to acute leukaemia occurs in 5-10%.

Treatment

2 Mild cases need careful observation only. More severe will need sup-

portive treatment with red cell and platelet transfusions and antibiotics

as needed. Blood products should be CMV -ve, and preferably leu-

codepleted to reduce risk of sensitisation.

2 Specific treatment options are between allogeneic transplant and

immunosuppression.

2 Sibling allogeneic transplant treatment of choice for those <50 with

sibling donor. Should go straight to transplant avoiding immunosup-

pression and blood products if possible.

2 Matched unrelated donor transplant should be considered in <25 age

group.

2 Immunosuppressive options include anti-lymphocyte globulin (ALG)

± cyclosporin. Response to ALG may take 3 months. Refractory or

relapsing patients may respond to a second course of ALG from

another animal.

2 Cyclosporin post-ALG looks promising.

2 Androgens or danazol may be useful in some cases.

Abkowitz, J.L. (2001) Aplastic anemia: which treatment? Ann Intern Med, 135, 524-526; Young,

N.S. & Barrett, A.J. (1995) The treatment of severe acquired aplastic anemia. Blood, 85,

3367-3377.

Paroxysmal nocturnal

haemoglobinuria

Definition

Acquired clonal abnormality of cell membranes rendering them more sen-

124

sitive to complement-mediated lysis, most noticeable in RBCs. Cells lack

phosphatidylinositol glycoproteins (PIG) transmembrane anchors.

Incidence

Rare. Aplastic anaemia is closely related.

Clinical features

2 Chronic intravascular haemolytic anaemia particularly overnight (?due

to lower blood pH). Infections trigger acceleration of haemolysis.

2 WBC and platelet production also often 5.

2 Chronic haemolysis may induce nephropathy.

2 Haemoglobinuria usually results in iron deficiency.

2 44 tendency to venous thrombosis particularly at atypical sites e.g.

hepatic vein (Budd-Chiari syndrome), sagittal sinus thrombosis.

2 Fatigue, dysphagia and impotence occasionally seen.

Diagnosis and treatment

2 FBC, blood film —polychromasia and reticulocytosis (cf. AA).

2 BM aspirate and trephine biopsy —usually hypoplastic with increased

fat space but with erythropoietic nests or islands distinct from AA.

2 Ham’s test (acidified serum lysis) is invariably +ve though seldom used

now.

2 Cellular immunophenotype shows altered PIG proteins, CD55 and

CD59.

2 Urinary haemosiderin +ve.

Complications

2 May progress to more severe aplasia.

2 Transforms to acute leukaemia in 5%.

2 Serious thromboses in up to 20%.

Treatment:

2 Chronic disease —supportive care may be satisfactory in mild cases.

2 Iron replacement usually required.

2 Trial of steroid/androgens/danazol may 5 symptoms and transfusion

need.

2 ALG/cyclosporin may be indicated for more severe cases as for

aplastic anaemia.

2 Acute major thromboses should be treated aggressively with urgent

thrombolysis and 10 days heparin. Long-term warfarin mandatory.

Consider warfarin prophylaxis after any one clotting episode.

2 Severe cases <50 years should be considered for sibling allogeneic

transplant if they have a donor —consider MUD in <25 age group if no

sibling donor.

Pure red cell aplasia

Definition

A severe anaemia characterised by reticulocytes <1% in PB, <0.5% mature

erythroblasts in BM but with normal WBC and platelets.

126

Incidence

Rare.

Classification of red cell aplasia

Congenital Diamond-Blackfan anaemia (DBA), see p452

Acquired Childhood: Transient erythroblastopenia of childhood (TEC)

Adults:

Primary: autoimmune or idiopathic

Secondary chronic: thymoma, haematological

malignancies especially CLL, pernicious anaemia,

some solid tumours, SLE, RA, malnutrition with

riboflavin deficiency

Secondary transient: infections especially Parvovirus

B19, CMV, HIV, many drugs

Recent interest following red cell aplasia in renal

patients treated with subcutaneous Epo

Clinical features

2 Lethargy usually only symptom of the anaemia since slow onset.

2 No abnormal physical signs except of any underlying disease.

Diagnosis and investigations

2 FBC shows severe normochromic, normocytic anaemia with retics

<1%. WBC and platelets normal.

2 BM shows absence of erythroblasts but is normocellular (distinguishes

from aplastic anaemia).

Treatment

2 Treat underlying cause first if identified.

2 Remove thymoma.

2 If due to parvovirus B19, try IVIg.

2 Assume immune origin if no other cause found and give prednisolone

60mg od PO as starter dose ~40% response. Failure of response, try

cyclosporin or ALG or azathioprine.

Prognosis

2 15% have spontaneous remission. 65% will respond to immunosup-

pression.

2 50% will relapse but 80% of relapsers will respond again.

2 A few progress to AA or AML.

Iron overload

Iron is an essential metal but overload occurs when intake of iron exceeds

requirements and occurs due to the absence in humans of a physiological

mechanism to excrete excess iron. Sustained 4 Fe intake (dietary or par-

enteral) may result in iron accumulation, overload and potentially fatal

128

tissue damage.

Timing and pattern of tissue damage is determined by rate of accumula-

tion, the quantity of total body iron and distribution of iron between retic-

uloendothelial (RE) storage sites and vulnerable parenchymal tissue. Iron

accumulation in parenchymal cells of the liver, heart, pancreas and other

organs is the major determinant of clinical sequelae.

Haemochromatosis

2 Inherited (autosomal recessive) occurring in up to 0.5% population (N.

Europe).

2 Haemochromatosis locus is tightly linked to the HLA locus on chro-

mosome 6p and up to 10% population are heterozygous.

2 Single missense mutation found in the homozygous state in 80% of

patients.

2 The gene designated HFE is an MHC class Ib gene.

2 Homozygotes develop symptomatic iron overload.

Caused by failure to regulate iron absorption from bowel causing progres-

sive increase in total body iron. Parenchymal accumulation occurs initially

in liver then pancreas, heart, skin and other organs rather than RE sites.

Symptoms do not usually develop until middle age when body iron stores

of ≥15-20g have accumulated. Environmental factors (e.g. alcohol use in

males and menstruation in females) affect rate of accumulation and age at

presentation. Clinical expression of haemochromatosis is seen 10¥ more

commonly in 9. Only 25% of heterozygotes show evidence of minor

increases in iron stores and clinical problems do not occur.

Clinical manifestations of iron overload only occur in homozygotes and

presentation as ‘bronze diabetes’ is characteristic.

Clinical features of Fe overload (homozygous haemochromatosis)

2 Skin pigmentation

Slate grey or bronze discolouration

2 Hepatic dysfunction

Hepatomegaly, chronic hepatitis, fibrosis,

cirrhosis, hepatocellular carcinoma (20-30%)

2 Diabetes mellitus

Retinopathy, nephropathy, neuropathy, vascular

complications

2 Gonadal dysfunction

Hypogonadism, impotence

2 Other endocrine dysfunction Hypothyroidism, hypoparathyroidism, adrenal

insufficiency

2 Abdominal pain

Unknown aetiology (25%)

2 Cardiac dysfunction

Cardiomyopathy, heart failure, dysrhythmias

(10-15%)

2 Chondrocalcinosis

Arthropathy

Red cell disorders

Evaluation of iron status

Most useful indirect measure of iron stores is serum ferritin estimation.

Rises to maximum concentration of 4000µg/L and may underestimate

129

extent of iron overload in some patients. Note: may be spuriously

increased by infection, inflammation or neoplasia. The % transferrin satu-

ration provides confirmatory evidence but no measure of the extent of

iron overload. Liver biopsy provides a direct albeit invasive measure of

iron stores (% iron concentration by weight) and visual assessment of iron

distribution, and the extent of tissue damage.

Diagnosis

May be difficult to differentiate haemochromatosis from iron overload 2°

to other causes, particularly that associated with chronic liver disease.

Recent identification of HFE gene will provide a tool for more definitive

diagnosis and screening of relatives (previously performed by serum fer-

ritin estimation).

Management

2 Aim to reduce iron stores to <50µg/L and prevent complications of

overload.

2 Achieved by regular venesection (500mL blood) on weekly basis until

iron deficiency develops (may take many months).

2 Hb should be measured prior to each venesection and response to

therapy can be monitored by intermittent measurement of the serum

ferritin.

2 Once iron deficiency develops a maintenance regimen can be com-

menced with venesection every 3-4 months.

Natural history

Cirrhosis and hepatocellular carcinoma are the most common causes of

death in patients with haemochromatosis and are due to hepatic iron

accumulation. Cirrhosis does not usually develop until the hepatic iron

concentration reaches

4000-5000µg/g of liver

(normal

50-500µg/g).

Hepatocellular carcinoma is the cause of death in 20-30% but does not

occur in the absence of cirrhosis which increases the risk over 200¥. If

venesection can be commenced prior to the development of cirrhosis and

other complications of haemosiderosis the life expectancy is that of a

normal individual. Reduction of iron overload by venesection has only a

small effect on symptomatology which has already developed: skin pig-

mentation diminishes, liver function may improve, cardiac abnormalities

may resolve, diabetes and other endocrine abnormalities may improve

slightly, arthropathy is unaffected.

Olynyk, J.K. et al. (1999) A population-based study of the clinical expression of the hemochro-

matosis gene. N Engl J Med, 341, 718-724; Sanchez, A.M. et al. (2001) Prevalence, donation prac-

tices, and risk assessment of blood donors with hemochromatosis. JAMA, 286, 1475-1481.

Transfusion haemosiderosis

Iron overload occurs in patients with transfusion dependent anaemia,

notably thalassaemia major, Diamond-Blackfan syndrome, aplastic

anaemia and acquired refractory anaemia. In many of these conditions iron

overload is aggravated by physiological mechanisms which promote

130

increased dietary absorption of iron in response to ineffective erythro-

poiesis. Each unit of blood contains 250mg iron and average transfusion

dependent adult receives 6-10g of iron/year. Distribution of iron is similar

to haemochromatosis with primarily liver parenchymal cell accumulation

followed by pancreas, heart and other organs. Cardiac deposition occurs

in patients who have received 100 units of blood (20g iron) without chela-

tion, and is followed by damage to the liver, pancreas and endocrine

glands.

Clinical features of iron overload in children who require transfusion

support for hereditary anaemia are listed. Similar problems excluding

those related to growth and sexual maturation develop in patients who

commence a transfusion programme for acquired refractory anaemia in

later life.

Features of transfusion haemosiderosis in hereditary anaemia

2 Growth retardation in second decade.

2 Hypogonadism —delayed or absent sexual maturation.

2 Skin pigmentation —slate grey or bronze discolouration.

2 Hepatic dysfunction —hepatomegaly, chronic hepatitis, fibrosis, cir-

rhosis, hepatocellular carcinoma.

2 Diabetes mellitus.

2 Other endocrine dysfunction —rarely hypothyroidism, hypoparathy-

roidism, adrenal insufficiency.

2 Cardiac dysfunction —cardiomyopathy, heart failure, dysrhythmias

(main cause of death).

2 Death from heart disease in adolescence.

Management

2 Iron chelation therapy by parenteral desferrioxamine is the only treat-

ment for patients with transfusion haemosiderosis, who remain

anaemic. Haemosiderosis due to previous transfusions in conditions

where Hb now normal e.g. treated AML, may be venesected to

remove iron.

2 Regular treatment is required in transfusion dependent children if they

are to avoid the consequences of iron overload in the second decade

of life.

2 SC administration of desferrioxamine by portable syringe pump over

9-12h on 5-7 nights/week is a common regimen.

2 Ascorbic acid supplementation may help mobilise iron and increase

excretion with desferrioxamine but can cause hazardous redistribution

of storage iron.

2 Early and regular desferrioxamine infusion 5 hepatic iron and improves

hepatic function, promotes growth and sexual development and pro-

tects against heart disease and early death.

Red cell disorders

2 Much work has been expended in the search for an effective non-toxic

oral chelator and deferiprone is currently under evaluation in clinical

trials.

131

Natural history

The prognosis of the underlying haematological condition in transfusion

dependent elderly patients may eliminate the need for iron chelation. In

others with a longer life expectancy, IV infusion of desferrioxamine with

each blood transfusion may adequately delay the rate of iron accumula-

tion.

Other causes of haemosiderosis

Dietary iron overload may also occur as a result of chronic over-ingestion

of iron-containing traditional home-brewed fermented maize beverages

peculiar to sub-Saharan Africa, which overwhelms physiological controls

on iron absorption. Iron stores may >50g and iron is initially deposited in

both hepatocytes and Kupffer cells but when cirrhosis develops, accumu-

lates in the pancreas, heart and other organs. Over-ingestion of medicinal

iron may possibly have a similar though less dramatic effect but is certainly

harmful to patients with iron-loading disorders. The excessive iron

absorption seen in patients with chronic liver disease is associated with

accumulation in Kupffer cells rather than hepatic parenchyma. Rare con-

genital defects associated with iron overload have been reported.

Neutrophilia

Neutrophils are derived from same precursor as monocytes. Cytoplasm

contains granules; the nucleus has

3-4 segments. Functions include

chemotaxis —neutrophils migrate to sites of inflammation by chemotactic

factors e.g. complement components

(C5a and C3), and cytokines.

Cytotoxic activity is via phagocytosis and destruction of particles/invading

microorganisms (latter often antibody coated

= opsonised). Granules

contain cationic proteins7lyse Gram -ve bacteria, ‘defensins’, myeloper-

134

oxidase —interacts with H₂O₂

and HCl7hypochlorous acid

(HOCl);

lysozyme (hydrolyses bacterial cell walls); superoxide (O_2-) and hydroxyl

(OH^-) radicals. Neutrophil lifespan is ~1-2d in tissues.

Normal neutrophil count 2.0-7.5

¥ 10⁹/L (neonate differs from adult; see

Normal ranges p690).

Neutrophilia is defined as an absolute neutrophil count >7.5

¥ 10⁹/L.

Mechanisms

2 Increased production.

2 Accelerated/early release from marrow7blood.

2 Demargination (marginal pool7circulating pool).

Causes

2 Infection (bacterial, viral, fungal, spirochaetal, rickettsial).

2 Inflammation (trauma, infarction, vasculitis, rheumatoid disease, burns).

2 Chemicals e.g. drugs, hormones, toxins, haemopoietic growth factors

e.g. G-CSF, GM-CSF, adrenaline, corticosteroids, venoms.

2 Physical agents e.g. cold, heat, burns, labour, surgery, anaesthesia.

2 Haematological e.g. myeloproliferative disease, CML, PPP (primary

proliferative polycythaemia), myelofibrosis, chronic neutrophilic

leukaemia.

2 Other malignancies.

2 Cigarette smoking.

2 Post-splenectomy.

2 Chronic bleeding.

2 Idiopathic.

Investigation

History and examination. Ask about cigarette smoking, symptoms

suggesting occult malignancy.

Other investigations

ESR, CRP.

Treatment

Usually treatment of underlying disorder is all that is required.

Leukaemoid reaction

May resemble leukaemia (hence name); see 4 WBC (myeloblasts and

promyelocytes prominent). Occurs in severe and/or chronic infection,

metastatic malignancy.

Neutropenia

Defined as absolute peripheral blood neutrophil count of <2.0

¥ 10⁹/L.

Racial variation: Black and Middle Eastern people may have neutrophil

count of <1.5

¥ 10⁹/L normally.

Congenital neutropenia syndromes

Kostmann’s syndrome:

Paediatric haematology, p459.

136

Chediak-Higashi:

Paediatric haematology, p465.

Shwachman-Diamond syndrome:

Paediatric haematology, p459.

Cyclical neutropenia: 3-4 week periodicity; often 21d cycle, lasts 3-6d.

Miscellaneous: transcobalamin II deficiency, reticular dysgenesis,

dyskeratosis congenita.

Acquired neutropenia

Acquired neutropenia: commonest causes

Infection

Viral, e.g. influenza, HIV, hepatitis,

overwhelming bacterial sepsis

Drugs

Anticonvulsants (e.g. phenytoin)

Antithyroid (e.g. carbimazole)

Phenothiazines (e.g. chlorpromazine)

Antiinflammatory agents (e.g. phenylbutazone)

Antibacterial agents (e.g. cotrimoxazole)

Others (gold, penicillamine, tolbutamide,

mianserin, imipramine, cytotoxics)

Immune mediated

Autoimmune (antineutrophil antibodies)

SLE

Felty’s syndrome (rheumatoid arthritis +

neutropenia + splenomegaly; no correlation

between spleen size and degree of

neutropenia)

As part of pancytopenia

Bone marrow failure

Leukaemia, lymphoma, LGLL, haematinic

deficiency, anorexia

Splenomegaly

Any cause

Clinical features—when severe neutropenia: throat/mouth infection, oral

ulceration, septicaemia.

Diagnosis—examine peripheral blood film, check haematinics,

autoimmune profile, anti-neutrophil antibodies, haematinics, bone

marrow aspirate and trephine biopsy if indicated (e.g. severe or prolonged

White blood cell abnormalities

neutropenia, or features suggestive of infiltration of marrow failure

syndrome).

Treatment—consists of prompt antibiotic therapy if infection, IVIg and

corticosteroids may be helpful but effects unpredictable. In seriously ill

137

patients consider use of G-CSF (need to exclude underlying leukaemia

before starting therapy with growth factors). Consider prophylaxis with

low dose antibiotics (e.g. ciprofloxacin 250mg bd) and antifungal (e.g.

fluconazole

100mg od) agents. Drug-induced neutropenia usually

recovers on stopping suspected agent (may take 1-2 weeks).

Bux, J. et al. (1998) Diagnosis and clinical course of autoimmune neutropenia in infancy: analysis

of 240 cases. Blood, 91, 181-186; Dale, D.C., Bolyard, A.A. & Aprikyan, A. (2002) Cyclic neu-

tropenia. Semin Hematol, 39, 89-94.

Lymphocytosis and lymphopenia

Lymphocytes are small cells with a high N:C ratio; some (e.g. natural killer

cells) have prominent cytoplasmic granules. Two principal types: B and T

lymphocyte. B-cells express monoclonal surface (not cytoplasmic) IgM and

often IgD. B-cell stimulation through cross linkage of surface Ig molecules

or via effector T cells causes their differentiation into plasma cells.

Predominant role is humoral immunity via Ig secretion.

138

T cells are derived from stem cells that undergo maturation in thymus and

express T-cell receptor molecule (CD3) on cell surface. Responsible for

cell-mediated immunity e.g. delayed hypersensitivity, graft rejection,

contact allergy and cytotoxic reactions against other cells.

Lymphocytosis (peripheral blood lymphocytes >4.5

¥ 10⁹/L)

2 Leukaemias and lymphomas including: CLL, NHL, Hodgkin’s disease,

acute lymphoblastic leukaemia, hairy cell leukaemia, Waldenström’s

macroglobulinaemia, heavy chain disease, mycosis fungoides, Sézary

syndrome, large granular lymphocyte leukaemia, adult T-cell leukaemia

lymphoma (ATLL).

2 Infections e.g. EBV, CMV, Toxoplasma gondii, rickettsial infection,

Bordetella pertussis, mumps, varicella, coxsackievirus, rubella, hepatitis

virus, adenovirus.

2 ‘Stress’ e.g. myocardial infarction, sickle crisis.

2 Trauma.

2 Rheumatoid disease (occasionally).

2 Adrenaline.

2 Vigorous exercise.

2 Post-splenectomy.

2 b thalassaemia intermedia.

Lymphopenia (peripheral blood lymphocytes <1.5

¥ 10⁹/L)

2 Malignant disease e.g. Hodgkin’s disease, some NHL, non-haematopoi-

etic cancers, angioimmunoblastic lymphadenopathy.

2 MDS.

2 Collagen vascular disease e.g. rheumatoid, SLE, GvHD.

2 Infections e.g. HIV.

2 Chemotherapy.

2 Surgery.

2 Burns.

2 Liver failure.

2 Renal failure (acute and chronic).

2 Anorexia nervosa.

2 Iron deficiency (uncommon).

2 Aplastic anaemia.

2 Cushing’s disease.

2 Sarcoidosis.

2 Congenital disorders (rare) such as SCID, reticular dysgenesis,

agammaglobulinaemia (Swiss type), thymic aplasia (DiGeorge’s syn-

drome), ataxia telangiectasia.

Eosinophilia

Differential diagnosis

Common

2 Drugs (huge list e.g. gold, sulphonamides, penicillin); erythema multi-

forme (Stevens-Johnson syndrome).

2 Parasitic infections: hookworm, Ascaris, tapeworms, filariasis, amoebi-

140

asis, schistosomiasis.

2 Allergic syndromes—asthma, eczema, urticaria.

Less common

2 Pemphigus.

2 Dermatitis herpetiformis (DH).

2 Polyarteritis nodosa (PAN).

2 Sarcoid.

2 Tumours esp. Hodgkin’s.

2 Irradiation.

Rare

2 Hypereosinophilic (Loeffler’s) syndrome.

2 Eosinophilic leukaemia.

2 AML with eosinophilia esp. M4Eo (see p151).

Discriminating clinical features

2 Drugs: history of exposure, time course of eosinophilia with resolution

on cessation of drug.

2 Allergic conditions: history of eczema, urticaria or typical rashes.

Symptoms and signs of asthma.

2 Parasites: history of exposure from foreign travel, symptoms and signs

of iron deficiency anaemia (hookworm is commonest cause world-

wide). Blood film may show filariasis. Stool microscopy and culture for

ova, cysts and parasites for amoebiasis, Ascaris, Taenia, schistosomiasis.

2 Skin diseases: typical appearances confirmed by biopsy e.g. dermatitis

herpetiformis and pemphigus.

2 PAN: renal failure, neuropathy, angiography and ANCA positivity.

2 Sarcoid: multi-system features with non-caseating granulomata in

biopsy of affected tissue or on BM biopsy; high serum ACE.

2 Hodgkin’s: lymphadenopathy, hepatosplenomegaly—BM or node

biopsy.

2 Hypereosinophilic syndrome: history of allergy, cough, fever and pul-

monary infiltrates on CXR, may be cardiac involvement. Eosinophils on

blood film have normal morphology and granulation. Diagnosis on

exclusion of similar causes.

2 Eosinophilic leukaemia: eosinophils on blood film have abnormal

morphology with hyperlobular and hypergranular forms. BM heavily

infiltrated with same abnormal cells. Other signs of myeloproliferative

disease may be present.

2 AML M4Eo: blasts with myelomonoblastic features on BM and blood

film (see p151).

Basophilia and basopenia

Basophils are found in peripheral blood and marrow (∫ mast cells in

tissues). Short lifespan (1-2d), cannot replicate. Degranulation results in

hypersensitivity reactions (IgE F_c receptors trigger), flushing, etc.

Basophilia (peripheral blood basophils >0.1

¥ 10⁹/L)

2 Myeloproliferative disorders

- CGL.

142

- Other chronic myeloid leukaemias.

- PRV.

- Myelofibrosis.

- Essential thrombocythaemia.

- Basophilic leukaemia.

2 AML (rare).

2 Hypothyroidism.

2 IgE-mediated hypersensitivity reactions.

2 Inflammatory disorders e.g. rheumatoid disease, ulcerative colitis.

2 Drugs e.g. oestrogens.

2 Infection e.g. viral.

2 Irradiation.

2 Hyperlipidaemia.

Basopenia (peripheral blood basophils <0.1

¥ 10⁹/L)

2 As part of generalised leucocytosis e.g. infection, inflammation.

2 Thyrotoxicosis.

2 Haemorrhage.

2 Cushing’s syndrome.

2 Allergic reaction.

2 Drugs e.g. progesterone.

Monocytosis and monocytopenia

Bone marrow monocytes give rise to blood monocytes and tissue

macrophages. Part of reticuloendothelial system (RES). Other compo-

nents of RES: lung alveolar macrophages; pleural and peritoneal

macrophages; Kupffer cells in liver; histiocytes; renal mesangial cells;

macrophages in lymph node, spleen and marrow.

Contain 2 sets of granules (1) lysosomal (acid phosphatase, arylsulphatase

144

and peroxidase), and (2) function of second set unknown.

Monocytosis (peripheral blood monocytes >0.8

¥ 10⁹/L)

Common

2 Malaria, trypanosomiasis, typhoid (commonest world-wide causes).

2 Post-chemotherapy or stem cell transplant esp. if GM-CSF used.

2 Tuberculosis.

2 Myelodysplasia (MDS).

Less common

2 Infective endocarditis.

2 Brucellosis.

2 Hodgkin’s lymphoma.

2 AML (M4 or M5).

Discriminating clinical features

2 Malaria: identification of parasites on thick and thin blood films.

2 Trypanosomiasis: parasites seen on blood film, lymph node biopsy or

blood cultures.

2 Typhoid: blood culture, faecal and urine culture and BM culture.

2 Infective endocarditis: cardiac signs and blood cultures.

2 Tuberculosis: AFB seen and cultured in sputum, EMU, blood or BM,

tuberculin positivity on intradermal challenge, caseating granulomata

on biopsy of affected tissue or BM.

2 Brucellosis: blood cultures and serology.

2 Hodgkin’s: lymphadenopathy, hepatosplenomegaly, eosinophilia, biopsy

of node or BM.

2 MDS: typical dysplastic features on blood film or BM (see p218).

2 AML (M4 or M5): monoblasts on blood film and BM biopsy. Skin and

gum infiltration common, see p150.

Monocytopenia (peripheral blood monocytes <0.2

¥ 10⁹/L)

2 Autoimmune disorders e.g. SLE.

2 Hairy cell leukaemia.

2 Drugs e.g. glucocorticoids, chemotherapy.

Mononucleosis syndromes

Definition

Constitutional illness associated with atypical lymphocytes in the blood.

Clinical features

Peak incidence in adolescence: may be subclinical or acute presentation

consisting of fever, lethargy, sweats, anorexia, pharyngitis, lym-

146

phadenopathy

(cervical>axillary>inguinal), tender splenomegaly

hepatomegaly, palatal petechiae, maculopapular rash especially if given

ampicillin. Rarely also pericarditis, myocarditis, encephalitis. Usually self-

limiting illness but complications include lethargy persisting for months or

years (chronic fatigue syndrome), depression, autoimmune haemolytic

anaemia, thrombocytopenia, secondary infection and splenic rupture.

Causes

EBV, CMV, Toxoplasma, Brucella, Coxsackie and adenoviruses, HIV sero-

conversion illness.

Pathophysiology

In EBV related illness, EBV infection of B lymphocytes results in immortal-

isation and generates a T cell response (the atypical lymphocytes) which

controls EBV proliferation. In severe immunodeficiency following pro-

longed use of cyclosporin, oligoclonal EBV-related lymphoma may

develop which usually regresses with reduction of immunosuppressive

therapy but may evolve to a monoclonal and aggressive lymphoma e.g.

after MUD stem cell transplant. In malarial Africa, EBV infection is associ-

ated with an aggressive lymphoma—Burkitt’s lymphoma see p204.

Diagnosis - haematological features

2 Atypical lymphocytes on blood film (recognised by the dark blue cyto-

plasmic edge to cells and invagination (scalloping) around red blood

cells).

2 Usually lymphocytosis with mild neutropenia.

2 Occasionally anaemia due to cold antibody mediated haemolysis

(anti-i)—identify with cold haemagglutinin titre.

2 Paul Bunnell/monospot test for presence of heterophile antibody +ve

when cause is EBV but only in the first few weeks. False +ves can

occur in lymphoma.

2 4 bilirubin and abnormal LFTs.

2 Serological testing should include EBV capsid Ag, CMV IgM,

Toxoplasma titre, Brucella titre, HIV 1 and 2 Ag and Ab.

2 Immunophenotype of peripheral blood B lymphocytes shows poly-

clonality (distinguishes from lymphoma and other lymphoproliferative

disorders).

Treatment

Rest and symptom relief are mandatory. No other specific treatment has

been shown to influence outcome.

Acute myeloblastic leukaemia (AML)

Malignant tumour of haemopoietic precursor cells of non-lymphoid

lineage, almost certainly arising in the bone marrow.

Incidence

Commonest acute leukaemia in adults. 3 per 100,000 annually. Increasing

frequency with age (median 64 years; incidence 35/100,000 at age 90).

Infrequent in children under 15 years.

Aetiology

Unclear—association with pre-existing myelodysplasia, previous cytotoxic

150

chemotherapy (particularly alkylating agents and epipodophyllotoxins),

ionizing radiation, benzene exposure, constitutional chromosomal abnor-

malities

(e.g. Down’s

(older patients) and Fanconi’s syndromes) and

smoking.

Diagnosis

Made by examination of the peripheral blood film and bone marrow

(≥20% blasts). Cytochemical stains, immunological markers, cytogenetic

analysis and molecular markers are necessary to differentiate AML from

ALL and further classify the disease in preparation for therapy.

Morphological classification

The French-American-British (FAB) system is based on predominant dif-

ferentiation pathway and degree of differentiation:

Bone marrow showing myeloblasts in AML

AML: myeloblast with large Auer rod (top left).

Leukaemia

AML with minimal differentiation (SB & MPO cytochemistry

negative but myeloid immunophenotyping; may also express CD4

& CD7); 3% of cases.

AML without maturation (<10% promyelocytes/myelocytes or

monocytes; may have Auer rods) 20% of cases.

AML with maturation (≥10% promyelocytes/myelocytes; < 20%

monocytes; may have Auer rods; t(8;21)) commonest subtype:

30% of cases.

151

Acute promyelocytic leukaemia (>30% promyelocytes; multiple

Auer rods (faggot cells); t(15;17)) 10% of cases.

M3v

Microgranular variant of APL (high WBC count; minimal

granulation; Auer rods rare; t(15;17)).

Acute myelomonocytic leukaemia (mixed myeloid (>20% blasts &

promyelocytes) & monocytic (≥20%) maturation; monocytic cells

are non-specific esterase positive; may have Auer rods) 20% of cases.

M4Eo

M4 variant with 5-30% eosinophils; associated with inv(16)

chromosome abnormality. 5% of cases

M5a

Acute monoblastic leukaemia (poorly differentiated subtype with

≥80% monocytoid cells of which ≥80% are monoblasts; Auer

rods unusual) 10-15% cases are M5a or M5b.

M5b

Acute monocytic leukaemia (differentiated subtype with ≥80%

monocytoid cells including NSE-positive cells with typical

monocytic appearance; Auer rods rare)

Acute erythroleukaemia (myeloblasts sometimes with Auer rods

plus ≥50% bizarre often multinucleated erythroblasts;

erythroblasts often PAS-positive) 3-5% of cases but 10-20% of

secondary leukaemias.

Acute megakaryoblastic leukaemia (difficult to diagnose

morphologically; often dry tap due to fibrosis; requires

immunophenotyping with anti-platelet antibodies or electron

microscope analysis of platelet peroxidase) rare.

Cytochemistry

Former mainstay of leukaemia diagnosis; Sudan black (SB), myeloperoxi-

dase (MPO) and esterase (chloroacetate and non-specific esterase) stains

are positive in AML and negative in ALL (<3% blasts positive). Non-spe-

cific esterase (NSE) is positive in monocytic cells.

World Health Organisation (WHO) classification of acute

myeloid leukaemia

Although the FAB classification has provided a morphological classification

of AML for almost 30 years the correlation between morphology and

both genetic and clinical features is imperfect. The WHO classification

attempts to correlate morphological, genetic and clinical features to cate-

gorise cases of AML into unique clinical and biological subgroups.

In the WHO classification the blast threshold for the diagnosis of AML is

reduced from 30% to 20% BM blasts (i.e. most patients previously diag-

nosed as RAEB-t will be classified as AML with multilineage dysplasia) and

patients with clonal recurring abnormalities t(8;21)(q22;q22),

inv(16)(q13q22), t(16;16)(p13;q22) or t(15;17)(q22;q12) should be con-

sidered to have AML regardless of the blast percentage.

WHO classification of acute myeloid leukaemia

Acute myeloid leukaemia with recurrent genetic abnormalities

2 Acute myeloid leukaemia with t(8;21)(q22;q22), (AML1/ETO)

2 Acute myeloid leukaemia with abnormal BM eosinophils and

inv(16)(q13;q22) or t(16;16)(p13;q22), (CBFb/MYH11) (= FAB M4Eo)

2 Acute promyelocytic leukaemia with t(15;17)(q22;q12), (PML/RARa) and

152

variants (= FAB M3)

2 Acute myeloid leukaemia with 11q23 (MLL) abnormalities

Acute myeloid leukaemia with multilineage dysplasia

2 Following MDS or MDS/MPD

2 Without antecedent MDS or MDS/MPD, but with dysplasia in at least 50%

of cells in 2 or more myeloid lineages

Acute myeloid leukaemia and myelodysplastic syndromes, therapy-related

2 Alkylating agent/radiation-related type

2 Topoisomerase II inhibitor-related type (some may be lymphoid)

2 Others

Acute myeloid leukaemia, not otherwise categorised

Categorise as:

2 Acute myeloid leukaemia, minimally differentiated (= FAB M0)

2 Acute myeloid leukaemia, without maturation (= FAB M1)

2 Acute myeloid leukaemia with maturation (= FAB M2)

2 Acute myelomonocytic leukaemia (= FAB M4)

2 Acute monoblastic/ acute monocytic leukaemia (= FAB M5a/5b)

2 Acute erythroid leukaemia: erythroid/myeloid (≥ 50% erythroid precursors

plus ≥20% blasts; = FAB M6) and pure erythroleukaemia (≥80% immature

erythroid precursors)

2 Acute megakaryoblastic leukaemia (= FAB M7)

2 Acute basophilic leukaemia

2 Acute panmyelosis with myelofibrosis (= acute myelofibrosis)

2 Myeloid sarcoma

Immunophenotyping

Monoclonal antibodies to cell surface antigens reliably differentiate AML

from ALL and confirm the diagnosis of M0, M6 and M7 ( p153).

Leukaemia

Panel of monoclonal antibodies to differentiate AML & ALL

Myeloid

Anti-MPO; CD13; CD33; CDw65; CD117

B lymphoid

CD19; cytoplasmic CD22; CD79a; CD10

T lymphoid

Cytoplasmic CD3; CD2; CD7

Immunophenotypic patterns in AML subtypes

153

Undifferentiated (M0)

Anti-MPO; CD13; CD33; CD34; CDw65;

CD117; negative cytochemistry; lymphoid

markers

Myelomonocytic (M1-M5): anti-MPO; CD13; CD33; CDw65; CD117

Monocytic (M4 & M5) Stronger expression of CD11b & CD14

Erythroid (M6)

Anti-glycophorin A

Megakaryocytic (M7)

CD41; CD61

Bain, B.J. et al. (2002) Revised guideline on immunophenotyping in acute leukaemias and

chronic lymphoproliferative disorders. Clin Lab Haematol, 24, 1-13.

http://www.bcshguidelines.com/pdf/CLH135.PDF

Lineage infidelity

It is sometimes impossible to define a single lineage for leukaemic blasts

on the basis of phenotypic marker expression. The expression of markers

of more than one cell lineage by a leukaemic cell is termed lineage infi-

delity and may reflect abnormal gene expression in the clone or abnormal

maturation of an early uncommitted precursor. Blasts can display cyto-

chemical and immunophenotypic markers of both myeloid and lymphoid

precursors. Up to 50% of myeloid leukaemias may be positive for lym-

phoid antigens, most commonly CD2 (34%) and CD7 (42%) and this does

not appear to have prognostic significance.

Biphenotypic leukaemias

A minority of acute leukaemias (~7%) have two distinct leukaemic cell

populations on phenotyping and are characterised as biphenotypic

leukaemias. Most commonly these cell populations express B-lymphoid

and myeloid markers and are associated with a high frequency of

t(9;22)(q34;q11), the Ph chromosome. These patients have variable

response rates. Some may display ‘lymphoid’ features such as marked lym-

phadenopathy and high blast counts.

Cytogenetic analysis

Should be performed in all cases of acute leukaemia. It detects translocations

and deletions that provide independent prognostic information in AML.

‘Favourable risk’ cytogenetics

2 t(8;21)(q22;q22): FAB M2; 5-8% adults <55 years, rare older; fusion

gene AML1/ETO.

2 inv(16)(p13;q22) or t(16;16)(p13;q22): FAB M4Eo; 10% adults <45

years, rare older; fusion gene CBFb/MYH11.

2 t(15;17)(q21;q11): FAB M3; 15% adults <45 years, rare older; fusion

gene PML-RARa. Variants: t(11;17)(q23;q11) fusion gene PLZF-RARa;

t(5;17)(q32;q11) fusion gene NPM-RARa; t(11;17)(q13;q11) fusion gene

NuMA-RARa.

‘Intermediate risk’ cytogenetics

2 Normal karyotype: any FAB type; 15-20% adults.

154

2 + 8: any FAB type; 10% adults.

2 abnormal 11q23*: >50% infant AML cases; 5-7% adults; fusion gene MLL.

2 Others: del(9q)*; del(7q)*; +6; +21; +22; -Y and 3-5 complex abnor-

malities* plus other structural or numerical defects not included in the

good risk or poor risk groups.

‘Poor risk’ cytogenetics

2 -5/del(5q): any FAB type; >10% adults >45years.

2 -7/del(7q): any FAB type; >10% adults >45 years.

2 Complex karyotypes (>5 abnormalities*)

2 Others: t(6;9)(p23;q34); t(3;3)(q21;q96); 20q; 21q; t(9;22); abn 17p.

Note: This classification is based on the MRC-UK scheme¹. Abnormalities

marked * are classed as ‘unfavourable’ i.e. ‘poor risk’ in the scheme used

by US Cooperative Groups².

Molecular analysis

Fluorescence in situ hybridisation (FISH) and reverse transcriptase-poly-

merase chain reaction (RT-PCR) methods add sensitivity and precision to

the detection of translocations, deletions and aneuploidy in cases where

conventional cytogenetics fails or gives normal results. RT-PCR detects

minimal residual disease overlooked by conventional methods.

Clinical features

2 Acute presentation usual; often critically ill due to effects of bone

marrow failure.

2 Symptoms of anaemia: weakness, lethargy, breathlessness, lightheaded-

ness and palpitations.

2 Infection: particularly chest, mouth, perianal, skin (Staphylococcus,

Pseudomonas, HSV, Candida). Fever, malaise, sweats.

2 Haemorrhage (especially M3 due to DIC): purpura, menorrhagia and

epistaxis, bleeding gums, rectal, retina.

2 Gum hypertrophy and skin infiltration (M4, M5).

2 Signs of leucostasis e.g. hypoxia, retinal haemorrhage, confusion or

diffuse pulmonary shadowing.

2 Hepatomegaly occurs in 20%, splenomegaly in 24%; the latter should raise

the question of transformed CML; lymphadenopathy is infrequent (17%)

2 CNS involvement at presentation is rare in adults with AML.

1 Grimwade, D. et al. (2001) The predictive value of hierarchical cytogenetic classification in older

adults with acute myeloid leukemia (AML): analysis of 1065 patients entered into the United

Kingdom Medical Research Council AML11 trial. Blood, 98, 1312-1320 2 Smith, M.A. et al. (1996)

The secondary leukemias: challenges and research directions. J Natl Cancer Inst, 88, 407-418.

Leukaemia

155

Gum hypertrophy in AML.

Investigations and diagnosis

2 FBC and blood film.

2 Bone marrow aspirate ± biopsy.

2 Bone marrow cytogenetics.

2 Immunophenotyping of blood or marrow blasts.

2 Total WBC usually increased with blasts on blood film—but WBC

may be low.

2 Hb, neutrophils and platelets usually 5.

2 Bone marrow heavily infiltrated with blasts (≥20%)

2 Further recommended investigations— p544.

Emergency treatment

2 Seek expert help immediately.

2 Intensive cardiovascular and respiratory resuscitation may be needed if

septic shock or massive haemorrhage.

2 Immediate empirical broad spectrum antibiotic treatment for neu-

tropenic sepsis.

2 Leucapheresis if peripheral blast count high or signs of leucostasis

(retinal haemorrhage, reduced conscious level, diffuse pulmonary shad-

owing on CXR, or hypoxia).

2 Intensive hydration with alkalinisation of the urine to prevent acute

tumour lysis syndrome in patients with a high peripheral blast cell

count (>100

¥ 10⁹/L).

Supportive treatment

2 Explain diagnosis and offer counselling—the word ‘leukaemia’ and

prospect of prolonged chemotherapy are often distressing.

2 RBC and platelet transfusion support will continue through treatment.

2 Start neutropenic regimen ( p550) as prophylaxis.

2 Start hydration aiming for urine output >100mL/h throughout induc-

tion therapy.

2 Start allopurinol or Rasburicase to prevent hyperuricaemia.

2 Insert tunnelled central venous catheter ( p568).

Specific treatment

Initial aim of therapy is to eliminate the leukaemic cells and achieve a com-

plete haematological remission (CR), defined as normal BM cellularity

with blast cells

<5% and normal representation of trilineage

haematopoiesis, normalisation of peripheral blood count with no blast

cells, neutrophils ≥1.5

¥ 10⁹/L, platelets ≥100

¥ 10⁹/L and Hb>10g/dL.

Leukaemia is undetectable by conventional morphological techniques but

may be demonstrated by more sensitive molecular techniques (when

available) and CR is not synonymous with cure. CR may result from a

three-log kill from 10¹² leukaemic cells at diagnosis to 10⁹ at CR.

Treatment consists of 3 phases: (1) remission induction to achieve CR

156

(usually 1-2 courses of combination chemotherapy); (2) consolidation

therapy to reduce leukaemia burden further and reduce risk of relapse

(optimum number unknown, usually 2-4 which may include an ‘intensifica-

tion’ phase or an autologous or allogeneic stem cell transplant); (3) main-

tenance therapy has been abandoned in AML except in some elderly

patients where intensive consolidation cannot be tolerated.

Enter patient into MRC or other high quality trial if possible. MRC ran-

domised studies in acute leukaemia are based on large patient numbers

and compare incremental experimental therapy with best treatment

arm from previous trials.

Treatment protocols are age related; patients >60 only tolerate less

intensive treatments and very rarely transplantation.

Supportive treatment alone is a valid treatment option in the >75 age

group or if there are coexistent serious general medical problems.

Outline treatment for patients <60 years is 4-5 courses of intensive

combination chemotherapy initially including daunorubicin or another

anthracycline and cytosine arabinoside each lasting 5-10 days with a

2-3 week period of profound myelosuppression.

Major complications are infective episodes which may be bacterial

(Gram +ve and Gram -ve), fungal (Candida and Aspergillus), and less

commonly viral (esp. HSV, HZV).

APML (FABM3) is a distinct category of AML requiring different treat-

ment. The risk of DIC prior to and during initial therapy due to release

of thromboplastins from leukaemic cells is an indication for urgent

treatment. The use of all-trans-retinoic acid (ATRA) with initial therapy

reduces the risk of DIC. After this the prognosis is good. ATRA

induces differentiation of the abnormal clone by overcoming the mole-

cular block resulting from the t(15;17) translocation. ATRA alone

cannot achieve sustained remission but in combination with

chemotherapy 70% of patients may be cured. Arsenic trioxide appears

to be a useful agent in those patients who relapse. Persistence of the

fusion product after therapy detected by RT-PCR predicts relapse.

Autologous stem cell transplantation is an option for intensive consoli-

dation of younger patients (<60) with intermediate or poor-risk

disease who achieve CR. It has lower procedure-related mortality or

morbidity than an allograft but lacks a graft-versus-leukaemia effect and

has a relapse rate of 40-50%.

Allogeneic stem cell transplantation from a compatible sibling donor is

an option for younger patients (<45) with intermediate or poor-risk

disease. Significant mortality (7-13%) and morbidity may be reduced

Leukaemia

by non-myeloablative conditioning regimens and increase the age

range. Unrelated donor grafts have higher toxicity. Donor lymphocyte

infusion (DLI) is used to treat recurrence after an allogeneic transplant.

2 In the longer term, relapse is the main complication.

Prognosis

2 70-80% of patients aged <60 years will achieve a CR with a modern

regimen and good supportive care; more intensive induction and con-

157

solidation regimens reduce the risk of relapse.

2 Relapse risk at 5 years in patients <60 with favourable risk cytoge-

netics is 29-42%; intermediate risk 39-60%; poor risk 68-90%.

2 50-60% of patients aged ≥60 years achieve CR with induction treat-

ment (rate drops with each decade) but relapse occurs in 80-90%; a

higher proportion have poor risk karyotype, previous myelodysplasia

and co-morbidity; treatment-related morbidity and mortality is high.

Prognostic factors

The most important prognostic factors predicting for achievement of

remission and for subsequent relapse are:

1. Advancing patient age; <50 favourable; >60 unfavourable.

2. Presenting leucocyte count; <25

¥ 10⁹/L favourable; >100

¥ 10⁹/L

unfavourable.

3. History of antecedent MDS or leukaemogenic therapy: unfavourable.

4. Presence of specific cytogenetic abnormalities ( p154).

5. FAB subtype: M3, M4Eo favourable; M0, M5a, M5b, M6, M7

unfavourable.

6. Failure to achieve CR with first cycle of induction therapy predicts for relapse.

Management of relapse

2 Most relapses occur in the first 2-3 years.

2 Younger age and longer duration of first CR are good prognostic

factors for achieving second CR.

2 ~50% of patients achieve second CR with further therapy; under 10%

survive over 3 years without a transplant procedure.

Acute lymphoblastic leukaemia (ALL)

Malignant tumour of haemopoietic precursor cells of the lymphoid lineage

probably arising from the marrow in most cases.

Incidence

Commonest malignancy in childhood with the majority of cases in the

2-10 age group (median 3.5 years). Five times more frequent in childhood

than AML. Rare leukaemia in adults, 0.7 to 1.8/100,000 annually. In adults,

there is a peak at 15-24 years and a further peak in old age (2.3/100,000

>80 years).

158

Aetiology

Unknown. Predisposing factors are ionizing radiation

(AML is more

common) and congenital predisposition in Down’s (20-fold in childhood),

Bloom’s, Klinefelter’s and Fanconi’s syndromes. Chemicals, pollution,

viruses, urban/rural population movements, father’s radiation exposure,

radon levels and proximity to power lines have all been postulated.

Morphological Classification (French-American-British, FAB)

Small monomorphic type—small homogeneous blasts, single

inconspicuous nucleolus, regular nuclear outline; commonest

subtype.

Large heterogeneous type—larger blasts, more pleomorphic and

multinucleolate, irregular frequently clefted nuclei with

conspicuous nucleoli.

Burkitt cell type—large homogeneous blasts, abundant strongly

basophilic cytoplasm with vacuoles; associated with B-cell

phenotype.

Immunophenotyping

A panel of monoclonal antibodies is used to differentiate ALL from AML

(

p153). A further panel of B-and T-lineage markers and lymphocyte

maturation markers subclassify ALL.

Immunological classification of ALL

B lineage

2 Pro B-ALL: HLA-DR+,TdT+,CD19+ (5% children; 11% adults).

2 Common ALL: HLA-DR+,TdT+,CD19+,CD10+ (65% children; 51%

adults).

2 Pre B-ALL: HLA-DR+,TdT+,CD19+,CD10±,cytoplasmic IgM+

(15% children; 10% adults).

2 B-cell ALL: HLA-DR+,CD19+,CD10±,surface IgM+ (3% children; 4%

adults)

T lineage

2 Pre-T ALL: TdT+,cytoplasmic CD3+,CD7+ (1% children; 7% adults).

2 T-cell ALL: TdT+,cytoplasmic CD3+, CD1a/2/3+,CD5+ (11% children;

17% adults).

Leukaemia

Cytogenetic analysis

2 Provides important prognostic information in both childhood and adult

ALL. Abnormalities are detected in up to 85%. The major abnormali-

ties are clonal translocations: t(9;22), t(4;11), t(8;14), t(1;19) or

t(10;14) and other structural abnormalities (9p, 6q or 12p). If no struc-

tural abnormalities are present, the abnormalities can be classified by

the modal chromosome number: <46 (hypodiploid); 46 with other

159

structural abnormalities (pseudodiploid); 47-50 (hyperdiploid); >50

(hyper-hyperdiploid). With the exception of t(9;22) each has an inci-

dence in the order of 5-10% or less.

2 t(9;22)(q34;q11) produces the Philadelphia chromosome found in 5% of

children and 25% of adults with ALL and is a very strong adverse prog-

nostic factor in both; the resultant BCR-ABL hybrid product is the same

210 kDa protein detected in CML in 33% but is a smaller 180 kDa

protein in 66%; it can be used for minimal residual disease detection.

2 t(8;14) is associated with B-cell ALL (L3 morphology) and occurs in 5%

of cases (dysregulates the myc proto-oncogene), t(1;19) is associated

with B-cell precursor ALL; t(4;11) occurs in 80% of infants with ALL

and 6% of adults and fuses the MLL gene from 11q23 to the AF4 gene

from 4q21 which can be detected by PCR; all these abnormalities are

associated with refractory disease and early relapse

2 Hyper-hyperdiploidy (>50 chromosomes) confers a favourable prog-

nosis; combined +4, +10 confers a favourable outcome in B-cell pre-

cursor ALL; patients with hypoploidy (<46 chromosomes) and

pseudodiploidy fare less well.

Clinical features

2 Acute presentation usual; often critically ill due to effects of bone

marrow failure.

2 Symptoms of anaemia: weakness, lethargy, breathlessness, lightheaded-

ness and palpitations.

2 Infection: particularly chest, mouth, perianal, skin (Staphylococcus,

Pseudomonas, HSV, Candida). Fever, malaise, sweats.

2 Haemorrhage: purpura, menorrhagia and epistaxis, bleeding gums,

rectal, retina.

2 Signs of leucostasis e.g. hypoxia, retinal haemorrhage, confusion or

diffuse pulmonary shadowing.

2 Mediastinal involvement occurs in 15% and may cause SVC obstruction

2 CNS involvement occurs in 6% at presentation and may cause cranial

nerve palsies especially of facial VII nerve, sensory disturbances and

meningism.

2 Signs include widespread lymphadenopathy in 55%, mild to moderate

splenomegaly (49%), hepatomegaly (45%) and orchidomegaly.

Investigations and diagnosis

2 FBC and blood film.

2 Bone marrow aspirate ± biopsy.

2 Bone marrow cytogenetics.

160

Mediastinal mass in T-ALL.

2 Immunophenotyping of blood or marrow blasts.

2 Total WBC usually high with blast cells on film but may be low (previ-

ously known as aleukaemic leukaemia).

2 Hb, neutrophils and platelets often low and clotting may be deranged.

2 Bone marrow heavily infiltrated with blasts (≥20%).

2 CXR and CT scan needed if ALL has B-cell or T-cell phenotype for

abdominal or mediastinal lymphadenopathy respectively.

2 Lumbar puncture mandatory to detect occult CNS involvement but

may be postponed until treatment reduces high peripheral blast count

to prevent seeding (Note—fundoscopy, CT head scan and platelet

transfusion usually required).

Bone marrow: lymphoblasts in ALL L1.

Bone marrow: lymphoblasts in ALL L3.

Leukaemia

Emergency treatment

2 iiSeek expert help immediately.

2 Cardiovascular and respiratory resuscitation may be needed if septic

shock or massive haemorrhage.

2 Immediate empirical broad spectrum antibiotic treatment for neu-

tropenic sepsis.

161

2 Leucapheresis may be needed if peripheral blast count high or signs of

leucostasis (retinal haemorrhage, reduced conscious level, diffuse pul-

monary shadowing on CXR or hypoxia).

2 LP if meningism (note precautions above).

Supportive treatment

2 Provide explanation and offer counselling—the word ‘leukaemia’ and

prospect of prolonged chemotherapy are often distressing.

2 RBC and platelet transfusion support will continue through treatment.

2 Start neutropenic regimen ( p550) as prophylaxis against infections.

2 Start hydration aiming for urine output >100mL/h throughout induc-

tion therapy ( p560 Tumour lysis syndrome—a special problem in B-

cell or T-cell ALL).

2 Start allopurinol to prevent hyperuricaemia (Note: interaction with 6-

mercaptopurine: discontinue allopurinol or reduce dose of 6-MP) or

Rasburicase (especially with high counts).

2 Insert tunnelled central venous catheter ( p568).

Specific treatment

The aims of treatment are outlined under specific treatment in AML. The

regimens used in adult ALL have evolved from successful treatments for

childhood ALL.

Treatment for ALL consists of four contiguous phases:

1. Remission induction using vincristine, prednisolone, daunorubicin and

asparaginase to achieve complete remission; more intensive induction

using more anthracycline improves leukaemia-free survival.

2. CNS prophylaxis generally combines cranial irradiation (18-24 Gy in

12 fractions over

2 weeks) and intrathecal

(IT) chemotherapy

(methotrexate ± cytarabine or prednisolone) given early in the consol-

idation phase; IT therapy is continued in the consolidation and mainte-

nance phases; CNS prophylaxis reduces the rate of CNS relapse from

30%75%.

3. Consolidation therapy to reduce tumour burden further and reduce

risk of relapse and development of drug-resistant cells; consists of

alternating cycles of induction agents and other cytotoxics; usually

includes one or two

‘intensification’ phases; combinations of

methotrexate at high dose, cytarabine, etoposide, m-amsacrine, mitox-

antrone (mitozantrone) and idarubicin are used.

4. Maintenance therapy is necessary for all patients who do not proceed

to a stem cell transplant; daily 6-MP and weekly methotrexate for 2-3

years plus cyclical administration of IV vincristine and IT methotrexate.

(ii simultaneous administration of IV vincristine and IT

methotrexate MUST be avoided as errors can be fatal)

Allogeneic stem cell transplantation: an option for adults <50 with a

compatible sib; leukaemia-free survival is superior after first remission

allograft in patients with high risk disease (40% vs. <10% for Ph+ ALL);

treatment-related mortality up to 30%; in low risk patients SCT should

be reserved for second CR.

Matched unrelated donor transplant: an option in younger patients

(<40) with very high risk disease (Ph/BCR-ABL positive ALL) but has

up to 48% treatment-related mortality.

162

Autologous stem cell transplantation: an alternative for adults up to 60:

lower treatment related mortality (up to 8%); no clear survival advan-

tage over maintenance therapy in first remission for most patients but

may improve survival in very high risk disease without option of allo-

graft.

2 Enter patient into MRC or other high quality trial if possible.

2 Major complications are infective episodes which may be bacterial

(Gram +ve and Gram -ve), viral (esp. HSV, HZV) and fungal (Candida

and Aspergillus).

2 In the longer term, relapse is the main complication.

2 Mature B-cell ALL is treated with shorter more intensive cycles

including high dose methotrexate, high dose cytarabine and fraction-

ated cyclophosphamide; it has a higher incidence of CNS disease at

diagnosis and relapse.

2 CNS leukaemia at diagnosis is treated by adding intensified intrathecal

triple therapy to cranial irradiation; IT methotrexate, cytarabine and

prednisolone 2-3

¥ times weekly over 3-4 weeks until 2 consecutive

CSF samples are negative; insertion of an Ommaya reservoir facilitates

such frequent IT therapy.

Minimal residual disease detection

Flow cytometry for clonal immunophenotypes or FISH or RT-PCR for

fusion proteins or clonal Ig/TCR gene rearrangements identified at diagnosis

can detect minimal residual disease (MRD) at a sensitivity of 10^-3-10^-6.

Morphological and molecular CR can be distinguished and detection of

MRD has strong negative prognostic implications.

Prognosis

Overall ~75% of adults with ALL achieve a CR with a modern regimen

and good supportive care; more intensive induction and consolidation

reduces relapse risk but adds toxicity; results in patients >50 are less

good.

In contrast to the high cure rate in childhood ALL, leukaemia free survival

in adult ALL in general is <30% at 5 years (patients > 50 years 10-20%).

Leukaemia-free survival (LFS) after chemotherapy in patients without

adverse risk factors is >50% whereas that for very high risk Ph/BCR-ABL+

ALL is <10%; hence the latter should have an allograft in CR1 if possible.

Leukaemia

Prognostic factors

The most important prognostic factors are listed below. These are useful

for risk stratification to identify patients who require transplantation in

first CR.

2 Patient age (<50y CR >80%, LFS>30%; ≥50y CR <60%, LFS <20%)

2 High leucocyte count (>30

¥ 10⁹/L in B precursor-ALL; >100

¥ 10⁹/L

in T-ALL) poor risk.

163

2 Immunophenotype: pro-B-ALL and pro-T-ALL have poorer outcomes;

common pre-B-ALL still poor; mature B-cell ALL and T-cell ALL had

poorer outcomes before the use of more intensive regimens, now better.

2 Cytogenetics: Ph+ very poor prognosis: <10% LFS after chemotherapy;

for others ( p159).

2 Long time to CR (>4-5 weeks)

2 High MRD level after induction (>10^-3); persistent/increasing MRD

during consolidation.

Management of relapse

2 Relapse rate is highest within the first 2 years but may occur after 7

years.

2 20% occur outside the bone marrow, generally CNS; testis and other

sites occur in 5%.

2 Isolated extramedullary relapse is often followed by haematological

relapse; these patients require local treatment followed by reinduction

therapy.

2 Best predictive factor for response is duration of first CR (better >18

months).

2 With second-line regimens 50-60% of patients will achieve a short

second CR (generally <6 months) and prompt BMT offers the only

prospect of LFS and cure.

Chronic myeloid leukaemia (CML)

Malignant tumour of an early haemopoietic progenitor cell. The clonal

marker is found in all three myeloid lineages and in some B and T lympho-

cytes demonstrating a primitive origin.

Incidence

Rare disease with a frequency of 1.25 per 100,000. Rare in children and

median age of onset is 50 years with slight 9 excess. Irradiation is the only

known epidemiological factor.

Classification

164

Classified as a myeloproliferative disorder ( p238) with which it shares

a number of clinical features. However, it also has certain unique biological

properties:

2 Characterised in >80% patients by the presence of the Philadelphia

chromosome (Ph). Reciprocal translocation between chromosomes 9

and 22, (t9;22)(q34;q11), involving two genes, BCR and ABL that form a

fusion gene BCR-ABL on chromosome 22. This produces an aberrant

210 kDa protein that has greater tyrosine kinase activity than the

normal ABL protein. This gene is believed to play a role in the patho-

genesis of CML but additional genetic changes appear necessary.

2 10% of patients have variant translocations involving chromosome 22 ± 9

and other chromosomes. A further 8% with typical clinical features lack

the Ph chromosome, i.e. have Ph-negative CML; half of these have the

hybrid BCR-ABL gene: Ph-negative, BCR-ABL-positive CML.

Natural history

2 Biphasic or triphasic disease—chronic phase, accelerated phase and

blast crisis; 50% transform directly from chronic phase to blast crisis.

2 >85% patients present in chronic phase.

2 Duration of chronic phase varies (typically 3-6 years; median 4.2 years).

2 Transformation is least likely in the 2 years immediately after diagnosis

but occurs at an annual rate of 20-25% thereafter.

2 Accelerated phase characterised by blood counts and organomegaly

becoming increasingly refractory to therapy; some have constitutional

symptoms; generally brief.

2 Blast crisis resembles acute leukaemia with >20% blasts and promyelo-

cytes in blood or marrow.

Clinical symptoms and signs

2 30% asymptomatic at diagnosis; present after routine FBC.

2 Fatigue, lethargy, weight loss, sweats.

2 Splenomegaly in >75%; may cause (L) hypochondrial pain, satiety and

sensation of abdominal fullness.

2 Gout, bruising/bleeding, splenic infarction and occasionally priapism.

2 Signs include moderate to large splenomegaly (40% >10cm),

hepatomegaly (2%), lymphadenopathy unusual.

2 Occasional signs of leucostasis at presentation.

Leukaemia

Diagnosis and investigations

2 FBC and blood film show 4 WBC (generally >25

¥ 10⁹/L, often

100-300

¥ 10⁹/L): predominantly neutrophils and myelocytes;

basophilia; sometimes eosinophilia.

2 Anaemia common; platelets typically normal or 4.

2 Neutrophil alkaline phosphatase (NAP) score and ESR 5 in absence of

secondary infection.

2 LDH and urate levels 4.

165

2 Bone marrow shows marked hypercellularity due to myeloid hyper-

plasia (blasts <10% in chronic phase; >10% in accelerated phase; >20%

blasts + promyelocytes = blast crisis); trephine useful to assess

marrow fibrosis.

2 Cytogenetic examination of blood or marrow for confirmatory t(9;22).

Peripheral blood film in CML: note large numbers of granulocytic cells at all stages

of differentiation.

Differential diagnosis

Differentiate chronic phase CML from leukaemoid reaction due to infec-

tion, inflammation or carcinoma (NAP 4 or normal; absent Ph chromo-

some) and CMML (absolute monocytosis; trilineage myelodysplasia; absent

Ph chromosome); 5% present with predominant thrombocytosis and must

be differentiated from ET (NAP 4/normal; absent Ph chromosome).

Prognostic factors

2 Sokal score based on age, spleen size, platelet count and % blasts in

blood can be used to identify good, moderate and poor prognosis

groups; (see p685)

2 Response to IFN-a therapy is an important prognostic factor.

Treatment of chronic phase

2 HLA-type patients aged <50 years and their sibs; 30% have a compat-

ible sibling donor; if no compatible sibling and aged <40, perform pre-

liminary MUD search to determine prospective donor availability.

2 Therapeutic decision making in chronic phase is difficult: allogeneic

transplantation is the only curative treatment; however, it carries sig-

nificant morbidity and mortality and many patients find this a difficult

option; it is vital that each patient is aware of treatment options and

their risks and benefits.

Leukapheresis should be performed with cryopreservation of stem cells

which may be used for future autologous rescue if required; it may also be

necessary for treatment of leucostasis or priapism.

Allopurinol should be commenced.

Hydroxyurea has been drug of choice for controlling WBC, ‘normalising’

the FBC and reducing spleen size in chronic phase. Maintenance 1-1.5g PO

od. No effect on cytogenetics or natural history. Side effects: rash, mouth

ulcers and diarrhoea.

Interferon-a (IFN-a) at a target dose of 5 million units/m²/day SC corrects

haematological abnormalities in 75% and produces complete cytogenetic

166

response (CCR) in 10-15% and major cytogenetic response (MCR; <33%

Ph+ cells) in 15-30%.

Treatment with IFN-a is associated with prolonged time to progression

and longer survival (57% at 5 years), most significantly in those with com-

plete and major responses; adding cytarabine increases CCRs to 25-35%

and improves survival.

IFN-a side effects (malaise, febrile reactions, anorexia and weight loss,

depression) reduce quality of life and not tolerable for many patients.

Polyethylene glycol-IFN administered once weekly and has a more

favourable side effect profile.

Imatinib (Glivec^‚) gives better cytogenetic responses and progression free

survival with fewer side effects; has changed the therapeutic algorithm in

CML; a small molecule signal transduction inhibitor that specifically targets

BCR-ABL and some other tyrosine kinases:

- 400mg PO od in newly diagnosed patients in chronic phase pro-

duces complete haematological response in 96%, major cytogenetic

response in 83% and complete cytogenetic response in 68%; only

3% achieve a molecular remission (negative RT-PCR for BCR-ABL

at 10^-5-10^-6).

- Most patients achieve major cytogenetic response (MCR) within

first 6 months of therapy; patients with MCR have lower risk of

relapse.

- Commonest side effects are myelosuppression, oedema, nausea,

muscle cramps, skin rash, fatigue, diarrhoea, headache and arthralgia;

most are mild to moderate and easily manageable.

- Now approved in both US by FDA, and in UK by NICE for not

only IFN-a-resistant patients for all newly diagnosed patients.¹

- Imatinib combined with IFN-a or cytarabine are under examination.

- Uncertainty about long term outcomes, resistance and response

duration.

Sibling-matched allogeneic stem cell transplant is treatment of choice

for age <50 unless they develop a major cytogenetic response, but

only 30% will have sibling match. Transplant related mortality is

approximately 20%. Outcomes best in younger patients (<30) in

chronic phase <1 year from diagnosis. RT-PCR for BCR-ABL is used

to monitor minimal residual disease once Ph-negative engraftment is

achieved.

1 www.nice.org.uk

Leukaemia

2 MUD allogeneic transplant, if available, should be used for <25 age group

and considered <40 years but transplant related mortality rises up to 45%.

2 Non-myeloablative conditioning has been used to reduce treatment related

toxicity in older patients using donor lymphocyte infusions to produce a

graft-versus-leukaemia (GvL) effect; it is too early to assess long term results.

A treatment ‘algorithm’

2 A young patient (<40) with CML in chronic phase with a matched sibling

167

donor should probably still be allografted within 6-12 months of diagnosis

but may prefer a trial of imatinib.

2 All other patients should receive imatinib (in the UK if fail to tolerate IFN-

a); review BM cytogenetics at 6 months.

2 If BM <35% Ph-negative, alternatives should be discussed: i.e. increased Imatinib,

trials of combination therapy or stem cell transplantation, if an option.

2 If BM ≥35% Ph-neg continue therapy as long as cytogenetics stable or

improving (RT-PCR for BCR-ABL if CCR).

2 Monitor at least annually; if progression, discuss above options especially BMT.

Complications

2 Modest increased infection risk—sometimes atypical organisms.

2 Acceleration to blast crisis (75% myeloid, 25% lymphoid).

2 Lymphoid blast crisis treatable with modified ALL protocol, may survive

>12 months.

2 Myeloid blast crisis usually refractory to conventional chemotherapy, sur-

vival 2-5 months.

Prognosis

Overall median survival with standard chemotherapy 5.5 years (range 3

months-22 years). Survival improvement with Imatinib not yet quantified.

Sibling matched allogeneic transplant (all ages 5 year median survival 60%).

MUD transplant (all ages—5 year median survival 40%). Blast crisis overall

median survival 6 months.

Treatment of advanced phase CML

2 Accelerated phase patients on imatinib 600mg od have haematological and

cytogenetic responses, prolongation of time to progression and improved

survival. Eligible patients should receive an allograft.

2 Blast crisis CML responds to imatinib 600mg od in a high proportion of

cases with less toxicity than chemotherapy but response duration is short

and where possible an allograft should be performed.

2 Allogeneic BMT offers eligible patients with advanced phase CML the only

prospect of prolonged survival and possible cure; results are significantly

less good than for BMT in chronic phase (0-10% 5 year survival in blast

crisis) though achievement of second chronic phase improves the

results after blast crisis.

2 Relapse after allogeneic BMT has been successfully treated with donor

lymphocyte infusions (DLI) (60-80% response in molecular or cytoge-

netic relapse); GvHD is a side effect but is less frequent with incre-

mental doses of DLI.

Chronic lymphocytic leukaemia (B-CLL)

Progressive accumulation of mature-appearing, functionally incompetent,

long-lived B lymphocytes in peripheral blood, bone marrow, lymph nodes,

spleen, liver and sometimes other organs.

Incidence

Commonest leukaemia in Western adults (25-30% of all leukaemias).

2.5/100,000 per annum. Predominantly disease of elderly (in over 70s,

>20/100,000). Median age at diagnosis 65 years. 9 : 3 ratio ~2:1.

Aetiology

168

Unknown. No causal relationship with radiation, chemicals or viruses.

Small proportion are familial. Genetic factors suggested by low incidence

in Japanese even after emigration. Lymphocyte accumulation appears to

result from defects in intracellular apoptotic pathways: 90% of CLL cases

have high levels of BCL-2 which blocks apoptosis.

Clinical features and presentation

2 Often asymptomatic; lymphocytosis (>5.0

¥ 10⁹/L) on routine FBC.

2 With more advanced disease: lymphadenopathy: painless, often symmet-

rical, splenomegaly (66%), hepatomegaly and ultimately BM failure due

to infiltration causing anaemia, neutropenia and thrombocytopenia.

2 Recurrent infection due to acquired hypogammaglobulinaemia: esp.

Herpes zoster.

2 Patients with advanced disease: weight loss, night sweats, general malaise.

2 Autoimmune phenomena occur; DAT +ve in 10-20% cases, warm anti-

body AIHA in <50% these cases. Autoimmune thrombocytopenia in 1-2%.

Diagnosis

FBC: lymphocytosis >5.0

¥ 10⁹/L; usually >20

¥ 10⁹/L, occasionally >400

10⁹/L; anaemia, thrombocytopenia and neutropenia absent in early stage

CLL; autoimmune haemolysis ± thrombocytopenia may occur at any stage.

Blood film: lymphocytosis with ‘mature’ appearance; characteristic artefactual

damage to cells in film preparation produces numerous ‘smear cells’ (Note:

absence of smear cells should prompt review of diagnosis); spherocytes,

polychromasia and 4 retics if AIHA; 5 platelets if BM failure or ITP.

Blood film in CLL: numerous ‘mature’ lymphocytes with smear cells. From Oxford

Textbook of Oncology, 2E, with permission.

Leukaemia

Immunophenotyping: crucial to differentiation from other lymphocytoses

(

table p174). First line panel: CD2; CD5; CD19; CD23; FMC7; SmIg

(k/l); CD22 or CD79b. CLL characteristically CD2 and FMC7 -ve; CD5,

CD19 and CD23 +ve; SmIg, CD22, CD79b weak; k or l light chain

restricted.

Immunoglobulins: immuneparesis

(hypogammaglobulinaemia) common;

monoclonal paraprotein (usually IgM) <5%.

169

Bone marrow: >30% ‘mature’ lymphocytes.

Trephine biopsy: provides prognostic information: infiltration may be

nodular (favourable); interstitial; mixed; diffuse (unfavourable).

Lymph node biopsy: rarely required; appearances of lymphocytic lymphoma.

Cytogenetics: prognostic value; abnormalities in >80% using FISH: 13q-

(55%), 11q- (18%), 12q+ (16%), 17p- (7%), 6q- (7%); 11q-, 17q- very

unfavourable; sole 13q- or 6q- favourable. Clonal evolution occurs over

time. 11q- and 17q- associated with advanced disease.

FISH showing trisomy 12 (three bright spots in each nucleus, each of which repre-

sents chromosome 12). From Oxford Textbook of Oncology, 2E, with permission.

Other tests: U&E; LFTs; LDH; b2-microglobulin; imaging as necessary for

symptoms.

Differential diagnosis

Morphology and immunophenotyping ( p174) will differentiate CLL

from other chronic lymphoproliferative disorders.

Scoring system in B-cell lymphoproliferative disorders

Devised to facilitate diagnosis based on the antigen profile of CLL using a

panel of 5 monoclonal antibodies¹:

Marker

(Score)

SmIg

weak

(1)

moderate/strong

(0)

CD5

positive

(1)

negative

(0)

CD23

positive

(1)

negative

(0)

FMC7

negative

(1)

positive

(0)

170

CD79b

weak

(1)

strong

(0)

Total scores for CLL range from 3-5 and for non-CLL cases from 0-2.

Poor prognostic factors

2 9 sex.

2 Advanced clinical stage (see below).

2 Initial lymphocytosis > 50

¥ 10⁹/L.

2 >5% prolymphocytes in blood film.

2 Diffuse pattern of infiltrate on trephine.

2 Blood lymphocyte doubling time <12 months.

2 Cytogenetic abnormalities 11q- or 17q-.

2 4 serum b2-microglobulin.

2 4 serum LDH.

2 4 serum thymidine kinase.

2 4 soluble CD23.

2 Unmutated IgV_H genes.

2 Poor response to therapy.

‘Atypical CLL’ includes those with >10% prolymphocytes ‘CLL/PLL’ which

may show an aberrant phenotype (SmIg strong +ve, FMC7/CD79b +ve) is

associated with trisomy 12 and p53 abnormalities and a more aggressive

course.

Clinical staging

2 systems widely used to classify patients as low, intermediate or high risk:

1 Moreau, E.J. et al. (1997) Improvement of the chronic lymphocytic leukemia scoring system with

the monoclonal antibody SN8 (CD79b). Am J Clin Pathol, 108, 378-382.

Leukaemia

Rai modified staging

Level of risk Stage

Median survival

Low

Lymphocytosis alone

>13 yrs

Intermediate

Lymphocytosis & lymphadenopathy

8 yrs

Lymphocytosis, spleno or hepatomegaly

5 yrs

171

High

III

Lymphocytosis, anaemia (Hb <11.0g/dL)*

2 yrs

Lymphocytosis, thrombocytopenia (<100

¥ 10⁹/L)*

1 yr

*not due to autoimmune anaemia or thrombocytopenia.

Binet clinical staging

Stage

Clinical features

Median survival

No anaemia or thrombocytopenia

12 yrs

<3 lymphoid regions enlarged

No anaemia or thrombocytopenia

5 yrs

3 or more lymphoid regions enlarged

Anaemia (Hb ≤10g/dL) and/or thrombocytopenia

2 yrs

(≤100

¥ 10⁹/L)

Clinical management

2 Patients with asymptomatic lymphocytosis simply require monitoring.

2 Note: some patients have very indolent disease (e.g. ‘Smouldering CLL’:

Binet stage A, non-diffuse bone marrow involvement; lymphocytes <30

¥ 10⁹/L, Hb >12g/dL, lymphocyte doubling time >12 months; Binet

stage A with somatic mutation of IgV_H gene have median survival 25

years).

- Chemotherapy reserved for patients with symptomatic or progres-

sive disease: anaemia (Hb <10g/dL) or thrombocytopenia (<100

10⁹/L), constitutional symptoms due to CLL (>10% weight loss in 6

months, fatigue, fever, night sweats), progressive lymphocytosis

>300

¥ 10⁹/L; doubling time <12 months, symptomatic lym-

phadenopathy/hepatosplenomegaly, autoimmune disease refractory

to steroids, repeated infections ± hypogammaglobulinaemia.

- Advise patients to report infection promptly since immunocompro-

mised ± added effects of hypogammaglobulinaemia.

- Monthly IVIg reduces recurrent infections but no effect on survival.

- Manage symptomatic autoimmune complications with corticos-

teroids.

2 First line therapy generally the alkylating agent chlorambucil at a dose

of 6-10mg/d (0.1-0.2mg/kg/d) PO for 7-14 days in 28 day cycles until

disease stabilised (usually 6-12 cycles). Produces improved FBC and

shrinks lymph nodes and spleen in most patients. CR 3%. No effect on

survival. Further responses in most patients if repeated on progression.

Side effect myelosuppression. Long-term exposure increases risk of

myelodysplasia or 2° leukaemia. Cyclophosphamide is alternative but

offers no advantage.

Higher doses of chlorambucil (15mg/d to maximum response or toxi-

city) followed by twice weekly maintenance for 3 years improves

response rate and survival.

- Avoid steroids except for autoimmune complications or for 1-2

weeks as preliminary treatment in very cytopenic patients with

extensive BM infiltration.

- Radiotherapy helpful for persistent or bulky lymphadenopathy;

splenic irradiation is sometimes helpful in frail patients unfit for

172

splenectomy.

- Splenectomy is useful therapy for massive splenomegaly or hyper-

splenism.

Purine analogue therapy induces apoptosis in CLL. Higher response

rate, CR rate (27%) and progression-free survival but not curative.

Fludarabine (25mg/m²/d IV or 40mg/m²/d PO ¥ 5 days q28) is cur-

rently second line treatment in UK. Cladribine is an alternative. Side

effects include infection, myelosuppression and autoimmune anaemia

or thrombocytopenia.

Note: purine analogues cause profound lymphodepletion with risk of

opportunistic infection due to P carinii, M tuberculosis, H zoster and

other organisms. Patients should receive cotrimoxazole prophylaxis

(480mg bd tiw) throughout therapy and for 6 months post therapy and

all blood products should be irradiated for 2 years post therapy.

Addition of cyclophosphamide (250mg/m² IV or 400mg/m² PO ¥ 5

days) concurrently to fludarabine improves response rates in refrac-

tory patients

p616.

Autologous SCT has been carried out after high dose chemotherapy ±

TBI for younger (<55 years) patients who achieve CR with fludarabine.

Remains an investigative treatment.

Allogeneic SCT has been successful in small numbers of younger,

symptomatic patients with high risk CLL and HLA-matched siblings.

Campath-1H is a humanised anti-CD52 monoclonal antibody (adminis-

tered IV or SC) which preferentially eliminates CLL cells from blood,

marrow and spleen. It has been approved in the USA for fludarabine-

refractory CLL but its role may be in the treatment of minimal residual

disease after fludarabine. Side effects: immunosuppression and virus

reactivation (HZV and CMV).

Rituximab is an anti-CD20 chimeric monoclonal antibody; less effective

monotherapy than campath-1H; addition to fludarabine-improves the

de novo patient CR rate to 47% and addition to fludarabine-cyclophos-

phamide improves the CR rate to 66% with no evidence of MRD by

RT-PCR.

Prognosis

CLL remains an incurable disease with current therapy apart from a few

allografted patients but most patients with early stage, asymptomatic CLL

die of other, unrelated causes. Infection is major cause of morbidity and

mortality in symptomatic patients. Advanced stage patients eventually

develop refractory disease and bone marrow failure. Terminally some

refractory patients show prolymphocytic transformation.

Cell markers in chronic

lymphoproliferative disorders

Mature B-cell lymphoproliferative disorders

Marker

CLL

PLL

HCL SLVL

MCL

Surface Ig weak

CD5

-/+

CD10

-/+

CD11c

-/+

+/-

174

CD19

CD20

-/+

CD22

-/weak

+/-

CD23

-/+

+/-

-/+

CD25

+/-

-/+

CD79b weak/-

FMC7

-/+

CD103

-/+

HC2

-/+

Cyclin D1

-/weak

CLL, chronic lymphocytic leukaemia; PLL, prolymphocytic leukaemia; HCL, hairy cell

leukaemia; SLVL, splenic lymphoma with villous lymphocytes; FL, follicular lymphoma; MCL,

mantle cell lymphoma.

Mature T-cell lymphoproliferative disorders

Marker T-LGLL NK-LGLL T-PLL ATLL

TdT*

CD2

CD3

CD4

+/-

CD5

CD7

-/+

+++

-/+

CD8

-/+

CD16

CD25

-/+

CD56

-/+

Other

CD11b+

HTLV1+

CD16+

CD57+

T-LGLL, T-cell large granular lymphocyte leukaemia; NK-LGLL, NK-cell large granular lym-

phocyte leukaemia; T-PLL, T cell prolymphocytic leukaemia; ATLL, adult T cell

leukaemia/lymphoma; SS, Sézary syndrome. *TdT: terminal deoxynucleotidyl transferase dif-

ferentiates these cells from lymphoblasts of ALL.

Prolymphocytic leukaemia (PLL)

Uncommon aggressive clinicopathological variant of CLL with character-

istic morphology and clinical features. B-cell and rare T-cell forms recog-

nised.

Epidemiology

Median age at presentation is 67 years; 9 : 3 ratio 2:1. Accounts for <2%

cases of ‘CLL’. B-PLL 75%, T-PLL 25%.

Clinical features

2 Symptoms of bone marrow failure and constitutional symptoms:

176

lethargy, weight loss, fatigue, etc.

2 Massive splenomegaly, typically >10cm below costal margin may cause

abdominal pain. Hepatomegaly common.

2 Minimal lymphadenopathy in B-PLL, generalised lymphadenopathy

more common in T-PLL.

2 Skin lesions occur in 25% T-PLL as do serous effusions.

Investigation and diagnosis

2 FBC : high WBC (typically >100

¥ 10⁹/L; commonly >200

¥ 10⁹/L in T-

PLL); anaemia and thrombocytopenia usually present.

2 Differential shows >55% (often >90%) prolymphocytes.

2 Morphology: large lymphoid cells, abundant cytoplasm (B-PLL mainly),

prominent single central nucleolus.

2 Bone marrow diffusely infiltrated.

2 Immunophenotype: table p174.

2 Cytogenetics—B-PLL: 14q+ in 60%; t(11;14)(q13;q32)in 20%; p53 gene

abnormalities in 75%; T-PLL chromosome 14 abnormalities in >70%;

+8 in 50%.

Blood film in PLL: cells are larger than those seen in CLL but have similar ‘mature’

nucleus.

Differential diagnosis

B-PLL and CLL are not always easily distinguished and mixed ‘CLL/PLL’

recognised (>10%, <55% prolymphocytes). Clinical features, morphology

and notably markers ( p174) used to distinguish PLL from other lym-

phoproliferative disorders.

Management

2 PLL is typically resistant to chlorambucil.

Leukaemia

2 Splenectomy: may be symptomatically helpful, ‘debulking’, follow up

with other therapy.

2 Splenic irradiation: offers symptomatic relief if unfit for splenectomy.

2 Combination chemotherapy: CHOP may achieve responses in about 33%

and prolong survival in younger patients.

2 Purine analogue therapy: Fludarabine, 2-CDA or deoxycoformycin may

produce responses in some patients.

177

2 Campath-1H: anti-CD52 monoclonal antibody produces responses in

both B-PLL and T-PLL. In T-PLL CR rates of 40-60% have been

achieved lasting several months and permitting subsequent high dose

therapy with autologous or allogeneic SCT and prolonged survival.

2 Rituximab: anti-CD20 monoclonal antibody: there are reports of

responses in B-PLL.

2 Stem cell transplantation: in view of the poor prognosis of PLL, younger

patients who achieve a CR should be considered for allogeneic SCT

where possible or autologous SCT.

Natural history

PLL is a relentlessly progressive disease and treatment is unsatisfactory. T-

PLL carries poor prognosis with median survival 6-7 months. Median sur-

vival in B-PLL is 3 years.

Hairy cell leukaemia and variant

Uncommon low grade B-cell lymphoproliferative disorder associated with

splenomegaly, pancytopenia and typical ‘hairy cells’ in blood and bone

marrow.

Epidemiology

Accounts for 2% of leukaemias, 8% of chronic lymphoproliferative disor-

ders. No known aetiological factors. Presents in middle age (>45 years)

with 9 : 3 ratio of 4:1

Clinical features

178

2 Typically non-specific symptoms: lethargy, malaise, fatigue, weight loss

and dyspnoea.

2 15% present with infections, often atypical organisms due to mono-

cytopenia.

2 ~30% have recurrent infection; 30% bleeding or easy bruising.

2 Splenomegaly in 80% (massive in 20-30%), hepatomegaly in 20%.

2 Lymphadenopathy rare (<5%).

2 Pancytopenia may be an incidental finding on a routine FBC.

2 Vasculitic polyarthritis and visceral involvement similar to polyarteritis

nodosa occurs in some patients with HCL.

Investigation and diagnosis

2 FBC: moderate to severe pancytopenia; Hb <8.5g/dL 35%.

2 Blood film: low numbers of ‘hairy cells’ in 95%; florid leukaemic fea-

tures unusual

2 Hairy cells—kidney shaped nuclei, clear cytoplasm and irregular cyto-

plasmic projections (more notable on EM).

2 WBC differential: neutropenia, <1.0

¥ 10⁹/L in 75%; monocytopenia is

a consistent feature.

2 Cytochemistry: +ve for tartrate-resistant acid phosphatase (TRAP) in

95%; now identified by flow cytometry using antibody to TRAP.

2 Immunophenotyping: typically CD11c, CD25, CD103 & HC2 +ve; dif-

ferentiates HCL from other chronic lymphoproliferative disorders

(

table, p174).

2 Bone marrow: aspiration often unsuccessful—‘dry tap’ due to 4 BM

fibrosis; trephine shows diagnostic features with focal or diffuse infiltra-

tion of HCL where cells have characteristic ‘halo’ of cytoplasm con-

firmed by immunocytochemistry with anti-CD20/DBA-44 and

anti-TRAP.

2 Abdominal CT for intra-abdominal lymphadenopathy (15-20%).

Differential diagnosis

Confirmation of diagnosis may be difficult because of low numbers of cir-

culating leukaemic cells and dry tap on marrow aspiration; trephine his-

tology usually diagnostic; differential diagnosis includes myelofibrosis and

other low grade lymphomas notably SLVL.

Prognostic factors

No established staging system. Response to therapy is probably the best

prognostic indicator. Bulky abdominal lymphadenopathy at diagnosis cor-

relates with poor response to first line therapy.

Leukaemia

179

Peripheral blood film in HCL showing typical ‘hairy’ lymphcytes. From Oxford

Textbook of Oncology, 2E, with permission.

Management

In <10% patients, often elderly with minimal or no splenomegaly and

cytopenia, the disease remains relatively stable and may be observed.

Therapy is required in patients with Hb <10g/dL, neutropenia <1.0

10⁹/L, thrombocytopenia <100

¥ 10⁹/L, symptomatic splenomegaly,

recurrent infection, extralymphatic involvement, autoimmune compli-

cations, florid leukaemia or progressive disease.

Supportive management is important particularly in the early stages of

therapy where cytopenias can worsen: treat infections promptly. Note:

increased incidence of atypical mycobacterial infections in HCL.

Splenectomy: indicated for massive splenomegaly and beneficial in man-

aging severe pancytopenia in patients with minimal marrow infiltration.

Non-curative but 2-15% will normalise FBC for up to 25 years without

further therapy. Histology shows characteristic infiltration of red pulp

and atrophy of white pulp. Avoid drug therapy for 6 months after

splenectomy to assess response.

Purine analogues are the established first line therapy and most patients

achieve a durable CR. CD4 lymphodepletion causes immunosuppres-

sion: require P carinii prophylaxis and irradiated blood products.

Deoxycoformycin 4mg/m² IV bolus every 1-2 weeks to maximum

response plus 2 cycles (generally 6-10); check creatinine clearance

pre-therapy (must be >60mL/min for full dose; half dose >40mL/min)

improvement begins after 2 cycles; maximum response generally 4-7

months; 90% objective responses; 75% CR; 15% in continued CR at 8

years; some patients are probably cured.

Cladribine: infusion of 0.1mg/kg/d ¥ 7 days will produce comparable

remission rates; remission duration may be shorter; temporarily

myelosuppressive, maximum 1 week after infusion; repeat at 6 months

if no CR; avoid cotrimoxazole during infusions (causes rash).

IFN-a 3 million units SC daily achieves a partial response in up to 80%

but CR in <5%; continue to maximum response then cut to three

times weekly for 6-24 months or indefinitely; normalisation of blood

counts generally occurs within 6 months and responses persist 12-15

months after discontinuation.

- IFN-a may be useful as initial therapy (tiw) for 2-4 months before

a purine analogue in patients with profound cytopenias and for

HCL refractory to purine analogue therapy. Side effects cause intol-

erance in some patients.

2 G-CSF may be useful in patients with severe neutropenia.

2 Monitor response by trephine biopsy stained for CD20/DBA-44 and

TRAP.

Natural history

Hairy cell leukaemia is associated with prolonged survival (95% at 5 years),

180

with newer agents capable of producing remissions; some patients may

achieve long term cure. For others careful application of available treat-

ments at points of disease relapse/progression will still allow prolonged,

good quality survival. If a remission of >5 years has been achieved then a

further remission with the same agent is likely.

Hairy cell variant

Describes a very rare variant of HCL where the presenting WBC count is

high due to circulating leukaemic cells (40-60

¥ 10⁹/L) and monocy-

topenia is absent. Cells are villous but have a central round nucleus and a

distinct nucleolus like PLL. Marrow is aspirated easily due to low reticulin

but the trephine appearance is similar to HCL and associated neutropenia.

Immunophenotype differs from typical HCL: CD11c+, CD25 & HC2 -ve,

CD103 usually -ve. Response to deoxycoformycin or IFN-a is poor but

chlorambucil appears active in this form, and the variant generally follows

an indolent course.

Splenic lymphoma with villous

lymphocytes (SLVL)

Rare B-cell lymphoproliferative disorder in which marked splenomegaly

and moderate lymphocytosis represent the main clinical findings. May cor-

respond histologically to splenic marginal zone lymphoma.

Clinical and laboratory features

2 Non-specific symptoms, e.g. fatigue.

2 Affects older patients, mean age at diagnosis 72 years.

182

2 Moderate to massive splenomegaly.

2 Hepatomegaly in 50%.

2 Lymphadenopathy rare.

2 Anaemia and thrombocytopenia in 25-30% usually due to hyper-

splenism. Neutropenia not marked.

2 Total WBC not grossly elevated (usually <40

¥ 10⁹/L; cf. PLL).

2 Monocytopenia not a feature (cf. HCL)

2 Cell morphology: larger than typical CLL cells, round/oval nuclei,

villous cytoplasmic projections at one/both poles of the cells.

2 Immunophenotype: CD19+, FMC7+, CD23- usually negative for CD5

& CD25: 20% +ve but fail to co-express CD11c and CD103 differenti-

ating SLVL from HCL; table p174.

2 Monoclonal IgM or IgG paraprotein; free urinary light chains in 66%.

2 BM aspirate may show lymphocytosis (some plasmacytoid) with typical

immunophenotype; biopsy may be normal but usually shows

patchy/nodular lymphoid infiltration.

2 Spleen histology: characteristic with nodular infiltration involving the

white pulp (cf. HCL).

Differential diagnosis

Main differentials are mantle cell lymphoma (especially 20% CD5+ SLVL)

CLL, PLL, HCL and hairy cell variant. Diagnosis requires careful morpho-

logical and immunophenotypic assessment ( p174).

Prognosis and treatment

Generally follows an indolent course. ≥10% may require no treatment.

Splenectomy recommended for bulky organ enlargement or hyper-

splenism (and/or to confirm diagnosis in some cases) and can control

most symptoms. Progression after splenectomy may respond to chloram-

bucil or fludarabine given as for CLL. Toxic effects may be marked with

purine analogues in this elderly group of patients. Median survival over 6

years.

Mantle cell lymphoma (MCL)

B-cell derived lymphoid neoplasm defined in the WHO/REAL classifica-

tion (p195) by clinical, morphological, immunophenotypic, cytogenetic

and molecular criteria.

Incidence and aetiology

4-8% of cases of adult NHL. Aetiology unknown. t(11;14) causes dysregu-

lation of BCL-1 and overexpression of cyclin D1, a protein involved in cell

proliferation.

Clinical features and presentation

184

2 Most common in 9 >50 years (median age 63).

2 36% have lymphocytosis in peripheral blood which may cause presen-

tation as ?CLL.

2 Commonly advanced disease at presentation (87%) with generalised

lymphadenopathy (57%); splenomegaly (47%); hepatomegaly (18%).

2 Extranodal involvement, particularly in GI tract is common (18%).

Diagnosis and investigation

2 FBC: lymphocytosis in 36%; anaemia and mild thrombocytopenia only

in very advanced disease.

2 Blood film: intermediate size lymphocytes; nucleus often has clefts and

indentations; smear cells unusual (cf. CLL).

2 Immunophenotype: critical to diagnosis ( p174); SmIg strongly+

CD5+, CD10-, CD19+, CD23-, CD79b+, cyclin D1+.

2 Cytogenetics: t(11;14) in 50-90% by FISH techniques.

2 Bone marrow: trephine biopsy demonstrates involvement in >70%

with nodular, interstitial or diffuse patterns similar to CLL.

2 Lymph node biopsy: mantle zone expansion or diffuse effacement of

nodal architecture by uniform ‘centrocytes’; characteristic immuno-

chemistry pattern: CD5+, CD10-, CD79b+, cyclin-D1+.

2 Up to 30% have detectable paraprotein band, usually IgM.

Differential diagnosis

In patients with lymphocytosis differentiation from CLL by immunopheno-

type, notably strong SmIg+, CD23- and cyclin-D1+; from PLL when CD5+

by morphology; from follicular lymphoma by CD5+, CD10- and cyclin D1.

Prognostic factors

Stage using Ann Arbor system (p210). Use International Prognostic Index

(p200) to assess prognosis. Age >70, HB <12g/dL, poor performance

status and blood involvement are unfavourable features.

Management and prognosis

There is no evidence that MCL has been cured by either conventional

chemotherapy or autologous SCT. Response rates of 50-90% have been

achieved with COP or CHOP including CR rates of 30-50%. Median

freedom from progression is <1 year. There is no survival advantage for

anthracycline containing regimens.

2 Fludarabine-cyclophosphamide regimens ( p616) appear to have a

high response rate in previously treated patients.

Large granular lymphocyte leukaemia

(LGLL)

Uncommon lymphoproliferative disorder, characterised by an increase in

LGLs in blood. Heterogeneous—may be T-cell or NK-cell phenotype; not

all cases are clonal.

Clinical features

2 Any age group; median age at diagnosis 55 years.

2 Asymptomatic, modest lymphocytosis with large granular lymphocytes

186

on routine FBC.

2 Occasional presentation with fatigue or recurrent bacterial infections.

2 Arthralgia, itching, rash (25%), mouth ulcers; association with seroposi-

tive rheumatoid arthritis in 20% and Felty’s syndrome (neutropenia +

splenomegaly + rheumatoid arthritis).

2 Splenomegaly recorded in 50-80% cases. Lymphadenopathy rare.

Laboratory findings

2 Hb and platelets usually normal; chronic neutropenia and mild anaemia

may be present.

2 Mild/moderate lymphocytosis (usually <10

¥ 10⁹/L); large cells with

abundant cytoplasm and distinct granules.

2 Most type as ‘cytotoxic’ T cells (CD3+ CD8+ CD16+ CD56- CD57+);

others as NK cells (CD3- CD8- CD16+ CD56+ CD57+/-).

2 Clonal rearrangement of T-cell receptor genes in T-LGLL.

2 Polyclonal hypergammaglobulinaemia, rheumatoid factor and antinu-

clear antibodies occur in 50% even without joint disease.

2 Bone marrow involvement is often subtle; may be diffuse or nodular

pattern usually non-paratrabecular.

2 No characteristic cytogenetic pattern.

Differential diagnosis

Reactive lymphocytosis (screen for infection especially EBV); other T-cell

lymphoproliferative disorders (immunophenotype; p174).

Prognosis and management

2 Incurable but generally stable benign disease. Patients with NK pheno-

type (more common in Japan) or a CD3+ CD56+ clonal disorder

established by TCR rearrangements, i.e. a true leukaemia, may have a

more aggressive course. Patients with polyclonal disease associated

with rheumatoid factor and modest neutropenia may run a more

benign course.

2 Care is essentially supportive with prompt treatment of infection with

appropriate broad spectrum antibiotics.

2 G-CSF may be of value in symptomatic chronic neutropenia.

Corticosteroids in modest dosage may improve neutropenia but can

predispose to infection, including fungal infections.

2 Immunosuppression with low dose methotrexate (10mg/m² PO

weekly), cyclosporin (2mg/kg PO bd) or cyclophosphamide (100mg

PO od) has been effective in ~50% of patients with persistent severe

neutropenia.

Adult T-cell leukaemia-lymphoma (ATLL)

Aggressive lymphoid neoplasm with viral pathogenesis and distinct geo-

graphical distribution.

Incidence

Highest incidence among populations where HTLV-I infection endemic:

Kyushi district of SW Japan, Caribbean, parts of Central and South

America, Central and West Africa. Incidence 2/1000 males and 0.5-1/1000

females seropositive for HTLV-I (37% males >40) in SW Japan. Risk 2.5%

at 70 years. Non-endemic cases generally originate from these areas.

188

Aetiology

HTLV-I provirus demonstrated in ATLL cells and all patients with ATLL are

seropositive for previous HTLV-I infection. HTLV-I clearly involved in

pathogenesis. Not all infected patients develop ATLL and long latent period

suggests that further event(s) are necessary for neoplastic transformation.

Clinical features and presentation

2 Median age at diagnosis 58 (range 20-90); 9 : 3 ratio 1:4.

2 Usually short history of rapidly increasing ill health.

2 Abdominal pain, diarrhoea, pleural effusion, ascites and respiratory

symptoms (often due to leukaemic infiltration of lungs).

2 History of residence or origin in HTLV-I endemic area usual.

2 Lymphadenopathy 60%; hepatomegaly 26%, splenomegaly 22%; skin

lesions 39%.

Diagnosis and investigation

2 FBC: WBC usually markedly 4 (up to 500

¥ 10⁹/L) but may be normal;

anaemia and thrombocytopenia common.

2 Blood film: large numbers of lymphoid cells with marked nuclear irregu-

larity occasionally multilobulated with ‘floral’ or ‘clover leaf’ appearance.

2 Immunophenotyping: generally CD4+, CD8-, CD25+, HLA-DR+ T

cells (

p174).

2 Cytogenetics: multiple abnormalities described; no consistent pattern.

2 Serum chemistry: hypercalcaemia in 33-50% of patients at diagnosis.

2 Bone marrow: diffuse infiltration by ATLL cells.

2 Serology: positive for HTLV-I.

Blood film in ATLL: note clover-leaf cell (centre). From Oxford Textbook of Oncology,

2E, with permission.

Leukaemia

Prognostic factors and staging

Poor prognostic features are

2 4 LDH.

2 Hypercalcaemia.

2 Hyperbilirubinaemia.

2 4 WBC.

189

Four clinical subtypes are described: acute, chronic, smouldering

and lymphomatous forms. Acute subtype most common (66%), median

survival 6 months despite therapy. Other forms have longer survival but

often progress to the acute form after several months. The smouldering

form is most indolent and is associated with few circulating cells, skin

lesions and occasional pulmonary involvement and survival >24 months.

Management and prognosis

Treatment of ATLL is unsatisfactory. Short responses including CRs (6-12

months) have been achieved with combination chemotherapy

(e.g.

CHOP) for acute and lymphomatous forms. Infectious complications are

frequent with this and more intensive therapy. Single agent deoxyco-

formycin has produced responses in relapsed or refractory patients.

Patients with acute ATLL or lymphomatous ATLL have median survivals

of 6 and 10 months respectively. Death is usually due to opportunistic

infection.

Sézary syndrome (SS)

Leukaemic phase of a low grade cutaneous mature T-cell lymphoma

(mycosis fungoides; MF).

Incidence

Occurs in up to 20% of cases of cutaneous T-cell lymphoma; median age

52; 9 : 3 ratio 2:1.

Clinical features

2 Generally diagnosed as a result of blood film report in a patient with

exfoliative erythroderma; but not necessarily end-stage and may

190

present de novo.

2 MF classically progresses through eczematoid plaque stage, infiltrative

plaque stage and overt tumour stage and has characteristic histology

on skin biopsy (epidermotropism and Pautrier microabscesses).

Investigations and diagnosis

2 FBC: generally moderate leucocytosis (WBC rarely >20

¥ 10⁹/L); Hb

and platelets usually normal.

2 Blood film: typically reveals large numbers of large lymphoid cells with

characteristic ‘cerebriform’ folded nucleus.

2 Immunophenotyping: CD3+, CD4+, CD7-, CD8-, CD25- T cells.

2 Cytogenetics: no typical pattern.

Blood film in Sézary syndrome showing typical cerebriform nuclei. Image on right is

from The Oxford Textbook of Oncology, 2E, with permission.

Management and prognosis

Patients with SS have a poor prognosis. There is no evidence that single

agent or combination chemotherapy improves survival. Median survival

6-8 months.

Non-Hodgkin’s lymphoma (NHL)

NHL is a diagnosis applied to a group of histologically and biologically het-

erogeneous clonal malignant diseases arising from the lymphoid system.

Epidemiology

The annual incidence in Western countries is 14-19 cases per 100,000

(i.e. 4% of all cancers) and has increased at a rate of 3-4% per annum since

the 1970s. Incidence increases with age. 9 : 3 ratio 3:2. The increased

incidence is only in part due to increased mean age of the population,

improvements in diagnosis, the HIV pandemic and immunosuppressive

194

therapy.

Aetiology

The rearrangement and mutation of immunoglobulin genes that occur in

B-cell differentiation and the response to antigen offers an opportunity for

genetic accidents such as translocations or mutations involving

immunoglobulin gene loci that have been characterised in many lym-

phomas. Most translocations involve genes associated with either prolifer-

ation (e.g. c-MYC) or apoptosis (e.g. BCL-2). Factors associated with NHL

are:

2 Congenital immunodeficiency: ataxia telangiectasia, Wiskott-Aldrich

syndrome, X-linked combined immunodeficiency (?EBV infection

important).

2 Acquired immunodeficiency: immunosuppressive drugs, transplantation,

HIV infection (typically high grade and often occur in extranodal sites

e.g. brain).

2 Infection: HTLV-I (ATLL); EBV (Burkitt lymphoma and immunodefi-

ciency related high grade lymphomas); Helicobacter pylori (gastric MALT

lymphomas).

2 Environmental toxins: association with exposure to agricultural pesti-

cides, herbicides and fertilisers, solvents and hair dyes.

2 Familial: risk increased 2-3 fold in close relatives (?genetic or environ-

mental).

Classification

The World Health Organisation (WHO) classification of lymphoid neo-

plasms (p195) has refined the Revised European American Lymphoma

(REAL) classification producing a list of clinico-pathologically well charac-

terised lymphomas using morphology, immunophenotype, genotype, the

normal cell counterpart and clinical behaviour. Inter- and intraobserver

reproducibility is 85-95%. In Europe and the USA 85% of lymphomas are

B-cell type.

The clinical behaviour of lymphomas informs management strategies in

clinical practice and current treatment protocols are still based on classifi-

cation systems that group histological diagnoses into indolent (low grade)

and aggressive (intermediate and high grade or simply high grade) NHL.

More biologically relevant classification of lymphoma diagnosis using the

WHO system and emerging therapeutic options based on immunological

and molecular characteristics may increase the diagnosis-specific nature of

therapy in the future.

Lymphoma

WHO classification of lymphoid neoplasms

B-cell neoplasms

Precursor B-cell neoplasms

Precursor B-lymphoblastic leukaemia/lymphoma (precursor B-cell acute lymphoblastic

leukaemia)

Mature (peripheral B-cell) neoplasms

Chronic lymphocytic leukaemia/B-cell small lymphocytic lymphoma

195

B-cell prolymphocytic leukaemia

Lymphoplasmacytic lymphoma

Splenic marginal zone B-cell lymphoma (splenic lymphoma with villous lymphocytes)

Hairy cell leukaemia

Plasma cell myeloma/plasmacytoma

Extranodal marginal zone B-cell lymphoma (MALT lymphoma)

Nodal marginal zone B-cell lymphoma

Follicular lymphoma

Mantle cell lymphoma

Diffuse large B-cell lymphomas

Burkitt lymphoma/leukaemia

T-cell neoplasms

Precursor T-cell neoplasms

Precursor T-lymphoblastic leukaemia/lymphoma (precursor T-cell acute lymphoblastic

leukaemia)

Blastoid NK-cell lymphoma

Mature (peripheral) T-cell neoplasms

T-cell prolymphocytic leukaemia

T-cell large granular lymphocytic leukaemia

Aggressive NK-cell leukaemia

Adult T-cell leukaemia/lymphoma

Extranodal NK/T-cell lymphoma (nasal type)

Enteropathy type T-cell lymphoma

Hepatosplenic T-cell lymphoma

Subcutaneous panniculitis-like T-cell lymphoma

Mycosis fungoides/Sézary syndrome

Primary cutaneous anaplastic large cell lymphoma

Peripheral T-cell lymphoma (not otherwise specified)

Angioimmunoblastic T-cell lymphoma

Primary systemic anaplastic large cell lymphoma

Hodgkin lymphoma

Nodular lymphocyte predominant Hodgkin lymphoma

Classical Hodgkin lymphoma

- Nodular sclerosis Hodgkin lymphoma (Grades 1 & 2)

- Lymphocyte-rich classical Hodgkin lymphoma

- Mixed cellularity Hodgkin lymphoma

- Lymphocyte depleted Hodgkin lymphoma

Harris, N.L. et al. (1994) A revised European-American classification of lymphoid neoplasms:

a proposal from the International Lymphoma Study Group. Blood, 84, 1361-1392; Jaffe ES

et al (2001). In Kleihues P, Sobin L eds. WHO Classification of Tumours. Lyon: ARC Press.

‘Clinical grade’ & frequency of lymphomas in the REAL classification

Diagnosis

% of all cases

Indolent lymphomas (low risk)

Follicular lymphoma

(Note: grade I & II; grade III intermediate risk)

22%

Marginal zone B-cell, MALT lymphoma

Chronic lymphocytic leukaemia/small lymphocytic lymphoma

Marginal zone B-cell, nodal

Lymphoplasmacytic lymphoma

196

Aggressive lymphomas (intermediate risk)

Diffuse large B-cell lymphoma

31%

Mature (peripheral) T-cell lymphomas

Mantle cell lymphoma

Mediastinal large B-cell lymphoma

Anaplastic large cell lymphoma

Very aggressive lymphomas (high risk)

Burkitt lymphoma

Precursor T-lymphoblastic

Other lymphomas

A clinical evaluation of the International Lymphoma Study Group classification of non-

Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. (1997) Blood,

89, 3909-3918.

Presentation

The features at presentation reflect a spectrum from low grade lymphoma

(widely disseminated at diagnosis but with an indolent course; non-

destructive growth patterns) to high grade lymphoma (short history of

localised rapidly enlarging lymphadenopathy ± constitutional upset with

drenching night sweats, >10% weight loss and/or fever; destructive growth

patterns).

In Europe and the USA almost 75% of adults present with nodal disease,

usually superficial painless lymphadenopathy. 25% are extranodal (~50%

in the Far East) and may present with oropharyngeal involvement

(5-10%), GI involvement (15%), CNS involvement (5-10%, esp. high

grade NHL) skin involvement (esp. T-cell lymphomas) or autoimmune

cytopenias. Patients with GI involvement have a higher frequency of

oropharyngeal involvement

(Waldeyer’s ring) and vice versa.

Hepatosplenomegaly is common in advanced disease.

Clinical features of indolent lymphomas:

Up to 40% of cases; slowly progressive disorders.

Follicular lymphoma: most common in middle and old age (median age 55

years); presents with painless lymphadenopathy at ≥1 sites, effects of BM

infiltration, constitutional symptoms (15-20%) or pressure effects of bulky

nodes (ureter, spinal cord or orbit); LN may fluctuate in size; at diagnosis,

66% stage III or IV, 70% BM involvement, 15-20% localised stage I or II

disease; median survival ~8-10 years; ~30% may transform to high grade

DLBCL (often resistant to treatment; median survival 12 months). Note:

Lymphoma

cases of FL with a high proportion of centroblasts (>50%) on histology

follow a more aggressive clinical course and are treated as aggressive

lymphomas.

Marginal zone lymphomas take 3 forms:

2 Mucosa-associated lymphoid tissue (MALT) lymphomas—associated

with local invasion at site of origin, e.g. stomach, small bowel, salivary

197

gland or lung; gastric MALT lymphomas present with long history of

abdominal pain; diagnosis by endoscopic biopsy; localised in 80-90%

and respond to antibiotic treatment for H pylori; good prognosis

(>80% 5 year survival).

2 Nodal marginal zone lymphoma (MZL) or monocytoid B-cell lym-

phoma rare; associated with Sjögren’s syndrome—usually localised to

head, neck and parotid gland.

2 Spleen MZL related to SLVL (p182); elderly patients with marked

splenomegaly ± hypersplenism, BM involvement ± villous lymphocy-

tosis, lymphadenopathy absent.

Small lymphocytic lymphoma: nodal form of CLL (p168); generally age

>60 years; disseminated peripheral lymphadenopathy and splenomegaly;

lymphocyte count <4.5

¥ 10⁹/L; BM involvement in 80%; constitutional

symptoms <20%; serum paraprotein, usually IgM in 30%; median survival

8-10 years; some patients evolve into CLL, others to DLBCL.

Lymphoplasmacytic lymphoma: occurs in older patients; usually isolated

lymphadenopathy

± serum paraprotein; usually IgM, symptoms of

hyperviscosity if markedly 4 ( Waldenström’s macroglobulinaemia, p284).

Clinical features of aggressive lymphomas

~50% of cases; rapidly progressive if untreated.

Diffuse large B-cell lymphoma: most common lymphoma diagnosis;

occurs at all ages, generally >40 years; presents with localised stage I or II

disease in 50% of patients but disseminated extranodal disease is not

uncommon; constitutional symptoms in 33%; extranodal sites in 30-40%

most commonly GI. Ascites and pleural effusions are common end-stage

symptoms.

T-cell rich B-cell lymphoma: subtype of DLBCL; occurs in younger

patients; more aggressive with early BM involvement.

Mature

(or peripheral) T-cell lymphomas: a number of different

conditions; most common T-cell NHL in the West but more common in

Far East; median age 56; 9 : 3 ratio 2:1; variable clinical behaviour; nodal

form generally more aggressive and less responsive to therapy than

DLBCL; heterogeneous group of extranodal forms; 80% stage III-IV at

diagnosis; constitutional symptoms, BM and skin involvement common;

41% 5 year survival with combination therapy.

Mycosis fungoides: mature T-cell lymphoma; presents as localised or

generalised plaque or erythroderma; lymphadenopathy in 50%; median

survival

10 years but prognosis poor with lymphadenopathy, blood

(

Sézary syndrome p190) or visceral involvement .

Angio-immunoblastic lymphadenopathy: constitutional symptoms,

generalised lymphadenopathy, hepatosplenomegaly, skin rash, polyclonal

hypergammaglobulinaemia, DAT+ve haemolytic anaemia and eosinophilia;

33% of patients progress to immunoblastic lymphoma; poor prognosis.

Mantle cell lymphoma: usually elderly; median 63 years; B symptoms

50%; usually disseminated at diagnosis: BM involvement

75%, GI

involvement 15-20%; poor therapeutic outcome: partial responses and

eventual chemoresistance; median survival 3-4 years ( p184).

198

Mediastinal large B-cell lymphoma: typically occurs in women <30 years;

anterior mediastinal mass sometimes causes superior vena caval

obstruction; tendency to disseminate to other extranodal sites including

CNS; cure rate with therapy similar to LBCL.

Anaplastic large cell lymphoma: usually occurs in younger patients and

children; typically as lymphadenopathy at a single site; favourable

prognosis as curable with chemotherapy; 64% overall 5 year survival.

Clinical features of very aggressive lymphomas

~10% cases of NHL; require prompt treatment.

Burkitt lymphoma

2 Endemic BL: presents in childhood/adolescence in Africa with large

extranodal tumours in jaw or abdominal viscera; 90% associated with

EBV infection; aggressive but curable disease.

2 Sporadic BL: often children, rare in adults (median age 31); presents

with rapidly growing lymphadenopathy, often intra-abdominal mass

arising from a Peyer’s patch or mesenteric node; BM, CNS and blood

involvement frequent; 30% associated with EBV infection; also associ-

ated with HIV infection; aggressive but curable disease in non-HIV-

associated cases.

Lymphoblastic lymphomas:

2 Young patients (median age 15 years; >50% of childhood lymphomas);

share features with ALL; T-cell LBL more frequent (85%) and usually

associated with thymic mass; 33-50% present with BM involvement;

CNS involvement common; commonly progresses to ALL; aggressive

but potentially curable in children.

Laboratory features

2 Normochromic normocytic anaemia common.

2 Leucoerythroblastic film if extensive BM infiltration ± pancytopenia.

2 Hypersplenism (occasionally).

2 PB may show lymphoma cells in some patients: moderate lymphocy-

tosis in MCL; cleaved ‘buttock’ cells in FL and blasts in high grade

disease.

2 LFTs abnormal in hepatic infiltration.

2 Serum LDH and b2-microglobulin are useful prognostic factors

(

p200).

2 Lymph node biopsy provides the best material for classification and

precise diagnosis using morphology, immunophenotype and genetic

Lymphoma

features e.g. translocations or immunoglobulin and T-cell receptor

gene rearrangement.

2 ~20% of patients with SLL or FL have a serum paraprotein, usually IgM.

Diagnostic immunohistochemical and cytogenetic features

Indolent lymphomas

199

Follicular lymphomas: Pan-B markers; CD5-, CD10+, BCL-2+.

t(14;18)(q32;q21) in 90% (cf. reactive lymphoid hyperplasia with normal

follicles BCL-2-).

Small lymphocytic lymphoma: Pan-B markers (CD20+, CD79a+); CD5+,

weak SmIg, CD23+, cyclin-D1- (cf. MCL).

Marginal zone lymphomas: Pan-B markers; CD5-, CD10-, BCL-2-.

t(11,19)(q21;q21) 50%, t(1;14)(p22;q32) rare, overexpress bcl-10 and

poor response to H pylori eradication.

Aggressive lymphomas

Diffuse large B-cell lymphoma: Pan-B markers

(CD20+, CD79a+),

generally Ig+; Ki67 <90% favours DLBCL (cf. Burkitt >99%); probably

multiple unrecognised entities; two subgroups delineated by gene

expression profiling using DNA microarrays: germinal centre-B-cell profile

(favourable) and activated B-cell profile

(unfavourable). Der(3)(q27)

involving BCL-6 gene mutations 35%; t(14;18) 25%; t(8;14) 15%.

Mature T-cell lymphomas: Pan-T markers (CD3+, CD2+); TdT- (cf. precursor

T-lymphoblastic TdT+).

Mantle cell lymphoma: Pan-B markers; CD5+, strong SIg, CD23-, cyclin-

D1+. t(11;14)(q13;q32) in 70%.

Anaplastic large cell lymphoma: Pan-T markers, TdT-, CD30+, ALK+.

t(2;5)(p23;q35) in 60%.

Very aggressive lymphomas

Burkitt lymphoma: Pan-B markers, Ig+, Ki67 >99% favours BL (cf. DLBCL

<90%). 80% t(8;14)(q24;q32), 15% t(2;8)(q11;q24), 5% t(8;22)(q24;q11)

juxtapose c-MYC with Ig gene loci and cause MYC overexpression but this

is not diagnostically useful as expressed in normal cells and other

lymphomas. Endemic cases have raised antibody titres to EBV antigens

and multiple copies of EBV DNA in the tumour (unusual in sporadic

cases).

Precursor B-lymphoblastic: Pan-B markers, Ig-, CD10+, TdT+.

Precursor T-lymphoblastic: Pan-T markers, TdT+.

Staging investigations

2 Histological diagnosis by expert haematopathologist: biopsy of lymph

node or extranodal mass with immunophenotyping ± molecular

analysis.

2 Detailed history and physical examination including Waldeyer’s ring

2 FBC, plasma viscosity/ESR and blood film.

2 U&E, uric acid, LFTs, LDH, serum b2-microglobulin.

2 Serum protein electrophoresis

2 Bone marrow trephine biopsy.

2 CXR.

2 CT of chest, abdomen and pelvis to define areas of nodal and extran-

odal disease.

2 Others as necessary e.g. LP and CT head/spine for patients with overt

CNS symptoms: LP also for high grade disease with marrow, testicular

or paranasal sinus involvement, lymphoblastic or Burkitt histology; MRI

spine, bone scan, gallium scan, PET scan etc

200

Staging helps to define prognosis and select appropriate therapy. Also

helps assess response to therapy. The Ann Arbor staging system devel-

oped for Hodgkin's disease is widely used in NHL ( Hodgkin’s disease

p210).

Prognostic factors

2 Histologic grade.

2 Performance status.

2 Constitutional (B) symptoms unfavourable.

2 Age (unfavourable >60 years).

2 Disseminated disease (stage III-IV) unfavourable.

2 Extranodal disease (poorer ≥2 extranodal sites).

2 Bulky disease (poorer if >10 cm).

2 Raised serum LDH (poorer if 4).

2 Raised serum b2-microglobulin.

2 High proliferation rate measured by Ki-67 immunochemistry.

2 BCL-2 protein expression.

2 P53 mutations.

2 T-cell phenotype.

2 High grade transformation from low grade NHL.

The International Prognostic Index (IPI) was developed for aggressive NHL

and validated in all clinical grades of NHL as a predictor of response to

therapy, relapse and survival. One point is awarded for each of the fol-

lowing characteristics: age >60, stage III or IV, ≥2 extranodal sites of

disease, performance status ≥2 and raised serum LDH to identify 4 risk

groups. An age-adjusted IPI has also been developed.

Score

Risk group

%CR

5yr CR-DFS

5yr overall survival

0 or 1

Low

87%

70%

73%

Low/intermediate

67%

50%

51%

Intermediate/high

55%

49%

43%

4 or 5

High

44%

40%

26%

A predictive model for aggressive non-Hodgkin's lymphoma. The International Non-

Hodgkin's Lymphoma Prognostic Factors Project. (1993) N Engl J Med, 329, 987-994.

Treatment of indolent lymphomas

FL and SLL comprise the majority of patients and are treated in a similar

way. These diseases are usually responsive to chemotherapy and radio-

Lymphoma

therapy but unless truly localised, inevitably recur. There is no firm evi-

dence of a curative therapy for advanced disease. Many patients have few

or no symptoms; the decision to initiate treatment and choice of treat-

ment must take account of individual quality of life issues. At each stage,

the pros and cons of treatment options should be shared with the patient

to reach an agreed treatment decision.

Initial treatment of localised FL and SLL

201

Involved field radiotherapy (35-40Gy) may be curative in the few patients

with localised disease. 5-year DFS >50% may be expected. Recurrence

generally outside radiation field. Late relapses occur. Addition of

chemotherapy improves DFS but not overall survival.

Initial treatment of advanced FL and SLL

Three options are available:

(1) watch and wait;

(2) conventional

chemotherapy and/or radiotherapy; (3) intensive chemotherapy and/or

radiotherapy.

Watch-and-wait: therapy may be deferred for many months/years after

diagnosis until clinical symptoms develop. Patients may have better quality

of life and avoid exposure to cytotoxic agents but must be monitored

closely to prevent or identify insidious complications promptly. Overall

survival >80% at 5 years.

Conventional therapy: generally involves one of the following approaches:

2 Chlorambucil (0.1-0.2mg/kg/d x 7-14 days, q28 or 0.4-0.6mg/kg every

2 weeks) or cyclophosphamide (50-150mg/d PO) as single agents or

with prednisolone; response rates of 50-80% after 12-18 months’

treatment; most relapse within 5 years; convenient oral regimen; well

tolerated.

2 ‘Simple’ combination chemotherapy e.g. CVP: more rapid response

than chlorambucil (useful with bulky disease or symptomatic patients)

but otherwise similar: response rates 80-90%; median response 1.5-3

years; few durable remissions; IV and oral regimen; causes alopecia.

2 ‘High grade’ regimens: high ‘CR’ rates (~60%) with CHOP-type regi-

mens but continuous pattern of relapse and overall survival not con-

vincingly improved in indolent FL (histological grades I and II). In

histological ‘grade III’ FL CHOP produces results equivalent to those in

DLBCL (see below).

2 Radiotherapy for treatment of local problems e.g. cord compression.

Intensive therapy: patients with high tumour burden and high LDH who

achieve CR have significantly longer survival

(63% at 10 years). To

improve the CR rate high dose chemotherapy

± TBI followed by

autologous SCT (with monoclonal antibody purging of the ‘graft’ in some

centres) has been utilised in younger patients with advanced FL and/or

poor prognostic features after initial response to chlorambucil or CHOP.

~80% CR rate; 66% overall survival and up to 40% DFS at 8 years. Still

largely investigational; continuing risk of relapse; too early to assess effect

on long term survival. Myelodysplasia develops in up to 15% of heavily

pre-treated long-term survivors.

Relatively few allografts have been undertaken. Most use TBI-containing

conditioning. CR rate >80% and relapse rates are clearly lower than after

autograft (12% vs. 55% at 5 years) and very few after 2 years. Curative

potential requires longer follow-up. The benefit of better disease control

is offset by a higher treatment-related mortality (15-30%). Non-myeloab-

lative regimens may reduce toxicity, preserve the GvL effect and widen

the availability of this treatment. AlloSCT should be considered in appro-

priate patients with poor prognosis disease. Total lymphoid (or nodal)

irradiation may achieve very high CR rates with 5-year DFS rates >60%

202

but is rarely utilised due to toxicity.

Further treatment of indolent lymphomas

When indolent lymphoma progresses after a partial or complete response

to initial therapy, it is important to rule out transformation to DLBCL

(esp. if LDH 4, LN rapidly enlarging, constitutional symptoms, extranodal

disease). In recurrent indolent NHL, further responses can be achieved

with the prior therapy in most patients who have achieved a durable

response (>12 months). However, chemoresistance to alkylating agents

ultimately develops.

Interferon-a maintenance: several large randomised trials demonstrate a

beneficial effect on survival for patients treated with ≥9 million units/week

administered with and after intensive chemotherapy for >18 months or

until progression; side effects reduce quality of life and the attraction of

this therapy.

Purine analogues: fludarabine has a response rate of 70% (38% CRs) in

untreated patients and ~50% (15% CRs) in previously treated patients.

Responses to cladribine are similar for previously treated patients but less

in de novo treatment and responses are less durable. Neither convincingly

improve disease free or overall survival. Fludarabine achieves responses in

most patients with FL or SLL refractory to chlorambucil. Combinations of

fludarabine with cyclophosphamide or with mitoxantrone (mitozantrone)

and dexamethasone (FMD) increase response rates and are widely used.

Prophylaxis of P carinii by cotrimoxazole in all patients and HZV by

acyclovir in some is required during and for 6 months after therapy.

Cellular blood products must be irradiated for 2 years after therapy.

Monoclonal antibody therapy:

2 Rituximab (MabThera, Rituxan) is a humanised anti-CD20 monoclonal

antibody. As a single agent 375mg/m² infusion weekly ¥ 4 weeks

achieves a response rate ~50% (6% CRs) in previously treated patients;

median duration 13 months¹. On relapse 40% will respond again. In

newly diagnosed patients 4 further doses given over 9 months as main-

tenance therapy enhances EFS (22 vs. 13 months). Toxicity is mild

though there is a risk of anaphylaxis with the first course. Combination

with chemotherapy enhances the response rate. In newly diagnosed

patients: CHOP-R 100% responses, 66% CRs, >50% progression-free

survival (PFS) with median follow up of 6 years. It has been used for ‘in

vivo purging’ prior to stem cell harvest to improve the prospect of a

PCR-negative harvest. In the UK, NICE recommends its use in

chemoresistant disease.

Lymphoma

2 Tositumomab, (Bexaar) a ¹³¹I-radiolabelled murine anti-CD20 mono-

clonal antibody; beta and gamma emission; due to the targeted radia-

tion a single infusion achieves higher response rates (97% OR and 76%

CR in untreated patients; 74% OR & 30% CRs in treated patients) and

a higher response rate and more prolonged responses in advanced

disease than the prior chemotherapy had achieved; transient mild to

moderate myelosuppression; antimurine antibodies develop especially

203

in untreated patients.

2 Ipritumomab (Zevalin) a ⁹⁰Yt-labelled murine anti-CD20 monoclonal

antibody; beta emission only; also achieves superior response rates

(80%) to rituximab in relapsed FL.

Treatment of marginal zone lymphomas

Gastric MALT lymphoma: eradication of H. pylori by 2 week course of clar-

ithromycin, amoxicillin with omeprazole achieves CR in up to 80% of

patients. Local radiotherapy or single agent chlorambucil can achieve CR

in non-responders. Non-gastric MALT lymphomas: single agent chlorambucil,

simple combination regimens or local radiotherapy achieve good

responses.

Initial treatment of aggressive lymphomas

Many patients can be cured by combination chemotherapy or by radio-

therapy.

Localised DLBCL: patients with stage I and non-bulky stage II (mass <10

cm) disease without adverse prognostic factors treated with 3 cycles of

CHOP followed by involved field radiotherapy (45-50Gy) achieve a 99%

response rate 77% PFS and 85% long term survival. This is superior to

radiotherapy alone (15% relapse in irradiation field) and to 8 cycles of

CHOP.

Advanced stage DLBCL: several chemotherapy regimens have curative

potential. CR rates 50% to >80%. Although CR rates to CHOP regimen

have been bettered by some multi-agent regimens, long-term follow-up

reveals comparable or inferior long-term PFS rates and greater treatment

related toxicity. A prospective randomised trial comparing CHOP, m-

BACOD, ProMACE-CytaBOM, and MACOP-B revealed no significant

difference in response rates, time to treatment failure or survival. Several

trials failed to demonstrate the superiority of any particular

chemotherapy regimen for NHL. The CHOP regimen (p604) has been

widely used because of ease of administration and relative tolerability.

Some 30% of patients are cured using CHOP alone. The addition of

Rituximab to CHOP improves responses and survival (see below).²

R-CHOP has been endorsed by NICE⁵ for use as first line therapy in

CD20+ DLBCL stage II, III or IV. Evaluate response to therapy after 3-4

courses and complete 6 courses if complete remission has been achieved.

Consolidation therapy in DLBCL: in future different protocols may be

appropriate for different risk groups of patients (risk-adapted therapy).

Consolidation of 1st CR by high dose therapy and autologous SCT has

been examined in randomised trials. Improved DFS (and overall survival in

one of three studies) was demonstrated for patients with ≥2 adverse

factors on IPI. Further studies are in progress. It seems likely that a group

of poor prognosis patients may benefit from intensive consolidation and

the option should be discussed with eligible high risk patients in first

remission.

Monoclonal antibody therapy: rituximab produces responses in ~30%

relapsed DLBCL. More promising role in combination with initial

chemotherapy: addition of Rituximab to CHOP initial therapy improved

the CR rate (76% vs. 63%) and EFS (57% vs. 38%) and overall survival

(70% vs. 57%) at 2 years with no added toxicity in a randomised study of

204

400 elderly patients with DLBCL². Confirms Phase II data and further

Phase III studies in progress has been endorsed by NICE⁵ R-CHOP for

use as first line therapy for DLBCL.

Tositusimab: under examination in combination with BEAM high dose

therapy to enhance tumour cell kill in autologous SCT for aggressive

lymphoma.

Mantle cell lymphoma: CHOP produces response rate ~80% (CR ~50%)

with PFS <18 months and overall survival of 3 years and is not markedly

different from results obtained with CVP. Regimens such as fludarabine

and cyclophosphamide can achieve further responses. Rituximab alone

achieves response rate ~35% (14% CR) with a median duration <1 year.

Combination of rituximab with CHOP achieved a high rate of ‘molecular

remissions’ as initial therapy but a disappointing median PFS of 16 months.

The combination of rituximab with several salvage regimens (e.g. FCM)

improves responses. Relapsed patients with MCL who respond to salvage

therapy achieve further remissions with high dose therapy and autologous

SCT but further relapse is usual. Rituximab pre-harvest acts as in vivo

purge increasing the proportion of PCR

-ve collections. High dose

therapy and ASCT in first remission prolongs response duration and

probably survival but is probably not curative³. Suitable patients with a

sibling allogeneic SCT option should receive an allograft.

Initial treatment of very aggressive lymphomas

Non-endemic Burkitt lymphoma: successful treatment of BL in children

has informed adult treatment. High remission rates and long-term DFS

achieved with intensive short duration

(3-6 months) multi-agent

chemotherapy regimens including high dose methotrexate, high dose

cytarabine, etoposide, ifosfamide and CNS prophylaxis. Protocols

designed for lymphoblastic lymphoma or ALL clearly inferior to specific

BL protocols. 90% EFS rates in childhood BL. Treatment of adults with BL

with intensive regimens including intrathecal therapy such as CODOX-

M/IVAC

(Vincristine, doxorubicin, cyclophosphamide, methotrexate,

folinic acid, G-CSF plus IT cytarabine and IT methotrexate/etoposide,

ifosfamide, mesna, cytarabine, folinic acid, G-CSF plus IT methotrexate)

improves response and survival rates (~50% curable) though not to

childhood results. The role of high dose therapy is uncertain. Meningeal

involvement still carries poor prognosis.

Lymphoblastic lymphoma: management in adults has also followed more

successful intensive regimens in childhood based on ALL treatment

Lymphoma

(including CNS prophylaxis). High CR rates (~85%) and 5 year DFS up to

45% reported. The poor outlook for patients has led to evaluation of

high-dose therapy with autologous or allogeneic BMT early in its

management.

Adult T-leukaemia/lymphoma: p188.

Salvage therapy in aggressive and very aggressive lymphoma

205

Patients who relapse or fail to achieve remission with initial therapy have

a poor prognosis. Without effective second-line (salvage) therapy, almost

all die of progressive lymphoma in a median period of 3-4 months.

Conventional chemotherapy: although relatively high CR rates have been

reported with several salvage regimens, <10% patients with relapsed or

refractory NHL will achieve long-term DFS. The addition of rituximab to

EPOCH and ICE salvage regimens improves response rates.

High dose therapy and SCT: high dose therapy (generally BEAM, BEAC or

CBV) and autologous SCT is used to treat patients with relapsed or

refractory aggressive or very aggressive NHL. A significant proportion of

patients with DLBCL are cured (5 year EFS 46%; overall survival 53%) and

its superiority to conventional dosage salvage therapy (5 year EFS 12%;

overall survival

32%) was demonstrated in a randomised trial⁴. Best

results are obtained when lymphoma still responsive to conventional

dosage therapy and SCT performed in a state of minimal residual disease.

HDT is generally preceded by 1-2 cycles of combination therapy e.g. mini-

BEAM, DHAP, ESHAP with aim of testing chemo-responsiveness, inducing

minimal residual disease and harvesting PBSCs. Syngeneic and allogeneic

transplants have been used less frequently but are associated with cures.

1 McLaughlin, P. et al. (1998) Rituximab chimeric anti-CD20 monoclonal antibody therapy for

relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin

Oncol, 16, 2825-2833 2 Coiffier, B. et al. (2002) CHOP chemotherapy plus rituximab compared

with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med, 346,

235-242 3 Vandenberghe, E. et al. (2003) Outcome of autologous transplantation for mantle cell

lymphoma: a study by the European Blood and Bone Marrow Transplant and Autologous Blood

and Marrow Transplant Registries. Br J Haematol, 120, 793-800. 4 Philip, T. et al. (1995)

Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of

chemotherapy-sensitive non-Hodgkin's lymphoma. N Engl J Med, 333, 1540-1545. 5 NICE

Technology Appraisal 65, September 2003

CNS lymphoma

Primary CNS lymphoma

2% of NHL cases; incidence increased partly by HIV pandemic; non-HIV

related aged 55-70; commonly involves frontal lobes, corpus callosum or

deep periventricular structures; cognitive or personality change common;

10% seizures;

40% evidence of leptomeningeal spread; diagnosis by

gadolinium-enhanced magnetic resonance and stereotactic needle biopsy;

systemic lymphoma uncommon; poor prognosis improved by addition of

systemic chemotherapy with high dose methotrexate to whole brain

206

radiotherapy; improves survival with >95% responses and median survival

30-60 months; 50% relapse risk; most relapses in CNS, others mainly

leptomeningeal and ocular,

<10% systemic; delayed neurotoxicity

common, esp. >60 years: dementia, ataxia, urinary dysfunction.

Secondary CNS lymphoma

Usually meningeal involvement; occurs in up to 10% of cases of NHL;

intrathecal methotrexate, cytarabine and prednisolone twice weekly until

CSF clear then weekly ¥ 6 ± cranial irradiation as for ALL; insertion of

Ommaya reservoir facilitates administration; simultaneous systemic

therapy including high dose methotrexate and cytarabine

(penetrate

CNS) normally necessary; poor prognosis; median survival <3 months.

Hodgkin’s lymphoma (Hodgkin’s

disease)

First described by Thomas Hodgkin in 1832 the lineage of the neoplastic

cells remained a subject of debate for over 160 years. Micromanipulation

of tissue sections followed by single cell PCR for Ig gene amplification

demonstrates that the neoplastic cells in Hodgkin’s lymphoma (HL) are

clonal B cells originating in a lymph node germinal centre. HL is a germinal

centre-derived B-cell lymphoma.

208

Incidence

2 1% cancer registrations per annum. Annual incidence ~3 per 100,000

in Europe and USA (less common in Japan).

2 Bimodal age incidence—major peak between 20 and 29 years and

minor peak 60 years.

2 Overall higher incidence in 9.

2 Nodular sclerosing (NS) histology is most common subtype in young

adults (>75% of NS cases are <40 years) and peak at this age is con-

fined to NS subtype and has a 3 preponderance.

Risk factors

2 Associated with high socioeconomic status in childhood (esp. NS in

young adults) and with Caucasian race in the USA.

2 Familial aggregations frequently reported: 99¥ 4 risk in identical twins;

7¥ risk for siblings of young adults (no increase for sibs of older

adults); ? genetic or environmental effect.

2 Considerable evidence linking EBV to HL: 4 risk of HL in individuals

with a history of infectious mononucleosis; EBV encoded nuclear

RNAs detected in Reed-Sternberg (RS) cells; 26-50% cases +ve for

EBV by molecular analysis (esp. mixed cellularity (MC) subtype).

Histology and classification

Immunological analysis has resulted in reclassification of HL in the REAL

and WHO Classifications of Lymphoid Neoplasia ( p195) into 2 major

groups:

Nodular lymphocyte-predominant HL

(NLPHL):

3-8%; contains large

atypical B cells and lymphocytic and histiocytic (L&H) ‘popcorn’ cells.

These cells are CD30-, CD15-, CD20+, CD45+, CD75+, CD79a+.

‘Classical’ HL: large mononuclear (Hodgkin’s cells) or binucleate/multinuclear

RS cells make up only 1-2% of the cellularity of the lymph node. These cells

are CD30+ and typically CD15+, CD20-, CD45-, CD75-, CD79a-. The

predominant cells are an infiltrate of lymphocytes, plasma cells, eosinophils

and histiocytes containing scattered neoplastic cells and a variable degree of

fibrosis.

Four histological subtypes:

Nodular sclerosing HL (NSHL): ~80%; prominent bands of fibrosis and

nodular growth pattern; lacunar Hodgkin’s cells; variable numbers of RS

cells.

Lymphoma

Mixed cellularity HL (MCHL): ~17%; mixed infiltrate of lymphocytes,

eosinophils and histiocytes with classical RS cells.

Lymphocyte depleted HL (LDHL): rare; diffuse hypocellular infiltrate with

necrosis, fibrosis and sheets of RS cells.

Lymphocyte rich classical HL (LRCHL): uncommon; diffuse predominantly

lymphoid infiltrate with scanty RS cells of ‘classical’ phenotype.

209

Clinical features

Presentation commonly with painless ‘rubbery’ supradiaphragmatic

lymph node enlargement: frequently cervical gland(s).

Initial mode of spread occurs predictably to contiguous nodal chains.

Often involves supraclavicular and axillary glands and other sites.

Waldeyer’s ring involvement is rare and suggests a diagnosis of NHL.

Lymphadenopathy in HL may wax and wane during observation.

Spleen involved in ~30% but palpable splenomegaly only in 10%,

hepatomegaly 5%.

Abdominal lymphadenopathy is unusual without splenic involvement.

Supradiaphragmatic disease ± intra-abdominal involvement is usual,

and regional disease limited to subdiaphragmatic sites is uncommon

(except NLPHL).

Bulky mediastinal and hilar lymphadenopathy may produce local symp-

toms (e.g. bronchial or SVC compression) or direct extension (e.g. to

lung, pericardium, pleura or rib). Pleural effusions in 20%.

Extranodal spread may also occur via bloodstream (e.g. to bone

marrow (1-4%), lung or liver). Presence of disseminated extranodal

disease is generally accompanied by generalised lymphadenopathy and

splenic involvement; usually a late event.

~33% patients have ≥1 associated constitutional ‘B’ symptoms at pre-

sentation: weight loss >10% body weight during the previous 6

months, unexplained fever or drenching night sweats. ‘B’ symptoms

correlate with disease extent, bulk and prognosis. Further systemic

symptoms associated with HD (but not ‘B’ symptoms) are generalized

pruritus and alcohol-induced lymph node pain.

A defect in cellular immunity has been documented in patients with HL

rendering them more susceptible to TB, fungal, protozoal and viral

infections including P carinii and HZV.

NLPHL more frequent in 9 (2-3¥); median age 35 years; typically

localised at presentation; usually cervical or inguinal; infrequent ‘B’

symptoms; late relapses occur; increased risk of DLBCL; otherwise

favourable prognosis; 10 year OS 80-90%.

NSHL occurs typically in young adults (median age 26) and has a good

prognosis if stage I/II.

MCHL has a median age of 30 years and an intermediate prognosis.

LDHL is more common in older adults; has a relatively poor prognosis.

LRCHL 9>3; tendency to localised disease; favourable prognosis.

Investigation, diagnosis and staging

Document ‘B’ symptoms in history.

Document extent of nodal involvement by clinical examination.

Confirm diagnosis by biopsy: best histology from lymph node excision

biopsy; image guided needle biopsy or even laparotomy, mediastinoscopy

or mediastinotomy may be necessary to obtain a tissue diagnosis.

Clinical staging is now usual; routine staging laparotomy for ‘patholog-

ical staging’ abandoned; useful only if result may substantially reduce

treatment.

Clinical staging includes the initial biopsy site and all other abnormali-

ties detected by non-invasive methods.

Pathological staging requires biopsy confirmation of abnormal sites.

210

FBC: may show normochromic normocytic anaemia, reactive leucocy-

tosis, eosinophilia and/or a reactive mild thrombocytosis.

ESR/plasma viscosity; U&E; LFTs; urate; LDH.

CXR.

CT chest, abdomen and pelvis to define occult nodal and extranodal

involvement.

Bone marrow trephine biopsy to exclude marrow involvement in

patients with stage III/IV disease or B symptoms (not essential in stage

IA/IIA disease); BM may show reactive features.

Isotope bone scan, MRI or PET scan may be necessary.

Biopsy of other suspicious sites may be necessary e.g. liver or bone.

Attempt semen cryopreservation in young males with advanced

disease (often unsuccessful in those with ‘B’ symptoms).

Ann Arbor staging classification (Cotswolds modification)

The Ann Arbor staging classification has strong prognostic value and is deter-

mined by the number of lymph node regions (not sites) involved and the

presence or absence of ‘B’ symptoms. The Cotswolds modification reflects

the use of modern imaging techniques, recognises clinical and pathological

staging and clarifies differences in disease distribution and bulk.

Stage I

involvement of a single lymph node region or structure

Stage II involvement of two or more lymph node regions on the same

side of the diaphragm (number of anatomical sites indicated by

a subscript, e.g. II₃).

Stage III involvement of lymph node regions or structures on both

sides of the diaphragm

III₁

± involvement of spleen, splenic hilar, coeliac or portal nodes;

III₂

with involvement of para-aortic, iliac or mesenteric nodes

Stage IV involvement of one or more extranodal sites (e.g. BM, liver or

other extranodal sites not contiguous with LN—cf. ‘E’ below).

A absence of constitutional symptoms

fever, weight loss >10% in 6 months or drenching night sweats

Additional subscripts applicable to any disease stage:

X bulky disease (widening of mediastinum by >33% or mass >10cm)

involvement of a single extranodal site contiguous or proximal to known

nodal site.

CS clinical stage

pathological stage

Lymphoma

Clinical imaging criteria

2 Lymph node involvement: >1cm on CT scan is considered abnormal.

2 Spleen involvement: splenomegaly may be ‘reactive’; filling defects on

CT or USS confirm involvement.

2 Liver involvement: hepatomegaly insufficient; filling defect on imaging

and abnormal LFTs confirm involvement.

2 Bulky disease: ≥10cm in largest dimension or mediastinal mass greater

than one third the maximal intrathoracic diameter.

211

Initial therapy

2 Aim of treatment is to provide each patient with the best probability

of cure while minimising early and late treatment-related morbidity.

2 Best strategy is determined by tumour-related and patient-related

factors.

2 Clinical trials remain necessary to evaluate therapeutic regimens in

order to achieve this objective. BNLI/UKLG coordinate nationwide

multicentre studies in UK.

Early stage HL

Prognostic factors: patients with stage I or II disease are generally divided

into favourable and unfavourable prognostic groups using risk factors, e.g.

2 Age >40.

2 ESR >50mm/h or >30 in presence of ‘B’ symptoms.

2 ≥4 separate sites of nodal involvement; mediastinal mass ratio > 0.35.

2 Other risk factors identified in studies have been gender, histology,

disease confined to upper cervical nodes, anaemia and low serum

albumin.

Favourable prognosis: stage I or II HL without any risk factors

Aim: cure with minimal side effects.

2 Treatment of choice is combined modality treatment, using attenuated

duration chemotherapy, e.g. ABVD ¥ 4 cycles + involved field radio-

therapy (36-40Gy).

2 Aims to eliminate local disease and treat occult disease with reduced

toxicity using limited field and attenuated number of cycles of

chemotherapy.

2 Expected outcome: ~90% failure-free survival (FFS) and >95% OS at 5

years.

Alternative therapeutic options:

Subtotal lymphoid irradiation (36-40Gy) offers ~80% FFS and >90% OS.

It has been argued that most patients relapsing after radiotherapy alone

can be salvaged by chemotherapy (e.g. ABVD) thus sparing most patients

the toxicity of combined modality therapy. However, long term toxicity

from extended field radiotherapy is significant.

EBVP ¥ 6 plus involved field radiotherapy (36-40Gy).

A very favourable subgroup (stage I, age <40, no ‘B’ symptoms, ESR <50,

3 and MT ratio <0.35) may achieve 65-75% FFS and >90% OS at 10

years following extended field radiotherapy treatment alone.

Patients with non-bulky NLPHL presenting with unilateral high cervical or

epitrochlear lymphadenopathy may be treated with involved field

radiotherapy alone; at median follow up >7 years, more patients with

NLPHL and LRCHL die of treatment-related toxicity than recurrent HL;

may be best treated with limited dose, limited field radiotherapy alone;

with similar aim of reduced toxicity anti-CD20 antibody treatment may

prove useful in NLPHL.

Stage IA patients with subdiaphragmatic disease should receive

212

chemotherapy

± involved field radiotherapy to avoid extended

pelvic/abdominal fields that are myeloablative and sterilising in women;

patients with NLPHL localised to inguinal or femoral region may receive

regional irradiation only.

Unfavourable prognosis: stage I or II HL with any risk factors

Aim: cure with some acceptable side effects.

2 Combined modality treatment essential, e.g. ABVD ¥ 6 cycles +

involved field radiotherapy (36-40Gy).

2 Expected outcome: >85% DFS and ~90% OS at 5 years.

2 Alternative therapeutic option: MOPP-ABV ¥ 6 cycles + involved field

radiotherapy (36-40Gy).

Advanced stage HL

Prognostic factors: a prognostic score has been devised by the

International Prognostic Factors Project¹ for patients with advanced HL.

Seven factors were identified:

2 Hb <10.5g/dL.

2 9 gender.

2 Stage IV.

2 Age ≥45.

2 WBC >16

¥ 10⁹/L.

2 Lymphopenia <0.6

¥ 10⁹/L or <8% of differential.

2 Albumin <40g/L.

Patients with no adverse factors had 5 year failure-free progression of

84%. Each additional factor reduces 5 year failure-free progression by ~7%

until the group with 4-7 factors have ~40% failure-free progression at 5

years.

Combination chemotherapy

2 Enter patient in a multicentre randomised clinical trial if possible.

2 ABVD ( p596) is the standard regimen for patients with advanced

HL (stage III or IV) not enrolled in a clinical trial.

2 In a randomised trial of 361 patients 6-8 cycles of ABVD was equiva-

lent to 12 cycles of MOPP-ABVD alternating regimen (CR 82% vs.

83%; FFS at 5 years 61% vs. 65%) and superior to 6-8 cycles of MOPP

(CR 67%; 5 year FFS 50%)².

2 ABVD has a much lower risk of infertility than MOPP regimens and is

not associated with increased risk of leukaemia but the anthracycline

Lymphoma

component may exacerbate the cardiac and pulmonary complications

of mediastinal irradiation.

2 Often poorly tolerated by elderly patients due to cumulative doses of

doxorubicin and bleomycin.

2 Alternative: brief duration dose intensified regimens, e.g. Stanford V

low cumulative doses of alkylators, doxorubicin and bleomycin over 12

weeks followed by radiotherapy to sites of bulk disease (≥5cm); FFS

213

89%, OS 96% at 6 years in a single institution study; multicentre ran-

domised trials in progress; fertility preserved in a high proportion; very

low risk of leukaemia.

Adjuvant radiotherapy

Involved field radiotherapy is frequently give to bulky mediastinal disease

after completion of combination chemotherapy. This improves DFS but

has no effect on OS. Meta-analysis suggest an overall 11% improvement in

DFS and that the benefits are greatest for NSHL histology (least for

MCHL and LDHL), for mediastinal bulk rather than other bulky sites and

that no benefit is gained in stage IV disease³. Late toxicity is increased. The

lack of difference in overall survival was attributed to a greater number of

second malignancies and poorer response and survival after relapse

among patients who received combined modality therapy.

Evaluation of response

2 Evaluate by physical examination and repetition of abnormal investiga-

tions at initial staging.

2 Often performed after 3-4 courses of chemotherapy to ensure ade-

quate response and to determine total duration of treatment.

2 Residual masses sometimes present at completion of therapy, notably

in mediastinum: may be residual fibrotic tissue with no viable tumour.

2 If residual mass evident on CT, gallium scintigraphy, MRI or PET scan

may exclude active disease if negative and obviate need for invasive

biopsy.

Cotswolds criteria:

CR:

complete resolution of all radiological and laboratory

evidence of active HL.

CRu:

‘uncertain CR’, identifies the presence of a residual mass that

remains stable or regresses on follow-up.

Salvage therapy

2 >50% of patients relapsing from primary radiotherapy of early stage

HL may be cured by ABVD chemotherapy.

2 Durable FFP and prolonged survival are not generally achieved by con-

ventional chemotherapy for patients relapsing after initial chemotherapy.

2 High-dose chemotherapy (BEAM or CBV) with autologous peripheral

blood stem cell transplantation (SCT) has become the standard salvage

approach for most patients relapsing after chemotherapy, producing

high complete response rates (up to 80%), durable complete remis-

sions in 40-65% and low morbidity and mortality in selected patients.

2 HDT plus autologous SCT may be the best option for patients with

refractory disease at initial therapy though patients with progressive

disease on conventional therapy still have an unfavourable prognosis.

2 Allogeneic SCT has been performed in a small number of patients.

Late complications of therapy

Treatment-induced sterility is frequently seen in 9 after treatment

with MOPP and MOPP-like regimens regardless of age (90%

azoospermic 1 year after ≥6 courses); the ABVD regimen produces

significantly less infertility. Abnormal menstruation due to MOPP is

more common in women over 30 (60-70%) and less common in those

<20 (20-30%).

Premature menopause is more common after MOPP in older 3.

214

ABVD + mantle radiotherapy causes higher incidence of post-irradia-

tion paramediastinal fibrosis causing persistent effort dyspnoea.

Patients cured of HL are at 4 risk of a second malignancy with a rela-

tive risk of 6.4.

Solid tumours (commonly breast, lung, melanoma, soft tissue sarcoma,

stomach and thyroid) comprise >50% of second malignancies; propor-

tion increases as follow-up lengthens; risk ~13% at 15 years and ~22%

at 25 years; associated with radiotherapy and young age at time of

treatment; 75% occur within radiation fields.

Acute myeloblastic leukemia risk ~3% at 10 years after treatment;

peak incidence between 5-9 years; risk 5 10 years after therapy; par-

ticularly associated with MOPP chemotherapy and age >40 and radio-

therapy dose >30Gy to mediastinum; risk 10 years after ABVD <1%.

NHL risk 7%; rises beyond 10 years and declines after 15 years; no

clear association with type of therapy.

Cardiac toxicity: myocardial infarction, radiation-induced pericarditis,

valvular disease and congestive failure occur at an increased frequency

in patients previously treated for HL; higher risk in patients <40 at

treatment.

Pulmonary toxicity: generally mild, usually asymptomatic changes in

pulmonary function; associated with mediastinal irradiation and

bleomycin containing chemotherapy (ABVD).

Thyroid toxicity: 50% risk at 20 years after radiation to the neck and

upper mediastinum; risk highest for ages 15-25; usually hypothy-

roidism, minority develop hyperthyroidism, Hashimoto’s thyroiditis,

nodules or thyroid cancer.

Patients treated with HDT and autologous SCT have an increased inci-

dence of myelodysplasia and AML and azoospermia in males and pre-

mature ovarian failure in females is usual.

1 Hasenclever, D. & Diehl, V. (1998) A prognostic score for advanced Hodgkin's disease.

International Prognostic Factors Project on Advanced Hodgkin's Disease. N Engl J Med, 339,

1506-1514 2 Canellos, G.P. et al. (1992) Chemotherapy of advanced Hodgkin's disease with

MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med, 327, 1478-1484 3 Loeffler, M. et

al. (1998) Meta-analysis of chemotherapy versus combined modality treatment trials in Hodgkin's

disease. International Database on Hodgkin's Disease Overview Study Group. J Clin Oncol, 16,

818-829.

Myelodysplastic syndromes (MDS)

The myelodysplastic syndromes (MDS) are a group of biologically and

clinically heterogeneous clonal disorders characterised by ineffective

haematopoiesis and peripheral cytopenia due to increased apoptosis and

by a variable tendency to evolve to acute myeloblastic leukaemia.

Incidence

Predominantly affects elderly but may occur at any age; median age 69;

annual incidence 4/100,000 in general population; rising from 0.5/100,000

aged <50 years to 89/100,000 aged ≥80 years.

Risk factors

2 Age.

218

2 Prior cancer therapy: notably with radiotherapy, alkylating agents

(chlorambucil, cyclophosphamide, melphalan; peak 4-10 years after

therapy) or epipodophyllotoxins (etoposide, teniposide; peak within 5

years). Note: prolonged alkylator therapy used in rheumatology and

other specialties.

2 Environmental toxins: notably benzene and other organic solvents;

related to intensity and duration of exposure; also smoking, petroleum

products, fertilisers, semi-metal, stone dusts and cereal dusts.

2 Genetic: rare familial syndromes; MDS increased in children with

Schwachman-Diamond syndrome, Fanconi anaemia and neurofibro-

matosis type 1.

Pathophysiology

2 Clonal haematopoietic stem cell disorder characterised by stepwise

genetic progression possibly due to a combination of genetic predispo-

sition and environmental exposures.

2 Abnormalities in the marrow microenvironment described: e.g. aber-

rant cytokine production (increased inhibitory pro-apoptotic cytokines

including TNF-a, IL-6, TGF-b, IFN-g and Fas ligand) and altered stem

cell adhesion.

2 MDS marrow stem cells display lowered apoptotic threshold to TNF-a,

IFN-g & anti-Fas antibodies and less response to haemopoietic growth

factors.

2 Early indolent pro-apoptotic MDS transforms to aggressive prolifera-

tive MDS as genetic lesions accumulate (ras, FLT3, FMS and p53 muta-

tions associated with disease progression).

2 Symptoms relate not only to the degree of cytopenia but to impaired

function of granulocytes and platelets and may occur at near-normal or

normal levels.

Classification systems

French-American-British (FAB) system

2 Morphology based classification widely adopted since 1982.

2 Defines five subtypes.

2 Requires dysplastic changes in ≥ 2 lineages.

2 Useful for predicting prognosis and risk of evolution to acute

leukaemia.

FAB classification

Refractory anaemia (RA): cytopenia of one peripheral blood (PB) lineage;

normo- or hypercellular marrow with dysplasia ≥2 lineages; <1% PB

blasts; <5% BM blasts. 25% of patients.

220

Refractory anaemia with ringed sideroblasts (RARS): defined as for RA

plus ringed sideroblasts account for >15% nucleated erythroid cells; 15%

of patients.

Refractory anaemia with excess blasts

(RAEB): cytopenia of

≥2 PB

lineages; dysplasia of all 3 BM lineages; <5% PB blasts; 5-20% BM blasts;

35% of patients.

Refractory anaemia with excess blasts in transformation

(RAEB-t):

cytopenia of ≥2 PB lineages; dysplasia of all 3 BM lineages; ≥5% PB blasts;

21-30% BM blasts or Auer rods in blasts; 15% of patients.

Chronic myelomonocytic leukaemia (CMML): PB monocytosis (>1

¥ 10⁹/L);

<5% PB blasts; ≤20% BM blasts; 10% of patients¹.

World Health Organisation (WHO) system

2 Proposed reclassification of MDS based on morphology, karyotype and

clinical features; not yet universally accepted.

2 Lower threshold for diagnosis of AML from 30%720% blasts in PB or

BM; eliminates FAB category ‘RAEB-t’.

2 Refined definitions for low grade MDS: RA and RARS.

2 Addition of new category ‘refractory cytopenia with multilineage dys-

plasia’ (RCMD).

2 Defines two subtypes of RAEB: RAEB-1 (5-9% BM blasts) and RAEB-2

(10-19% BM blasts) reflecting worse clinical outcomes with ≥10%

blasts.

2 Recognises the ‘5q- syndrome’ as a distinct narrowly defined entity.

2 Removes CMML to a newly created disease group: MDS/MPD.

Myelodysplasia

WHO Classification System

Condition

PB findings

BM Findings

Refractory anaemia

anaemia >6 months

erythroid dysplasia only

(RA)

no or rare blasts

<5% blasts

<15% ringed sideroblasts

Refractory anaemia with

anaemia >6 months

erythroid dysplasia only

ringed sideroblasts

no blasts

≥15% ringed sideroblasts

(RARS)

<5% blasts

221

Refractory cytopenia with

cytopenias (bi- or pan-)

dysplasia in ≥10% cells in

multilineage dysplasia

no or rare blasts

≥2 myeloid cell lines

(RCMD)

no Auer rods

<5%blasts

¥ 10⁹/L monocytes

no Auer rods

<15% ringed sideroblasts

Refractory cytopenia with

cytopenias (bi- or pan-)

dysplasia in ≥10% cells in

multilineage dysplasia and

no or rare blasts

≥2 myeloid cell lines

ringed sideroblasts

no Auer rods

≥15% ringed sideroblasts

(RCMD-RS)

¥ 10⁹/L monocytes

<5% blasts

no Auer rods

Refractory anaemia with

cytopenias

unilineage or multilineage

excess blasts

<5% blasts

dysplasia

(RAEB-1)

no Auer rods

5-9% blasts

¥ 10⁹/L monocytes

no Auer rods

Refractory anaemia with

cytopenias

unilineage or multilineage

excess blasts

5-19% blasts

dysplasia

(RAEB-2)

Auer rods ±

10-19% blasts

¥ 10⁹/L monocytes

Auer rods ±

Myelodysplastic syndrome,

cytopenias

unilineage dysplasia in

unclassified

no or rare blasts

granulocytes or

(MDS-U)

no Auer rods

megakaryocytes

<5% blasts

no Auer rods

MDS associated with

anaemia

normal to increased

isolated del(5q)

<5% blasts

megakaryocytes with

platelets normal or 4

hypolobated nuclei

<5% blasts

no Auer rods

isolated del(5q)

Vardiman, J.W. et al. (2002) The World Health Organization (WHO) classification of

the myeloid neoplasms. Blood, 100, 2292-2302.

Clinical features of MDS

2 Presentation ranges from mild anaemia to profound pancytopenia.

2 May be asymptomatic with mild anaemia identified on routine FBC.

2 Macrocytic or normochromic anaemia usual (60-80%) ± neutropenia

(50-60%) ± thrombocytopenia (40-60%).

2 Isolated thrombocytopenia would be a most unusual presentation for

MDS.

2 Symptoms of underlying cytopenias and cellular dysfunction may

develop:

- Anaemia: fatigue, shortness of breath, exacerbation of cardiac

symptoms.

- Neutropenia and dysfunctional granulocytes: recurrent infection.

224

- Thrombocytopenia and dysfunctional platelets: spontaneous

bruising, purpura, bleeding gums.

2 Constitutional symptoms including anorexia, weight loss, fevers and

sweats usually feature of the more ‘advanced’ subgroups; may be due

to cytokine release.

2 Splenomegaly commonly occurs in CMML and may cause abdominal

pain and easy satiety.

Investigation and diagnosis

History: prior exposure to chemotherapy/radiation; FH of MDS/AML;

recurrent infection or bleeding/bruising.

Examination: pallor; infection; bruising; splenomegaly.

FBC: macrocytic/normochromic anaemia ± neutropenia ± thrombocy-

topenia ± neutrophilia ± monocytosis ± thrombocytosis.

Blood film: may demonstrate dimorphic red cells ± Pappenheimer

bodies in RARS; basophilic stippling in RBCs; dysplastic granulocytes:

pseudo-Pelger forms, hypersegmented neutrophils, hypogranular neu-

trophils, dysmorphic monocytes ± blasts; platelets may be large or

hypogranular.

U&E, LFTs, ECG and CXR: to assess co-morbidity.

Serum ferritin, vitamin B₁₂ and RBC folate: usually normal levels; fer-

ritin may be elevated in RARS.

Serum Epo level: indicates probability of therapeutic response to Epo.

BM aspirate: demonstrates >10% dysplastic cells in ≥ 2 lineages (for

FAB system): megaloblastoid erythropoiesis, nuclear-cytoplasmic asyn-

chrony in myeloid or erythroid precursors, dysmorphic megakary-

ocytes or micro-megakaryocytes; normal or increased storage iron;

≥15% ringed sideroblasts in RARS; increased monocytes in CMML.

BM trephine biopsy: allows assessment of cellularity—usually 4 or

normal; may demonstrate abnormal localisation of immature myeloid

precursors centrally in the intertrabecular interstitium (ALIPs),

megakaryocyte dysplasia, fibrosis or hypocellular MDS variant.

BM cytogenetic analysis: may demonstrate clonal chromosome abnor-

mality(s) confirming diagnosis and with prognostic value.

Definitive diagnosis of early MDS (e.g. isolated cytopenia) may be diffi-

cult; regular review with repeat blood count and film assessment rec-

ommended; in all cases a measure of the pace of the disease over a

2-6 week period is of prognostic value.

Myelodysplasia

225

Blood film in MDS showing bilobed pseudo-Pelger neutrophil.

Cytogenetic analysis

2 Abnormalities found in BM cytogenetic analysis of 40-70% of patients

with de novo MDS and 80-90% of patients with secondary MDS.

2 Single or complex abnormalities at diagnosis may evolve during course

of disease.

2 More complex abnormalities associated with more aggressive subtypes

and higher % blasts and with secondary MDS.

2 Most frequent abnormalities involve chromosomes 5, 7, 8, 11, 12 and

20; most typical are 8+, 7- or 7q-, 5- or 5q-.

2 Isolated 5q-, 20q- and normal karyotype favourable; complex kary-

otypes (≥3 abnormalities), 7- or 7q- unfavourable.

Differential diagnosis

Exclude:

2 Other causes of anaemia (haematinic deficiency, haemolysis, blood

loss, renal failure).

2 Other causes of neutropenia (drugs, viral infection).

2 Other causes of thrombocytopenia (drugs, ITP).

2 Other causes of bi-/pancytopenia (drugs, infection, aplastic anaemia).

2 Other causes of monocytosis (infection, AML) or neutrophilia (infec-

tion, CML).

2 Reactive causes of BM dysplasia: megaloblastic anaemia, HIV infection,

alcoholism, recent cytotoxic therapy, severe intercurrent illness.

2 Other causes of marrow hypoplasia in hypoplastic MDS: aplastic

anaemia, PNH.

Prognostic factors in MDS

FAB classification

RARS RAEB RAEB-t CMML

Proportion of patients

25%

15%

12%

15%

10%

Median survival (months) 43

Transformation to AML

15%

40%

50%

35%

Transformed at 1 year

25%

55%

Transformed at 2 years

10%

35%

65%

np - data not provided

CMML median survival <5% blasts 53 months; 5-20% blasts 16 months.

226

Greenberg P.L. (2000) In: Hoffman R et al. eds Hematology: Basic Principles & Practice. 3rd ed.

New York, NY: Churchill Livingstone 2000:1106-1129.

International Prognostic Scoring System (IPSS)

2 Uses BM blast %, BM cytogenetics and number of cytopenias to

compute a risk score and stratify patients into 4 distinct groups.

2 Improved prognostic power for both survival and evolution into AML

compared with earlier systems.

2 Analysis excluded CMML with a WBC >12

¥ 10⁹/L as this was consid-

ered myeloproliferative rather than MDS.

2 IPSS score should be calculated during a stable clinical state not, for

example, during florid infective initial presentation.

2 May be used to assist management decisions.

Score value

Prognostic variable

0.5

1.0

1.5

2.0

BM blast %

5-10

11-20

21-30

Karyotype

Good

Intermediate

Poor

Cytopenias

0/1

2/3

Karyotype: Good: normal, -Y, del(5q), del(20q); Poor: complex (≥3

abnormalities) or chromosome 7 anomalies; Intermediate: other abnormalities.

Cytopenias: Hb <10g/dL; neutrophils <1.8

¥ 10⁹/L; platelets <100

¥ 10⁹/L.

IPSS risk group Combined score Median survival

25% AML evolution

Low

5.7 yrs

9.4 yrs

Intermediate-1

0.5-1.0

3.5 yrs

3.3 yrs

Intermediate-2

1.5-2.0

1.2 yrs

1.1 yrs

High

>2.5

0.4 yrs

0.2 yrs

Greenberg, P. et al. (1997) International scoring system for evaluating prognosis in

myelodysplastic syndromes. Blood, 89, 2079-2088.

Clinical variants of MDS

CMML: classified as MDS/MPD in the WHO classification; clinical

outcome relates to BM blast % rather than PB monocyte count ( p234).

5q- syndrome: clinically distinct form of MDS in WHO classification;

characterised by more indolent clinical course, lower rate of evolution to

AML, macrocytic anaemia, thrombocytosis and dysplastic megakaryocytes

Pure sideroblastic anaemia (PSA): defined as sideroblastic anaemia with

dysplasia confined to erythropoietic cells (RARS in WHO classification);

survival better (77% OS at 3yrs) than where dysplastic features are also

present in myeloid or megakaryocytic lineages

(RCMD-RS in WHO

classification; 56% OS at 3yrs) and very low risk of AML, even in the long

228

term.

Secondary MDS: incidence increasing due to successful chemotherapy

and increased pollution; multiple chromosomal abnormalities in almost all

patients; poorer prognosis than de novo MDS.

Hypoplastic MDS: <15% of cases of MDS have hypocellular BM on biopsy

(<30% cellularity age <60; <20% aged ≥60); dysplastic megakaryocytes ±

myeloid cells or excess blasts should be present; may be difficult to

distinguish from aplastic anaemia in which pancytopenia usually more

severe: cytogenetic findings typical of MDS may be necessary; no

particular age range, FAB type and no difference in prognosis; may

respond to immunosuppressive therapy.

Fibrotic MDS: up to 50% of cases have increased BM fibrosis but <15%

have marked fibrosis; all FAB types; more common in secondary MDS; BM

hypercellular with myelofibrosis; PB shows pancytopenia and dysplastic

features and sometimes leucoerythroblastic picture; organomegaly

unusual; rapid deterioration usual.

Bone marrow in RARS stained for iron: note iron granules round the nucleus of the

erythroblast.

Management of MDS

For patients with low risk indolent MDS, a watch and wait approach may

be adopted prior to the introduction of therapy.

Supportive care

Supportive care is administered to most patients with MDS with the aim

of reducing morbidity and maintaining quality of life. For many if not most

patients this will be the mainstay of management.

Red cell transfusion should be administered for symptomatic anaemia;

individual symptomatology rather than ‘trigger’ level should initiate red

cell support.

Iron chelation therapy should be considered once a patient has received

230

25 units of RBCs if long term transfusion is likely e.g. pure sideroblastic

anaemia or 5q- syndrome; Desferrioxamine 20-40mg/kg by 12h SC

infusion 5-7 nights/week reduced to 25mg/kg when ferritin <2000mg/L;

vitamin C 100-200mg/day PO may be added after 1 month; audiometric

and ophthalmological assessments prior to therapy and annually; aim for

serum ferritin <1000mg/L.

Platelet transfusion should be administered for patients with

haemorrhagic problems and those with severe thrombocytopenia with

the aim of maintaining a platelet count >10

¥ 10⁹/L.

Anti-infective therapy i.e. empirical broad spectrum antibiotics and/or

antifungals should be administered promptly for neutropenic sepsis; no

evidence to support routine use of prophylactic anti-infectives in

neutropenic patients; prophylactic anti-infective agents may be useful in

neutropenic patients with recurrent infection.

Low intensity therapy

Erythropoietin

± G-CSF treatment of symptomatic anaemia in MDS:

maintenance of stable augmented Hb may provide better quality of life

than the cyclical fluctuations of transfusion programmes; responses in

20-30% to Epo alone, 40-60% to Epo+G-CSF; synergistic effect most

evident in RARS or patients with serum Epo levels <500U/L; check iron

stores and replete if necessary.

2 For patients with RA/RAEB with symptomatic anaemia, transfusion

requirement <2 units/month and a basal Epo level of <200U/L con-

sider trial of Epo (10,000 units daily for 6 weeks); in non-responders

consider adding daily G-CSF (1mg/kg/day) SC or double dose Epo or

both for further 6 weeks; no response after 2-3 months = treatment

failure; in responders, reduce G-CSF to 3

¥ weekly and Epo in steps to

lowest dose retaining response.

2 For patients with RARS with symptomatic anaemia, transfusion

requirement < 2 units/month and basal Epo levels <500 U/L combined

therapy should be used from outset; consider Epo dose escalation if no

response after 6 weeks; no response after 2-3 months = treatment

failure; in responders titrate doses and frequency as tolerated.

Myelodysplasia

G-CSF treatment of neutropenia: for patients with neutropenia and

recurrent or antibiotic resistant infections but not recommended for

chronic prophylaxis.

Immunosuppression: may be effective notably for patients with

hypoplastic MDS but also for other patients with low risk MDS (IPSS≤

intermediate-1).

2 ATG in clinical trials at a dose of 40mg/kg/d ¥ 4d achieved transfusion

independence in ~33% patients (median response >2 years); sustained

neutrophil and platelet responses in up to 50%; response associated

231

with significant survival benefit.

2 Cyclosporin A has achieved transfusion independence in a high pro-

portion of patients with RA in small clinical trials; improved neutrophil

and platelet counts also.

2 Younger age, shorter duration of transfusion dependence, HLA-DRB1* 15,

hypoplastic BM and presence of a PNH clone associated with response to

immunosuppression.

Non-intensive chemotherapy: may be tolerated by elderly patients with

transformed or ‘transforming’ MDS; but transient reductions in blast

counts may be at the price of increased cytopenia and transfusion

dependence.

2 Hydroxyurea is used to control monocytosis in CMML; titrate dose to

achieve optimum control of myeloproliferation with minimum addi-

tional cytopenia; it is preferable to oral etoposide.

2 Low dose melphalan (2mg/d) is under examination after small trials

show a response rate of 40% in patients with RAEB or RAEB-t without

severe side effects and prolonged survival in responders; best

responses in hypoplastic MDS.

2 5-azacytidine: shows promise with 60% responses, decreased risk of

AML transformation, improved QoL and improved survival in phase III

trials.

High intensity therapy

Chemotherapy

2 AML-type chemotherapy should be considered in patients <60 years

with relatively high risk disease and good performance status (high risk

IPSS/RAEB or RAEB-t); responses lower (40-50%) and treatment

related morbidity and mortality higher than de novo AML; age >50 and

karyotypic abnormalities associated with poor response.

2 5-aza-2-deoxycytidine achieved 64% responses in patients with high

risk IPSS scores; myelosuppressive; requires hospitalisation; phase III

trials under way.

High dose therapy

2 Sibling allogeneic SCT offers the best prospect of prolonged survival

and possible cure (35-40% 3 year DFS); few eligible but treatment of

choice for patients aged <50 with ≥IPSS intermediate-1 and sibling

donor; high treatment related mortality (>40%); relapse rate up to

40%; relapse risk relates to IPSS score—low risk <5%, high risk >25%

as does DFS—IPSS low/intermediate-1 60%, intermediate-2 36% and

high risk 28% at 5 years; favourable outcome associated with younger

age, shorter disease duration, compatible graft, primary MDS, <10%

blasts, good risk cytogenetics; lower intensity non-myeloablative regi-

mens under trial for toxicity and response rate and may increase age

range to 65 years.

2 MUD allogeneic SCT associated with lower DFS (<30% at 2 years),

higher treatment related mortality (>50%) but lower relapse rates

(<15%); high mortality associated with patient age; this treatment

should be discussed with patients ≤40 with ≥IPSS intermediate-1 who

lack a sibling donor.

2 Autologous SCT under trial for patients in CR after AML regimens;

poor harvests; low TRM; high relapse rate.

232

A ‘treatment algorithm’ (BCSH Guideline: Br J Haematol

(2003), 120, 187-200)

2 IPSS low: high intensity therapy inappropriate; for symptomatic anaemia

and RA with serum Epo <200U/L, RARS <500U/L consider trial of

Epo±G-CSF; otherwise supportive care.

2 IPSS intermediate-1: offer allograft to patients <50 years with sibling

donor; consider patients aged 50-65 with good performance status

and sibling donor for non-ablative conditioning and allograft within clin-

ical trial; offer allograft within clinical trial (ablative or non-ablative con-

ditioning) to patients ≤40 with MUD donor; Note: pre-transplant cyto-

reductive chemotherapy not recommended for IPSS intermediate-1;

patients ≥65 or <65 without donors should be offered supportive care

or Epo±G-CSF.

2 IPSS intermediate-2/high: consider patients <65 for AML-type cytoreduc-

tive chemotherapy; those achieving CR or good PR after induction and

consolidation chemotherapy should receive sibling or MUD allograft as

detailed for IPSS intermediate-1 patients; those in CR or good PR

without any donor but with good performance status and adequate

harvest should receive autologous SCT within clinical trial.

Myelodysplastic/myeloproliferative

diseases (MDS/MPD)

This category was created in the World Health Organisation (WHO) clas-

sification of myeloid neoplasms for a group of disorders that have both

dysplastic and proliferative features at diagnosis and are difficult to assign

to either myelodysplastic or myeloproliferative groups.

WHO classification MDS/MPD diseases

2 Chronic myelomonocytic leukaemia.

2 Atypical chronic myeloid leukaemia.

2 Juvenile myelomonocytic leukaemia.

2 MDS/MPD unclassifiable.

234

Chronic myelomonocytic leukaemia (CMML)

Myeloproliferative element in CMML formerly recognised by subclassifica-

tion into MDS-like or MPD-like on the basis of the WBC at presentation;

MPD-like CMML associated with WBC >12

¥ 10⁹/L, splenomegaly and con-

stitutional symptoms; not a distinct condition as many patients who present

with low WBC count and minimal splenomegaly ultimately progress to meet

‘proliferative’ criteria.

Clinical features

2 Predominantly presents in >60 age group.

2 Often asymptomatic and found on routine FBC.

2 Weight loss, fatigue, night sweats may occur.

2 Skin and gum infiltration may occur.

2 Splenomegaly (50%) and hepatomegaly (up to 20%) usually only in

cases with leucocytosis and symptoms.

2 Serous effusions (pericardial, pleural, ascitic and synovial) associated

with high PB monocytosis.

Investigation and diagnosis

2 Investigation as for MDS.

2 Variable leucocytosis; marked in 50%; neutrophilia in some patients.

2 Monocyte count >1.0

¥ 10⁹/L is diagnostic minimum.

2 Variable anaemia; platelets usually normal or decreased.

2 Marrow typically hypercellular; blasts and promyelocytes <20%.

2 Karyotypic abnormalities associated with MDS found in most patients

but no specific cytogenetic features apart from rarity of 5q-.

2 Lysozyme raised in serum and urine.

2 Hypokalaemia may be present.

2 Reactive causes of monocytosis must be excluded ( p144).

WHO diagnostic criteria for CMML

1. Persistent peripheral blood monocytosis >1.0

¥ 10⁹/L.

2. No Philadelphia chromosome or BCR-ABL fusion gene.

<20% myeloblasts, monoblasts and promyelocytes in PB or BM.

4. Dysplasia in ≥1 myeloid lineages or if myelodysplasia absent but above

criteria present, CMML may be diagnosed if:

- An acquired clonal cytogenetic abnormality present in BM cells

- Monocytosis persistent for ≥3 months and all other causes excluded.

Myelodysplasia

Diagnose CMML-1 if <5% PB blasts and <10% BM blasts.

Diagnose CMML-2 = 5-19% PB blasts or 10-19% BM blasts or Auer rods

present with <20% BM blasts.

Diagnose CMML-1 or CMML-2 with eosinophilia with above criteria + PB

eosinophil count >1.5

¥ 10⁹/L.

Prognostic factors

BM blasts: median survival for CMML with <5% BM blasts 53 months

versus 16 months for those with 5-20%.

235

Management

2 Asymptomatic cases with near normal haematology apart from a

monocytosis of >1.0

¥ 10⁹/L require no intervention and should simply

be monitored. Therapy otherwise supportive.

2 Patients with symptoms, organomegaly and/or 44 WBC may respond

to oral chemotherapy e.g. hydroxyurea (preferred) or etoposide.

2 Rare young patients may be treated with myeloablative therapy and

allogeneic SCT which offers only curative option.

Natural history

Prognosis for asymptomatic patients is favourable (several years). For

those requiring therapy median survival is

6-12 months. Acute

myelomonocytic leukaemia (AMML) develops in ~20%; poorly responsive

to intensive chemotherapy.

Atypical chronic myeloid leukaemia (ACML)

2 Heterogeneous group of patients with Philadelphia chromosome and

BCR-ABL fusion gene negative CML.

2 Other cytogenetic abnormalities frequent.

2 Dysplastic myeloid series and often multilineage dysplasia; monocytosis

frequent; no basophilia (cf. CML).

2 Short median survival (11-18 months).

Juvenile myelomonocytic leukaemia (JML)

2 Clonal disorder arising in pluripotent stem cell causing selective hyper-

sensitivity to GM-CSF due to dysregulated signal transduction through

Ras pathway.

2 Affects infants and young children usually ≤5 years of age.

2 Marked hepatosplenomegaly, neutrophilia and monocytosis, anaemia

and thrombocytopenia.

2 4 haemoglobin F.

2 No Philadelphia chromosome or BCR-ABL fusion gene.

2 Normal karyotype in >80%.

2 No consistently effective therapy including allogeneic SCT (relapse

rates up to 55%). 5 year survival after allograft 25-40%.

Myelodysplastic/myeloproliferative disease, unclassifiable

Category for patients with features of both MDS and MPD who do not

meet the criteria for the three conditions above.

WHO classification of chronic

myeloproliferative diseases

2 Chronic myeloid leukaemia (Ph chromosome, t(9;22)(q34;q11),

BCR-ABL-positive).

2 Chronic neutrophilic leukaemia.

2 Chronic eosinophilic leukaemia (and hypereosinophilic syndrome).

2 Polycythaemia vera.

2 Chronic idiopathic myelofibrosis (with extramedullary haematopoiesis).

2 Essential thrombocythaemia.

2 Chronic myeloproliferative disease, unclassifiable.

Chronic myeloid leukaemia

p164.

238

Chronic neutrophilic leukaemia (CNL)

2 Very rare; <150 cases reported.

2 Exclude underlying infection or neoplasia e.g. myeloma, before consid-

ering diagnosis of CNL.

2 Neutrophilia without left shift, eosinophilia or basophilia.

2 Modest splenomegaly common ± hepatomegaly.

2 NAP usually 44.

2 Marrow hypercellular.

2 BM cytogenetics usually normal.

2 Most patients asymptomatic.

2 Treatment often unnecessary.

Chronic eosinophilic leukaemia (CEL) and hypereosinophilic

syndrome (HES)

2 Must exclude infectious, inflammatory and neoplastic causes of

eosinophilia including CML, AML with inv(16), other chronic myelo-

proliferative disorders, lymphoma (esp. Hodgkin’s).

2 Evidence of clonality = CEL; no evidence of clonality = HES.

2 CEL is uncommon; marked increase in mature and immature

eosinophils in PB and BM. Often >5% blasts in BM. Associated with

tissue infiltration by immature eosinophils, anaemia and thrombocy-

topenia. No dysplastic features. No Philadelphia chromosome or

BCR-ABL fusion gene. Short history of malaise, sweats, weight loss, skin

rash and increased susceptibility to infection. Splenomegaly common.

End-organ damage as per HES may occur. Proliferative element may be

controlled by hydroxyurea. In symptomatic younger patients consider

sibling allogeneic SCT.

2 HES is characterised by PB eosinophilia >1.5

¥ 10⁹/L for >6 months

and by end-organ damage, commonly endomyocardial fibrosis, skin

lesions (angioedema, urticaria), thromboembolic disease , pulmonary

lesions and CNS dysfunction. Associated with polyclonal increased in

immunoglobulins including IgE. Splenomegaly 40%. Anaemia 50%; neu-

trophilia with left shift frequent; platelets may be normal, decreased or

increased. BM hypercellular with 25-75% eosinophils with left shift.

Eosinophilia may be controlled by prednisolone, hydroxyurea or IFN-a.

Allogeneic SCT may be curative in younger patients.

Polycythaemia vera (PV)

Erythrocytosis is defined as increase in total red cell mass (RCM). It is sus-

pected by finding a raised haematocrit (Hct) (packed cell volume, PCV).

The term ‘polycythaemia’ is widely used synonymously but lacks precision

and can lead to confusion. Polycythaemia vera (PV) is a neoplastic clonal

disorder of the BM stem cell causing excessive proliferation of the ery-

throid, myeloid and megakaryocyte lineages and carrying a risk of throm-

botic complications. Persistent elevation of Hct >0.48 in adult female and

>0.51 in adult male is abnormal (Note: Hct can be raised with a normal

RCM if plasma volume is reduced).

Classification of polycythaemia

See table opposite.

Clinical evaluation of a patient with suspected erythrocytosis

240

May be asymptomatic or may present with thrombosis or vague symp-

toms of headache, dizziness, tinnitus or visual upset. Take detailed history

with attention to smoking habits, alcohol consumption and diuretic

therapy. History of pruritus (especially after bathing) suggests PV (occurs

in 50%). Burning sensation in fingers and toes (erythromelalgia) typical of

PV. Physical examination may identify plethoric facies or abnormalities

associated with a cause of secondary erythrocytosis such as gross obesity,

hypertension, evidence of obstructive airways disease or cyanotic cardiac

conditions. The presence of hepatomegaly or splenomegaly should be

sought. An elevated Hct in the absence of identifiable factors in clinical

assessment requires referral for specialist evaluation.

Investigation and diagnosis

2 FBC: 44 RCC and 5 or 6 MCV and MCH (may be evidence of iron

deficiency).

2 Neutrophils and platelets 4 in PV (rare in other causes of erythrocytosis).

2 NAP score: 4 score usually present in PV (but not diagnostic in isolation).

2 Red cell mass and plasma volume: patient red cells labelled with ⁵¹Cr

and re-injected; simultaneous plasma volume measurement using ¹³¹I-

labelled albumin. RCM 4 >25% above mean predicted value is diag-

nostic of absolute erythrocytosis. Plasma volume also 4 if marked

splenomegaly present.

Red cell mass

4 within NR or N

Plasma volume

N or 4

5 within NR or 5

PV, polycythaemia vera; SE, secondary erythrocytosis; RE, relative erythrocytosis

2 Arterial oxygen saturation: pulse oximetry most convenient to detect

chronic hypoxia. SaO₂ <92% suggests causal relationship with absolute

erythrocytosis. Sleep studies may be indicated by a history of snoring,

waking unrefreshed and somnolence.

2 Haematinic assays: serum ferritin: 5 or 6 (esp. PV) and occasionally

overt iron deficiency. Serum vitamin B₁₂: levels commonly 4 in PV due

to 4 transcobalamin reflecting associated granulocytosis. Folate defi-

ciency may occur.

Myeloproliferative disorders

Classification of erythrocytosis

Primary erythrocytosis

Congenital

Truncation of erythropoietin receptor

Acquired

Polycythaemia vera (PV)

(syn. polycythaemia rubra vera (PRV);

primary proliferative polycythaemia

(PPP)).

Secondary erythrocytosis

Congenital

High oxygen-affinity haemoglobin

(SE) due to 4 endogenous

Congenital low 2,3-DPG

Epo production

Autonomous high Epo production

Acquired

241

Hypoxaemia

COAD

Cyanotic congenital heart disease with

right7left shunt

Living at high altitude

Chronic alveolar hypoventilation e.g.

gross obesity

Sleep apnoea syndromes

Other causes of

Smoking (4 COHb)

impaired tissue

O2 delivery

Renal disease

Polycystic kidneys

Renal tumours

Renal artery stenosis

Post-renal transplantation

Tumours

Cerebellar haemangioblastoma

Uterine leiomyoma

Hepatoma

Bronchial carcinoma

Adrenal tumours

Liver disease

Cirrhosis

Hepatitis

Drugs

Androgens

Idiopathic erythrocytosis (IE)

Persistent 4 RCM, no cause found but no

evidence of myeloproliferative disease

or clear cause of secondary

erythrocytosis.

Relative erythrocytosis (RE)

Normal RCM and 5 plasma volume

Syn. apparent polycythaemia,

Diuretic therapy or dehydration

spurious erythrocytosis,

Gaisbock’s syndrome (see p248)

pseudopolycythaemia

Smoking, alcohol, hypertension, obesity.

Investigation and diagnosis, cont.

2 Serum U&E: to screen for renal impairment.

2 Uric acid: often 4 in MPD.

2 Urinalysis: haematuria or proteinuria should prompt further renal

investigations.

2 LFTs: to screen for liver disease.

2 Abdominal USS: for hepatosplenomegaly, renal or pelvic abnormalities.

2 CXR: to screen for pulmonary disease (plus pulmonary function tests if

indicated) and congenital cardiac abnormalities.

2 Serum erythropoietin: assays not yet part of routine laboratory investi-

gation in UK: serum Epo 5 in PV and 4 in SE; may also be low in RE

and idiopathic erythrocytosis.

2 BM examination: trephine may be diagnostic in PV. Typical features

include hypercellularity and trilineage hyperplasia with abnormal

megakaryocytes (clustering with giant forms and increased ploidy).

Increased fibrosis may be present. Normal BM histology does not

242

exclude PV but is more usual in SE.

2 Cytogenetics: not routine; ~30% have abnormalities, typically 20q-. 8+,

9+ and 13q-.

2 BFU-E culture: not routine; PV progenitors show increased sensitivity

to growth factors and develop ‘endogenous erythroid colonies’

without added Epo.

Proposed diagnostic criteria for PV

Raised RCM (>25% above mean normal predicted value)

or Hct ≥0.60 in 9 or 0.56 in 3

Absence of cause of secondary erythrocytosis

Palpable splenomegaly

Clonality marker, i.e. acquired abnormal BM karyotype

Thrombocytosis (platelet count >400

¥ 10⁹/L)

Neutrophil leucocytosis (neutrophils >10

¥ 10⁹/L; >12.5

¥ 10⁹/L

in smokers)

Splenomegaly demonstrated on isotope or ultrasound scan

Characteristic BFU-E growth or reduced serum erythropoietin

A1 + A2 + A3 or A4 establishes PV

A1 + A2 + two of B establishes PV

Pearson, T.C. & Messinezy, M. (1996) The diagnostic criteria of polycythaemia rubra vera.

Leuk Lymphoma, 22 Suppl 1, 87-93.

Natural history of PV

Untreated PV carries a significant risk of thrombotic complications and a

further long term risk of transformation into myelofibrosis or less com-

monly AML. There is also an 4 risk of bleeding notably from peptic ulcers.

The aim of treatment is to reduce the risk of thrombotic complications

and to prevent progression to myelofibrosis or leukaemia. Current treat-

ments improve the untreated median survival of 18 months to >15 years

though some myelosuppressive treatments (notably chlorambucil and ³²P)

have been associated with an increased risk of AML. Thrombotic compli-

cations notably MI, stroke and venous thromboembolism are the most

Myeloproliferative disorders

common causes of death. Age and thrombotic history are the most

important risk factors.

PV characteristically presents during the proliferative phase when control

of erythrocytosis and prevention of thrombotic complications is often an

urgent priority. This is often followed by a stable phase of variable (but

often short) duration where near normal counts are maintained without

therapy due to decreasing proliferative capacity due to early myelofibrosis.

This is followed by an advanced or ‘spent phase’ which is due to extensive

myelofibrosis and associated with progressive hepatosplenomegaly and

pancytopenia. Incidence 10-15% after 10 years rising to >30% at 20 years;

median survival <18 months. The incidence of AML is estimated at 2% in

243

the absence of therapy but is over 14% after myelosuppressive therapy.

Management of PV

In younger patients (<40) who have a low risk of cerebrovascular or car-

diovascular events the use of venesection in combination with low dose

aspirin and non-leukaemogenic therapy such as anagrelide or IFN-α

should be considered to reduce the risk of leukaemia.

Venesection: to 5 blood volume to normal as rapidly as possible and

prevent complications

(target Hct

<0.45). Removal of RBCs by

venesection is the quickest way of reducing red cell mass. 450mL blood

(± isovolaemic replacement with

0.9% saline) removed safely from

younger adults every 2-3 days (5 volume or frequency to twice weekly in

older patients). If Hct very high (>0.60) venesection may be technically

difficult due to extreme viscosity.

Maintenance therapy: venesection alone can be used to maintain the Hct

at 0.42-0.45. Individual requirements are variable (e.g. 2 procedures per

year to monthly venesection). However, early studies showed 4 risk of

thrombosis in first 3 years after treatment with venesection alone thus

additional myelosuppressive treatment is required in most patients.

Hydroxyurea: an antimetabolite (ribonucleotide reductase inhibitor), is

most commonly used therapy. Onset of myelosuppression with

hydroxyurea is rapid, but overdosage quickly corrected by temporary

withdrawal. Once Hct

5, a daily dosage of

10-20mg/kg/d normally

sufficient as maintenance therapy. Lower incidence of thrombosis by

ensuring better Hct (<0.45) and platelet counts (<400

¥ 10⁹/L). Lower

incidence of leukaemia than ³²P/alkylator therapy but still concerns.

Radioactive phosphorus (³²P) and busulfan: long established treatments

for PV. Produce 5 in RCM 6-12 weeks after administration (³²P 2.3

mCi/m² by IV injection every 12 weeks as necessary; busulfan by single

oral dose 0.5-1mg/kg). Either agent may be repeated after 3-6 months if

further myelosuppression is required. Both individually 5 thrombosis and

myelofibrosis but markedly 4 the risk of AML. The use of ³²P and either

busulfan or hydroxyurea in an individual is associated with a very high risk

of AML. Neither is recommended for patients ≤65 years who should

receive hydroxyurea. However, in patients >65 in whom compliance or

regular monitoring of hydroxyurea dose may be a problem busulfan or

³²P can be considered as both offer intermittent therapy rather than long

term maintenance.

Anagrelide: oral imidazoquinazoline with anti-cyclic AMP phosphodiesterase

activity and profound effect on megakaryocyte maturation resulting in

reduced platelet production. No evidence of mutagenic activity. Useful for

control of thrombocytosis in PV but no effect on splenomegaly or other

lineages. Side effects: headache (50%), forceful heartbeat, fluid retention,

dizziness, arrhythmia (<10%) and CCF (2%). Use with caution in patients

with known or suspected cardiac disease.

Aspirin:

75mg daily as antiplatelet therapy is common practice in

myeloproliferative conditions. Higher doses are associated with

haemorrhage. Large trial of low dose aspirin

(40mg/d) in progress.

Meantime reasonable to use 40mg/d aspirin in patients with history of MI

244

or thrombotic CVA, erythromelalgia and other microvascular

neurological and ocular disturbances. Avoid in those with a history of

haemorrhage particularly in the GI tract.

Interferon-a therapy at a dose of 3-5MU three times weekly can control

erythrocytosis and 5 leucocytosis, thrombocytosis and splenomegaly in

60-75% of patients over 6-12 months. A useful observation is that it can

diminish the severity of pruritus in

80% of patients. Tolerance is a

problem but may be reduced by the use of pegylated-interferon.

Supportive treatment: maintain adequate fluid intake and avoid

dehydration. Give allopurinol to minimise complications of hyperuricaemia.

Acute gout is managed by standard therapies. Pruritus is a troublesome

complication for some patients, unfortunately there is no satisfactory

treatment. Sometimes abates when excess myeloproliferation controlled

and Hct reduced but may persist despite adequate control of the Hct.

Worth trying antihistamines, H₂-antagonists or interferon-a.

Surgical procedures relatively contraindicated in active PV: defer until Hct

and platelets normalised for ≥2 months due to risk of thrombotic and

haemorrhagic complications; if emergency surgery necessary perform

venesection and cytapheresis.

Continued care and follow-up

Patients with PV and idiopathic erythrocytosis should have long-term

haematological follow-up. Measure Hct at least 3 monthly. For patients on

cytotoxic therapy with hydroxyurea the FBC should be checked every

8-12 weeks.

Treatment of advanced phase PV

Symptomatic management should be prioritised and the patient often

requires blood product support. Splenectomy is often considered due to

discomfort, recurrent infarction or hypersplenism but is often followed by

massive hepatomegaly due to extramedullary haematopoiesis.

Secondary erythrocytosis

Causes of secondary erythrocytosis are listed in the table on page 241.

Effects of the increased red cell mass

2 4 peripheral vascular resistance.

2 5 cardiac output.

2 5 systemic O₂ transport resulting in e.g. 5 cerebral blood flow and

oxygen and glucose delivery to the brain.

2 Thromboembolic complications also occur. Thus ‘compensatory’ ery-

throcytosis is a pathological rather than physiological condition.

Symptoms and signs are non-specific and those of the underlying cause

(particularly if cardiac or pulmonary) may predominate. Pruritus,

splenomegaly or the presence of leucocytosis or thrombocytosis suggest

the alternative diagnosis of PV.

246

Investigation as listed under PV, notably RCM and plasma volume, arterial

oxygen saturation, renal and hepatic function, urinalysis, serum erythro-

poietin, renal ultrasound and if necessary abdominal CT.

The aim of therapy must be correction of the underlying cause where pos-

sible and reduction of the red cell mass. Venesection is the treatment of

choice and if possible should be continued until a target Hct of <0.45 is

achieved. In patients with cyanotic congenital heart disease, pulmonary

disease or high O₂-affinity haemoglobin, the extent of venesection can be

determined by symptomatic response or by using the serum Epo level as a

measure of tissue hypoxia. Induction of iron deficiency by chronic vene-

section assists control of erythrocytosis. Myelosuppressive therapy is not

indicated.

Relative erythrocytosis (RE)

Elevation of Hb and Hct with normal or minimally 4 RBC mass and normal

plasma volume defines RE. Apparent/spurious polycythaemia,

pseudopolycythaemia, stress erythrocytosis and Gaisbock’s syndrome are

synonymous terms for this disorder.

Aetiology

Unclear. Some cases may represent extreme ends of normal ranges for

red cell and plasma volumes, but in most obesity, cigarette smoking and

hypertension are present singly or in combination. Haemoconcentration

from dehydration or diuretic therapy should be excluded.

Investigation

2 FBC generally shows only modest 4 Hct.

2 Further investigations should be undertaken as appropriate for persis-

248

tent erythrocytosis but, by definition, fail to reveal any other abnor-

mality.

2 RCM studies demonstrates normal RCM and 5 plasma volume in

~33%; most have high normal RCM and low normal plasma volume.

2 Important to exclude renal disease and arterial hypoxaemia.

2 Bone marrow biopsy is not usually necessary but is normal when

carried out.

Management

2 Involves dealing with reversible associated features, i.e. weight reduc-

tion, cessation of smoking, control of 4 BP and reduction in stress

(where possible). Correction of these factors will result in sponta-

neous improvement.

2 Venesection is not standard management; however, it is suggested that

patients with Hct levels chronically >0.54 should be considered for

venesection.

Natural history and treatment

2 Not clear. Retrospective analysis appears to suggest an 4 incidence of

vaso-occlusive episodes that may relate to associated risk factors in the

lifestyle of the patients under observation (rather than the 4 PCV).

2 Low dose aspirin (75mg/d) advisable for patients with overt throm-

botic risks and no GI contraindication.

2 No role for myelosuppressive therapy.

2 Many patients improve with the simple measures specified. In ~33%

the Hct returns to the normal range. In a further 33% the Hct oscil-

lates between minimal elevation and the normal range. In the

remaining 33% the Hct remains elevated and these patients should

receive long term follow-up. In a minority absolute erythrocytosis may

develop.

Essential (1°) thrombocythaemia (ET)

ET (syn. primary or idiopathic thrombocythaemia) is characterised by per-

sistent thrombocytosis that is neither reactive (i.e. secondary to another

condition; pXXX) nor due to another myeloproliferative or myelodys-

plastic disorder. It is a diagnosis of exclusion and may be biologically het-

erogeneous.

Incidence

True incidence unknown; slight excess in 3; median age at diagnosis 60

years; frequently occurs <40 years; very rare <20 years.

Pathogenesis

Aetiology unknown. No association with radiation, drugs, chemicals or

viral infection. Not all cases are clonal. Clonal and non-clonal cases may

have different natural histories: thrombosis is less common in polyclonal

250

ET as is the risk of leukaemic transformation. Platelets in ET are often

functionally abnormal showing impaired aggregation in vitro. High platelet

counts (>1000

¥ 10⁹/L) are associated with an acquired von Willebrand

syndrome; reduction in the platelet count corrects the abnormality and

reduces haemorrhagic episodes.

Clinical features

2 Diagnosis often follows routine FBC; up to 30% patients asymptomatic.

2 Presentation may be due to ‘vasomotor’, thrombotic and/or haemor-

rhagic symptoms.

2 Vasomotor symptoms occur in 40%: headache, light-headedness,

syncope, atypical chest pain, visual upset, paraesthesiae, livedo reticu-

laris and erythromelalgia (erythema and burning discomfort in hands or

feet due to digital microvascular occlusion).

2 Haemorrhagic symptoms occur in 25% (major <5%): easy bruising,

mucosal or GI bleeding or unexplained or prolonged bleeding after

trauma or surgery.

2 Thrombosis occurs in ~20% (major <10%): arterial > venous, e.g. MI, CVA.

2 Splenomegaly is found in <40% (less common and less marked than in

other myeloproliferative disorders).

2 Splenic atrophy may occur from repeated microvascular infarction.

2 Recurrent abortions and fetal growth retardation due to multiple pla-

cental infarctions may occur in young women with ET.

Investigation and diagnosis

2 FBC

- Platelets persistently >600

¥ 10⁹/L (may be as high as 5000

¥ 10⁹/L).

– Hb usually normal; may be 5 with 5 MCV due to chronic blood loss.

- WBC usually normal; raised platelet distribution width (PDW).

- Mean platelet volume (MPV) usually normal.

- Automated FBC may give erroneous data in severe cases as giant

platelets may be counted as RBCs.

2 Blood film

- Thrombocytosis, variable shapes and sizes (platelet anisocytosis),

giant platelets and platelet clumps; megakaryocyte fragments;

basophilia may be present; variable degree of RBC abnormality:

Myeloproliferative disorders

may be hypochromic and microcytic; may be changes of hypos-

plenism (p44).

2 Bone marrow aspirate: not reliable for diagnosis; may show 4 platelet

clumps, atypical megakaryocytes including micromegakaryocytes and

other maturation abnormalities.

2 Bone marrow trephine biopsy: cellularity usually 4; megakaryocytes 4,

with clustering, nuclear pleomorphism and atypical nuclear ploidy.

Other elements may show abnormal distribution and maturation

abnormalities. Reticulin normal or 4 (25%); no fibrosis.

2 Cytogenetics: abnormal in 5%; no recognised diagnostic abnormalities;

occasionally 20q- or 21q-.

2 Uric acid: 4 in 25%.

251

2 Pseudohyperkalaemia: in 25%.

2 Acute phase proteins: CRP and fibrinogen, and ESR usually normal.

2 Bleeding time: usually normal (4 in ~20%)—rarely necessary; platelet

aggregation studies not clinically helpful nor diagnostic.

DIagnostic criteria for ET

1. Persistent elevation of the platelet count >600

¥ 10⁹/L.

2. Absence of identifiable cause of reactive thrombocytosis.

3. Normal red cell mass or Hct <0.40.

4. Normal BM iron stores or normal serum ferritin or normal MCV.

5. Absence of Ph chromosome and BCR-ABL fusion gene.

6. Absence of significant BM fibrosis (<33% of biopsy in absence of

splenomegaly and leucoerythroblastosis.

7. Absence of cytogenetic or morphological evidence of MDS.

Differential diagnosis

Before a diagnosis of ET is made, causes of reactive thrombocytosis

(p254) must be excluded as must PV, CML, idiopathic myelofibrosis (IMF)

and MDS with a predominant thrombocytosis which can mimic ET.

Prognostic factors in ET

2 Thrombosis associated with previous thrombosis and age >60.

2 Haemorrhage associated with extreme thrombocytosis (>1000

10⁹/L) and antiplatelet therapy.

Risk stratification in ET

Low risk

2 Age < 60 and

2 No history of thrombosis and

2 Platelet count < 1500

¥ 10⁹/L and

2 No cardiovascular risk factors (smoking, obesity, hypertension)

Intermediate risk

2 Neither low risk nor high risk.

High risk

2 Age ≥ 60 or

2 Previous history of thrombosis.

Natural history

ET generally follows an indolent course and life expectancy is near normal.

The risk of life-threatening complications or of leukaemic transformation

is very low. However, the risk of AML is increased by cytotoxic therapy

and such treatment should be used cautiously. The need for therapy must

be individualised balancing risks of therapy against thrombotic risks (e.g.

cigarette smoking, family history), FBC results, co-morbidity and age. Risk

of AML 5-10%; risk of evolution to myelofibrosis ~5%.

Management

2 Aim to 5 risks and incidence of haemorrhagic and thrombotic compli-

cations by normalisation of platelet count (target <400

¥ 10⁹/L); need

to balance these risks with potential short and long term risks of

therapy (e.g. aspirin) and cytotoxic therapy.

2 Patients should be advised to make lifestyle changes (smoking, exer-

cise, obesity) to reduce their risk of thrombosis and atherosclerosis.

2 NSAIDs and standard dose aspirin should be avoided.

252

Low risk patients

2 Incidence of thrombosis <2/100 patient years and haemorrhage

~1/100 patient years only; no added risk with pregnancy or surgery.

2 Observation ± aspirin 75mg/d (if no contraindication) without cyto-

toxic therapy.

Intermediate risk patients

2 Cytoreductive therapy (see below) for patients with marked thrombo-

cytosis (>1500

¥ 10⁹/L) who are at increased risk of thrombosis.

2 Others in this group may be treated with low dose aspirin (if no con-

traindication) and observation.

2 Smokers should be encouraged to stop smoking and obese patients to

lose weight to reduce their risks of thrombosis.

High risk patients

2 Control of thrombocytosis with hydroxyurea reduces the risk of

thrombosis in these patients (<4% vs. 24% after 2 years in a ran-

domised study).

2 Hydroxyurea: treatment of choice for patients >60 years (0.5-1.5g/d

maintenance after higher initial doses to bring platelets <400

¥ 10⁹/L);

used in symptomatic patients <60 intolerant of anagrelide and inter-

feron-a; some patients may need combination therapy with anagrelide

or interferon-a to achieve normalisation of the platelet count; side

effects myelosuppression, oral ulceration, rash; contraindicated in preg-

nancy and breast feeding.

2 Anagrelide (2-2.5mg/d) is preferred in younger patients <60 years

(especially those of childbearing potential); interferes with megakary-

ocyte differentiation; side effects: headache, palpitations, fluid reten-

tion; contraindicated in pregnancy and patients with CCF or known

cardiac disease.

2 Interferon-a: (3-5mU 3-5

¥ weekly) can control thrombocytosis due to

ET in younger patients intolerant of anagrelide; not associated with risk

of AML; rarely used due to inconvenience of administration and poor

tolerance.

2³²P therapy (2.3mCi/m² IV which may be repeated after 3-6 months)

may be more appropriate in elderly patients (>75) or those unable to

Myeloproliferative disorders

comply with regular hydroxyurea therapy; side effects: myelosuppres-

sion, long term risk of AML.

2 Aspirin 75mg/d recommended for patients with thrombotic event;

increases risk of haemorrhage (safest when platelets <1000

¥ 10⁹/L);

relieves erythromelalgia quickly (2-4 days); extreme caution in patients

with haemorrhagic complications or history of peptic ulceration; H₂-

antagonist or proton pump inhibitors may be needed; markedly

increased bleeding risk with higher aspirin doses. Dipyridamole is an

alternative agent for those unable to tolerate aspirin.

ET in pregnancy

2 First trimester abortion frequent in young women with ET (>40%).

253

2 Low dose aspirin and interferon-a are treatments of choice because of

the theoretically greater teratogenic risk of hydroxyurea.

2 However, successful pregnancy reported following first trimester treat-

ment with hydroxyurea.

Life-threatening haemorrhage in ET

2 Stop anti-platelet agents.

2 Identify site of bleeding.

2 DDAVP/Factor VIII concentrate if evidence of acquired von

Willebrand disease.

2 Platelet transfusion if no evidence of acquired vWD.

2 Plateletpheresis if persistent haemorrhage.

2 Hydroxyurea 2-4g/day ¥ 3-5d (takes 3-5d for effect).

Arterial thrombosis in ET

2 Commence aspirin 75mg/d (rapid response in TIA and erythrome-

lalgia).

2 Hydroxyurea to normalise platelet count.

2 Plateletpheresis if life threatening.

Surgery in ET

2 Surgical procedures may require specific antithrombotic strategies e.g.

heparin.

2 Thrombotic risks lessened if platelet count normal.

Murphy, S. et al. (1997) Experience of the Polycythemia Vera Study Group with essential throm-

bocythemia: a final report on diagnostic criteria, survival, and leukemic transition by treatment.

Semin Hematol, 34, 29-39.

Reactive thrombocytosis

Platelet counts of >450

¥ 10⁹/L occur as a reactive phenomenon and may

be seen in:

2 Infection.

2 Following surgery, especially splenectomy.

2 Malignancy e.g. underlying carcinoma.

2 Trauma.

2 Chronic inflammatory states e.g. collagen disorders.

2 Blood loss and iron deficiency.

2 Rebound in response to haematinics and/or chemotherapy.

2 Any severely ill patient on ITU.

Raised platelet count in clonal haematological disorders occurs in CML,

ET, PV, IMF and also in MDS (esp. 5q- syndrome).

254

In reactive thrombocytosis platelets are usually <1000

¥ 10⁹/L but levels

of 1500

¥ 10⁹/L may occur. Platelet morphology usually normal but differ-

entiation from ET relies on full clinical evaluation. No specific treatment is

required for reactive thrombocytosis. Short term anticoagulant or

antiplatelet therapy is advised for marked thrombocytosis in the imme-

diate post-splenectomy period.

Idiopathic myelofibrosis (IMF)

Idiopathic myelofibrosis (syn. agnogenic myeloid metaplasia) is a myelo-

proliferative disorder characterised by marrow fibrosis, splenomegaly,

extramedullary haematopoiesis and a leucoerythroblastic peripheral

blood.

Incidence

Rare disorder; ~5 cases per million per annum; predominantly elderly

patients (median 65 years).

Pathogenesis

2 Clonal neoplastic proliferation arising from early haematopoietic stem

cell.

2 May evolve from PV (~9% of cases evolve into MF) or ET (~2% of

cases evolve to MF); minority may follow previous chemotherapy or

256

radiotherapy.

2 Haemopoietic cells clonal, fibroblasts not clonal.

2 Fibrosis is a cytokine-mediated reactive process (TGF-b, PDGF, IL-1,

EGF, calmodulin and bFGF); can develop in response to chronic

myeloproliferative disorders, myelodysplasia and secondary carcinoma.

2 Exaggeration of normal BM reticulin pattern progresses to intense col-

lagen fibrosis which disrupts and finally obliterates normal marrow

architecture; ultimately osteosclerosis may develop.

2 High levels of immature progenitors appear in PB.

2 Extramedullary haemopoiesis develops in spleen and/or liver-occasion-

ally other sites, e.g. lymph nodes, skin and serosal surfaces.

Clinical features and presentation

2 ≤20% may be asymptomatic at diagnosis: mild abnormalities identified

on routine FBC or splenomegaly at clinical examination.

2 Most present with symptoms of progressive anaemia and

hepatosplenomegaly associated with hypercatabolic features of fatigue,

weight loss, night sweats and low grade fever.

2 Abdominal discomfort (heavy sensation in left upper quadrant) and/or

dyspepsia from pressure effects of splenic enlargement may prompt

presentation.

2 Symptoms and signs of marrow failure: lethargy, infections, bleeding.

2 Splenomegaly is almost universal (>90%): moderate to massive (35%)

enlargement; variable hepatomegaly (up to 70%); lymphadenopathy is

uncommon (<10%).

2 Gout in ~5%; portal hypertension, pleural effusion and ascites (due to

portal hypertension or peritoneal seeding) also occur.

Investigation and diagnosis

2 FBC: Hb usually 5 or normal (<10g/dL in 60%); normochromic normo-

cytic indices; WBC 5, normal or 4 (rarely >100

¥ 10⁹/L); platelets

usually 5 or normal; occasionally 4.

2 Blood film: leucoerythroblastic anaemia (nucleated red cells, myelo-

cytes) with tear drop poikilocytes (96%) and polychromasia; giant

platelets and megakaryocyte fragments.

2 Bone marrow aspirate: usually unsuccessful (‘dry tap’).

Myeloproliferative disorders

2 BM trephine biopsy: essential for diagnosis; characteristically shows

patchy haemopoietic cellularity (often focally hypercellular) and vari-

able reticulin fibrosis (often coarse and branching); 4 numbers of large

irregular megakaryocytes; distended marrow sinusoids with intravas-

cular haematopoiesis.

2 Coagulation screen: features of DIC in 15%; usually occult but causes

problems at surgery (e.g. splenectomy); defective platelet aggregation

common.

2 Cytogenetics: abnormalities in up to 75%: 13q-, 20q- and 1q+ most

frequent.

2 Serum chemistry: bilirubin 4 in 40%; alkaline phosphatase and ALT 4 in

50%; urate 4 in 60%.

257

2 MRI: readily distinguishes fibrotic BM from cellular BM.

Bone marrow trephine in myelofibrosis: note streaming effect caused by intense

fibrosis

Differential diagnosis

2 Exclude other myeloproliferative disorders (CML, PV, ET) M7 AML

(acute myelofibrosis), myelodysplasia, lymphoproliferative disorders

(particularly hairy cell leukaemia), metastatic cancer (esp. breast, lung,

prostate, stomach), tuberculosis, histoplasmosis and SLE.

2 IMF is -ve for Ph chromosome and BCR-ABL fusion gene.

2 Metastatic cancer in marrow, especially breast, prostate and thyroid,

can give similar FBC features but without splenomegaly; metastatic car-

cinoma cells are apparent on marrow biopsy and/or aspirate.

2 Prefibrotic stage recognised: classical features may be minimal or

absent and difficult to distinguish from PRV/ET; prominent neutrophil

proliferation, decreased erythroid precursors and markedly abnormal

megakaryocytes.

Prognostic factors

Short survival associated with:

2 Hb <10 g/dL.

2 WBC <4

¥ 10⁹/L or >30

¥ 10⁹/L.

2 Constitutional symptoms.

2 ≥1% blasts in PB or >10% blasts + promyelocytes + myelocytes in BM.

Management

Myelofibrosis incurable except by allogeneic SCT; no other treatment

alters disease course or prevents leukaemic transformation.

Treatment palliative; aiming to improve anaemia, alleviate symptomatic

organomegaly and hypercatabolic symptoms.

Asymptomatic cases with minimal FBC abnormalities and splenic

enlargement should simply be observed with regular follow-up.

Regular blood transfusion for anaemic symptoms; transfuse on basis of

symptoms not at a specific Hb level; iron chelation therapy with des-

ferrioxamine should be considered after 25 units.

Corticosteroids: ~33% of anaemic patients respond to combination

therapy with an androgen (oxymethalone 50mg tds) and corticosteroid

(prednisolone 1mg/kg/day).

Allopurinol to treat or prevent hyperuricaemia.

Hydroxyurea: often effective in reducing spleen size, leucocytosis,

258

thrombocytosis, hypercatabolic symptoms.

Analgesia: for acute splenic infarction; severe pain may respond to

splenic irradiation.

Splenectomy indicated for massive or symptomatic splenomegaly,

excessive blood transfusion requirements, refractory thrombocy-

topenia, hypercatabolic symptoms unresponsive to hydroxyurea; eval-

uate coagulation system pre-operatively; 10% mortality; 40% morbidity.

Splenic irradiation to reduce splenic size and discomfort in those unfit

for splenectomy (3-6 month benefit).

Radiotherapy also a useful treatment of extramedullary haemopoietic

infiltrates at other sites e.g. pleural and peritoneal cavities.

Allogeneic SCT: should be discussed with younger patients (e.g. ≤55)

with ≥ 2 adverse risk factors (see above) and a sibling donor; median 5

year survival ~50%; actuarial probability of disease recurrence at 5

years ~30%.

Prognosis

2 Median survival 4-5 years (range 1-30 years).

2 Hypersplenism often develops as the spleen enlarges.

2 Progressive cachexia occurs due to hypercatabolic state in advanced

IMF.

2 Death in symptomatic cases usually due to infection and haemorrhage.

2 Around 5-10% transform to AML refractory to intensive

chemotherapy.

2 Asymptomatic cases usually die from unrelated causes.

Mast cell disease (mastocytosis)

Mastocytosis is a heterogeneous group of diseases characterised by

abnormal proliferation of mast cells in one or more organ systems,

including skin, bone marrow, liver, spleen and lymph nodes.

Epidemiology

Median age of systemic mastocytosis 50-60 years; range 5-88; median age

of urticaria pigmentosa 2.5 months; after age 10 median age of urticaria

pigmentosa 26 years.

Pathogenesis

Mast cells are derived from pluripotential haemopoietic dells and are the

effector cells of the immediate allergic reaction via high affinity receptors

for IgE. Most varients of systemic mast cell disease are clonal and a

somatic mutation of c-KIT, the proto-oncogene that encodes the receptor

260

for stem cell factor, is usually present. These mutations lead to constitu-

tive activation of KIT which causes mast cell proliferation and prevents

mast cell apoptosis. In paediatric mastocytosis KIT-activating mutations

are rare. Clinical symptoms are due to the release of mast cell mediators

(including histamine, tryptase, heparin, TNF-a, PGD2, cytokines and

chemokines) which have both local and systemic effects, and to organ infil-

tration.

WHO classification of mast cell disease (mastocytosis)

2 Cutaneous mastocytosis.

2 Indolent systemic mastocytosis.

2 Systemic mastocytosis with associated clonal, haematological non-mast

cell lineage disease.

2 Aggressive systemic mastocytosis.

2 Mast cell leukaemia.

2 Mast cell sarcoma.

2 Extracutaneous mastocytoma.

Clinical features and presentation

2 Patients usually present with symptoms of mediator release: urticaria,

flushing, dermatographism, pruritus, angioedema; paroxysmal hyper- or

hypotension; abdominal pain, dyspepsia, diarrhoea and malabsorption

(80% of SM), multiple peptic ulcers, haemorrhage; wheezing, dyspnoea,

rhinorrhoea; neuropsychiatric symptoms (headache, fatigue, irritability,

cognitive disorganisation, nightmares); bone pain (25%).

2 Most cases are seen in infants and children; involvement is generally

limited to the skin; commonest forms are solitary cutaneous tumours

(mastocytomas) or widespread cutaneous involvement with a few or

many small lightly pigmented red-brown macules and papules (urticaria

pigmentosa). Usually transient; begins in first year of life and disappears

at puberty.

2 Adult urticaria pigmentosa is associated with small heavily pigmented

macular lesions; onset in young adults; often progressive with systemic

organ involvement usually bone marrow (46%), lymph nodes (~25% at

diagnosis), spleen (~50% at diagnosis), liver and GI tract.

2 Familial mastocytosis causes cutaneous disease in infancy, persists into

adult life and may progress to systemic involvement; rare.

Myeloproliferative disorders

Investigation and diagnosis

Diagnosis of cutaneous mastocytosis (usually in children) based on

typical clinical and histological skin lesions and absence of definitive

signs of systemic involvement.

Diagnosis of systemic mastocytosis (SM):

- Bone marrow trephine biopsy: essential for diagnosis; multifocal

lesions consisting of foci of spindle shaped mast cells with

eosinophils and lymphocytes in a fibrotic stroma (90%); in advanced

SM diffuse mast cell infiltration may occur.

- Bone marrow aspirate: increased numbers of mast cells; clusters of

confluent mast cells are a more specific finding (<30%); features of

accompanying haematological disorder may be present, usually

261

myelodysplastic or myeloproliferative disorder rarely lymphoprolif-

erative.

- Biopsy of other extracutaneous tissue: notably liver or lymph node;

rarely necessary.

- Serum mast cell tryptase and/or histamine:elevated in SM but not in

isolated urticaria pigmentosa.

- 24 hour urine for mediators (histamine metabolites, tryptase,

PGD2 metabolites).

- Bone scan/skeletal survey: bone lesions in 60%; generalised

osteosclerosis, focal sclerosis or generalised osteopenia.

- FBC and film: no characteristic features; circulating mast cells rare

(2%) unless very advanced disease or mast cell leukaemia; mild to

moderate anaemia in about 45%; eosinophilia up to 25%; thrombo-

cytopenia about 20%; monocytosis about 15%; pancytopenia may

develop due to BM infiltration or hypersplenism.

- GI studies: as necessary.

- EEG: if necessary.

Variants of SM

2 Indolent SM: commonest form of SM; associated with maculopapular

skin lesions (90%), slow involvement of target organs and good prog-

nosis.

2 Aggressive SM: characterised by impaired organ function due to infil-

tration of BM, liver, spleen, GI tract or skeletal system and predisposi-

tion to severe mediator release attacks with haemorrhagic

complications.

2 SM with associated haematological non-mast cell disease: <50% have

urticaria pigmentosa; generally CML or CMML; classified according to

FAB/WHO criteria; poorer survival.

2 Mast cell leukaemia: defined by ≥20% MC in BM aspirate and ≥10% in

PB; diffuse infiltration on trephine biopsy; no skin lesions, severe peptic

ulcer disease, hepatosplenomegaly, anaemia, multiorgan failure and

short survival.

2 Mast cell sarcoma: a tumour consisting of atypical MC; locally destruc-

tive growth; no systemic involvement.

Differential diagnosis

Diagnosis often delayed due to protean clinical features. Exclude reactive

mast cell hyperplasia, mast cell activation syndromes, myeloproliferative

disorders with increased mast cells, carcinoid syndrome, phaeochromocy-

toma, myelofibrosis, liver disease and lymphoma.

Management

No curative treatment; management consists of prevention of medi-

ator effects and treatment of accompanying haematological disease

where present.

Avoid factors triggering acute mediator release: extremes of tempera-

ture, pressure, friction; aspirin, NSAIDs, opiates, alcohol, specific aller-

gies.

Treat acute mast cell mediator release.

Anaphylaxis: epinephrine (adrenaline) 0.3mL of 1:1000 dilution (adult

dose) every 10-15 minutes as needed.

Refractory hypotension and shock: fluid resuscitation and epinephrine

262

(adrenaline) IV bolus plus infusion of 1:10,000 dilution (up to

4-10mg/min); add inotropes if unresponsive.

Commence H₁ plus H₂ receptor antagonists and steroids.

Treat chronic mast cell mediator release: H₁ plus H₂ receptor antago-

nists: H₁ antihistamines: diphenhydramine (25-50mg PO 4-6 hourly;

10-50mg IM/IV), hydroxyzine (25mg PO tid or qid; 25-100 mg IM/IV)

or loratadine (non-sedating; 10mg PO od); H₂ antihistamines: ranitidine

(150mg PO bd; 50mg IV) or cimetidine (400-1600mg/day PO in

divided doses; 300mg IV). Titrate doses for individual patient require-

ments; prednisolone 40-60 mg/day PO for malabsorption tailing; bis-

phosphonates and radiotherapy for bone pain; PUVA for urticaria

pigmentosa; a small number of patients gain symptomatic relief from

interferon-α or cyclosporin-A for refractory symptoms.

Treat any associated haematological disorder: generally achieve short

partial remission at best; splenectomy may help pancytopenic patients.

SCT should be considered in appropriate patients.

Attempt to control organ infiltration by mast cells: daunorubicin plus

cytarabine and CVP have been reported to produce partial responses.

Prognosis

Most patients with SM have only slowly progressive disease and many

survive several decades. 33% evolve into a haematological malignancy, fre-

quently leukaemia. Mast cell leukaemia is resistant to intensive

chemotherapy and has a survival of only a few months.

Escribano, L. et al. (2002) Mastocytosis: current concepts in diagnosis and treatment. Ann Hematol,

81, 677-690; Valent, P. et al. (2001) Diagnostic criteria and classification of mastocytosis: a con-

sensus proposal. Leuk Res, 25, 603-625.

Paraproteinaemias

Heterogeneous group of disorders characterised by deranged prolifera-

tion of a single clone of plasma cells or B lymphocytes and usually associ-

ated with detectable monoclonal immunoglobulin

(paraprotein or

M-protein) in serum and/or urine.

Conditions associated with paraprotein production

Stable production

2 Monoclonal gammopathy of undetermined significance (MGUS).

2 Asymptomatic (smouldering) myeloma.

Progressive production

2 Multiple myeloma (MM).

2 Complete immunoglobulins: IgG, IgA, IgD, IgM, IgE.

2 Free light chains (Bence Jones protein).

2 ‘Non-secretory’.

2 Plasma cell leukaemia (PCL).

2 Solitary plasmacytoma of bone (SPB).

266

2 Extramedullary plasmacytoma (SEP).

2 Waldenström’s macroglobulinaemia (WM).

2 Chronic lymphocytic leukaemia.

2 Malignant lymphoma.

2 Primary amyloidosis (AL).

2 Heavy chain disease.

Monoclonal gammopathy of

undetermined significance (MGUS)

MGUS describes the presence of a stable monoclonal paraprotein in

serum or less commonly in urine in the absence of clinicopathological evi-

dence of multiple myeloma (MM), Waldenström’s macroglobulinaemia

(WM), amyloidosis (AL) or other lymphoproliferative disorder.

Incidence

Median age 66 years. Incidence rises with age. Occurs in 1% population

>50 years of age, 3% >70 years, 5% >80 years. More frequent in Afro-

Caribbeans than Caucasians.

Pathophysiology

There is intraclonal variation in the Ig gene mutation and MGUS appears

to arise from a pre-germinal centre cell whose progeny pass through the

germinal centre and undergo mutation. Progression to MM may be due to

outgrowth of a single clone. There is a continuing rate of progression to

268

MM, WM, AL and other lymphoproliferative disorders. FISH demon-

strates same MM cytogenetic abnormalities in MGUS often acquired over

time. Expression microarrays show MGUS much closer to MM than to

normal plasma cells. No specific trigger for progression yet identified.

Natural history

2 >50% patients die of unrelated causes over a ~25 year follow-up

period.

2 1% progress to MM, WM, AL or other lymphoproliferative disorder

per annum.

2 ~10% progress within 8 years; 26% after 25 years.

2 5% patients do not progress, some may show a 4 in paraprotein levels.

Clinical features

2 Typically asymptomatic and often incidental finding on investigation of

4 ESR/PV or 4 globulin on routine LFTs.

2 No abnormal physical findings (end-organ damage) except unrelated.

2 Lack of progression and absence of additional evidence of progressive

plasma cell or B-cell lymphoproliferative malignancy.

Investigation and diagnosis

2 Perform investigations listed for MM ( p273).

2 Serum protein electrophoresis with immunofixation and densitometry

to detect, characterise and quantitate paraprotein levels: IgG 66%; IgA

20%; IgM 10%; biclonal 1%; light chain 1%; median ~15g/L.

2 Urine electrophoresis: identifies only low levels of Bence Jones pro-

teinuria (generally <1g/24h).

2 Stable paraprotein and other parameters on prolonged observation.

2 Immunoglobulin quantitation: by nephelometry; only 25% have

immuneparesis of uninvolved Ig classes (cf. myeloma).

2 Serum b₂-microglobulin levels normal (unless renal impairment).

2 BM aspirate: <10% plasma cells in BM; median ~5%.

Paraproteinaemias

2 BM cytogenetics: normal by conventional techniques but all abnormalities

in MM described in MGUS by FISH; del(13), t(4;14), ras mutations, p16 and

p53 inactivation less common.

2 BM trephine biopsy: no evidence of diffuse plasma cell infiltration or osteo-

clast erosion of trabeculae.

2 FBC: no anaemia or other cytopenia except due to unrelated causes.

2 Serum chemistry: no hypercalcaemia or unexplained renal impairment.

2 Skeletal radiology: no evidence of lytic lesions or pathological fracture;

osteoporosis may co-exist from other causes e.g. post menopausal

females.

2 Other imaging: not routine; MRI of the spine; FDG-PET and ^99mTc-MIBI

scan are negative in MGUS.

Diagnostic criteria for MGUS

2 Paraprotein <30g/dL.

269

2 BM plasma cells <10%.

2 No evidence of other B-cell lymphoproliferative disorder.

2 No myeloma-related organ or tissue impairment (end-organ damage,

see Myeloma-related organ or tissue impairment below).

Differential diagnosis

2 Exclude conditions listed on p266 notably MM, WM and AL.

2 Bone pain/damage, unexplained anaemia or impaired renal function sug-

gests MM.

2 Lymphadenopathy or splenomegaly with an IgM paraprotein suggests WM.

Risk factors for progression

2 No specific features at initial presentation predict those who will progress

but risk increased if:

2 Paraprotein >15g/L.

2 Paraprotein type: IgM>IgA>IgG;

2 BM plasma cells >5%.

2 Circulating plasma cells by immunofluorescence.

2 Other possible risk factors under examination: immuneparesis; presence of

urinary paraprotein; BM angiogenesis.

Management

2 No treatment; long term follow-up with review of clinical and laboratory

features required due to risk of progression.

2 Clinical and laboratory (FBC, PV, renal function, serum Ca²⁺, serum Igs,

paraprotein quantitation and urine electrophoresis) re-evaluation at 3

months then 6 months then annually.

2 Where diagnosis in doubt (e.g. elderly woman with paraprotein <30g/L and

osteoporosis) review over 3-6 months usually differentiates MGUS from MM.

2 Advise patients to seek early assessment if unexplained symptoms develop.

Kyle, R.A. (1997) Monoclonal gammopathy of undetermined significance and solitary plasmacy-

toma. Implications for progression to overt multiple myeloma. Hematol Oncol Clin North Am, 11,

71-87; Kyle, R.A. et al. (2002) A long-term study of prognosis in monoclonal gammopathy of

undetermined significance. N Engl J Med, 346, 564-569.

Asymptomatic (smouldering) myeloma

Asymptomatic or smouldering myeloma identifies patients with a parapro-

tein over 30g/dL and/or more than 10% plasma cells in the bone marrow

but in whom the natural history is that of MGUS rather than MM, i.e. no

clinical evidence of progression or of complications associated with MM.

Prognosis

2 Important to recognise because there is no survival advantage from

chemotherapy before progressive or symptomatic disease develops.

2 Clinical stability may persist for months or years and careful clinical

follow-up is required.

2 Survival is same as for newly diagnosed myeloma from the time

chemotherapy is started.

Clinical and laboratory features

2 Absence of symptoms or physical signs attributable to myeloma.

2 Performance status >50%.

2 Perform investigations listed for MM ( p273).

270

2 FBC: pre-transfusion haemoglobin >10g/dL.

2 Serum chemistry: post-rehydration creatinine <130µmol/L; normal

serum Ca²⁺.

2 b2-microglobulin: normal or minimally raised.

2 BM aspirate: plasmacytosis >10% but normally <25%.

2 BM cytogenetics: FISH identifies the abnormalities associated with MM;

some patients have detectable chromosomal abnormalities by standard

karyotype analysis.

2 Skeletal radiology: should be normal.

2 Other imaging: not yet routine; CT, MRI of spine FDG-PET and^99mTc-

MIBI scan identify bone lesions in ~25% of patients with normal con-

ventional radiology.

2 BM plasma cell labelling index: (when measured) <1%.

2 Stable paraprotein and other parameters on prolonged observation.

Diagnostic criteria for asymptomatic (smouldering) myeloma

2 Paraprotein ≥30g/dL and/or

2 BM clonal plasma cells ≥ 10%.

2 No evidence of other B-cell lymphoproliferative disorder.

2 No myeloma-related organ or tissue impairment (end-organ damage,

see Myeloma-related organ or tissue impairment below).

Risk factors for early progression of asymptomatic MM

Shorter time to progression associated with:

2 Abnormal MRI (median <2 years vs. ~7 years).

2 Serum paraprotein >30g/L.

2 b2-microglobulin >2.5mg/L.

2 BM plasmacytosis >25%.

2 Suppression of uninvolved IgM to ≤3g/L.

2 IgA protein type.

2 Urinary Bence Jones proteinuria >50mg/day.

Paraproteinaemias

These risk factors have no impact on survival after progression. Other risk

factors for progression are high plasma cell labelling index; circulating

plasma cells and karyotype abnormalities on conventional cytogenetics.

Management

2 Chemotherapy is not indicated for these patients until there is evi-

dence of clinical progression.

2 Review of clinical and laboratory features as for MGUS; more frequent

review may be appropriate for patients with risk factors for progres-

sion.

2 Median survival following chemotherapy is 3-5 years, i.e. identical to

that of de novo symptomatic myeloma.

271

Weber D. et al. (2003) Risk factors for early progression of asymptomatic multiple myeloma.

Hematol J. 4(Suppl. 1): S31-S32.

Multiple myeloma (MM)

MM (syn. myelomatosis) is a clonal B-cell malignancy characterised by pro-

liferation of plasma cells that accumulate mainly within bone marrow and

usually secrete paraprotein. MM is associated with lytic bone lesions or

diffuse osteoporosis and normal Ig production is impaired by immune-

paresis (hypogammaglobulinaemia). <1% cases are non-secretory.

Epidemiology

MM accounts for 1% of all malignancies; 10% of haematological malignan-

cies. Incidence ~4 per 100,000 per annum, 2500 new cases/year in UK.

Median age 65 years; <3% <40 years. Incidence in Afro-Caribbeans 2

Caucasians; lowest in Asians. Most present de novo but minority arise from

MGUS. Association with radiation, benzene and pesticide exposure and

farm working.

Pathophysiology

MM arises from a post germinal centre B cell (probably in LN or spleen)

that has undergone antigen selection, VDJ recombination, somatic hyper-

272

mutation of V regions and switch-recombination of IgH genes. Aberrant

class-switch recombination may contribute to neoplastic transformation

(IgH translocations common in MM). BM microenvironment critical to

clonal expansion. Secretion of IL-6, IL-1, TNF-a and RANK-ligand stimu-

late MM proliferation and osteoclast proliferation and activation (causes

bone destruction plus hypercalcaemia). BM infiltration causes anaemia.

Immuneparesis of normal Ig production predisposes to infection. Physico-

chemical properties of paraprotein determine amyloid deposition, renal

damage and hyperviscosity (IgA and IgG₄).

Clinical features and presentation

2 Spectrum from asymptomatic paraproteinaemia detected on routine

testing (~20%) to rapidly progressive illness with extensive, destructive

bony disease.

2 Most present with bone (usually back) pain (~75%) or pathological

fracture; kyphosis and loss of height may occur from vertebral com-

pression fractures.

2 Weakness and fatigue (>50%), recurrent infection (10%) and thirst,

polyuria, nocturia or oedema due to renal impairment (~10%) also

common.

2 Acute hypercalcaemia, symptomatic hyperviscosity (mental slowing,

visual upset, purpura, haemorrhage), neuropathy, spinal cord compres-

sion, amyloidosis and coagulopathy less frequent at presentation.

Electrophoresis: from L 7 R, urine BJP, serum M band (myeloma); polyclonal Igs;

normal.

Paraproteinaemias

Investigation of patients with suspected myeloma

Screening tests

FBC and film

Normochromic normocytic anaemia in 60%; film

may show rouleaux

ESR or PV

4 in 90% ; not in LC or NS MM

Urea & creatinine

May identify renal impairment (~25%)

Uric acid

May be 4

Serum albumin, calcium,

may reveal low albumin or hypercalcaemia (~20%)

phosphate, alk phos:

with normal alk phos

Serum immunoglobulins

To detect immuneparesis

Serum protein electrophoresis To detect serum paraprotein (80%)

Routine urinalysis

To detect proteinuria (~70%)

Urine electrophoresis with

To detect Bence Jones proteinuria: 22% have BJP only and

immunofixation:

no serum M-band: LC myeloma)

273

X-ray sites of bone pain

May reveal pathological fracture(s) or lytic lesion(s)

Diagnostic tests

BM aspirate

Demonstrates plasma cell infiltration—may be only way to

diagnose non-secretory (NS) myeloma

Radiological skeletal survey

Identifies lytic lesions, fractures and osteoporosis (80%;

5-10% osteoporosis only; 20% normal)

Paraprotein immunofixation Characterises and quantifies paraprotein; IgG ~55%; IgA ~22%

and densitometry

IgD ~2%; IgM 0.5%; IgE <0.01%; LC ~22%; Note: serum &

urine EPS -ve in NS ~1%

Tests to establish tumour burden and prognosis

Serum b2-microglobulin

Measure of tumour load

Serum C-reactive protein

Surrogate measure of IL-6 which correlates with tumour

aggression

Serum LDH

Measure of tumour aggression

Serum albumin

Hypoalbuminaemia correlates with poor prognosis

BM cytogenetics

Clear prognostic value (see below)

BM trephine biopsy with

Shows light chain restriction, extent of infiltration and

immunohistochemistry

haematopoietic reserve

Tests which may be useful in some patients

Creatinine clearance

With 24h protein—to assess renal damage

MRI

Not routine but useful in patients with cord compression or

solitary plasmacytoma; abnormal in ~25% of patients with

normal skeletal survey

Not routine but useful for detailed evaluation of localised

sites of disease

Biopsy for amyloid + SAP scan Where amyloid suspected ( p288)

Serum free light chain assay Provides treatment response parameter in LC myeloma,

amyloidosis and most cases of ‘non-secretory’ MM

FDG-PET scan

Under evaluation; abnormal in ~25% with normal skeletal

survey; persistent positive post-therapy may predict early

relapse; identifies focal recurrent disease and focal

extramedullary disease

^99mTc-MIBI scan

Under evaluation; may identify extensive BM involvement

Diagnostic criteria for multiple myeloma

Paraprotein in serum and/or urine (Note: no minimum level).

BM clonal plasma cells (Note: no minimum level; 5% have <5% plasma cells) or

plasmacytoma.

Myeloma-related organ or tissue impairment (end-organ damage)

Myeloma-related organ or tissue impairment (end-organ

damage)

2 Elevated calcium levels: serum calcium >0.25mmol/L above upper limit

of normal or corrected serum calcium >2.75mmol/L or >11mg/dL.

2 Renal insufficiency: (creatinine >173µmol/L or >2mg/dL).

2 Anaemia: Hb 2g/dL below normal range or Hb <10g/dL.

2 Bone lesions: lytic lesions or osteoporosis with compression fractures

recognised by conventional radiology.

2 Others: symptoms of hyperviscosity; amyloidosis; recurrent bacterial

infection.

274

Bone marrow aspirate in myeloma showing numerous plasma cells (note binucleate

cell, centre left).

Cytogenetics

2 Using conventional techniques abnormal karyotypes found in 30-50%;

heterogeneous pattern and complex abnormalities are common.

2 FISH techniques demonstrate aneuploidy in nearly all patients:

- Monosomies in vast majority (8, 13, 14, 16, 22).

- Abnormalities involving 14q32 (Ig heavy chain locus) in 60-75%

(esp. non-hyperdiploid karyotypes): t(11;14), t(4;14), t(14;16) and

non-recurrent.

- Hyperdiploidy in 50-60% (trisomy 3, 5, 7, 9, 11, 15, 19).

- del(13) in 50%.

- del(17p;13.1): loss of p53 tumour suppressor gene also occurs in MM.

2 Prognostic value

- Poor prognosis: t(4;14), t(14;16), del(17p), del(13), hypodiploidy.

- Favourable prognosis: others including t(11;14).

Differential diagnosis

2 Suspect MM in a patient >50 with bone pain, lethargy, anaemia, recur-

rent infection, renal impairment, hypercalcaemia or neuropathy or in

whom rouleaux or an 4 ESR or PV is detected.

Paraproteinaemias

2 Exclude MGUS and other conditions associated with a paraprotein

(

p266), notably solitary plasmacytoma, primary amyloidosis and

lymphoproliferative disorders.

Prognostic factors: adverse prognostic factors at diagnosis

2 Age >65.

2 Performance status 3 or 4.

2 High paraprotein levels (IgG >70g/L; IgA >50g/L; BJP >12g/24h).

2 Low haemoglobin (<10g/dL).

2 Hypercalcaemia.

2 Advanced lytic bone lesions.

2 Abnormal renal function (creatinine >180mmol/L).

2 Low serum albumin (<30g/L).

2 High b2-microglobulin (≥6mg/mL).

2 High C-reactive protein (≥6mg/mL).

275

2 High serum LDH.

2 High % BM plasma cells (>33%).

2 Plasmablast morphology.

2 Adverse cytogenetics (see above).

2 Circulating plasma cells in PB.

2 High serum IL-6 (measured in only a few centres).

2 High plasma cell labelling index (measured in only a few centres).

Skull x-ray in myeloma showing multiple lytic lesions.

Myeloma: humerus shows marked osteoporosis, lytic lesions and healing patholog-

ical fracture.

Staging systems

Durie-Salmon staging system in wide use since 1975 attempts to assess

tumour bulk but may not provide as good prognostic discrimination as

276

newer systems:

Patients staged as I, II or III & A or B; stage represents tumour burden

Stage I

Stage II

Stage III

Tumour cell mass

Low

Medium

High

all of the

not fitting

one or more of

following:

Stage I or III

the following:

Monoclonal IgG (g/L)

<50

>70

Monoclonal IgA (g/L)

<30

>50

BJP excretion (g/24h)

>12

Hb (g/dL)

>10

<8.5

Serum Ca²⁺ (mmol/L)

<2.6

>2.6

Lytic lesions

none or one

advanced

Stage A: serum creatinine <175mmol/L

Stage B: serum creatinine >175mmol/L

Durie, B.G. & Salmon, S.E. (1975) A clinical staging system for multiple myeloma.

Correlation of measured myeloma cell mass with presenting clinical features, response to

treatment, and survival. Cancer, 36, 842-854.

Serum b2-microglobulin

(b₂-M) is most powerful prognostic factor

(measure of tumour bulk) and can be used with serum C-reactive protein

(CRP) a surrogate measure for serum IL-6 (measure of tumour aggres-

sion) to assess prognosis:

Paraproteinaemias

Low risk

both b₂-M <6mg/L & CRP <6mg/L median survival 54 mo

Intermed. risk

either b₂-M or CRP ≥6mg/L

median survival 27 mo

High risk

both b₂-M ≥6mg/L & CRP ≥6mg/L

median survival 6 mo

Bataille, R. et al. (1992) C-reactive protein and beta-2 microglobulin produce a simple and

powerful myeloma staging system. Blood, 80, 733-737.

International Prognostic Index (IPI) has been devised using serum b₂-M

and serum albumin (ALB):

Stage 1

b₂-M <3.5mg/L; ALB ≥35g/L

median survival 62 mo

Stage 2

b₂-M <3.5mg/L; ALB <35g/L

median survival 41 mo

or b₂-M 3.5-5.5mg/L

277

Stage 3

b₂-M >5.5mg/L

median survival 29 mo

Greipp, PR. et al. (2003) Development of an international prognostic index (IPI) for

myeloma: report of the international myeloma working group. Hematol J, 4, (Suppll) 542-44.

Good and poor risk groups in IPI

2 Age is only additional factor that significantly impacts outcome:

- Survival >5 years associated with age <60 years (very low risk if

stage 1).

- Survival <2 years associated with age >60years, platelets <130

10⁹/L or 4 serum LDH.

2 Cytogenetics affect outcome but do not add to impact of age, b₂-M

and ALB.

Management (UKMF Guidelines, Br J Haematol 115, 522-540)

Initial considerations and general aspects

2 Pain control: titrate simple analgesia and opiates (MST + prn

Oramorph) ± NSAIDs (monitor renal function) ± local radiotherapy

(8-20Gy) ± spinal support corset for severe back pain.

2 Correction of renal impairment: rehydration with high fluid input

(3-4L/day) and rapid treatment of hypercalcaemia, infection and hyper-

uricaemia may improve renal function; caution with nephrotoxic drugs

including NSAIDs; ?role of plasmapheresis in established renal failure;

peritoneal or haemodialysis if required (<5%); VAD-type regimen

treatment of choice after response to rehydration or established CRF;

follow with PBSC harvest (mobilised by G-CSF alone) and HDM

(140mg/m²) and SCT in younger patients; after response EFS and OS

same as other patients.

2 Hypercalcaemia: rehydration (3-6L/day IV); loop diuretics; IV bisphos-

phonate; (pamidronate 30-90mg IV or zoledronate 4mg IV; 5 dose in

renal impairment); chemotherapy.

2 Bone disease: local radiotherapy for localised pain (8-20Gy); fixation of

fractures/potential fractures; long term bisphosphonate prophylaxis.

2 Infection: vigorous antibiotic therapy; annual influenza immunisation.

2 Anaemia: blood transfusion for symptomatic anaemia; Epo for Hb per-

sistently ≤10g/dL (10,000IU tiw or 30,000IU once weekly ~70%

response rate with ≥2g/dL rise in Hb).

2 Hyperviscosity syndrome: plasmapheresis (3L exchange) followed by

prompt chemotherapy.

2 Cord compression: MRI scan to define lesion; oral dexamethasone stat;

urgent local radiotherapy.

Melphalan and prednisolone (M&P)

2 4 day courses of M&P (M 6-9mg/m²/day PO; P 40-100mg/day PO) at

4-6 week intervals achieve ≥50% reduction of paraprotein in 50-60%

patients; monitor response by serum/urine paraprotein level (serum

free light chains in most non-secretors); response often slow; continue

treatment to maximum response (9-12 months); CR uncommon.

2 Patients with ≥50% response may achieve plateau phase (stable para-

protein without further treatment; median duration 12-18 months);

maintenance chemotherapy in plateau ineffective and toxic; monitor

paraprotein 6-8 weekly to detect progression; further responses to

278

M&P after durable plateau; melphalan resistance ultimately develops in

all patients.

2 Median survival ~36 months; well tolerated; remains appropriate first

line treatment for elderly patients treated outside a clinical trial; side

effects myelosuppression and steroid toxicity (add PPI or H₂ antagonist).

Combination chemotherapy

2 ABCM ( p620),VMCP/VBAP and VBMCP showed improved objec-

tive responses in 3 large studies; CR still <10%; but no survival benefit

over M&P on meta-analysis; ?superior results in younger patients with

poor risk disease; side effects myelosuppression and infection; more

toxicity in elderly patients.

2 VAD infusional regimen ( p624) produces improved overall

responses (60-80%) and CRs (10-25%); maximum response rapidly

achieved (~12 weeks); responses not durable without consolidation by

melphalan-containing regimen; non-toxic to stem cells thus good initial

therapy in patients destined for PBSC harvest, HDT and autograft;

useful regimen in patients with renal failure; VAMP gives similar results;

no convincing advantage for C-VAMP ( p622); side effects myelosup-

pression, infection (esp. indwelling IV catheter), alopecia, neuropathy,

proximal myopathy (add PPI or H₂ antagonist).

Approach to treatment of myeloma in non-trial patients

Age ≥65 years

M&P to plateau

Repeated on progression if durable response to

initial therapy

Thal-Dex or low dose CTX for short response/

refractory disease

Age <65 or very fit ≥65

VAD ¥ 4-6; PBSC mobilisation; HDM; repeat

on progression if durable response;

Thal-Dex for short response/refractory disease

Thal-Dex, thalidomide + dexamethasone; CTX, cyclophosphamide.

Paraproteinaemias

Other agents

2 Bisphosphonates inhibit osteoclast activation; patients on long term

therapy experience less bone pain and fewer new bone lesions and

fractures; there is evidence of improved quality of life and possible

prolongation of survival; as yet no evidence for superiority of either

daily oral clodronate or monthly IV pamidronate/zoledronate.

2 Interferon-a administered as maintenance therapy during plateau

phase at a dose of 3mu/m² SC tiw improves response duration on a

meta-analysis (median 6 months) and has a small effect on survival; side

effects reduce patient compliance and cost-utility profile is

unfavourable.

2 Cyclophosphamide (300-500mg PO/IV once weekly; ‘C-weekly’) may

be used as a single agent for patients intolerant of melphalan due to

persistent cytopenia and is capable of achieving durable plateau phase.

279

Radiotherapy

2 Important modality of treatment in myeloma at all stages of disease;

local radiotherapy (8-20Gy) often rapidly effective treatment for bone

pain associated with pathological fracture.

2 Multiple widespread lesions may be palliated with hemibody irradia-

tion: 10Gy for the lower hemibody or 6Gy for the upper hemibody;

side effect myelosuppression; sequential hemibody irradiation may be

performed after an interval of 6 weeks.

High dose therapy and stem cell transplantation

2 Autologous SCT after high dose melphalan (HDM; 200mg/m²)

achieves high CR rates (25-80%) after initial therapy with a VAD-type

regimen and PBSC harvest; median duration of response 2-3 years;

treatment of choice for patients <65 years; best responders have best

survival, median >5 years; improved progression free survival (32 vs. 20

mo) and overall survival (54 vs. 42mo) in large randomised study¹; side

effects: myelosuppression, infection, delayed regeneration; not cura-

tive.

2 Addition of TBI to melphalan 140mg/m² with autologous SCT adds

toxicity but no benefit; no convincing benefit for ‘double/tandem’ auto-

grafts though may be of value for those converted to CR after second

procedure; no benefit from stem cell purification procedures.

2 Intermediate dose melphalan (60-80mg/m²) + G-CSF offers an alterna-

tive consolidation treatment for patients with failed PBSC mobilisation.

2 Allogeneic SCT: applicable to fit patients ≤50 years; transplant-related

mortality with standard conditioning regimens ( p310) is high

(~33%) due to infection and GvHD; 35-45% long term survival (>5

years); ~33% chance of durable remission and possible cure; ~33%

chance of survival with recurrence; evidence of graft vs. myeloma

effect; non-myeloablative regimens ( p310) reduce toxicity, increase

age limit but reduce response rate; allogeneic SCT should be discussed

with all patients <55 with a suitable sibling donor.

Treatment of primary refractory disease

2 Patients with MM who progress or fail to respond (<25% reduction in

paraprotein) to initial therapy with melphalan may respond to single

agent dexamethasone (20-40mg/d ¥ 4 days weekly ¥ 3 weeks), VAD-

type regimens thalidomide and dexamethasone or combination

chemotherapy; failure to respond to VAD is an indication for thalidomide

based therapy followed by HDM and autologous SCT where possible.

Disease progression

Patients who achieve a durable response (>12 months) to initial

therapy may respond to further treatment with the same regimen

(response rate 25-50%).

Patients who relapse early after initial therapy with M&P or fail to

respond at relapse may respond to single agent dexamethasone

(20-40mg/day ¥ 4 days weekly ¥ 3 weeks/month initially) or thalido-

mide (50-200mg/day) or these drugs in combination (response rate up

to 70%) to which may be added cyclophosphamide (300-500mg/week)

or clarithromycin (4 responses).

Thalidomide (50-400mg/day) as a single agent achieves up to 30%

280

responses in chemotherapy-resistant myeloma; addition of dexametha-

sone (20-40mg/day ¥ 4 days/month) 4 response rates (up to 70%);

side effects constipation, tremor, headache, oedema, somnolence;

thromboembolism risk esp. in combination with anthracyclines (full

dose warfarin or LMW heparin prophylaxis advised).

Patients who relapse after prolonged response to HDM (>18 months)

with a PBSC harvest sufficient for 2 procedures or with a further suc-

cessful harvest may benefit from second HDM ± re-induction with VAD.

There is evidence of a graft-versus-myeloma effect and DLI has re-

induced responses in patients with recurrence after allogeneic SCT.

The immunomodulatory drug Revimid and the proteosome inhibitor

Velcade are both active in refractory and resistant myeloma; studies to

define the role of these agents are in progress.

Cyclophosphamide (50-100mg/day PO) is well tolerated palliative

therapy for patients with advanced refractory disease or cytopenia

who are intolerant of thalidomide or dexamethasone.

1 Child, J.A. et al. (2003) High-dose chemotherapy with hematopoietic stem-cell rescue for mul-

tiple myeloma. N Engl J Med, 348, 1875-1883.

Paraproteinaemias

Variant forms of myeloma

Non-secretory myeloma

2 ~1% of MM cases; no detectable serum or urine paraprotein by

immunofixation; (Note: serum free light chain ratio abnormal in 70%);

clonal plasma cells ≥5% in BM or plasmacytoma on biopsy; myeloma-

related end-organ damage.

2 Treat as above; response rates comparable to secretory MM; response

more difficult to assess in absence of paraprotein; serum free light

chain assay provides alternative to surrogate markers (b₂-M, CRP) and

BM assessment.

IgD myeloma

2 ~1% of cases of MM; younger mean age; high rate of Bence Jones pro-

281

teinuria and associated higher frequency of acute and chronic renal

failure; tendency to present with other poor prognostic features (high

b₂-M; low Hb).

2 Treat aggressively when possible.

IgM myeloma

2 Very rare; <0.5% of MM; 1% of all IgM gammopathies; plasma cell infil-

trate in BM associated with osteolytic lesions as opposed to lympho-

plasmacytoid infiltrate characteristic of WM; response and survival

equivalent to MM.

IgE myeloma

2 Rarest form of MM; younger age; high incidence of plasma cell

leukaemia.

2 ?shorter survival.

Plasma cell leukaemia

2 Defined as PB plasma cells >2

¥ 10⁹/L or 20% of differential count;

may occur de novo at presentation or in the terminal stages of other-

wise typical MM.

2 Aggressive disease associated with BM failure and organomegaly; poor

response to conventional dose therapy; few survive >6 months; better

responses to HDM.

Cryoglobulinaemia

2 Rare complication of paraprotein precipitation at low temperature;

2 Leg ulcers, Raynaud’s phenomenon, renal impairment, gangrene, CNS

and GI symptoms; biopsy usually shows vasculitis.

2 Treat myeloma and avoid cold.

POEMS syndrome

2 Polyneuropathy, Osteosclerosis, Endocrinopathy, M-protein, Skin

changes.

2 Association of plasmacytoma with chronic inflammatory demyelinating

polyneuropathy causing predominantly motor disability.

2 Confirm diagnosis by demonstrating monoclonal plasma cells in

osteosclerotic bone lesion (plasmacytoma).

2 BM usually <5% plasma cells; low level paraprotein; hypercalcaemia

and renal impairment rare.

2 Other features: lymphadenopathy, organomegaly, diabetes mellitus,

male gynaecomastia and impotence, female amenorrhoea, hypertri-

chosis and hyperpigmentation.

2 Treat solitary bone lesions with aggressive radiotherapy (45Gy) ±

surgery.

Solitary plasmacytoma of bone (SPB):

Diagnostic criteria

Generally no paraprotein in serum or urine though small band may be

present.

Single area of bone destruction due to clonal plasma cells.

BM not consistent with MM.

Otherwise normal skeletal survey (and MRI of spine and pelvis).

No myeloma-related organ or tissue impairment (end-organ damage).

Represents ~5% plasma cell neoplasia: 9 : 3 ratio 2:1; median age 55.

282

Lesion usually in axial skeleton; 66% in spine.

Generally presents with bony pain; may cause cord/root compression.

Diagnosis requires biopsy or FNA, exclusion of MM (p273) and exclu-

sion of other bone lesions with MRI (FDG-PET/^99Tc-MIBI under exami-

nation).

Serum or urine paraprotein detected in 24-72%; generally low level.

Adverse prognostic factors for progression to MM include persistence of

paraprotein >1 year after radiotherapy, immuneparesis and lesion >5cm.

Negative MRI of spine is good prognostic feature.

Treat with fractionated radical radiotherapy 40Gy (50Gy for lesions

>5cm); local control 80-95%; curative in 50% if solitary lesion; DFS

~40% at 5 years.

Treat non-responders with chemotherapy as for myeloma (p278).

Regular follow-up to monitor paraprotein; disappears in 25-50% (often

slowly over several years).

~75% progress to MM; treat as de novo MM (p278); high response rate.

Some patients develop multiple solitary recurrences; treat each with

local radiotherapy.

Median survival ~10 years.

Extramedullary plasmacytoma (SEP)

Diagnostic criteria

2 Generally no paraprotein in serum or urine though small band may be

present.

2 Extramedullary tumour of clonal plasma cells.

2 BM not consistent with MM.

2 Normal skeletal survey (and MRI of spine and pelvis).

2 No myeloma-related organ or tissue impairment (end-organ damage).

2 Rare; may occur anywhere but 90% in head and neck; most in upper

airways.

2 Diagnosis requires biopsy or FNA of the lesion; exclusion of MM and

other lesions.

2 <25% have serum or urine paraprotein.

Paraproteinaemias

2 Treat with radical radiotherapy (40Gy; 50Gy if lesion >5cm) including

cervical lymph nodes when involved; radical surgery only for SEP

outside head and neck.

2 Most cured; <5% local recurrence; relapse <30%; MM, SBP or soft

tissue involvement: chemotherapy for refractory or relapsed disease

(p278).

2 >70% survival at 10 years.

283

Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disor-

ders: a report of the International Myeloma Working Group (2003) Br J Haematol, 121, 749-757;

BCSH UKMF Guidelines Diagnosis and management of solitary plasmacytoma of bone (SBP) and

solitary extramedullary plasmacytoma (SEP). www.bcshguidelines.com

Waldenström’s macroglobulinaemia

(WM)

WM is an uncommon indolent chronic B-cell lymphoproliferative disorder

characterised by bone marrow infiltration by lymphoplasmacytic cells and

an IgM paraproteinaemia. It is classified as a lymphoplasmacytic lymphoma

in the REAL and WHO classifications (p195).

Epidemiology

2 Incidence <0.5 per 100,000 per annum; mean age 65; rare <40; M:F

~2:1.

2 Cause unknown; several familial clusters described; 23% of patients

have 1st degree relative with B-cell disorder.

Pathophysiology

WM appears to arise from IgM+ memory B lymphocytes (suggested by

the immunophenotype and Ig somatic hypermutation without intraclonal

variation); slowly progressive; symptoms may be due to infiltration of BM

284

(BM failure) spleen (splenomegaly) or liver (hepatomegaly) or to hypervis-

cosity due increased serum levels of pentavalent monoclonal IgM (when

IgM >30g/L). Autoimmune disorders may also develop due to the para-

protein: neuropathy, cold agglutinin disease

Clinical features and presentation

2 Occasional diagnosis following routine ESR/PV/FBC/blood film.

2 Usually insidious onset of weakness and fatigue.

2 Often present with symptoms of anaemia, epistaxis, recurrent infec-

tion, dyspnoea, CCF and weight loss.

2 Usually no bone pain and no evidence of destructive bone disease.

2 Symptoms of hyperviscosity (headache, dizziness, visual upset, bleeding,

ataxia, CCF and somnolence, stupor and coma) 15-20%.

2 Peripheral neuropathy—usually sensory or sensorimotor (~20%):

distal, symmetrical, slowly progressive, usually lower extremities.

2 Hepatomegaly (~25%); splenomegaly and lymphadenopathy less fre-

quent.

2 Fundoscopy reveals distended sausage-shaped veins, retinal haemor-

rhage ± papilloedema.

2 Cryoglobulinaemia (<5%) may cause Raynaud’s syndrome, arthralgia,

purpura, peripheral neuropathy, liver dysfunction and renal failure.

2 Haemorrhagic symptoms (e.g. epistaxis or easy bruising) may develop

as a result of abnormalities of platelet function or coagulation due to

the paraprotein.

2 Amyloidosis may occur (<5%) causing cardiac, renal, hepatic or pul-

monary dysfunction or macroglossia.

Investigation and diagnosis

2 FBC and film: normochromic normocytic anaemia 80% (often spuri-

ously low due to increased plasma volume); rarely lymphocytosis or

pancytopenia; blood film shows rouleaux or agglutination (cold agglu-

tinins ~5%); may contain circulating lymphoplasmacytic cells.

2 ESR/plasma viscosity: 4 in almost all patients (~70% PV >1.8cP), often

markedly (ESR commonly >100mm/h); risk of hyperviscosity symptoms

Paraproteinaemias

when PV >4cP (5-10% at diagnosis); most have symptoms when PV

>6cP; PV often correlates well for symptoms in an individual though

not between patients.

Biochemistry: renal impairment unusual; LFTs may be abnormal in

advanced disease or cryoglobulinaemia; uric acid may be 4.

Serum immunoglobulins: 4 IgM; may be mild immuneparesis of IgG

(60%) and IgA (20%).

Serum protein electrophoresis, immunofixation and densitometry: con-

firms and quantifies IgM paraprotein.

Urine electrophoresis: scanty Bence Jones protein present in ~50%.

b2-microglobulin: 4 in 33%.

C-reactive protein: 4 in ~66%.

BM aspirate: often hypocellular; may show infiltration by lymphoplas-

macytic cells of variable degrees of differentiation; mast cells may be

285

increased.

BM trephine biopsy—essential—usually hypercellular; demonstrates

intertrabecular infiltrate (diffuse, interstitial or nodular) of lymphoplas-

macytic cells (Note: paratrabecular infiltrate suggests follicular NHL);

immunochemistry demonstrates light chain restriction.

BM immunophenotyping: useful in differentiating WM from other B-

cell disorders; characteristically pan B-cell marker (CD19, CD20,

CD22, CD79) positive (cf. myeloma plasma cells); light chain restricted

surface IgM; CD10 negative (cf. FL), CD23 negative (cf. CLL); 5-20%

express CD5 (must differentiate from CLL and MCL); CD103 and

CD138 rarely positive.

Cytogenetics: no disease defining abnormality described; many normal;

presence of IgH translocations (14q) suggests myeloma.

Proposed diagnostic criteria

2 IgM monoclonal gammopathy of any concentration.

2 BM infiltration by small lymphocytes, plasmacytoid cells and plasma

cells.

2 Intertrabecular pattern of BM infiltration.

2 Immunophenotype: surface IgM+, CD5±, CD10-, CD19+, CD20+,

CD22+, CD23-, CD25+, CD27+, FMC7+, CD103-, CD138-.

2 WM may be divided into symptomatic WM and asymptomatic (smoul-

dering) WM (~25%) by the presence or absence of symptoms attribut-

able to either the IgM paraprotein (e.g. hyperviscosity or neuropathy)

or tumour infiltration (BM failure or symptomatic organomegaly).

Differential diagnosis

2 IgM MGUS: IgM monoclonal protein <30g/L; Hb >12g/dL; no BM infil-

trate; no organomegaly or lymphadenopathy; no end-organ symptoms.

2 IgM-related disorders: IgM monoclonal protein; no overt evidence of

lymphoma; symptomatic cryoglobulinaemia, peripheral neuropathy,

cold agglutinin disease or amyloidosis.

(Owen, R.G. et al. (2003) Clinicopathological definition of Waldenström’s macroglobulinaemia.

Semin Oncol 30:110-115)

2 Other B-cell lymphoproliferative disorders: IgM monoclonal protein can

be demonstrated in most B-cell lymphoproliferative disorders e.g. CLL,

NHL; generally very low levels; no lymphoplasmacytic BM infiltration;

hyperviscosity rare; features of other lymphoproliferative disorder e.g.

phenotype.

2 IgM myeloma: very rare; BM contains plasma cells (cytoplasmic IgM+,

CD20-, CD138+) not lymphoplasmacytic cells; myeloma associated

cytogenetic abnormalities (esp. 14q translocations) and lytic bone lesions

frequent.

Prognostic factors

Predictors of early progression in asymptomatic WM:

2 Hb <11.5g/dL.

2 b2-microglobulin ≥3.0mg/L.

2 IgM >30g/L.

Predictors of shorter survival in WM:

2 Age ≥60.

2 Hb <10g/dL.

286

2 High b2-microglobulin.

2 Other less consistently identified factors: cytopenias: WBC <4.0

¥ 10⁹/L; neu-

trophils <1.8

¥ 10⁹/L; platelets <150

¥ 10⁹/L; 5 serum albumin; 9 sex; con-

stitutional symptoms; plasmacytic and polymorphous morphology in BM.

Management

Therapeutic principles as for CLL and FL; no indication for therapy in

asymptomatic WM; regular review (3-6 monthly) of clinical and labo-

ratory features required: consistently monitor paraprotein by densito-

metry (more reliable than IgM nephelometry).

Initiation of therapy should not be based simply on IgM level alone as this

does not correlate directly with clinical manifestations of WM but for:

- Constitutional symptoms: recurrent fever, night sweats, fatigue due

to anaemia, weight loss.

- Progressive symptomatic lymphadenopathy or splenomegaly.

- Hb ≤10g/dL and/or platelets <100

¥ 10⁹/L due to BM infiltration.

- Hyperviscosity syndrome, symptomatic peripheral neuropathy, sys-

temic amyloidosis, symptomatic cryoglobulinaemia, renal failure.

- Note: avoid red cell transfusion simply to correct low Hb (plasma

volume 4 causing spuriously low Hb; low Hb protects against clin-

ical effects of hyperviscosity).

Plasmapheresis may be necessary as urgent initial therapy for patients

with symptoms of hyperviscosity; 3L exchange efficiently reduces

plasma viscosity (80% of large IgM molecule is intravascular); may

rarely be required regularly in treatment of neuropathic or chemo-

intolerant patients; in an emergency venesection and exchange transfu-

sion will 5 plasma viscosity.

Chlorambucil at a dose of 6-10mg/d for 7-14 days ± prednisolone in a

28d cycle is widely used initial therapy; continue to maximum

response; up to 75% achieve ≥50% reduction in paraprotein; duration

of response 2-4 years; <10% achieve CR; reinstitute treatment when

paraprotein approaches previously symptomatic levels; often effective

on several occasions; resistance ultimately develops; side effects;

myelosuppression; cyclophosphamide may achieve comparable results.

Paraproteinaemias

Purine analogues: fludarabine (40mg/m² PO ¥ 5d or 25mg/m² IV ¥ 5d

repeated monthly for 4-6 cycles) has a response rate of 40-80% in

untreated patients and achieves ~33% response rate even after chlo-

rambucil resistance; response duration 30-40 months; similar results

with cladribine (0.1mg/kg continuous infusion ¥ 7d); both agents

achieve more rapid responses than chlorambucil; side effects: myelo-

suppression; profound immunosuppression (see p558); need P carinii

prophylaxis and irradiated blood products; addition of cyclophos-

phamide to a purine analogue increases response rates.

Rituximab: monoclonal anti-CD20 antibody administered on 4 occa-

sions achieves 60% responses ≥25% 5 in WM and useful in patients

with marked cytopenia; abrupt elevation in serum paraprotein and PV

may occur after rituximab therapy and patients should be closely mon-

itored; may be of benefit for symptomatic neuropathy; administration

287

of 4 further doses over 12 months extends the response from ~9

months to up to 3 years; under examination in clinical trials in combi-

nation with purine analogue therapy.

High dose therapy and autologous or allogeneic SCT: has been under-

taken in a small number of younger patients; high response rates

(~80%; up to 40% CR) are achieved but relapse rate is high after auto-

graft and treatment related mortality of ~40% occurs after allograft;

the latter does offer survivors the prospect of long-term disease

control; HDT should be performed in a trial context where possible

and patients in whom this treatment is planned should have limited

prior exposure to alkylator and purine analogue therapy.

Treatment of relapse: if a response of >1year has been achieved most

patients will respond to the same therapy; refractory patients or those

relapsing shortly after prior therapy may respond to an alternative

listed above; ~33% of patients with refractory WM respond to thalido-

mide (50-200mg) in combination with dexamethasone (20-40mg once

weekly) and/or clarithromycin (250-500mg bd).

Prognosis

2 Median time to progression of asymptomatic WM ~7 years.

2 Median survival of patients with WM ~5 years; patients who achieve

CR with chlorambucil have median survival of ~11 years.

2 Up to 20% die of unrelated causes and 33% from infection; others

from disease progression, transformation and bleeding.

2 Indolent course may be interrupted by transformation into aggressive

high grade NHL which is often poorly responsive to treatment; poor

tolerance of aggressive treatment due to poor marrow reserve.

Gertz, M.A. et al. (2003) Treatment recommendations in Waldenstrom's macroglobulinemia: con-

sensus panel recommendations from the Second International Workshop on Waldenstrom's

Macroglobulinemia. Semin Oncol, 30, 121-126; Kyle, R.A. et al. (2003) Prognostic markers and cri-

teria to initiate therapy in Waldenstrom's macroglobulinemia: consensus panel recommendations

from the Second International Workshop on Waldenstrom's Macroglobulinemia. Semin Oncol, 30,

116-120; Weber, D. et al. (2003) Uniform response criteria in Waldenstrom's macroglobu-

linemia: consensus panel recommendations from the Second International Workshop on

Waldenstrom's Macroglobulinemia. Semin Oncol, 30, 127-131.

Heavy chain disease (HCD)

Uncommon lymphoplasmacytic cell proliferative disorder characterised

by production of incomplete immunoglobulins comprising heavy chains

without light chains. Alpha (a) HCD is most frequent, g and m HCD also

described but rare.

a-HCD

2 Usually occurs in residents or immigrants from Mediterranean or

Middle East; associated with low socio-economic group, poor hygiene,

recurrent infectious diarrhoea and chronic parasitic infection.

2 Commonly presents with diarrhoea, steatorrhoea, weight loss, abdom-

inal pain and vomiting; a-HCD protein detectable in serum of most

patients, concentration often low; mild to moderate anaemia; low

serum albumin; hypokalaemia and hypocalcaemia (tetany); infiltrative

lesions in duodenum and jejunum in most patients; histology ranges

from lymphoplasmacytic infiltration of mucosa (Stage A) to

immunoblastic lymphoma invading entire intestinal wall.

288

2 Progressive course without treatment; treat Stage A initially with oral

metronidazole and tetracycline for 6 months; treat non-responders

and Stage B or C with CHOP-type regimen.

AL (primary systemic) amyloidosis

AL (primary systemic) amyloidosis is a clonal plasma cell disorder in which

systemic disease results from organ dysfunction due to extracellular deposi-

tion of fibrillar protein. It can also complicate most clonal B-cell lymphoplas-

macytic disorders, notably myeloma, Waldenström’s macroglobulinaemia,

MGUS and lymphoma.

Incidence

Estimated incidence 0.5-1 per 100,000 per annum; 9:3 ratio 2:1; most

cases aged 50-70; <10% <50 years; ~1% <40 years; 15% of patients with

MM develop amyloid (lower % of MGUS and WM).

Pathophysiology

In AL amyloidosis the fibrillar deposits are composed of the variable

regions of immunoglobulin light chains

(VL) in association with gly-

cosaminoglycans and amyloid P component derived from the normal

plasma protein serum amyloid P (SAP) component. More commonly l

light chains. Unique amino acid insertions may render the proteins amy-

loidogenic. Without treatment deposits progressively accumulate in

viscera notably kidneys, heart, liver and peripheral nervous system causing

increasingly severe dysfunction. Under favourable circumstances, further

amyloid deposition can be prevented, deposits can regress and improve-

ment in organ dysfunction can occur.

Clinical features and presentation

2 Renal involvement is the predominant feature in 33% with nephrotic

syndrome (oedema, fatigue and lethargy) ± renal impairment (usually

mild).

Paraproteinaemias

2 Cardiac symptoms predominate in 20-30%: CCF due to restrictive

cardiomyopathy notably with right sided features (4 JVP, peripheral

oedema and hepatomegaly).

2 Peripheral neuropathy occurs in 20%; 10-15% present with isolated

neuropathic symptoms; typically painful sensory polyneuropathy; carpal

tunnel syndrome in 40%; autonomic neuropathy may cause postural

hypotension, impotence and disturbed GI motility.

2 GI involvement may be focal or diffuse: malabsorption, perforation,

haemorrhage and obstruction may occur; hepatomegaly 25%;

macroglossia 10%.

2 Haemorrhage occurs at some time in up to 33% of patients; usually

non-thrombocytopenic purpura, often periorbital causing characteristic

‘raccoon eyes’ appearance.

2 Vocal cord infiltration may cause dysphonia; large joint arthropathy;

289

adrenal and thyroid infiltration may cause endocrine dysfunction; cuta-

neous plaques and nodules usually on face or upper trunk; pulmonary

infiltration rarely symptomatic.

Investigation and diagnosis

High index of suspicion required; consider in patient with nephrotic

syndrome, cardiomyopathy, peripheral neuropathy, hepatomegaly or

autonomic neuropathy.

Confirm diagnosis by histological examination of biopsy of affected

organ or subcutaneous fat aspirate, rectal biopsy or labial salivary gland

biopsy stained with Congo Red for red-green birefringence under

polarised light; confirm AL amyloidosis by immunochemistry for k or l

light chains (50% are negative).

Assess severity of organ involvement:

- FBC: 5 Hb suggests probable myeloma.

- Serum chemistry: to assess renal and hepatic function.

- b2-microglobulin: prognostic indicator in MM (see p276).

- Coagulation screen; may be a coagulopathy due to absorption of

factor X and sometimes FIX by the amyloid.

- Serum protein electrophoresis, immunofixation and densitometry:

to detect, type and quantitate any paraprotein present (~70%;

usually only modest quantity).

- Serum immunoglobulins: to identify immuneparesis (suggests MM).

- Serum free light chain assay: useful in patients with no detectable

paraprotein in serum or urine (10-15%).

- Creatinine clearance and 24h quantitative proteinuria: to assess

renal dysfunction.

- Urine electrophoresis: to detect, type and quantify paraprotein

(85%; 90% have albuminuria).

- BM aspirate and trephine biopsy: usually only mild 4 in % plasma

cells; overt MM in 20%.

- Skeletal survey: if MM suspected.

- ECG and echocardiography: low voltage ECG; echo shows concen-

trically thickened ventricles, normal to small cavities and a normal

or mild reduction in ejection fraction.

- SAP (serum amyloid protein) scan: radiolabelled serum amyloid P

component allows detection and quantification of amyloid deposits

and assessment of extent of organ involvement by scintigraphy. (In

UK contact National Amyloidosis Centre at UCLMS Royal Free

Hospital, London Campus).

Differential diagnosis

Exclude MM (as above), reactive (AA) amyloidosis (history of chronic

inflammatory disorder) and familial amyloidosis (family history).

Prognostic factors

Poor prognostic features:

2 CCF.

2 Multisystem involvement.

2 Renal failure.

2 Jaundice.

2 High total body amyloid load on SAP scan.

290

Management

Aims: suppress underlying plasma cell neoplasia and paraprotein produc-

tion to reduce further deposition of amyloid and permit regression

resulting in improvement in organ dysfunction.

Supportive care

2 Nephrotic syndrome: loop diuretic + salt ± fluid restriction.

2 Renal failure: peritoneal or haemodialysis if required; rigorous control

of hypertension.

2 CCF: diuretic + ACE inhibitors if tolerated; digoxin hypersensitivity

common; calcium channel blockers and b-blockers contraindicated;

cardiac transplantation should be considered in appropriate patients.

Chemotherapy

2 Melphalan ± prednisolone: slow response rate; consider for patients

not eligible for HDT; prolongs median survival in a randomised trial vs.

colchicine (but survival only 12-18 months).

2 VAD: induces a more rapid response than M&P; suitable initial therapy

in those patients eligible for HDT; caution with vincristine in neuro-

pathic patients and adriamycin in those with CCF; dexamethasone

alone may produce responses.

2 High dose melphalan and autologous PBSCT: improves organ function

in up to 60% of survivors; up to 40% procedure related mortality; Note:

stem cell mobilisation associated with mortality and morbidity due to

cardiac complications (avoid cyclophosphamide), oedema and splenic

rupture (low doses of G-CSF recommended); better tolerance of HDT

if ≤2 organ systems involved; younger patients with good performance

status and good renal and cardiac function do best; cardiac involve-

ment or elevated creatinine poor prognostic factor; reduce melphalan

dose to 100-140mg/m² in high risk patients; GI haemorrhage a fre-

quent complication; HDT should be undertaken in trial context.

2 Allogeneic SCT: few patients have been treated; complete resolution

has been reported.

Paraproteinaemias

Follow-up

Response to therapy should be monitored by quantitation of the serum or

urine paraprotein (or serum free light chains); SAP scintigraphy; ECG,

echocardiography and assessment of other organ dysfunction should be

reviewed every 6 months.

Prognosis

2 Median survival 1-2 years; 4-6 months if CCF at diagnosis.

2 Most common cause cardiac: progressive congestive cardiomyopathy

or sudden death due to VF or asystole.

2 Others succumb to uraemia or other complications.

Other causes of amyloid

Acquired

2 AA amyloid: reactive systemic amyloidosis associated with chronic

291

inflammatory diseases e.g. rheumatoid arthritis, TB; due to AA fibrils

derived from serum amyloid A protein (SAA).

2 Senile systemic amyloidosis due to transthyretin deposition.

2 Endocrine amyloidosis, associated with APUDomas.

2 Haemodialysis associated amyloidosis, localised to osteoarticular

tissues or systemic due to b2-microglobulin deposition.

2 Non-familial Alzheimer’s disease, Down syndrome due to b-protein.

2 Sporadic Creutzfeldt-Jakob disease, kuru due to prion protein deposition.

2 Type II diabetes mellitus due to islet amyloid polypeptide.

Hereditary

2 Numerous syndromes with characteristic patterns of peripheral or

cranial neurological involvement or visceral or cardiac involvement due

to a variety of proteins.

2 Familial Alzheimer’s disease due to a b-protein.

2 Familial Mediterranean fever due to AA derived from SAA.

BCSH/UKMF Guideline. Guidelines on the dignosis and management of AL amyloidosis.

http://www.bcshguidelines.com

Transplantation

Stem cell transplantation

294

Allogeneic stem cell transplantation

296

Autologous stem cell transplantation

300

Investigations for BMT/PBSCT

302

Bone marrow harvesting

304

Peripheral blood stem cell mobilisation and harvesting

306

Microbiological screening for stem cell cryopreservation

308

Stem cell transplant conditioning regimens

310

Infusion of cryopreserved stem cells

312

Infusion of fresh non-cryopreserved stem cells

314

Blood product support for stem cell transplantation

316

GvHD prophylaxis

320

Acute GvHD

324

Chronic GvHD

326

Veno-occlusive disease

328

Invasive fungal infections and antifungal therapy

330

CMV prophylaxis and treatment

334

Post-transplant vaccination programme

336

Treatment of relapse post-allegeneic SCT

338

Discharge and follow-up

340

Stem cell transplantation

Stem cell transplantation (SCT) achieves reconstitution of haematopoiesis

by the transfer of pluripotent haemopoietic stem cells. In allogeneic SCT

stem cells are obtained from a donor e.g. a matched sibling or normal vol-

unteer (matched unrelated donor; MUD), in syngeneic SCT the donor is a

monozygotic (identical) twin. For autologous SCT the patient acts as

his/her own source of stem cells. Placental cord blood has become a

useful source of stem cells for paediatric transplants.

The aim of SCT is

1. To permit haemopoietic reconstitution after potentially curative but

myeloablative doses of chemotherapy or chemoradiotherapy (high

dose therapy; HDT) in the treatment of malignant disease.

2. To replace congenital or acquired life threatening abnormal BM or

immune function with a normal haematopoietic and immune system.

Stem cells may be obtained from bone marrow (BMT) by multiple aspira-

294

tions under general anaesthesia (BM harvest) or obtained from peripheral

blood after ‘mobilisation’ by G-CSF (± chemotherapy in the case of autol-

ogous SCT) and collection by apheresis (peripheral blood stem cell trans-

plants; PBSCT). Whether used fresh from donor harvest or thawed after

cryopreservation, stem cells are re-infused IV. PBSCT carries the advan-

tages of avoiding general anaesthesia for the donor and more rapid

engraftment (~7 days) but may be associated with a higher incidence of

chronic graft versus host disease (cGvHD). In the autologous setting not all

previously treated patients will mobilise adequate numbers of stem cells.

Stem cell collection for autologous SCT with curative intent in diseases

involving the bone marrow should be undertaken after a complete

response has been achieved by initial therapy. In some settings e.g.

myeloma where HDT is being used with the aim of disease control rather

than with curative intent, BM involvement up to 30% is often accepted.

Comparison of autologous and allogeneic SCT

Autologous

Allogeneic

Wide age range, generally ≤65

Age range generally ≤55

No need for donor search if BM clear

Sibs have ~1 in 4 chance of match

Not feasible if BM involved

May be used in patients with BM disease

Risk of tumour cell re-infusion

No tumour contamination of graft

Not all patients can be mobilised

Donor search may impose delay

No GvHD

GvHD mortality and morbidity

No immunosuppression

Graft-versus-leukaemia (GvL) effect

Low early treatment related mortality

Higher early treatment related mortality

(2-5%)

from GvHD and infection (20-40%)

Risk of long term MDS from BM injury

Less risk of late MDS

Transplantation

Patient receives high dose chemo-(±radio)therapy (conditioning) which

ablates the BM and immune system. After conditioning is completed, BM

or PBSC are infused IV. After a period of profound myelosuppression

(7-25d), engraftment occurs with production of WBCs, platelets and

RBCs. Immunosuppression is required after allogeneic transplantation to

prevent GvHD and graft rejection.

Early complications of the transplant procedure

Chemoradiotherapy

2 Nausea/vomiting.

2 Reversible alopecia.

2 Fatigue.

2 Dry skin.

2 Mucositis.

2 VOD* (p328).

Infection

295

2 Bacterial (Gram -ve and +ve).

2 Viral—HZV.

2 CMV (particularly pneumonitis)*.

2 Fungal—Candida, Aspergillus*, Mucor*.

2 Atypical organisms—Pneumocystis (PCP)*, Toxoplasma*, Mycoplasma*,

Legionella*.

*Low risk in autologous SCT; significant to high risk in allogeneic SCT

Graft-versus-host disease (GvHD)

May occur in recipients of allogeneic SCT due to tissue incompatibility

between donor and recipient undetected by standard tissue-typing tests.

Acute and chronic forms occur. Higher incidence of severe GvHD fol-

lowing unrelated donor SCT and mismatched (haploidentical) grafts.

Late complications of transplantation

2 Infertility (both sexes).

2 Hypothyroidism.

2 Secondary malignancy.

2 Late sepsis due to hyposplenism.

2 Cataracts (where TBI used).

2 Psychological disturbance.

Follow up and post-transplant surveillance

Life-long supervision required. The particular risks and monitoring

required depend on the type of graft and whether TBI was used. Suitable

conditioning regimens are outlined on p310.

Allogeneic stem cell transplantation

Patient selection

2 Recipients should be in good physical condition, and ≤55 years old.

2 Donor and recipient should be fully or closely HLA-matched to reduce

the risk of life threatening GvHD or graft rejection.

2 Greatest chance of full HLA match is with siblings (small chance of full

match with cousins); each sib has ~1:4 chance of full HLA-match.

2 Matched-volunteer unrelated donor (MUD) may be sought from

donor registries e.g. in UK The National Blood Authority and Anthony

Nolan panels.

2 Haploidentical sibling may considered as a donor for patients in whom

no matched sibling or volunteer donor is available (~40%) and the

increased risks of the procedure are acceptable (e.g. poor risk adult

AML, Ph-positive adult ALL).

Indications for allogeneic SCT

2 Adult AML (poor risk first CR or any second CR)¹.

2 Adult ALL (poor risk first CR or any second CR)².

2 Severe aplastic anaemia.

2 Chronic myeloid leukaemia.

296

2 Myelodysplasia.

2 Multiple myeloma (stage II/III).

2 Primary immunodeficiency syndromes.

2 Thalassaemia major.

2 Sickle cell disease.

2 Inborn errors of metabolism.

2 Relapsed aggressive histology NHL.

2 Relapsed Hodgkin’s lymphoma.

1. Good risk adult AML should not receive SCT in first remission as out-

comes are good for most patients with standard treatment (p156)

2. Most children with ALL will be cured by standard chemotherapy

alone—transplantation is reserved for those who relapse. (p475)

Outline of allogeneic SCT procedure

2 Patient receives standard conditioning therapy with high dose

chemoradiotherapy (e.g. cyclophosphamide (CTX) 120mg/kg + 14Gy

fractionated total body irradiation (TBI)) or chemotherapy (e.g.

cyclophosphamide 120mg/kg + busulfan 16mg/kg).

2 Non-myeloablative conditioning regimens use moderate doses of

chemotherapy and immunosuppression to achieve engraftment and

have a lower transplant-related mortality and morbidity; utilised to

increase age range for allogeneic SCT and permit the use of adoptive

immunotherapy with donor lymphocyte infusion (DLI) for residual

disease post-transplant.

2 In patients receiving MUD or haploidentical SCT, Campath-1H

(humanised anti-CD52 monoclonal antibody) is often administered

daily for 5d prior to conditioning as an immunosuppressant to 5 the

risk of graft rejection.

2 For patients with aplastic anaemia less intensive conditioning is used

(200mg/kg CTX combined with anti-thymocyte globulin) and because

Transplantation

of sensitivity to alkylating agents in Fanconi’s anaemia still less intensive

conditioning is used.

2 One day after completing conditioning treatment, BM or PBSC are

harvested from donor and infused IV through a central line.

2 In MUD and haploidentical SCT the graft is usually depleted of T lym-

phocytes prior to infusion to reduce the risk of severe GvHD.

2 After 7-21d of severe myelosuppression, haematopoietic engraftment

occurs.

2 Reverse barrier nursing in a filtered air environment, prophylactic anti-

infectives (ciprofloxacin, itraconazole, acyclovir) reduce the risk of

infective complications.

2 Immunosuppression is required to prevent GvHD and graft rejection;

generally methotrexate (in the early engraftment phase) + cyclosporin

A (for 6 months).

Mechanism of cure: evidence for graft versus leukaemia (GvL)

effect

297

1. Reduced risk of relapse in patients with acute and chronic GvHD.

2. Increased risk of relapse after syngeneic SCT (no GvHD).

3. Increased risk of relapse after T-lymphocyte-depleted SCT.

4. Delayed clearance of minimal residual disease detected post-SCT.

5. Induction of remission by donor lymphocyte infusion

(DLI) after

relapse post-SCT.

Early complications of allogeneic SCT

2 Overall transplant related mortality for matched sibling allografts is

15-30%, for volunteer unrelated donors may reach 45%.

2 Infection: severe myelosuppression together with immune dysfunction

from delayed reconstitution or GvHD predisposes to a wide variety of

potentially fatal infections with bacterial (Gram +ve and -ve), viral,

fungal and atypical organisms. Both HSV and HZV infections are

common—may present with fulminant extensive lesions. Main causes

of infective death post-transplant are: CMV pneumonitis and invasive

fungal infections with moulds e.g. Aspergillus.

2 Graft versus host disease (GvHD): Acute GvHD occurs ≤100d of

transplant and chronic >100d. (p324-327)

2 Other complications:

- Endocrine infertility (both sexes), early menopause and occasionally

hypothyroidism.

- Cataract (TBI induced) >12 months post-transplant.

- 2° malignancies (esp. skin).

- EBV associated lymphoma.

- Mild psychological disturbances common (serious psychoses rare).

Follow-up treatment and post-transplant surveillance

Immunosuppression requires careful monitoring to avoid toxicity. Unlike

solid organ transplant recipients, lifelong immunosuppression not

required and cyclosporin is usually discontinued at about 6 months post-

transplant. Prophylaxis against pneumococcal sepsis secondary to hypos-

plenism, HZV reactivation and PCP infections required. Despite these

complications, most patients return to an active, working life without the

need for continuing medication.

Future developments

Molecular HLA gene loci mapping: improved DNA characterisation of

HLA gene loci should permit greater applicability and success of

transplants from volunteer unrelated donors.

Umbilical cord blood transplants: umbilical cord blood donation post-

delivery shown to be safe for mother and child. Cord blood stem cells are

immunologically immature and may be more permissive of HLA

donor/recipient mismatches with less risk of GvHD. Successful grafts in

children; cell dose insufficient for adult grafts.

298

Autologous stem cell transplantation

Patient selection

Patients should good physical condition; age range for some procedures

can be extended up to ~70. BM should be uninvolved or in CR at the

time of harvest/mobilisation unless disease control rather than cure is the

primary intent cf. myeloma.

Accepted indications

2 Relapsed aggressive and very aggressive NHL.

2 Relapsed Hodgkin’s lymphoma.

2 Adult AML (poor risk first CR without allogeneic option or second CR

without allogeneic option).

2 Adult ALL (poor risk first CR without allogeneic option or second CR

without allogeneic option).

2 Multiple myeloma (stage II/III).

2 AL amyloid.

Possible indications

2 Sclerosing mediastinal B-cell NHL in 1st CR.

300

2 Patients with aggressive or very aggressive NHL with 2 of: stage III/IV,

high LDH, ECOG performance status 3 or 4, bulk disease (mass

>10cm).

2 Indolent NHL (aged ≤60) relapsing after 2nd line therapy if still

responsive to therapy.

2 Relapsed germ cell tumours.

2 Ewing’s sarcoma.

2 Neuroblastoma.

2 Soft tissue sarcoma.

2 Autoimmune disease (multiple sclerosis, systemic sclerosis, rheumatoid

arthritis, juvenile chronic arthritis, SLE).

Outline of autologous SCT procedure

2 Haematopoietic stem cells harvested in CR are processed, frozen and

stored in liquid N₂.

2 SCT may take place within days of harvest or several years later after

treatment for recurrent disease.

2 Different conditioning chosen for underlying indication e.g. cyclophos-

phamide plus busulphan for AML or BEAM (p612) for NHL or HL.

2 After completion of conditioning (generally plus 24 hours to allow

clearance of chemotherapeutic agents), the stem cell product is

thawed rapidly and infused IV. Bags are thawed by transfer directly

from liquid N₂ into water at 37-43°C. Product is infused IV rapidly

through indwelling central line.

2 There is period of myelosuppression (7-25d) followed by WBC,

platelet and RBC engraftment.

Early complications of the transplant procedure

2 Overall transplant related mortality is 5-10%.

2 Morbidity from conditioning regimens e.g. nausea from chemoradio-

therapy and mucositis from the widespread mucosal damage to GIT:

Transplantation

oral ulceration, buccal desquamation, oesophagitis, gastritis, abdominal

pain and diarrhoea may all be features.

2 Spectrum of infective organisms seen is similar to allografts but

severity and mortality are 5.

Late complications of autologous SCT

2 Single commonest long-term complication is relapse of underlying

disease.

2 Other late complications similar to allografts, but less frequent and

less severe.

Follow-up treatment and post-transplant surveillance

2 Regular haematological follow-up is mandatory and psychological

support from the transplant team, family and friends is important for

readjustment to normal life.

2 Prophylaxis against specific infections required including Pneumococcus,

HZV and PCP. Most patients return to an active, working life without

301

continuing medication.

Investigations for BMT/PBSCT

Haematology

2 FBC, reticulocytes, ESR.

2 Serum B₁₂ and red cell folate, ferritin.

2 Blood group, antibody screen and DAT.

2 Coagulation screen, PT, APTT, fibrinogen.

2 BM aspirate for morphology (cytogenetics if relevant); BM trephine

biopsy.

Biochemistry

2 U&Es, LFTs.

2 Ca²⁺, phosphate, random glucose.

2 LDH.

2 TFTs.

2 Serum and urine Igs.

2 EDTA clearance.

Virology

2 Hepatitis BsAg.

302

2 Hepatitis C antibody.

2 HIV I and II antibody (counselling and consent required).

2 CMV IgG and IgM.

2 EBV, HSV and VZV IgG.

2 Parvovirus B19 titre (allografts only).

2 Toxoplasma titre (allografts only).

Immunology

2 Autoantibody screen.

2 HLA type—(if not known) in case HLA matched platelets are subse-

quently required.

2 HLA and platelet antibody screen (if previously poor increments to

platelet transfusions).

2 CRP.

Bacteriology

2 Baseline blood cultures (peripheral blood and Hickman line).

2 Routine admission swabs: throat, central line site.

2 MSU, stool cultures.

Cardiology

2 ECG.

2 Echocardiogram, to include measurement of systolic ejection fraction.

Respiratory

2 Lung function tests.

Radiology

2 CXR.

2 Sinus x-rays.

Cytogenetics

2 Blood for donor/recipient polymorphisms (allografts only).

Bone marrow harvesting

Pre-operative preparations

Important to give advanced notice so that theatre time can be booked if

necessary and the virological screening results obtained.

Within 30 days before the harvest procedure, arrange the following

virological investigations

1. Hepatitis B surface antigen.

2. Hepatitis C antibody.

3. HIV 1 and 2.

4. VDRL.

5. Spare serum stored.

Admit patient day before harvest. Clerk patient and arrange:

2 U&E.

2 FBC.

2 X match 2-3 units blood (CMV -ve). If harvest is on normal donor—

offer autologous blood collection to donor. If declined, arrange for

genotyped, CMV negative and irradiated X-matched blood to be avail-

able for the donor. A CXR and ECG may also be arranged, if felt clini-

304

cally appropriate.

Harvest procedure

1. Give heparin 50units/kg IV at anaesthetic induction.

2. Prepare harvest bag: adding ACD with a dilution factor of 1:10 for the

prospective marrow volume; i.e. 100mL of ACD if expected harvest is ~1L.

3. Heparinise aspirate needles/syringes (0.9% saline containing at least

100U heparin/mL).

4. Begin with posterior superior iliac crests, limiting the number of skin

entry points, the aspirate needle should be manoeuvred to collect as

much marrow as possible with 5-10mL maximum from each penetra-

tion of the bone. Each aspirate should be deposited in a sterile harvest

bag and syringe rinsed in the heparinised saline prior to re-use. Gently

agitate bag at intervals.

5. Midway through harvest (or 500mL) a bag sample should be sent for

FBC to determine the adequacy of the harvest. The final total WBC

count should be at least 2 x 10⁸ cells/kg of the recipient for autografts

and 3 x 10⁸ cells/kg for allografts.

Transplantation

The volume of marrow required may be calculated as follows:

Total volume required for autograft

= 2.0 x recipient weight (kg) ÷ (bag WBC x 10)

e.g. recip. 100kg and bag WBC 20 x10⁹/L then vol. required = (2.0 x100) ÷ (20 x10) = 1.0L

Volume still needed to be harvested = total volume - volume already taken at time

of count + ~10%

Notes

1. The extra 10% compensates for reduced harvesting efficiency and the ACD.

2. The formula works at whatever volume you choose to do the first WBC but is a more

accurate prediction at ~500mL.

3. If need to harvest >1L, remember to add additional ACD in the same 1 in 10 ratio.

305

4. For allograft calculations, substitute 3.0 for 2.0 in the formula.

If yield not adequate from the posterior iliac crests, other sites may be

considered (e.g. anterior superior iliac crests and sternum). Review punc-

ture sites the following morning for signs of local infection or continuing

bleeding. For normal donors, offer out-patient follow-up appointment as

additional safeguard and provide access to counselling services.

Peripheral blood stem cell

mobilisation and harvesting

Properties of stem cells

2 Stem cells are defined as the most primitive haemopoietic precursor

cell.

2 Unique property is capability of both infinite self-renewal and differen-

tiation to form all mature cells of the haemopoietic and immune

systems.

2 In the resting state almost all stem cells reside in the bone marrow

although a tiny minority circulate in peripheral blood.

2 Stem cells in marrow can migrate into the blood after treatment with

chemotherapy and/or haemopoietic growth factors.

2 Once circulating, they can easily be harvested using a cell separator

machine.

2 Stem cell levels in peripheral blood can be assessed by CD34 immuno-

phenotype analysis.

2 More than one day of apheresis may be necessary to achieve required

yield.

306

2 The yield can be assessed for engraftment potential.

Protocols

Mobilisation and harvesting protocols differ between diseases. The fol-

lowing illustrate the principal types of schedule:

1. Mobilisation after standard chemotherapy

2 No specific additional stimulus given.

2 Harvest times determined by WBC and platelet recovery, and CD34

count.

2 Yields variable. Improved by addition of G-CSF.

Suitable for

2 NHL post DHAP chemotherapy.

2 AML post ADE/DAT chemotherapy.

2 ALL post high dose methotrexate.

2. Mobilisation with chemotherapy and haemopoietic growth factors

The commonest schedule and the best evaluated. Harvest timing and

yields more predictable.

Typical protocol for NHL

Day 0 cyclophosphamide 1.5g/m² IVI with Mesna.

Day +4 to day + 10 G-CSF 5µg/kg/d SC continued until last day of har-

vesting.

Harvest ~day +10 when CD34 >10

¥ 10⁶/L and/or WBC >10

¥ 10⁹/L

Typical protocol for myeloma

Day 0 cyclophosphamide 4g/m² IVI with Mesna.

Day +1 to day +10 to14, G-CSF 5-10µg/kg/d SC.

Harvest day +10 to14 when CD34 > 10

¥ 10⁶/L and/or WBC >10

¥ 10⁹/L

Mobilisation with haemopoietic growth factor alone

Suitable for normal volunteers e.g. allograft donors.

Microbiological screening for stem cell

cryopreservation

Infective agents, particularly viruses, can be transmitted through stem cell

preparations as through blood products and may cause significant mor-

bidity and mortality in the recipient. It has been demonstrated that trans-

mission of hepatitis B virus has occurred following common storage in a

liquid nitrogen tank which contained one patient’s hepatitis BsAg +ve

bone marrow.

The following tests should be performed on all patients in

whom it is planned to cryopreserve stem cells

2 Hepatitis B surface antigen.

2 Hepatitis B surface antibody.

2 Hepatitis B core antigen.

2 Hepatitis B core antibody.

2 Hepatitis C antibody.

2 HIV 1 and 2 antibodies.

2 HIV 1 and 2 antigen.

2 HTLV1 antibody.

308

2 VDRL.

2 Additional serum for storage for retrospective analysis.

These results must be available to transplant laboratories before cryop-

reservation. Since many of these patients will be receiving blood products

as part of their on-going treatment, they must be performed within 30

days of cryopreservation to prevent false -ve antibody tests due to the

interval between exposure and seroconversion. In practice these con-

straints dictate that samples should be taken between 7 and 30 days prior

to cryopreservation.

Patient samples shown to be -ve for all the above infectious agents should

have stem cells stored in a dedicated liquid nitrogen freezer convention-

ally in the liquid phase.

Patient samples shown to be +ve for any of the above agents should be

double bagged and stored in a separate liquid nitrogen freezer in the

vapour phase (to reduce transmissibility). Data on all stem cell product

samples must be registered in a secure environment on a computerised

database with a logical inventory and retrieval system. No material should

be imported to the freezers unless a complete negative virological audit

storage trail can be demonstrated.

Stem cell transplant conditioning

regimens

Conditioning is the treatment the patient undergoes immediately prior to

a stem cell transplant. The purpose is to reduce the burden of residual

disease; in allogeneic transplant recipients, it also acts as an immunosup-

pressant to prevent rejection of the graft. There are many different proto-

cols using chemotherapy alone or in combination with total body

irradiation (TBI). Unrelated transplants require immunosuppression with

ALG or anti-T-cell monoclonal antibodies or total lymphoid Irradiation

(TLI).

Examples are

AML-allo and autografts

2 Cyclophosphamide 120mg/kg + 13.2Gy fractionated TBI

or Cyclophosphamide 120mg/kg + busulfan 16 mg/kg.

ALL-Allo and autografts

2 Cyclophosphamide 120mg/kg + 13.2Gy fractionated TBI

or Etoposide 60mg/kg + 14.4Gy fractionated TBI.

310

Non-myeloablative allografts

2 Campath-1H 100mg + fludarabine 150mg/m² + melphalan 140mg/m².

NHL-autografts

2 BEAM (BCNU, etoposide, ara-C and melphalan; p612).

Myeloma-autografts

2 High dose melphalan 200mg/m².

Infusion of cryopreserved stem cells

Equipment

1. Dewar containing stem cells in liquid N₂.

2. Water bath heated to 37°C-40°C.

3. Tongs.

4. Protective gloves.

5. Patient’s notes.

6. Trolley with: syringes, needles, ampoules of 0.9% saline, blood giving

sets, sterile dressing towels, chlorhexidine spray, bags of

500mL

N/Saline, sterile gloves.

Ensure the patient has had procedure and any possible side

effects explained.

Method

1. Write up the stem cell infusion on the blood product infusion chart.

2. 30 mins before re-infusion, ensure water bath is filled and heated to

37°C-40°C and give (chlorpheniramine) 10mg IV and paracetamol 1g

PO.

3. When ready to return the stem cells take the dewar and equipment

trolley to the patient’s bedside.

312

4. Check the patient’s vital signs.

5. Set up a standard blood giving set with microaggregate filter. Never

use additional filters. Prime with 500mL 0.9% saline, connect to the

patient and ensure good flow before starting to thaw any cells.

6. Check the water bath is 37°C-40°C and using the protective gloves

and large tongs remove a bag of cells from liquid nitrogen dewar and

place on the trolley. Carefully remove from the outer sleeve and place

in water bath and allow one minute. DMSO cryopreservative is very

toxic to cells once thawed so it is important to go straight from rapid

thaw to infusion.

7. Remove bag of cells from water bath using the tongs, spray with

chlorhexidine and allow to dry. Check patient identification number

and DOB with the patient and if correct then connect to the giving set.

8. Cells should be returned as quickly as possible. Each bag contains

approximately 100-150mL. Providing the flow is good, start thawing

the next bag. Only thaw the next bag if you are able to finish the pre-

vious bag within the next minute. Check the patient’s details on every

bag.

9. Check the patient’s observations at 15 minute intervals.

10.If the patient complains of abdominal pain, nausea or feeling faint, slow

down the IVI for a short time. If symptoms persist or patient develops

chest tightness or wheezing—stop the infusion. O₂ ± nebulised salbu-

tamol may be required. Anaphylaxis rarely occurs.

11.At the end of re-infusion ensure no more bags of stem cells in the

dewar and clear away all equipment.

12.Write the infusion details in the patient’s notes in red ink.

Special considerations

iIf the bag splits/leaks do not re-infuse—contents will not be sterile. Very

rarely, a bag could start to expand rapidly upon thawing if all air not

removed from the bag before freezing. A sterile needle may be used to

pierce the bag if release of pressure appears essential.

Infusion of fresh non-cryopreserved

stem cells

Explain procedure and side effects to patient. In general, bone marrow will

be in a larger volume than an apheresis product.

Procedure

1. A medical staff member must be available to start the infusion and stay

with the patient for the first 30 minutes.

2. Prime blood giving set without an in-line filter with 500mL 0.9% saline

and connect to the patient—check there is a good flow.

3. Check BP, pulse and chest auscultation before the infusion.

4. Give paracetamol 1g PO and chlorpheniramine 10mg IV at beginning of

infusion.

5. Give stem cells as slowly as possible for the first 15 minutes, then

increase the rate to 100mL in 60 minutes. If after 2h the patient is toler-

ating infusion without problems, increase to 200mL/h until completion.

6. Watch for fluid overload—give diuretic if necessary.

7. Nursing staff should monitor BP and pulse every 15-30 mins.

8. Write infusion details in the patient’s notes in red ink.

314

Complications of stem cell infusion

2 Microemboli occasionally cause dyspnoea and cyanosis. O₂ should be

available. Slow down or stop the stem cell infusion if dyspnoea.

2 Pyrexia, rash and rigors can occur—treat with hydrocortisone 100mg

IV and chlorpheniramine 10mg IV.

2 Hypertension may occur (especially if patient fluid overloaded). Usually

responds to diuretic.

ii Acute anaphylaxis is very rare but adrenalin (1mL of 1:1000 ) should

be available in the patient’s room for SC or IM administration.

Daily ward management

Each day check patient for

2 Fever.

2 Nausea and vomiting.

2 Diarrhoea.

2 Bleeding.

2 Rashes.

2 Fatigue.

2 Dyspnoea.

2 Pain.

2 Weight loss.

2 Jaundice.

2 Mucositis.

2 Skin surveillance needed to observe for signs of acute and chronic

GvHD, HSV, HZV and drug related problems.

2 Hickman line infections are common post-transplant. If any signs of

infection and fever, line cultures and exit site swab should be taken.

Remove line as soon as infusional support no longer needed.

Blood product support for stem cell

transplantation

All cellular blood products, i.e. red cells and platelets, must be irradiated.

Irradiation

2 All cellular blood products given to allogeneic and autologous SCT

patients must be irradiated to prevent transfusion associated GvHD

due to transfused T lymphocytes.

2 Transfusion associated GvHD is usually fatal particularly in allografts.

2 Fatality can sometimes be avoided by immediate administration of anti-

lymphocyte globulin or Campath antibody.

2 Irradiation protocol is standard 2500cGy.

2 Commence blood product irradiation two weeks prior to allogeneic

SCT until one year post-SCT or off all immunosuppression whichever

is later.

2 Commence blood product irradiation two weeks prior to autologous

SCT until six months post-SCT.

2 Cell-free blood products e.g. FFP, cryoprecipitate or albumin do not

need to be irradiated.

316

2 Marrow or blood stem cell transplant itself is never irradiated.

CMV status of blood products

2 CMV is not destroyed by irradiation.

2 All transplant recipients should ideally receive CMV -ve red cells and

platelet transfusions regardless of their own CMV status if sufficient

CMV -ve blood products available. This is because of good evidence

that transfused CMV carried in donor white cells may cause disease

post-transplant regardless of the CMV status of the patient. CMV -ve

recipients must always have -ve products.

2 Should CMV negative platelets not be available at any time, it is

acceptable to use unscreened leucodepleted red cells or platelets. This

is because CMV is carried predominantly in leucocytes.

2 For allograft recipients, additional preventive measures are taken

against CMV reactivation (see p334).

Indications for RBC and platelet transfusions

Identical to those for patients undergoing intensive chemotherapy (see,

pp546-650).

Management of ABO incompatibility

ABO incompatibility between donor and recipient does not affect the

long-term success of the transplant nor the incidence of graft failure or

GvHD. However, major ABO incompatibility transfusion reactions will

occur unless specific steps are taken to manipulate the graft where donor

and recipient are ABO mismatched. Furthermore, additional care must be

given post-transplant in providing appropriate ABO matched products.

ABO mismatched definitions

1. Major ABO mismatch. This is where the recipient has anti-A or anti-B

antibody to donor ABO antigens e.g. group O recipients with group A

donor.

Transplantation

2. Minor ABO mismatch. This is where the donor has antibodies to recip-

ient ABO antigens e.g. group A recipient with group O donor.

Management of major ABO mismatch

Manipulation of donor marrow/stem cells: red cells are removed in the

transplant laboratory by starch sedimentation or Ficoll centrifugation,

prior to infusion of the graft.

Choice of red cell and platelet supportive transfusions

2 Transfuse packed group O red cells only for all major mismatch

donor-recipient pairs.

2 The choice of platelet group is less critical and may be affected by

availability. First, second and third choice groups for platelet transfu-

sions are shown in the table below.

Management of minor ABO mismatch

Manipulation of donor stem cells: prior to infusion, the product will have

317

been plasma reduced in the transplant laboratory by centrifugation to

remove antibody that could be passively transferred. Delayed immune

haemolysis, which may be severe and intravascular, can occur after minor

ABO mismatch due to active production of antibody by engrafting donor

lymphocytes. Maximum haemolysis occurs 9-16 days post-transplant.

Choice of red cell and platelet transfusions

2 Always transfuse packed O red cells, i.e. the same as in major ABO

mismatch.

2 Platelet transfusions first, second and third choice group is shown in

the table below.

Choice of ABO group of blood/platelets in ABO mismatch BMT

Platelets

Donor

Recipient

Red cells

1st choice

2nd choice

3rd choice

Major ABO

mismatch

Minor ABO

mismatch

(*Risk of haemolysis but do not withhold)

Rhesus (D) mismatch

Anti-D is not a naturally occurring antibody but may be induced by sensi-

tisation with D +ve cells through pregnancy or previous incompatible

transfusion. Important to screen both recipient and donor serum for the

presence of anti-D.

2 When either donor or recipient serum contains anti-D, rhesus D -ve

blood products should always be given post-transplant. Note: in the sit-

uation where a rhesus D +ve recipient receives a graft from a donor

whose serum contains anti-D, immune haemolysis may occur despite

plasma reduction of the donor marrow due to active production of

donor lymphocyte derived anti-D. Cannot be prevented but is rarely

severe.

2 Provided neither donor nor recipient have anti-D in the serum, specific

pre-transplant manipulation of the product is only required in the situ-

ation of rhesus D +ve donor going into rhesus D -ve recipient where

red cell depletion is required pre-transplant.

2 It will occasionally be necessary to give rhesus D +ve platelet support

when rhesus D -ve is preferable simply due to lack of abundant avail-

ability of rhesus -ve platelet products.

2 If rhesus D +ve platelets have to be given, give anti-D 250iu SC imme-

diately post-transfusion.

318

GvHD prophylaxis

In vitro T-cell depletion of graft or in vivo T-cell depletion with Campath-

1H or anti-lymphocyte globulin (ALG) are successful in reducing both the

incidence and severity of GvHD in graft recipients. The former is associ-

ated with an increased risk of relapse. Both are used in MUD and hap-

loidentical grafts where the risk of severe GvHD is increased. The ‘Seattle

protocol’ is most commonly used post graft infusion: consists of a combi-

nation of stat pulses of IV methotrexate (MTX) with bd infusions of

cyclosporin:

Methotrexate MTX (IV bolus) 15mg/m² on day +1, then 10mg/m² days

+3, +6 and +11. Folinic acid rescue 15mg/m² IV tds may be given 24 hours

after each MTX injection for 24 hours (rescue protocol designed to

reduce mucositis).

Dosage reductions

2 If renal/hepatic impairment 5 MTX dose as follows:

Creatinine (µmol/L) MTX dose (%)

<145

100

320

146-165

166-180

>180

omit dose

Bilirubin (µmol/L) MTX dose (%)

<35

100

36-50

51-85

>85

omit dose

Side effects although reduced by folinic acid rescue mucositis may remain

severe and require IV diamorphine.

Cyclosporin administration

Powerful immunosuppressant with profound effects on T-cell suppressor

function. Available for IV and oral use.

Intravenous regimen—commence on day -1 at 1.5mg/kg IV bd as IVI in

100mL 0.9% saline/2h. If flushing, nausea or pronounced tremor, slow

infusion rate 4-6h/dose. Following loading, on day +3 onwards, adjust

cyclosporin dosage based on plasma cyclosporin A level together with

renal and hepatic function.

Oral regimen—switch intravenous7oral when patient can tolerate oral

medication and is eating (usually day +10 to +20). Dosage on conversion

is ~1.5-2.0

¥ IV dose (still bd).

Monitoring cyclosporin levels

2 Cyclosporin is toxic and renal impairment is the most frequent dose

limiting toxicity.

2 Cyclosporin A levels should be monitored at least twice weekly.

2 Never take blood for cyclosporin A levels from the central catheter

through which cyclosporin has been given as cyclosporin adheres to

Transplantation

plastic and falsely high levels will be obtained. One lumen should be

marked for cyclosporin administration and another lumen marked for

blood levels testing.

2 12h pre-dose trough whole blood levels are measured.

Instruct patient to delay the morning dose of cyclosporin until after the

blood level has been taken. The optimum blood cyclosporin level is not

known. Target range: 100-300ng/mL. Aim towards the top of the thera-

peutic range in the early post-transplant period and lower part of the

range at other times. In practice, the dose is often limited by a rise in

serum creatinine. If serum creatinine >130µmol/L—adjust dose. Do not

give cyclosporin if serum creatinine >180µmol/L.

Dosage adjustment—cyclosporin has a very long t1⁄so dosage adjustment

similar to warfarin adjustment.

1. To 5 cyclosporin level omit 1-2 doses and make a 25-50% reduction

321

in ongoing maintenance dose, recheck levels at 48h.

2. To 4 levels, give 1 additional dose, increase maintenance dose by

25-50%, recheck level in 48h.

3. Monitor renal function and LFTs daily. Check serum calcium and mag-

nesium twice weekly.

Cyclosporin toxicity

2 Nephrotoxicity (see above). Worse with concurrent use of aminoglyco-

sides, vancomycin and amphotericin.

2 Hypertension—often associated with fluid retention and potentiated

by steroids. Treat initially with diuretic to baseline weight and then

nifedipine if persists. Sub-lingual nifedipine useful where emergency

reduction of blood pressure is required.

2 Neurological syndromes, esp. grand mal seizures (usually if untreated

hypertension/fluid retention).

2 Anorexia, nausea, vomiting, tremor (almost always occurs—if severe

suggests overdosage).

2 Hirsutism and gum hypertrophy with prolonged usage.

2 Hepatotoxicity—less common than nephrotoxicity. Usually intrahep-

atic cholestatic picture on LFTs. Potentiated by concurrent drug

administration e.g. macrolide antibiotics, norethisterone and the azole

antifungals.

2 Hypomagnesaemia commonly occurs. Potentiated by combination with

amphotericin. Give 20mmol IVI if levels <0.5µmol/L or if symptoms

develop.

Note: only one orally absorbed preparation of magnesium. For hypomag-

nesaemia persisting on cyclosporin post-discharge, consider magnesium

glycerophosphate tablets qds.

Cyclosporin drug interactions

There are substantial and important drug interactions with cyclosporin:

Drugs that 4 cyclosporin A levels

Drugs that 5 cyclosporin levels

Azole antifungals

Rifampicin 7 major effect

Digoxin

Phenytoin 7 major effect

Macrolide antibiotics, especially

Sulphonamides

erythromycin

Carbamazepine

Imipenem/meropenem

Calcium channel blockers

Oral contraceptives

Drugs WORSENING cyclosporin nephrotoxicity

2 Aminoglycosides.

2 Amphotericin B.

2 Ciprofloxacin.

2 Cotrimoxazole.

2 ACE inhibitors.

322

Note: This is not an exhaustive list. Check cyclosporin levels 48h after any

drug addition or cessation.

Tacrolimus

2 Calcineurin inhibitor that prevents early T-cell activation; mechanism

of action, pharmacology, drug interactions and toxicity similar to

cyclosporin.

2 Superior to cyclosporin in three randomised trials when used in com-

bination with methotrexate as GvHD prophylaxis.

2 Dosage: 0.03mg/kg/day by continuous IV infusion from day -2; taper

20% every 2 weeks from day 180; monitor blood level and toxicities

and modify dose accordingly; used with standard dose MTX or mini-

MTX (5mg/m² IV days +1, +3, +6 and +11).

Acute GvHD

Risk factors for acute GvHD include: older recipients, older donors, male

recipient of female SCT

risk with previous donor pregnancies),

matched unrelated donors, haploidentical sibling donor. Defined as GvHD

occurring within first 100d post-transplant (usually starts between day 7

and 28 post-transplant). Ranges from mild self-limiting condition to exten-

sive disease (may be fatal). Characterised by fever, rash, abnormal LFTs,

diarrhoea, suppression of engraftment and viral reactivation, particularly

CMV.

Classified according to the Seattle system by a staging for each organ

involved (skin, liver, gut) and overall clinical grading based on the organ

staging.

Skin—involved in

>90% cases. May be mild and unremarkable

maculopapular rash (esp. palms of hands and soles of feet, but can affect

any part of the body). In more severe cases, erythroderma and extensive

desquamation and exfoliation can occur.

Liver—typical pattern of LFT abnormalities is intrahepatic cholestasis with

4 bilirubin and alkaline phosphatase (relative sparing of transaminases).

324

Note: this picture often does not discriminate between other causes of

post-transplant liver dysfunction (e.g. drugs, infection - particularly CMV

and fungal).

Gut—may occasionally be only organ involved, with nausea, vomiting,

diarrhoea. Stool appearance may be highly abnormal with mincemeat or

redcurrant jelly stools or green coloration.

Diagnosis

2 Perform skin biopsy—but do not delay treatment if strong clinical sus-

picion.

2 Rectal biopsy may be helpful (to distinguish infective from pseudo-

membranous colitis) but beware risk of bleeding and bacteraemia—

perform only if it will alter management.

2 Where GI symptoms are predominantly upper GI, gastroscopy with

oesophageal, gastric and duodenal biopsies may be helpful (e.g. to dis-

tinguish between CMV and fungal oesophagitis and gastritis). Liver

biopsy is hazardous and should only be performed where other con-

vincing diagnostic guides are not available. It should be performed only

by the transjugular route by an experienced operator and covered

appropriately with blood products.

Transplantation

Consensus criteria for grading acute GvHD

Stage Skin

Liver

Gut

Rash <25% body

Bilirubin 35-50µmol/L

Diarrhoea >0.5L/d or

persistent nausea

Rash 25-50% body

Bilirubin 51-100µmol/L

Diarrhoea 1-1.5L/d

Rash >50% body

Bilirubin 101-250µmol/L Diarrhoea >1.5L/d

Generalised erythroderma Bilirubin >250µmol/L

Severe abdominal

with bullae

pain ± ileus

Overall clinical grading for the patient

Grade

Stage 1-2

None

Stage 3

Stage 1

III

Stage 2-3

Stage 2-4

Stage 4

325

Treatment

General measures—good nutrition and weight maintenance important.

TPN may be necessary. IV antibiotics and antifungals often necessary in

the absence of neutropenia and signs of infection may be masked by

steroids. Continue cyclosporin during acute GvHD ensuring levels are not

toxic.

Specific treatment should always be discussed with an experienced

haemato-oncologist. Now known that mild GvHD confers a GvL effect

(see p297) in the patient and mild forms of skin GvHD may require no

treatment.

Overall grade

I-II

Begin with prednisolone 1-2mg/kg/d PO. If response, taper dose

slowly. If no response, consider progressing to high dose methyl

prednisolone.

II-IV Give high dose methylprednisolone 20mg/kg/over 1h bd IV for

48h, then 5 dose by 50% every 48h.

Side effects of methylprednisolone

2 Gastritis/peptic ulceration—use proton pump inhibitors rather than H₂

blockers.

2 Hyperglycaemia, particularly when TPN in use. May require insulin

infusion.

2 Hypertension may be potentiated by cyclosporin and by fluid reten-

tion—treat with diuretics and nifedipine.

2 Insomnia and psychosis.

Failure of response to high dose methylprednisolone

Discuss with senior colleague. Outlook poor. Various empirical possibili-

ties include tacrolimus, infusion of Campath or ALG.

Chronic GvHD

Occurs between 100-300d post-allogeneic transplant. There may not

have been preceding acute GvHD, and acute GvHD may have resolved

prior to onset of chronic GvHD. Conventionally subdivided into limited

or extensive chronic GvHD. Major clinical features are debility, weight

loss with malabsorption, sclerodermatous reaction due to excessive col-

lagen deposition, severe immunosuppression and features of autoimmune

disease.

Limited chronic GvHD: clinical features

2 Localised skin involvement <50% total surface.

2 Hepatic dysfunction—portal lesions but lacking necrosis, aggressive

hepatitis or cirrhosis.

2 Other localised involvement of eyes, salivary glands and mouth.

Extensive chronic GvHD—clinical features

2 Generalised skin involvement >50% of surface—may include sclero-

dermatous changes and ulceration.

2 Abnormal liver function—histology shows centrilobular changes,

chronic aggressive hepatitis, bridging necrosis or cirrhosis.

326

2 Liver dysfunction ± localised skin GvHD with involvement of eyes, sali-

vary glands or oral mucosa on labial biopsy.

2 Involvement of any other major organ system.

Criteria for classification of chronic GvHD

Classification

Criteria

Subclinical

Histological evidence on screening biopsies

without clinical signs or symptoms.

Limited

Localised skin or single organ involvement not

requiring systemic therapy.

Extensive low risk

Platelet count >100

¥ 10⁹/L and extensive skin

disease or other organ involvement requiring

systemic therapy.

Extensive high risk

Platelet count <100

¥ 10⁹/L and extensive skin

disease or other organ involvement requiring

systemic therapy.

Prognostic factors

Thrombocytopenia is an adverse prognostic factor for survival from diag-

nosis of chronic GvHD. Other factors associated with poor outcome are

progressive onset, lichenoid skin rash, elevated bilirubin, poor perfor-

mance status, alternative donor and sex mismatched donor.

Treatment

Discuss with a senior member of transplant team.

General measures

1. Adequate nutrition, vitamin/calorie supplements may be required and

severe cases may require TPN.

2. Pneumococcal prophylaxis must be continued lifelong.

Transplantation

3. Consider restarting conventional prophylactic antifungal and antibacte-

rial agents.

4. CMV surveillance is critical (reactivation is more common).

5. P carinii prophylaxis must be commenced with cotrimoxazole or nebu-

lised Pentamidine and continued for 6 months after immunosuppres-

sive therapy.

6. Psychological support may be required to adjust to chronic disability.

Specific treatment

1. Commonest protocol used is the Seattle regimen of prednisolone and

cyclosporin A on alternate days; typically: begin daily prednisolone

1mg/kg/day with cyclosporin A 10mg/kg/day divided bd.

2. If disease stable or improved after 2 weeks taper prednisolone by 25%

per week to target dose of 1mg/kg every other day.

3. After successful completion of steroid taper, reduce cyclosporin A by

25% per week to alternate day dosage of 10mg/kg/day divided bd.

4. If resolved completely at 9 months, slowly wean patient from both

medications with dose reductions every 2 weeks.

327

5. Incomplete responses should be re-evaluated after 3 months more

therapy; if fail to respond or progress then salvage therapy required.

6. If no response or progression add in azathioprine 1.5mg/kg/d initially

(monitor FBC, renal and liver function).

7. Severe refractory cases may respond to thalidomide, tacrolimus,

hydroxychloroquine or mycophenolate mofetil (all of which may at

least have a steroid sparing effect) or experimental measures such as

extracorporeal PUVA therapy or anti-lymphocyte globulin.

Veno-occlusive disease

Presents clinically early post-transplant

(usually within the first

14d).

Pathophysiology poorly understood. Risk factors for severe VOD include:

intensive conditioning regimens, pre-transplant hepatitis and second trans-

plants. VOD is characterised by a triad of hepatomegaly, jaundice and

ascites (resulting in rapid post-transplant weight gain) as a result of this.

Commoner in allografts than autografts.

Diagnosis is largely clinical but may be supported by typical findings on

Doppler ultrasound study of hepatic arterial and venous flows, or by ele-

vated plasminogen activator inhibitor (PAI 1) levels. However, the only

definitive diagnostic investigation is transjugular liver biopsy, the risks of

which must be weighed against the importance of the information

obtained.

There is no treatment currently universally accepted as effective prophy-

laxis.

Strategies include

2 Heparin 100u/kg/d by continuous IVI.

2 LMWH SC od or a prostaglandin E1 (PGE1) infusion.

328

No universally accepted effective treatment. The key is supportive therapy

with management of fluid overload with spironolactone and frusemide

while maintaining intravascular volume with albumin or plasma substitute.

In severe VOD, infusion of TPA or PGE1 may be considered.

If thrombolysis required

2 Ensure no active bleeding is occurring and keep platelets >20 x10⁹/L.

2 Give tissue-type plasminogen activator (Altaplase™).

- 10mg IV into central line over 30 minutes

- Then 40mg as IVI over next 60 minutes

i.e. total dose of 50mg over 90 minutes

(5 doses proportionally for patients weighing <than 60kg).

2 Give daily for 3 days minimum and assess against VOD parameters.

Invasive fungal infections and

antifungal therapy

Invasive fungal infections are an important cause of morbidity and mor-

tality after allogeneic SCT with a frequency of 10-25% and mortality of

>70%.

Pathogenesis

2 Majority of infections are due to Candida species and Aspergillus species

though infections due to other opportunistic fungi increasing

(Trichosporon spp., Fusarium spp., Bipolaris spp. and Zygomycetes amongst

others.

2 Invasive Candida infections classified as candidaemia or acute dissemi-

nated candidiasis and arise from invasion of bloodstream from infected

mucosal surfaces or via central venous catheters; decreasing incidence

due to introduction of fluconazole prophylaxis though increased non-

albicans spp. (esp. glabrata and krusei).

2 Invasive Aspergillus infections affect paranasal sinuses and lungs and

arise from airborne exposure; increasing incidence, particularly late

after transplantation.

330

2 Risk factors: prolonged and profound neutropenia; use of corticos-

teroids.

Prophylaxis

2 Prophylaxis: high efficiency (>90%) particulate air (HEPA) filtration or

positive pressure ventilation; prophylaxis with fluconazole (400mg/day

does not cover Aspergillus spp., C glabrata or C krusei) or itraconazole

(200-400mg/day; poor absorption from capsules; extremely unpalat-

able liquid preparation).

Amphotericin

2 If a febrile neutropenic transplant patient is unresponsive to second

line antibiotics after 48-96h and/or there is a suspicion of possible

fungal infection (unwell; chest symptoms; peripheral nodules, halo sign

or cavitation on CT chest, evidence of candidaemia), then standard

formulation of amphotericin (Fungisone™) should be started.

2 Give test dose of 1mg IV over 30 mins with observation of the patient

for abreaction for 30 mins followed by 1mg/kg daily.

2 Daily urea and electrolytes are recommended and amiloride 5mg

(increasing to 10mg if required) should be prescribed to counteract

the frequently accompanying hypokalaemia. Oral K⁺ supplements often

required. Serum Mg²⁺ and LFTs should be checked twice weekly.

2 All doses of amphotericin should be preceded by a 0.9% saline

preload. 500mL 0.9% saline should be infused as fast as tolerated

(usually over 1h)—reduces nephrotoxicity and side effects.

Paracetamol 1g PO should be given 30 minutes prior to infusion

together with chlorpheniramine 10mg IV. Pethidine 25-30mg IV stat

may be given if a troublesome reaction occurs.

Liposomal amphotericin

Suggested indications for prescribing a liposomal or other lipid formula-

tion of amphotericin.

1. Refractory fever >72h on standard amphotericin at 1mg/kg.

Transplantation

2. A rise in the creatinine to >50% baseline levels with standard ampho-

tericin despite optimal hydration.

3. Deteriorating LFTs.

4. Evidence of severe disseminated fungal infection-ie multiple lesions on

CXR or CT scan, or any two sites of sinuses, lung, liver, spleen or

brain.

5. Patients receiving cyclosporin after an allograft. These patients should

receive lipid formulation product if baseline creatinine is >130µmol/L.

Otherwise, the indication for lipid formulation product is as in 1-4

above.

Lipid formulation amphotericin products

2 lipid formulations of amphotericin in extensive use—both expensive.

No comparative trial of the 2 products but efficacy data appear similar. An

appropriate protocol is suggested:

Commence either liposomal amphotericin

(AmBisome™) at

1-5mg/kg/day or amphotericin B lipid complex (Abelcet™) at 2.5mg/kg

331

(in practice round up or down to standard vial size to avoid wastage and

minimize cost). Follow data sheet instructions carefully, observing for ana-

phylaxis. The dosage should be increased to a maximum of 5mg/kg

Abelcet™ or 3-5mg/kg AmBisome™ in patients who have either a con-

firmed mycological diagnosis or a fever which does not respond within

72h on the lower dose.

Paracetamol and chlorpheniramine pre-medication cover is advised for

Abelcet™ (may also be required for AmBisome™). 0.9% saline preload is

not normally required unless renal or liver function deteriorate during

treatment. Renal function should be checked on alternate days for the

duration of the treatment. Serum Mg²⁺ and LFTs should be checked

weekly.

Total duration of treatment difficult to asses. General principles are that

therapy should continue for at least 2 weeks and until neutrophil recovery

and no signs of progression radiologically.

Voriconazole

A second-generation triazole that has been shown to be superior to

amphotericin in antifungal efficiency and survival in an international ran-

domised trial and likely to become treatment of choice for invasive

aspergillosis due to more favourable toxicity profile. Dose 6mg/kg IV bd

day 1 then 4mg/kg IV bd maintenance converting to oral 200mg bd (may

commence orally with 400mg bd loading dose on day 1). No dose adjust-

ment required for renal or acute hepatic impairment but monitor renal

and hepatic function. Side effects: visual disturbances, rash, elevated LFTs

and with IV administration, flushing, fever, tachycardia and dyspnoea.

Caspofungin

An echinocandin which targets the fungal cell wall and is active against

Candida and Aspergillus spp. Higher response rate demonstrated in com-

parison to amphotericin in treatment of invasive candidiasis. Loading dose

CMV prophylaxis and treatment

All transplant recipients who are CMV sero-negative should receive CMV

-ve blood products. If supplies are available, this is recommended also for

CMV sero-positive recipients. Limits risk of CMV blood product transmis-

sion regardless of donor/recipient serological status.

CMV surveillance

2 All allograft patients and CMV sero-positive autograft recipients should

receive CMV surveillance.

2 The minimum surveillance required is the DEAFF (detection of early

antigen fluorescent foci) test. Should detect CMV antigen in culture by

immunofluorescence within 48 hours and virus culture continues for

1-2 weeks. Urine and throat washings are not sent routinely for CMV

detection.

2 5 ml EDTA blood should be sent weekly on the above cohort of trans-

plant patients from admission until day 100. Screening of allograft

recipients should continue until 1 year post-transplant although the

frequency of testing may be reduced in the absence of appropriate

symptoms.

2 More sensitive tests now available to detect CMV antigen or genome

334

by PCR technology in buffy coat of EDTA peripheral blood will soon

replace DEAFF as standard tests.

CMV prophylaxis

Indicated in allograft patients when either donor or recipient are CMV

sero-positive. Not recommended when both donor and recipient are

sero-negative, nor for autograft recipients, even if sero-positive.

Suggested protocol

1. Acyclovir 800mg tds IV from day -5 to discharge, then 800mg tds PO

for 3 months plus

2. IVIg 200mg/kg IV day -1, day +13 and then every 3 weeks until day

+100.

Note: The graft suppression of this dose of acyclovir may sometimes be

dose limiting.

Treatment of CMV infection

A +ve CMV identification in buffy coat by either surveillance method

should be treated even if the patient is asymptomatic:

2 Gancyclovir: 5 mg/kg IV bd for 14 days minimum then continue main-

tenance dose 5mg/kg/day IV daily (6mg/kg/day 5 days weekly as outpa-

tient).

2 Stop acyclovir when gancyclovir commenced.

2 Side effects: myelosuppressive, may be abrogated by G-CSF, nephro-

toxic.

2 Renal function must be monitored and dose reductions implemented

according to the BNF.

2 Abnormal LFTs may occur.

2 Fever, rashes and headaches.

2 Alternative—foscarnet 90 mg/kg IV bd for 14d minimum.

2 Administer through a central line as IVI over 2 hours (may be given as

a peripheral IVI but should be given concurrently with a fast running

Transplantation

litre of 0.9% saline). Side effects-nephrotoxic and hepatotoxic (follow

BNF dosage adjustments).

Treatment plan

On a first episode of CMV antigenaemia, start with gancyclovir. Failure to

become CMV antigen -ve by the end of the 2 week course would lead to

immediate progression to foscarnet.

CMV-related disease

May cause pneumonitis, oesophagitis, gastritis, hepatitis, retinitis and

myelosuppression. Where CMV antigenaemia accompanied by symp-

toms/signs of CMV disease high titre anti-CMV Ig 200mg/kg/day IV should

be administered on days 1, 3, 5 and 7 of antiviral therapy with gancyclovir

or foscarnet. Broncho-alveolar lavage (BAL) should be performed to

establish the presence of CMV locally in the lung.

335

Post-transplant vaccination

programme

General

The subject of re-vaccination post-transplant remains a contentious topic.

The general principles are that live vaccination is forbidden, probably for

the lifetime of the patient. Secondly, antibody and T-cell responses to vac-

cination in the first year following transplantation are sub-optimal. In allo-

geneic transplants, immune reconstitution continues beyond 1 and up to 2

years post-transplant. These general considerations have been used to

suggest the following policy.

Allogeneic transplants

No immunisations should be given in the presence of acute or chronic

GvHD. In the absence of this, proceed as follows:

At 12 months post-transplant

2 Diphtheria and tetanus toxoid primary course (3 doses).

2 Primary course of inactivated polio vaccine (3 doses).

2 Pneumovax II (repeated every 6 years).

336

2 Haemophilus influenzae B.

2 Meningococcal A and C.

2 Influenza vaccine (and annually thereafter).

The vaccinations should be staggered with only diphtheria and tetanus

being administered concurrently. It would be reasonable to leave a gap of

2 weeks between each vaccination. Not only may this enhance antibody

responses but it will easily identify the cause if there are any reactions.

At 2 years post-transplant

2 Measles if the patient is at high risk but patient free of GvHD and off

immunosuppressive therapy.

2 Rubella if the patient is a female of child-bearing age who has a low

titre but patient free of GvHD and off immunosuppressive therapy.

Autologous SCT for lymphoma or myeloma—1 year

post-transplant

2 Tetanus booster.

2 Inactivated polio vaccine booster.

2 Pneumovax II (repeated every 6 years).

2 Haemophilus influenzae B.

2 Meningococcal A and C.

2 Influenza vaccine (repeated annually).

Foreign travel

All transplant recipients should take medical advice from their transplant

team before travelling abroad.

2 Typhoid, cholera, hepatitis A/B and meningococcal vaccines are safe.

2 Yellow fever and Japanese B encephalitis are not safe.

2 Remember malaria prophylaxis.

Avoid live vaccines. e.g.:

2 Yellow fever

Transplantation

2 BCG.

2 Oral polio.

2 Oral typhoid.

Post-transplant complications

2 Bacterial and fungal infections.

2 Pneumonitis.

2 CMV reactivation.

2 Veno-occlusive disease (VOD)—see p328.

Allografts only

2 Acute GvHD (see p324).

2 Chronic GvHD (see p326).

Longer term effects

2 Endocrine: hypothyroidism may occur post-transplant. Check TFTs at

3 monthly intervals71 year.

2 Respiratory: check lung function tests at 6 months and 1 year if TBI has

337

been given.

2 Skin: advise about sun protection (following TBI avoid the sun). If

exposure is unavoidable, total sun block factor 15 or higher is essential

for at least 1 year.

2 Fertility: most patients will be infertile after transplant (almost invari-

ably if TBI given). Since this cannot be absolutely guaranteed, contra-

ceptive precautions should be taken until the confirmatory tests have

been performed.

2 Males: check sperm counts at 3 and 6 months post-transplant. Zero

motile sperm on both samples confirms infertility.

2 Females: check FSH, LH and oestradiol at 3 months. FSH and LH levels

should be high and oestradiol levels low if no ovulation is occurring.

2 Menopause-women may have an early menopause due to the treat-

ment and may experience symptoms such as hot flushes, dry skin,

dryness of the vagina and loss of libido. Most women should have

hormone replacement therapy (Prempak C 1.25 initially starting as

soon as early menopause is confirmed) and counselled about HRT

problems.

2 Cataracts—patients who have had TBI are at risk of developing

cataracts. Refer for ophthalmological assessment at 1 year post BMT.

2 Immunisations at 12-24 months post-transplant (see p336).

Treatment of relapse post-allogeneic

SCT

Recurrence of leukaemia, myeloma or lymphoma after an allogeneic SCT

may be treated by donor lymphocyte infusion (DLI), a second transplant

(in those patients with a durable first response who are fit enough to with-

stand the rigours of a second allograft) or conventional dose or palliative

treatment.

DLI

2 May be used in CML, AML and ALL, NHL, HL and myeloma.

2 DLI can promote full donor chimerism in patients with mixed

chimerism or residual tumour after reduced intensity non-myeloabla-

tive conditioning.

2 Patient should discontinue cyclosporin and steroid therapy at least 2

weeks before DLI and chemotherapy at least 24h before DLI.

2 Donor lymphocytes are collected by leucapheresis; a typical collection

of 150mL contains ~50

¥ 10⁸ T lymphocytes.

2 Escalating doses are generally used to limit GvHD e.g. first dose 10⁷

donor lymphocytes followed 12 weeks later if no response by 5

¥ 10⁷

338

cells, then if no response 12 weeks later 10⁸ cells then >10⁸

cells 12

weeks later if no response; lower initial doses and increments are

utilised in MUD SCT.

2 Where possible e.g. CML, AML molecular monitoring may be under-

taken and DLI may be utilised for molecular relapse with molecular

monitoring of response.

2 The main adverse effect of DLI is acute or chronic GvHD especially if

administered early after SCT. The incidence of these complications has

been reduced by the adoption of an escalating dose regimen but

increased with MUD SCT.

Discharge and follow-up

Criteria for discharge

Blood counts should ideally be: Hb >10.0g/dL (but may require transfu-

sion), neutrophils >1.0

¥ 10⁹/L, platelets >25

¥ 10⁹/L, and patients should

be able to maintain a fluid intake of 2-3L/d, tolerating diet and oral med-

ications particularly in allografts on cyclosporin. Should be apyrexial and

no longer losing weight.

Counsel patients

1. Possible need for blood/platelets.

2. Adherence to neutropenic diet.

3. Check temperature bd and report immediately if febrile.

4. Fatigue post-transplant in irradiated patients due to the late TBI effect

usually 6-10 weeks post transplant.

5. Risk of HZV (explain the early symptoms).

6. To continue with mouth care.

7. To report any new symptoms.

Blood tests—initially twice weekly

2 FBC, reticulocytes and blood film.

340

2 Biochemistry including LFTs.

2 CyA levels pre-dose (EDTA sample)—allografts only.

Initially once a week

2 Magnesium.

2 CRP.

2 Coagulation screen.

2 CMV screening test e.g DEAFF—allografts and seropositive autograft

recipients only.

2 Stool culture—allografts only unless relevant symptoms.

Drugs

Cyclosporin capsules—allografts only.

Acyclovir prophylaxis against HZV 400mg qds PO for minimum of 3

months in non-TBI patients and 6 months in TBI autografts and all

allografts. Allografts may be on 800mg tds if acyclovir chosen for

CMV prophylaxis. Consider low dose 200mg bd maintenance until

1-2 years post-transplant.

Penicillin V

250mg bd PO should be given to all patients.

Erythromycin 250mg od PO if penicillin allergic.

Ciprofloxacin 250mg bd PO if neutrophils <1.0

¥ 10⁹/L.

Cotrimoxazole 480mg bd PO Monday, Wednesday, Friday for 1 year

minimum and until CD4 count >500. Cotrimoxazole should be

started when neutrophils >1.5

¥ 10⁹/L and platelets >60

¥ 10⁹/L.

Until then, use nebulised pentamidine 300mg every 3 weeks.

Itraconazole—allografts only.

Nystatin mouth care.

Folic acid 5mg bd until full engraftment.

Sanatogen Gold™ multivitamins 1/d may be advisable while gaining

weight.

10. Antiemetics PRN.

Haemostasis and thrombosis

Coagulation disorders - a clinical approach

344

Coagulation disorders - laboratory approach

346

von Willebrand’s disease (vWD) and vWF-related bleeding

348

Haemophilia A and B

352

Other congenital coagulation deficiencies

356

Vitamin K deficiency

360

Haemorrhagic disease of the newborn

362

Liver disease

364

Acquired anticoagulants

366

Platelet function tests

370

Hereditary platelet disorders

372

Osler-Weber-Rendu (OWR) syndrome

374

Henoch-Schönlein purpura

376

Acquired disorders of platelet function

378

Numerical abnormalities of platelets - thrombocytosis

382

Numerical abnormalities of platelets - thrombocytopenia

384

Investigation of thrombocytopenia

386

Immune thrombocytopenia

388

Other causes of thrombocytopenia

392

Thrombophilia

394

Inherited thrombophilia

396

Acquired thrombophilia

400

Anticoagulation therapy

402

Anticoagulation in pregnancy and post-partum

404

Coagulation disorders—a clinical

approach

Haemophilia is the name given to an increased bleeding tendency. It can

be heritable or acquired. The commonest heritable bleeding disorder is

mild von Willebrand disease, affecting 1 per few hundred of the popula-

tion. This heritable disorder is not typically referred to as haemophilia but

in the broadest sense of the definition it is a form of haemophilia. ‘Classical

haemophilia’, also termed ‘haemophilia A’, is due to factor VIII deficiency

and affects only 1 per 10,000 male births. It is therefore encountered

infrequently in non-haematological practice. The most common acquired

form of haemophilia is that due to oral anticoagulant therapy as 1 per 100

of the population of many countries are now taking long-term warfarin or

similar anticoagulants.

Conversely, thrombophilia is used to describe an increased tendency to

thrombosis. This can also be heritable or acquired. Heritable throm-

bophilic defects are often insufficient on their own to cause thrombosis

and an additional acquired factor, such as surgery, is often the trigger for

an acute thrombotic event.

Bleeding disorders

344

Causes of bleeding—surgery, trauma, non-accidental injury, coagulation

disorders (including anticoagulant drugs), platelet dysfunction (including

aspirin and other anti-platelet drugs), vascular disorders.

Clinical features—is there a lifelong bleeding history, has the patient been

previously challenged, is this an isolated symptom? Type of bleeding

problem that led to presentation e.g. mucocutaneous, easy bruising,

spontaneous, post-traumatic. Duration and time of onset. Menstrual

history is important. Absence of obstetric bleeding may be misleading as

haemostatic capacity increases significantly in pregnancy.

Systemic enquiry—do symptoms suggest a systemic disorder, bone

marrow failure, infection, liver disease, renal disease?

Past medical history—previous episode, previous known disorder e.g.

ITP. Exposure to trauma, surgery, dental extraction, or pregnancies.

Family history—similar bleeding tendency in other family members?

Pattern of inheritance (autosomal dominant, sex-linked).

Drugs—thrombocytopenia ( p384), platelet dysfunction ( p378); not

always obvious—aspirin, warfarin. Drug reaction—allergic purpura.

Physical examination

Signs of systemic disease—anaemia, lymphadenopathy

± hepato-

splenomegaly?

Assess bleeding site—check palate and fundi. Check size e.g petechiae

(pinhead); purpura (larger =1cm); bruises (ecchymoses) =1cm—measure

them.

Joints—swelling or other signs of chronic arthritis, joint destruction or

muscle contractures from previous bleeds?

Haemostasis and thrombosis

Vascular lesions—purpura e.g. allergic, Henoch-Schönlein (p376), senile,

steroid-related, hypergammaglobulinaemic, HHT—capillary dilatations

(blanches on pressure), vasculitic lesions, autoimmune disorders, hyper-

sensitivity reactions.

Investigation

2 FBC (especially platelet count), film, biochemistry (especially creati-

nine and LFTs), ESR, coagulation tests (PT and APTT).

2 Special tests will be dictated by history. The bleeding time is not a reli-

able test and is rarely indicated. von Willebrand’s disease (vWD)

often missed because PT and APTT and platelet count are normal. If

history suggestive of vWD then plasma level of von Willebrand factor

must be measured.

2 Family studies should be considered to identify other family members

at risk of bleeding.

Summary

Pre-operative history is most important aspect of identifying clinically sig-

nificant bleeding risk. If abnormal bleeding does occur exclude surgical

345

bleeding and take blood for testing before blood transfusion compounds

the problem. Decide whether platelet or coagulation defect or both? Is it

hereditary or acquired?

Treatment

Establish diagnosis and treat as appropriate.

Classification of bleeding disorders

Inherited

von Willebrand’s disease (vWD)

p348

Haemophilia A and B

p352

Other congenital deficiencies

p356

Acquired

Anticoagulant therapy

Heparin

p588

Warfarin

p590

Thrombolysis

p516

Vitamin K deficiency

p360

Liver disease

p364

DIC

p512

Acquired inhibitors

p366

Massive blood transfusion

p524

Coagulation disorders—laboratory

approach

Establish whether bleeding is of recent origin (suggests acquired) or long-

standing (congenital), spontaneous or induced by trauma/surgery, mucocuta-

neous (?platelet defect) or generalised (?coagulation defect or ?drug induced).

Laboratory tests

2 FBC with platelet count, coagulation tests (PT, APTT, fibrinogen).

2 Fill blood sample tube to the mark to ensure correct anticoagulant

concentration.

2 Repeat test if result abnormal before investigating further.

2 Check patient not on anticoagulants.

Further investigation

Abnormal platelet count

2 Both high and low counts may cause bleeding.

2 If isolated low platelets

p384; if platelets high

p382.

2 If platelets low and coagulation screen abnormal—could be DIC, liver

disease, massive blood transfusion, primary blood disorder (e.g.

leukaemia).

Abnormal coagulation result

346

PT 4 APTT normal

Warfarin, vitamin K deficiency, early liver disease, rarely congenital factor

VII deficiency.

PT 4 APTT 4

Warfarin overdose, vitamin K deficiency, liver failure, DIC.

PT normal APTT 4

Unfractionated heparin (UFH), haemophilia A or B, lupus anticoagulant,

rarely vWD affects APTT, factor VIII inhibitors are rare but typically

prolong APTT.

PT normal APTT normal

Normal PT and APTT do not exclude a significant bleeding tendency, for

example effect of low molecular weight heparin, mild factor deficiency,

platelet abnormality, or very rare factor deficiency such as factor XIII.

Further investigation

2 DIC: check blood film, platelets, thrombin time, fibrinogen, XDPs/D-dimer.

2 Vit K deficiency: assay VII and II; give vitamin K and repeat 24h later.

2 Liver disease: check LFTs; will not correct to normal with vitamin K.

2 Isolated factor deficiency: assay as indicated by PT/APTT results.

2 Inhibitor-specific LA tests: check ACL; other factor-specific assays.

2 Heparin: 4 APTT ratio, PT normal if APTT ratio 1.5-2.5, TT 4, repti-

lase normal.

2 Warfarin: PT prolongation>than APTT, low vitamin K dependent factors.

2 vWD: diagnosis of von Willebrand disease requires measurement of

vWF level and function. Note: bleeding time is neither sensitive nor

specific for diagnosis or bleeding tendency.

Haemostasis and thrombosis

TEST

TISSUE INJURY

TF-VII

TFPI

TF-VIIa

1. Anticoagulant pathway

IXa

APTT

Protein S

Factor V

VIIIa

APC

Thrombin

347

Protein C

and

APTT

XIa

2. Fibrinolytic pathway

TPA

Fibrinogen

Fibrin

Plasmin

Plasminogen

becomes active

activates

FDPs Plasmin

inhibitor

inhibits

Blood coagulation network

Tissue injury triggers off a cascade of zymogen-to-protease reactions which

amplify resulting in thrombin generation and fibrin clot.

Natural anticoagulation network

Natural anticoagulants: Tissue Factor Pathway Inhibitor (TFPI), Antithrombin

and Activated Protein C. Thrombin binds to a receptor, thrombomodulin (TM)

on the surface of endothelial cells. Bound to TM thrombin loses anticoagulant

activity and becomes a potent activator of protein C7Activated PC (APC)

with co-factors PS and FV, cleaves and inactivates Factors Va and VIIIa.

Fibrinolytic network

Tissue plasminogen activators (TPA) activate plasminogen to plasmin; this

breaks down fibrin releasing degradation products (FDPs, or XDPs when

cross-linked) into the circulation.

von Willebrand’s disease (vWD) and

vWF-related bleeding

Autosomal inherited bleeding disorder due to reduced production of von

Willebrand factor (vWF) or production of defective protein, affects both

sexes with estimated incidence of 1 per few hundred. First described in

1926 in the Åland Islands in the Baltic, it has a worldwide distribution.

Pathophysiology

vWF, produced in endothelial cells and megakaryocytes, is a protein of

250kDa molecular weight. Initial dimerisation and subsequent removal of

propeptide allows polymerisation and secretion of large multimers. The

higher molecular weight (HMW) multimers, up to 20 x 10³ kDa, are par-

ticularly haemostatically active. vWF has two main functions:

1. Its primary haemostatic function is to act as a ligand for platelet adhe-

sion and it is this reduced activity that causes bleeding.

2. It has a secondary function as a carrier protein for factor VIII protecting

it from degradation. In most patients with vWD the associated mild

reduction in factor VIII level is not the cause of the haemostatic defect.

Many cases of heritable/congenital vWD are currently thought to be

caused by genetic mutations at the vWF locus but some may be due to

defects in other genes, which affect vWF levels. Increasingly vWF is con-

348

sidered a continuous variable with low levels associated with an increased

bleeding tendency.

Many subtypes but for simplicity the disease is classified into 3

main types:

2 Type 1—quantitative deficiency of vWF (autosomal dominant).

2 Type 2—qualitative deficiency of vWF (autosomal dominant/recessive).

2 Type 3—complete deficiency of vWF (autosomal recessive).

Clinical features

2 Type 1 is common (70% of cases).

2 Type 2 ~25%.

2 Type 3 is rare.

The clinical picture varies markedly. Symptoms may be intermittent, due

to dysfunction of platelet adhesion e.g. mucocutaneous bleeding, easy

bruising, nose bleeds, prolonged bleeding from cuts, dental extractions,

trauma, surgery and menorrhagia.

Type 2B causes thrombocytopenia which may present in pregnancy.

Usually the picture is consistent within a family. Laboratory diagnosis

2 vWF is an acute phase protein—increasing with stress, oestrogens,

pregnancy, neoplasm, thyrotoxicosis, etc. vWF levels are dependent on

ABO blood group being lower in group O than non-O.

2 In type 1 APTT usually normal as are PT and platelets. VIII may be

normal or 5. vWF level and function typically mildly or moderately 5.

Bleeding time is often normal and is no longer used in many

haemophilia centres. It has been largely replaced by automated in vitro

platelet function analysis at high shear rate (PFA-100). When mild, the

Haemostasis and thrombosis

condition may be difficult to diagnose as many of the tests are normal,

including the VIII and variably the vWF level. Repeat testing is neces-

sary. Family testing is useful.

Classification of von Willebrand’s disease

Type

VIII

vWF Ag vWF RIPA HMW

activity low dose multimer

N/5

5/N

N/5

5/N

N/5

5/N

N/5

Usually undetectable

349

vWF activity measured as ristocetin cofactor activity (Ricof) or collagen

binding activity (CBA), which is measured in plasma and is not the same as

RIPA (see below) which is ability of ristocetin to agglutinate platelet rich

plasma.

The main subtypes of type 2 are 2A and 2M. In 2A there is a qualitative

defect with absent HMW multimers and in 2M there is a qualitative defect

but with HMW multimers present.

RIPA is ristocetin-induced platelet agglutination performed on a patient’s

platelet rich plasma. Only value of RIPA test is for detection of type 2B

when RIPA is increased due to high affinity variant vWF which produces

thrombocytopenia and reduced circulating level of VWF

Factor VIII is seldom low enough to cause the joint bleeds seen in

haemophilia except in Type 3 which is a severe bleeding disorder.

Type 2N is rare autosomal recessive variant in which the VIII:C carrier

function of vWF is reduced. May be misdiagnosed as haemophilia A but

clue is that females are affected as well as males and autosomal recessive

inheritance.

Management

2 Avoid aspirin and NSAIDs.

2 Mild bleeding symptoms—easy bruising, bleeding from cuts may settle

with local pressure.

2 Tranexamic acid (TXA) is a useful antifibrinolytic drug (15mg/kg PO tds).

2 TXA mouthwash 5% is useful for dental work.

2 Moderate disease and minor surgery

- DDAVP (0.3mg/kg SC or by slow IV injection/infusion). Fewer

side effects with SC route.

- Most responders have type 1 vWD but may work in some type 2

patients. Avoid in type 2B (may reduce platelets).

2 Major surgery, bleeding symptoms or severe disease.

- If DDAVP insufficient use vWF rich factor VIII concentrate e.g.

intermediate purity VIII concentrate, e.g. Alphanate, BPL 8Y,

Haemate P.

- Monitor treatment with VWF:Ricof or VWF:Ag. Bleeding time or

PFA-100 (see below) may not correct despite good clinical

response. Treat post-op for 7-10 days.

2 Pregnancy—VIII and VWF rise in pregnancy so rarely presents a

problem for type 1. Post-partum vWF falls so watch out for PPH in

mod/severely affected women. Give DDAVP or vWF concentrate to

maintain levels >30% if clinical problem. In Type 2B abnormal HMW

multimers can cause platelet aggregation and thrombocytopenia in

pregnancy. Avoid TXA in pregnancy/type 2B as there may be risk of

thrombosis.

2 Menorrhagia—may be major problem. TXA for first 3 days of the

menstrual period helps some patients. Combined oral contraceptive

pill is useful. Mirena (hormone impregnated) coil very effective in some

patients.

Complications

Vaccination against HBV and HAV recommended for all patients.

350

Inhibitors infrequent—usually type 3 disease.

Natural history

Majority of patients will have type 1 disease which rarely causes life-

threatening bleeds; may have little impact on quality of life/life expectancy.

Management with vWF rich factor VIII concentrates as for severe

haemophilia should enable patients with severe vWD to have good quality

of life.

Sadler, J.E. (2003) Von Willebrand disease type 1: a diagnosis in search of a disease. Blood, 101,

2089-2093.

Haemophilia A and B

Congenital bleeding disorders caused by defective production of factor

VIII (haemophilia A) or IX (haemophilia B); sex-linked recessive inheri-

tance. Females carriers are rarely symptomatic. Queen Victoria passed the

disease on to her great-grandson, Alexis, son of the Tsar, contributing to

the fall of Tsarist Russia.

Pathophysiology

Factor VIII activated by thrombin, and IX activated by the TF/factor VIIa

complex, together activate factor X, leading to thrombin generation and

conversion of soluble fibrinogen to insoluble fibrin (px). Haemophilia A

and B are disorders characterised by inability to generate cell surface-

associated factor Xa. Genetic abnormalities include: inversions within

intron 22 of factor VIII gene in 50%, point mutations and deletions. Gross

gene alterations common in haemophilia A but infrequent in haemophilia

B. This may account for low frequency of inhibitors in haemophilia B.

Third of haemophilia B patients have dysfunctional molecule.

Carrier detection and antenatal diagnosis now possible in many cases by

direct gene mutation detection. Affected family member usually required.

Linkage analysis no longer recommended as first line method.

Epidemiology

352

Haemophilia A occurs in 1:10,000 9 in the UK, in ~¹⁄3 cases no family

history as new mutation; 5¥ more frequent than haemophilia B; no striking

racial distribution.

Clinical presentation

Haemophilia A and B—clinically indistinguishable. Symptoms depend on

the factor level.

Severe disease (plasma level <1%)

Usually presents in the first years of life

with easy bruising and bleeding out of

proportion to injury

Moderate disease (1-5% factor level) Intermediate & variable severity

Mild disease (>5%)

May only present after trauma/surgery

in later life

General features

Haemarthrosis; spontaneous

bleeding into joints

(knees>elbows>ankles>hips>wrists)

produce local tingling, pain;

later—swelling, limitation of

movement, warmth, redness, severe pain

Bleeds into muscles, spontaneous bleeding into arms, legs, iliopsoas, or

any site—may lead to nerve compression, compartment syndrome,

muscle contractures—look for these. Haematuria is common; retroperi-

toneal and CNS bleeds are life threatening.

Haemostasis and thrombosis

Diagnosis

Assess duration, type of bleeding, exposure to previous trauma/surgery

and family history. Look for bruising, petechial haemorrhages, early signs

of joint damage. Exclude acquired bleeding disorders.

Laboratory tests

PT normal, APTT 4 depending on degree of deficiency (note: a normal

APTT does not exclude mild disease). Assay VIII first, then IX. Exclude vWD.

Radiology

Acute bleed—USS or CT scan if in doubt. In established disease—chronic

synovitis, arthropathy and other pathological changes seen.

Complications

Chronic arthropathy

Repeated joint bleeds preventable but older patients often have

arthropathy.

Development of factor VIII inhibitors

Suggested by 5 response to concentrates; occurs in 15-25% haemophilia

353

A patients following treatment (IX inhibitors are uncommon; <2%).

Transmission of HBV, HCV and HIV

Transmission high prior to the introduction of viral inactivation of concen-

trates (1985 in the UK).

HIV management

Prophylaxis against infections and retroviral inhibition have significantly

improved prognosis.

HCV

HCV infection of most haemophiliacs treated with pooled human factor

concentrates before 1985. Approximately 20% have chronic liver disease.

HCV PCR is used to identify patients at higher risk of progressive liver

disease. Liver biopsy is not contraindicated if haemophilia management at

time of biopsy is optimal. Combined antiviral therapy superior to inter-

feron alone.

Variant CJD

There is no evidence as yet of transmission of vCJD by pooled human

blood products.

Haemophilia management

General regular medical and haemophilia review and lifelong support are

essential. At presentation establish blood group, liver function and base-

line viral status (HIV, HCV, HBV, HAV). Vaccinate against HBV and HAV if

not immune. Regularly check inhibitor status, LFTs, FBC. Avoid aspirin,

anti-platelet drugs, and IM injections. Early treatment of bleeding episodes

is essential. Prophylaxis is preferable to demand treatment for many

patients with severe haemophilia. Prophylaxis started in first year or two

of life can prevent most if not all joint damage and almost eliminate signif-

icant bleeding. Portacath may be required to deliver prophylaxis. Factor

concentrate needs to be administered every 2 or 3 days. If not on

prophylaxis home demand treatment is preferable to hospital demand

treatment.

Haemophilia A-specific treatment

Mild disease

2 Minor bleeds may stop without factor concentrate therapy.

2 Tranexamic acid (15-25mg/kg tds oral)—useful for cuts or dental

extraction. Do not use when haematuria.

2 DDAVP (desmopressin) for minor surgery and bleeds that fail to settle

(0.3µg/kg SC or slow IVI/20 min); may also be given by nasal spray. 30

min later take blood sample to check response (if required); plasma

level increased 3-4 fold. Reduced response with repeated exposure

sometimes observed.

2 Cryoprecipitate no longer recommended.

Severe disease

2 Factor VIII concentrates are cornerstone of management for severe

disease and life-threatening situations.

Products

2 Recombinant products are treatment of choice. Second generation

recombinants do not contain any human material in product. Human

354

donor-derived products are now subjected to double viral inactivation

(solvent-detergent and heat treatment, e.g. 80°C for 72h); good

record of viral safety.

- High and intermediate purity human donor-derived products avail-

able for patients not receiving recombinant therapy. No particular

advantage for high purity over intermediate except possibly useful

in patients with allergic reactions to intermediate purity.

High purity previously recommended for HIV +ve patients.

- Principle of treatment: raise factor VIII to haemostatic level

(15-50u/dL for spontaneous bleeds, 40u/dL minor ops; 100u/dL

major surgery or life-threatening bleeds).

Formula

1u/kg body weight raises plasma concentration by about 2u/dL. t

6-12h.

¹/2

Spontaneous bleeds usually settle with single treatment if treated early. In

major surgery provide cover for up to 10d.

Haemophilia B

2 General approach: as for haemophilia A—DDAVP typically of no

value.

2 Products—recombinant factor IX treatment of choice. If not recombi-

nant then high purity factor IX preferable to intermediate (also known

as prothrombin complex concentrate) as high risk of thrombosis with

intermediate purity product.

Formula

1u/kg body wt raises plasma concentration 1u/dL; t

12-24h.

¹/2

Haemostasis and thrombosis

Special considerations

Antenatal diagnosis

Carriers can be identified be genetic mutation analysis. Factor VIII: vWF

ratio is unreliable. Antenatal diagnosis in carriers with 9 fetus ideally per-

formed by chorionic villus sample DNA analysis at ~10 weeks gestation

to allow termination of pregnancy; rarer nowadays because of improved

treatment and prognosis. Issue is complex and counselling/testing should

be at comprehensive care centre.

Home treatment has transformed the life of the haemophiliac. Parents,

the local GP, the boy himself from age 6-7 onwards, can be trained to

give IV factor concentrates at home. Treatment usually starts in first year

or two of life and portacath may be needed until age 4 or more.

Prophylaxis—e.g. 3

¥ weekly injections of concentrate (average dose

15-25u/kg) given at home.

Specialist support—physiotherapy plays key role in preservation of

muscle and joint function in patients with haemarthroses. Combined

clinics with orthopaedic surgeons, dental surgeons, hepatologists,

355

paediatricians, HIV physicians, and geneticists are required to give

comprehensive care.

ii Do not give IM injections when factor is low.

Other congenital coagulation

deficiencies

Pathophysiology

Deficiency of other coagulation factors is described but with a prevalence

of 1-2 per million is rare cf. vWD and haemophilia A and B. Autosomal

recessive inheritance, the deficiency either due to reduced synthesis (type

1) or production of a variant protein (type 2). All coagulation factors are

produced in the liver and their interaction in the coagulation cascade is

shown.

2 The t1 of the factors vary and will determine the frequency and ease of

treatment.

2 Factor concentrates should be considered when available, e.g. factor

XI, factor XIII.

2 Recombinant VIIa for factor VII deficiency. The use of recombinant

factor VIIa is increasing and it is increasingly used to treat a variety of

factor deficiencies and severe platelet function disorders.

2 FFP can be used and virally-inactivated plasma should be used when

available. FFP is a source of all coagulation factors but large volumes

may be required and even with viral inactivation there is risk of disease

transmission.

356

Diagnosis

Conditions rarely produce haemarthrosis, except factor XIII deficiency,

and may only present at time of surgery. Clinical and laboratory features

of the different conditions are listed.

Treatment

Many patients with inherited coagulation deficiencies will not bleed unless

exposed to surgery or trauma, and may seldom require treatment. When

bleeding arises or cover for surgery is needed, the aim is to achieve a

plasma factor concentration at least as high as the minimal haemostatic

value and make sure it does not drop below this until haemostasis is

secure.

Specific conditions

Factor XI

Deficiency more common in certain ethnic groups such as Ashkenazi Jews.

Clinically of variable severity, often mild; even low factor levels may not

produce symptoms whilst significant bleeding can occur with mild defi-

ciency.

Diagnosis

PT normal, APTT normal unless factor XI <40u/dL. Therefore necessary

to measure factor XI level to make diagnosis in many cases.

Treatment

Tranexamic acid and DDAVP for oral and dental surgery. Factor XI con-

centrates sometimes available. Otherwise, use virally-inactivated FFP.

Haemostasis and thrombosis

Fibrinogen

Normal range 2.0-4.0g/L. Produced by liver, it is an acute phase protein,

raised in inflammatory reactions, pregnancy, stress, etc. Converted into

fibrin by the action of thrombin and is a key component of a clot.

Abnormalities of fibrinogen are more often acquired than inherited.

Inherited defects are usually quantitative and include heterozygous

hypofibrinogenaemia or homozygous afibrinogenaemia. Qualitative

defects—the dysfibrinogenaemias—are inherited as incomplete auto-

somal dominant traits with >200 reported fibrinogen variants; defective

fibrin polymerisation or fibrinopeptide release may occur. Most patients

are heterozygous.

Clinical presentation

Symptoms of bruising, bleeding usually after trauma or operations will

depend on the concentration and are more severe when

<0.5g/L.

Afibrinogenaemia (fibrinogen <0.2g/L) is a severe disorder with sponta-

neous bleeding, cerebral and gastrointestinal haemorrhage and

haemarthrosis. It may present as haemorrhage in the newborn. Recurrent

miscarriages occur. Most patients with dysfibrinogenaemia are heterozy-

357

gous and bleeding symptoms are usually minor; arterial and venous

thrombosis is described with some variants.

Diagnosis

4 PT, APTT and thrombin time; in afibrinogenaemia, the blood may be

unclottable. Fibrinogen level measured by Clauss assay. Acquired hypofib-

rinogenaemia needs to be excluded (DIC, liver disease) and family studies

are necessary.

Dysfibrinogenaemia

4 PT and APTT. Variable abnormalities of thrombin time and reptilase

time; fibrinogen-dependent platelet function may be defective. Confirm

diagnosis by demonstrating normal chemical/immunological fibrinogen

concentrations with reduced functional properties.

Treatment

Fibrinogen has a long t

(3-5d), severe deficiency managed by repeated

¹/2

(twice weekly) prophylactic injections with fibrinogen concentrates, FFP

or cryoprecipitate. Fibrinogen levels should be raised to 0.5-1.0g/L to

achieve haemostasis.

Factor VII

Vitamin K dependent factor playing a pivotal role in initiating coagulation

but low level required. The t1 is short (4-6h). In severe deficiency,

bleeding symptoms

(similar to haemophilia) occur and spontaneous

intracerebral haemorrhage at a young age has been reported.

Diagnosis

4 PT and normal APTT. Assay factor VII to assess severity.

Treatment

Use factor VII concentrate 1u/kg body wt to elevate plasma conc ~20u/dL

or recombinant factor VIIa. For cerebral bleed give a >50u/dL rise and

continue treatment for 10d. Very short t1 makes management difficult,

requiring IV replacement 3-4

¥/24h. If using FFP, give initial IV injection

(15mL/kg) and check response.

Other deficiencies

Factor II, V, X deficiencies very rare. Bleeding less severe with factor V

deficiency than with factor X or prothrombin deficiency.

Factor XIII (fibrin stabilising factor)

Clinical

Characteristically produces delayed post-operative bleeding (6-24h later).

Neonatal umbilical stump bleeding more common than with other defi-

ciencies. High risk of cerebral haemorrhage.

Diagnosis

APTT and PT both normal so will be missed in a bleeding investigation

unless specifically looked for by screening test (clot formed with thrombin

and stability in acetic acid is measured).

Treatment

Only very low levels required for haemostasis; t1 is very long. Severe defi-

ciency should be treated with once-monthly prophylaxis with factor XIII

358

concentrate.

Multiple defects

Rare familial coagulation factor deficiencies described; may be consan-

guineous parents. Often involves factor VIII and another factor

(V>IX>VII). Other combinations seen.

Vitamin K deficiency

Pathophysiology

Vitamin K (vit K) is a fat-soluble vitamin obtained either by dietary intake

(vit K₁) from vegetables and liver, and absorbed in the small gut or pro-

duced by bacterial synthesis in the gut and absorbed in the colon (vit K₂).

Its essential role in coagulation is as cofactor for the gamma carboxylation

of the precursor proteins for factors II, VII, IX, X, protein C and S, all of

which are produced in the liver. Until the routine prophylactic administra-

tion of vit K, deficiency was common in the neonate, almost exclusively a

disease of breast-fed babies because 5 vit K in human breast milk cf.

formula feeds, and 5 synthesis in the neonatal gut.

Clinical features

2 Dietary deficiency may arise within a few weeks in patients who are

not eating well since body stores are limited and the t1 of the vitamin

is short (days). Coagulopathy due to deficiency common in ITU

patients unless vitamin K administered.

2 Systemic illness, parenteral nutrition, hepatic or renal failure, hypo-

albuminaemia, antibiotics (e.g. cephalosporins) are compounding

factors.

2 Haemorrhagic disorder of the newborn. Prematurity and maternal

360

intake of anticonvulsants increase the incidence. Usually presents in

first few days of life with bleeding (e.g. umbilical stump). Cerebral

haemorrhage is rare. A late form seen 3-6 months after birth is rare

may be due to liver disease, intestinal malabsorption.

Malabsorption

2 Disease of the small gut (e.g. coeliac disease) may lead to clinically

manifest vit K deficiency.

2 Obstruction of bile flow, either extrahepatic (gallstones, Ca pancreas,

or bile ducts) or intrahepatic (liver disease, liver fibrosis) may be asso-

ciated with overt bleeding or noted on routine coagulation laboratory

testing.

Laboratory diagnosis

2 Clotting screen shows 4 PT and APTT.

2 Thrombin time and platelet count are normal.

2 PT is more prolonged than APTT, and corrects with normal plasma.

2 Further investigation (factor assays, PIVKA levels, vit K concentration)

rarely required. A therapeutic trial of vit K will confirm diagnosis, with

rapid (± 24h) PT correction.

Treatment

Asymptomatic patients—adult dose vit K 10mg IV; repeat as necessary;

can be given by mouth in dietary deficiency.

Neonate prophylaxis—1mg IM 1-3 mg PO.

Bleeding patients—in addition to vit K as above, give FFP (10-20mL/kg

body wt) for immediate replacement of the clotting factors. PCC

Haemorrhagic disease of the newborn

Haemorrhagic disease of the newborn is caused by deficiency of the

vitamin K dependent factors and is a significant cause of bleeding in the

neonatal period unless prevented by vitamin K. Two forms described; an

early classical and a late form with different aetiology

Pathophysiology

Classical haemorrhagic disease of the newborn is almost exclusively a

disease of breast fed babies; incidence may be as high as 1/2500 deliveries

in the UK. This is a true deficiency; human milk has less vitamin K than

formula milk and there is less bacterial synthesis of vitamin K due to the

sterile gut of the newborn. Immaturity of the liver and impaired produc-

tion of the vitamin K factors may be a contributing factor. The late form

~40-100/million live births also is seen in breast fed babies but is mainly

due to malabsorption of vitamin K, secondary to cholestasis, or GIT

pathology.

Clinical features

2 Early haemorrhagic disease of the newborn presents in the first week

of life with bleeding—umbilical cord, the skin, post circumcision

bleeding is common; ICH is rare. Presents <24h in haemorrhagic

disease of the newborn 2° to maternal drug ingestion (anti-epileptic,

362

anti-TB).

2 Late haemorrhagic disease of the newborn has a peak incidence at 2-6

weeks but can occur up to 6 months of age. Underlying cholestatic

disease is often present, biliary atresia, cystic fibrosis, a-1 antitrypsin

deficiency and diarrhoea are documented causes. About half of cases

present with ICH.

Diagnosis—laboratory findings

2 PT/APTT—may be markedly prolonged (normal TT, fibrinogen, D-

dimer/FDPs low cf. DIC).

2 Factor assay (II, VII, IX, X) if in doubt. High PIVKA and low vit K—not

routinely available tests.

2 Correction of coagulation abnormality in ~24h with parenteral vitamin

K confirms diagnosis.

Differential diagnosis

2 Exclude other causes of bleeding in the neonatal period.

2 Thrombocytopenia—platelets are normal in haemorrhagic disease of

the newborn.

2 DIC—see below.

2 Congenital disorders e.g. haemophilia.

2 Radiological—scan for ICH/internal bleeding as required.

Management

Treatment—general support as indicated by clinical presentation. FFP for

immediate correction of bleeding. Vitamin K₁

1mg IV will correct

PT/APTT to normal for age—takes ~24 h.

Prophylaxis—1mg at birth will prevent all early and most delayed vit K

deficiency in neonate

Haemostasis and thrombosis

Because of concerns of cancer risk in neonates given parenteral vitamin K

some SCBU give oral vitamin K (2-3mg) to neonates at routine risk,

reserving IM for high risk babies

(prems/sick/maternal drugs/birth

trauma/LSCS birth). Further oral vitamin K at intervals recommended for

breast-fed babies, to prevent late onset HDN but is difficult to enforce.

Outcome

Treatment with FFP/vitamin K will correct the abnormal coagulation and

stop bleeding. In ICH damage done to CNS leads to death or morbidity

in ~¹⁄3 cases particularly likely in late onset HDN.

363

von Kries, R. (1998) Neonatal vitamin K prophylaxis: the Gordian knot still awaits untying. BMJ,

316, 161-162.

Liver disease

Most coagulation factors, including the vitamin K dependent factors, are

made exclusively in the liver. Any damage to the liver may cause rapid

reduction in their concentration and coagulopathy because of their short

half-life. Associated thrombocytopenia is common in established liver

disease, increasing the risk of bleeding.

Pathophysiology

Haemostasis is a fine balance between procoagulant and anticoagulant

mechanisms. Because of its central role in the production of these factors,

haemostasis is often disturbed in liver disease. Clotting tests become

abnormal in liver damage and are useful monitors of liver function. The

liver functions as a reticuloendothelial organ, clearing activated coagula-

tion factors from the circulation. Impairment of this function leads to the

scene for DIC which is usually low grade but may be fulminant. Fibrinolysis

may be decreased in chronic liver disease but is high in liver transplant

patients. Dysfibrinogenaemia due to increased sialic acid content of the

fibrinogen molecule is described. In obstructive jaundice, impaired bile

flow leads to malabsorption of vit K, a fat soluble vitamin. A degree of

intrahepatic obstruction secondary to hepatocyte swelling and fibrosis

may also have this effect. Thrombocytopenia may be due to portal hyper-

tension, splenic pooling, alcohol, viral infection, drugs or DIC. Altered

364

platelet function with a prolonged bleeding time may occur.

Clinical features

Most patients with established hepatic dysfunction will have an abnormal

coagulation profile but may be asymptomatic. Bleeding becomes a

problem when other complications arise such as oesophageal varices,

thrombocytopenia, surgery, liver biopsy and infection.

Laboratory diagnosis

Coagulation defect

Laboratory diagnosis

Clinical significance

5 vit K dependent factors

4PT>>4APTT

Fibrinogen

quantitative defect

Fibrinogen assay

4 infection, neoplasm,

obstruction

5 severe liver disease

dysfibrinogenaemia

4 thrombin/reptilase time uncertain; occurs in cirrhosis

Factor VIII

4, also vWF Ag

seen in acute viral hepatitis

cirrhosis, hepatic failure

Antithrombin

5 conc (N=80-120iu/dL)

5 CLD and liver failure

DIC

4 PT, APTT , F/XDPs

low grade common in CLD

5 fibrinogen, platelets

rarely fulminant

N = normal

Management

Asymptomatic patients do not require treatment other than that directed

at the underlying condition. Give vit K to exclude added vit K deficiency.

Complete correction of the PT confirms this diagnosis; partial correction

Haemostasis and thrombosis

indicates combined hepatocellular dysfunction and vit K deficiency.

Further doses of vit K for 1-2d may be given.

Liver biopsy—aim to get the INR <1.4 and platelet count >70

¥ 10⁹/L.

Check on day of biopsy. Give FFP 10mL/kg ; check INR and repeat FFP

dose until PT is satisfactory—not always achieved. PCC contraindicated

as may cause DIC and/or thrombosis. Platelet transfusion to 4 platelets to

>70

¥ 10⁹/L if necessary.

Active bleeding—blood transfusion as required. Give vit K, FFP, platelets

as set out for liver biopsy and monitor the response. FFP only temporary

correction; repeat

6-12 hourly as indicated. Surgical manoeuvres to

control oesophageal bleeding (Sengstaken tube, etc.) will be explored.

DIC is a feature of fulminant liver failure and after liver surgery and

transplantation. Control underlying condition, support with platelet/FFP

as required. The use of aprotinin, tranexamic acid, AT concentrates, and

heparin has varying success.

Natural history

In fulminant liver failure the coagulopathy may be severe contributing to

365

the mortality. The degree of the hepatocellular failure will be the final

denominator determining the outcome.

Acquired anticoagulants

The development of inhibitors against coagulation factors is fortunately

uncommon other than antiphospholipid antibodies ( p400). Factor VIII

antibodies, either spontaneous or in treated haemophiliacs, are a major

clinical problem. Acquired vWD, inhibitors against other coagulation

factors and heparin-like inhibitors are all very rare.

Factor VIII inhibitors

Pathophysiology

Spontaneous development of VIII inhibitors in non-haemophiliacs is

reported in 1 per million population. Antibody is usually IgG, occasionally

IgM or IgA and will neutralise the functional VIII protein. In 15-25% of

haemophilic patients antibodies develop as a result of treatment with

factor VIII concentrates usually within the first 10-20 treatment expo-

sures. A familial tendency is noted, inhibitors occurring more often in

patients with deletions or mutations within factor VIII gene. The antibody

acts against part of the amino-terminal component of the A2 domain or

the carboxy-terminal part of the C2 domain of the VIII molecule. It may be

quantitated by the Bethesda titre (BU; see below). Factor IX very rarely

(<2%) stimulates antibody formation.

366

Clinical features

Acquired inhibitors develop in the elderly, during pregnancy, in association

with autoimmune and malignant disease, various skin disorders (psoriasis,

pemphigus, erythema multiforme) infections, drug therapy

(penicillin,

aminoglycosides, phenothiazines, etc). Symptoms include bleeding (post-

operatively this can cause major problems), easy bruising—haemarthrosis

is rare. The mortality is significant, as many as 25% patients with persisting

VIII inhibitors will die from bleeding.

15-25% of haemophilia A patients develop inhibitors. In half, inhibitors are

transient and low titre, being noted incidentally on review. In half,

however, an VIII inhibitor will present a major clinical problem. Suspicion

is aroused by bleeding that fails to respond to the usual doses of factor

concentrate. Patients may be low (<5BU) or high (>10BU) responders; in

the latter, treatment will be difficult.

Laboratory diagnosis

2 4 APTT with failure to correct with normal plasma.

2 Inhibitor assay—patient’s plasma reducing the factor VIII in normal

plasma over 2h incubation period. Antibody titres reported in BU

(Bethesda units). Check titre against porcine VIII as porcine VIII is often

an effective treatment.

Differential diagnosis of spontaneous inhibitors—need to exclude non-

specific inhibitors e.g. myeloma paraproteins which bind non-specifically

to coagulation plasma proteins. Ensure sample not contaminated with

heparin.

Haemostasis and thrombosis

Management of patients with spontaneous inhibitor

2 Severe bleeding—may be life threatening. Suppress inhibitor with

prednisolone (1mg/kg/d); may take weeks to work, cyclophosphamide

can be added. Treat active bleeding. If no cross-reactivity porcine VIII

concentrates can be used if available (50-150u/kg). FEIBA and recom-

binant VIIa are also effective as ‘bypassing agents’.

2 Mild bleeding—may respond local pressure, tranexamic acid or

DDAVP ( p354).

2 Monitor lab and clinical response.

2 Long term immunosuppression may be required.

Management of haemophilic patients with inhibitor

2 Asymptomatic patients—observation may be all that is necessary. The

inhibitor level may gradually subside; avoid treatment with concen-

trates to limit exposure to the antigen.

2 Mild bleeding—in low responder/low titre patients large (20-100u/kg)

doses of human factor VIII are usually effective. If activity against

porcine VIII < human VIII this can be more effective.

2 High responders/high titre patients—will require bypassing agents

367

such as recombinant factor VIIa or FEIBA.

2 Immune tolerance induction—overcomes the VIII inhibitor in about

80% selected patients.

2 High responders—need high intensity immune tolerance regimes

which may take up to 18 months to work (expensive and may fail to

work).

Acquired vWD

Rare disorder presenting in later life, has a variable bleeding pattern

similar to the inherited condition. An associated monoclonal gam-

mopathy/lymphoproliferative disorder is common but the condition may

be autoimmune or idiopathic. Bleeding symptoms vary from mild to

major e.g. catastrophic GI haemorrhage requiring frequent blood transfu-

sion.

Laboratory diagnosis

As type 1 congenital vWD: PT normal; 5 VIIIC, 5 vWF antigen, 5 vWF

activity. In vitro evidence of the vWF inhibitor not always demonstrable.

Management

High dose immunoglobulin is often effective (1g/kg/day for 2d). Measures

used in the treatment of the hereditary condition can be used (DDAVP,

vWF-containing factor VIII concentrate e.g. BPL

8Y, Haemate-P,

Alphanate) are effective. maintenance IVIg may have a role. Platelet trans-

fusions may help.

Other coagulation inhibitors

Factor IX inhibitors are much less common (<2%) in patients with

haemophilia B than A and this is true also of the spontaneously devel-

oping IX inhibitors. Immune tolerance with high doses of factor IX con-

centrate is complicated by hypersensitivity reactions and nephrotic syn-

drome. Recombinant VIIa is effective for bleeding episodes.

Inhibitors, spontaneous or post-treatment, are reported against most

other coagulation factors (V, XI and XII, Prothrombin, XI, VII and X); all

are very rare. Factor V antibodies may arise in congenitally deficient

patients following treatment or spontaneously following antibiotics, infec-

tion, blood transfusion. Post-operative cases may develop as a result of

exposure to haemostatic agents contaminated with bovine factor V, e.g.

fibrin glue. Most are low titre and transient. Treat with FFP and platelets (a

source of factor V).

Heparin-like inhibitors are reported in patients with malignant disease, fol-

lowing chemotherapy (e.g. suramin, mithromycin) and may cause bleeding.

Protamine sulphate neutralisation in vitro and in vivo is a feature of this

inhibitor.

Diagnosis

Screening tests (PT, APTT, thrombin time) will give abnormal results

depending on the factor involved, with failure to correct with normal

plasma. Defining the specific factor requires detailed laboratory workup.

Exclude acquired deficiencies e.g. factor X deficiency in amyloidosis.

Treatment

368

Reserved for actively bleeding patients since acquired inhibitors may not

give rise to symptoms. First line treatment is often FFP but large volumes

may be required and efficacy may be limited. Some specific concentrates

are available. Recombinant VIIa can be considered in many cases.

Treatment of the underlying condition may cause the inhibitor to disap-

pear.

Hay, C.R. et al. (1996) Recommendations for the treatment of factor VIII inhibitors: from the UK

Haemophilia Centre Directors' Organisation Inhibitor Working Party. Blood Coagul Fibrinolysis, 7,

134-138.

Platelet function tests

Platelets play an essential role in arresting bleeding. Following vascular

injury they adhere to subendothelial collagen via the ligand vWF, then

stick to each other to form a cohesive mass. Release of internal factors—

serotonin, ADP, TXA2, and platelet factor 4 (PF4) induces vascular con-

striction, and coagulation cascade activation. Finally, together with fibrin

they form a thrombus, plugging the hole in the vessel. Within the platelet

prostaglandin synthetic pathway, arachidonic acid forms thromboxane A2,

a potent platelet aggregant and vasoconstrictor. From platelet activation

cessation of bleeding takes 3-5 minutes.

Tests of function

Blood collection needs to be optimal with non-traumatic venepuncture,

rapid transport to the lab with storage at room temperature and testing

within a maximum of 6h.

Tests in use

Platelet count, morphology, aggregation, and function at high shear rate.

Platelet count

Normal range 150-450

¥ 10⁹/L. Adequate function is maintained even

when the count is <¹⁄3 normal level, but progressively deteriorates as it

drops. With platelet counts <20

¥ 10⁹/L there is usually easy bruising,

370

petechial haemorrhages (although more serious bleeding can occur).

Morphology

Large platelets are often biochemically more active; high mean platelet

volume is associated with less bleeding in patients with severe thrombo-

cytopenia. Reticulated platelets can be counted by new analysers and may

prove to be useful in assessing platelet regeneration. Altered platelet size

is seen in inherited platelet disorders.

Platelet adhesion

Rarely performed in routine lab practice.

Platelet aggregation

Performed on fresh sample using aggregometer but poor correlation with

bleeding tendency except in specific circumstances, e.g. Glanzmann’s

thrombasthenia, Bernard-Soulier syndrome.

Aggregants

2 Adenosine 5-diphosphate (ADP) at low and high concentrations.

Induces 2 aggregation waves: primary wave may disaggregate at low

conc. ADP; the second is irreversible.

2 Collagen has a short lag phase followed by a single wave and is particu-

larly affected by aspirin.

2 Ristocetin induced platelet aggregation (RIPA) is carried out at a high

(1.2mg/mL) and lower concentrations (0.5mg/dL)and is mainly used to

diagnose type 2B vWD.

2 Arachidonic acid.

2 Adrenaline, not uncommonly reduced in normal people.

For aggregation patterns in the various platelet disorders

p372.

Haemostasis and thrombosis

PFA-100

This is an automated machine that measures the ability of platelets to

close an aperture at high shear rate. Reproducible on sample with minimal

manipulation. Increasingly replacing bleeding time in laboratory practice.

Platelet release

ELISA or RIA are used to measure the a granule proteins b-thromboglob-

ulin (b-TG) and platelet factor 4 (PF4). These are beyond the scope of the

routine laboratory.

Practical application of the tests

Main role is in diagnosis of inherited platelet functional defects (

p372).

In acquired platelet dysfunction secondary to causes such renal and

hepatic disease, DIC, macroglobulinaemia, platelet function is rarely

tested.

Drug induced thrombopathy

Many drugs e.g. aspirin, NSAIDs, corticosteroids, antiplatelet drugs (e.g.

dipyridamole), antibiotics (penicillin, cephalosporins), membrane stabil-

ising agents (b-blockers), antihistamines, tricyclic antidepressants, a antag-

371

onists, miscellaneous agents (e.g. heparin, alcohol, dextran) may affect

platelet function but tests are rarely performed.

Hereditary platelet disorders

All rare. Acquired platelet dysfunction is much more likely to be a cause of

bleeding or easy bruising. Two main hereditary qualitative defects are found

1. Defective platelet membrane glycoproteins

(GPs). GPIIb/IIIa is a

receptor for fibrinogen and other adhesive GPs; also affected is GPIb

(specific platelet receptor for vWF). Disorders include Glanzmann’s

thrombasthenia (abnormal GPIIb/IIIa) and Bernard-Soulier syndrome

(BSS)—abnormal GPIb, a specific receptor for vWF with defective

adhesion to blood vessels.

2. Abnormalities of platelet granules ie storage pool deficiency (SPD).

Either the alpha (a) granules (grey platelet syndrome), the dense gran-

ules (May-Hegglin anomaly, Hermansky-Pudlak syndrome, Chediak-

Higashi syndrome and the thrombocytopenia-absent radius (TAR) syn-

drome), or both.

Clinical features

Presenting symptoms of inherited platelet dysfunction: mucocutaneous

bleeding (skin, nose, gums, gut) with a positive family history (though not

always found). All autosomal recessive. Clinically the bleeding symptoms

are similar but may be other clinical features to distinguish the syndromes.

Carriers asymptomatic. Menorrhagia may be troublesome. Symptoms may

suggest the diagnosis of non-accidental injury in young children. Bleeding

in Glanzmann’s may be severe and life threatening.

372

Laboratory findings

2 Normal platelet count and size (except for BSS where platelets large

and count 5).

2 Abnormal PFA-100. Abnormal platelet aggregation with common

aggregants (see table).

2 Occasionally aggregation is normal.

2 Consider aspirin and vWD in the differential diagnosis.

Condition

Platelet

Aggregation with

Count

Size

ADP

Collagen Ristocetin

Thrombasthenia

absent

Bernard-Soulier

Absent

Storage pool disease N

N/abnormal N/abnormal N/abnormal

Aspirin ingestion

N/abnormal abnormal N/abnormal

von Willebrand’s

N/abnormal

N = normal; L = low

Defining abnormality in Glanzmann’s thrombasthenia is absent aggregation

to both low and high dose ADP and confirmation of membrane defect by

flow cytometry with monoclonal antibodies to GPIIbIIIa. Similarly in BSS

absent aggregation with ristocetin and confirmation by flow cytometry and

monoclonal antibodies to GPIb. In the grey platelet syndrome, the platelet

count is often low and the platelets pale, grey and larger than normal.

Osler-Weber-Rendu (OWR) syndrome

Definition

Autosomal dominantly inherited disorder characterised by multiple skin

telangiectases. Also known as hereditary haemorrhagic telangiectasia. The

basic pathology is a developmental structural abnormality of blood

vessels. This results in dilatation and convolution of the venules and capil-

laries which may be present throughout the body. Theses telangiectases

are thin-walled and likely to bleed giving rise to recurrent haemorrhage

and anaemia.

Incidence

Rare. 9 = 3.

Clinical features

2 Presentation may not be until later life.

2 Facial and buccal mucosa and nail fold telangiectases.

2 Iron deficiency common as a result of bleeding from GIT telangiec-

tases.

2 Epistaxis—commonest presenting symptom.

2 Menorrhagia.

2 Prolonged bleeding after dental surgery.

374

Diagnosis and investigation

2 Recognition of typical telangiectases and family history.

2 Beware, another cause of bleeding may co-exist in a OWR patient.

2 FBC and film may show iron deficient picture, i.e. microcytic,

hypochromic anaemia, 5 MCV, raised platelets. 5 serum ferritin.

2 Angiography of mesenteric circulation in recurrent bleeding.

2 ENT examination.

2 CT scan to identify pulmonary AV malformations or desaturation on

exercise.

Treatment

2 Antibiotics for surgical/dental procedures as risk of cerebral abscess

due to bacteraemia and shunting in lungs.

2 Observation for iron deficiency.

2 Iron replacement therapy.

2 Consider interventional procedure e.g. embolisation (if angiography +ve).

2 Oestrogen reduces frequency of bleeding episodes.

Prognosis

Generally a benign chronic disorder provided follow-up as above.

Henoch-Schönlein purpura

Definition

An immune complex disease characterised by a leucocytoclastic vasculitis.

Purpura is not of haematological origin.

Incidence and epidemiology

Predominantly affects children aged 2-8 years. Clear preponderance in

the winter. Commonly presents 1-3 weeks after upper respiratory tract

illness. Various infections, toxins, physical trauma and possibly insect bites,

and allergies have all been postulated as triggers of the disease but no

clear causation established. May also occur with malignancy.

Clinical features

2 Rapid onset usual.

2 Classically a palpable purpuric rash over buttocks/legs (extensor sur-

faces).

2 Urticarial plaques and haemorrhagic bullae seen, often bizarrely sym-

metrical.

2 Abdominal pain ?due to mesenteric vasculitis.

2 Arthritis, particularly knees and ankles.

2 Renal involvement—haematuria ± proteinuria, may lead to either

acute or chronic renal failure.

376

Diagnosis and investigations

2 Made by the presence of typical findings above and exclusion of other

causes.

2 FBC and film normal. Platelet numbers and function are normal. The

purpura is not of haematological origin. ESR usually raised.

2 Other markers of autoimmune disorders may be present.

Treatment and prognosis

2 Spontaneous resolution within a month is commonest outcome in chil-

dren.

2 Long-term sequelae more common in adults e.g. chronic renal failure.

2 Steroids may be of benefit particularly if joint pains are troublesome.

Acquired disorders of platelet function

Acquired disorders may affect platelet-vessel wall interaction and are

among the most common causes of a haemorrhagic tendency. These con-

ditions may be associated with a prolonged bleeding time, abnormal

platelet aggregation studies and clinical bleeding or bruising.

Drugs that induce platelet dysfunction

2 Aspirin.

2 NSAIDs.

2 b-lactam antibiotics: penicillins and cephalosporins.

2 ‘Antiplatelet agents’: prostacyclin, dipyridamole.

2 Heparin.

2 Plasma expanders: dextran, hydroxyethyl starch.

2 Other drugs: antihistamines, local anaesthetics, b-blockers.

2 Food additives: fish oil.

Systemic conditions which affect platelet function

2 Renal failure.

2 Liver failure.

2 Glycogen storage disorders types Ia and Ib.

Conditions causing platelet exhaustion

2 Cardiopulmonary bypass surgery.

378

2 DIC.

2 Others: valvular heart disease, renal allograft rejection, cavernous hae-

mangioma.

Dysproteinaemias and antiplatelet antibodies

2 Multiple myeloma.

2 Waldenström’s macroglobulinaemia.

2 Autoimmune disorders.

Haematological conditions with production of abnormal

platelets

2 Chronic myeloproliferative disorders.

2 Myelodysplasia.

2 Leukaemia.

Drugs

Wide range of drugs reported to impair platelet function (most commonly

implicated drugs are listed).

Aspirin is commonest cause of clinically significant bleeding, due to

irreversible acetylation and inhibition of cyclooxygenase which interferes

with formation of thromboxane A2 in the platelet prostaglandin pathway.

Effect on bleeding time occurs within 2h of ingestion of 75mg. Aspirin

effect may last up to 10d after long term use. Greater effect on clinical

bleeding seen in patients who already have bleeding tendency. Laboratory

effects on a normal individual is usually mild and there is marked individual

variation in the risk of bleeding.

Effects of aspirin

2 Easy bruising, epistaxis, haematomas, haemorrhage after surgery espe-

cially in patients with a pre-existing bleeding tendency.

Haemostasis and thrombosis

2 Prolonged bleeding time/abnormal PFA-100.

2 Inhibition of platelet release reaction and second wave of platelet

aggregation to low concentrations of ADP and collagen.

NSAIDs cause reversible inhibition of cyclooxygenase. Effect on bleeding

and platelet aggregation is brief (only as long as circulating drug present)

and less likely to cause clinical bleeding in patients without a prior

bleeding disorder. b-lactam antibiotics affect platelet function by

lipophilic attachment to cell membrane in dose-dependent manner. Do

so only after sustained high dosage though effect may last 7-10d after

discontinuation. Antiplatelet agents, prostacyclin and dipyridamole high

cAMP concentration in platelets and inhibit platelet aggregation with

little/no effect on bleeding time. A diet rich in fish oils (omega-3 fatty

acids) can cause mild prolongation of bleeding time. Ethanol ingestion can

impair in vitro platelet function.

Aspirin should be avoided in patients with bleeding tendency. A patient on

aspirin should discontinue the drug at least a week prior to a surgical pro-

cedure. DDAVP or platelet transfusion should be administered to a

379

patient with severe haemorrhage due to aspirin-induced platelet function

defect. In cases with less severe bleeding, discontinuation of the suspected

drug is usually effective.

Renal failure—clinical bleeding occurs in patients with uraemia due to

chronic renal failure—the former correlates with the severity of the

uraemia. Bleeding time does not predict risk of haemorrhage and is not

indicated. PFA-100 requires evaluation as a predictor of risk of bleeding in

this situation. Associated anaemia also contributes to prolongation of

bleeding and correction of anaemia improves the abnormality.

Abnormalities of platelet aggregation studies are seen frequently. If

haemorrhage occurs in a patient with chronic renal failure, other causes

should be excluded before it is attributed to uraemia. Dialysis is mainstay

of treatment. DDAVP useful. Conjugated oestrogens improve platelet

function.

Liver failure—chronic liver disease, most notably cirrhosis, may be

associated with platelet function defects which may be due to

abnormalities in the platelet membrane glycoproteins. Abnormalities in

bleeding time and platelet aggregation studies may be improved by

DDAVP. Haemorrhage in a patient with liver disease is usually

multifactorial including decreased levels of coagulation factors,

dysfibrinogenaemia, thrombocytopenia due to splenic pooling and DIC.

Conditions causing platelet exhaustion—a number of conditions have

been associated with platelet exhaustion (acquired storage pool defect) in

which there is laboratory evidence of in vivo platelet activation and

decreased platelet aggregation in the pattern of a storage pool defect.

2 Cardiopulmonary bypass surgery.

2 DIC.

2 Valvular heart disease.

2 Renal allograft rejection.

2 Cavernous haemangioma.

2 Aortic aneurysm.

2 Transfusion reaction.

2 TTP and HUS.

Cardiopulmonary bypass surgery—abnormal platelet function and

thrombocytopenia are frequently seen in patients subjected to

cardiopulmonary bypass surgery. Impaired aggregation studies in vitro

occur in proportion to duration of the bypass procedure. Believed due to

platelet activation and fragmentation in the extracorporeal loop. Platelet

transfusion is required in patients with a prolonged bleeding time and

excessive haemorrhage after cardiopulmonary bypass surgery.

DIC—platelet exhaustion due to an acquired storage pool defect may

occur in DIC due to in vivo platelet stimulation and this may cause

abnormal platelet aggregation in in vitro tests. However, haemorrhage in

DIC is multifactorial (

p512).

Dysproteinaemias—binding of M-proteins to platelet cell membranes in

myeloma (particularly IgA) or Waldenström’s macroglobulinaemia may

result in acquired platelet function defects and less commonly clinical

bleeding. Severity of platelet function defect correlates with M-protein

concentration. Note: haemorrhage is more commonly due to

thrombocytopenia or hyperviscosity. Plasmapheresis to remove

380

circulating M-protein may be necessary in bleeding patient in whom the

M-protein may be contributory factor through hyperviscosity or

impairment of platelet function.

Antiplatelet antibodies—impaired platelet function may be a rare

consequence of binding of IgM or IgG molecules to platelet membrane in

ITP, SLE and platelet alloimmunisation where the most common result is

accelerated platelet destruction and thrombocytopenia. May result in

haemorrhagic manifestations at unexpectedly high platelet counts, and in

longer than expected bleeding time. If bleeding occurs treatment is that of

ITP (

p388).

Haematological disorders

Myeloproliferative disorders—qualitative platelet disorders occur in

association with a prolonged bleeding time and clinical bleeding in MPD.

Includes abnormal morphology with decreased granules, acquired storage

pool defects, abnormalities of platelet glycoproteins, receptors and

arachidonic acid metabolism. Haemorrhage

(mucocutaneous) and

thrombosis can occur in the same patient. Neither platelet function tests

nor degree of thrombocytosis correlates well with risks of bleeding or

thrombosis. An increased whole blood viscosity in patients with

polycythaemia is clearly related to risk of haemorrhage. There is evidence

that that lowering an elevated platelet count to <600

¥ 10⁹/L is associated

with a reduced risk of thrombosis. Hydroxyurea is effective. The role of

anagrelide is not yet clear. In patients with polycythaemia rubra vera the

haematocrit should be kept below 0.44 (3) or 0.47 (9). ( p243).

Myelodysplasia and leukaemia—abnormalities of platelet morphology

and in vitro aggregation occur in these disorders but haemorrhagic

problems are commonly due to thrombocytopenia.

Numerical abnormalities of

platelets—thrombocytosis

Defined as platelet count >450

¥ 10⁹/L. May be secondary (or reactive) to

another pathological process or it may be due to a myeloproliferative dis-

order. In MPD it may be associated not only with an increased risk of

thrombosis but also with an increased risk of haemorrhage.

Causes of reactive thrombocytosis

2 Haemorrhage.

2 Surgery.

2 Trauma.

2 Iron deficiency (

p56).

2 Splenectomy ( p582).

2 Infection.

2 Malignant disease.

2 Inflammatory disorders (rheumatoid arthritis, inflammatory bowel

disease).

Myeloproliferative disorders associated with thrombocytosis

2 Primary (essential) thrombocythaemia ( p250).

2 Primary proliferative polycythaemia (polycythaemia rubra vera,

382

p240).

2 Chronic myeloid leukaemia ( p164).

2 Idiopathic myelofibrosis (

p256).

Management

See relevant sections.

Numerical abnormalities of

platelets—thrombocytopenia

Defines a platelet count <150

¥ 10⁹/L. May be due either to decreased

bone marrow production of platelets or to increased destruction or

sequestration of platelets from the circulation (or both). Platelet counts

>100

¥ 10⁹/L are not usually associated with any haemorrhagic problems.

Purpura, easy bruising and prolonged post-traumatic bleeding are increas-

ingly common as the platelet count falls <50

¥ 10⁹/L. Although there is no

platelet count at which a patient definitely will or will not experience

spontaneous haemorrhage the risk is greater in patients with a platelet

count <20

¥ 10⁹/L and increases further in those with a count <10

10⁹/L.

Causes of decreased bone marrow production of platelets

2 Marrow failure: aplastic anaemia (

p122).

2 Marrow infiltration: leukaemias, myelodysplasia, myeloma, myelofi-

brosis, lymphoma, metastatic carcinoma.

2 Marrow suppression: cytotoxic drugs and radiotherapy, other drugs

(e.g. chloramphenicol).

2 Selective megakaryocytic: ethanol, drugs (phenylbutazone, co-trimoxa-

zole; penicillamine), chemicals, viral infection (e.g. HIV, parvovirus).

384

2 Nutritional deficiency: megaloblastic anaemia (

p60-62).

2 Hereditary causes (rare): Fanconi’s syndrome (

p456), congenital

megakaryocytic hypoplasia, absent radii (TAR) syndrome.

Causes of increased destruction of platelets

Immune

2 ITP ( p388).

2 Associated with other autoimmune states SLE, CLL, lymphoma (

p392).

2 Drug-induced: heparin, gold, quinidine, quinine, penicillins, cimetidine,

digoxin.

2 Infection: HIV, other viruses, malaria.

2 Post-transfusion purpura (

p506).

2 Neonatal alloimmune thrombocytopenia (NAIT,

p448).

Non-immune

2 DIC ( p512).

2 TTP/HUS ( p530).

2 Kasabach-Merritt syndrome.

2 Congenital/acquired heart disease.

2 Cardiopulmonary bypass ( p378).

Causes of platelet sequestration

2 Hypersplenism ( p392).

Causes of dilutional loss of platelets

2 Massive transfusion (

p524).

2 Exchange transfusion.

Investigation of thrombocytopenia

2 History—drugs, symptoms of viral illness.

2 Examination—signs of infection, lymphadenopathy, hepatosplenomegaly.

2 FBC—isolated thrombocytopenia or associated disorders.

2 Blood film—red cell fragmentation (DIC), WBC differential (atypical

lymphocytes/blasts), platelet size (large in ITP and some hereditary

conditions), platelet clumps (pseudothrombocytopenia).

2 Serology—antinuclear antibody, DAT, monospot, antiplatelet anti-

bodies (unreliable), platelet-associated antibodies (unreliable), HIV

serology.

2 Routine chemistry—renal disease, hepatic disease.

2 BM examination—megakaryocyte numbers, marrow disease or infiltra-

tion.

Thrombocytopenia due to decreased platelet production

Diagnosis is confirmed on bone marrow examination, and management is

essentially that of the underlying condition. Platelet transfusion may be

necessary for the treatment of haemorrhage in patients with bone

marrow failure and prophylactic platelet transfusion may be necessary if

persistent severe thrombocytopenia (<10

¥ 10⁹/L) occurs.

386

Immune thrombocytopenia

These conditions are due to IgG and IgM antibodies which react with anti-

genic sites (usually GPIIb/IIIa in ITP, platelet alloantigens in post-transfu-

sion purpura and neonatal isoimmune purpura) on the platelet cell

membrane, may fix complement and cause accelerated platelet destruc-

tion through phagocytosis by reticulo-endothelial cells in liver and spleen.

A compensatory increase in bone marrow megakaryocytopoiesis usually

occurs which may occasionally prevent or delay the development of

severe thrombocytopenia.

ITP

Usually presents with haemorrhagic manifestations, purpura, epistaxis,

menorrhagia or bleeding gums but may occasionally be detected in an

asymptomatic adult patient on a routine blood test. Intracranial bleeds

occur in <1% (associated with platelet count <10

¥ 10⁹/L). Commonest in

young adults (3>9). The natural history of childhood cases is acute in

90% and usually follows a self-limiting course without treatment. They are

often associated with a history of previous viral illness and complete reso-

lution may be expected within 3 months. In adults a chronic course is

usual and spontaneous resolution is rare (<5%).

Diagnosis

388

The platelet count may be <5-100

¥ 10⁹/L. Platelet size often 4 on the

blood film, reflected in 4 MPV; represents production of young platelets

by the reactive bone marrow. Diagnosis of ITP is confirmed by exclusion

of a secondary (other autoimmune or drug-induced cause) or hereditary

cause of thrombocytopenia in a patient with a normal physical examina-

tion, no splenomegaly and normal bone marrow examination. The

demonstration of platelet antibodies or increased platelet associated Ig

may be confirmatory but neither positive nor negative results are defini-

tive. A small proportion of patients have associated DAT +ve AIHA

(Evans’ syndrome), most of whom have an underlying disorder (CLL, lym-

phoma, SLE).

Treatment of ITP

No need to treat mild compensated ITP (>30

¥ 10⁹/L) unless haemor-

rhagic manifestations. Keep under regular review and advise urgent FBC if

haemorrhagic manifestations. Most children do not require treatment—

but those in whom chronic ITP develops are treated in the same way as

adults. 90% of children eventually recover completely. Aim of therapy of

adult ITP is to achieve an improved (preferably normal) platelet count

without need for long term maintenance therapy.

Prednisolone

2 First-line therapy for most patients.

2 Probably 5 platelet antibody production and interferes with phagocy-

tosis.

2 Dose is 1mg/kg/d PO, maintained for at 2 weeks.

2 Up to 75% patients will respond but only 15% CR. Note: magnitude

and speed of response correlates with long term prognosis.

2 Once patient has responded, taper prednisolone dose over several

months.

Haemostasis and thrombosis

2 Some patients will maintain an adequate platelet count (>30

¥ 10⁹/L)

on discontinuation of steroids or on a low maintenance dose.

2 Most adults relapse on tapering the prednisolone dose and require

other therapy.

IVIg

2 Action: blockade of phagocytes and possible anti-idiotype effect.

2 Most ITP patients will have significant platelet rise following administra-

tion of 2g/kg over 5d.

2 Effect often rapid (within 4d) but usually transient and lasts ~3 weeks

(may be prolonged in a minority).

2 Increment may be maintained with boosters of 0.4g-1g/kg.

2 Relatively non-toxic but expensive.

2 Useful in patients

- refractory to other treatments.

- who require an urgent increment for surgery and in pregnancy.

Splenectomy

2 The only proven curative therapy for ITP (spleen is major site of

389

platelet destruction). Usual pre- and post-splenectomy care (

p582).

2 Indium labelled platelet scan appears to be the only test able to

predict those patients who will benefit.

2 Consider for patients

- who fail to respond to prednisolone.

- requiring prednisolone >10mg/d to maintain acceptable platelet

count.

- who have unacceptable side effects with lower maintenance dose.

2 60-80% of patients achieve at least a partial response to splenectomy.

2 A brisk rise in platelet count in the immediate post-operative period is

a good prognostic sign.

Immunosuppressive agents

2 Act through inhibition of antibody production.

2 Effect takes at least 2 weeks (may be up to 3 months).

2 May be useful in patients

- who have failed to achieve an adequate response to splenectomy.

- in whom splenectomy is contraindicated.

- in whom an unacceptably high dose of prednisolone is necessary to

maintain a ‘safe’ platelet count.

2 Effective in up to 25% refractory patients.

2 Azathioprine is the most widely used agent in the UK (max 150mg/d).

(maintain neutrophil count >1.0

¥ 10⁹/L and platelet count >30

10⁹/L.

2 May be used with prednisolone to obtain an acceptable platelet count

and minimise the toxicity of each agent.

2 Cyclophosphamide and vincristine are alternatives.

2 Long term therapy carries risk of serious toxicity including MDS and 2°

leukaemias with azathioprine and cyclophosphamide.

Danazol

2 Effective in ITP.

2 Better for elderly (don’t use in young 3).

2 May be used as alternative to prednisolone or in combination.

2 Normal dose 400-800mg/d for 1-3 months tapering to 50-200mg/d.

2 Side effects: virilisation, weight gain and hepatotoxicity.

Other treatments

Intravenous anti-D

2 Will produce platelet increment in Rh(D) +ve non-splenectomized

patients.

2 Role in the management of children with chronic ITP and HIV-infected

patients.

2 Mode of action is reticuloendothelial blockade.

High dose dexamethasone

2 E.g. dexamethasone 20-40mg/d PO for 4 days; repeated 4-weekly.

2 May produce a response (less good in patients who have failed

splenectomy).

390

BCSH Guidelines: Investigation and management of ITP in adults, children and in

pregnancy can be found at www.bcshguidelines.com/pdf/BJH574.pdf

Other causes of thrombocytopenia

Gestational thrombocytopenia

Benign thrombocytopenia (platelets >80

¥ 10⁹/L) occurs in 5% of preg-

nancies. No treatment is indicated

ITP in pregnancy

Fetal thrombocytopenia may occur due to placental transfer of IgG anti-

platelet antibodies in a pregnant woman with ITP. Risk of intracranial

haemorrhage in fetus during delivery is low although thrombocytopenia

<50

¥ 10⁹/L may occur in the fetus in up to 30% of pregnancies in women

with previously diagnosed ITP. No good predictor for fetal thrombocy-

topenia. Differential diagnosis: gestational thrombocytopenia

(common);

count rarely <70

¥ 10⁹/L. Neonatal count normal. Other causes include

pre-eclampsia. Treatment with prednisolone, or IVIg should be adminis-

tered to the mother with thrombocytopenia severe enough to constitute

a haemorrhagic risk to her. Avoid splenectomy—high rate of fetal loss.

Severe maternal haemorrhage at delivery is rare but may require platelet

transfusion, IVIg and possibly splenectomy. Special antenatal treatment of

the fetus is unnecessary but avoid prolonged and complicated labour.

Ensure paediatric support at delivery and check neonatal platelet count -

monitor for several days (delayed thrombocytopenia). IVIg, prednisolone

or exchange transfusion may be required.

392

Other autoimmune thrombocytopenias

E.g. 2° to SLE and lymphoproliferative disorders (esp. low grade NHL and

CLL). May present with isolated thrombocytopenia and underlying dis-

order may only be discovered on further investigation. Often refractory to

therapy. Those with lymphoproliferative disorders will require

chemotherapy for that condition.

Neonatal alloimmune thrombocytopenia ( p448)

Post-transfusion purpura ( p506)

Rare but life threatening. Causes severe haemorrhage due to thrombocy-

topenia

~1 week after transfusion of blood or blood products.

Thrombocytopenia may persist for several days. Occurs most commonly

in 3 and is usually due to antibody to the platelet antigen HPA-1a in an

individual lacking this (2% of population) who has been previously sensi-

tised (usually by pregnancy).

Hypersplenism

Thrombocytopenia primarily due to platelet pooling in enlarged spleen. If

haemorrhagic complications, consider splenectomy if the underlying cause

is unknown or if treatment of underlying disorder has been ineffective.

Non-immune thrombocytopenia due to increased destruction

If haemorrhage occurs platelet transfusion is necessary. Patients with

platelet counts >50

¥ 10⁹/L may respond to DDAVP.

Drug-induced thrombocytopenia

Many drugs implicated in idiosyncratic thrombocytopenia, largely through

increased destruction—usually immune mechanism. In most cases the

patient has been using the drug for several weeks/months and thrombocy-

Haemostasis and thrombosis

topenia is severe (<20

¥ 10⁹/L). Most commonly implicated are heparin,

quinine, quinidine, gold, sulphonamides, trimethoprim, penicillins,

cephalosporins, cimetidine, ranitidine, diazepam, sodium valproate,

phenacetin, rifampicin, PAS, thiazides,

(furosemide), chlorpropamide,

tolbutamide, digoxin, methyldopa. If drug-induced thrombocytopenia sus-

pected, discontinue the offending agent(s). If the patient is bleeding

platelet transfusion should be administered. IVIg may be helpful.

Thrombocytopenia usually resolves quickly but may persist for a pro-

longed period notably that due to gold which may be permanent.

Implicated drugs should be avoided by that patient in future.

393

Thrombophilia

Thrombophilia is a heritable or acquired disorder of the haemostatic

mechanism predisposing to thrombosis, typically venous.

Arterial thrombosis is usually the result of atherosclerosis not blood

hypercoagulability. Important exceptions are antiphospholipid activity

(APL), paroxysmal nocturnal haemoglobinuria and rarely severe hyperho-

mocysteinaemia. Virchov’s triad of vessel, flow and blood is still a useful

aide memoire for causes of thrombosis. Testing for heritable throm-

bophilic is not indicated in patients with arterial thrombosis.

Pathogenesis

Arterial thrombosis (myocardial infarction or stroke) is a major cause of

death in people over the age of 40 and is usually secondary to underlying

arterial disease, atherosclerosis. Coagulation defects are rarely implicated

as significant determinant. Venous thrombosis also is a major cause of

morbidity and mortality with an overall annual incidence of 1/1000. Stasis

following trauma and surgery is a common aetiological factor as is

increasing age. Up to 40% of people >40 may develop deep vein throm-

bosis (DVT) following orthopaedic or major abdominal surgery; as many

as a third of medical patients in ITU may do so. Many medical conditions

increase the risk of thrombosis.

394

Arterial thrombosis

Venous thrombosis

Smoking

Surgery or trauma

Hypertension

Malignant disease

Atherosclerosis

Pregnancy/oral contraceptive pill/HRT

Hyperlipidaemia

Chronic inflammatory bowel disease

Diabetes mellitus

PNH

Clinical features

In many patients with thrombosis an underlying clinical risk factor will be

identified.

Who should be referred for investigation?

2 Arterial thrombosis—patients <50 years, without obvious arterial

disease: test for APL.

2 Venous thrombosis

- Familial thrombosis.

- Unexplained recurrent thrombosis.

- Unusual site e.g. mesenteric, portal vein thrombosis.

- Unexplained neonatal thrombosis.

- Recurrent miscarriage (=3).

- VTE in pregnancy and the OCP.

Laboratory investigation

1. Test for underlying medical causes of thrombosis.

2. FBC, ESR, LFTs, autoimmune profile, fasting lipids (arterial disease).

3. Lupus anticoagulant and anticardiolipin antibody titres.

Haemostasis and thrombosis

When should tests for heritable thrombophilia be performed?

2 When there is evidence of familial venous thrombosis and diagnosis of

thrombophilic defect may help determine management of symptomatic

patients.

2 When case-finding by family studies is likely to reduce risk of VTE at

high risk periods in family members.

Heritable defects typically tested for

2 Antithrombin.

2 Protein C.

2 Protein S.

2 APC resistance.

2 Factor V Leiden.

2 Prothrombin gene mutation (F2 G20210A).

2 High factor VIII level.

Conclusion

In most patients with thrombosis, trigger factors will be identified in the

history. APL is a relatively common acquired thrombophilic defect

395

detected by lupus anticoagulant activity or elevated anticardiolipin titres.

Should be considered in patients with VTE and young patient with arterial

thrombosis or those without evidence of atherosclerosis. Testing for

inherited thrombophilia is complex, more expensive and only worthwhile

in familial thrombosis. A strong family history of VTE will increase the

chance of identifying such defects.

British Committee for Standards in Haematology (2001) Investigation and management of heri-

table thrombophilia. Br J Haematol 114, 512-528.

www.bcshguidelines.com/pdf/BJH512.pdf

Inherited thrombophilia

At present 30-50% patients with thrombosis and a positive family history

will have a demonstrable thrombophilic abnormality on testing but this

rarely influences clinical management. The frequency of the commonly

identified heritable major factors is set out in table.

Defect

Relative risk of VTE

Patients with

Familial patients

first VTE

with VTE

FVL

2-6

15-20%

10-50%

F2 G20210A

2-4

5-10%

AT deficiency

1-2%

PC deficiency

1-2%

PS deficiency

4-10

3-6%

6-8%

Activated protein C resistance and factor V Leiden

APC resistance described in 1993 by Dahlback and colleagues. This is the

most frequent thrombophilic abnormality in Caucasians (see above), ~ 1

per 5000 of population homozygous. APC resistance is due to factor V

Leiden mutation in more than 95% of cases.

396

Pathogenesis

APC inactivates membrane bound factor Va through proteolytic cleavage

at 3 specific sites in the heavy chain. >95% cases APCR due to mutation in

factor V gene, resulting in glutamine to arginine at position 506 (denoted

FV:Q506, or factor V Leiden, FVL). APCR without FVL may be due to

other genetic defects, or acquired for example as a result of increased

factor VIII concentration.

Clinical features

VTE is increased 2- to 6-fold in heterozygotes and 50- to 100-fold in

homozygotes. Most individuals with FVL will not develop thrombosis;

other risk factors (e.g. trauma, surgery, OCP, pregnancy) are present in

>50% of patients who develop a thrombotic event, and increasing age is a

major risk factor. Recent studies indicate little if any value of case-finding

in relatives of affected symptomatic patients.

Pregnancy—risk of VTE estimated from personal and family history will

determine whether antenatal or postnatal prophylaxis is required..

OCP users have 4

¥ VTE risk compared to non-users generally. The FVL

mutation increase the risk a further 7-fold. Thus the absolute annual VTE

risk in women not taking COCs is 0.5/10,000. In women taking COCs the

risk is 2/10,000. In women COC users with the FVL mutation the risk is

15/10,000.

The FVL mutation is a minimal risk factor for arterial thrombosis and of no

consequence compared to typical risk factors such as smoking, hyperten-

sion and hyperlipidaemia.

Haemostasis and thrombosis

Laboratory diagnosis

Detected by PCR technique. APC sensitivity test measures prolongation

of APTT in response to added activated protein C. A reduced response

indicates APC resistance. Positive result is not specific for FVL defect.

Prothrombin gene mutation

A G7A nucleotide transition at position 20210 in the 3’ untranslated

region of the prothrombin gene was reported in 1996. Incidence: 5%

patients with first episode of VTE.

Proteins C and S deficiency

Vitamin K dependent factors. Protein S is a cofactor for anticoagulant

activity of activated protein C (APC). APC cleaves factors V and VIII on

phospholipid surfaces thus limiting thrombin generation. Deficiency

results in prothrombotic state and increased risk of VTE.

Less common than FVL, they account for 4-8% of familial thrombosis.

Concentrations are low in early life (up to 4 years for PC), following

recent thrombosis, vitamin K deficiency, warfarin therapy, in pregnancy

(PS) so care must be taken before diagnosing an inherited deficiency.

397

DNA techniques available but not practical for routine diagnosis.

Many patients are asymptomatic and will never have a VTE. Clinically PC

and PS deficiency are similar—spontaneous and sometimes recurrent

thrombophlebitis and VTE. In neonates with severe deficiency (homozy-

gous) purpura fulminans is life threatening. This is due to microvascular

thrombosis (DIC). Skin necrosis may complicate warfarin therapy.

Antithrombin III (AT) deficiency

AT, the main co-factor of heparin and inhibitor of thrombin, was the first

major familial defect described

(1965). VTE thrombosis risk appears

greater than PC/PS deficiency particularly during pregnancy. Homozygous

severe AT deficiency is probably incompatible with life.

Homocysteinaemia

Hyperhomocysteinaemia may be due to genetic defects, vit B₁₂ or folate

deficiency. A severe form (congenital homocystinuria) is associated with

arteriosclerosis, thromboembolic disease and mental retardation. Arterial

and venous thrombosis is reported in ~10% patients with moderate

hyperhomocysteinaemia; may be familial and linked to other throm-

bophilic defects e.g. PC deficiency. Treatment with folate, vit B₁₂ may

reduce the hyperhomocysteinaemia but clinical benefit is unproven.

Treatment of thrombophilic states

Treatment often the same in patients with and without laboratory evi-

dence of thrombophilia.

Acute thrombotic event

2 Treat appropriately—usually with heparin/warfarin.

2 In PC/PS patients make sure heparinisation is adequate—monitor war-

farin induction closely to avoid skin necrosis. Patients with AT defi-

ciency do not usually require high heparin doses.

2 Duration of anticoagulation following a first event will depend on the

severity of the VTE and clinical risk factors for recurrence; each patient

needs to be individually assessed. Heritable thrombophilia is not an

indication of itself for life-long anticoagulation.

Recurrent thrombosis

2 Long-term anticoagulation should be considered

Concentrates

AT and PC concentrates have been used rarely in patients with heritable

deficiency during surgical and pregnancy high risk periods but they are not

used routinely in the majority of patients.

PC concentrate should be used in fulminant neonatal thrombosis,

including purpura fulminans, in severe homozygous deficiency.

Prophylaxis

2 Anticoagulation is not recommended for asymptomatic patients.

2 Prophylaxis in pregnancy depends on family history and nature of

thrombophilic defect. For management of pregnant patient with history

of VTE, prophylactic heparin has been successful in subsequent preg-

398

nancies.

2 High risk situations e.g. surgery, trauma, should be identified and

covered with prophylactic SC heparin. Dose will depend on the

thrombotic risk.

p588

2 Patients must be informed of factors that increase thrombotic risk and

given an information sheet.

2 Patients with an identified thrombophilic defect should be advised of

increased risk of VTE with the OCP or HRT.

Counselling

Before embarking on a search for heritable thrombophilia, it is essential

that careful thought be given to any possible value for the patient and

family.

Natural history

Complicated. At one end of the spectrum, FVL occurs in 3.5% of a healthy

population and may give rise to no problems throughout life; at the other

PC deficiency causes fatal neonatal purpura fulminans and homozygous

AT deficiency is incompatible with life. Thrombophilia has a whole range

of clinical problems and new information is accumulating. The patient is

best managed in a specialist clinic.

Acquired thrombophilia

Lupus anticoagulant

The paradoxically named lupus anticoagulant (LA) is arguably the com-

monest coagulation abnormality predisposing to thrombosis. It is some-

thing of a misnomer as it increases the risk of thrombosis not bleeding. It

is an IgG /IgM autoantibody and prolongs phospholipid dependent coagu-

lation tests (hence the use of the term anticoagulant); bleeding is very rare

despite the prolonged APTT. The LA and other antiphospholipid anti-

bodies (APL) are found in association with arterial or venous thrombosis

and/or recurrent fetal loss, the

‘antiphospholipid syndrome’, first

described by Hughes in 1988.

Pathogenesis

APL may be idiopathic or secondary when associated with other disor-

ders. The two main aPL are the LA and the anticardiolipin antibody (ACL)

occurring together in most cases but also independently. The antibody

specificity is actually to b2-glycoprotein 1 (b2GP1), a phospholipid mem-

brane-associated protein. Rarely antibodies to prothrombin co-exist and

can cause hypoprothrombinaemia and bleeding. The mechanism of throm-

bosis is not clear; APL may act against other vitamin K dependent proteins

PC and PS, or possibly the autoimmune state may lead to endothelial

400

damage and/or platelet activation.

Acquired thrombophilia due to APL is a much commoner cause of throm-

bosis than the congenital defects; the incidence depends on the patient

group-e.g. 18% in young stroke patients, 21% young patients with MI. The

LA occurs in 1-2% of the population; most patients will not develop

thrombosis.

Diagnosis

Clinical features

The LA was first described in patients with SLE—hence its name. Other

underlying disorders include the lymphoproliferative disorders, HIV, other

autoimmune disorders and drugs (e.g. phenothiazines). The antiphospho-

lipid syndrome (APS) is seen in patients with SLE but is often primary.

Thrombosis, the major defining feature, may be arterial (stroke, ocular

occlusions, MI, limb thrombosis) or venous (DVT, PE, renal, hepatic and

portal veins). Fetal loss may be as high as ~80% in women with APL.

Other clinical manifestations

2 Migraine, visual disturbances.

2 Thrombocytopenia.

2 Livedo reticularis.

2 Heart valve disease.

2 Myelopathy.

2 Catastrophic widespread intravascular thrombosis is reported.

Laboratory diagnosis

1. Must double spin or filter plasma to remove all platelets and prevent

false negative result.

2. Coagulation screen: APTT maybe prolonged and does not correct

with normal plasma. Normal result does not rule out the condition as

Haemostasis and thrombosis

different reagents have different sensitivity. PT usually normal unless

hypoprothrombinaemia is present.

4. Dilute Russell’s viper venom time (DRVVT).

5. Exner test— kaolin clotting time: platelet extract or excess phospho-

lipid corrects the abnormal test and confirms antiphospholipid defect.

6. aCL is detected using an immunoassay technique and is quantified.

7. Autoimmune profile: ± ANA ± DNA binding.

Treatment

Asymptomatic patients APL positive without thrombosis—no specific

action; the risk of thrombosis is estimated at <1% per patient year.

Prophylaxis—probably wise to consider peri-operative thrombo-

prophylaxis.

Antiphospholipid syndrome

Acute thrombotic events—treat as appropriate with heparin/warfarin.

Long term anticoagulation is required; target INR 2.5-3.5 depending on

clinical risk of recurrence.

401

Recurrent abortion—subsequent pregnancies have been successfully

achieved in women with the antiphospholipid syndrome with combined

aspirin and heparin (UFH or LMWH) begun as soon as pregnancy is

confirmed. Steroids are not indicated.

Prophylactic anticoagulation—pregnancy in a woman with APL and a past

history of thrombosis will require prophylactic anticoagulation with

heparin (

p588).

Natural history

The LA may be transient and spontaneous remissions of the APS are

reported. Long term follow-up of these patients is indicated since the clin-

ical manifestations can be severe despite long term anticoagulation.

BCSH Guidelines for the investigation and management of antiphospholipid syndrome. Br J

Haematol 109, 704-715 (2000).

www.bcshguidelines.com/pdf/bjh2069.pdf

Anticoagulant therapy

Heparin

LMWH is treatment of choice in most cases as low risk of HITT (heparin-

induced thrombocytopenia with thrombosis), given by SC injection and

usually does not require monitoring or dose adjustment. Indicated for pre-

vention and treatment of VTE and acute coronary syndromes.

If UFH is given then IV infusion should be monitored by regular APTT

measurement, at least once daily. APTT ratio usually maintained at 1.5-2.5

¥ normal.

HITT is an uncommon complication but high risk of death and limb ampu-

tation. Should be considered if 50% reduction in platelet count whilst on

heparin therapy. Difficult to confirm diagnosis with lab tests so diagnosis

should be made on clinical suspicion. Treatment is to stop all heparin,

including flushes, and give direct thrombin inhibitor such as recombinant

hirudin or danaparoid (non-heparin activator of antithrombin). HITT can

complicate low dose as well as therapeutic doses of heparin.

Warfarin:

Many indications. 1/100 population now taking warfarin. Monitored by

402

INR (International Normalized Ratio) which is a standardised PT ratio.

Target INR typically 2.5. Over anticoagulation common. More likely with

target INR >2.5 and when other drugs, particularly antibiotics, are pre-

scribed. Avoided by lowest possible target INR, testing within 5-7d of any

change in other drug therapy and patient awareness of change in bleeding

tendency.

Over anticoagulation due to warfarin increasingly treated with small doses

of vitamin K. For example INR >8.0 give 1-2.5mg vitamin K PO.

Note: severe overanticoagulation complicated by major bleeding should be

reversed by emergency administration of factor concentrate containing vitamin

K-dependent factors, e.g. beriplex. Recombinant factor VIIa may be considered if

beriplex or similar concentrate is unavailable. Alternatively FFP can be given but

reversal is often incomplete and massive volumes of FFP have to be given.

BCSH Guidelines on oral anticoagulation. Br J Haematol 101, 374-387 (1998).

www.bcshguidelines.com/pdf/bjh715.pdf

Anticoagulation in pregnancy and

post-partum

Pregnancy is a hypercoagulable state with an increased risk of thrombosis

throughout and up to 6 weeks post-partum. In addition to increased

venous stasis secondary to abdominal pressure and reduced mobility,

physiological prothrombotic changes in coagulation take place—see figure.

Incidence

The risk of venous thromboembolic events (VTE) increased 10-fold in

normal pregnancy ~1/1000 deliveries; fatal PE 10/year in UK is the major

cause of maternal death in pregnancy and the puerperium. The risk rises

when the pregnancy is complicated (sepsis, prolonged bed rest, advanced

maternal age, delivery by LSCS). Previous VTE particularly in pregnancy,

inherited/acquired thrombophilia further increase the risk.

Indications for anticoagulation in pregnancy

2 Acute VTE presenting in pregnancy.

2 Long term anticoagulation for prosthetic heart valves/recurrent VTE.

2 Previous VTE, particularly in pregnancy/post-partum.

2 Antiphospholipid syndrome (APS).

2 Inherited thrombophilia with/without a history of VTE.

404

General considerations

There are no universally accepted protocols for the management of anti-

coagulation in pregnancy. There are few controlled studies and much of

the information relates to non-pregnant subjects. Both oral anticoagulants

and heparin have advantages and disadvantages in pregnancy. LMWH are

a significant advance in management.

Warfarin crosses the placenta and is teratogenic in the first trimester.

Exposure during weeks 6-12 can cause warfarin embryopathy with nasal

hypoplasia, stippled epiphyses and other manifestations. Incidence ranges

from <5% to 67% in reported series. Warfarin at any stage of pregnancy is

associated with CNS abnormalities and increased risk of fetal haemor-

rhage in utero and at delivery.

Heparin (UFH and LMWH) does not cross the placenta and poses no ter-

atogenic or haemorrhagic threat to the fetus. Maternal complications

include haemorrhage (severe in <2%), thrombocytopenia (severe in <1%)

and osteoporosis, usually asymptomatic and reversible but rare cause of

vertebral fractures. LMWH may have fewer complications cf. unfraction-

ated (UF) heparin.

Treatment of VTE presenting in pregnancy

2 Heparin 5-7d

either monitored IV UF heparin; aim for APTT ratio 1.5-2.0

or therapeutic SC LMWH based on body wt ( BNF)

then monitored therapeutic SC 12-hrly UF heparin or LMWH od or bd

2 Heparin requirements vary as pregnancy advances so adjust dose as

necessary.

2 Continue heparin until delivery; omit heparin during labour.

2 Recommence heparin after delivery and start warfarin if desired.

Haemostasis and thrombosis

2 Continue treatment for at least 6 weeks post-partum; stop heparin

once INR in therapeutic range.

Prophylaxis of thromboembolism in pregnancy

National guidelines should be consulted and patients treated in centres

with special expertise.

Conclusion

There is an urgent need for controlled trials to establish the appropriate

level of anticoagulation in pregnancy. Currently many centres use LMWH

for all women except possibly those with prosthetic heart valves because

of ease of administration and 5 risk of complications.

Coagulation changes in normal pregnancy

Fibrinogen

VII

Increase during pregnancy

VIII

vW factor

405

XIII

Decrease during pregnancy

Protein S

Fibrinolysis

Rapid return to normal

post-partum

Toglia, M.R. & Weg, J.G. (1996) Venous thromboembolism during pregnancy. N Engl J Med, 335,

108-114.

Congenital immunodeficiency

syndromes

Incidence: rare, though as knowledge increases there is recognition of

an increasing number of inherited defects in the complex human host

defence system. The classical life-threatening disorders of specific

immunity with major dysfunction or absence of T cells and/or B cells are

all diseases that present in childhood, but milder variants may not be

recognized until later life. ‘Immunodeficiency’ is a vague term that is

generally taken to encompass also defects in opsonisation and

phagocytosis, so can be taken to include neutrophil and macrophage

disorders of number, function or both.

Classification of inherited immune deficiency syndromes

2 Affecting T cells, B cells and neutrophils.

2 Affecting B and T cells.

2 Affecting T cells.

2 Affecting B cells.

2 Affecting neutrophils.

1. Affecting T cells, B cells and neutrophils.

Reticular dysgenesis

An rare autosomal recessive or sometimes X-linked disorder where T

408

cells, B cells and granulocytes are absent. Such children present with

serious infection at birth or shortly afterwards. They have no lymph nodes

or tonsils, and the usual thymic shadow is absent. Bone marrow is

hypoplastic, and there may also be thrombocytopenia and anaemia. It

appears to be a pluripotential stem cell failure and carries a dire prognosis.

The only curative therapy is BMT.

2. Affecting T cells and B cells (combined immunodeficiency

disorders).

Severe combined immunodeficiency—SCID

A mixed group of disorders that all have grossly impaired T- and B-cell

function leading to death normally within the first years of life. They can

be broadly classified into 5 groups depending on their clinical and patho-

logical characteristics. Reticular dysgenesis (see above) is generally consid-

ered to be a SCID variant, accounting for 3% of the total. Other types are:

1. Adenosine deaminase deficiency (16%).

2. T- B- SCID (27%).

3. T- B+ SCID (44%).

4. T+ B+ SCID (9%).

Adenosine deaminase deficiency

A recessively inherited enzyme deficiency. ADA is rate limiting in purine

salvage metabolism and is essential for the synthesis of nucleotides in cells

incapable of de novo purine synthesis—including lymphocytes. The gene

for ADA is on chromosome 20q13.4, and many mutations have been

defined. Gene deletion leads to very low ADA activity and a profound T

and B lymphopenia with early onset of clinical symptoms. Other tissues

Immunodeficiency

are involved, and there may be bony defects and neurologic disturbances.

A similar rare syndrome is seen with deficiency of the enzyme purine

nucleoside phosphorylase. It is less severe and presents later.

Other forms of SCID

SCID with both T-cell and B-cell lymphopenia is a recessive disorder that

also occurs without the enzyme deficiencies described above, but the com-

monest form of the disease is X-linked and shows a lack only of T cells. It

appears to be due to a defect in the gene coding for the g chain of the

interleukin (IL)-2 receptor. There are other rare SCID variants where T

cells are present but dysfunctional, including MHC class II deficiency, where

lymphocytes fail to express MHC class II molecules; and Omenn’s syn-

drome which presents in early infancy with the clinical features of acute

widespread graft versus host disease (skin rash, hepatosplenomegaly, diar-

rhoea, failure to thrive) coupled with persistent infections. It is thought to

be due to a failure in T-cell development with inability to recognise self

antigens.

Treatment of SCID

2 Matched BMT is the treatment of choice for all varieties; a good

outcome can be expected in >90%.

2 No pre-conditioning needed for matched donors.

409

2 Mis-matched BMT results improving but donor marrow needs careful

mature T-cell depletion and patients may need conditioning.

2 ADA deficiency can be treated with regular enzyme replacement using

a polyethylene glycol-linked ADA preparation.

2 ADA deficiency has also been treated with gene replacement therapy,

with so far only a transient effect, but the technique shows promise.

Wiskott-Aldrich Syndrome

An X-linked disorder with a triad of (1) eczema, (2) thrombocytopenia

with characteristically small platelets, and (3) T- and B-cell dysfunction

with susceptibility to infections, particularly otitis media and pneumonia.

Due to a mutation in the gene encoding the Wiskott-Aldrich syndrome

protein (WASP), important inter alia in regulating the cytoskeleton of

haemopoietic cells.

2 Presents in childhood.

2 Tendency to immune cytopenias—compounding pre-existing throm-

bocytopenia and causing haemolytic anaemia.

2 Herpes simplex, EBV, varicella and CMV may be severe and life threat-

ening.

2 Greatly increased risk of lymphoid malignancy in adulthood for sur-

vivors.

2 Splenectomy greatly increases risk of fatal infection.

2 Need prophylactic antibiotics and immunoglobulin replacement

therapy.

2 BMT now treatment of choice; early in childhood if possible.

Ataxia telangiectasia

A recessive disorder with increased chromosome fragility and a single

gene defect on chromosome 11q22-23. This affects several systems. The

first is neuromotor development with cerebellar ataxia appearing around

18 months of age and progressing to include dysarthria associated with

degeneration of the Purkinje cells. Telangiectases appear between 2 and 8

years of age affecting the eyes, face and ears. An immune deficiency is

evident affecting both humoral and cellular immunity, though less severe

than SCID. Affected children get:

2 Sinopulmonary infections.

2 Progressive failure of antibody production.

2 Hypogammaglobulinaemia.

2 CD4+ lymphopenia.

2 Small thymus.

2 Increased incidence of lymphoid malignancies.

3. Affecting T cells

DiGeorge syndrome

Absence or hypoplasia of the thymus and parathyroid glands with aortic

arch anomalies or other congenital heart defects. This congenital anomaly

of the 3rd and 4th branchial arches usually presents with hypocalcaemic

fits or problems with a heart defect. Total thymic aplasia occurs only in a

minority, with severe immunodeficiency and a high risk of transfusion-

transmitted GvHD. Most have some T-cell function, and relatively minor

problems with impaired immunity for which treatment is supportive.

410

4. Affecting B cells

X-linked agammaglobulinaemia (Bruton tyrosine kinase deficiency)

Boys with this condition have mutations in the gene for Bruton tyrosine

kinase (locus Xq22), resulting in a failure of B-cell development and lack of

antibody production. Early infancy is not a problem because of maternally

transmitted IgG, but by 2 years of age serious infections become apparent.

These include bacterial invasion of the respiratory system, the GI tract,

meninges, joints and skin. Viruses, particularly coxsackie and echoviruses,

are also a major threat.

2 Absent or very low numbers of B cells.

2 Absent or low levels of all immunoglobulins.

2 Treatment is by regular antibody replacement with polyvalent IVIg.

Hyper IgM syndrome

An X-linked disorder with B-cell dysfunction due to defective T-cell CD40

ligand production and thus lack of signaling to B-cell CD40 receptors. B

cells are normal, but receive no instructions to generate isotypes of Ig

other than IgM. Low levels of IgG, IgA and IgE result. There is also defi-

cient function of some tissue macrophages and a tendency to develop

Pneumocystis carinii pneumonia. Treatment is with IVIg replacement

therapy and cotrimoxazole prophylaxis.

IgA deficiency

A relatively benign and common disorder affecting 1:500 individuals. They

may develop anti-IgA antibodies in serum which can cause urticarial and

anaphylactic reactions to blood product infusions. No replacement

therapy is needed.

Immunodeficiency

5. Affecting neutrophils, monocytes and macrophages.

Inherited disorders of neutrophil function mostly present in childhood and

are described in the paediatric section on congenital neutropenia. Primary

functional disorders of monocytes and macrophages are also described in

the paediatric section under histiocytic syndromes.

6. Poorly characterised primary immune deficiency syndromes.

There are a number of syndromes where susceptibility to certain types of

infection is not associated with a clear pattern of inheritance and where

the clinical picture is variable. Few are as severe as the specific syndromes

referred to above. They include chronic mucocutaneous candidiasis, where

there is persistent superficial skin and mucous membrane fungal infection,

and where there may be defective T-cell regulation or dendritic cell func-

tion. CMC is also associated with a wide variety of autoimmune phe-

nomena, particularly thyroid and adrenal disease, and different patterns of

inheritance are seen in different kindreds.

There is also a heterogeneous group of disorders collectively referred to

as common variable immunodeficiency. Defined by the clinical susceptibility

to infection and in the absence of any other apparent cause, this collec-

tively named syndrome is usually a diagnosis of exclusion and presents in

adult life. Low rather than absent levels of several isotypes of Ig are usual,

411

and the condition is rarely life threatening.

Acquired immune deficiencies

Clinically important defects in lymphocyte numbers and/or function can

be seen as a complication of a variety of acquired diseases. They can also

be due to drugs, both those given deliberately to suppress an autoimmune

process and those given primarily for other reasons. Similarly neutrophils

can be reduced by a large number of acquired disorders and a long list of

drugs and toxins. An acquired susceptibility to infection also arises in

patients with absent or poorly functioning spleens.

Acquired hypogammaglobulinaemia

Causes

2 Malignant lymphoproliferative disorders including CLL and myeloma.

2 Immunosuppressive therapy with e.g. azathioprine.

2 Maintenance therapy for ALL.

2 Nephrotic syndrome.

Clinical features

Bacterial infections—recurrent chest infections (may lead to bronchiec-

tasis), sinus, skin and urinary tract infections common. Fulminant viral

infections, especially measles, varicella.

Treatment

2 May improve with treatment of the underlying disease.

2 IVIg should not be used routinely as prophylaxis.

2 High titre specific antibody can be given for serious zoster/varicella

infections if available; polyvalent for measles.

412

2 Patients with severe hypogammaglobulinaemia and recurrent infections

may be considered for IVIg replacement therapy—give 200mg/kg every

4 weeks.

Acquired T-lymphocyte abnormalities

Reduced numbers

2 HIV infection (see following pages).

2 High dose steroids.

2 ALG.

2 Purine analogues especially fludarabine and cladribine.

2 Deoxycoformycin (adenosine deaminase inhibitor).

2 After allogeneic stem cell transplantation.

Reduced function: Lymphoproliferative disorders, Hodgkin’s disease,

immunosuppressive agents e.g. cyclosporin and steroids, burns, uraemia.

Clinical features: Increased risk of viral, fungal and atypical infections

including HSV, HZV, CMV, EBV, Candida, Aspergillus, Mycoplasma, PCP,

toxoplasmosis, TB and atypical mycobacteria.

Treatment: Treat specific infection where possible. Consider prophylaxis

against HZV, CMV, PCP and Candida in high risk groups e.g. post-

allogeneic stem cell transplant.

Immunodeficiency

Combined B- and T-lymphocyte abnormalities

Causes

2 Chronic lymphocytic leukaemia.

2 Intensive chemotherapy.

2 Extensive radiotherapy.

2 Severe malnutrition.

Clinical features and treatment

As above.

Neutrophil/macrophage abnormalities

Reduced numbers: See Neutropenia p136.

Abnormal function: See Myelodysplasia p218, Myeloproliferative disorders

p237, Histiocytic syndromes p490.

Clinical features: Bacterial and fungal sepsis.

Treatment: Treat specific infections and consider prophylaxis.

Hyposplenism

Hyposplenism is an acquired immunodeficiency without lymphocyte or

neutrophil abnormalities. It arises either following splenectomy, or due to

413

functional deficiency as part of another disorder, especially sickle cell

disease, inflammatory bowel disease, and following BMT. It gives rise to

susceptibility to overwhelming infection with certain organisms due to

lack of the spleen’s function as a filter. These include:

2 Streptococcus pneumoniae.

2 Neisseria menigitidis.

2 Haemophilus influenzae type B.

2 Falciparum malaria.

The risk of hyposplenic infection is greatest in children in the first 6 years

of life. It dwindles thereafter but the risk continues into adult life. All facing

splenectomy should be vaccinated against HIB and pneumococcus, and all

splenectomised children and young adults (and those with sickle cell

disease) should probably take prophylactic penicillin 250-500mg daily.

HIV infection and AIDS

Infection with HIV-1 or HIV-2 produces a large number of haematological

effects and can simulate a number of haematological conditions during

both the latent pre-clinical phase and once clinical syndrome of AIDS has

developed. HIV infection divided into four stages.

Stage 1: primary infection

Entry of HIV-1 or HIV-2 through a mucosal surface after sexual contact,

direct inoculation into the bloodstream by contaminated blood products,

or IV drug abuse can be followed by a transient febrile illness up to 6

weeks later associated with oral ulceration, pharyngitis, and lym-

phadenopathy. Photophobia, meningism, myalgia, prostration,

encephalopathy and meningitis may also occur. FBC may show lym-

phopenia or lymphocytosis often with atypical lymphocytes, neutropenia,

thrombocytopenia or pancytopenia. Major differential diagnoses are acute

viral meningitis and infectious mononucleosis. False +ve IM serology may

occur. Specific IgM then IgG antibody to HIV appears 4-12 weeks after

infection and routine tests for HIV may be -ve for up to 3 months.

However, the virus is detectable in plasma and CSF from infected individ-

uals during this period and the patient is highly infectious.

Stage 2: pre-clinical HIV infection

Although viral titres fall in the circulation at this time there is significant

and persistent virus replication within lymph nodes and spleen. The clini-

cally latent period may last 8-10 years and circulating CD4 T-cell count

414

remains normal for most of this period. However, there is a delayed,

gradual but progressive fall in CD4 T lymphocytes in most patients, who

may remain asymptomatic for a prolonged period despite modest lym-

phopenia. A number of minor skin problems such as seborrhoeic der-

matitis are characteristic of the end of the latent phase.

A patient with latent HIV infection may have isolated thrombocytopenia

on routine blood testing. This is due to an immune mechanism and may be

confused with ITP as there is frequently

platelet associated

immunoglobulin.

Stage 3: clinical symptoms

Marked by onset of symptoms, rising titre of circulating virus and decline

in circulating CD4 T-cell count to <0.5

¥ 10⁹/L. Wide variation in indi-

vidual patient’s rate of progression at this stage. A number of minor

opportunistic infections are common: oral/genital candida, herpes zoster,

oral leucoplakia. Lethargy, PUO and weight loss occur frequently.

Deepening lymphopenia (CD4 <0.2

¥ 10⁹/L) invariably present when

opportunistic infection occurs. Persistent generalised lymphadenopathy is

a condition where lymphadenopathy >1cm at 2 or more extra-inguinal

sites persists for >3 months. It is a prodrome to severe immunodeficiency,

opportunistic infection and neoplasia.

Stage 4: AIDS

AIDS is now defined as the presence of a +ve HIV antibody test associated

with a CD4 lymphocyte count <0.2

¥ 10⁹/L rather than by the develop-

ment of a specific opportunistic infection or neoplastic complication. This

Immunodeficiency

final stage of HIV infection is associated with a marked reduction in CD4

T cells, severe life-threatening opportunistic infection, neoplasia and neu-

rological degeneration. Severity of these complications usually reflects the

degree of immunodeficiency as measured by the CD4 T-cell count.

However, there is evidence that prophylactic therapy reduces the inci-

dence of complications and newer antiviral therapies slow the progression

of this stage.

Haematological features of HIV infection

2 Lymphopenia—CD4 lymphopenia may be masked by CD8 lymphocytosis

in stage 2; improved by antiviral therapy.

2 Neutropenia—marrow suppression by virus or therapy; splenic sequestra-

tion.

2 Normochromic/normocytic anaemia due to suppression of marrow by

virus or therapy. Microangiopathic haemolysis associated with TTP.

2 Thrombocytopenia—suppression of marrow by virus or therapy or short-

ened survival due to immune destruction (may respond to antiviral

therapy), infection, TTP or splenic sequestration.

2 Bone marrow suppression—direct HIV effect or complication of antiretro-

viral therapy, ganciclovir, trimethoprim or amphotericin B therapy.

2 Bone marrow infiltration—by NHL, Hodgkin’s disease, granulomas due to

M. tuberculosis and atypical mycobacteria or disseminated fungal disease.

415

Complications of HIV infection

Opportunistic infections

Complications of HIV infection

Fungal

Pneumocystis carinii

pneumonia

Candida albicans

oro-oesophageal

Aspergillus fumigatus

pneumonia

Histoplasma capsulatum

meningo-encephalitis, pneumonia

Mycobacterial

M. avium intracellulare

disseminated, intestinal

M. tuberculosis

pulmonary, intestinal

Parasitic

Cryptosporidium

hepatobiliary, intestinal

Isospora

colon, hepatobiliary

Toxoplasma gondii

multiple abscesses: CNS ocular, lymphatic

Viral

Cytomegalovirus

retinal, hepatic, intestinal, CNS

Herpes zoster

mucocutaneous

Herpes simplex

mucocutaneous

JC virus

CNS

Bacterial

Haemophilus influenzae

meningitis

Streptococcus pneumoniae pneumonia, meningitis, septicaemia

Therapy of HIV infection

Infection prophylaxis

Drugs

Activity against

Fluconazole/itraconazole

Oro-oesophageal candidiasis ±

cryptococcal meningitis

Trimethoprim

Pneumocystis carinii, ± ocular/CNS

toxoplasmosis

Dapsone/nebulised pentamidine

Pneumocystis carinii

Rifabutin/azithromycin/clarithromycin

M. avium-intracellulare

Acyclovir

HSV and HZV

?Ganciclovir

CMV

Antiviral therapy

2 Nucleoside class of viral reverse transcriptase (RT) inhibitors have

been widely used both as single agents and in combination: zidovudine

(AZT), didanosine (ddI), zalcitabine (ddC), stavudine (d4T), lamuvidine

(3TC) and abacavir.

2 Specific therapy is followed within hours by rapid clearance of virions

from the circulation and subsequently by reappearance of circulating

T cells and a rising count over several days. Viral resistance develops

418

with time, especially to single agent treatment.

2 Non-nucleoside class of reverse transcriptase inhibitors used in combi-

nation therapy: nevirapine and efavirenz.

2 Protease inhibitors interfere with virus assembly and have dramatic

effects on viral load: saquinavir, ritonavir, indinavir, amprenavir, nelfi-

navir.

2 The most effective antiretroviral therapy uses a combination of two

nucleoside RT inhibitors plus either a non-nucleoside RT inhibitor or

one or two protease inhibitors .and is currently recommended for all

patients with stage 3 and 4 disease.

Immunodeficiency

Treatment of complications

Oro-oesophageal candidiasis

Systemic fluconazole or amphotericin

then lifelong prophylaxis

Pneumocystis pneumonia

High dose co-trimoxazole or pentamidine

then lifelong prophylaxis

Tuberculosis

Multi-agent therapy (drug resistance

common) ± lifelong isoniazid prophylaxis

Fungal pneumonia

Amphotericin B then lifelong prophylaxis

CMV pneumonitis/retinitis

Ganciclovir/foscarnet then lifelong

prophylaxis

CNS toxoplasmosis

Pyrimethamine then lifelong prophylaxis.

Cryptococcal meningitis

Amphotericin/fluconazole

AIDS-related Kaposi’s sarcoma

Limited disease: local DXT, cryotherapy,

intra-lesional vincristine, interferon-α;

advanced disease: combination

chemotherapy such as adriamycin,

bleomycin and vincristine (ABV),

419

liposomal daunorubicin, paclitaxel

Non-Hodgkin’s lymphoma

Poor prognosis; combination chemotherapy

(often standard regimens at reduced

dosage due to toxicity) 50% response,

median survival <9 mo; CNS lymphoma

particularly poor prognosis;

palliative dexamethasone DXT

Paediatric haematology

Blood counts in children

422

Red cell transfusion and blood component therapy—special

424

considerations in neonates and children

Polycythaemia in newborn and childhood

428

Neonatal anaemia

430

Anaemia of prematurity

432

Haemolytic anaemia in the neonate

434

Congenital red cell defects

436

Acquired red cell defects

438

Haemolytic disease of the newborn (HDN)

440

Hyperbilirubinaemia

444

Neonatal haemostasis

446

Neonatal alloimmune thrombocytopenia (NAIT)

448

Congenital dyserythropoietic anaemias

450

Congenital red cell aplasia

452

Acquired red cell aplasia

454

Fanconi’s anaemia

456

Rare congenital marrow failure syndromes

458

Neutropenia in childhood

462

Disorders of neutrophil function

464

Childhood immune (idiopathic) thrombocytopenic purpura (ITP)

466

Haemolytic uraemic syndrome

468

Childhood cancer and malignant blood disorders

470

Childhood lymphoblastic leukaemia

474

Childhood lymphomas

478

Childhood acute myeloid leukaemia

482

Childhood myelodysplastic syndromes and chronic leukaemias

486

Histiocytic syndromes

490

Haematological effects of systemic disease in children

494

Blood counts in children

Blood counts in children are often different from adults, to varying

degrees at different ages. The differences are greatest during the neonatal

period.

Red cells

The relatively hypoxic intrauterine environment means that the newborn

is polycythaemic by adult standards, a phenomenon that self-corrects

during the first 3 months of life by which time the normal infant is anaemic

relative to adults. Neonatal red cells are also macrocytic by adult stan-

dards, a feature that also disappears during the first 6 months as HbA

replaces HbF.

2 Neonatal red cells show much greater variation in shape than those

from adults, particularly in premature babies—alarming microscopists

more used to adult blood films.

2 Occasional nucleated red cells are normal in the first 24-48h of life.

2 Iron lack is common around 12 months of age due to increased

demand from 4 red cell mass and (often) poor oral intake—cows’ milk

has virtually no iron content. The MCV falls to what would be abnor-

mally low levels for adults as a reflection of this.

2 In healthy premature neonates all these red cell differences may be

exaggerated, with a nadir Hb at 2-3 months of 8-9g/dL in those with

birth weight 1-1.5kg.

2 Children have slightly lower Hb than adults until puberty.

White cells

422

The most striking difference between children and adults is the high lym-

phocyte count in infants and young children. This means that the normal

differential WBC in those <4 years shows more lymphocytes than neu-

trophils. Otherwise most of the changes in white cell counts seen in chil-

dren are similar to those seen in adults and due to the same causes, with

a few exceptions:

2 Healthy term babies show a transiently raised neutrophil count in the

first 24h after birth (7-14

¥ 10⁹/L) which returns to the normal (adult)

range by 48h.

2 Immature neutrophils (band cells and myelocytes) may comprise

5-10% of the total WBC in healthy neonates.

2 Sick neonates with bacterial infections commonly show a paradoxical

neutropenia, with or without an increased band cell count.

2 Black children have lower neutrophil counts that other ethnic groups.

2 Lymphocytoses with very high counts occur in children with specific

infections—notably pertussis.

Platelets

Platelet counts in children are essentially the same as adults as far as the

lower limit is concerned, but there is greater volatility at the upper end

and infants tend to produce high counts (>500

¥ 10⁹/L) as part of an acute

phase reaction more frequently. There is a statistically significant fall in the

upper limit (95th centile) from 4 years onwards from around 500 to reach

350-400 by the end of childhood.

Paediatric haematology

Cord blood platelets are less reactive to aggregating agents in vitro and

have other features of hypofunction compared with mature platelets.

Normal blood count values from birth to adulthood

(source Pediatric Hematology 2E; eds. Lilleyman, Hann and Blanchette;

Churchill Livingstone, London 1999).

Age

Hb (g/dL) MCV (fL) Neuts

Lymph

Platelets

Birth

14.9-23.7

100-125

2.7-14.4

2-7.3

150-450

2 weeks

13.4-19.8

88-110

1.5-5.4

2.8-9.1

170-500

2 months

9.4-13.0

84-98

0.7-4.8

3.3-10.3

210-650

6 months

10.0-13.0

73-84

1-6

3.3-11.5

210-560

1 year

10.1-13.0

70-82

1-8

3.4-10.5

200-550

2-6 years

11.5-13.8

72-87

1.5-8.5

1.8-8.4

210-490

6-12 years 11.1-14.7

76-90

1.5-8

1.5-5

170-450

Adult 9

12.1-16.6

77-92

1.5-6

1.5-4.5

180-430

Adult 3

12.1-15.1

77-94

1.5-6

1.5-4.5

180-430

Neuts, neutrophils; lymph, lymphocytes and platelets, all ¥ 10⁹/L

Other haematological variables in childhood

423

There are important differences in the concentration of various clotting

factors during early infancy as described on p690. Other laboratory inves-

tigations where children differ include:

2 Reticulocyte counts low in the first 8 weeks of life as neonatal poly-

cythaemia corrects itself.

2 HbF comprises 75% of the total Hb at birth, 10% at 5 months, 2% at 1

year and <1% thereafter.

2 Some red cell enzymes (G6PD, PK, hexokinase) have greater activity

(150-200% of adult values) in neonatal RBC.

2 The lower limit of normal for serum ferritin at 1 year (12.5mg/L) is

50% of the LLN at 12 years (25mg/L).

2 B₁₂ and folate levels are around 2¥ higher in infants and younger chil-

dren than adults.

Red cell transfusion and blood

component therapy—special

considerations in neonates and children

Babies in Special Care Baby Units are now amongst the most intensively

transfused of our hospital patients.

2 To replace blood losses of investigative sampling.

2 To alleviate anaemia of prematurity.

Note:

2 Hb estimation alone is an inadequate assessment.

2 Hb reduction with symptoms, e.g. failure to thrive, is needed to justify

transfusion.

2 Generally, neonatal Hb <10.5g/dL + symptoms—transfuse; if neonate

requiring O₂ support, aim for Hb 13.0g/dL.

Source of blood

Directed donations from ‘walking donors’ (including donations from rela-

tives) cannot be regarded as safe as microbiologically-screened volunteer

donor blood—therefore not recommended.

Small volume transfusions

QUAD ‘pedipacks’ (SAGM blood) ensure that 4 transfusions possible

from a single donor and so 5 donor exposure in infant needing multiple

transfusions.

424

Pre-transfusion testing

Maternal and neonatal samples should be taken and tested as follows:

Maternal samples

1. ABO and Rh group.

2. Antibody screen.

Infant samples

3. ABO and Rh group.

4. DAT.

5. Antibody screen (if maternal sample unavailable).

Note: Provided no atypical antibodies are present in maternal or infant

serum and the DAT on the infant’s cells is -ve, a conventional cross-

match is unnecessary. Small volume replacement transfusions can be given

repeatedly during the first 4 months of life without further serological

testing. Transfusion centres may specifically designate a supply of low anti-

A, B titre group O Rh (D) -ve blood for use in neonatal transfusions.

After the first

4 months, compatibility testing should conform to

requirements for adults.

Exchange transfusions

2 To prevent kernicterus caused by rapidly rising bilirubin.

2 Most commonly needed in haemolytic disease of the newborn.

2 Plasma-reduced red cells (Hct 0.50-0.60).

Paediatric haematology

2 For small volume transfusions, age of red cells does not matter. For

exchange transfusions within 5d of collection. ([K⁺] levels rise in older

blood).

2 Transfusion should not take >5h/unit due to risk of bacterial prolifera-

tion.

2 Volumes of 5mL/kg/h usually safe.

Special hazards

2 GvHD: in congenitally immunodeficient neonates immunocompetent

donor T lymphocytes can cause GvHD—rare.

2 Need to irradiate all blood products in these children. Also irradiate if

first degree relatives used as donors.

2 CMV infection: particular risk in low birth weight babies, or immuno-

compromised children undergoing transplantation. CMV seronegative

donations should be used. Alternatively use (modern) leucodepletion

filter to reduce risk.

2 Hypocalcaemia—rare now, due to change of additive.

2 Citrate toxicity, also rare nowadays due to improvements in additive.

2 Rebound hypoglycaemia, induced by high glucose levels of blood trans-

fusion anticoagulants.

2 Thrombocytopenia—dilution, DIC.

2 Volume overload.

2 Haemolytic transfusion reactions in necrotising enterocolitis. Thought

to be due to the ‘T’ antigen on baby’s RBCs becoming exposed due to

425

action of bacterial toxin entering the blood from diseased gut. Anti ‘T’

is present in almost all donor plasma.

Use of 4.5% albumin

Use controversial, but may be helpful after large volume paracentesis, as

fluid replacement in therapeutic plasma exchange, or in nephrotic syn-

drome resistant to diuretics. There are better products for resuscitation

and volume expansion. Should NOT be used in nutritional protein defi-

ciency or chronic hypoalbuminaemia

(e.g. cirrhosis or protein-losing

enteropathy). Risk of infection transmission minimal but not zero.

Use of immunoglobulin

Intravenous polyvalent immunoglobulin widely used as replacement

therapy in immunodeficiencies, for Kawasaki disease to prevent the for-

mation of coronary microaneurysms, and also as non-specific agent for

reticuloendothelial blockade in immune cytopenias, chiefly (and usually

unnecessarily) in childhood ITP. Can get immunoglobulin with particularly

high titre against RSV, HZV and hepatitis B. Usually this is for intramus-

cular use only and should not be given IV due to risk of complement acti-

vation. IVIg has transmitted hepatitis C in the past due to poor virus

inactivation procedures, so should not be used in trivial conditions.

Use of FFP

Available in aliquots of 50mL. Must be ABO and Rh compatible. Infused

via filter. Main indication—DIC. No need for CMV screening, or irradia-

tion. Dose: 10-15mL/kg. Check PT and APTT. Repeat as necessary. May

need cryoprecipitate also (

p524, 654), if evidence of 5 fibrinogen

(<1.0g/L). Both contain untreated plasma, so potential infection risk,

though FFP should be virus-inactivated in future.

Use of platelets

2 Thrombocytopenia more hazardous in neonates, so prophylactic trans-

fusion if count <30

¥ 10⁹/L.

2 Reserve for children with marrow failure and counts <10

¥ 10⁹/L oth-

erwise:

- Only use in immune thrombocytopenia for life-threatening bleeding.

- Then use massive ‘swamping’ dose to overwhelm antibody.

- One dose (one paediatric platelet concentrate) contained in ~50mL

‘fresh’ plasma, available either from apheresis or buffy coat derived.

- Check increment 1h later if no clinical response.

- Care with volume overload.

- Must be administered within 2h of receipt on ward.

- Irradiate for immunosuppressed children.

- Refractoriness can arise due to alloimmune antibodies.

Use of granulocytes

2 Severely infected neonates may develop profound neutropenia.

2 Usually respond to antibiotic therapy.

2 Granulocyte transfusions very rarely given because of lack of effect,

risk of CMV and toxoplasmosis and respiratory distress syndrome.

2 Blood products now routinely leucodepleted to reduce risk of CMV

transmission.

426

Polycythaemia in newborn and

childhood

As in adults, polycythaemia in children may be relative or absolute (

p240, 248). The condition is usually secondary and most commonly seen

as a clinical problem in neonates or older children with congenital cyan-

otic heart disease or high-affinity abnormal haemoglobins. Primary poly-

cythaemia is very unusual in childhood; benign familial erythrocytosis is a

very rare autosomal dominant self-limiting condition of unknown aeti-

ology.

Pathophysiology

Polycythaemia is physiological in the neonatal period with 4 Hct (range

42-60% in cord blood) persisting in the first few days of life. Pathological

polycythaemia is defined in the neonate as Hct >65% (Hb >22.0g/dL), is

uncommon (<5% of all births) and usually due to hypertransfusion or

hypoxia.

Causes of polycythaemia in the newborn

2 Relative—dehydration, reduced plasma volume.

2 Hypertransfusion—delayed cord clamping, maternofetal, twin to twin.

2 Hypoxia—placental insufficiency, intrauterine growth retardation.

2 Endocrine—congenital adrenal hyperplasia, thyrotoxicosis.

2 Maternal disease—toxaemia of pregnancy, DM, heart disease, drugs

e.g. propranolol.

2 Other miscellaneous conditions such as Down syndrome.

428

Clinical features

Hyperviscosity may give rise to vomiting, poor feeding, hypotonia, hypo-

glycaemia, lethargy, irritability and tremulousness. On examination—

plethora, cyanosis, jaundice, hepatomegaly. Complications include

intracranial haemorrhage, respiratory distress, cardiac failure, necrotising

enterocolitis and neonatal thrombosis.

Diagnosis

2 Clinical presentation may suggest the diagnosis e.g. anaemic twin.

2 FBC (free-flowing venous sample) 4 neonatal Hct >65%.

2 Hypoglycaemia, hypocalcaemia, unconjugated hyperbilirubinaemia.

2 Hb studies for excess HbA—? maternal haemorrhage.

2 Radiology: CXR shows 4 vascularity, infiltrates, cardiomegaly.

Management

2 Supportive—IV fluids, close observation for complications.

2 Exchange transfusion—partial with FFP/albumin to 5 Hct<60%.

Vol of exchange (mL) = Blood vol ¥ (observed - desired Hct)

observed Hct

Treatment

As required for associated abnormalities.

Neonatal anaemia

Intrauterine conditions require a state of polycythaemia. Congenital

anaemia is present with cord blood Hb <14.0g/dL in term babies. In the

healthy infant, Hb drops rapidly after birth (

Blood Counts in Children

p690) and by end of the neonatal period (4 weeks in a term baby), the

mean Hb may be as low as 10.0g/dL. With 4 RBC destruction, there is a

concomitant 4 in serum bilirubin. Thus complex changes occur in this

period making distinction between physiology and pathology difficult.

Pathophysiology

In normal full term babies, red cell production 5 in the first 2-3 months of

life. RBC survival shortens; reticulocytes and erythropoietin production 5;

iron, folate and vitamin B₁₂ stores are normal. Anaemia in the neonate

may be due either to impaired production of RBCs or to increased destruc-

tion or loss.

Impaired production Increased destruction

Anaemia of prematurity Overt or concealed haemorrhage; repeated

Infection

venepuncture

a thalassaemia

Haemolytic anaemia

DBA

Non-immune

Immune

Fanconi anaemia

TORCH infection

Rh/ABO HDN

CDA

Congenital RBC abn.

Maternal autoimmune

Drugs, MAHA

haemolytic anaemia

TORCH, toxoplasmosis, rubella, CMV, herpes simplex; DBA, Diamond-Blackfan anaemia;

CDA, congenital dyserythropoietic anaemia; Rh/ABO HDN, rhesus/ABO haemolytic disease

430

of the newborn; MAHA, microangiopathic haemolytic anaemia.

Blood loss during delivery is common, in ~1% severe enough to produce

anaemia. Infection is also a significant cause of anaemia; primary haemato-

logical disorders are rare. Anaemia in premature infant is almost invariably

present, induced and multifactorial. Jaundice arises in 90% healthy infants

making interpretation of a raised bilirubin (

hyperbilirubinaemia, p444) a

critical piece of the jigsaw when investigating an anaemic neonate.

Clinical features

History may make the diagnosis. Check events at time of delivery, past

obstetrical history, maternal and family history. Non-specific symptoms—

lethargy, reluctance to feed, failure to thrive—all may indicate anaemia.

Laboratory tests

2 FBC and reticulocytes.

2 MCV and RBC morphology, bilirubin and Kleihauer (on mother)

Interpret as follows:

- Reticulocyte count normally very low in first 6 weeks of life.

- 4 haemolysis, blood loss.

- +ve Kleihauer suggests fetomaternal bleed (quantitate amount).

- Bilirubin 4 (unconjugated).

- Check DAT: +ve in immune haemolytic anaemia (except ABO

HDN).

Anaemia of prematurity

Anaemia is an almost invariable finding in the premature infant. By week

3-4 of life the Hb may be as low as 7.0g/dL in untreated infants. In a study

of very low birth weight infants (750-1499g) 75% required blood transfu-

sion. A number of factors are causal.

Pathogenesis

2 RBC production and survival are 5.

2 Erythropoietin production very low in the first few weeks.

2 Iatrogenic from repeated blood sampling (depletes the RBC mass and

Fe stores—by 4 weeks the premature baby may have had its total

blood volume removed).

Clinical features

The increased oxygen needs and metabolic demand of the premature

baby makes them less able to tolerate 5 Hb. Over 50% infants <30 weeks

gestation develop tachycardia, tachypnoea, feeding difficulties and

activity when anaemic. High HbF level and 4 O₂ affinity exaggerates the

hypoxia.

Treatment

2 Delayed cord clamping increases Fe stores.

2 Close control of blood sampling is important.

2 Transfusion indications will vary in neonatal units—decide on clinical

grounds, particularly if ventilated. The following are guidelines only:

- Prems <2 wk with Hb <14.0g/dL, Hct <40%.

- Prems >2 wk, Hb <11.0g/dL, Hct <32%.

432

2 A rising reticulocyte count in some centres is used as a sign to with-

hold transfusion.

2 Some studies have shown better weight gain in transfused infants (not

confirmed by others).

2 Fe supplementation (2mg/kg/d PO) after first 2 weeks and until iron

sufficient.

2 Erythropoietin—controversial. It can be effective but its indiscriminate

use is not encouraged. Large randomised trials have shown it to have

an effect, but its expense makes cost effectiveness a concern and

modern neonatal practice has already reduced the need for transfusion

making it less necessary. Its best use is probably reserved for transfu-

sion avoidance in infants weighing <1000g. A suitable regimen would

be 200-250u/kg SC ¥ 3/week between day 3 and week 6.

Natural history

Despite the growing safety of blood and its ready availability and conve-

nient packaging to reduce donor exposure, blood transfusion carries defi-

nite risks and is to be avoided. It is likely that in affluent societies the use

of erythropoietin will increase, despite its limited effect.

Haemolytic anaemia in the neonate

Normal red cell life span in term infants is <80 days, in pre-term infants

<50 days. Red cell ‘cull’ in first month with jaundice is physiologic.

Pathological haemolysis, when present, is most commonly due to isoim-

mune HDN secondary to fetomaternal blood group incompatibility in

Caucasian populations. In other ethnic groups G6PD deficiency and con-

genital infection are major causes.

Pathophysiology

Physiological haemolysis occurs soon after birth and there is a marked

drop in the Hb and RBC count in the first weeks of life. Neonatal RBCs

are more susceptible to oxidative stress and there is altered RBC enzyme

activity compared to adult RBC and reticulocytes. So pathological haemol-

ysis occurs in the neonatal period more than at any other time.

Causes of haemolytic anaemia

Haemolysis may be due to intrinsic defects of the RBC, usually congenital,

or to acquired extracorpuscular factors which may be immune or non-

immune as described below.

Clinical features

2 Pathological jaundice may be clinically obvious at birth or within 24h

(distinguishing it from the common physiological anaemia which occurs

>48h after birth,

Hyperbilirubinaemia, p444).

2 Anaemia may be severe depending on cause.

2 Infections are common cause of hyperbilirubinaemia ( p444) with

specific clinical findings. In utero infections (TORCH) do not usually

434

cause severe jaundice cf. post-natal bacterial sepsis where jaundice may

be striking and associated with MAHA.

2 Splenomegaly at birth indicates a prenatal event; when noted later it may

be secondary to splenic clearance of damaged RBC and is non-specific.

2 Kernicterus is the major complication of neonatal hyperbilirubinaemia.

2 Family history and drug history may be informative.

Laboratory diagnosis of haemolysis

2 4 unconjugated bilirubin with anaemia is hallmark of haemolytic

anaemia.

2 4 reticulocytes (haptoglobins are unreliable in the newborn).

2 Blood film—may show RBC abnormalities e.g. spherocytes, ellipto-

cytes, fragmented cells.

2 DAT, if +ve indicates immune haemolysis; -ve does not rule this out—

especially consider ABO HDN.

2 Heinz body test—positive in drug-induced haemolysis, G6PD defi-

ciency and occasionally other enzyme disorders.

2 Intravascular haemolysis—look for haemoglobinuria/haemoglobinaemia.

Congenital red cell defects

Pathophysiology

The neonate is uniquely disadvantaged when it comes to handling patho-

logical haemolysis because of hepatic immaturity and altered enzyme

activity. Thus congenital defects of the RBC commonly present in the

newborn except for defects involving the b globin chain (e.g. SCD, b tha-

lassaemia) which become clinically manifest several weeks after birth but

can be diagnosed in utero, or in the neonatal period if suspected. HS is the

commonest congenital haemolytic anaemia in Caucasian populations; half

present in the neonatal period. Worldwide, G6PD deficiency occurs in 3%

population; neonatal presentation is common in Mediterranean and

Canton peoples. a thalassaemia is incompatible with life causing hydrops

fetalis (all 4 a globin genes deleted), or may present as HbH disease (3 of

the 4 a globin genes deleted) with mild to moderate haemolysis in

neonate.

Hereditary RBC defects in neonatal haemolytic anaemia

2 Membrane defects

- Hereditary spherocytosis, hereditary elliptocytosis and variants

e.g. stomatocytosis and pyropoikilocytosis (Afro-Americans).

2 Haemoglobin defects

- adb thalassaemia.

- Unstable haemoglobins (e.g. HbKöln, HbZurich).

2 Enzyme defects

- Glycolytic pathway; pyruvate kinase and other enzyme deficiencies.

- Hexose monophosphate shunt; G6PD deficiency, other enzymes.

436

Clinical features

Congenital haemolytic anaemia with mild or moderate unconjugated

hyperbilirubinaemia. No gross excess of bile pigments in urine (old collec-

tive name for these diseases was

‘acholuric jaundice’),

hepatosplenomegaly. A +ve family history is common but not invariable.

Laboratory investigation

May be difficult to diagnose in neonate, especially if post-transfusion.

Often have to wait until clinically stable some weeks/months later.

2 Exclude acquired disorders, and immune lysis (DAT).

2 RBC morphology is one key to diagnosis and further investigation, but

spherocytes not specific for HS.

2 Further tests for suspected

- Membrane defect (osmotic fragility, autohaemolysis, membrane

chemistry).

- Hb defect; Hb electrophoresis, HbF, A₂ measurement.

- Enzyme defect; Heinz body prep, screening tests for specific

enzymes, G6PD, PK.

2 Heinz body test +ve

- Drug or chemical induced in neonate without hereditary defect.

- Enzyme deficiency: G6PD commonest but consider others.

- Unstable Hb.

- athalassaemia.

Acquired red cell defects

These may be either immune or non-immune. Main cause of the latter will

be underlying infection either acquired in utero or in the days following

delivery. Drug-induced haemolysis in the newborn is rare.

Pathophysiology

Neonatal RBCs have 4 sensitivity to oxidative stress due to altered

enzyme activity, and are more liable to be destroyed by altered physical

conditions, mechanical factors, toxins and drugs than adult RBC. Infection

acquired in utero post-natally is a common cause of mild to moderate

haemolytic anaemia. The mechanism is multifactorial, and includes 4 retic-

uloendothelial activity and microangiopathic damage. Drug-induced

haemolysis and Heinz body formation is occasionally noted as a transient

phenomenon in normal neonatal RBCs as a result of chemical or drug tox-

icity but is much more often seen when there is an underlying RBC defect

such as G6PD deficiency.

Acquired RBC defects causing congenital haemolytic anaemia

2 Infection

- Congenital TORCH infections (TOxoplasmosis, Rubella,

Cytomegalovirus, Herpes simplex), also rare but serious are

malaria (can cause stillbirth) and syphilis.

- Post-natal, either viral or (more commonly) bacterial.

2 Microangiopathy—2° to severe infections ± DIC, also

Kasabach-Merritt syndrome (giant haemangioma with haemolysis and

thrombocytopenia).

2 Drug or chemically induced.

438

2 Infantile pyknocytosis (

Vitamin E deficiency, below).

(Rare) metabolic disease such as Wilson’s disease, galactosaemia.

Clinical features

Congenital infections: all rare with adequate antenatal care. Most infants

with herpes simplex will be symptomatic with DIC and hepatic

dysfunction—haemolysis is not a major finding. Haemolytic anaemia is

also mild in CMV and rubella infections but

50% infants with

toxoplasmosis will be anaemic (may be severe).

Post-natal infections: viral, bacterial and protozoal (congenital malaria can

be delayed for some days or weeks or it can be acquired early in life).

Anaemia can be severe and associated with DIC.

MAHA 2° to toxic damage to the endothelium is rare in the neonate

outside the context of DIC and sepsis, and is seen in burns and

(classically) in the Kasabach-Merritt syndrome—a visible or covert giant

haemangioma with haemolysis, RBC damage and profound

thrombocytopenia.

Drugs/chemical exposure are more likely to cause Heinz body haemolysis

in premature babies or those with G6PD deficiency. Incriminating agents

include sulphonamides, chloramphenicol, mothballs, aniline dyes, maternal

intake of diuretics and, in the past, water-soluble vitamin K analogues.

Vitamin E (a potent antioxidant) has a number of RBC stabilising activities.

Now rare due to dietary supplements, deficiency used to be seen

Paediatric haematology

occasionally in premature infants, following oxygen therapy and diets rich

in polyunsaturated fatty acids. Clinical findings included haemolysis, pre-

tibial oedema and CNS signs. Acanthocytosis/pyknocytosis of the RBC is

characteristic, and this may have been the main cause of infantile

pyknocytosis.

Infantile pyknocytosis: indicates the diagnostic feature of this uncommon

acquired disorder. Haemolysis with increased numbers

(>6-50%) of

pyknocytes (irregularly contracted RBCs with multiple projections) in the

peripheral blood. Cause unknown, though may be associated with vitamin

E deficiency. Anaemia may be severe and present at birth, and is most

striking at

~3 weeks

(Hb

<5g/dL reported). Exchange transfusion

occasionally required but the condition spontaneously remits by

months. Its self-limiting nature and ill-understood pathology means that it

may not be a distinct clinical entity.

Metabolic disorders—rare.

Laboratory investigation

Criteria set out above will establish the diagnosis of haemolytic anaemia.

A +ve DAT points to an immune process—probably Rh/ABO disease. If

non-immune, further tests to look for a congenital abnormality.

The diagnosis may be made by

2 Peripheral blood findings.

439

2 Heinz body positive—?chemical/drug-induced haemolysis.

2 RBC enzyme screen to exclude G6PD or PK deficiency.

2 Hb electrophoresis to exclude Hb defects.

Often no definitive cause is found and the HA will be presumed 2° to

underlying systemic illness.

Management

1. General supportive measures for hyperbilirubinaemia (

p444).

2. Treatment of specific conditions

- Haemolytic disease of the newborn— p440.

- Neonatal infection as appropriate.

- Exchange transfusion almost never needed.

Outlook

Prognosis is that of the underlying condition. Anaemia will usually respond

as the condition is brought under control.

Haemolytic disease of the newborn

(HDN)

Arises when there is blood group incompatibility between mother and

fetus. Maternal Abs produced against fetal RBC antigens cross the pla-

centa and destroy fetal RBCs. Most commonly caused by the rhesus D

antigen, but maternal passive immunisation with rhesus

(Rh) D

immunoglobulin (anti-D) introduced in the late 1960s transformed the

outlook. Despite this, HDN due to anti-D and other red cell antibodies

(e.g. anti-c, anti-Kell) still remains an important cause of fetal morbidity.

Pathogenesis

Placental transfer of fetal cells7maternal circulation is maximal at

delivery; the condition does not usually present in the firstborn (Note:

ABO incompatibility is an exception). Previous maternal transfusion, abor-

tion, amniocentesis, chorionic villus sampling (CVS) or obstetric manipula-

tions can cause antibody formation. Maternal IgG crosses placenta, reacts

with Ag +ve fetal RBCs.

Rh HDN classically presents as jaundice in first 24h of life.

Mild HDN may go unnoticed and presents as persistent hyper-

bilirubinaemia or late anaemia weeks after birth.

Severe HDN may result in a macerated fetus, fresh stillbirth or severely

anaemic, grossly oedematous infant

(hydrops fetalis) with hepato-

splenomegaly 2° to compensatory extramedullary haemopoiesis in utero.

Kernicterus: Neurological damage secondary to bilirubin deposition in the

440

brain, depends on a number of factors including the unconjugated

bilirubin level, maturity of the baby, the use of interacting drugs.

Diagnosis

Rh HDN is the commonest cause of neonatal immune haemolysis; routine

antenatal screening should identify most cases prior to delivery allowing

appropriate action.

In suspected case at delivery cord blood is tested for

2 ABO and Rh (D) group.

2 Presence of antibody on fetal RBCs by DAT.

2 Hb and blood film (spherocytes, increased polychromasia, NRBCs).

2 Serum bilirubin (4).

Maternal blood is tested for

2 ABO and Rh (D) group.

2 Serum antibodies against fetal cells (by indirect antiglobulin test,

IAGT).

2 Antibody titre.

2 Kleihauer test—detects and quantitates fetal RBCs in maternal circula-

tion.

Diagnostic findings include

2 DAT +ve haemolytic anaemia ± spherocytosis in the infant.

Paediatric haematology

2 Maternal anti-D, or other anti Rh antibody—the next most common

to produce severe disease is anti-c.

ABO HDN

Theoretically should occur more frequently since ~1 in 4/5 babies and

mothers are ABO incompatible. Usually occurs in group O mothers who

may have high titres of naturally occurring IgG anti-A or B, and with a

boost to this during pregnancy haemolysis can occur.

Clinical features

First pregnancies are not exempt, but condition is usually mild.

Presentation is later than with Rh HDN (2-4d, but may be weeks after

birth).

Diagnosis

May be difficult—DAT commonly and puzzlingly -ve, but offending anti-

body can be eluted from infant RBC.

Antibody studies

Maternal high titre anti-A/B almost always in a group O mother cord-

blood/infant’s serum-an inappropriate antibody (e.g. anti-A in a group A

baby).

Other blood group antibodies

Can occasionally produce severe HDN; anti-Kell in particular. Serological

testing will establish diagnosis. Maternal autoimmune haemolytic anaemia

441

may produce a similar picture to alloimmune HDN where the auto-anti-

body cross-reacts with the infant RBC. Usually the diagnosis will have

been made antenatally. Severity in infant varies depending on maternal

condition.

Management—prevention

Routine antenatal maternal ABO and Rh D grouping and antibody testing

carried out at booking visit (~12-16 weeks).

If antibody positive repeat at intervals to check the antibody titre.

If antibody negative and Rh D negative repeat at ~28 weeks’ gestation.

Establish if paternal red cells heterozygous, homozygous or negative for

the specific Ag.

Anti-D prophylaxis

2 250iu IM during pregnancy to Rh D negative women without anti-

bodies to cover any intrauterine manoeuvre or miscarriage.

2 After delivery, a standard dose of 500iu anti-D within 72h unless baby

is known to be Rh (D) -ve.

2 If Kleihauer test result shows a bleed of >4mL give further anti-D.

Treatment of affected fetus—before delivery

Treatment depends on past obstetric history, the nature and titre of the

antibody and paternal expression of the antigen. The fetal genotype can

be established by CVS, fetal blood sampling and PCR.

Examination of the amniotic fluid to assess the degree of

hyperbilirubinaemia is indicated with a poor past history

(exchange

transfusion or stillbirth in previous baby) and high titre (1:8-1:64) of an

antibody likely to cause severe HDN (e.g. anti-D, anti-c or anti-Kell). The

amniotic fluid bilirubin at optical density

450nm dictates treatment

according to the Liley chart

(opposite), which estimates the blood

concentration.

Options include intrauterine transfusion (IUT) if fetus is not deemed

mature enough for delivery (check lung maturity on phospholipid levels)

or induction of labour if it is. Intensive maternal plasmapheresis may be

useful to reduce antibody titre. Advances in management of very

premature babies are such that nowadays IUT rarely performed.

After delivery

2 Full paediatric support—metabolic, nutritional and respiratory.

2 If unconjugated hyperbilirubinaemia not a problem, treat anaemia (note:

cord blood Hb <14.0g/dL) by simple transfusion.

2 Exchange transfusion with Rh (D) neg and (if possible) group specific

blood for:

- A severely affected hydropic anaemic baby.

- Hyperbilirubinaemia (bilirubin level at or near 340mmol/L (20mg/dL)

or rapidly rising level e.g. >20mmol/h) in first few days of life.

- Signs suggesting kernicterus—exchange transfusion may have to be

repeated.

2 Phototherapy to reduce the bilirubin level.

2 Follow-up required—late anaemia can be severe particularly if

exchange transfusion has not been carried out.

442

Outcome

With modern techniques, the outlook is good even for severely affected

infants.

Hyperbilirubinaemia

Bilirubin results from the breakdown of haem, mostly Hb haem. It may be

unconjugated water insoluble pre-hepatic (a mark of excessive RBC break-

down) or conjugated soluble post-hepatic (4 in cholestasis). Unconjugated

bilirubin 4 in most neonates and is usually physiological; conjugated hyper-

bilirubinaemia, on the other hand, is almost always pathological.

Pathophysiology

Physiological jaundice is defined as a temporary inefficient excretion of

bilirubin which results in jaundice in full-term infants between the 2nd and

8th day of life. Occurs in ~90% of healthy neonates. Hepatic immaturity

and 4 RBC breakdown overloads the neonate’s ability to handle the

bilirubin which is mainly unconjugated. The bilirubin is rarely >100µmol/L,

though between 2-5 days occasionally can be >200 in a term baby or 250

in a healthy pre-term. Levels much above this need investigation. Reaches

a maximum by days 3-6 and usually 5 to normal by day 10. In premature

neonates it may take longer to settle. HDN due to blood group incom-

patibility accounts for ~10% cases of hyperbilirubinaemia and about 75%

of those requiring exchange transfusion.

Causes of hyperbilirubinaemia

Unconjugated

Conjugated

Physiological jaundice

Mechanical obstruction

Haemolytic anaemia

Bile duct abnormalities

Haematoma

(e.g. atresia, cysts)

444

Polycythaemia

Hepatocellular disorders

Biochemical defects

Hepatitis

Clinical features

2 Note: clinical jaundice in the first 24h of life is always pathological.

2 Presenting after this, the jaundice may/not be pathological—usually

not. Inadequate food/fluid intake with dehydration can aggravate the

physiological bilirubin. A higher concentration is acceptable for the full-

term breast-fed baby (serum bilirubin 240µmol/L) than bottle-fed baby

(190µmol/L).

2 Jaundice in an active healthy infant is likely to be physiological.

2 In a sick infant the underlying cause of the jaundice may be clinically

evident—e.g. infection, anaemia, shock, asphyxia, haemorrhage (may be

occult).

2 Physical examination—hepatosplenomegaly is pathological.

2 Maternal history (drugs, known condition) and family history may help.

Laboratory investigation

2 FBC, reticulocyte count and film-?haemolytic anaemia.

2 Serum bilirubin—?conjugated or unconjugated

- Unconjugated hyperbilirubinaemia.

DAT, maternal and neonatal blood group serology.

Infection evaluation including TORCH.

Thyroid function.

Paediatric haematology

Reducing substances.

- Conjugated hyperbilirubinaemia.

Abdominal USS, bile pigments in stool, liver pathology.

2 Further investigation as determined by results and clinical picture.

Management

2 General—adequate hydration, nutrition, other supportive measures.

2 Treat underlying cause—antibiotics, metabolic disturbances.

2 Haemolytic anaemia—blood transfusion.

2 Specific phototherapy (light source with wavelength between

400-500mm) effective in treating most causes of unconjugated hyper-

bilirubinaemia. Note: contraindicated in conjugated hyperbilirubinaemia.

2 Exchange transfusion—the indications are complex. Main indication is

severe haemolytic anaemia and is used in full-term infants when the

bilirubin is >340µmol/L and at a lower concentration in premature

infants.

2 Hyperbilirubinaemia due to mechanical obstruction may need surgery.

Outcome

In most infants hyperbilirubinaemia resolves by 2 weeks. When pathology

has been excluded the commonest cause of prolonged hyperbilirubi-

naemia persisting beyond this period is breastfeeding. In 20% healthy

breast-fed infants the bilirubin is still significantly 4 at day 21. Kernicterus

is not a complication but the condition causes concern before it sponta-

445

neously remits.

Neonatal haemostasis

Neonates can develop bruising and/or purpura due to defects in platelets,

coagulation factors or both. Coagulation tests should be interpreted with

caution because in the term infant the concentration of vitamin K-depen-

dent proteins (II, VII, XI and X together with protein C and protein S) are

50% of normal adult values, contact factors (XI, XII, PK and HMWK) are

30-50% of adult concentrations, and all are lower in pre-terms. Factors

VIII, V and vWF are normal. Thrombin inhibitors antithrombin (AT, previ-

ously called antithrombin III) and HCII are 5 but a2-M is 4. Platelet count

is the same as adults in both term and pre-term infants. There are tech-

nical problems in obtaining uncontaminated (heparin from catheters or IV

lines) and adequate venous samples from neonates, causing in vitro inhibi-

tion or pre-test activation of clotting factors or dilution due to short sam-

pling and thus excess anticoagulant. All can give spurious results.

Pathophysiology

Haemostatic and fibrinolytic system in neonates is immature. Sepsis, liver

disease, necrotising colitis and RDS can precipitate DIC easily.

Thrombocytopenia can be caused by DIC and also immune mechanisms

or marrow failure.

Disorders causing bleeding in neonates

Inherited (rare)

Acquired (common)

Haemophilia

DIC (sepsis, necrotising colitis,

hypoxia, RDS)

446

von Willebrand’s disease (only type 3) Vitamin K deficiency

Other inherited factor deficiencies

Liver disease

Inherited thrombotic disorders

Acquired thrombotic disorders

Glanzmann’s thrombasthenia

Neonatal alloimmune thrombocytopenia

Maternally derived ITP

Endogenous ITP

Aplasia

Leukaemia

Clinical features

2 Petechiae indicate problems with small vessels or platelets, bruises can

be due to platelet deficiencies and/or coagulation disorders.

2 Oozing from multiple venepunture sites in sick infants usually indicates

generalised haemostatic failure and DIC.

2 Haemorrhagic disease of the newborn due to functional vitamin K defi-

ciency presents in 3 forms with bruising, purpura and GI bleeding in oth-

erwise well babies; early (within 24h) usually due to maternal drugs such

as warfarin, classical (days 2-5) in babies who have not been given ade-

quate vitamin K prophylaxis and who have been breast fed and late, a

variant of the classical form (i.e. insufficient vitamin K, breast-fed) arising

at 2-8 weeks and with a higher morbidity and 4 incidence of ICH.

Paediatric haematology

2 Thrombosis usually catheter related, can be rarely associated with AT

III deficiency or homozygous protein C and protein S deficiency

(neonatal purpura fulminans—a life-threatening condition with wide-

spread peripheral gangrene).

2 Haemophilia and other coagulant deficiencies can cause large

haematomas but rarely cause trouble in the neonatal period except

factor XIII lack—typically presents with bleeding from the umbilical

stump.

2 In well babies, petechiae and bruises with thrombocytopenia suggests

immune basis—antibody usually from mother (alloimmune or autoim-

mune). Rarely, infants under a month can develop endogenous ITP.

2 Clear symptoms of thrombocytopenia with normal platelet count sug-

gests major functional defect—Glanzmann’s.

2 Marrow failure due to infiltration, aplasia.

447

Neonatal alloimmune

thrombocytopenia (NAIT)

Occurs when mothers form alloimmune antibodies against fetal platelet-

specific antigens that their own platelets lack. These antibodies react with

fetal platelets in utero causing thrombocytopenia which can be severe, and

in some cases life threatening in late pregnancy and early life. A more

serious condition with greater morbidity than thrombocytopenia due to

maternal autoantibodies against platelets—i.e. where the mother has ITP.

Pathophysiology

In >90% cases the mother will be HPA-1a (old term PLA1) -ve with anti-

HPA-1a antibodies against the HPA-1a +ve fetus; only 2% population are

HPA-1a -ve (i.e. homozygous HPA-1b). Incidence of NAIT is 1/1000 preg-

nancies and accounts for 10-20% cases of neonatal thrombocytopenia.

Other antigens may be involved e.g. HPA-5 (Br) and HPA-3 (Bak) are the

commonest.

Clinical features

2 Commonly presents in first born infant and recurs in 85-90%.

2 Maternal platelet count normal with no past history of ITP.

2 Bleeding manifestations in 10-20% evident within the first few days of

life e.g. umbilical haemorrhage, petechiae, ecchymosis, internal haem-

orrhage, intracranial haemorrhage (ICH).

2 Baby’s platelet count 4 to normal over the next 2-3 weeks as the anti-

body is cleared.

2 Haemorrhage in utero with fatal ICH in ~1% cases.

448

Laboratory diagnosis

Baby

Parents

Severe thrombocytopenia

Mother’s platelet count normal

platelets <20

¥ 10⁹/L in 50% Serology

BM has megakaryocytes ++

Mother’s platelets usually HPA-1a -ve

(not usually necessary)

Rarer Ab include anti-HPA-3a,

HPA-5b, HPA-4 (Yuk/Pen)

Mother’s serum contains anti-platelet

antibody

(Note: antibody titre cannot predict

degree of thrombocytopenia in fetus

in subsequent pregnancies)

Father’s platelets carry offending antigen

Management

Of bleeding neonate: transfuse platelets -ve for Ag (usually HPA-1a -ve);

use random donor platelets in an emergency. Maternal platelets

(irradiated) are a good source. Repeat platelet transfusion PRN. IVIg as for

Paediatric haematology

ITP can be used in exceptional cases (response within days). Close

observation (ICH is potentially lethal—screen using USS).

Of subsequent pregnancies: cordocentesis in utero at ~24 weeks; take

1-3mL blood for platelet count and phenotype. If affected, treatment

needs to be started immediately.

Options

1. In utero CMV -ve compatible platelet transfusions at 2-4 weekly inter-

vals

(depending on severity and history). Invasive and technically

demanding. Keep platelet count >50

¥ 10⁹/L (platelets 5 rapidly so fre-

quent follow-up mandatory).

2. Maternal administration of IVIg

(1g/kg) weekly from

~24 weeks

onwards: check fetal platelet count ~4 weeks later and again near

term; response variable—around 75% respond—transfuse platelets if

non-responsive. Check cord blood at birth and treat as necessary.

Outcome

With aggressive treatment the outcome is good, death in utero and ICH

occur rarely. A history of a previous ICH correlates with severe thrombo-

cytopenia in subsequent pregnancies.

449

Congenital dyserythropoietic

anaemias

A rare group of inherited lifelong anaemias with morphologically abnormal

marrow erythroblasts and ineffective erythropoiesis. Three clinically dis-

tinguishable types are recognised where inheritance may be recessive

(types I and II) or dominant (type III). A number of families have been

described that share some features but do not fit with the typical patterns.

Pathophysiology

Ineffective erythropoiesis (cell death within the BM); RBC survival in PB is

not much reduced (III). Abnormal serological and haemolytic characteris-

tics (type II CDA) and membrane abnormalities are described but as yet

no defining shared defect in all cases of CDA.

Type

Bone marrow

Blood findings

Inheritance

Megaloblastic + intranuclear

Macrocytic RBC

Recessive

chromatin bridges

II (HEMPAS)* Bi/multinuclearity with

Normocytic RBCs

Recessive

pluripolar mitosis

Lysis in acidified serum

(not autologous serum)

III

Giant erythroblasts with

Macrocytic

Dominant

multinuclearity

450

*Hereditary erythroblast multinuclearity with positive acidified serum test; commonest

form, found in ~66% cases

Clinical features

2 Age of presentation variable; but usually in older children (>10 years).

Can rarely present as neonatal jaundice and anaemia.

2 Anaemia—in type I, Hb 8.0-12.0g/dL; type II anaemia may be more

severe, patient may be transfusion dependent. Type III (rare) anaemia

is mild/moderate.

2 Jaundice (2° to intramedullary RBC destruction).

2 Gallstones.

2 Splenomegaly common.

Laboratory diagnosis

2 Peripheral blood—normocytic/macrocytic RBC with anisopoikilocytosis.

2 WBC and platelets usually normal; reticulocytes slightly 4.

2 BM appearance—striking, showing 4 cellularity with excess abnormal

erythroblasts.

2 Type II shows positive acidified serum test.

2 4 Serum ferritin due to 4 Fe absorption; haemosiderosis can occur

without transfusion dependence. Type III very occasionally Fe deficient

due to intravascular haemolysis and haemosiderinuria.

Paediatric haematology

Differential diagnosis

2 CDA variants—not all CDA falls neatly into 3 subtypes on BM findings,

serology or clinical features.

2 PNH—acidified serum test is +ve with heterologous and autologous

serum. In HEMPAS +ve with heterologous serum only.

2 Other megaloblastic/dyserythropoietic anaemias—including vitamin B₁₂

and folate deficiency.

2 Primary/acquired sideroblastic anaemia.

2 Erythroleukaemia (M6 AML).

Treatment

2 Mostly unnecessary.

2 Avoid blood transfusion if possible (iron overload)—iron chelation as

necessary.

2 Splenectomy not curative but may decrease transfusion requirements.

2 Type I may respond to high dose IFN-a; not recommended as routine

therapy.

Natural history

Severity of CDA varies considerably and many patients have good quality

of life with no therapy. Haemosiderosis is a long term complication which

may impact on survival.

451

Congenital red cell aplasia

Diamond and Blackfan first described congenital red cell aplasia in infants

in 1938 giving rise to the name of Diamond-Blackfan anaemia (DBA).

Incidence now estimated to be 4-7/million live births.

Pathophysiology

Probably always due to an as yet undefined germline genetic mutation,

either inherited or arising in the affected infant. Familial patterns with both

autosomal dominant and recessive inheritance have been described.

Surviving sporadic cases (i.e. non-familial) have transmitted the disease to

their children. Nature of underlying defect not known. Gene(s) involved

not yet identified despite multiple associated developmental abnormali-

ties. Anaemia likely to be due to intrinsic RBC progenitor cell defect

rather than one of the microenvironment. 5 sensitivity of these cells to

Epo and other cytokines described.

Clinical features

2 Usually presents in the first year of life: in 25% at birth and 90% <6

months of age. Rarely presents >1 year.

2 Mildly affected individuals may rarely be detected as older children or

adults during family studies.

2 Associated physical anomalies in 50%; abnormal facies with abnormal

eyes, webbed neck, malformed (including triphalangeal) thumbs, other

skeletal abnormalities, short stature, congenital heart lesions, renal

defects.

2 Anaemia usually severe and child commonly transfusion dependent.

2 Susceptibility to infection is not 4.

452

2 Hepatosplenomegaly absent.

2 Family history is +ve in only 10-20% cases; most are sporadic.

2 4 risk of AML in long survivors; ~5% in biggest series reported to date.

Laboratory diagnosis

2 Hb 5, reticulocytes 5, MCV 4 (> normal for age), WBC and platelets

not 5.

2 Red cells—normal morphology, have 4 i antigen positivity, 4 ADA

activity.

2 HbF 4, Epo 4, serum Fe/ferritin 4.

2 BM findings—usually absent erythroid precursors; other cell lines

normal.

2 No evidence of parvovirus infection.

2 Radiological investigation to define other congenital defects.

Differential diagnosis

2 Transient erythroblastopenia of childhood (

following section; later

presentation, transient, no other defects).

2 Drugs, malnutrition, infection.

2 Haemolytic anaemias in hypoplastic phase, with parvovirus B19,

delayed recovery in HDN.

2 Megaloblastic anaemia in aplastic phase.

Paediatric haematology

Treatment

2 Prednisolone 2mg/kg PO in divided doses, slowly 5 over weeks; 70%

respond well. Titrate to lowest dose to maintain Hb >7g/dL. Many

achieve this on almost homeopathic doses despite true dependence.

Around 10% need high dose maintenance and have trouble with side

effects. 30% steroid resistant (try high dose methylprednisolone).

2 Transfusion dependency usual in those who cannot be maintained on

very low dose steroids. Need chelation to prevent iron overload. Use

CMV -ve leucocyte-depleted packed RBC.

2 Splenectomy not helpful (unless hypersplenism).

2 Bone marrow transplantation worth considering for transfusion depen-

dents with suitable donor; risk stratification as for severe thalassaemia

(iron overload). Complicated decision due to chance of spontaneous

remission even after years of transfusion dependency.

Natural history

Spontaneous remission in 10-20% (even after several years). Median sur-

vival estimated at

30-40 years, though data patchy. Death due to

haemosiderosis, complications of steroid therapy, or evolution of AML or

aplastic anaemia. BMT may offer better outlook. DBA Registry established

in 1993 is prospectively gathering new data.

453

Acquired red cell aplasia

Isolated failure of erythropoiesis. Most commonly transient—either due

to parvovirus B19 infection or transient erythroblastopenia of childhood

(TEC). Acquired pure red cell aplasia (PRCA) seen in adults with or

without thymoma and probably autoimmune in nature ( p122) virtually

unknown in childhood, though very occasionally seen in adolescents.

Parvovirus B19 infection

Clinical features

2 Causes transient reticulocytopenia and (occasionally) neutropenia and

thrombocytopenia in otherwise healthy individuals.

2 In children with increased red cell turnover for any reason (compen-

sated haemolysis, ineffective erythropoiesis) or those with reduced red

cell production (marrow suppression or hypoplasia) can produce dra-

matic falls in Hb.

2 Can affect any age.

2 Self-limiting as infection subsides following antibody response, 7-10d.

2 In immunosuppressed children (e.g. chemotherapy, HIV) anaemia can

occasionally become chronic with persisting viraemia.

Pathogenesis

Parvovirus shows tropism for red cells through the P antigen, and is cyto-

toxic for erythroid progenitor cells at the colony forming stage (CFU-E) in

vitro.

Transient erythroblastopenia of childhood

454

Pathogenesis

Serum and cellular inhibitors of erythropoiesis and defective bone marrow

response to stimulating cytokines have been demonstrated. The condition

may be idiopathic or associated with viral infection. It is uncommon but

not excessively rare and there may be many subclinical cases where a

blood count is not done.

Clinical features

2 Boys and girls equally affected: age range 6 months to 5 years; most

commonly around 2 years.

2 Typically a previously well young child presents with symptoms and

signs of anaemia, sometimes but not invariably following an infection.

Onset is insidious and the child becomes listless and pale—or just pale.

2 Associated infections are usually viral (EBV, mumps), preceding the

onset of TEC by some weeks.

2 Fever is rare.

2 Pallor may be striking.

2 No lymphadenopathy or hepatosplenomegaly.

2 No physical abnormalities.

Laboratory diagnosis

2 Normocytic, normochromic anaemia which may be severe (Hb <5g/dL).

2 Reticulocytes absent unless in early recovery phase; WBC and

platelets usually normal.

2 Blood film shows no abnormality other than anaemia.

2 Biochemical profile normal.

Paediatric haematology

2 Bone marrow shows normocellular picture with absent erythroid pre-

cursors. Iron content is normal.

2 No karyotypic abnormalities.

2 Exclude parvovirus infection (

p454).

2 No other investigation is of diagnostic help.

Differential diagnosis

2 Exclude acute blood loss and anaemia of chronic disease.

2 Exclude common ALL.

2 Diamond-Blackfan anaemia (see previous section). Usually presents

within the first 6 months of life and other abnormalities (skeletal mal-

formation, short stature, abnormal facies) are commonly present.

2 Parvovirus infection (see above).

Treatment

Blood transfusion should be avoided but may be necessary if symptomatic.

Natural history

Spontaneously remits (if not then diagnosis probably wrong) commonly

within 4-8 weeks but may be up to 6 months. Relapse is rare. There are

no long-term sequelae or associations.

455

Fanconi’s anaemia

First described by Fanconi in 1967, Fanconi’s anaemia (FA) is a clinically

heterogeneous disorder usually presenting in childhood with the common

feature being slowly progressive marrow failure affecting all 3 cell lines

(RBC, WBC and megakaryocytes) and manifest by peripheral blood pan-

cytopenia and eventual marrow aplasia. It is a recessively inherited dis-

order with several different germline genetic mutations involving at least 8

genes, 4 of which have been identified and characterised, and all of which

are on different chromosomes.

Pathophysiology of Fanconi’s anaemia.

FA affects all cells of the body and the cellular phenotype is characterised

by increased chromosomal breakage, hypersensitivity to DNA cross-

linking agents such as diepoxybutane (DEB) and mitomycin C (MMC),

hypersensitivity to oxygen, increased apoptosis and accelerated telomere

shortening. The increased chromosomal fragility is characteristic and used

as a diagnostic test. Apart from progressive marrow failure, 70% of FA

patients show somatic abnormalities, chiefly involving the skeleton. 90%

develop marrow failure and survivors show an increased risk of devel-

oping leukaemia, chiefly AML. Rarely, FA can present as AML. There is

also an increased risk of liver tumours and squamous cell carcinomas.

Clinical features

2 Autosomal recessive inheritance: in 10-20% the parents are related.

2 Phenotypic expression of the disease varies widely, though similar in

any given kindred. Most commonly presents as insidious evolution of

pancytopenia, presenting in mid-childhood with a median age of pre-

456

sentation of 9 years. Cell lines affected asynchronously; isolated throm-

bocytopenia may be first manifestation, lasting 2-3 years before other

cytopenias occur.

2 10% present in adolescence or adult life, 4% present in early infancy

(<1 year).

2 Disorders of skin pigmentation common (60%)—café-au-lait spots,

hypo- and hyperpigmentation.

2 Short stature in 60%, microcephaly and delayed development in >20%.

2 Congenital abnormalities can affect almost any system—skeletal

defects common, >50% in the upper limb especially thumb, spine, ribs.

2 Characteristic facies described—elfin-like, with tapering jaw line.

Diagnosis

Laboratory findings

2 Pancytopenia and hypoplastic marrow—patchy cellularity.

2 Bone marrow may also show dyserythropoietic morphology.

2 Anaemia varies in its severity and may be macrocytic (MCV 100-120fL).

2 Excessive chromosomal breaks/rearrangements in culture of peripheral

blood lymphocytes challenged with clastogens (DEB or MMC) is the

defining abnormality, and can be used on fetal cell culture for antenatal

diagnosis.

2 Direct probing for mutations in the FA genes that have been identified

and characterised permits molecular diagnosis in around 80% of

patients, but is complex and slow.

Paediatric haematology

2 Further investigation for systemic congenital abnormalities is indicated.

Differential diagnosis

2 Acquired aplastic anaemia ( p122).

2 Other congenital or inherited childhood marrow failure syndromes—

see following page.

2 Bloom’s syndrome—clinically like Fanconi’s anaemia with similar con-

genital defects, spontaneous chromosomal breaks and a predisposition

to leukaemia but without pancytopenia, or bone marrow hypoplasia.

Autosomal recessive. Characteristically have photosensitivity and

telangiectatic facial erythema. Genetic mutation mapped to chromo-

some 15q26.

Treatment

General

2 Supportive—blood transfusion with iron chelation as required.

2 Treatment of associated congenital anomalies where necessary.

Specific

2 Combined therapy with steroids (moderate dosage alternate days) and

androgens (oxymethalone 2-5mg/kg/d). Most patients respond to

treatment but eventually become refractory.

2 Haemopoietic growth factors may offer temporary relief from neu-

tropenia and anaemia.

2 BMT is potentially curative, but FA patients hypersensitive to condi-

457

tioning agents cyclophosphamide and radiation. Using low doses,

matched sibling grafts give 70% actuarial survival at 2 years; unrelated

donor results less good but improving. Early survivors showed 4 risk of

tumours, especially head and neck.

2 Much interest in gene therapy. Early trials have occurred, but no major

therapeutic success. Theoretically should be possible to transduce

patient stem cells from those with known mutations with the appro-

priate wild type FA gene, and for these stem cells to have a natural

growth advantage over FA cells. So far responses have been disap-

pointing and short-lived.

Outcome

Median survival of conventional treatment responders who do not

undergo BMT is ~25 years. Non-responders have a median survival of

~12 years. Death most commonly due to marrow failure, but 10-20% will

develop MDS or AML after a median period of observation of 13 years.

Rare congenital marrow failure

syndromes

Amegakaryocytic thrombocytopenia (congenital

amegakaryocytic thrombocytopenia)

Presents in infancy (usually at birth or within 2 months) with profoundly 5

platelets and associated physical signs (petechiae and bruising). Around

40% of affected children also have other congenital abnormalities—chiefly

neurologic or cardiac. Developmental delay is common. The marrow

completely lacks megakaryocytes and the disorder evolves to severe

aplastic anaemia in around 50% of sufferers, usually in the first few years of

life. Has none of the unstable DNA features of Fanconi’s anaemia (see pre-

vious page). Also quite distinct from the syndrome of thrombocytopenia

with absent radius (TAR syndrome, see below) since it is a trilineage

problem with a much greater mortality. Usually sporadic, but familial cases

occur and disorder thought to be inherited. No gene yet identified.

Outlook

Without BMT, mortality from bleeding, infection or (occasionally) pro-

gression to leukaemia near 100%.

Amegakaryocytic thrombocytopenia with absent radii (TAR

syndrome)

2 Usually diagnosed at birth because of lower arm deformity due to

bilateral radial aplasia.

2 No hyperpigmentation.

2 Isolated thrombocytopenia with other cell lines normal.

458

2 Bone marrow lacks megakaryocytes; has adequate WBC/RBC precursors.

2 No chromosomal breaks in cell culture.

2 Autosomal recessive; no gene yet identified.

2 Thrombopoietin 4; platelets gradually increase as child grows.

2 Bleeding problems greatest in infancy.

2 Supportive therapy only needed.

Outlook

Usually good, with problems receding as childhood proceeds. Occasional

patients continue to have problems with 5 platelets. No 4 malignancy.

Dyskeratosis congenita

2 Inherited disorder of mucocutaneous and haemopoietic systems.

2 Clinical triad of skin pigmentation, leucoplakia of the mucous mem-

branes, dystrophic nails and, in 50% patients, severe aplastic anaemia

develops, usually in the second decade.

2 Usually sex-linked inheritance through single gene at Xq28, though

15% autosomal so phenotype dependent on more than 1 gene.

2 Other congenital and immunological abnormalities described.

2 Chromosome fragility on challenge with DEB or mitomycin C normal—

important to distinguish DC from Fanconi’s anaemia (see previous page).

2 Despite this some evidence of DNA instability; results of BMT for

aplastic anaemia in DC patients poor, perhaps because of this.

2 Anecdotal reports of good response to haemopoietic growth factors.

Paediatric haematology

Outlook

10% develop cancers before the age of 40—mostly epithelial, but also

MDS/AML. Life expectancy depends on development of aplasia or malig-

nancy. 30% survive to middle age.

Kostmann’s syndrome (congenital neutropenia)

2 Autosomal recessive.

2 Severe neutropenia with neutrophils <0.2

¥ 10⁹/L.

2 Marrow shows maturation arrest at promyelocyte/myelocyte stage.

2 High risk of severe infection in untreated state.

2 Not due to germline mutation in G-CSF receptor gene, though

abnormal receptor may be present in myeloid precursors.

2 90% will respond to pharmacological doses of G-CSF and continue to

do so for years.

2 Up to 10% develop AML/MDS—role of G-CSF not clear, but probably

complication of disease revealed by longer survival.

Diagnosis

Distinguish from cyclical neutropenia (by observation); benign congenital

neutropenia (by WBC) and reticular dysgenesis a severe inherited immun-

odeficiency with congenital lack of all white cells, including lymphocytes.

Outlook

Good provided response to G-CSF satisfactory and maintained. Non-

responders may need BMT.

459

Shwachman-Diamond syndrome

2 Congenital exocrine pancreatic insufficiency; chronic diarrhoea, malab-

sorption and growth failure associated with neutropenia.

2 Bone marrow failure not usually trilineage, though platelets and red

cells can be involved.

2 Bone marrow varies—may be dysplastic/hypo/aplastic.

2 Probably autosomal recessive, but no gene yet identified.

2 Psychomotor delay common.

Diagnosis

2 Exclude cystic fibrosis (by normal sweat test).

2 Exclude Fanconi’s anaemia (by normal chromosome fragility).

2 Pearson’s syndrome clinically similar with severe pancreatic insuffi-

ciency but with anaemia rather than neutropenia and marrow shows

ring sideroblasts and vacuolisation of red and white cell precursors.

Treatment

2 Supportive with pancreatic enzymes, G-CSF and antibiotics.

2 Greatly increased risk (up to 30%) of progression to MDS/leukaemia

(AML > ALL).

2 Limited experience with BMT for aplasia/leukaemia; may be increased

risk of cardiotoxicity—ventricular fibrosis seen at autopsy in 2/5

patients who died post BMT.

Outlook

Depends on development of severe aplasia or leukaemia; long survivors

few if so. Pancreatic insufficiency improves as childhood progresses.

Seckel’s syndrome—bird-headed dwarfism

2 Rare autosomal recessive disorder with (proportionate) very short

stature and mental deficiency.

2 Facial features fancifully described as bird-like.

2 Gene(s) responsible unknown.

2 Progression to aplastic anaemia common, clinically similar to Fanconi’s

anaemia (see previous page) but chromosome fragility normal.

Infantile osteopetrosis

2 Pancytopenia can arise in this autosomal recessive disorder where the

marrow cavity is obliterated with cortical bone due to a functional

deficiency of osteoclasts.

2 It is a primary marrow failure in the sense that there is no marrow, but is

a failure of the microenvironment rather than haemopoietic stem cells.

Outlook

Poor due to cranial compression, and children usually die in early child-

hood unless successful allogeneic BMT can replace normal osteoclast

function.

460

Neutropenia in childhood

Apart from primary marrow failure due to aplastic anaemia or other

marrow failure syndromes ( p122) or marrow suppression due to anti-

neoplastic, immunosuppressive or antiviral chemotherapy, neutropenia

can also arise as an immune phenomenon, a cytokine mediated problem

or due to cyclic or non-cyclic disturbances of the homeostasis of neu-

trophil production.

Pathophysiology

2 Commonest cause of a clinically important low neutrophil count in

children (<0.5

¥ 10⁹/L) is myelosuppression due to drugs.

2 Primary marrow stem cell failure failure either involving all cell lines or

granulopoiesis alone is rare.

2 Neutropenia can also be due to less serious inherited deficiencies of

neutrophil production where neutropenia can be variable or cyclical

and the problem seems to be one of production control rather than

primary stem cell failure.

2 Probably due to cytokine disturbances, several microbial infections can

cause paradoxical neutropenia, particularly in neonates but also in

older children.

2 Autoimmune causes of neutropenia can arise in infancy or later in

childhood.

2 Isoimmune neutropenia in the newborn—due to maternal anti-neu-

trophil antibodies and analogous to HDN.

Homeostatic disorders

Cyclic neutropenia: Rare. Neutropenia arising every 21d lasting 3-6d.

462

Counts may fall <0.2

¥ 10⁹/L. Associated with episodes of fever, malaise,

mucous membrane ulcers, lymphadenopathy. Serious infection can arise

and deaths May improve after puberty. Usually positive family history

when problem encountered in childhood. Treatment supportive with

antibiotics. G-CSF may be useful.

Chronic benign neutropenia: More common. Persistent rather than

cyclical, though often variable without clear periodicity. Neutrophil count

usually >0.5

¥ 10⁹/L, so clinically mild or silent. May have autosomal

dominant or autosomal recessive family history. Variable severity, often

mild with few problems. To be distinguished from severe congenital

neutropenia ( Kostmann’s syndrome, p459) by milder clinical course and

(usually) later presentation. Therapy not usually necessary.

Paediatric haematology

Infections causing neutropenia

Viruses

Bacteria

Others

RSV

Tuberculosis

Rickettsiae

Malaria

Typhoid/paratyphoid

Influenza

E coli (neonates)

Measles

Varicella

HIV

Autoimmune neutropenia (AIN)

Infant form of isolated autoimmune neutropenia occurs within 1st year of

life; demonstrable autoantibodies. Not familial; girls>boys. Self-limiting

and usually relatively benign. Therapy supportive. Steroids not usually

needed and can increase infection risk. IVIg has been used.

Older children may get

2 Isolated AI neutropenia.

2 Neutropenia as part of Evans’ syndrome ( p388).

2 Neutropenia as part of multi-system AI disease—lupus erythematosus

2 Immune neutropenia following allogeneic BMT.

2 Felty’s syndrome (rheumatoid arthritis with splenomegaly and hyper-

splenic cytopenias— p17) may also be associated with neutrophil

463

autoantibodies.

2 All are potentially more serious and complicated than the infant form

and may require immunosuppression as well as supportive therapy.

Isoimmune neutropenia of the newborn

2 Maternal antibodies to fetal neutrophil antigens cross the placenta and

give rise to neutropenia in the newborn child.

2 Most commonly antibodies directed at neutrophil-specific antigens

NA1 and NA2. (Maternal HLA antibodies do not cause trouble

because antigens expressed on many tissues so quickly absorbed.)

2 Estimated incidence up to 3% of newborns, so may be more common

than generally appreciated; perhaps because usually clinically mild and

neutropenia thought to be acquired due to drugs/infection.

2 Condition resolves by 2 months as antibody disappears.

2 Severely affected babies may show recurrent staphylococcal skin infec-

tions. Therapy supportive. Need for exchange transfusion very rare.

2 Diagnosis based on serology.

Prognosis of neutropenia

Whatever the cause, severe neutropenia (<0.2

¥ 10⁹/L) is serious and

incompatible with long survival if prolonged. It requires careful expert

management.

Disorders of neutrophil function

Acquired

Mild defects arise in many clinical situations; following some infections,

associated with drugs (steroids, chemotherapy) and systemic disease (mal-

nutrition, diabetes mellitus, rheumatoid arthritis, CRF, sickle cell

anaemia)—here the underlying condition will dominate the clinical

picture.

Congenital

Inherited defects rare but several important and disabling syndromes

occur in children.

Pathophysiology

Neutrophils produced in BM are released into circulation where they

survive for only a few hours. Fundamental role is to kill bacteria. Do this

by moving to site of infection drawn there (chemotaxis) by interaction of

bacteria with complement and Ig (opsonisation) and engulf them (phago-

cytosis). Killing is accomplished by H₂O₂ generation, release of lysosomal

enzymes, neutrophil degranulation (respiratory burst). Several enzyme

systems are involved (MPO, cytochrome system, HMP shunt). In the

neonate neutrophil function is defective (5

chemotaxis, phagocytosis,

motility) particularly if premature, jaundiced. Killing is normal.

Classification

Disorders of all aspects of neutrophil function are described and there is

no consensus as to how best to classify them. All are rare. In several of the

best described conditions multiple defects are present.

464

Classification

5 Chemotaxis

5 Opsonisation

5 Killing

Lazy leucocyte syndrome

Complement C3 deficiency Chronic granulomatous disease

Hyper IgE syndrome

MPO deficiency

Chediak-Higashi syndrome

5 Specific neutrophil granules

Clinical features

All congenital syndromes are rare and diagnosis of the specific defect diffi-

cult. Few haematological/immunological labs are set up to perform the

required range of tests. Specialist referral for diagnosis and treatment is

indicated and may be able to alter the otherwise grim prognosis in many

of these conditions.

Lazy leucocyte syndrome: Leucocyte adhesion deficiency due to 5 HMW

membrane glycoproteins. Rare. Autosomal recessive.

Recurrent

infections often in oral cavity, delayed wound healing. Lab features: 4

neutrophil count, normal BM, abnormal chemotaxis on Rebuck skin

Paediatric haematology

window test. The condition is relatively mild. Treatment is of specific

infections with the need for prophylaxis in some patients.

Hyperimmunoglobulin E syndrome: Also known as Job’s syndrome

(

Old Testament) because of recurrent staphylococcal abscesses. Autosomal

recessive inheritance, associated with atopic dermatitis and other

autoimmune phenomena. Bacterial/fungal infection, chronic dermatitis.

Lab features: 4 IgE, 4 eosinophils.

Complement deficiency: Autosomal recessive inheritance of C₃ deficiency,

homozygotes have severe recurrent bacterial infection, particularly

encapsulated organisms.

Chronic granulomatous disease (CGD): Though rare, commonest life-

threatening inherited neutrophil functional defect. More than one

disorder. Most are sex linked and boys affected 7¥ more frequently than

girls, but 3 autosomal mutations recognised. Presents in early life but also

in adults; carriers asymptomatic. Multiple skin and visceral abscesses,

systemic infection

(pneumonia, osteitis etc.)—bacterial/fungal,

lymphadenopathy, hepatosplenomegaly. Lab features: nitro blue

tetrazolium (NBT) test (an index of defective respiratory burst) +ve.

Specific mutational analysis now possible for earlier and prenatal

diagnosis. Outlook better than it used to be. Improved by aggressive

antibiotic policy and IFN-g. BMT little used due to improving outlook with

conservative/prophylactic treatment. Early results poor. Prospect of gene

465

therapy attractive but awaits development.

Chediak-Higashi syndrome: Rare autosomal recessive disorder. Multiple

defects. Partial oculocutaneous albinism, recurrent infection, lymphadeno-

pathy, peripheral neuropathy and cerebellar ataxia. A fatal accelerated phase

occurs in ~85%, usually in the second decade, with lymphocytic infiltration of

liver/spleen/nodes/BM, pancytopenia.

Lab findings

2 5 Hb, 5 neutrophil count, 5 platelet count.

2 Characteristic giant greenish grey refractile granules in neutrophils

(also lymph inclusions).

2 Treatment is supportive. High dose ascorbic acid may help some

patients. Anecdotal reports of successful BMT.

Myeloperoxidase deficiency:

Autosomal recessive. Commonest of neutrophil dysfunction conditions

(1:2000) but also least serious. Often asymptomatic. Manifest in diabetics

with recurrent infections—commonly Candida albicans. Good prognosis.

Lab findings

2 4 neutrophil/monocyte peroxidase on histochemical analysis.

2 Automated cell counters using MPO activity to count neutrophils may

show spurious neutropenia.

Childhood immune (idiopathic)

thrombocytopenic purpura (ITP)

ITP occurring in children differs from the adult form of the disease (

p388) in two ways—first, most cases are of abrupt onset and rapidly self-

limiting, and secondly those that progress to chronicity have a lower mor-

bidity and mortality.

Epidemiology

Incidence of ITP in children overall around 4-5 per 100,000 per year.

10-20% become chronic—i.e. last >6 months.

Pathophysiology

Thrombocytopenia mediated by antibodies opsonizing platelets that are

then destroyed by the reticuloendothelial system. Antibodies can be part

of immune complexes non-specifically attached to platelet Fc receptors

(as in typical acute childhood ITP) or true autoantibodies usually targeted

at glycoproteins IIb/IIIa and Ib (as found in up to 75% of chronic childhood

ITP and commonly in adults).

Clinical features

2 Onset of bruising ± petechiae abrupt (80-90%) or insidious (10-20%).

2 May have gingival and oral mucosal bleeding or epistaxis.

2 Life threatening bleeding extremely rare.

2 Child otherwise perfectly well.

2 May have history of recent infection; specific (rubella, varicella) or non-

specific (URTI).

466

2 Can follow vaccination.

Laboratory diagnosis

2 Isolated thrombocytopenia; blood count otherwise normal.

2 Marrow shows abundant megakaryocytes and is otherwise normal (not

necessary to investigate unless clinical course or presenting features

unusual).

2 Platelet antibody studies difficult to perform and not necessary in most

cases since they do not alter management.

2 Exclude EBV infection (infectious mononucleosis).

2 Exclude multisystem autoimmune disease (ACL, ANA, positive DAT

test)—not necessary unless disease becomes chronic.

2 Exclude underlying immunodeficiency syndrome (HIV,

Wiskott-Aldrich).

Differential diagnosis

2 Congenital or familial thrombocytopenias.

2 Leukaemia or aplastic anaemia.

2 Other rare thrombocytopenias (e.g. type IIB vWD).

2 Multisystem autoimmune disease—Evans’ syndrome (AIHA + immune

thrombocytopenia), systemic lupus erythematosus.

2 Immune thrombocytopenia associated with immunodeficiency due to

other disease—HIV infection, Hodgkin’s disease, Wiskott-Aldrich syn-

drome.

Paediatric haematology

Management

Newly presenting

Seldom require urgent therapy though this is frequently given, either poly-

valent IVIg 0.8g/kg (single dose) or prednisolone 4mg/kg. Never justified in

the absence of obvious bleeding since neither therapy without risk. Simple

observation for spontaneous recovery should be preferred.

Chronic

No therapy is needed based on platelet count alone. Absence of symp-

toms and signs is sufficient. Excessive restriction of activities is seldom jus-

tified. Open access to expert help and advice provides reassurance to

families and teachers. If therapy required to control symptoms (recurrent

nosebleeds, menorrhagia) try local measures or hormonal control.

Regular IVIg or steroids seldom effective and may produce more prob-

lems than untreated disease. For the most difficult cases (very rare)

splenectomy still worth considering, though post-splenectomy mortality

may be > than that of untreated ITP. Newer therapies include danazol and

rituximab, though experience still anecdotal and long-term risks not yet

evaluated.

Life-threatening haemorrhage or other emergency

Risk of life-threatening haemorrhage very small (<1/1000 in first week

after diagnosis) though is a function of a platelet count <10-20

¥ 10⁹/L

and the time exposed to this. Risk consequently rises in rare children with

467

chronic unremitting severe disease for >1-2 years for whom more adven-

turous therapy (splenectomy, rituximab) can be contemplated, though

risk still small and those of treatment may be higher. If a large intracranial

(ICH) or other catastrophic bleed occurs, this can be dealt with by simul-

taneous massive platelet transfusion, IVIg, IV methylprednisolone and (if

the diagnosis is beyond doubt) emergency splenectomy. Mortality of

major ICH less than 50% given active therapy.

Outlook

Most children with ITP recover irrespective of therapy, usually within

weeks or occasionally within months. Even 75% of those whose problem

persists for >6 months eventually spontaneously remit, sometimes several

years later. It is very rare for children to carry ITP into adult life and

beyond, and the occasional individuals who do are unlikely to much trou-

bled by it or to develop autoimmune disease of other systems.

Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in

adults, children and in pregnancy (2003) Br J Haematol, 120, 574-596.

Haemolytic uraemic syndrome

Characterised by a triad of microangiopathic haemolytic anaemia (MAHA),

renal failure and thrombocytopenia. More common in children than adults

and of two types; the more common epidemic form and the less common

sporadic form closely related to thrombotic thrombocytopenic purpura

(TTP)—a disease primarily of adults that also rarely occurs in children.

TTP has the same triad of signs with two others—fever and neurologic

disturbances (

p530)

Pathogenesis

HUS usually occurs in outbreaks and in 90% is due to Escherichia coli 0157

and other verocytotoxin-producing E coli. Food sources of the infection

include uncooked/under-cooked meats, hamburgers and poor food

hygiene. The verocytotoxin causes endothelial damage, particularly of the

renal endothelium, leading to the formation of fibrin-rich microthrombi

and MAHA.

Clinical features

2 Young children (<4 years) are especially prone to the disease.

2 Acute onset with a history of abdominal pain and bloody diarrhoea.

2 Onset of 5 urine output heralding renal failure occurs days later.

2 In ~10% onset is non-epidemic and insidious—can be associated with

chemotherapy/TBI.

2 Other symptoms: anaemia (may be severe), jaundice, bruising, bleeding.

2 Absence of fever and neurologic signs distinguish it from TTP.

Laboratory findings

468

2 MAHA may be severe.

2 Film shows fragmented RBCs/schistocytes/spherocytes.

2 Thrombocytopenia.

2 Coagulation tests: PT/APTT—usually normal; fibrinogen and F/XDPs

also normal. Reduced large vWF multimers.

2 Proteinuria and haematuria.

2 Biochemical evidence of renal failure.

2 Stool culture may be +ve for E coli.

Differential diagnosis

2 TTP ( p530).

2 Other causes of MAHA and renal failure.

Complications

2 ARF7CRF rare but more likely in older children and those with spo-

radic insidious onset HUS.

2 Microvascular thrombosis and infarction of other organs.

Treatment

2 Renal failure—fluid restriction, correct electrolyte imbalance.

2 If anuria persists >24h—dialysis as necessary.

2 Blood transfusion for anaemia.

2 Platelet transfusion rarely needed—may 4 thrombotic risk.

2 Severe persistent disease may require plasmapheresis as for TTP (

p530).

2 Specific treatment: none of proven value.

Childhood cancer and malignant blood

disorders

Epidemiology

In Europe 1 child in 600 develops cancer before the age of 15. Annual inci-

dence 1:10,000;

~1200 new cases/year in UK. Pattern of childhood

cancers is very different from that seen in adults: carcinomas are rarely

seen. Overall, childhood cancer is slightly more common in boys than

girls.

2 Leukaemias account for about 35% of the total: 80% are some type of

ALL, 15% some type of AML. 5% chronic myeloid leukaemias, (adult

and juvenile types) or myelodysplastic syndromes. CLL does not occur

in children.

2 Brain tumours are commonest solid malignancies, 25% of the total.

Different tumour types from adults; commonest medulloblastoma in

posterior fossa.

2 Embryonal tumours 15%, seen almost exclusively in children. Include

neuroblastoma, nephroblastoma (Wilms’ tumour), rhabdomyosar-

coma, hepatoblastoma.

2 Bone tumours 5% osteosarcoma, Ewing’s sarcoma.

2 Lymphomas 9%—NHL and Hodgkin’s disease. NHL in children closely

related biologically to ALL; low grade disease very rare.

2 Remainder of cases are mainly germ cell and primitive neuroecto-

dermal tumours (PNETs), including retinoblastomas.

Aetiology

2 Childhood cancer generally represents aberrant growth and develop-

470

ment rather than defective repair and renewal from which most adult

tumours arise.

2 Growths arising in infancy are mostly congenital and the genetic muta-

tions concerned arise in utero. Causes of such mutations and those

arising later in childhood largely unknown.

2 Although isolated cases are attributable to high dose radiation (e.g.

thyroid cancer in Chernobyl survivors), there is no convincing link to

levels of background radiation or electromagnetic fields.

2 Population mixing studies have suggested that patterns of exposure to

infection may contribute to some cases of ALL in the peak years of

incidence (2-6 years).

2 Childhood cancer rarely familial, but study of retinoblastoma (rare

tumour that is commonly familial) has led to better understanding of

tumour suppressor genes; germline mutation in one allele of RB gene

in affected families only gives rise to tumours in cells where there is an

acquired mutation in the other, healthy, wild type allele (the ‘two hit’

hypothesis).

2 Cancer arising in older children may still be due to intrauterine event

as concordance studies in identical twins with ALL have shown iden-

tical genetic mutations in malignant cells some years after birth. This

suggests twin7twin transfer of potentially malignant clone through

shared circulation.

Paediatric haematology

Haematological effects of non-haemic tumours (for leukaemias,

lymphomas and MDS see following sections)

2 Marrow infiltration may be evident at the time of presentation (most

commonly neuroblastoma, less commonly Ewing’s sarcoma, rhab-

domyosarcoma).

2 Associated with anaemia, occasionally other cytopenias. Blood count

hardly ever normal if marrow involved.

2 Peripheral blood may show leucoerythroblastic picture, but not as

commonly in adult cancers metastasising to bone marrow.

2 Non-haemic tumours appear on cytomorphology as poorly differenti-

ated fragile blast cells, often in sheets or clumps (unlike leukaemic

blasts).

2 Marrow infiltration may arise as a late event in terminally progressive

disease in other tumours, including CNS malignancies, PNETS and

germ cell tumours.

Investigations in suspected childhood cancer

Haematology

2 FBC and film. Leukaemia usually reflected in the blood count: 4 or 5

WBC, ± thrombocytopenia and anaemia. Blasts often present. In a

small percentage, blood count entirely normal. With other malignan-

cies there may be signs of marrow infiltration (see above), anaemia or

no abnormalities at all.

471

2 BM aspirate and trephine if blood count abnormal. In children generally

done under GA. Bilateral samples needed in the staging of neuroblas-

toma.

Biochemistry

2 Full biochemical profile.

2 Urinary catecholamines for neuroblastoma (easy test to do in unex-

plained bone pain).

2 Tumour markers: a-FP, bHCG in hepatoblastoma or germ cell

tumours.

Radiology

2 CXR for mediastinal mass (mandatory pre-anaesthetic).

2 Abdominal USS.

2 CT/MRI scan of primary lesion. CT chest/abdomen may be required

for staging. In young children sedation/general anaesthetic usually

needed for CT/MRI scans.

Histology

2 Solid tumours need adequate biopsy material for diagnosis taken under

general anaesthetic.

Genetics

2 Fresh tumour material from all childhood cancers should be sent for

cytogenetic and molecular genetic studies. Information from these is

increasingly being used in risk-stratifying therapy and in predicting

outcome.

Specialist centres for treatment and investigation

Children with suspected malignancy should be referred to a specialist

centre for investigation and initial treatment. Thereafter, shared care may

be carried out nearer to home at a local hospital. Most children across the

country receive treatment as part of a national trial or protocol. This is

co-ordinated by the United Kingdom Children’s Cancer Study Group and

similar groups in other countries, and the success of such trials and studies

is one of the reasons for the improved outlook for childhood cancer.

Overall long-term survival is ~60%.

Late effects

It is estimated that soon 1:1000 adults will be survivors of childhood

cancer. Long term follow-up clinics are needed to monitor growth, fer-

tility, side effects from drugs (e.g. cardiotoxicity) and psychological well-

being. There is an increased risk of further malignancy developing which

varies according to both the primary diagnosis and treatment used.

472

Childhood lymphoblastic leukaemia

Lymphoblastic leukaemia (‘acute’ is superfluous, but disease widely known

as ALL) is a group of clonal malignancies all arising in developing lympho-

cytes. There is more overlap with lymphomas than in adults. Commonest

malignant disease in childhood (35% of all cancers). Incidence 4-5/100,000 chil-

dren per year with a peak incidence between 2-6 years of age.

Aetiology

Many cases thought to be due to antenatal mutations in developing B-cell

clones; Majority of cases B-cell derived, occur between 2 and 6 years, and

may be abnormal response to infection where exposure to pathogens

delayed or precipitated by population mixing. Evidence implicating back-

ground ionising or electromagnetic radiation now discredited. Cause of T-

ALL unknown.

Pathophysiology

~80% childhood ALLs arise in developing B lymphocytes; ~20% in

developing T cells. Acquired genetic mutations found in the various

sub-types are growing in number as the molecular biology of leukaemia

unravels.

In early B cells commonest mutation is a fusion between the TEL gene

at 12p13 and the AML1 gene at 21q22—arises in 20% overall; other

common mutations are t(1;19)(q23;p13.3)—8% overall,

t(9;22)(q34;q11.2) BCR-ABL (Philadelphia chromosome); 5% overall.

~30% have ‘high hyperdiploidy’ (>50 chromosomes per cell) with or

without translocations; 7% show hypodiploidy.

Infants (<18 months) frequently have a mutation of the MLL gene on

474

chromosome 11 involving a range of fusion partners; most commonly

AF4 on chromosome 4.

The above changes mark biologically different types of precursor B-

derived ALL in terms of clinical features and response to treatment.

1-2% of ALLs have features of mature B cells and a mutation where

the MYC gene is translocated adjacent to the Ig heavy chain locus—

t(8;14). Also called Burkitt-type as the cell biology is similar to that of

Burkitt’s lymphoma.

T-ALL shows greater genetic diversity than B-derived disease but 12

recurring cytogenetic abnormalities now defined and under study.

Clinical importance yet to be defined.

ALL also classified by immunophenotyping using antibody cell markers

for various differentiation antigens designated clusters of differentiation

(CD), numbered according to their order of discovery.

Immunophenotypes so defined include early pre-B (60%), pre-B (20%),

transitional pre-B (1%), B-ALL (1%) and T-ALL (18%).

Clinical features

2 Commonly presents insidiously in three ways, separately or combined.

2 Signs of marrow failure—often anaemia predominates, with extreme

pallor and listlessness (60%); also bruising/petechiae (40%).

2 Hepatosplenomegaly and lymphadenopathy (‘lymphomatous’ features)

10-20%.

2 Bone pain mimicking irritable hip(s) or juvenile rheumatoid 10-20%.

Paediatric haematology

Laboratory features

2 Usually pancytopenia with circulating blast cells indicates diagnosis.

2 Confirmed by bone marrow examination and classified by immunophe-

notyping and cytogenetic/molecular genetic analysis.

2 In sick children with very high blast cell counts classification studies can

be carried out on peripheral blood, but marrow always preferred.

2 Peripheral blood count may show cytopenias without obvious blasts

(aleukaemic picture) when differential diagnosis is aplastic anaemia.

2 Kidney/liver function usually normal, but ALLs with high blast counts

and rapid cell turnover may have tumour-lysis organ dysfunction

before therapy (urate nephropathy with 4 urea, creatinine and 5 urine

output).

Treatment of newly diagnosed disease

2 All modern protocols have common elements of remission induction

(RI), consolidation/intensification (C/I), CNS directed treatment and

continuing (maintenance) therapy with or without delayed intensifica-

tion (DI).

2 RI drugs include dexamethasone, vincristine and asparaginase.

2 C/I and DI drugs include anthracyclines, cytarabine, cyclophosphamide

asparaginase and thioguanine.

2 CNS therapy is intrathecal cytarabine and methotrexate (radiotherapy

now reserved for those with active CNS infiltration only).

2 Maintenance therapy is a 2-3 year schedule of daily thiopurine (6-mer-

475

captopurine) and weekly oral methotrexate.

2 ALL is the only human malignancy that requires such a drawn-out

chemotherapy module, immunosuppressive rather than antineoplastic.

2 B-ALL is an exception; it does not respond to conventional ALL

therapy, does not need maintenance and is treated on a 6 month

intensive lymphoma schedule ( p478).

2 Treatment is usually risk-directed based on biological features of the

disease with more intensive schedules reserved for those with adverse

prognostic factors (see below).

2 BMT rarely used as first-line therapy.

Outlook

98% overall will remit on modern therapy, 75-80% overall will become

long term disease-free survivors—figures vary according to prognostic

factors (see below). >90% long term survivors in low risk disease.

Treatment of relapse

2 Some 20-25% of children will relapse; either on treatment or after its

completion.

2 Outlook depends on length of first remission; very bleak if relapse on

treatment.

2 Salvage therapy more successful if relapse >2 years off therapy.

2 Relapsed T-ALL more difficult to treat successfully than other types.

2 Treatment includes intensive chemotherapy with the addition of

podophyllins, anthracycline analogues and fludarabine.

2 BMT reserved for those who show slow-to-clear residual disease by

PCR amplification of unique disease-specific Ig or TCR gene

rearrangements, those who relapse on treatment and those with

relapsed T-ALL.

Prognostic factors

2 Several features of ALL predict response to current standard therapies

and are used to stratify treatment. Infants <1 year have a poor

outlook, and older children >10 years do less well than those 1-10

years.

2 High presenting WBC (>100

¥ 10⁹/L) in boys marks high risk, as do

some genetic features (MLL gene rearrangements, BCR-ABL fusion

genes, hypodiploidy).

2 All children with T-ALL , and all with slow disease clearance during the

first few days of therapy, are excluded from being classified as low risk.

2 Low risk B-precursor ALL is that which shows none of these features.

Late effects of therapy

With 4 long survivors, late effects of therapy are becoming more impor-

tant. Most morbidity seen after TBI given for BMT.

Problems include

2 Growth failure due to CNS damage from radiation.

2 Intellectual deficit due to CNS damage from radiation.

2 Precocious puberty (girls> boys) after cranial radiation.

2 Infertility (boys > girls) not dependent on radiation.

2 Obesity (girls > boys) not dependent on radiation.

2 7-10 fold 4 risk of brain tumours not dependent on radiation.

476

Childhood lymphomas

Lymphomas account for around 8-10% of all childhood cancers (this

equates to around 1 per 100,000 children per year). Around 30-35% are

Hodgkin’s disease, the rest non-Hodgkin lymphomas.

Hodgkin’s disease

Clinical features

Uncommon <5 years; incidence increases during the early teenage years.

The disease is biologically the same as that of adults and the histological

classification is identical (for more details

p208), though mixed cellu-

larity disease may be more common in the young. Staging is also similar to

adults (

p210), but overall children and adolescents have a greater pro-

portion of low-stage disease (I and II). Stage IV accounts for <10% of child-

hood cases.

Treatment and outcome

Treatment is so successful that most efforts are currently directed at

reducing toxicity and late effects. Radiotherapy for stage I disease is being

attenuated, and some therapists have abandoned it as first line treatment

and rely on chemotherapy alone. Chemotherapy regimens in turn are

evolving (to avoid or minimise alkylating agents and their effect on fertility

and anthracyclines with their potential for cardiotoxicity), but at present

the traditional drugs are still being used with or without involved field

radiotherapy, particularly in stage III or IV disease.

The outlook for even stage IV disease is good, given the best current

regimen of chemotherapy and involved field radiotherapy, and over 80%

478

should achieve long term EFS.

Non-Hodgkin’s lymphoma

Childhood non-Hodgkin’s lymphomas are a heterogeneous group of

tumours quite different from those seen in adults. Virtually all are dissemi-

nated, high-grade diffuse malignancies of immature B or T lymphocytes, and

many are closely related to subtypes of ALL that occur in this age group.

Classification of NHL has always been confusing, but the Revised

European American Lymphoma system is currently preferred. This maps

disease in children into 6 categories:

1. Burkitt’s lymphoma, Burkitt-like lymphoma, high grade B-cell disease.

Different manifestations of biologically very closely related diseases

and pathologically indistinguishable from B-ALL. ~45% of the total.

Characteristic ‘starry sky’ histological pattern and deeply basophilic

blasts on Romanowsky stains with prominent vacuoles (FAB L3 fea-

tures). Associated with chromosomal translocation involving MYC

locus on chromosome 8 and Ig heavy chain gene on 14 (or less com-

monly with a k or l light chain gene on 2 or 22) with resultant dysreg-

ulation of MYC gene transcription; the MYC product functions as a

transcription factor.

2. Precursor B lymphoblastic lymphoma. Indistinguishable pathologically

from common ALL. ~5% of the total. Commonly presents as a solitary

subcutaneous swelling, typically on the scalp.

Paediatric haematology

3. Precursor T lymphoblastic lymphoma. Indistinguishable pathologically

from T-ALL. ~20% of the total. 66% have mediastinal involvement.

Marrow involvement common in advanced disease; so may be classi-

fied as T-ALL rather than stage IV NHL.

4. Diffuse large B-cell lymphoma, including primary sclerosing medi-

astinal form; no leukaemic counterpart, accounts for ~3-4% of the

total. Chiefly abdominal. Occasionally mediastinal. Has some features

of Burkitt’s but no MYC gene mutation.

5. Peripheral T-cell lymphoma unspecified; no leukaemic counterpart.

Skin involvement. Retrospective review shows most so classified to be

type 6 (large cell anaplastic, see below). Poorly defined entity hardly ever

seen in children.

6. Large cell anaplastic, T or null cell type. No leukaemic counterpart.

More frequently recognised, and complex biological features gradually

becoming better understood. ~15% of the total. Used to be diagnosed

as peripheral T-cell lymphomas or ‘malignant histiocytosis’. Biological

hallmarks are Ki-1 (CD30)+, also t(2;5).

Around 9 % childhood NHLs defy classification and <1% adult type follic-

ular lymphomas will occasionally arise in older children.

St Jude staging system for childhood NHL

A staging system for childhood NHL has been developed, though therapy

is increasingly being directed more by the biology of the disease rather

than its anatomical distribution or extent. Staging affects prognosis only

479

within given tumour type.

St Jude staging system for childhood NHL

Stage I

Single tumour (extranodal or single nodal anatomic area),

excluding mediastinum or abdomen

Stage II

Single extranodal tumour with regional node involvement

= 2 nodal areas on the same side of the diaphragm

2 single extranodal tumours ± regional node involvement on

same side of the diaphragm

Primary GIT tumour, usually ileocaecal, ± involvement of

associated mesenteric nodes

Stage III

2 extranodal tumours on opposite sides of the diaphragm

= 2 nodal areas above and below the diaphragm

Presence of 1° intrathoracic tumour (mediastinal, pleural or

thymic)

Presence of extensive primary intra-abdominal disease

Presence of paraspinal or epidural tumours, regardless of other

sites

Stage IV Any of the above with initial CNS and/or bone marrow

involvement

Treatment

Burkitt’s lymphoma/B-ALL: Short 6 month course of pulsed intensive high

dose therapy

(vincristine, steroids, methotrexate, cyclophosphamide,

anthracyclines and etoposide) including CNS treatment. No maintenance

treatment needed.

B precursor lymphoblastic: If isolated to one site, 6 month program of

ALL-type therapy may suffice, else treat as common ALL with extended

maintenance ( lymphoblastic leukaemia p475).

T precursor lymphoblastic: Treated as T-ALL ( p161).

Diffuse large B-cell lymphoma: Treated as Burkitt’s lymphoma.

Large cell anaplastic Ki-1+: Skin, CNS and mediastinal involvement and

splenomegaly are adverse features. Best therapy undefined but usually

treated with short intensive Burkitt-like regimens. EFS is around ~75%

(high risk cases ~60%).

General points on therapy/outlook

2 Surgery usually indicated for the complete resection of a localised

abdominal primary tumour when possible.

2 Low-dose involved field radiotherapy indicated for airway or spinal

cord compression. Mediastinal irradiation for persistent local disease.

2 Given best current therapy, the outlook for most patients is good with

around 80% EFS for childhood lymphomas overall.

480

Childhood acute myeloid leukaemia

Acute myeloid leukaemia in children accounts for ~15% of all malignant

blood disorders, with around 80-90 new cases arising in the UK each

year. Unlike ALL, the disease is classified on morphological grounds using

the FAB classification, as is AML in adults (

p150). The frequency of the

different subtypes differs in children, however. M6 AML is very rare

whereas M7 (megakaryocyte derived AML) is more common—especially

in children with Down syndrome.

Proportion of children with de novo AML by FAB type

% of total

Pathophysiology

AML is a clonal neoplasm arising from developing blood cells affecting all

haemopoietic cell lines, most commonly granulocyte or monocyte precur-

sors but also occasionally involving immature erythroblasts or megakary-

ocytes. Apart from primary, de novo disease for which no cause can be

identified, some cases of AML are due to chemotherapy given for other

diseases (secondary AML), and some arise in children with predisposing

syndromes where the risk is greatly increased and where specific sub-

types of AML may develop.

2 Secondary AML caused by topoisomerase II inhibitors (e.g. etoposide)

has a latency of 1-3 years and is of FAB type M4/M5 with a character-

482

istic MLL gene mutation.

2 Secondary AML caused by alkylating agents (e.g. cyclophosphamide)

has a latency of 4-6 years, a myelodysplastic phase and loss or dele-

tions of chromosomes 5, 7 or both.

2 Down syndrome children are 20 times more likely to develop

leukaemia than normal children; infants are more likely to develop M7

AML, older Down children develop ALL.

2 Other conditions predisposing to AML in children are Fanconi’s anaemia

and Bloom’s syndrome ( p457), dyskeratosis congenita, Kostmann’s

syndrome and Shwachman-Diamond syndrome ( p459), Diamond-

Blackfan anaemia ( p452), and neurofibromatosis.

Apart from the specific changes in secondary AMLs (see above), clonal

chromosome abnormalities are found in blasts from ~90% of those with

de novo disease. Two-thirds of these are non-random, and many are asso-

ciated with characteristic clinical and biological features.

Paediatric haematology

Commonest genetic mutations in childhood AML

Abnormality Involved genes FAB type Frequency Clinical features

t(8;21)

ETO; AML1

10-15%

Extramedullary chloromas

good outlook

t(15;17)

PML; RARA

5-10%

Coagulopathy

responds to retinoids

Inv16(p13q32) MYH11; CBFB

M4eo

7-10%

Extramedullary deposits

good outlook

t(9;11)

AF9; MLL

M4/M5

7-10%

Infants, CNS disease

poor outlook

t(1;22)

N/K

2-3%

Secondary myelofibrosis

Down syndrome

Laboratory features

2 Peripheral blood shows a variety of abnormalities—usually pancy-

topenia with circulating blasts.

2 WBC seldom >50

¥ 10⁹/L though can occasionally be very high with

symptoms of leucostasis—deafness, confusion and impaired conscious-

ness.

483

2 Bone marrow usually shows heavy overgrowth of blasts with different

morphology depending on FAB type. Auer rods (abnormal elongated

primary granules seen on Romanowsky stains in cytoplasm of malig-

nant myeloblasts) are diagnostic of AML and are not found in health.

Seen in all types of AML except M6 and M7, most common in M1/2/3,

particularly M3.

2 Cytochemistry may help; non-specific esterase positive in M4/M5 AML,

not other types and myeloperoxidase positivity can help distinguish

between poorly differentiated AML and ALL. M7 AML may develop

extensive marrow fibrosis making aspiration difficult; trephine histology

needed.

2 Genetic abnormalities common in blast cells (see above).

2 Immunophenotyping less important that in ALL, though essential for

immediate diagnosis of M7 AML which has no distinguishing morpho-

logical or cytochemical features. CD antigens expressed vary according

to FAB type; CD33 strongly +ve in all, CD13 in M2/3; CD4 in M4/M5

and CD41/61 in M7. M6 disease expresses glycophorin A.

Clinical features

Children with advanced AML are commonly more sick than those with

ALL. They can present with bleeding, haemostatic failure and/or septi-

caemia as manifestations of marrow failure and profound neutropenia.

Extramedullary chloromas (solid deposits of malignant cells) arise in

around 10% of cases. They may precede marrow failure

(or even

detectable marrow infiltration). They can arise internally around the spine

or spinal cord, causing pressure symptoms and mimicking non-haemic

solid tumours. They are more common in AML with t(8;21). Peri-orbital

chloromas are also not unusual in infants with M4/M5 AML.

Treatment and outlook

Outcome of therapy for childhood AML has shown a dramatic improve-

ment over the last 15 years. From a dismal outlook in the 1970s through

around 30% EFS in the 1980s we have now achieved >50% EFS at the turn

of the

21st century. This has been due to increasingly intensive

chemotherapy and parallel improvements in supportive treatment for the

secondary marrow failure it produces.

The principle of treatment is to ablate marrow with chemotherapy to the

point that endogenous recovery occurs within 4-6 weeks and to repeat

the process with different drug combinations 4 or 5 times, giving a total

treatment time of around 6 months. Results using this approach have

improved for children in the best risk groups to the point where allo-

geneic BMT is no longer considered the consolidation treatment of choice

even if a matched donor is available.

2 Drugs used in remission induction include daunorubicin, etoposide,

cytarabine and mitoxantrone (mitozantrone).

2 Drugs used in post induction and consolidation treatment include

amsacrine, high-dose cytarabine, L-asparaginase, etoposide and mitox-

antrone (mitozantrone).

2 Good risk patients are those with t(8;21), t(15;17) and inv (16)—

together accounting for around 20-25% overall; standard risk patients

are those without good risk genetic changes but that respond well and

remit after one course of chemotherapy (65% overall), and poor risk

484

are those without good genetics who have residual disease at the start

of course 2 of treatment (around 10% of the total).

2 Long term EFS for good risk children is around 75-80%, for standard

risk around 60-65%, and for poor risk around 15%.

2 Allogeneic BMT as consolidation therapy of first remission is reserved

for children in standard and poor risk groups. It is also used as a

salvage strategy for good risk patients who relapse.

2 The role of autologous stem cell rescue following myeloablative condi-

tioning in children with AML has not been established.

2 The need for skilled supportive therapy confines AML therapy to spe-

cialist units.

Childhood myelodysplastic syndromes

and chronic leukaemias

Myelodysplastic syndromes of childhood present a different spectrum of

disease from that seen in adults. All are rare. The FAB classification of

adult MDS ( p220) has been translated to paediatric disease, but sits

uncomfortably and is of limited use clinically or in understanding the

complex biology of this diverse group of clonal disorders of marrow func-

tion. The proportion that map to the various adult categories is shown

below.

Adult vs. childhood MDS based on the FAB classification

Category

% Adults

% Children

Refractory anaemia (RA)

Refractory anaemia with ring sideroblasts (RARS)

Refractory anaemia with excess blasts (RAEB)

Refractory anaemia with excess blasts in transformation

(RAEB-t)

Chronic myelomonocytic leukaemia (CMML)

Unclassifiable

2 Many children with MDS have a monocytosis which results in their

being classified as CMML, also the clinical features and outlook for

486

childhood CMML are quite different.

2 RARS is virtually never seen in children.

Individual disorders

Refractory anaemia: Children with a clonal genetic marker in the marrow

who present with refractory anaemia usually progress to RAEB and AML.

Those without such a marker probably do not have MDS but some other

cause of erythropoietic failure.

RAEB and RAEB-t: Many of the RAEB syndromes in children arise in those

with pre-existing disease like Down syndrome, trisomy 8, neurofibro-

matosis type 1, Fanconi’s anaemia, Kostmann’s syndrome, Diamond-

Blackfan anaemia and Shwachman-Diamond syndrome

(see previous

section). All these diseases predispose to leukaemia, and RAEB is merely

part of the evolution of AML. A substantial proportion of childhood MDS

in the RA or RAEB category is also induced by previous chemotherapy as

a prodrome to secondary AML. In other words all paediatric cases of

RAEB/RAEB-t are best regarded as AML and treated as such if the

diagnosis is not in any doubt.

2 Down syndrome children have a particular predisposition to develop

M7 (megakaryoblastic) AML in the first few years of life. This is com-

monly preceded by a RAEB prodrome where the marrow is hard to

aspirate through secondary sclerosis. The decision when to start

therapy is difficult, but the overall outlook is potentially good with EFS

>50%.

Paediatric haematology

Transient abnormal myelopoiesis (TAM): Down children also have a

predisposition to develop a transient blast cell overgrowth in infancy that

looks like frank leukaemia with blasts in the peripheral blood. It is

completely self-limiting within days or weeks and is not associated with

marrow failure, arising alongside normal haemopoiesis. There is no

genetic abnormality in the marrow apart from trisomy 21. It is important

that chemotherapy is withheld in what is regarded as a temporary stem

cell instability. Rarely the problem can arise in non-Down children, where

trisomy 21 is found in the bone marrow only.

JCMML (juvenile chronic myelomonocytic leukaemia): Originally called

juvenile chronic myeloid leukaemia to distinguish it from adult type

chronic myeloid leukaemia (see below), this pernicious disease still has a

high mortality. It is now recognised to be a clonal disorder, with all

marrow cell lines involved. It has several distinctive clinical and

haematological features.

2 Stigmata of fetal erythropoiesis; high HbF, 4 red cell i antigen expres-

sion and carbonic anhydrase activity, 4 MCV.

2 Modest 4 WBC; average 30-40

¥ 10⁹/L, with evident monocytosis,

blasts 5-10%, and occasionally a basophilia.

2 Marrow appearances unremarkable; modest 4 blasts.

2 Thrombocytopenia; sometimes profound.

2 Skin rashes; butterfly distribution on face.

487

2 Increasing hepatosplenomegaly.

2 Associated with neurofibromatosis type 1. May be present in >10% of

cases.

2 Poor outlook with progression associated with wasting, fever, infec-

tions, bleeding and pulmonary infiltrations.

Monosomy 7 syndrome: Conventional cytogenetic analysis of the marrow

in JCMML shows no abnormality in the classic syndrome, though there is

a subvariety (or similar condition that may nevertheless be biologically

distinct) where monosomy 7 is found. Whether this is a different disorder

is not clear. Apart from the different genetics, monosomy 7 syndrome

and JCMML have several features in common. However, monosomy 7

children may have:

2 A longer prodrome with RA or RAEB and no monocytosis.

2 They may respond to AML chemotherapy (JCMML responds poorly

and seldom remits).

2 They may remain stable for years without therapy.

2 They respond better to BMT (JCMML achieve <40% EFS even with

BMT).

Adult-type chronic myeloid (granulocytic) leukaemia (ATCML, see Adult

CML p164): More common than JCMML, though still rare, ATCML arises

in around 1 in 500,000 children per year (20 in whole of UK). Tends to

affect older children (60% >6 years) though it has been reported in a 3

month old infant.

2 Associated with Ph chromosome and t(9;22) BCR-ABL fusion gene in all

haemopoietic cells exactly as seen in adults.

2 Natural history exactly the same as the disease in adults with benign

phase and eventual progression to accelerated acute phase.

2 Only curative therapy is allogeneic BMT, but impressive remissions of

so far unknown length are now being achieved with novel tyrosine

kinase inhibitor, STI571 (imatinib). This is set to replace the conven-

tional management of the chronic phase with a-interferon or hydrox-

yurea, but at present is reserved for those who fail to respond to IFN

or those entering the accelerated phase.

488

Histiocytic syndromes

Monocytes are formed in the marrow and move through the peripheral

blood into the tissues where they become histiocytes, either in the

mononuclear phagocytic system (MPS) or the dendritic cell system (DCS).

MPS cells are antigen processing, are predominantly phagocytic and include

many organ-specific cells such as Kupffer cells and pulmonary alveolar

macrophages. DCS cells include tissue-based Langerhans cells (LC) which

are antigen presenting. There is a variety of syndromes where histiocytes

proliferate and malfunction and some of these carry a high mortality. A

few are clonal neoplasms but most are produced by cytokine distur-

bances. In 1991 a new classification of histiocytic syndromes was set out as

shown:

Histiocytic syndromes

Class I

Disorders of dendritic cells

Langerhans cell histiocytosis

(previously known as histiocytosis X)

Class II

Disorders of macrophages

Haemophagocytic syndromes

Haemophagocytic lymphohistiocytosis (HLH)

Primary (genetic)

Secondary (to infection or malignant disease)

Sinus histiocytosis with massive lymphadenopathy

Histiocytic necrotising lymphadenitis

490

Class III

Malignant histiocytic disorders

Malignant histiocytosis

Monocytic leukaemias

Class I: Langerhans cell histiocytosis (LCH)

Cellular destructive tissue infiltration with LC. These are well differenti-

ated large cells (15-25µm) with an indented nucleus and inconspicuous

nucleolus; they are not phagocytic. Other reactive cells (granulocytes,

eosinophils, macrophages) are often present. Diagnostic criteria of LC

include the presence of Burbeck granules on electron microscopy and

immunochemical positivity for CD1A. The aetiology of LCH remains

unclear. Despite some evidence of clonality (not itself evidence of malig-

nancy), no genetic mutations have been identified and the disorder is not

regarded as a form of cancer.

Clinical features: LCH is primarily a disease of the very young with a peak

incidence of 1-3 years. It can present in a variety of ways, from a small

bone lesion heavily admixed with eosinophils (eosinophilic granuloma),

through multiple lytic bone lesions, exophthalmos and diabetes insipidus

(Hand-Schuller-Christian disease) to multiple tissue infiltration involving

skin, liver, lung bone and bone marrow (Letterer-Siwe disease). The

eponymous terms are no longer used for what is now regarded as a

common pathology and the overarching term LCH is preferred. This is

staged on the basis of the number of organ systems showing infiltration,

Paediatric haematology

and virtually any can be involved. The skin rash of LCH is characteristically

in skin folds and scaly with red/brown papules. It may be mistaken for

nappy rash. Systemic symptoms including fever and weight loss are

common in advanced disease. It can be staged as follows:

Stage A Involvement of bones ± local nodes and adjacent soft tissue.

Stage B

Skin ± mucous membranes involvement, ± related nodes.

Stage C

Soft tissue involvement—not stage A, B or D.

Stage D

Multisystem disease with combinations of A, B, C.

Diagnosis

Based on tissue biopsy. Skeletal survey to define extent of disease; also

bone scan, MRI. Urine osmolality studies for diabetes insipidus. BM aspi-

rate and biopsy if anaemic or other cytopenias present.

Treatment

Local curettage of any isolated lesion, with or without intra-lesional

steroids. Stable and symptomless disease can be simply observed for

spontaneous resolution. Options for widespread disease include steroids

and chemotherapy—rarely radiotherapy. Indications for chemotherapy

include organ dysfunction and/or disease progression/recurrence. Drugs

commonly used include steroids, vinblastine or etoposide, singly or com-

bined.

Outcome

491

Generally good, but widespread organ involvement with dysfunction and

progression indicates a poor prognosis. Overall mortality 15-20%. Long

term sequelae include pulmonary/liver fibrosis, diabetes insipidus, growth

failure. Risk of malignant disease increased, chiefly leukaemias and lym-

phomas.

Class II: macrophage functional disorders—haemophagocytic

syndromes

Primary (genetic)

Primary haemophagocytic lymphohistiocytosis (HLH) is an autosomal

recessively inherited disease of infants and young children (>50% <1 year)

also known as familial erythrophagocytic lymphohistiocytosis (FEL) due to

the striking degree of marrow red cell phagocytosis. The gene defect is

not known, and the pathology of the condition is unclear apart from

cytokine dysregulation and high concentrations of IL-1 and 2, GM-CSF and

TNF. CNS involvement common. Laboratory investigation shows periph-

eral blood cytopenias, hypertrigliceridaemia and hypofibrinogenaemia.

Histopathology shows histiocyte/lymphocyte infiltration and haemo-

phagocytosis in BM, nodes and spleen.

Treatment and outcome: Seldom effective, steroids, chemotherapy, ALG,

cyclosporin A, BMT. Disease usually rapidly fatal.

Secondary

2 Clinical and laboratory picture is similar to primary (genetic) HLH.

Distinction between the two may be difficult.

2 Affects more older patients, often immunocompromised.

2 Commonly associated with underlying viral/bacterial infection when

called infection-associated haemophagocytic syndrome (IAHS).

2 Triggered by a wide variety of infections including (especially) EBV and

malaria. Also associated with some malignancies (usually involving T

cells) and lipid infusions.

Treatment and outcome: Good survival rates if underlying infection easily

treatable. Otherwise has high mortality.

Class III: Malignant histiocytosis

Monocyte-derived acute leukaemias account for 10% of AMLs arising in

children. What used to be called

‘malignant histiocytosis’ with

hepatosplenomegaly, fever, wasting and pancytopenia and tissue infiltra-

tion with large monocytoid cells is now recognised as a lymphocyte-

derived lymphoma (large cell anaplastic, CD30+,

p198). It is doubtful

whether true histiocyte-derived malignancies other than AML occur in

children.

492

Haematological effects of systemic

disease in children

Non-haematological disease in children can produce a variety of haemato-

logical effects specific to the disease, to childhood, or both. Some of the

more striking examples are listed below.

Wilson’s disease: Genetic defect in copper metabolism that occasionally

presents as a brisk non-immune haemolytic anaemia without specific

features. More commonly presents with liver dysfunction, neurological

symptoms or renal disease.

Cyanotic congenital heart disease: Commonly associated with mild

thrombocytopenia for ill-understood reasons.

Mast cell disease: Abnormal accumulations of mast cells in the skin or

internal organs. Mast cell leukaemia does not occur in children.

Commonest manifestation is urticaria pigmentosa in infants. Bullous or

urticarial lesions eventually become infiltrated with mast cells. Marrow

involvement rare. The cells produce histamine and cause itching.

Condition resolves by adulthood.

Juvenile rheumatoid arthritis: Classically the anaemia of chronic

inflammatory disease—a defective marrow response to anaemia in a

variety of chronic inflammatory disorders primarily due to cytokine

mediated inhibition of erythropoiesis rather than deficiency of

erythropoietin. True iron deficiency also occurs due to NSAID therapy.

Neutropenia may arise, either immune mediated or due to hypersplenism.

494

Systemic lupus erythematosus: Commonly associated with immune

cytopenias (all cell lines) and anticardiolipin antibodies. May also produce

marrow hypoplasia.

Epstein-Barr virus infection: Infects CD21 positive B lymphocytes and

other tissues including nasopharyngeal epithelium. Primary infection in the

immunocompetent may be asymptomatic in the early years of childhood

but in adolescence produces the syndrome of infectious mononucleosis

(‘glandular fever’) associated with a striking atypical lymphocytosis.

Occasionally there are associated self-limiting immune cytopenias—

especially thrombocytopenia. The majority of adults harbour the latent

virus in B cells. EBV in some cellular immune deficiency states (such as X-

linked lymphoproliferative disease also known as Purtilo’s or Duncan’s

syndrome) can produce a fatal infection with uncontrolled

lymphoproliferation and infection associated haemophagocytosis

(

HLH, p491).

Parvovirus B19 infection: Causes

‘fifth disease’ in infants and young

children with the characteristic ‘slapped cheek’ rash on the face. More

importantly shows trophism for marrow erythroblasts and causes

temporary red cell hypoplasia. This causes very low Hb concentrations in

Paediatric haematology

children with chronic haemolysis. Persistent viraemia can arise in the

immunosuppressed and can cause transfusion dependency.

TORCH infections: A miscellaneous group of congenital infections—

TOxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex and syphilis.

All can cause neonatal anaemia and thrombocytopenia.

Leishmaniasis: The Mediterranean type of visceral leismaniasis primarily

affects young children under 5. Infected sand flies transmit parasites that

develop in macrophages and the child presents often several weeks or

months later with fever and progressive pancytopenia and

hepatosplenomegaly. Fatal if untreated but responds well to pentavalent

antimony or amphotericin B.

Hookworms (ankylostoma): Are a common cause of iron deficiency in

tropical underdeveloped countries. Infestations may be heavy with each

worm consuming up to 0.2mL blood per day.

Tapeworms: A rare cause of vitamin B₁₂ deficiency in societies that eat

raw fish—Baltic states, Japan and Scandinavia, due to infestation by

Diphyllobothrium latum.

Kawasaki disease: An acute multisystem disease of young children,

presumed to be infective but no organism has so far been identified.

Presents with conjunctivitis, rashes, reddening of the mucous membranes,

hands and feet with desquamation and lymphadenopathy. Coronary

495

artery aneurysms develop in

~20%; fatal in

3%. Haematological

manifestations include anaemia (normochromic normocytic), neutrophilia,

and a striking secondary thrombocytosis that may linger after the acute

phase has passed. Treatment is with aspirin and high dose IVIg.

Nutritional disorders

Iron deficiency: Occurs in apparently healthy children (cf. adults where

main cause is blood loss). Linked to rapid growth and poor intake the first

2 years of life and again at adolescence. Cows’ milk is a poor source of

iron. Cereals inhibit its absorption Premature infants run out of iron by 2

months of age.

Protein-calorie malnutrition: Covers adequate calories with protein lack

(kwashiorkor) and simple calorie lack (marasmus)—or both. Chiefly in

undeveloped countries, but also occasionally in vegan families, with

gastrointestinal disease or other chronic illness. Concomitant iron or

folate deficiency may be present. Normochromic normocytic anaemia is

usual.

Scurvy: Occasionally seen in infants due to poor intake with fruit juices

being boiled. Pseudoparalysis due to painful legs. Petechial, periorbital or

subdural haemorrhages can arise. Bleeding tendency due to loss of

vascular integrity with collagen deficiency.

Poisons

Lead poisoning:

Inhibits haem synthesis and the activity of pyrimidine-5'-nucleotidase,

causing hypochromic anaemia with basophilic stippling of red cells and ring

sideroblasts in the bone marrow. Also causes abdominal pain.

Commonest in toddlers eating flakes of old lead-based paint.

Sodium chlorate: A common weedkiller, also a powerful oxidising

substance causing acute intravascular haemolysis and renal failure if

ingested.

Nitrates, aniline dyes, nitrobenzene and azo compounds: Can all cause

methaemoglobinaemia. If >20% metHb formed, exchange transfusion may

be needed.

Storage disorders

Gaucher’s disease: Inherited (autosomal recessive) disorder resulting in

deficiency of the enzyme glucocerebrosidase

(b-glucosidase) Most

common form has accumulated glycolipid in macrophages of spleen, liver

and bone marrow. May be diagnosed at any time during life depending on

severity. Some cases are not identified until adulthood. Rarer type 2

disease has severe progressive neurological deterioration from birth,

usually fatal within 1 year due to glycolipid accumulation in the CNS.

Diagnosis by assay of deficient enzyme, but characteristic (not diagnostic,

see below) Gaucher cells evident in bone marrow (laden macrophages

with appearance of crumpled tissue paper).

Neimann-Pick (N-P) disease: Though rare, commonest cause of foamy

macrophages in marrow of affected patients. Caused by the inherited

496

deficiency of sphingomyelinase resulting in accumulation of sphingomyelin.

Four types of Niemann-Pick disease have been defined, type A (classic N-

P disease) presents in the first year of life with developmental delay,

neurodegeneration and death within 3 years; type B with visceral rather

than CNS involvement also presents in infancy and is also progressive and

fatal but spares the CNS; type C presents later in childhood but then

shows neurodegeneration with death in the 2nd or 3rd decade; and type

4 patients simply store sphingomyelin in viscera without ill health and live

to adulthood.

Marrow and blood cells in storage disorders: The foamy macrophages

seen in the marrow of N-P patients vary between types and are not in any

way diagnostic or specific. Foamy macrophages are also seen in several

other storage disorders and a variety of other clinical circumstances.

Pseudo-Gaucher cells are seen in chronic granulocytic leukaemia,

thalassaemia and some atypical mycobacterial infections. Several storage

disorders produce vacuolation of peripheral blood leucocytes, particularly

lymphocytes, and this is also a non-specific finding. Diagnosis always rests

on the appropriate enzyme assay.

Septic shock/neutropenic fever

One of the commonest haemato-oncological emergencies.

2 May be defined as the presence of symptoms or signs of infection in a

patient with an absolute neutrophil count of <1.0

¥ 10⁹/L. In practice,

the neutrophil count is often <0.1

¥ 10⁹/L.

2 Similar clinical picture also seen in neutrophil function disorders such

as MDS despite normal neutrophil numbers.

2 Beware —can occur without pyrexia, especially patients on steroids.

Immediate action

Urgent clinical assessment.

Follow ALS guidelines if cardiorespiratory arrest (rare).

More commonly, clinical picture is more like cardiovascular shock ±

respiratory embarrassment viz: tachycardia, hypotension, peripheral

vasodilatation and tachypnoea. Occurs with both Gram +ve (now

more common with indwelling central catheters) and Gram -ve organ-

isms (less common but more fulminant).

Immediate rapid infusion of albumin 4.5% or Gelofusin to restore BP.

Insert central catheter if not in situ and monitor CVP.

Start O₂ by face mask if pulse oximetry shows saturations <95%

(common) and consider arterial blood gas measurement —care with

platelet counts <20

¥ 10⁹/L—manual pressure over puncture site for

30 mins.

Perform full septic screen (see guidelines on IV antibiotics, p552).

Give the first dose of first line antibiotics immediately e.g ureidopeni-

cillin and loading dose aminoglycoside (ceftazidime or ciprofloxacin if

pre-existing renal impairment). Follow established protocols.

If the event occurs while patient on first line antibiotics, vancomycin/

ciprofloxacin or vancomycin/meropenem are suitable alternatives.

500

Commence full ITU-type monitoring chart.

Monitor urine output with urinary catheter if necessary —if renal shut-

down has already occurred, give single bolus of IV frusemide

(furosemide). If no response, start renal dose dopamine.

If BP not restored with colloid despite 4 CVP, consider inotropes.

If O₂ saturations remain 5 despite 60% O₂ delivered by rebreathing

mask, consider ventilation.

Alert ITU giving details of current status.

Subsequent actions

2 Discuss with senior colleague.

2 Amend antibiotics according to culture results or to suit likely source if

cultures negative (see p554, 556).

2 Check aminoglycoside trough levels after loading dose and before

second dose as renal impairment may determine reducing or with-

holding next dose. Consider switch to non-nephrotoxic cover e.g cef-

tazidime/ciprofloxacin.

2 Continue antibiotics for 7-10d minimum and usually until neutrophil

recovery.

2 If cultures show central line to be source of sepsis, remove immedi-

ately if patient not responding.

Transfusion reactions

Rapid temperature spike (>40°C) at start of transfusion indicates transfu-

sion should be stopped (suggests acute intravascular haemolysis).

If slow rising temperature (<40°C), providing patient not acutely unwell,

slow IVI. Fever often due to antibodies against WBCs (or to cytokines in

platelet packs).

Immediate transfusion reaction

Intravascular haemolysis

(7haemoglobinaemia and haemoglobinuria).

Usually due to anti-A or anti-B antibodies (in ABO mismatched transfu-

sion). Symptoms occur in minutes/hours.

Immediate transfusion reaction or bacterial contamination of

blood

Symptoms

Signs

Patient restless/agitated

Fever

Flushing

Hypotension

Anxiety

Oozing from wounds or venepuncture sites

Chills

Haemoglobinaemia

Nausea and vomiting

Haemoglobinuria

Pain at venepuncture site

Abdominal, flank or chest pain

Diarrhoea

If predominantly extravascular may only suffer chills/fever 1h after starting

502

transfusion —commonly due to anti-D. Acute renal failure is not a feature.

Mechanism

Complement (C3a, C4a, C5a) release into recipient plasma7smooth

muscle contraction. May develop DIC (see p512); oliguria (10% cases) due

to profound hypotension.

Initial steps in management of acute transfusion reaction

2 Stop blood transfusion immediately.

2 Replace giving set, keep IV open with 0.9% saline.

2 Check patient identity against donor unit.

2 Insert urinary catheter and monitor urine output.

2 Give fluids (IV colloids) to maintain urine output >1.5mL/kg/h.

2 If urine output <1.5mL/kg/h insert CVP line and give fluid challenge.

2 If urine output <1.5mL/kg/h and CVP adequate give furosemide

(frusemide) 80-120 mg.

2 If urine output still <1.5mL/kg/h consult senior medical staff for advice.

2 Contact Blood Transfusion Lab before sending back blood pack and

for advice on blood samples required for further investigation.

Complications

Overall mortality ~10%.

Immediate-type hypersensitivity

reactions

May occur soon (30-90min) after transfusion of blood/component.

Antibody often unknown but in some cases is due to antibody directed

against IgA (in recipients who have become sensitised).

2 Mild reaction: urticaria, erythema, maculopapular rash, periorbital

oedema.

2 Severe reaction: bronchospasm.

2 Hypotension.

Management

2 Stop transfusion immediately.

2 Change giving set.

2 IV colloids to maintain BP/circulatory volume.

2 Give

- epinephrine (adrenaline)

1:1000 1mL IM stat

– hydrocortisone

100mg IV stat

– chlorphenamine (chlorpheniramine)

10mg IV stat

Febrile transfusion reactions

Seen in 0.5-1.0% blood transfusions. Mainly due to anti-HLA antibodies in

recipient serum or granulocyte-specific antibodies (e.g. sensitisation during

pregnancy or previous blood transfusion). Less common now that all

blood is leucodepleted after donation.

504

Treatment

2 Slow down rate of transfusion.

2 Antipyretic.

Delayed transfusion reaction

Occurs in patients immunised through previous pregnancies or transfu-

sions. Antibody weak

(so not detected at pretransfusion stage).

2°

immune response occurs—antibody titre 4.

Symptoms/signs

2 Occur 7-10d after blood transfusion.

2 Fever, anaemia and jaundice.

2 ± haemoglobinuria.

Management

2 Check DAT and repeat compatibility tests.

2 Transfuse patient with freshly cross-matched blood.

Bacterial contamination of blood

products

Uncommon but potentially fatal adverse effect of blood transfusion

(affects red cells and blood products e.g. platelet concentrates).

Implicated organisms include Gram -ve bacteria, including Pseudomonas,

Yersinia and Flavobacterium.

Features

2 Fever.

2 Skin flushing.

2 Rigors.

2 Abdominal pain.

2 DIC.

2 ARF.

2 Shock.

2 Cardiac arrest.

Management —as per Immediate transfusion reaction

2 Stop transfusion.

2 Urgent resuscitation.

2 IV broad-spectrum antibiotics if bacterial contamination suspected.

506

Post-transfusion purpura

Profound thrombocytopenia occurring 5-10d after blood or platelet

transfusion. Usually due to high titre of anti-HPA-1a antibody in HPA-1a

-ve patient.

Features

2 Rare.

2 Multiparous 3 most commonly (previous pregnancies or transfusions).

2 Caused by platelet-specific alloantibodies (usually anti-HPA-1a).

2 Platelets 55 with associated bleeding/bruising —may be severe and

even life threatening.

Management

2 IVIg if bleeding.

2 Plasma exchange worth considering.

2 If platelet transfusion needed, use random donor platelets (no evi-

dence that HPA-1a superior).

Hypercalcaemia

Clinical symptoms

2 General —weakness, lassitude, weight loss.

2 Mental changes—impaired concentration, drowsiness, personality

change and coma.

2 GIT —anorexia, nausea, vomiting, abdominal pain (peptic ulceration

and pancreatitis are rare complications).

2 Genitourinary —polyuria, polydipsia.

Clinical effects

2 Cardiovascular —5 QT interval on ECG, cardiac arrhythmias and

hypertension.

2 Renal —dehydration, renal failure and renal calculi.

Haematological causes

1. Myeloma.

2. High grade lymphoma.

3. Adult T-cell leukaemia/lymphoma (ATLL).

4. Acute lymphoblastic leukaemia.

Hypercalcaemia occurs in other clinical situations including metastatic

carcinoma of breast, prostate and lung. Theories for occurrence in

haematological malignancy include increased bone resorption mediated by

osteoclasts under the influence of locally or systemically released

cytokines such as PTH-related peptide, TGF, TNF-a, M-CSF, interleukins

and prostaglandins. Increased intestinal absorption of calcium secondary

to increased 1,25-hydroxycholecalciferol.

Normal range for plasma [Ca²⁺] 2.12-2.65mmol/L. 40% of plasma Ca²⁺ is

bound to albumin. Most laboratories measure the total plasma Ca²⁺

508

although only unbound Ca²⁺ is physiologically active. For accurate mea-

surement of plasma or serum Ca²⁺ blood sampling should be taken from

an uncuffed arm, i.e. without the use of a tourniquet.

Correct for albumin

Albumin <40g/L

corrected calcium = (Ca²⁺) + 0.02 [40-(Albumin)]

Albumin >45g/L

corrected calcium = (Ca²⁺) - 0.02 [(Albumin)-45]

Management

An emergency if Ca²⁺ >3.0mmol/L.

1. Rehydrate with normal saline 4-6L/24h.

2. Beware fluid overload—use loop diuretics and CVP monitoring if nec-

essary.

3. Stop thiazide diuretics and consider regular loop diuretics.

4. Give bisphosphonates e.g. disodium pamidronate 60-90mg IV stat (see

table).

5. Treat underlying malignancy.

6. Consider dialysis if complicating factors (CCF, advanced renal failure).

7. Other therapeutic options:

- Calcitonin 200IU 8-hourly.

Hyperviscosity

Common haematological emergency. Defined as increase in whole blood

viscosity as a result of an increase in either red cells, white cells or plasma

components, usually Ig.

Commonest situations arise as a result of

2 4 in red cell volume in polycythaemia rubra vera.

2 High blast cell numbers in peripheral blood e.g. AML or ALL at presen-

tation.

2 Presence of monoclonal Ig e.g. Waldenström’s macroglobulinaemia (IgM).

Clinical features —polycythaemia (e.g. PRV)

2 Lethargy, itching, headaches, hypertension, plethora, arterial throm-

boses viz: MI, CVA and visual loss (central retinal artery occlusion).

Emergency treatment

Isovolaemic venesection. Remove 500mL blood volume from large bore

vein (antecubital usually) with simultaneous replacement into another vein

of 500mL 0.9% saline. Repeat daily until PCV <0.45.

Clinical features —high WBC (e.g. AML)

2 Dyspnoea and cough (pulmonary leucostasis); confusion, 5 conscious

level, isolated cranial nerve palsies (cerebral leucostasis), visual loss

(retinal haemorrhage or CRVT).

Emergency treatment

2 Unless machine leucapheresis can be obtained immediately, venesect

500mL blood from large bore vein and replace isovolaemically with

packed red cells if Hb <7.0g/dL—otherwise replace with 0.9% saline to

avoid increasing whole blood viscosity.

2 Arrange leucapheresis on cell separator machine. Use white cell inter-

face programme to apherese with replacement fluids depending on Hb

510

as above. 2h is usually maximum tolerated.

2 Initiate tumour lysis prophylactic protocol (see p560) in preparation

for chemotherapy.

2 Start chemotherapy as soon as criteria allow (high urine volume of

pH>8 and allopurinol commenced). This is crucial as leucapheresis in

this situation is only a holding manoeuvre while the patient is prepared

for chemotherapy.

2 Continue leucapheresis daily until leucostasis symptoms resolved or

until WBC <50

¥ 10⁹/L.

Hypergammaglobulinaemia (e.g. Waldenström’s)

Lethargy, headaches, memory loss, confusion, vertigo, visual disturbances

from cerebral vessel sludging —rarely MI, CVA.

Emergency treatment

2 Unless immediate access to plasma exchange machine available, vene-

sect 500mL blood from large bore vein with isovolaemic replacement

with 0.9% saline unless Hb <7.0g/dL when use packed red cells.

2 Arrange plasmapheresis on a cell separator machine using plasma

exchange programme (see p584). Replacement fluids on criteria as

above. Aim for 1-1.5

¥ blood volume exchange (usually 2.5-4.0L)

Haematological emergencies

starting at lower end of range initially. Repeat daily until symptoms

resolved.

2 Maintenance plasma exchanges at 3-6 weekly intervals may be suffi-

cient treatment for some forms of Waldenström’s macroglobuli-

naemia. However, if hyperviscosity due to IgA myeloma or occasionally

IgG myeloma, chemotherapy will need to be initiated.

Note

Diseases in which the abnormal Ig shows activity at lower temperature

e.g. cold antibodies associated with CHAD (see p118) require mainte-

nance of plasmapheresis inlet and outlet venous lines and all infusional

fluids at 37°C. Polyclonal 4 in Ig (e.g. some forms of cryoglobulinaemia)

can also rarely cause hyperviscosity symptoms. Management is as above

for monoclonal immunoglobulins.

511

Disseminated intravascular

coagulation

Pathological process characterised by generalised intravascular activation

of the haemostatic mechanism producing widespread fibrin formation,

resultant activation of fibrinolysis, and consumption of platelets/coagula-

tion factors (esp I, II, V). Usually the result of serious underlying disease

but may itself become life threatening (through haemorrhage or throm-

bosis). Mortality in severe DIC may exceed >80%. Haemorrhage usually

the dominant feature and is the result of excessive fibrinolysis, depletion

of coagulation factors and platelets and inhibition of fibrin polymerisation

by FDPs. Wide range of disorders may precipitate DIC.

Pathophysiology —DIC may be initiated by

2 Exposure of blood to tissue factor (e.g. after trauma).

2 Endothelial cell damage (e.g. by endotoxin or cytokines).

2 Release of proteolytic enzymes into the blood (e.g. pancreas, snake

venom).

2 Infusion or release of activated clotting factors (factor IX concentrate).

2 Massive thrombosis.

2 Severe hypoxia and acidosis.

Causes of DIC

Tissue damage (release of tissue factor) e.g. trauma (esp brain or crush

injury), thermal injury (burns, hyperthermia, hypothermia), surgery, shock,

asphyxia/hypoxia, ischaemia/infarction, rhabdomyolysis, fat embolism.

Complications of pregnancy (release of tissue factor) e.g. amniotic fluid

embolism, abruptio placentae, eclampsia and pre-eclampsia, retained dead

512

fetus, uterine rupture, septic abortion, hydatidiform mole.

Neoplasia (release of tissue factor, TNF, proteases) e.g. solid tumours,

leukaemias (esp. acute promyelocytic).

Infection

(endotoxin release, endothelial cell damage) e.g. Gram -ve

bacteria (e.g. meningococcus), Gram +ve bacteria (e.g. pneumococcus),

anaerobes, M tuberculosis, toxic shock syndrome, viruses (e.g. Lassa fever),

protozoa (e.g. malaria), fungi (e.g. candidiasis), Rocky Mountain spotted

fever.

Vascular disorders (abnormal endothelium, platelet activation) e.g. giant

haemangioma (Kasabach-Merritt syndrome), vascular tumours, aortic

aneurysm, vascular surgery, cardiac bypass surgery, malignant

hypertension, pulmonary embolism, acute MI, stroke, subarachnoid

haemorrhage.

Immunological

(complement activation, release of tissue factor)

anaphylaxis, acute haemolytic transfusion reaction, heparin-associated

thrombocytopenia, renal allograft rejection, acute vasculitis, drug

reactions (quinine).

Proteolytic activation of coagulation factors e.g. pancreatitis, snake

venom, insect bites.

Haematological emergencies

Neonatal disorders e.g. infection, aspiration syndromes, small-for-dates

infant, respiratory distress syndrome, purpura fulminans.

Other disorders e.g. fulminant hepatic failure, cirrhosis, Reye’s syndrome,

acute fatty liver of pregnancy, ARDS, therapy with fibrinolytic agents,

therapy with factor IX concentrates, massive transfusion, acute

intravascular haemolysis familial ATIII deficiency, homozygous protein C

or S deficiency.

Clinical features

Acute (uncompensated) DIC Rapid and extensive activation of

coagulation, fibrinolysis or both,

with depletion of procoagulant

factors and inhibitors and signifi

cant haemorrhage.

Chronic (compensated) DIC

Slow consumption of factors with

normal or increased levels; often

asymptomatic or associated with

thrombosis.

Clinical features may be masked by those of the disorder which precipi-

tated it and rarely is the cause of DIC obscure. DIC should be considered

in the management of any seriously ill patient. The specific features of DIC

are:

2 Ecchymoses, petechiae, oozing from venepuncture sites and post-op

bleeding.

513

2 Renal dysfunction, ARDS, cerebral dysfunction and skin necrosis due

to microthrombi.

2 MAHA.

Laboratory features

The following investigations are useful in establishing the diagnosis of DIC

though the extent to which any single test may be abnormal reflects the

underlying cause of DIC.

2 D-dimers—more specific and convenient than FDP titre (performed

on plasma sample). Significant 4 of D-dimers plus depletion of coagula-

tion factors ± platelets is necessary for diagnosis of DIC.

2 PT—less sensitive, usually 4 in moderately severe DIC but may be

normal in chronic DIC.

2 APTR—less useful. May be normal or even <normal, particularly in

chronic DIC.

2 Fibrinogen—5 or falling fibrinogen levels are characteristic of many

causes of DIC in the presence of D-dimers. Greatest falls are seen

with tissue factor release.

2 Platelet count—5 or falling platelet counts are characteristic of acute

DIC, most notably in association with infective causes.

2 Blood film may show evidence of fragmentation (schistocytes) though

the absence of this finding does not exclude the diagnosis of DIC.

2 Antithrombin levels are frequently 5 in DIC and degree of reduction in

plasma antithrombin and plasminogen may reflect severity.

2 Factor assays rarely necessary or helpful. In severe DIC levels of most

factors are reduced with the exception of FVIIIc and von Willebrand

factor which may be increased due to release from endothelial cell

storage sites.

Management of DIC

1. Identify and, if possible, remove the precipitating cause.

2. Supportive therapy as required (e.g. volume replacement for shock).

3. Replacement therapy if bleeding: platelet transfusion if platelets <50

10⁹/L, cryoprecipitate to replace fibrinogen, and FFP to replace other

factors (10 units cryoprecipitate for every 3 units FFP).

4. Prophylactic platelet transfusion may be helpful if platelets <20

¥ 10⁹/L.

5. Monitor response with platelet count, PT, fibrinogen and D-dimers.

6. Heparin (IVI 5-10iu/kg/h) for DIC associated with APML, carcinoma,

skin necrosis, purpura fulminans, microthrombosis affecting skin,

kidney, bowel and large vessel thrombosis.

7. ATIII concentrate in intractable shock or fulminant hepatic necrosis.

8. Protein C concentrate in acquired purpura fulminans or severe

neonatal DIC.

514

Overdosage of thrombolytic therapy

2 Large doses of any thrombolytic agent (streptokinase, urokinase, TPA)

will cause primary fibrinolysis by proteolytic destruction of circulating

fibrinogen and consumption of plasminogen and its major inhibitor

antiplasmin.

2 Overdosage is associated with high risk of severe haemorrhage partic-

ularly at recent venepuncture sites or surgical wounds; intracranial

haemorrhage occurs in 0.5-1% of patients treated with thrombolytic

therapy.

2 Superficial bleeding at venepuncture site may be managed with local

pressure and the infusion continued.

2 Bleeding at other sites or where pressure cannot be applied necessi-

⁄2

of the thrombin time (if used to monitor thrombolytic therapy) or fib-

rinogen level. If strongly indicated and bleeding minimal or stopped the

infusion may be restarted at 50% the initial dose when the thrombin

time has returned to the lower end of the therapeutic range (1.5

baseline).

Treatment of serious bleeding after thrombolytic therapy

2 Stop thrombolytic infusion immediately.

2 Discontinue any simultaneous heparin infusion and any antiplatelet

agents.

2 Apply pressure to bleeding sites, ensure good venous access and com-

mence volume expansion.

2 Check fibrinogen and APTR.

2 Transfuse 10 units cryoprecipitate.

2 Monitor fibrinogen, repeat cryoprecipitate to maintain fibrinogen

>1.0g/L.

516

2 If still bleeding, transfuse 2-4 units FFP.

2 If bleeding time >9 mins, transfuse 10 units platelets.

2 If bleeding time <9 mins, commence tranexamic acid.

Heparin overdosage

The most serious complication of heparin overdosage is haemorrhage.

The therapeutic range using the APTT is 1.5-2.5¥ average normal control.

The plasma t^1/2 following IV administration is 1-2h. The t1⁄after SC admin-

istration is considerably longer.

Management guidelines —APTT > therapeutic range

Without haemorrhage Continuous IV infusion

stop infusion, if markedly elevated, recheck

after 0.5-1h; restart at lower dose when

APTT in therapeutic range

Intermittent SC heparin

reduce dose recheck 6h after administration

With haemorrhage

Continuous IV infusion

stop infusion; if bleeding continues, administer

protamine sulphate by slow IV injection (1mg

neutralises 100iu heparin, max dose 40mg/injection)

Intermittent SC heparin

if protamine is required, administer 50% of

calculated neutralisation dose 1h after heparin

administration and 25% after 2h

518

Heparin-induced thrombocytopenia (HIT)

Uncommon but sometimes life-threatening condition due to immune

complex-mediated thrombocytopenia in patients treated with heparin.

Early recognition reduces morbidity and mortality.

Incidence

Estimated incidence

1-3% of patients receiving heparin for

≥1week.

Occurs both with full dose regimens and ‘minidose’ regimens (5000IU bd)

or low doses used for ‘flushing‘ IV lines. Less common with low molecular

weight heparin.

Pathogenesis

IgG antibodies formed in response to heparin therapy form immune com-

plexes with heparin and PF4, bind to platelet Fc receptors, trigger aggre-

gation and cause thrombocytopenia. Thrombin activation causes vascular

thrombosis and microthrombi cause microvascular occlusion.

Clinical features

2 HIT causes a fall in the platelet count ~8d (4-14d) after a patient’s first

exposure to heparin but may occur within 1-3d in a patient who has

recently had prior exposure to heparin.

2 Platelet count generally falls to ~60

¥ 10⁹/L but may fall to <20

¥ 10⁹/L.

2 Venous and arterial thromboses occur in up to 15%.

2 Bleeding is rare.

2 Microvascular occlusion may cause progressive gangrene extending

proximally from the extremities and necessitating amputation. In

patients with HITT (thrombocytopenia and thrombosis) limb amputa-

tion is required in ~10% and mortality approaches 20%.

520

HIT should be suspected in any patient on heparin in whom the platelet

count falls to <100

¥ 10⁹/L or drops by ≥30-40% or develops a new

thromboembolic event 5-10d after ongoing heparin therapy.

ii Heparin should be discontinued immediately and confirmatory

investigations undertaken.

Diagnostic test

ELISA using PF4 to detect antibodies to heparin-low molecular weight

protein complex; may miss 5-10% of cases with antibodies to other pro-

teins and up to 50% false positives after CABG.

Management

2 Discontinue heparin (platelet count normally recovers in 2-5d).

2 Substitute alternative anticoagulation where necessary and to prevent

further thromboembolic events:

2 Recombinant hirudin

- Thrombin inhibitor; anticoagulant effect lasts ~40min.

- Slow IV bolus followed by IVI.

- Dose determined by body weight and renal function (see product lit-

erature).

- Monitor 4h after IV bolus dose using APTT or ecarin clotting time

(ECT); target range 1.5-2.5

¥ mean normal APTT; reduce target to

Haematological emergencies

1.5 if concomitant warfarin therapy and discontinue hirudin when

INR ≥2.0.

- Adverse effects bleeding (esp. with warfarin), anaemia, haematoma,

fever and abnormal LFTs.

2 Argatroban

- Thrombin inhibitor; t

~45min.

¹⁄2

- Initiate IV infusion at dose of 2µg/kg/min.

- Check APTT at 2h and adjust dose for APTT 1.5-3

¥ baseline (max

100s).

- 5 dose by 75% if hepatic insufficiency.

- Side effect—bleeding.

2 Danaparoid

- A heparinoid with low level cross-reactivity with HIT antibodies.

- IV bolus dose by weight (see product literature) followed by decre-

mental infusion schedule and maintenance infusion.

- Monitor by factor Xa inhibition assay 4h after dose (target range

0.5-0.8U/ml).

- Prolonged t1⁄of 25h.

- Side effect—bleeding.

ii Low molecular weight heparins frequently cross-react with HIT anti-

bodies and are not recommended.

521

Warfarin overdosage

Haemorrhage is a potentially serious complication of anticoagulant

therapy and may occur with an INR in the therapeutic range if there are

local predisposing factors e.g. peptic ulceration or recent surgery, or if

NSAIDs are given concurrently.

Management guidelines

INR

Action

>7.0

Without haemorrhage: stop warfarin & consider a single 5-10mg

oral dose of vitamin K if high bleeding risk; review INR daily

4.5-7.0

Without haemorrhage: stop warfarin & review INR in 2d

>4.5

With severe life-threatening haemorrhage: give factor IX

concentrate (50U/kg) or FFP (1L for an adult), consider a single

2-5mg IV dose of vitamin K

>4.5

With less severe haemorrhage: e.g. haematuria or epistaxis,

withhold warfarin for ≥1d and consider a single 0.5-2mg IV dose

of vitamin K

2.0-4.5

With haemorrhage: investigate the possibility of an underlying

local cause; reduce warfarin dose if necessary; give FFP/factor IX

concentrate only if haemorrhage is serious or life threatening

Vitamin K administration to patients on warfarin therapy

Effect of vitamin K is delayed several hours even with IV administration.

Doses >2 mg cause unpredictable and prolonged resistance to oral anti-

coagulants and should be avoided in most circumstances where prolonged

522

warfarin therapy is necessary. Particular care must be taken in patients

with prosthetic cardiac valves who may require heparin therapy for

several weeks to achieve adequate anticoagulation if a large dose of

vitamin K has been administered.

Massive blood transfusion

Massive transfusion defined as replacement of >1 blood volume (5L) in

less than 24h. Haemostatic failure may result from dilution or consump-

tion of coagulation factors and platelets, DIC, systemic fibrinolysis or

acquired platelet dysfunction.

Pathophysiology

2 Dilution/consumption e.g. replacement of intravascular volume

with fluids lacking coagulation factors or platelets e.g. packed red cells

and crystalloids.

2 DIC may follow tissue damage, hypoxia, acidosis, sepsis or haemolytic

transfusion reaction. Causes coagulopathy due to consumption of

platelets and coagulation factors, fibrinolysis and circulating fibrin

degradation products (see p512).

2 Systemic fibrinolysis particularly associated with liver disease; causes

rapid lysis of thrombi at surgical sites and plasmin-induced fibrinogenol-

ysis; may be assessed by the euglobulin lysis time.

2 Platelet dysfunction may be due to circulating FDPs, exhausted

platelets activated by intravascular trauma or effects of transfusion of

stored platelets.

Investigations

2 Baseline tests

- Haematocrit.

- Platelet count.

- Fibrinogen.

- PT.

- APTT ratio.

- D-dimers.

524

2 Frequent reassessment of tests to monitor effect of, and need for,

further replacement therapy.

Management

Haematocrit

<0.30

Transfuse red cells

Platelet count

<75

¥ 10⁹/L

Transfuse platelets

Fibrinogen

<1.0g/L

Transfuse cryoprecipitate

PT ± APTT ratio

>1.5

¥ control

Transfuse FFP

Red cell transfusion

2 Full crossmatch takes 30-40 minutes.

2 Uncrossmatched group-specific blood can be available in 10 minutes.

2 Uncrossmatched group O Rh (D) -ve blood may be transfused in the

emergency situation until group-specific blood can be made available;

group O Rh (D) +ve red cells may be given to males and older women

if necessary.

Platelet transfusion

2 Usually available within 10-15 minutes.

2 Standard adult dose (6 units equivalent) will raise platelet count by

~60

¥ 10⁹/L in absence of dilution or consumption.

Haematological emergencies

2 As platelets do not carry Rh antigens, type incompatible platelets may

be administered when necessary; Rh immune globulin should be

administered when a Rh -ve patient has received Rh +ve platelets.

2 6 units of platelets contain ~300mL plasma.

Fresh frozen plasma

2 Takes up to 30 minutes to thaw; dose required ~10mL/kg.

2 Use immediately for optimum replacement of coagulation factors.

2 Each unit contains ~200-280mL plasma and 0.7-1.0iu/mL activity of

each coagulation factor

2 ABO group compatible FFP should be administered —no crossmatch is

required.

2 If large volumes infused, serum [Ca²⁺] should be monitored to exclude

hypocalcaemia due to citrate toxicity.

Cryoprecipitate

2 Precipitate formed when FFP is thawed at 4°C; resuspended in

10-15mL plasma and refrozen at -18°C; takes up to 15 minutes to

thaw and pool.

2 No grouping required.

2 Contains 80-100IU FVIIIC, 100-250mg fibrinogen, 50-60mg

fibronectin and 40-70% of the original von Willebrand factor.

2 Should be used immediately for optimum replacement of fibrinogen

and factor VIIIC.

2 Infusion of 8-10 bags raises fibrinogen concentration by 0.6-1.0g/L in a

70kg patient.

525

Paraparesis/spinal collapse

May be due to tumour in the cord, spinal dura or meninges or by exten-

sion of a vertebral tumour into the spinal canal with compression of the

cord or as a result of vertebral collapse.

Spinal cord compression from vertebral collapse in a haematological

patient is most commonly due to myeloma (in up to 20% of patients) but

may occur in a patient with Hodgkin’s disease (3-8%) or occasionally non-

Hodgkin’s lymphoma. Spinal cord involvement by leukaemia is most

common in AML, less so in ALL and CGL and least common in CLL.

Onset of paraplegia may be preceded for days or weeks by paraesthesia

but in some patients the onset of paraplegia may follow initial symptoms

by only a few hours.

Symptoms suggestive of spinal cord compression require urgent assess-

ment by CT or MRI and referral to a neurosurgical unit for assessment for

surgical decompression. Where this is not possible early radiotherapy may

provide symptomatic improvement. However, if treatment is delayed until

paraparesis has developed, this often proves to be irreversible despite

surgery and/or radiotherapy.

526

Leucostasis

Term is applied both to organ damage due to ‘sludging’ of leucocytes in

the capillaries of a patient with high circulating blast count and to the

lodging and growth of leukaemic blasts, usually in AML, in the vascular

tree eroding the vessel wall and producing tumours and haemorrhage.

Features

2 More common in AML and blast crisis of CML.

2 Leucostatic tumours are associated with an exponential increase in

blasts in the peripheral blood and, prior to the development of effec-

tive chemotherapy, haemorrhage from intracerebral tumours was not

an uncommon cause of death.

2 Pulmonary or cerebral leucostasis are serious complications which may

occur in patients who present with a blast count >50

¥ 10⁹/L.

2 Leucocyte thrombi may cause plugging of pulmonary or cerebral capil-

laries. Vascular rupture and tissue infiltration may occur.

2 Less common manifestations are priapism and vascular insufficiency.

2 Pulmonary leucostasis causes progressive dyspnoea of sudden onset

associated with fever, tachypnoea, hypoxaemia, diffuse crepitations and

a diffuse interstitial infiltrate on CXR.

2 Pulmonary haemorrhage and haemoptysis may occur. More common

with monocytic leukaemias and the microgranular variant of acute

promyelocytic leukaemia. Differentiation from bacterial or fungal pneu-

monia may be difficult.

2 Cerebral leucostasis may cause a variety of neurological abnormalities.

2 Anaemia may protect a patient with marked leucocytosis from the

effects of increased whole blood viscosity. Transfusion of RBCs to

correct anaemia prior to chemotherapy may initiate leucostasis.

528

Management

Urgent leucapheresis is required for a patient with marked leucostasis

(>200

¥ 10⁹/L) or in any patient in whom leucostasis is suspected.

Chemotherapy may be commenced concomitantly to further reduce the

leucocyte count but may be associated with a high incidence of pulmonary

and CNS haemorrhage.

Thrombotic thrombocytopenic purpura

Definition

Fulminant disease of unknown aetiology characterised by increased

platelet aggregation and occlusion of arterioles and capillaries of the

microcirculation. Considerable overlap in pathophysiology and clinical fea-

tures with HUS —fundamental abnormality may be identical.

Incidence:

Rare, ~1 in 500,000 per year. 3:9 = 2:1. HUS much commoner in chil-

dren, TTP commoner in adults—peak age incidence is 40 years, and 90%

of cases <60 years old. There is some case clustering.

Clinical features

2 Classical description is of a pentad of features:

1. Microangiopathic haemolytic anaemia.

2. Severe thrombocytopenia.

3. Neurological involvement.

4. Renal impairment.

5. Fever.

In practice, few patients have the full monty. 50-70% have renal abnor-

malities (cf. nearly all with HUS) and they are less severe. Neurological

involvement is more prevalent in TTP than HUS. 40% of TTP patients

have fever.

2 Haemolysis —severe and intravascular causing jaundice.

2 Thrombocytopenia —severe, mucosal haemorrhage likely and intracranial

haemorrhage may be fatal.

2 Neurological —from mild depression and confusion7visual defects,

coma and status epilepticus.

2 Renal —haematuria, proteinuria, oliguria and 4 urea and creatinine.

530

HUS >TTP.

2 Fever—very variable, weakness and nausea common.

2 Other disease features: serious venous thromboses at unusual sites (e.g.

sagittal sinus—microthrombi in the brain seen on MRI scan).

Abdominal pain severe enough to mimic an acute abdomen is some-

times seen due to mesenteric ischaemia. Diarrhoea is common, partic-

ularly bloody in HUS.

Diagnosis and investigations

2 Made on the clinical features above —exclude other diseases e.g. cere-

bral lupus, sepsis with DIC.

2 FBC shows severe anaemia and thrombocytopenia.

2 Blood film shows gross fragmentation of red cells, spherocytes and

nucleated red cells with polychromasia.

2 Reticulocytes 44 (>15%).

2 LDH 44 (>1000iu/L).

2 Clotting screen including fibrinogen and FDPs usually normal (cf. DIC).

2 Serum haptoglobin low or absent.

2 Urinary haemosiderin +ve.

2 Unconjugated bilirubin 4.

2 DAT -ve.

2 BM hypercellular.

Haematological emergencies

2 U&E show increases (HUS > TTP).

2 Proteinuria and haematuria.

2 Renal biopsy shows microthrombi.

2 Stool culture for E. coli 0157 +ve in most cases of HUS in children, less

often in adult TTP.

2 MRI brain scan shows microthrombi and occasional intracranial haem-

orrhage.

2 Lumbar puncture - do not proceed with LP unless scans clear and

there is suspicion of infective meningitis.

2 Look for evidence of viral infection. Association of syndrome with HIV,

SLE, cyclosporin usage and the 3rd trimester of pregnancy.

Treatment is a haematological emergency—seek expert help

immediately

Unless antecubital venous access is excellent, insert a large bore

central apheresis catheter (may need blood product support).

May need ITU level of care and ventilation.

Initiate plasmapheresis as soon as possible.

Exchange 1-1.5

¥ plasma volume daily until clinical improvement.

May need 3-4L exchanges. Replacement fluid should be solely FFP.

In the event of delayed access to cell separator facilities, start IV infu-

sions of FFP making intravascular space with diuretics if necessary.

Once response achieved, 5 frequency of exchanges gradually.

If no response obtained within one week, change FFP replacement to

cryosupernatant (rationale: it lacks high molecular weight multimers of

von Willebrand factor postulated in endothelial damage disease trig-

gers).

531

Give RBC as necessary but reserve platelet transfusions for severe

mucosal or intracranial bleeding as reports suggest they may worsen

the disease.

Cover for infection with IV broad spectrum antibiotics including

teicoplanin if necessary to preserve the apheresis catheter.

Start anticonvulsants if fitting.

Most would start high dose steroids (prednisolone 2mg/kg/d PO) with

gastric protection although evidence is equivocal.

Aspirin/dipyridamole/heparin may be considered for non-responders.

Refractory patients (~10%) should be considered for IV vincristine.

10.

Still refractory patients may achieve remission with splenectomy.

11.

Response to treatment may be dramatic e.g. ventilated, comatose

patient watching TV in the afternoon after plasma exchange in the

morning!

Prognosis

2 90% respond to plasma exchange with FFP replacement.

2 ~30% will relapse. Most respond again to further plasma exchange but

leaves 15% who become chronic relapsers.

2 Role of prophylaxis for chronic relapsers unclear. Intermittent FFP

infusions or continuous low dose aspirin may help individual cases.

Sickle crisis

Management

Early and effective treatment of crises essential (hospital).

Rest patient and start IV fluids and O₂ (patients often dehydrated

through poor oral intake of fluid + excessive loss if fever).

Start empirical antibiotic therapy (e.g. cephalosporin) if infection is sus-

pected whilst culture results (blood, urine or sputum) are awaited.

Analgesia usually required —e.g. intravenous opiates

(diamorphine/morphine) especially when patients are first admitted to

hospital. Switch later to oral medication after the initial crisis abates.

Consider exchange blood transfusion (if neurological symptoms, stroke

or visceral damage). Aim to 5 HbS to <30%.

Exchange transfusion if PaO₂ <60mm on air ( chest syndrome).

a-adrenergic stimulators for priapism.

Seek advice of senior haematology staff.

Consider regular blood transfusion if crises frequent or anaemia is severe

or patient has had CVA/abnormal brain scan.

Top-up transfusion if Hb <4.5g/dL (hunt for cause).

Transfusion and splenectomy may be lifesaving in children with splenic

sequestration.

532

www.bcshguidelines.com/pdf/SICKLE.V4_0802.pdf

Quality of life

In managing any disease problem a key objective is to improve the quality

of a patient’s survival as well as its duration. Part of the clinical decision-

making process takes into account quality of life (QoL) in judging the most

appropriate treatment.

Defining quality of life precisely is not easy; it has been described as a

measure of the difference at a particular time point between the hopes

and expectations of the individual and that individual’s present experi-

ences. QoL is multifaceted and can only be assessed by the individual since

it takes into account many aspects of that individual’s life and their current

perception of what, for them, is good QoL in their specific circumstances.

A clear distinction exists between performance scores (e.g. Karnofsky or

WHO) which record functional status and assess independence; these are

assessed by the physician according to pre-set criteria. They have erro-

neously been considered to be surrogate markers of QoL.

Patient QoL as assessed by the treating physician has been shown to be

unreliable in an oncological setting.

There is no single determinant of good QoL. A number of qualities which

go to make up QoL are capable of assessment; these include ability to carry

on normal physical activities, ability to work, to engage in normal social activities,

a sense of general well-being and a perception of health.

Several validated instruments now exist to measure QoL; these mainly

involve questionnaires completed by the patient. They are simple to com-

plete and involve ‘yes’ or ‘no’ answers to specific questions, answers on a

linear analogue scale or the use of 4- or 7- point Likert scales.

536

Available QoL instruments include

2 Functional Living Index - Cancer (FLIC)¹

2 Functional Assessment of Cancer Therapy (FACT)²

2 European Organisation for Research and Treatment in Cancer

(EORTC) Quality of Life Questionnaire C-30 (QLQ C30)³

Data from validated QoL questionnaires are now accepted as a require-

ment and a clinical end point in many major clinical trials, especially in

malignancies, particularly those where survival differences are minimal

between contrasting therapy approaches. Where survivals are minimally

affected it is then essential to focus on treatments which will offer the best

QoL.

Schipper, H. et al. (1984) Measuring the quality of life of cancer patients: the Functional Living

Index-Cancer: development and validation. J Clin Oncol, 2, 472-483; Cella, D.F. et al. (1993) The

Functional Assessment of Cancer Therapy scale: development and validation of the general

measure. J Clin Oncol, 11, 570-579; Aaronson, N.K. et al. (1993) The European Organization for

Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international

clinical trials in oncology. J Natl Cancer Inst, 85, 365-376.

Pain management

Pain is a clinical problem in diverse haematological disorders, notably in

sickle cell disease, haemophilia and myeloma. Acknowledgement of the

need to manage pain effectively is an essential part of successful patient

care and management in clinical haematology.

Pain may be local or generalised. More than one type of pain may be

present and causes may be multifactorial. It is most important to listen to

the patient and give him/her the chance to talk about their pain(s). Not

only will this help determine an appropriate therapeutic strategy, the act

of listening and allowing the patient to talk about their pains and associ-

ated anxieties is part of the pain management process.

Engaging the patient in ‘measuring’ their pain is often helpful; it enables

specific goals to be set and provides a means to assess the effectiveness of

the analgesic strategy.

Basic to the control of pain is to manage and remove the pathological

process causing pain, wherever this is possible. Analgesia must be part of

an integrated care plan which takes this into account.

Analgesic requirements should be recorded regularly as these form a valu-

able ‘semi-quantitative’ end point of pain measurement. Reduction in

requirements, for example, is an indicator that attempts to remove or

control the underlying cause are succeeding.

Managing pain successfully involves patient and family/carer participation, a

collaborative multidisciplinary approach in most categories of haematolog-

ical disorder related pain; medication should aim to provide continuous

pain relief wherever possible with a minimum of drug related side effects

538

Analgesics

Simple non-opioid analgesics Paracetamol: 1g 4-6 hourly, oral as tablets or liquid;

suppositories available. No contraindication in liver

disease; useful in mild to moderate pain.

Anti-inflammatory drugs

Ibuprofen 800mg or diclofenac 75-100mg bd as

slow release formulations can be synergistic with

other analgesics; combined formulations of

diclofenac with misoprostol may reduce risks of

gastric irritation bleeding; useful in combination with

paracetamol or weak opioids

Weak opioids

Dextropropoxyphene 100mg usually combined with

paracetamol 1g as coproxamol tablets; usual dosage

is 2 tablets 6 hourly or codeine 30-60mg or dihy-

drocodeine 30-60mg up to 4 hourly provide effec-

tive analgesia for moderate pain. Confusion,

drowsiness may be associated with initial usage in

some. Weak (and strong) opioids cause constipa-

tion; usually requires simple laxatives

Strong opioids

Morphine available as liquid or tablets commencing

at 5-10mg and given 4 hourly is treatment of choice

Supportive care

in severe pain. Once daily requirements are estab-

lished patients can be ‘converted’ to 12 hourly slow

release morphine preparations. Breakthrough pain

can be treated with additional doses of 5-10mg

morphine. Diamorphine preferred for parenteral

usage. Highly soluble and suitable for use in a

syringe driver for continuous administration or as a

4 hourly injection.

Alternatives to opioids

Tramadol may be given orally. Fentanyl given as

slow release transdermal patches may be a valuable

alternative to slow release morphine for moderate

to severe chronic pain.

For chronic pain give analgesia PO regularly, wherever possible.

2 Pain control is very specific to the individual patient, there is no

‘correct’ formula other than the combination of measures which alle-

viate the pain.

2 The clinician should work ‘upwards’ or ‘downwards’ through the levels

of available analgesics to achieve control.

2 Constipation due to analgesics should be managed with aperients.

2 Nausea or vomiting may occur in up to 50% patients with strong

opiates; cyclizine 50mg 8 hourly, metoclopramide 10mg 6 hourly or

haloperidol 1.5mg 12 hourly are available options to limit nausea or

vomiting.

2 Additional general measures include

- Radiotherapy for localised cancer pain.

- Physical methods e.g. TENS or consideration of nerve root block.

539

- Surgery, especially in myeloma where stabilising fractures and

pinning will relieve pain and allow mobility.

- Encouraging/allowing patients to utilise ‘alternative’ approaches.

including relaxation techniques, aromatherapy, hypnosis, etc.

2 Additional drug therapy

- Antidepressants e.g. amitriptyline may help in neuropathic pain.

- Anticonvulsants e.g. carbamazepine may be helpful in neuropathic

pains especially in post-herpetic neuralgia.

- Corticosteroids, particularly dexamethasone, to relieve leukaemic

bone pain in late stage disease.

Many hospitals also run specific pain clinics. The support and expertise

available should be enlisted particularly for difficult problems with persis-

tent localised pain e.g. post-herpetic neuralgia. For long term painful con-

ditions it is essential to work with medical and nursing colleagues in

Primary Care and in Palliative Care so that the patient receives appro-

priate support in the community setting.

Psychological support

Many haematological disorders are long term conditions; the specific diag-

nosis can be seen to ‘label’ the patient as different or ill and therefore will

exert a profound influence on their life and that of their immediate family

or carers. Patients (and their families) experience and demonstrate a

number of reactions to their diagnosis, the clinical haematologist needs to

have an awareness of this and respond accordingly.

Reactions to serious diagnosis include

2 Numbness.

2 Denial.

2 Anger.

2 Guilt.

2 Depression.

2 Loneliness.

Ultimately most patients come to acceptance of their condition; carers/

partners will also go through a similar range of reactions. The clinician

needs to be aware of the way in which news of a diagnosis is likely to

affect a patient and his/her family/carers and respond appropriately. In the

first instance this will often involve the need to impart the diagnosis, what

it means and what needs to be done clinically. There is no ‘right way’ to

impart bad or difficult news. It is very important to make and take time to

tell the patient of the diagnosis. Wherever possible this should be done in

a quiet, private setting. Numbness at learning of a serious diagnosis often

means that very little is taken in initially other than the diagnostic label.

The various reactions listed above may subsequently emerge during the

time the patient comes to accept the diagnosis, what it means and what is

to be done clinically.

Within the haematological team there should be support available to the

540

patient and family/carers which can provide them with practical informa-

tion about the disease and its management. Simply knowing there is a sym-

pathetic ear may be all that is required in the way of support; however, for

some patients and families/carers more specialised support may be

needed e.g. availability of formal counselling or access to psychological or

psychiatric support.

Use can be made of local or national patient support groups; knowledge

of others in similar predicaments can help diffuse anger and loneliness.

Support groups can also be a valuable resource in providing information

and experience which patients and families/carers find helpful.

The most effective psychological support for haematological patients is to see

them as individuals and not ‘diseases’.

Protocols and procedures

Acute leukaemia - investigation

544

Platelet storage and administration

546

Platelet transfusion support

547

Platelet reactions and refractoriness

548

Prophylactic regimen for neutropenic patients

550

Guidelines for use of IV antibiotics in neutropenic patients

552

Treatment of neutropenic sepsis when source unknown

554

Treatment of neutropenic sepsis when source known/suspected

556

Prophylaxis for patients treated with purine analogues

558

Tumour lysis syndrome (TLS)

560

Management of chronic bone marrow failure

562

Venepuncture

564

Venesection

566

Tunnelled central venous catheters

568

Bone marrow examination

570

Administration of chemotherapy

572

Antiemetics for chemotherapy

574

Intrathecal chemotherapy

576

Management of extravasation

578

Specific procedures following extravasation

580

Splenectomy

582

Plasma exchange (plasmapheresis)

584

Leucapheresis

586

Anticoagulation therapy - heparin

588

Oral anticoagulation

590

Management of needlestick injuries

592

Chemotherapy protocols

594

VAPEC-B

594

ABVD

596

ChlVPP

598

MOPP

600

MOPP/ABVD

602

CHOP

604

R-CHOP

605

DHAP

606

ESHAP

608

Mini-BEAM

610

BEAM (myeloablative conditioning regimen)

612

CVP

614

Fludarabine and cyclophosphamide

616

FMD

618

ABCM

620

C-VAMP

622

VAD

624

Z-DEX

626

C-Thal-Dex (CTD)

628

Note

Please check local protocols since these may differ to those outlined in this handbook.

Acute leukaemia - investigation

Haematology

2 FBC, blood film, reticulocytes, ESR.

2 Serum B₁₂, red cell folate, and ferritin.

2 Blood group, antibody screen and DAT.

2 Coagulation screen, INR, APTT, fibrinogen (and XDPs if bleeding).

2 BM aspirate for morphology, cytogenetics, immunophenotype (and

peripheral blood if relevant) plus samples required by the MRC trials.

2 BM trephine biopsy.

Biochemistry

2 U&E, LFTs.

2 Ca²⁺, phosphate, random glucose.

2 LDH.

2 Serum and urine lysozyme (if M4 or M5 AML suspected).

Virology

2 Hepatitis BsAg.

2 Hepatitis A antibody.

2 Hepatitis C antibody.

2 HIV I and II antibody (counselling and consent required).

2 CMV IgG and IgM.

Immunology

2 Serum immunoglobulins.

2 Autoantibody screen profile.

2 HLA type—Class 1 always in case HLA matched platelets are required,

Class 1 and 2 if allogeneic transplant indicated.

Bacteriology

2 Baseline blood cultures.

2 Throat swab.

2 MSU.

2 Stool for fungal culture.

544

2 Nose swab for MRSA if transferred from another hospital/unit.

Cardiology

2 ECG.

2 Echocardiogram, only if in cardiac failure or infective endocarditis sus-

pected or significant cardiac history.

Radiology

2 CXR.

2 Sinus radiographs.

Other

2 If any evidence of severe dental caries or gum disease refer patient for

dental assessment before chemotherapy.

2 Consider semen storage.

Platelet storage and administration

Storage

Platelets should be stored at room temperature (20-22°C) in a platelet

agitator until infused. Helps to retain function. Use before expiry date on

pack.

2 Platelet packs should be inspected before infusion—platelet packs that

look visibly pink due to RBC contamination should not be used.

- Occasionally fine fibrinoid strands may be seen in concentrates

(give a slightly stringy or cloudy appearance). Such strands disperse

with gentle massage and are safe to use.

- Occasionally larger aggregates of platelets and/or white cell clumps

are seen in the bags which do not disperse with gentle massage.

Such bags are dangerous and should never be infused.

Dosage and timing

2 A single dose of platelets is generally supplied as a single bag.

2 Represents a standard transfusion dose although twice this amount

may be required to cover insertions of central lines or minor surgery.

2 Occasionally double doses may be required for patients becoming

refractory.

2 The frequency of platelet transfusion will be determined by clinical cir-

cumstances. In general, a patient who is well, afebrile and with no evi-

dence of new bruising or bleeding need only have a platelet count

maintained above 10

¥ 10⁹/L. May be achieved with platelets given as

infrequently as every 2-4 days with this estimate being guided on daily

platelet counts.

2 Patients who are infected or bleeding have much greater platelet

requirements—aim to keep the platelet count >20

¥ 10⁹/L. This will

usually mean daily platelet infusions for the duration of this clinical

episode.

2 Platelet counts of <10

¥ 10⁹/L should always be avoided but within

these constraints the fewer platelets transfused the better since this

reduces the risk of alloimmunisation to HLA and platelet antigens.

546

2 Anyone with a persistent platelet count <10

¥ 10⁹/L should be started

on tranexamic acid 1g qds PO or IV unless specific contraindications

exist such as genitourinary tract bleeding.

Choice of blood group for platelet support

At diagnosis, all patients should have a blood group and CMV antibody

status determined. Patients should receive platelets of their own blood

group as far as possible. Due to fluctuations in supply, this is not always

possible and the choice is less critical than for red cell transfusions as

platelet ABO blood group antigen expression is weak and the recipient is

exposed only to donor plasma.

Protocols and procedures

Patient’s blood group

first choice

second choice

B (if available)

A preferably or O

2 Rh (D) +ve patients may receive Rh (D) +ve or Rh (D) -ve products.

2 Rh (D) -ve patients should receive Rh (D) -ve platelets.

2 Occasionally necessary to give Rh (D) +ve platelets to Rh (D) -ve

patients. The Blood Bank should be informed as all future red cell

transfusions must be Rh (D) -ve. Anti-D administration may be given

to such patients routinely or may be reserved for women of child-

bearing age (dose: 250iu (50µg). Anti-D SC immediately after the

transfusion.

Platelet transfusion support

See p546 and p650.

547

Platelet reactions and refractoriness

Reactions to platelet transfusion are common and range from mild tem-

peratures to rigors. The development of an urticarial rash is also fre-

quently seen. When a transfusion reaction develops, the following steps

should be taken:

Stop the transfusion.

Give 10mg chlorphenamine (chlorpheniramine) IV and 1g of paracetamol

PO.

Cover future transfusions with chlorpheniramine and paracetamol 30

mins pre-transfusion.

2 Hydrocortisone 100mg IV stat may be (sparingly) used for refractory

reactions

2 Pethidine is a suitable alternative for severe reactions and is almost

invariably effective. Give 25mg IV stat with repeat dose if necessary or

set up an IVI of 25-50mg IV over 8h.

2 The possibility of generation of HLA and platelet-specific antibodies

should also be considered (see below).

Platelet refractoriness

Occasionally patients show little/no increment in the platelet count after

platelet transfusions. This is called platelet refractoriness. May be due to

physical or immunological mechanisms in the patient. The commonest

physical mechanism is of platelet circulatory half-life reduction caused by

concurrent sepsis or coagulopathy e.g. DIC. Immunological causes include

induction of anti-HLA antibodies due to allosensitisation from previous

transfusions or generation of anti-platelet antibodies such as in ITP.

Investigation should be considered if platelet transfusions fail to maintain a

platelet count >10

¥ 10⁹/L at all times.

Proceed as follows

1. Check FBC pre-platelet infusion, 1 and 12h post-infusion to assess the

rate of platelet count decay. Failure to show a rise of platelet count by

at least 10

¥ 10⁹/L at 1h or any rise after 12h post-infusion merits

548

further testing.

2. Samples should be sent to a blood transfusion centre for HLA and

platelet antibody screening (10mL EDTA samples and 20mL serum).

3. The patient’s own HLA type should be checked.

4. If HLA or platelet antibodies are identified, the provision of HLA or

platelet antigen matched platelet products may improve the platelet

transfusion responsiveness.

Platelet refractoriness—More than two-thirds of patients receiving

multiple transfusion with random platelets develop anti-HLA antibodies.

Refractoriness defined as failure of 2 consecutive transfusions to give

corrected increment of

>7.5

¥ 10⁹/L 1h after platelet transfusion in

absence of fever, infection, severe bleeding, splenomegaly, or DIC.

GvHD—Rare complication where there is engraftment of donor

lymphocytes in platelet concentrate in severely immunocompromised

patients.

Prophylactic regimen for neutropenic

patients

Infective risk is related to the severity and duration of neutropenia. Higher

risk is associated with concurrent immunological defects e.g.

hypogammaglobulinaemia in myeloma, T-cell defects e.g. HIV disease,

additional immunosuppressive agents e.g. cyclosporin post-transplant, and

older patients. Principal risk is from bacterial organisms but fungi and

viruses, especially herpes (HSV, HZV) and CMV are also seen in pro-

longed neutropenia.

Typical protocols include

2 Isolation procedures —strict handwashing by all patient contacts is

the only isolation measure of universally proven benefit. Others

include visitor restriction, gloves, aprons, gowns, masks and full reverse

barrier nursing. Isolation rooms with positive pressure filtered air will

prevent fungal infection.

2 Drinks —avoid mains tap water/still mineral water (use boiled water or

sparkling mineral water). Avoid unpasteurised milk and freshly

squeezed fruit juice.

2 Food —avoid cream, ice-cream, soft, blue or ripened cheeses, live

yoghurt, raw eggs or derived foods e.g. mayonnaise and soufflés, cold

chicken, meat paté, raw fish/shellfish, unpeeled fresh vegetables/salads,

unpeeled fruit, uncooked herbs and spices, ground pepper (contains

Aspergillus spores).

2 General mouthcare —antiseptic mouthwash e.g. Corsadyl 10mL 4

hourly swish and spit. If soreness develops, substitute Difflam mouth-

wash. For discrete oral ulcers, use topical Adcortyl in Orobase; for

generalised ulceration use 0.9% saline mouthwash hourly, swish and

spit. Corsodyl toothpaste should replace standard preparations. Oral

antifungal prophylaxis should be nystatin susp. 1mL 4 hourly swish and

spit or swallow, or amphotericin lozenges one to suck slowly 4 hourly.

Antibacterial prophylaxis —aim to alter flora and prevent exogenous

colonisation. Principal agents: ciprofloxacin 250mg bd or cotrimoxa-

550

zole 480mg bd or colistin 1.5MU tds and neomycin 500mg qds. All

given PO starting 48h after antifungal prophylaxis.

Antifungal prophylaxis —a systemic imidazole compound is most

routinely used e.g. fluconazole 100mg PO od. Itraconazole liquid

2.5mg/kg bd PO may offer additional protection against Aspergillus.

Antiviral prophylaxis —Acyclovir is the most useful drug at pre-

venting herpes reactivation. Dose is dependent on degree of immuno-

suppression and thus the likely organism to be encountered. 400mg bd

will prevent HSV reactivation e.g. post-standard chemotherapy; 400mg

qds may prevent HZV reactivation e.g. post-SCT; 800mg tds or more

may prevent CMV reactivation post-allogeneic SCT.

Additional prophylaxis for specials situations —history of, or radio-

logical evidence of, tuberculosis (TB). Consideration should be given to

standard anti-TB prophylaxis e.g. rimactazid/pyridoxine particularly if

prolonged neutropenia expected. Splenectomised patient —at extra

risk from encapsulated organisms particularly Streptococcus pneumoniae,

Haemophilus influenzae and Neisseria meningitidis. Use penicillin V 500mg

Guidelines for use of IV antibiotics in

neutropenic patients

Urgent action required if neutropenic patient develops

2 Single fever spike >38°C.

2 2 fever spikes >37.5°C 1h apart.

2 Symptoms or signs of sepsis even without fever.

Assessment

2 Search for localising symptoms or signs of infection.

2 Full clinical examination noting BP, pulse, mouth, chest, perineum, line

sites, skin and fundi.

2 O₂ saturation (pulse oximetry).

2 FBC, U&E, creatinine, LFTs, CRP, INR, APTT, fibrinogen.

2 Perform a septic screen:

- 3 sets of blood cultures (10mL per bottle optimises organism

recovery) if central line present, take paired peripheral and central

samples.

- Single further blood culture set if non-response at 48-72h or con-

dition changes.

2 Swab relevant sites: wounds, central line exit site, throat.

2 Sputum culture.

2 MSSU.

2 Faeces if symptomatic incl. C difficile toxin.

2 Viral serology if clinically relevant.

2 CXR.

2 Other imaging as relevant, consider sinus x-ray.

2 Consider bronchoalveolar lavage if chest infiltrates present.

2 Consider risk of invasive fungal infection: CT chest if high risk.

Empirical treatment

Start IV antibiotics to provide broad spectrum cover. Stop prophylactic

ciprofloxacin. Follow local protocol if available.

552

First line: Tazocin 4.5g tds plus gentamicin 6mg/kg/day.

If patient has history of penicillin allergy use ceftazidime 2g tds instead of

tazocin; if anaphylaxis with penicillin discuss with microbiologist.

If suspected line infection (exit site inflammation) add vancomycin 1g bd

and consider line removal. Vancomycin dose should be split and adminis-

tered through each lumen. May be locked in the line for 1h then flushed.

If there are signs of perianal sepsis, mucositis or intra-abdominal infection

or if C difficile is suspected add metronidazole 500mg tds IV.

1. Patients on od gentamicin should have pre-dose level checked 24h

after first dose then twice weekly if satisfactory.

2. Patients on vancomycin should have pre-dose levels checked immedi-

ately before 3rd or 4th dose (2nd if renal impairment) then twice

weekly if satisfactory.

Protocols and procedures

Reassess at 48-72h:

If no response to antibiotics and negative blood cultures:

Add vancomycin 1g bd.

If already on vancomycin, consider line removal.

Consider risk of invasive fungal infection. CT chest if high risk.

Reassess after further 48-72h:

If no response to antibiotics and negative blood cultures:

If high risk for invasive fungal infection:

Stop above antibiotics. Commence amphotericin 1mg/kg/day plus ciproflo-

xacin 500mg bd PO/IV. Stop prophylactic fluconazole/itraconazole.

If low risk for invasive fungal infection:

Switch antibiotics to meropenem 1g tds plus gentamicin 6mg/kg/day.

Reassess after further 48h:

If no response to amphotericin, change ciprofloxacin to meropenem 1g

tds plus gentamicin 6mg/kg/day.

If not on amphotericin, consider switching to amphotericin 1mg/kg/day

plus ciprofloxacin 500mg bd PO/IV. Stop prophylactic fluconazole/itra-

conazole.

Duration of therapy

If temperature responds but cultures are negative, continue anti-infective

treatment until apyrexial for 72h or minimum 5d course. If still neu-

tropenic restart prophylactic anti-infectives. Amphotericin should be con-

tinued until neutrophil regeneration or total dose of 1g administered.

Positive cultures

Antibiotic therapy may be changed on the basis of positive cultures.

553

Treatment of neutropenic sepsis when

source unknown

One of the commonest haemato-oncological emergencies.

2 May be defined as the presence of symptoms or signs of infection in a

patient with an absolute neutrophil count of <1.0

¥ 10⁹/L. In practice,

the neutrophil count is often <0.1

¥ 10⁹/L.

2 Similar clinical picture also seen in neutrophil function disorders such

as MDS despite normal neutrophil numbers.

2 Beware —can occur without pyrexia, especially patients on steroids.

Immediate action

Urgent clinical assessment.

Follow ALS guidelines if cardiorespiratory arrest (rare).

More commonly, clinical picture is more like cardiovascular shock ±

respiratory embarrassment viz: tachycardia, hypotension, peripheral

vasodilatation and tachypnoea. Occurs with both Gram +ve (now

more common with indwelling central catheters) and Gram -ve organ-

isms (less common but more fulminant).

Immediate rapid infusion of albumin 4.5% or gelofusin to restore BP.

Insert central catheter if not in situ and monitor CVP.

Start O₂ by face mask if pulse oximetry shows saturations <95%

(common) and consider arterial blood gas measurement —care with

platelet counts <20

¥ 10⁹/L—manual pressure over puncture site for

30 mins.

Perform full septic screen (see p552).

Give the first dose of first line antibiotics immediately e.g ureidopeni-

cillin and loading dose aminoglycoside (ceftazidime or ciprofloxacin if

pre-existing renal impairment). Follow established protocols.

If the event occurs while patient on first line antibiotics, vancomycin/

ciprofloxacin or vancomycin/meropenem are suitable alternatives.

Commence full ITU-type monitoring chart.

Monitor urine output with urinary catheter if necessary —if renal shut-

down has already occurred, give single bolus of IV frusemide. If no

554

response, start renal dose dopamine.

If BP not restored with colloid despite elevated CVP, consider

inotropes.

If O₂ saturations remain low despite 60% O₂ delivered by rebreathing

mask, consider ventilation.

Alert ITU giving details of current status.

Subsequent actions

2 Discuss with senior colleague.

2 Amend antibiotics according to culture results or to suit likely source if

cultures negative.

2 Check aminoglycoside trough levels after loading dose and before

second dose as renal impairment may determine reducing or with-

holding next dose. Consider switch to non-nephrotoxic cover e.g. cef-

tazidime/ciprofloxacin.

2 Continue antibiotics for 7-10d minimum and usually until neutrophil

recovery.

Treatment of neutropenic sepsis when

source known/suspected

Central indwelling catheters

Very common. Organisms usually Staph. epidermidis but can be other Staph

spp. and even Gram -ve organisms. May be erythema/exudate around

entry or exit sites of line, tenderness/erythema over subcutaneous tunnel

or discomfort over line tract. Blood cultures must be taken from each

lumen and peripherally and labelled individually. Add vancomycin 1g bd IV

if not in standard protocol. Split dose between all lumens unless cultures

known to be +ve in one lumen only. Lock and leave in line for 1h, then

flush through. If no response or clinical deterioration, remove line imme-

diately.

Perianal or periodontal

Both are common sites of infection in neutropenic patients. Perianal

lesions may become secondarily infected if skin abraded. Add metronida-

zole 500mg IV tds to standard therapy. Painful SC abscesses may form and

may require surgical incision. Gum disease and localized tooth infec-

tions/abscesses are frequently seen. Add metronidazole to therapy as

above, arrange OPG and dental review as surgical intervention may be

required in non-responders. If possible, best delayed until neutrophil

recovery in most cases —then do electively before next course of

chemotherapy.

Lung

Atypical organisms

Risk group

HIV infection, HCL, post-SCT.

Mycoplasma and other atypicals are commonly found and usually commu-

nity acquired (except Legionella)—typically occur shortly after return to

hospital and in patients with chronic lung disease.

556

Treatment

Azithromycin (or clarithromycin if IV preparation needed) is now treat-

ment of choice—well absorbed and fewer side effects than erythromycin.

5d rather than 3d course may be needed.

Pneumocystis carinii pneumonia

Risk group

Lymphoid malignancy long-term treatment esp. ALL, steroid usage, purine

analogues e.g. fludarabine and 2-CDA.

Treatment

High dose cotrimoxazole IV initially—watch renal function and adjust

dose to creatinine. Give short pulse of steroid 0.5mg/kg at start of treat-

ment. At-risk patients should remain on long-term prophylaxis until

chemo finished and absolute CD4 lymphocyte count >500 × 10⁶/L. Use

cotrimoxazole 480mg bd on Monday, Wednesday and Friday only, pro-

vided neutrophil count maintained >1.0

¥ 10⁹/L. Otherwise use nebulised

Protocols and procedures

pentamidine 300mg every 3 weeks with preceding nebulised salbutamol

2.5mg.

Fungal

Risk group

Prolonged, severe neutropenia, chronic steroid and antibiotic usage,

GvHD. Aspergillus and other moulds increasingly common with intensive

chemotherapy protocols and post-stem cell transplant esp. MUDs.

Treatment

2 Amphotericin IV (see p330).

2 Once neutrophil recovery has occurred, maintenance may be with oral

itraconazole liquid 2.5mg/kg bd —may also be used for prophylaxis.

Viral —CMV

Risk group

Allogeneic SCT esp. MUDs where donor or recipient is CMV +ve.

Disease usually due to reactivation rather than de novo infection. Apart

from pneumonitis, may cause graft suppression, gastritis, oesophagitis,

weight loss, hepatitis, retinitis, haemorrhagic cystitis and vertigo.

Treatment

Ganciclovir or foscarnet (see CMV, p334) + IV immunoglobulin. Lack of

response, switch to the other drug.

Viral —HSV/HZV

Risk group

Rare causes of lung disease. SCT recipients at greatest risk esp. MUDs and

intensively treated lymphoid malignancy.

Treatment

High dose IV acyclovir 5-10mg/kg tds IV for minimum 10d.

557

Viral —RSV

Risk group

Post-SCT recipients esp. MUDs.

Treatment

Consider ribovarin therapy.

TB and atypical mycobacteria

Risk group

Prolonged T-cell immunosuppression e.g. chronic steroid or cyclosporin

therapy, chronic GvHD, previous history and/or treatment for TB, HIV

related disease.

Treatment

Often difficult to diagnose —empirical treatment required with standard

triple therapy.

Prophylaxis for patients treated with

purine analogues

The purine analogues fludarabine and 2-CDA used in standard lympho-

proliferative protocols induce neutropenia in all cases. Nadir ~14d post-

treatment initiation and neutrophil counts may fall to zero for several days

or even weeks. They are therefore associated with the usual neutropenic

infections. In addition, purine analogues have a particular property of inhi-

bition of T4 helper lymphocyte subsets within weeks of initiation of

therapy (nadir at 3 months) and may last for >1 year following cessation

of therapy. This profound T4 function inhibition predisposes to fungal

infection, as well as a higher incidence of Herpes zoster infection and PCP.

↓ lymphocyte function also predisposes to transfusion associated GvHD in

passenger lymphocytes of donor blood transfusions.

The following preventive measures are recommended

Recommended

1. Irradiation of cellular blood products (2500cGy) from day 1 of initia-

tion of therapy and continue until 2 years post-treatment.

2. PCP prophylaxis from start of therapy—usually cotrimoxazole 1 tablet

bd Mondays, Wednesdays and Fridays. In patients who are already

severely neutropenic, cotrimoxazole may be substituted by pentami-

dine nebulisers 300mg 3-weekly with 2.5mg of salbutamol nebuliser

pre-treatment. PCP prophylaxis should continue until a year after the

end of treatment.

3. HZV prophylaxis —acyclovir 400mg qds is the minimum continuous

dose required to prevent HZV reactivation. Most physicians will not

wish to have patients continuously on this dosage throughout the

treatment cycle and for a year post-treatment so suggest: counsel

patients about the risk of shingles and advised to contact the hospital

immediately if shingles suspected. Patients who have already had a

zoster reactivation should be maintained continuously on acyclovir

400mg qds and continuation of the purine analogue reviewed.

558

Optional

1. Anti-bacterial prophylaxis —consider use of ciprofloxacin 250mg bd

PO from day 7721 of each course.

2. Anti-fungal prophylaxis: Patients with no history of fungal reactivation

should perform nystatin suspension 1mL qds mouthcare from day

7721 of each course, taught symptoms of oral and genital thrush and

supplied with fluconazole 200mg to be taken daily for 7d in the event

of thrush.

3. Patients with previous history of suspected fungal infection with a

mould-type organism e.g. Aspergillus —give itraconazole capsules

400mg daily or oral liquid 2.5mg/kg bd throughout treatment.

Tumour lysis syndrome (TLS)

Potentially life threatening metabolic derangement resulting from

treatment-induced or spontaneous tumour necrosis causing renal, cardiac

or neurological complications. Usually occurs in rapidly proliferating, highly

chemosensitive neoplasms with high tumour load: leukaemias with high

WBC counts (ALL >50

¥ 10⁹/L; AML >100

¥ 10⁹/L; CML blast crisis >100

10⁹/L; CLL >200

¥ 10⁹/L; PLL or ATLL >100

¥ 10⁹/L) and high grade NHL

(particularly Burkitt lymphoma or high serum LDH). May occur before or up

to 5 days (usually 48-72h) after initiation of chemotherapy.

Pathophysiology and clinical features

Rapid lysis of large numbers of tumour cells releases intracellular ions and

metabolites into the circulation causing numerous metabolic abnormali-

ties to develop rapidly:

2 Hyperuricaemia due to metabolism of nucleic acid purines; (solubility

decreased by high acidity); may cause arthralgia and renal colic.

2 Hyperkalaemia due to rapid cell lysis; often earliest sign of TLS; aggra-

vated by renal failure; may cause paraesthesiae, muscle weakness and

arrhythmias.

2 Hyperphosphataemia due to rapid cell lysis,; precipitates calcium phos-

phate in tissues (insolubility exacerbated by overzealous alkalinisation),

2 Hypocalcaemia secondary to hyperphosphataemia; may cause paraes-

thesiae, tetany, carpo-pedal spasm, altered mental state, seizures and

arrhythmias.

2 Acute renal failure predisposed by volume depletion and pre-existing dys-

function; due to uric acid nephropathy, acute nephrocalcinosis and pre-

cipitation of xanthine; oliguria leads to volume overload and pulmonary

oedema; uraemia causes malaise, lethargy, nausea, anorexia, pruritus and

pericarditis; may require dialysis; usually reversible with prompt therapy.

Principles of management

Identify high risk patients, initiate preventative measures prior to

chemotherapy and monitor for clinical and laboratory features of TLS.

Detect features of TLS promptly and initiate supportive therapy early.

560

Prevention and management

2 Monitor daily weight bd, urine output, fluid balance, renal function,

serum potassium, phosphate, calcium, uric acid and ECG for 72h after

initiation of chemotherapy; monitor parameters at least three times

daily in patients with TLS.

2 Ensure aggressive intravenous hydration:

- Aim for urine output >100mL/h (>3L/d) and total input >4Ld

(3L/m²/d) from 24-48h prior to chemotherapy and in high risk

patients, until 48-72h after completion of chemotherapy.

- Frusemide (20mg IV) may be given cautiously to maintain adequate

diuresis in well hydrated patients; may be used to treat hyperkalaemia

or fluid overload but may cause uric acid or calcium deposition in

dehydrated patients; no proven benefit in initial treatment of TLS.

2 Prevent hyperuricaemia:

- Allopurinol: xanthine oxidase inhibitor; 300-600mg/d PO for pro-

phylaxis if renal function normal (100mg/d if creatinine

>100mmol/L) up to max 500mg/m²/d for treatment of TLS; may

Protocols and procedures

be given IV if necessary (max 600mg/d); side effects: rash, xanthine

urolithiasis; reduce dose in renal impairment or mercaptopurine,

6-thioguanine or azathioprine therapy.

- Rasburicase: recombinant urate oxidase; converts uric acid to water

soluble metabolites without increasing excretion of xanthine and

other purine metabolites; very rapidly 5 uric acid levels and simpli-

fies management of high risk patients; dose 200mg/kg/d IVI over

30 mins for 5-7d; recommended in Burkitt lymphoma, high count

leukaemia and as rescue treatment in hyperuricaemia plus rapidly

rising creatinine, oliguria, phosphate ≥ 2mmol/L or K⁺ ≥5.5mmol/L;

side effects: fever, nausea, vomiting; less common: haemolysis,

allergic reactions or anaphylaxis; contraindicated in G-6-PD defi-

ciency and pregnancy.

Alkalinisation of urine:

- Not routine; administer NaHCO₃ PO (3g every 2h) or IV through

central line (500mL 1.26% NaHCO₃ over 1h; 1L 5% dextrose over

4h; 500mL 0.9% NaCl over 1h, repeated 6 hourly) to increase

urinary pH to 7.0 and maximise uric acid solubility.

- Risk of more severe symptoms or hypocalcaemia and increased

calcium phosphate precipitation in tubules.

- Requires close monitoring of urinary pH (test all urine passed),

serum bicarbonate and uric acid; withdraw IV sodium bicarbonate

when serum bicarbonate >30 mmol/L, urinary pH>7.5 or serum

uric acid normalised.

Control of electrolytes

- Hyperkalaemia: treat aggressively:

1 Restrict dietary K⁺ intake and eliminate K⁺ from IV fluids.

2 Use K⁺-wasting diuretics with caution.

3 Measure arterial blood gases (correction more difficult if acidosis).

4 K⁺ >5mmol/L, start calcium resonium 15g PO qds and increase

hydration; recheck K⁺ after 2h.

561

5 K⁺>6mmol/L, check ECG; commence IVI of 50mL 50% dextrose

with 20 U actrapid insulin over 1h.

6 ECG changes or K⁺ >6.5mmol/L, give 10mL calcium gluconate 10%

or calcium chloride 10% IV cardioprotection.

- Hyperphosphataemia:

1 Commence oral phosphate binding agent, e.g. aluminium hydroxide

20-100mL or 4-20 capsules daily or Sevelamer

2.4-4.8g/d in

divided doses; adjust dose according to serum phosphate.

2 Infuse 50mL 50% dextrose with 20 U actrapid insulin IV over 1h.

Dialysis

- Seek renal and critical care consultations early if initial measures fail

to control electrolyte abnormalities or renal failure.

- Dialysis indicated if persistent hyperkalaemia (>6mmol/L) or hyper-

phosphataemia (>3.33mmol/L) despite treatment, fluid overload,

rising urea or creatinine (>880mmol/L), hyperuricaemia

(>0.6mmol/L) or symptomatic hypocalcaemia.

- Haemodialysis achieves better phosphate and uric acid clearance

than peritoneal dialysis.

Management of chronic bone marrow

failure

Introduction

Common haematological problem. Occurs as result of marrow infiltrated

with disease e.g. MDS, or following chemotherapy or other causes of

marrow aplasia. Extent of RBC, WBC and platelet production failure

varies greatly in individual clinical situations. Production failure may not

affect all three cell lines equally.

Management

2 Mainstay is supportive treatment with blood products and antibiotics.

2 Underlying disease should be treated where possible.

Red cell production failure

2 Where anaemia is due solely to absence of RBC production, transfu-

sion requirement should be ~1 unit packed red cells/week. Suitable

protocol is 3 unit transfusion every 3 weeks as day case.

2 If requirement is greater, investigate for bleeding and haemolysis.

2 If requirement is chronic e.g. a young patient with MDS, consider giving

desferrioxamine as long-term iron chelation (see p90).

2 Erythropoietin may be tried where some red cell production capacity

remains and transfusion needs to be avoided or minimised e.g.

Jehovah’s Witnesses.

White cell production failure

2 Mainstay of treatment is with antibiotics.

2 Prompt treatment of fever in neutropenic patient with combination IV

antibiotics is lifesaving .

2 Simple mouthcare with Corsadyl or similar mouthwash, plus nystatin

suspension orally reduces risk of bacterial and fungal colonisation in

oropharynx. Dietary modifications may also be helpful.

2 Role of prophylactic antibiotics remains controversial as resistance

generation is an increasing problem.

562

2 Ciprofloxacin 250mg bd PO is probably the best single agent.

2 Patients with recurring foci of infection may have prophylaxis targeted

to their usual or most likely organisms.

2 Patients with neutropenia and low Igs who have developed bronchiec-

tasis may benefit from regular infusions of IVIg 200mg/kg every 4

weeks ± rotating antibiotic courses.

2 WBC infusions are not generally useful except in rare situations —they

are toxic and cause HLA sensitisation.

2 Haemopoietic growth factors should not be used routinely.

2 Life-threatening infections despite IV antibiotics and anti-fungals can be

considered for trial of G-CSF or GM-CSF at 5µg/kg/d SC.

Platelet production failure

Where low platelets are due solely to absence of platelet production,

transfusion requirement should be

~1-2 adult dose packs/week.

Tranexamic acid 1g qds PO may reduce clinical bleeding episodes and

transfusion requirement. Thrombopoietin

(TPO) is a potent in vitro

Venepuncture

Blood samples are best taken from an antecubital vein using a 21G needle

and a Vacutainer^™ system or syringe. If a large volume of blood is required

a 21G butterfly may be inserted to facilitate changing the vacutainer

sample bottle or the syringe.

A tourniquet should be gently applied to the upper arm and the antecu-

bital fossa inspected and palpated for veins. In an obese individual antecu-

bital veins may be more easily palpated than seen. The skin over the vein

should be ‘sterilised’ (alcohol swab or Mediswab™) and allowed to dry.

The needle should then be gently introduced along the line of the chosen

vein at an angle of 45° to the skin surface. It may be helpful to attempt to

penetrate the skin with the initial introduction of the needle and then

slowly penetrate the vessel wall by continuing the forward movement of

the needle. The tourniquet on the upper arm should be loosened once

the needle has been inserted into the vein to reduce haemoconcentration.

If a syringe is used the piston should be withdrawn slowly to prevent col-

lapse of the vein. Once an adequate sample has been obtained, the tourni-

quet should be completely removed, a dry cotton wool ball applied gently

above the site of venepuncture and gentle pressure increased as the

needle is removed. Firm pressure should be directly applied to the

venepuncture site for 3-5 minutes to ensure haemostasis and prevent

extravasation and bruising. A small elastoplast or if allergic, suitable light

dressing, should be applied to the venepuncture site.

In patients in whom it is difficult to obtain a sample, the arm should be

kept warm, a sphygmomanometer cuff inflated on the upper arm to the

diastolic pressure and the vein may be dilated by smacking the overlying

skin. With patience it is rarely impossible to obtain a venous sample. In

very obese individuals or those in whom iatrogenic thrombosis or scle-

rosis has occurred in the antecubital veins, the dorsal veins of the hand

may be used for sampling, though a smaller gauge needle (23G) or but-

terfly is often necessary.

564

Venesection

Aim of venesection or phlebotomy is the removal of blood for donation

to the Blood Transfusion Service or as a therapeutic manoeuvre for a

patient with haemochromatosis or polycythaemia rubra vera or for a

patient who requires an exchange transfusion. In patients with

haemochromatosis or PRV the therapeutic effect of the venesection pro-

gramme to date should be assessed on a full blood count sample taken

prior to venesection.

Procedure

Patient or donor is best placed lying on a couch with the chosen arm

placed comfortably on a supporting pillow.

A large gauge needle attached to a collection pack containing anticoag-

ulant is inserted in an antecubital vein or forearm vein after application

of a sphygmomanometer cuff to the upper arm (inflated to diastolic

pressure) and sterilisation of the skin. It is widespread practice to infil-

trate the skin over the chosen vein with local anaesthetic (1% lidocaine

(lignocaine)) prior to insertion of the large bore needle.

Inflation of the sphygmomanometer cuff is maintained until the desired

volume of blood is collected.

The patient may assist the flow of blood by squeezing a soft ball or

similar object in the hand of the arm from which the blood is drawn.

Blood is allowed to drain into the collection pack until the desired

volume has been obtained (usually 500mL).

The volume collected may be monitored by suspension of the pack

from a simple spring measuring device.

The positioning of the collection pack below the patient’s (or donor’s)

level facilitates blood flow into the bag.

Once the desired volume has been collected the cuff is deflated, the

line should be clamped and the needle removed and a dry cotton wool

ball used to apply pressure to the venesection site.

Direct firm pressure should be applied for 5 minutes and the site

inspected for haemostasis prior to application of a firm bandage.

The patient should slowly adopt the erect posture and should remain

566

seated for several minutes if symptoms of lightheadedness occur.

Patients should not be permitted to drive after venesection.

The collected blood from a therapeutic venesection should be dis-

posed of by incineration.

Note: for patients with PPP/PRV isovolaemic venesection is recommended

to minimise volume depletion whilst still reducing Hct.

Tunnelled central venous catheters

A tunnelled central venous catheter is required in all patients undergoing

intensive cytotoxic chemotherapy and those undergoing bone marrow or

peripheral blood stem cell transplantation. Also indicated for some

patients on long-term regular transfusion programmes.

Catheter type

A double or triple lumen catheter preferred, and essential for patients

undergoing transplantation procedures. Hickman catheters are available

from Vygon UK and the Groshong lines (Bard) are available for use in all

patients except those needing stem cell collections who will require

apheresis catheters (Kimal).

Requirements

An x-ray screening room with facility for aseptic procedures or an oper-

ating theatre is required. A trained radiographer must be available for x-

ray screening throughout the procedure. In addition a minimum of two

staff are required for the safe execution of this procedure. One should be

a member of medical staff

(radiologist/surgeon/anaesthetist/haemato-

oncologist) to insert the catheter and administer sedation and antibiotics

and the other to generally assist. The second person can be an IV trained

nurse.

Patient assessment

Assess for fitness for sedation and the ability to lie flat. Plan position of

central venous catheter in advance. The first choice is the right subclavian

vein, followed by the left subclavian vein. Check FBC and clotting screen.

Platelets should be available if platelet count is less than 50

¥ 10⁹/L.

Patient preparation

The patient should be well hydrated (5 CVP makes procedure difficult),

and fasting for 6h prior to the procedure as sedative drugs will be admin-

istered. Good peripheral venous access must be established

(with

Venflon™) before commencing central venous cannulation, for the

administration of sedative drugs and prophylactic antibiotics as well as for

568

emergency venous access.

Technique

Follow manufacturer’s instructions. Sequence of stages during insertion is

as follows:

1. Cannulation of the central vein, placement of guide wire and creation

of the upper central wound.

2. Creation of lower peripheral wound, formation of subcutaneous

tunnel and threading of the catheter through subcutaneous tunnel with

cuff buried.

3. Placement of the vessel dilator/sheath in the central vein over the

guide wire.

4. Placement of the catheter into the sheath.

5. Careful removal of the sheath whilst retaining position of catheter.

6. Suturing of the upper and lower wounds with suture around the body

of the catheter close to the exit site to hold the catheter in position.

7. Manipulate catheter so tip lies in SVC above right atrium. Patency must

be confirmed by easy aspiration of blood, and the catheter flushed with

heparinised saline. Check position with standard PA chest radiograph.

Protocols and procedures

Sedation and analgesia

IV sedation is used if the patient is particularly anxious before or during

the procedure.

Prophylactic antibiotics

2 Teicoplanin 400mg is administered by peripheral vein immediately

prior to central venous cannulation.

2 400mg teicoplanin is also administered into the central venous

catheter immediately after the insertion procedure (200mg is locked

into each lumen for 1h and then the catheter is flushed with

heparinised saline).

Catheter aftercare

2 Catheter may be used immediately after above procedures. All

patients should be educated in the care of their indwelling tunnelled

intravenous catheter. This may include self-flushing of the catheter.

Catheter should be flushed after each use with saline and locked with

heparinised saline. Flush twice weekly when not in use.

2 Urokinase may be used if line blockage occurs, insert urokinase and

leave for 4-12h and remove.

2 Clindamycin roll-on lotion may be applied to the exit site to minimise

local infections.

2 Upper wound suture is removed 7d post-insertion.

2 Lower exit site suture can be removed at 2 weeks post-insertion for

most lines and 3 weeks for apheresis lines to ensure SC embedding of

the cuff.

569

Bone marrow examination

Bone marrow is the key investigation in haematology. It may prove diag-

ostic in the follow-up of abnormal peripheral blood findings. It is an impor-

tant staging procedure in defining the extent of disease, especially

lymphoproliferative disorders. It is a helpful investigative procedure in

unexplained anaemia, splenomegaly or selected cases of pyrexia of

unknown origin (PUO). Preferred site for sampling7posterior iliac crest;

aspirate and biopsy material can easily be obtained from this location. The

anterior iliac crest is an alternative. The sternum is suitable only for

marrow aspiration (see below for contraindications).

Marrow aspirate material provides information on

2 Cytology of nucleated cells.

2 Qualitative and semi-qualitative analysis of haematopoiesis.

2 Assessment of iron stores.

2 Smears for cytochemistry of atypical cells.

Suspensions of marrow cells in medium are suitable for

2 Chromosome (cytogenetic) analysis.

2 Immunophenotype studies using monoclonal antibodies directed

against cell surface antigens.

2 Aliquots of marrow can be cryopreserved for future molecular

analysis.

Marrow trephine biopsy yields information on

2 Marrow cellularity.

2 Identification/classification of abnormal cellular infiltrates.

2 Immunohistochemistry on infiltrates.

Note: Cytology of trephine imprints can be helpful, especially when aspi-

rate yields a ‘dry tap’. Trephine biopsy information complements that

obtained at aspiration.

Contraindications

570

None, other than physical limitations e.g. pain or restricted mobility.

Avoid sites of previous radiotherapy (inevitably grossly hypocellular and

not representative).

Procedure

1. Bone marrow aspiration may be performed under local anaesthesia

alone, but short acting intravenous benzodiazepines (e.g. midazolam)

may be administered—with appropriate monitoring (pulse oximetry),

oxygen administration and available resuscitation equipment—when

trephine biopsy is performed. General anaesthesia rarely used (except

in children).

2. Best position is with patient in L or R lateral position.

3. Skin and periosteum over the posterior iliac spine are infiltrated with

local anaesthetic.

4. A small cutaneous incision is made, the aspirating needle is introduced

through this and should penetrate the marrow cortex 3-10mm before

removal of the trocar.

5. No more than 0.5-1mL marrow should be aspirated initially, and

smears made promptly.

Protocols and procedures

6. Further material can be aspirated and placed in EDTA or other anti-

coagulant media for other studies.

7. An Islam or Jamshidi needle is preferred for trephine biopsy.

8. The needle is advanced through the same puncture site to penetrate

the cortex.

9. The trocar is removed and using firm hand pressure the needle is

rotated clockwise and should be advanced as far as possible.

10. The needle is removed by gentle anti-clockwise rotation. In this

manner an experienced operator should regularly obtain biopsy

samples of 25-35mm in length.

11. Simple pressure dressings are sufficient aftercare and minor discom-

fort at the location may be dealt with by simple analgesia such as

paracetamol.

571

Administration of chemotherapy

Cytotoxic chemotherapeutic drugs may cause serious harm if not pre-

scribed, dispensed and administered with great care. Drugs should be pre-

scribed, dispensed and administered by an experienced multidisciplinary

team with shared clear information on:

2 The fitness of the patient to receive chemotherapy (e.g. recent FBC for

myelosuppressive agents, renal function studies for cisplatinum).

2 Appropriate protocol and chemotherapeutic regimen for the patient.

2 Prescribed drugs and individualised dosage for the patient’s surface

area (see p682), taking note of cumulative maximum doses (e.g. anthra-

cyclines).

2 Appropriate supportive treatment required e.g. allopurinol, antiemetic

prophylaxis, anti-infective prophylaxis, and hydration.

Chemotherapy for IV administration should be reformulated carefully in

accordance with the manufacturer’s instructions by an experienced phar-

macist using a class B laminar airflow hood. Care should be taken to

ensure that the drug is administered within the expiry time after it has

been reformulated in the form chosen.

Many cytotoxic drugs are best administered as a slow IVI in dextrose or

0.9% saline over 30 minutes to 2h. Vesicants e.g. vincristine, daunorubicin,

adriamycin and mitozantrone should be administered as a slow IV ‘push’.

However this should only be administered through the side access port of

a freely flowing infusion of 0.9% saline or dextrose and should never be

injected directly into a peripheral vein.

If the patient does not have an indwelling intravenous catheter (Hickman

line), a Teflon or silicone intravenous cannula of adequate bore (≤21G)

should be inserted into a vein of sufficient diameter to permit a freely

flowing 0.9% saline infusion to be commenced. Site chosen should be one

where cannula can be easily inserted and observed, can be fastened

572

securely and will not be subject to movement during drug administration.

The veins of the forearm are the most suitable for this purpose followed

by those on the dorsum of the hand. Antecubital fossae and other sites

close to joints are best avoided. The risk of extravasation (see p578) is

increased by the use of a cannula which has not been inserted recently and

by the use of steel (butterfly) cannulae.

A slow ‘push’ injection should be administered carefully into the side

access port on the IV line with continuous observation of the drip

chamber ensure that the infusion is continuing to run during injection of

the cytotoxic drug. The patient should be asked whether any untoward

sensations are being experienced at the site of the infusion and the site

should be carefully observed to ensure that no extravasation is occurring.

Patency of the IV site should be verified regularly throughout the proce-

dure. The saline or dextrose infusion should be continued for 30 minutes

after the chemotherapy administration has been completed before the

cannula is removed.

Antiemetics for chemotherapy

Classification of drugs

Dopamine antagonist—block D₂ receptors in the chemoreceptor trigger

zone (CTZ). Examples are metoclopramide and domperidone—both

have additional effect on enhancing gastric emptying. Side effects include

extrapyramidal reactions and occasionally oculogyric crisis.

Phenothiazines—examples are prochlorperazine and cyclizine—particular

benefit in opioid-induced nausea. Side effects include anticholinergic

effects and drowsiness.

Benzodiazepine—lorazepam commonest used. Advantages are long t^1/2

and additional anxiolytic effect. Side effects include drowsiness.

5HT₃ antagonists—block 5HT₃ receptors in the CTZ. Examples include

ondansetron, granisetron and tropesitron. Side effects include headaches,

bowel disturbance and rashes.

Cannabinoids—nabilone is the major drug. Side effects include

depersonalisation experiences.

Steroids —examples are dexamethasone and predniso(lo)ne. Side effects

include fungal infection predisposition, hypertension, irritability and

sleeplessness, gastric erosions and, with chronic use, diabetes and

osteoporosis.

Emesis with chemotherapy

Categorised as: anticipatory, early or late.

Anticipatory—occurs in advance of chemotherapy. Psychogenic in origin,

it occurs in patients with previous bad experiences of nausea and vomiting

and almost unknown prior to first dose. May be largely prevented by

ensuring a positive experience with first dose by use of prophylactic

antiemetics.

Early—occurs within minutes of IV chemotherapy administration or

574

within hours of oral chemotherapy. The easiest to respond to antiemetics

generally.

Late—occurs after the end of a chemotherapy course—up to 7d. The

most difficult form to treat—requires continuation of antiemetics

throughout post chemo period and even the newer agents such as the

5HT₃ receptor antagonists are relatively ineffective.

Antiemetics may be used singly or in combination. Choices determined

largely by patient preferences and degree of emetic potential of the

chemo regimen to be used. These may be divided into high, medium and

low.

Highly emetogenic regimens

Examples include cisplatinum, high dose cyclophosphamide and TBI.

Suitable cocktail might be domperidone, 5HT₃ antagonist and dexametha-

sone ± lorazepam.

Intrathecal chemotherapy

Usage

2 Given for both prophylaxis and treatment of CNS disease.

2 May be used in addition to other CNS disease strategies such as high

dose IV methotrexate or cranial irradiation.

2 CNS involvement is detected by presence of blasts on CSF cytospin.

2 The ONLY cytotoxic drugs used intrathecally are:

- Methotrexate.

- Cytosine arabinoside (ara-C).

- Hydrocortisone.

2 All have strict upper dosage limits —follow the protocol.

Never use any other cytotoxic drugs for intrathecal

injection —fatal consequences may ensue.

Common protocols

1. CNS prophylaxis for ALL and high grade NHL:

- methotrexate 10mg/m² (max 12.5mg)

¥ 6 injections at weekly inter-

vals.

2. CNS prophylaxis for AML:

- ara-C 30mg/m² (max 50mg), dosage schedule varies.

3. CNS treatment for ALL:

Triple IT regimen viz:

methotrexate 15mg/m² (max 12.5-15mg).

ara-C 30mg/m²(max 50mg).

hydrocortisone 15mg/m².

Usually given twice weekly until CSF clear of blasts then weekly to a

maximum of 6 total courses. Consider using folinic acid rescue.

Technique

2 Standard contraindications to lumbar puncture apply —alternatives will

be needed in these situations. Cytotoxics should be made up freshly in

smallest possible volume in a sterile pharmacy.

2 Consider GA for children and IV sedation for adults.

2 Use special LP ‘blunt’ needle or small gauge bevelled LP needle.

576

2 Aim to remove the same volume of CSF as you are injecting intrathe-

cally (may be several mL if giving triple chemotherapy).

2 Take samples for CSF cytospin to determine blast cell concentration,

microbiology for M/C/S, biochemistry for protein and glucose.

2 Check syringe cytotoxic dose carefully with another person before

connecting.

2 Connect syringe and aspirate gently to confirm position in CSF. Inject

slowly, drawing back at intervals to reconfirm position. Disconnect

syringe and connect other syringes in turn if giving ‘triple’.

2 Follow standard post-LP precautions. Document procedure in notes.

2 Repeated IT chemotherapy carries risk of CSF leakage and post-LP

headache. Manometry pre-injection may help assess whether less CSF

should be withdrawn pre-injection.

2 A syndrome of methotrexate-induced neurotoxicity occurs in a few

patients presenting with features of meningo-encephalitis. Aetiology is

unknown. Treat with short pulse of high dose steroids.

Do not give further IT methotrexate to these patients.

Management of extravasation

Inappropriate or accidental administration of chemotherapy into subcuta-

neous tissue rather than into the intravenous compartment causes pain,

erythema and inflammation which may lead to sloughing of the skin and

severe tissue necrosis. Appropriate early treatment can prevent the most

serious consequences of extravasation. All chemotherapy units should

have a protocol with which all staff administering chemotherapy are

familiar and a regularly updated extravasation kit for the management of

extravasation giving first aid instructions and further directions.

The risk of tissue damage relates to the drug’s ability to bind to DNA, to

kill replicating cells, to cause tissue or vascular dilatation and its pH, osmo-

larity, concentration, volume and formulation components e.g. alcohol,

polyethylene glycol.

Drugs may be divided into three risk groups:

Group 1: Vesicants

Aclarubicin; amsacrine; carmustine; cisplatinum; dacarbazine; dactino-

mycin; daunorubicin; docetaxel; doxorubicin; epirubicin; idarubicin; mito-

mycin; mustine; paclitaxel; plicamycin; treosulfan; vinblastine; vincristine;

vindesine.

Group 2: Irritants (may cause local inflammation, pain and necrosis)

Carboplatin; etoposide; liposomal daunorubicin; methotrexate;

mitoxantrone (mitozantrone).

Group 3: Non-vesicants

Asparaginase; bleomycin; cladribine; cyclophosphamide; cytarabine; flu-

darabine; fluorouracil; gemcitabine; ifosfamide; melphalan; pentostatin;

raltitrexed; thiotepa; aldesleukin (IL-2).

Symptoms and signs

2 Burning, stinging or pain at the injection site.

2 Induration, swelling, venous discolouration/erythema at injection site.

2 No blood return.

578

2 Reduced flow rate.

2 Increased resistance to administration.

Pre-extravasation syndrome

2 Severe phlebitis and/or local hypersensitivity.

2 Local risk factors e.g. difficult cannulation and one patient symptom.

2 Withdraw IV therapy immediately to prevent progression to extravasa-

tion.

Type I extravasation

2 Bleb or blister with defined area of induration around site of extravasa-

tion.

2 Often due to rapid IV bolus injection with excessive pressure.

Type II extravasation

2 Diffuse boggy tissue injury with dispersal into the intracellular space.

2 Associated with IV infusion or IV bolus into side arm port of infusion

with dislodged cannula.

Protocols and procedures

General treatment guidelines

Stop the infusion, disconnect the IV line but do not remove the

cannula.

Mark the area of injury around the cannula tip.

Seek the help of a more experienced individual if available.

Aspirate the site of extravasation to remove as much of the offending

drug as possible through cannula with a fresh 10mL syringe; this may

be facilitated with SC injection of 0.9% saline.

Remove the cannula.

Administer 100mg hydrocortisone intravenously at another site.

Administer a further 100mg hydrocortisone locally by 6-8 SC injec-

tions around the area of injury.

Administer SC injections of specific antidote where available.

Apply 1% hydrocortisone cream to the area and repeat bd whilst ery-

thema persists.

Cover with gauze and apply heat to disperse the drug or cool to

localise the extravasation.

Administer oral antihistamine (terfenadine 60mg/chlorpheniramine

4mg).

Administer analgesia if required (indomethacin 25mg tds).

Document site and extent of extravasation and treatment in case

notes.

Photograph site if possible.

Complete a ‘Green Card’ to report the extravasation episode.

Monitor injured site twice daily for erythema, induration, blistering or

necrosis.

Photograph injured site weekly until healed.

579

Specific procedures following

extravasation

Group 1:

Vesicant drugs

All vesicants except

Apply cold pack instantly. SC dexamethasone 4mg around

vinca alkaloids &

margins. Elevate limb but encourage movement.

cisplatinum

Reapply cold pack for 24h.

Actinomycin D

Infiltrate area with 1-3mL 3% sodium thiosulphate.

Aclarubicin

Topical DMSO painted every 2h followed by

Daunorubicin

hydrocortisone cream and 30 mins cold compression.

Doxorubicin

Repeated for 24h thereafter DMSO and hydrocortisone

Epirubicin

should be alternated every 3h; if blistering occurs

Idarubicin

stop DMSO.

Mitomycin

Cisplatinum

Infiltrate area with 1-3mL 3% sodium thiosulphate, aspirate

off then administer 1500 units hyaluronidase and apply heat

and compression.

Carmustine

Infiltrate area with 1-3mL sodium bicarbonate diluted to

plicamycin 2.1%, avoid normal tissue at the margins, leave 2

mins then aspirate off.

Docetaxel

Infiltrate area with 1-3mL of a mixture of 100mg

Paclitaxel

hydrocortisone and 4mg chlorphenamine (chlorpheniramine)

as 0.2mL pin-cushion injections, followed by 1500U of

hyaluronidase then warm compression alternated with topical

antihistamine cream; hydrocortisone and antihistamine creams

should be applied alternately for 3d. In severe cases administer

1g sodium cromoglicate PO as soon as possible.

Chlormethine (mustine)

Infiltrate area with 1-3mL 3% sodium thiosulphate then

infiltrate with 100mg hydrocortisone, apply cold compression

intermittently for 12h.

Vincristine, vinblastine &

Infiltrate area with 1500 units of hyaluronidase as 0.2mL SC

580

vindesine

injections over and around the affected area; apply heat and

compression for 24h then apply topical non-steroidal anti-

inflammatory cream to the area qds.

Group 2: Irritant drugs

Aspirate as much as possible.

Administer 100mg hydrocortisone IV.

Administer 100mg hydrocortisone SC at multiple sites around margins of extravasation.

Apply topical hydrocortisone.

Cover area with an ice pack.

Manage symptoms.

Group 3: Non-vesicant drugs

Aspirate as much as possible.

Disperse extravasated drug with SC hyaluronidase injection around the area.

Apply heat and compression to aid dispersal.

Manage symptoms.

Splenectomy

Splenectomy is an established procedure in management of selected

haematological disorders. Removal of the spleen is usually required for

one or more of the following reasons:

2 Extreme enlargement.

2 Hyperfunction.

2 Autoimmune activity.

2 Diagnostic and therapeutic purposes.

Indications include:

2 Lymphoproliferative disorders, e.g. CLL, mantle zone lymphoma,

hairy cell leukaemia. Reasons include massive organomegaly, occur-

rence of autoimmune complications and for diagnostic and/or thera-

peutic purposes.

2 Myeloproliferative disorders —commonly used in myelofibrosis to

reduce transfusion requirements, abdominal discomfort from massive

splenic enlargement and may reduce constitutional symptoms e.g.

weight loss and night sweats. Occasionally used in the management of

chronic myeloid leukaemia.

2 Autoimmune conditions —an accepted treatment in autoimmune

thrombocytopenic purpura and autoimmune haemolytic anaemia fol-

lowing the failure of immunosuppression with corticosteroids and

immunoglobulin (in the case of thrombocytopenic purpura). The pro-

cedure is not curative but may result in prolonged remissions and cer-

tainly will have steroid-sparing effect.

2 Hereditary disorders —reduces red cell sequestration and transfusion

requirements in homozygous

-thalassaemia. Recurrent, severe heredi-

tary spherocytosis. Rare indications include pyruvate kinase deficiency

and type 1 Gaucher's disease. Other circumstances where splenec-

tomy may help include Felty's syndrome.

2 Staging splenectomy is no longer a routine procedure for non-

Hodgkin’s lymphoma or Hodgkin’s disease.

The clinician has to balance the risks and benefits of the procedure in an

582

individual patient bearing in mind the long-term risk of post-splenectomy

sepsis as well as immediate surgical factors. There are now established

consensus guidelines for carrying out splenectomy.

Pre-operatively the need for the procedure is agreed with the patient and

surgical team. At least 2 weeks pre-operatively immunisation with pneu-

mococcal and Haemophilus vaccine should be given. Meningococcal

vaccine may be offered but this covers sub-types A and C only and does

not give long-lasting immunity. Peri-operative thromboembolic risks

should be considered (e.g. standard surgical risks and those posed by the

rebound thrombocytosis after splenectomy). Low dose heparin may be

appropriate peri-operatively followed by low dose aspirin (may require

modification in thrombocytopenia or if platelet dysfunction). Before dis-

charge, patients must be given a leaflet/card which they carry. Life-long

prophylaxis with penicillin V 250mg bd recommended or erythromycin

250mg bd if the patient is allergic to penicillin. The patient and his/her

Plasma exchange (plasmapheresis)

Plasmapheresis is the therapeutic removal of plasma from the peripheral

blood usually carried out by a cell separator machine. The removed

plasma is replaced isovolaemically usually by albumin/saline combinations

depending on indication, plasma albumin level and frequency of exchange.

Blood products may also be given as part of replacement which is useful in

patients with fluid intolerance e.g. on renal dialysis. The exception to this

is TTP where the replacement fluid is always FFP or cryosupernatant.

~1-1.5

¥ plasma volume is exchanged in each procedure, i.e. 2.5-4L for

average adult. Procedure takes

2-4h depending on volume to be

exchanged and the line flow rates. Procedure may need to be repeated

daily until response e.g. TTP, or until a total volume exchange has been

achieved e.g. 10-15L over 2 weeks (e.g. Guillain-Barré syndrome), or

monthly to control hyperviscosity

(e.g. Waldenström’s macroglobuli-

naemia).

Indications—generally accepted in:

2 Hyperviscosity syndromes.

2 Guillain-Barré syndrome resistant to IVIg.

2 Myasthenia gravis: peri-operatively for thymectomy, and refractory

disease.

2 Paraproteinaemic neuropathy.

2 Goodpasture’s syndrome.

2 Thrombotic thrombocytopenia purpura.

2 Post-transfusion purpura.

2 Cold haemagglutinin disease.

Efficacy contentious but may be indicated in:

2 Severe warm type AIHA.

2 Lupus, Wegener’s and other vasculitides.

2 Rheumatoid arthritis.

2 Peripheral neuropathies other than paraproteinaemic neuropathy.

2 Multiple sclerosis.

2 Chronic inflammatory demyelinating polyradiculopathy.

584

2 Eaton-Lambert syndrome.

2 Renal transplant rejection.

Venous access

If exchange is to be performed via peripheral veins, one large antecubital

vein is required sufficient to tolerate cannulation by a 16G butterfly needle

as the drawing line (return line need only be 18G). If not possible, make

arrangements for insertion of a central line prior to the planned exchanges

inserting a double lumen renal dialysis type catheter of 16G or larger.

Regular medication due immediately prior to exchange may be best

deferred until immediately post-exchange particularly for drugs which are

predominantly protein bound (see facing page).

Problems with apheresis

General—patient anxiety, discomfort and boredom.

Citrate toxicity—parasthesiae, tremors, tetany.

Vascular and cardiac—poor venous access giving poor flow rates.

Protocols and procedures

Extravasation, with haematoma at puncture sites, local vein thrombosis —

during and after procedure, sepsis at puncture sites, hypo/hypervolaemia,

vasovagal attacks, arrhythmias.

Metabolic and pharmacological—hypoalbuminaemia, hypoglycaemia,

removal of drugs (plasma bound).

Allergic reactions—including anaphylaxis.

Drugs>75% bound: If drugs on the list below are due immediately prior

to exchange, delay administration until after procedure.

Beta blockers

Antipsychotics

Propranolol

Chlorpromazine

Timolol

Haloperidol

Penbutolol

Thioridazine

Ca²⁺ channel blockers

Antifungal agents

Diltiazem

Amphotericin B

Nifedipine

Ketoconazole

Verapamil

Antihistamines

Anti-arrhythmics

Chlorpheniramine

Amiodarone

Antimalarials

Propofenone

Mepacrine

Quinidine

Pyrimethamine

Digitoxin (Digoxin is OK)

Antibiotics

Diuretics

Cloxacillin

Furosemide (frusemide)

Flucloxacillin

Metolazone

Penicillin V

Bendroflumethazide (bendrofluazide)

Sulphonamide

Diazoxide

Doxycycline

Acetazolamide

Anti-TB

Hypolipidaemics

Rifampicin

Clofibrate

585

Anticoagulants

Gout drugs

Heparin

Probenecid

Warfarin

Sulfinpyrazone

Thyroid Drugs

Analgesics

Thyroxine

NSAIDs (all)

Tri-iodothyronine

Aspirin

Propylthiouracil

Coproxamol

Oestrogens and progestogens

Benzodiazepines

All

Hypoglycaemics

Antidepressants

Tolbutamide

All

Glipizide

Antiepileptics

Gliclazide

Carbamazepine

Glibenclamide

Phenytoin

Chlorpropamide

Sodium valproate

Leucapheresis

Leucapheresis is the removal from the peripheral blood of white blood

cells, usually leukaemic blasts, via a cell separation machine.

Procedure

Usually now a standard computer controlled programme on modern

machines e.g. Cobe Spectra^™ or Fenwall CS^™. May be performed manu-

ally in an emergency (see p510).

Indications

In patients with high WBC e.g. AML, CML and with symptoms or signs of

leucostasis, leucapheresis should be performed urgently. Leucostatic fea-

tures are less common in lymphoid than in myeloid malignancies.

Leucostatic features

2 Confusion.

2 Decreased conscious level.

2 Fits.

2 Retinal haemorrhages.

2 Papilloedema.

2 Hypoxia and miliary shadowing on CXR.

2 Bleeding and coronary ischaemia.

Should not be performed routinely just because of a high WBC.

Leucostatic clinical features are the indication. Conversely, leucostasis

may occur in some patients with AML without a very high blast count but

these patients should be considered for leucapheresis.

Chemotherapy should be started as soon as possible after leucapheresis

as WBC will ‘rebound’ quickly due to outpouring of cells from marrow.

Leucapheresis may need to be repeated daily until chemotherapy has

suppressed marrow.

Other indications

2 Leucapheresis should be performed routinely at diagnosis of CML in

patients <60 for stem cell cryopreservation which can be used in the

586

future as a stem cell rescue procedure.

2 Leucapheresis may be used as an alternative to chemotherapy in low

grade haematological malignancies in pregnancy.

Anticoagulation therapy - heparin

For acute thrombosis DVT/PE start with heparin and warfarin simultane-

ously. Essential to confirm diagnosis —but start treatment whilst awaiting

results of investigations. When warfarin stable —stop heparin.

Heparin

Main advantage over oral anticoagulation is immediate anticoagulant effect

⁄2

(UFH), a mixture of polysaccharide chains, mean MW 15,000, t

1.0-1.5h,

¹⁄2

and low molecular weight heparin (LMWH), fragments of UFH (mean

MW 5000) with longer t

(3-6h) and greater bioavailability. LMWH has sig-

¹⁄2

nificant advantages: one daily SC injection, no monitoring, no dose adjust-

ment, low risk of HITT. Heparins act by potentiating coagulation inhibitor

antithrombin (AT) resulting in antithrombin and anti-Xa activity. Both UFH

and LMWH depend on renal clearance.

Therapeutic anticoagulation

LMWH—given SC once daily on basis of weight (see individual products for

dosage). Usually continued for 4-7 days until warfarin effect, INR>2.0.

Standard IV UFH—initial IV bolus 5000iu in 0.9% saline given over 30

mins (lower loading dose for small adult/child). Follow with 15-25iu/kg/h

using a solution of 25,000iu heparin in 50mL 0.9% saline (= 500iu/mL) and

a motorised pump, e.g. for 80kg adult dose is 80

¥ 25 = 2000iu/h. Monitor

IVI with APTT ratio, aim for ratio of 1.5-2.5, check 6h after starting

treatment. Adjust dose as shown opposite.

Check APTT ratio 10h after dose change; daily thereafter. Use fresh

venous sample—do not take from line. Continue heparin until INR in

therapeutic range for warfarin —takes

~5 days; massive ileo-femoral

thrombosis and severe PE may require 7-10 days’ heparin.

Contraindications—caution if renal, hepatic impairment, recent

surgery, known bleeding diathesis, severe hypertension.

588

Immediate complications of therapy

Bleeding occurs even when APTT ratio within the therapeutic range but

risk 4 with 4APTT ratio. Treatment: Stop heparin until APTT ratio <2.5. In

life-threatening bleeding use protamine sulphate: 1mg/100iu of heparin

given in preceding hour. Thrombocytopenia —Mild 5 platelets common

early in heparin therapy; not significant. Severe thrombocytopenia less

common (HITT); occurs 6-10d after therapy begun; may be associated

thrombosis. Stop heparin. Give alternative antithrombin drug such as lep-

irudin or danaparoid. Do not start warfarin until thrombocytopenia

resolved.

Prophylactic anticoagulation

LMWH now used in preference to UFH. LMWH given at low dose SC

once daily. Recommended dose usually greater for orthopaedic surgery

than general surgery. Continue until patient discharged and mobile.

Moderate/high risk patients

LMWH given 2h pre-op and once daily (see BNF for dosage). UFH SC

5000iu 2h before surgery and bd until patient is mobile.

Oral anticoagulation

Warfarin is the drug of choice; few side effects, well tolerated. A vitamin K

antagonist, it takes ~72h to be effective; stable state takes 5-7d. t

~35h.

¹⁄2

Circulates mainly bound to albumin; free warfarin is active. Many drugs ↑

warfarin effect by displacing it from albumin. Monitored by PT using the

international normalised ratio (INR).

Administration

Given daily. Usually given with heparin on day 1. If massive thrombosis,

delay warfarin for 2-3d. Standard adult regimen = 10mg/d for 2d. Load

with caution using reduced dose if liver disease, interacting drugs, patient

>80 years. Check INR <1.4 before loading. Check INR daily for first 4 days

(see Appendix II, Guidelines on oral anticoagulation: third edition, Brit J

Haematol 1998, 101, 374-378) on Day 3, ~16h after second dose, and

adjust as follows.

Target INR usually 2.5 except for mechanical heart valves in mitral posi-

tion when target is 3.0 or 3.5.

Complications

Haemorrhage. Easy bruising common within therapeutic range —is patient

on aspirin? Rate of major bleeds ~2.7/100 treatment years, 4 age 4 INR.

Rare side effects —alopecia, warfarin-induced skin necrosis, hypersensi-

tivity, purple toe syndrome.

Management of over-anticoagulation: See p522 for details

Asymptomatic patient

INR >5.0—stop warfarin and reduce dose by at least 25%. Check INR

within 1 week.

INR >8.0—consider oral vitamin K 1-5mg.

Symptomatic patient

Moderate bleeding, INR 5.0-8.0, give vitamin K 1mg slowly IV. INR >8.0:

give vitamin K 1mg and FFP or factor concentrate. Severe bleeding:

590

vitamin K 5mg IV, and concentrate containing factors II, VII, IX and X (e.g.

beriplex). Observe in hospital. Vitamin K reverses over-anticoagulation in

24h. Look for causes of over-anticoagulation e.g. heart failure, alcohol,

drugs.

Kearon, C. & Hirsh, J. (1997) Management of anticoagulation before and after elective surgery.

N Engl J Med, 336, 1506-1511.

Management of needlestick injuries

Every doctor dealing with high risk patients is concerned to prevent expo-

sure to blood and body fluids, particularly a needlestick injury. The UK

DoH published guidance on post-exposure prophylaxis (PEP) for HIV in

1997 (tel 0203 9724385 for copy). Your hospital/GP surgery should have

a policy for the prevention and management of contamination incidents —

check this out.

Risk to health care workers

2 types of injury —sharps injury where intact skin is breached by sharp

object contaminated with blood/blood-stained body fluids or unfixed

tissue, and contamination injury where blood/blood-stained body fluid

comes into contact with mucous membranes or non-intact skin. HBV and

HIV are the 2 major concerns. All health care workers should be vacci-

nated against HBV. Risk of contracting HIV from percutaneous exposure

to HIV-infected blood is ~0.3%. The amount of blood injected and a high

viral load in the patient’s blood increase the risk.

General guidelines

Prevention

All health care workers must adopt universal precautions when handling

blood/blood stained fluids —wear gloves, avoid blood spillage, use decon-

tamination procedures if spillage occurs, label high risk specimens, care

with needles (do not resheath), disposal in burn bins, etc.

Immediate action in event of exposure

2 Encourage bleeding and/or wash under running water.

2 Contact Occupational Health/A&E departments for help.

2 Establish patient status re blood-borne viruses.

2 Take blood from patient/test for viruses (with consent).

2 Take blood from needlestick victim and store. Check HBV

immunity/later tests if necessary.

Treatment

592

Decision to treat will be made by an experienced medical staff member.

Treatment recommended for ‘all health care workers exposed to high risk

body fluids or tissues known to be, or strongly suspected to be, infected with HIV

through percutaneous exposure, mucous membrane exposure or through expo-

sure of broken skin.’ Zidovudine alone given as soon as possible 5 risk of

seroconversion by 80% but failures are well described. Prophylaxis with

triple therapy now recommended. Treat for 4 wks as soon as possible

with:

2 Zidovudine 200mg tds/250mg bd + Lamivudine 150mg bd + Indinavir

800mg tds. A ‘starter pack’ should be available in an accessible place at

all times.

2 Known exposure to hepatitis B

- No immunity—give HepB Ig 500mg IM; vaccinate immediately.

- Known immunity with HepB Ab >100 IU/L in past 2 yr—no action.

- Immunity—HepB Ab status not known—give booster dose.

Chemotherapy protocols

VAPEC-B

Vincristine, doxorubicin, prednisolone, etoposide, cyclophosphamide,

bleomycin

Indication

Hodgkin’s lymphoma stage IA or IIA only without B symptoms or bulky

disease.

Schedule: 6-week chemotherapy and radiotherapy regimen

given once only.

Days

Drug

Dose

Route

Comments

1-28

Prednisolone

50mg daily

Take with food in

morning; taper off

after days 29-38;

consider adding

H₂ antagonist or

PPI

1 & 15

Adriamycin

35mg/m²

Bolus injection via

(doxorubicin)

fast-running drip

or IVI in 100mL

0.9% saline over

15 min

Cyclophosphamide

350mg/m²

IVI in 250mL 0.9%

saline over 15min

15-19

Etoposide

100mg/m² for

Take 1h before

5 consec. days

food on empty

stomach

594

8 & 22

Vincristine

1.4mg/m²

Bolus injection via

(max 2mg)

fast-running drip;

dilute in 20mL

0.9% saline as per

national guideline

8 & 22

Bleomycin^†

10,000iu/m²

IVI in 250mL 0.9%

saline over 60 min

IF radiotherapy

^†Prescribe hydrocortisone 100mg IV before bleomycin.

Administration

2 Involved field radiotherapy is given in week 6, 2 weeks after last dose

of chemotherapy. The dose is 30-40Gy to the initial volume of the

disease.

2 Outpatient treatment.

2 Consider sperm banking in males (low risk of infertility).

Protocols and procedures

2 Oral systemic PCP prophylaxis is recommended for the first 6 weeks.

2 Oral systemic antifungal prophylaxis is optional.

2 Antiemetic therapy for moderately emetogenic regimens on days 1 and

15.

2 Delay doxorubicin, cyclophosphamide or etoposide by 1 week if

platelets <100

¥ 10⁹/L or neutrophils <1

¥ 10⁹/L.

2 Reduce cyclophosphamide to 75% dose if creatinine clearance

10-50mL/min, 50% dose if creatinine clearance <10mL/min.

2 Reduce doxorubicin, vincristine and etoposide to 50% dose if serum

bilirubin

1.7-2.5

¥ upper limit normal and 25% if 2.5-4

¥ upper limit

normal. Caution with cyclophosphamide if hepatic impairment.

2 All cellular blood components should be irradiated indefinitely.

2 Total regimen 6 weeks’ treatment.

595

ABVD

Adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine

Indication

Hodgkin’s disease.

Schedule

28 day cycle

Day 1 (A)

Day 15 (B)

Doxorubicin

25mg/m² IV

Bleomycin

10,000iu/m² IV

Vinblastine

6mg/m² IV (max l0mg)

Dacarbazine

375mg/m² IVI

in normal saline

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/day throughout first treatment cycle.

2 Antiemetic therapy for moderate emetogenic regimens.

2 Consider doxorubicin dose reduction if significant liver impairment.

2 Repeat treatment if WBC >3.5

¥ 10⁹/L and platelet count >100

¥ 10⁹/L.

2 25% dose reduction if WBC 2.5-3.5

¥ 10⁹/L or platelets 75-100

¥ 10⁹/L.

2 Delay treatment 1 week if WBC <2.5

¥ 10⁹/L or platelets <75

¥ 10⁹/L.

2 Treat to complete remission + 2 cycles.

596

ChlVPP

Chlorambucil, vinblastine, procarbazine, prednisolone

Indication

Hodgkin’s disease.

Schedule

28 day cycle

Chlorambucil

6mg/m² PO

days 1-14

Vinblastine

6mg/m² IV (max. 10mg)

days 1 & 8

Procarbazine

100mg/m² PO (max. 150mg) days 1-14

Prednisolone

40mg/m²(max 60mg) PO

days 1-14

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for moderate emetogenic regimens.

2 Consider H₂-antagonist or PPI.

2 Alcohol prohibited with procarbazine; avoid monoamine oxidase

inhibitors.

2 Repeat treatment when WBC >3.0

¥ 10⁹/L and platelets >100

¥ 109/L.

2 Treat to complete remission + 2 cycles.

598

MOPP

Chlormethine (mustine), vincristine, procarbazine, prednisolone.

Indication

Hodgkin’s disease.

Schedule

28 day cycle

Chlormethine (mustine)

6mg/m² IV

days 1 & 8

Vincristine

1.4mg/m² IV (max. 2mg*)

days 1 & 8

Procarbazine

100mg/m² PO (max. 150mg) days 1-14

Prednisolone

100mg/m² PO

days 1-14

*Original protocol put no maximum limit on vincristine dosage; higher doses are associated

with severe neuropathy.

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for highly emetogenic regimens.

2 Alcohol prohibited with procarbazine; avoid monoamine oxidase

inhibitors.

2 Repeat treatment if WBC >3.5

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 25% dose reduction if WBC 2.5-3.5

¥ 10⁹/L or platelets 75-100

¥ 10⁹/L.

2 Delay treatment 1 week if WBC <2.5

¥ 10⁹/L or platelets <75

¥ 10⁹/L.

2 Treat to complete remission + 2 cycles.

600

MOPP/ABVD

Chlormethine (mustine), vincristine, procarbazine, prednisolone, adriamycin

(doxorubicin), bleomycin, vinblastine, dacarbazine.

Indication

Hodgkin’s disease.

Schedule

8 week cycle

Chlormethine (mustine)

6mg/m² IV

days 1 & 8

Vincristine

1.4mg/m² IV (max. 2mg*)

days 1 & 8

Procarbazine

100mg/m² PO (max. 150mg) days 1-14

Prednisolone

100mg/m² PO

days 1-14

day 29

day 43

Doxorubicin

25mg/m² IV

Bleomycin

10,000 units/m² IV

Vinblastine

6mg/m² IV (max. 10mg)

Dacarbazine

375mg/m² IVI

in N saline

•Original protocol put no maximum limit on vincristine dosage; higher doses are associated

with severe neuropathy.

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for highly emetogenic regimens.

2 Alcohol prohibited with procarbazine; avoid monoamine oxidase

inhibitors.

602

2 Consider doxorubicin dose reduction if significant liver impairment.

2 Repeat treatment if WBC >3.5

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 25% dose reduction if WBC 2.5-3.5

¥ 10⁹/L or platelets 75-100

¥ 10⁹/L.

2 Delay treatment 1 week if WBC <2.5

¥ 10⁹/L or platelets <75

¥ 10⁹/L.

2 Treat for 12 months (6 cycles).

CHOP

Cyclophosphamide, doxorubicin, vincristine, prednisolone.

Indications

2 Intermediate and high grade non-Hodgkin’s lymphoma.

2 Low grade non-Hodgkin’s lymphoma resistant to first-line therapy.

Schedule

21 day cycle

Day 1

Cyclophosphamide

750mg/m² IV

Vincristine

1.4mg/m² IV

(max. 2mg*)

Doxorubicin

50mg/m² IV

Prednisolone

50mg/m² (max 100mg) PO

X X X X X

*max 1mg for patients > 70 years

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Consider doxorubicin dose reduction if significant liver impairment.

2 Repeat treatment when WBC >3.0

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 Treat to complete remission + 2 cycles (max 8 cycles).

604

Protocols and procedures

R-CHOP

Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone

Indication

2 First line treatment of CD20+ diffuse large B cell lymphoma stage II, III

or IV.

Schedule

21 day cycle

Day 1

Rituximab 375mg/m²IV

Cyclophosophamide 750mg/m²IV

Vincristine 1.4mg/m²IV (max 2mg*)

Doxorubicin 50mg/m²IV

Prednisolone 50mg/m² PO (max 100mg)

X X X X X

*max 1mg for patients>70 years.

Administration

2 Outpatient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for moderately emetogenic regimen.

2 Administer rituximab after first dose of prednisolone on day 1 before

administering chemotherapy.

2 Premedication with paracetamol and chlorpheniramine should be

administered before each rituximab infusion.

2 Monitor closely for cytokine release syndrome: fever, chills, rigors

605

within first 2 hours usually.

2 Less common side effects include: flushing, angioedema, nausea,

urticaria/rash, fatigue, headache, throat irritation, rhinitis, vomiting,

tumour pain and features of tumour lysis syndrome, bronchospasm,

hypotension.

2 Interrupt rituximab infusion if severe dyspnoea, bronchospasm or

hypoxia.

2 Consider doxorubicin dose reduction if significant liver impairment.

2 Repeat treatment when WBC>3.0 X 10⁹ L and platelets >100 X 10⁹/L.

2 Treat to complete remission + 2 cycles, max 8 cycles.

DHAP

Dexamethasone, cytarabine, cisplatin

Indication

2 Salvage chemotherapy for relapsed/refractory NHL and Hodgkin’s lym-

phoma.

2 Mobilisation of peripheral blood stem cells.

Schedule: 21-28 day cycle depending on count recovery

Days Drug

Dose

Route

Comments

1-4

Dexamethasone

40mg

Taken in the

morning with

food

Cisplatin

^†100mg/m²

IVI in 500mL 0.9%

saline over 1h

Cytarabine

^†2g/m²X 2

IVI in 1L 0.9%

saline over 3h

twice 12h apart

^†cap surface area at 2m²

Administration

In-patient regimen.

Ensure adequate venous access by inserting a dual lumen tunnelled

central venous catheter.

Severe myelosuppression (neutrophils <0.2

¥ 10⁹/L and need for red

cell and platelet transfusion support) should be expected.

Allopurinol 300mg od PO (100mg if renal impairment) for first 2

cycles.

Consider acyclovir prophylaxis if previous history of VZV or HSV reac-

tivation.

Antiemetic therapy for highly emetogenic regimens.

Aggressive pre- and post-hydration including potassium/magnesium

606

supplementation is required with cisplatin.

Predsol 0.5% eye-drops qds until 5 days after completion of

chemotherapy.

Standard antimicrobial prophylaxis as dictated by local policy to cover

duration of severe neutropenia.

G-CSF 5-10mg/kg SC daily starting day +5 optional to shorten neu-

tropenia and necessary to mobilise peripheral blood stem cells.

Reduce cisplatin to 75% dose if creatinine clearance 45-60mL/min,

50% dose if creatinine clearance 30-45mL/min; do not give if creatinine

clearance <30mL/min.

Creatinine clearance should be assessed before each course of treat-

ment.

Cytarabine should be used with caution in severe renal impairment;

consider reducing dose of cytarabine if hepatic impairment.

Delay next cycle for 1 week if neutrophils <1.0

¥ 10⁹/L or platelets

<100

¥ 10⁹/L.

ESHAP

Etoposide, methylprednisolone, cytarabine, platinium

Indications

2 Treatment of refractory/relapsed NHL and Hodgkin’s lymphoma.

2 Mobilisation of peripheral blood stem cells for NHL and Hodgkin’s

lymphoma.

Schedule: 21-28 day cycle as soon as neutrophils >1.0

¥ 10⁹/L

and platelets (unsupported) >100

¥ 10⁹/L

Days Drug

Dose

Route

Comments

Cytarabine

2g/m²

IVI in 500mL 0.9%

saline over 2h

1-4

Etoposide

40-60mg/m²

IVI in 250mL 0.9%

saline over 60 min

1-4

Cisplatin

25mg/m2

IVI in 1L 0.9%

saline over 24h

1-5

Methylpred.

500mg

IVI in 100mL 0.9%

saline over 30 min

Administration

2 In-patient regimen.

2 Ensure adequate venous access by inserting a dual lumen tunnelled

central venous catheter.

2 Severe myelosuppression (neutrophils <0.1

¥ 10⁹/L and platelets <20

¥ 10⁹/L) is expected.

2 Add allopurinol 300mg (100mg if creatinine clearance <20mL/min) od

for first 2 weeks.

2 Antiemetic therapy for highly emetogenic regimens.

2 Aggressive pre- and post-hydration including potassium/magnesium

608

supplementation required with cisplatin.

2 Predsol 0.5% eye-drops qds until 5 days after completion of

chemotherapy.

2 Give mouth care (nystatin and chlorhexidine M/W) and oral systemic

antibacterial and antifungal prophylaxis until neutrophil recovery ≥ 1.0

¥ 10⁹/L.

2 Consider H₂ antagonist or PPI.

2 Consider starting G-CSF 5mg/kg/day on day 7 either to shorten neu-

tropenia or to facilitate peripheral blood stem cell collection around

day 16.

2 Reduce cisplatin to 50% dose if creatinine clearance 40-60mL/min; do

not give if creatinine clearance <40mL/min.

2 Reduce cytarabine to 50% dose and omit etoposide if serum bilirubin

>50µmol/L.

2 Creatinine clearance should be assessed before each course of treat-

ment.

Mini-BEAM

BCNU (carmustine), etoposide, cytarabine, melphalan

Indications

2 Treatment of refractory/relapsed NHL and Hodgkin’s lymphoma.

2 To demonstrate persistent chemosensitivity of tumour.

2 Mobilisation of peripheral blood stem cells.

Schedule

Days Drug

Dose

Route

Comments

Carmustine

60mg/m²

IVI in 250mL 5%

dextrose over 1h;

avoid storage in

PVC container for

>24h

2-5

Cytarabine

100mg/m² bd

IVI in 100mL 0.9%

saline over 30 min

2-5

Etoposide

75mg/m²

IVI in 500mL 0.9%

saline over 1h

Melphalan^†‡

30mg/m2

IVI in 100mL 0.9%

saline within 30

min reconstitution

† Ensure adequate diuresis before administering melphalan.

‡ Ensure that melphalan is administered on a week day (Mondays or Tuesdays provide

optimal timing for stem cell collection).

Administration

2 In-patient regimen.

2 Ensure adequate venous access by inserting a dual lumen tunnelled

central venous catheter.

610

2 Severe myelosuppression (neutrophils <0.1

¥ 10⁹/L and platelets <20

¥ 10⁹/L) is expected.

2 Add allopurinol 300mg (100mg if creatinine clearance <20mL/min) od

for first 2 weeks.

2 Antiemetic therapy for moderately emetogenic regimens

2 Give mouth care (nystatin and chlorhexidine M/W) and oral systemic

antibacterial and antifungal prophylaxis until neutrophil recovery ≥1.0

¥ 10⁹/L.

2 Consider H₂ antagonist or PPI.

2 Consider starting G-CSF 5mg/kg/d on day 9 either to shorten neu-

tropenia or to facilitate peripheral blood stem cell collection around

day 18.

2 Note: do not use mini-BEAM if creatinine clearance ≤40mL/min.

2 Patients with Hodgkin’s lymphoma and those in whom stem cell

collection is planned within 2 weeks must receive irradiated cel-

lular blood components to prevent transfusion associated graft

versus host disease.

BEAM (myeloablative conditioning

regimen)

BCNU (carmustine), etoposide, cytarabine, melphalan

Indications

High dose chemotherapy consolidation for patients with:

2 Aggressive NHL: chemosensitive relapse or poor prognostic disease.

2 Hodgkin's lymphoma: refractory or second remission.

2 Indolent NHL refractory to second-line therapy.

Schedule

Days

Drug

Dose

Route

Comments

–7

Carmustine

300mg/m²

IVI in 500mL 5%

dextrose over 1h;

avoid storage in

PVC container for

>24h

-6 to -3

Cytarabine

200mg/m² bd

IVI in 100mL 0.9%

(inclusive)

saline over 30 min

–6 to -3

Etoposide

200mg/m²

IVI in 1L 0.9%

(inclusive)

saline over 2h

–2

Melphalan^†

140mg/m²

IVI in 250mL 0.9%

saline within 60min

of reconstitution

Thaw and reinfuse haematopoietic stem cells^‡

^†Ensure excretion of melphalan by aggressive hydration (± furosemide (frusemide)).

^‡Ensure stem cell dose ≥ 2.0

¥ 10⁶/L CD34+ cells; do not re-infuse stem cells within 24h of

melphalan infusion.

612

Administration

2 In-patient regimen.

2 Ensure adequate venous access by inserting a dual lumen tunnelled

central venous catheter.

2 Severe myelosuppression (neutrophils <0.1

¥ 10⁹/L and platelets <20

¥ 10⁹/L) is expected.

2 Add allopurinol 300mg (100mg if creatinine clearance <20mL/min) od

for first week.

2 Antiemetic therapy for highly emetogenic regimens.

2 Give mouth care (nystatin and chlorhexidine M/W) and oral systemic

antibacterial and antifungal prophylaxis until neutrophil recovery ≥ 1.0

¥ 10⁹/L—refer to local protocol for patients with severe neutropenia.

2 Consider H₂ antagonist or PPI

2 Consider starting G-CSF 5mg/kg/day on day +5 to shorten the dura-

tion of neutropenia.

2 Consider acyclovir antiviral prophylaxis if previous history of VZV or

HSV reactivation.

CVP

Cyclophosphamide, vincristine, prednisolone.

Indications

● Low grade non-Hodgkin’s lymphoma.

● Advanced chronic lymphocytic leukaemia.

Schedule

21 day cycle

Day 1

Cyclophosphamide

750mg/m² IV

Vincristine

1.4mg/m² IV

(max. 2mg)*

Prednisolone

60mg/m² (max 100mg) m² PO X

X X

*max 1mg in patients > 70.

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/d throughout first treatment cycle.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Consider doxorubicin dose reduction if significant liver impairment.

2 Repeat treatment when WBC >3.0

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 Treat to complete remission + 2 cycles.

614

Fludarabine and cyclophosphamide

Indications

2 Third line therapy for CLL.

2 Mantle cell lymphoma.

Schedule: 28 day cycle

Days

Drug

Dose

Route

Comments

1-3

Cyclophosphamide

250mg/m²

IV bolus in 50mL

0.9% saline

immediately prior

to fludarabine

1-3

Fludarabine

25mg/m²

IV bolus in 10mL

0.9% saline

Alternative oral schedule

Days

Drug

Dose

Route

Comments

1-5

Cyclophosphamide

150mg/m^2†

1-5

Fludarabine

24mg/m^2†

^†Appropriate rounding to the next available tablet size.

Administration

2 Out-patient regimen.

2 Check direct antiglobulin test (DAGT) pre-treatment; +ve DAGT is a

relative contraindication to fludarabine therapy.

2 Allopurinol 300mg od PO (100mg if significant renal impairment) for

first 2 cycles.

2 Oral systemic PCP prophylaxis according to local protocol (generally

480mg bd tiw) throughout treatment and for 8 weeks after comple-

tion.

2 Consider acyclovir prophylaxis if previous history of VZV or HSV reac-

616

tivation.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Reduce to 50% doses if renal impairment (creatinine clearance

30-60mL/min); do not give if creatinine clearance <30mL/min.

2 Delay next cycle for 1 week if neutrophils <1

¥ 10⁹/L or platelets <75

¥ 10⁹/L.

2 All cellular blood components should be irradiated for 1 year

after therapy to prevent transfusion associated graft versus host

disease.

2 Administer 6 cycles.

FMD

Fludarabine, mitoxantrone (mitozantrone), dexamethasone

Indications

2 Follicular and other indolent NHL.(beyond second line)

2 Waldenström’s macroglobulinaemia. (beyond second line)

2 Chronic lymphocytic leukaemia. (beyond second line)

Schedule: 28 day cycle

Days Drug

Dose

Route

Comments

1-3

Fludarabine

25mg/m²

IV bolus in 10mL

0.9% NaCl

or 40mg/m²

Mitoxantrone

10mg/m²

Bolus in fast-

(mitozantrone)

running drip or

infusion in 100mL

0.9% saline over

15 min

1-5

Dexamethasone

20mg

PO/IV

Administration

2 Out-patient regimen.

2 Check direct antiglobulin test (DAGT) pre-treatment and after each

cycle; positive DAGT is a relative contraindication to fludarabine

therapy.

2 Allopurinol 300mg od PO (100mg if significant renal impairment) for

first 2 cycles.

2 Oral systemic PCP prophylaxis according to local protocol (generally

480mg bd tiw) throughout treatment and for 8 weeks after comple-

tion.

2 Consider acyclovir prophylaxis if previous history of VZV or HSV reac-

618

tivation.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Consider H₂ antagonist or PPI.

2 Reduce fludarabine to 50% dose if renal impairment (creatinine clear-

ance 30-60mL/min); do not give if creatinine clearance <30mL/min.

2 Reduce mitoxantrone (mitozantrone) to 50% dose if serum bilirubin

>1.5

¥ upper limit normal and 25% if >3

¥ upper limit normal.

2 Delay next cycle for 1 week if neutrophils <1.5

¥ 10⁹/L or platelets

<100

¥ 10⁹/L.

2 All cellular blood components should be irradiated for 1 year

after therapy to prevent transfusion associated graft versus host

disease.

2 Repeat to maximum clinical response; usually 6 cycles.

ABCM

Adriamycin (doxorubicin), BCNU (carmustine), cyclophosphamide, melphalan

Indication

Multiple myeloma.

Schedule

6 week cycle

Day 1

Doxorubicin

30mg/m² IV

Carmustine

30mg/m² IV

Cyclophosphamide

100mg/m² PO X 4 days

Melphalan

6mg/m² PO X 4 days

Administration

2 Out-patient regimen.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/day throughout first treatment cycle.

2 Add infection prophylaxis with cotrimoxazole 2 tabs tiw and nystatin

mouthwash/fluconazole 100mg/day.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Repeat treatment when WBC >3.0

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 Treat to plateau phase (normally 4-8 courses).

620

C-VAMP

Cyclophosphamide, vincristine, adriamycin (doxorubicin), methylprednisolone

Indications

2 Multiple myeloma. Suitable for intensive therapy or resistant to alky-

lator therapy.

Schedule

21 day cycle

Day 1

Vincristine

0.4mg/day

X X X X

cont. IVI

Doxorubicin

9mg/m²/day

X X X X

cont. IVI

Methylprednisolone

1.5g IV/PO

X X X X X

Cyclophosphamide

500mg IV

X X

Administration

2 Out-patient regimen.

2 Indwelling central venous catheter required with ambulatory infusion

pump.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/day throughout first treatment cycle.

2 Add infection prophylaxis with cotrimoxazole 2 tabs tiw and nystatin

mouthwash/fluconazole 100mg/day.

2 Antiemetic therapy for mildly emetogenic regimens.

2 Repeat treatment when WBC >2.0

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 Treat until maximum paraprotein and bone marrow response (nor-

mally 4-8 courses).

622

VAD

Vincristine, adriamycin (doxorubicin), dexamethasone

Indication

2 Multiple myeloma. Suitable for intensive therapy or resistant to alky-

lator therapy.

Schedule

21 day cycle

Day 1

Vincristine

0.4mg/day

X X X X

(continuous IVI)

Doxorubicin

9mg/m²/day

X X X X

(continuous IVI)

Dexamethasone

40mg/day PO X

X X X

(repeated days 9-12 and days 17-20 on first cycle only)

Administration

2 Out-patient regimen.

2 Indwelling central venous catheter required with ambulatory infusion

pump.

2 Consider sperm banking in males.

2 Add allopurinol 300mg/day throughout first treatment cycle.

2 Add infection prophylaxis with cotrimoxazole 2 tabs tiw and nystatin

mouthwash/fluconazole 100mg/day.

2 Antiemetic therapy for mildly emetogenic regimens.

2 Repeat treatment when WBC >2.0

¥ 10⁹/L and platelets >100

¥ 10⁹/L.

2 Treat until maximum paraprotein and bone marrow response (nor-

mally 4-6 courses).

624

CVAD used in MRC/UKMF Study ‘Myeloma IX’ adds cyclophosphamide 500mg PO (or IV if pre-

ferred) on days 1, 8 and 15 of each cycle. Omit cyclophosphamide in patients with a serum creati-

nine >300µmol/L.

Z-DEX

Idarubicin (zavedos), dexamethasone

Indications

Multiple myeloma suitable for intensive therapy or resistant to alkylator

therapy.

Schedule: 21 day cycle

Days

Drug

Dose

Route

Comments

1-4

Idarubicin

Total dose 40mg/m² PO

in divided doses over

4 days

1-4*

Dex.

40mg daily

Take in the

mornings;

swallow whole

with food

*Dexamethasone (Dex.) also on days 8-11 and days 15-18 for the first cycle only

Administration

2 Out-patient regimen.

2 Add allopurinol 300mg od PO (100mg if significant renal impairment)

for first cycle.

2 Antiemetic therapy for moderately emetogenic regimens.

2 Commence H₂ antagonist or PPI.

2 Nystatin and chlorhexidine mouthcare.

2 Oral systemic PCP prophylaxis is recommended until 2 weeks after the

end of treatment.

2 Consider oral systemic antibacterial, antiviral and/or antifungal prophy-

laxis if patient is neutropenic.

2 Reduce dose of idarubicin by 50% if bilirubin 20-50µmol/L; caution if

626

bilirubin is >50µmol/L. Maximum cumulative dose = 400mg/m².

2 Delay treatment for 1 week if neutrophils <1.0

¥ 10⁹/L or platelets

<50

¥ 10⁹/L. Reintroduce at 300mg or 400mg per dose.

2 Consider G-CSF if treatment delays are prolonged or frequent.

2 Continue to maximal response, usually 4-6 cycles.

C-Thal-Dex (CTD)

cyclophosphamide, thalidomide, dexamethasone

Indications

2 Multiple myeloma: melphalan-resistant disease; myeloma-IX randomi-

sation

2 Waldenström’s macroglobulinaemia.

Schedule: 21 day schedule

Days

Drug

Dose

Route Comments

1,8,15

Cyclophos.

500mg

1-21

Thalidomide

100mg for 3

Pregnancy testing as

weeks then

below

200mg

1-4 & 12-15 Dexamethasone

40mg/day

Administration

2 Out-patient regimen.

2 Women of childbearing potential must have negative pregnancy

test within 24h before starting thalidomide, every 2-4 weeks

while on thalidomide and 4 weeks after last dose.

2 Add allopurinol 300mg od PO (100mg if significant renal impairment)

for first cycle.

2 Antiemetic therapy for mildly emetogenic regimens.

2 Commence H₂ antagonist or PPI.

2 Consider regular laxative.

2 Do not give cyclophosphamide if serum creatinine >300µmol/L after

rehydration.

2 Omit cyclophosphamide for 3 weeks if neutrophils <1.0

¥ 10⁹/L or

platelets <100

¥ 10⁹/L. Reintroduce at 300mg or 400mg per dose.

2 Consider G-CSF if treatment delays are prolonged or frequent

2 Omit thalidomide for one cycle if grade 3/4 constipation, neuropathy,

628

fatigue, sedation, rash, tremor or oedema; reintroduce at 50mg/day.

2 Treat with full dose warfarin or LMW heparin if thromboembolic

event. Stop thalidomide and restart at 50mg/day escalating on the sub-

sequent cycle to 100mg/day.

2 Repeat for 4-6 cycles

Full blood count

Rapid analysis by the latest generation automated blood counters using

either forward angle light scatter or impedance analysis provides enumer-

ation of leucocytes, erythrocytes and platelets and quantification of

haemoglobin, MCV plus derived values for haematocrit, MCH and MCHC,

red cell distribution width (a measure of cell size scatter), mean platelet

volume and platelet distribution width and a 5 parameter differential leu-

cocyte count. The counter also flags samples which require direct mor-

phological assessment by examination of a blood film.

Sample: peripheral blood EDTA; the sample should be analysed in the

laboratory within 4h.

Blood film

Morphological assessment of red cells, leucocytes and platelets should be

performed by an experienced individual of all samples in which the FBC

has revealed any result significantly outside the normal range, samples in

which a flag has been indicated by the automated counter and if clinically

indicated. A manual differential leucocyte count may be performed and

may differ from that produced by the automated counter most notably in

patients with haematological disease affecting the leucocytes.

Sample: peripheral blood EDTA; the sample should be analysed in the

laboratory within 4h. May be made directly from drop of blood or EDTA

sample, air-dried and fixed.

Plasma viscosity

This test is a sensitive but non-specific index of plasma protein changes

which result from inflammation or tissue damage. The plasma viscosity is

unchanged by haematocrit variations and delay in analysis up to 24h and is

therefore more reliable than the ESR. It is not affected by sex but is

affected by age, exercise and pregnancy.

632

Sample: peripheral blood EDTA; the sample should be analysed in the

laboratory within 24h.

ESR

This test is a sensitive but non-specific index of plasma protein changes

which result from inflammation or tissue damage. The ESR is affected by

haematocrit variations, red cell abnormalities (e.g. poikilocytosis, sickle

cells) and delay in analysis and is therefore less reliable than measurement

of the plasma viscosity. The ESR is affected by age, sex, menstrual cycle,

pregnancy and drugs (e.g. OCP, steroids).

Sample: peripheral blood EDTA; the sample should be analysed in the

laboratory within 4h.

Haematological investigations

Haematinic assays

Measurement of the serum B₁₂ and red cell folate are necessary in the

investigation of macrocytic anaemia, and serum ferritin in the investigation

of microcytic anaemia in order to assess body stores of the relevant

haematinic(s). Serum folate levels are an unreliable measurement of body

stores of folate. The serum ferritin may be elevated as an acute phase

protein in patients with underlying neoplasia or inflammatory disease (e.g.

rheumatoid arthritis) and may give an erroneously normal level in an iron

deficient patient.

Sample: clotted blood sample and peripheral blood EDTA.

Haemoglobin electrophoresis

This test is performed in the diagnosis of abnormal haemoglobin produc-

tion (haemoglobinopathies or thalassaemia). It is usually performed on

cellulose acetate at alkaline pH (8.9) but may be performed on citrate agar

gel at acid pH

(6.0) to detect certain haemoglobins more clearly.

Haemoglobin electrophoresis has been largely replaced by HPLC analysis.

Sample: peripheral blood EDTA.

Haptoglobin

The serum haptoglobin should be measured in patients with suspected

intravascular haemolysis and is frequently reduced in patients with

extravascular haemolysis. It should generally be accompanied by estima-

tion of the serum methaemalbumin, free plasma haemoglobin and urinary

haemosiderin.

Sample: clotted blood.

633

Schumm’s test

This spectrophotometric test for methaemalbumin (which has a distinc-

tive absorption band at 558nm) should be measured in patients with sus-

pected intravascular haemolysis and may be abnormal in patients with

significant extravascular (generally splenic) haemolysis. It should generally

be accompanied by estimation of the serum haptoglobin level, free plasma

haemoglobin and urinary haemosiderin.

Sample: heparinised blood or clotted blood.

Kleihauer test

The Kleihauer test which exploits the resistance of fetal red cells to acid

elution should be performed on all Rh(D) negative women who deliver a

Rh(D) positive infant. Fetal cells appear as darkly staining cells against a

background of ghosts. An estimate of the required dose of anti-D can be

made from the number of fetal cells in a low power field.

Sample: maternal peripheral blood EDTA.

Reticulocytes

Definition

2 Immature RBCs formed in marrow and found in normal peripheral

blood.

2 Represent an intermediate maturation stage in marrow between the

nucleated red cell and the mature red cell.

2 No nucleus but retain some nucleic acid.

Detection and measurement

2 Demonstrated by staining with supravital dye for the nucleic acid.

2 Appear on blood film as larger than mature RBCs with fine lacy blue

staining strands or dots.

2 Some modern automated blood counters using laser technology can

measure levels of reticulocytes directly.

2 Usually expressed as a % of total red cells e.g. 5%, though absolute

numbers can be derived from this and total red cell count.

Causes of 4 reticulocyte counts

Marrow stimulation due to

2 Bleeding.

2 Haemolysis.

2 Response to oral Fe therapy.

2 Infection.

2 Inflammation.

2 Polycythaemia (any cause).

2 Myeloproliferative disorders.

2 Marrow recovery following chemotherapy or radiotherapy.

2 Erythropoietin administration.

634

Causes of 5 reticulocyte counts

Marrow infiltration due to

2 Leukaemia.

2 Myeloma.

2 Lymphoma.

2 Other malignancy.

Marrow underactivity (hypoplasia) due to

2 Fe, folate or B₁₂ deficiency. Note: return of reticulocytes is earliest sign

of response to replacement therapy.

2 Immediately post-chemotherapy or radiotherapy.

2 Autoimmune disease especially rheumatoid arthritis.

2 Malnutrition.

2 Uraemia.

2 Drugs.

Haematological investigations

2 Aplastic anaemia (see p122).

2 Red cell aplasia (see p126).

Urinary haemosiderin

Usage

The most widely used and reliable test for detection of chronic intravas-

cular haemolysis.

Principle

Free Hb is released into the plasma during intravascular haemolysis. The

haemoglobin binding proteins become saturated resulting in passage of

haem-containing compounds into the urinary tract of which haemosiderin

is the most readily detectable.

Method

1. A clean catch sample of urine is obtained from the patient.

2. Sample is spun down in a cytocentrifuge to obtain a cytospin prepara-

tion of urothelial cells.

3. Staining and rinsing with Perl’s reagent (Prussian blue) is performed on

the glass slides.

4. Examine under oil-immersion lens of microscope.

5. Haemosiderin stains as blue dots within urothelial cells.

6. Ignore all excess stain, staining outside cells or in debris all of which are

common.

7. True positive is only when clear detection within urothelial squames is

seen.

Cautions

An iron-staining +ve control sample should be run alongside test case to

ensure stain has worked satisfactorily. Haemosiderinuria may not be

635

detected for up to 72 hours after the initial onset of intravascular haemol-

ysis so the test may miss haemolysis of very recent onset - repeat test in

3-7 days if -ve. Conversely, haemosiderinuria may persist for some time

after a haemolytic process has stopped. Repeat in 7 days should confirm.

Causes of haemosiderinuria

Common causes

Red cell enzymopathies e.g. G6PD and PK

deficiency but only during haemolytic episodes

Mycoplasma pneumonia with anti-I cold haemag-

glutinin

Sepsis

Malaria

Cold haemagglutinin disease

TTP/HUS

Severe extravascular haemolysis (may cause

intravascular haemolysis)

Rarer causes

PNH

Prosthetic heart valves

Red cell incompatible transfusion reactions

Unstable haemoglobins

March haemoglobinuria

Ham’s test

Usage

Diagnostic test for paroxysmal nocturnal haemoglobinuria (PNH). Now

replaced by immunophenotyping methods.

Principle

2 Abnormal sensitivity of RBCs from patients with PNH to the

haemolytic action of complement.

2 Complement is activated by acidification of patient’s serum to pH of

6.2 which induces lysis of PNH red cells but not normal controls.

Specificity: high—similar reaction is produced only in the rare syndrome

HEMPAS (a form of congenital dyserythropoietic anaemia type II) which

should be easily distinguished morphologically.

Sensitivity: low—as the reaction is crucially dependent on the

concentration of magnesium in the serum.

It appears to be a technically difficult test in most laboratories. Patients

with only a low % of PNH cells may be missed at an early stage of the

disease. Markedly abnormal PNH cells are usually picked up in ~75% of

patients. Less abnormal cells are detected in only ~25% of patients.

Alternative tests

2 Sucrose lysis —an alternative method of complement activation is by

mixing serum with a low ionic strength solution such as sucrose.

Sensitivity of this test is high but specificity is low —i.e. the opposite

of the Ham’s test.

2 Immunophenotypic detection of the deficiency of the PIG transmem-

brane protein anchors in PNH cells is becoming a more widely used

636

alternative cf. PNH section p124. Monoclonal antibodies to CD59 or

CD55 (DAF) are used in flow cytometric analysis. Major advantage is

that test can be performed on neutrophils and platelets in PB which

are more numerous than the PNH red cells.

Immunophenotyping

Definition

Identification of cell surface proteins by reactivity with monoclonal anti-

bodies of known specificity.

Uses

2 Aids diagnosis and classification of haematological malignancy.

Haematological investigations

2 Assess cellular clonality.

2 Identify prognostic groups.

2 Monitor minimal residual disease (MRD).

Terminology and methodology

Cell surface proteins are denoted according to their cluster differentiation

(CD) number. These are allocated after international workshops define

individual cell surface proteins by reactivity to monoclonal antibodies.

Most cells will express many such proteins and pattern of expression

allows cellular characterisation.

Monoclonal antibodies (MoAbs) are derived from single B-lymphocyte

cell lines and have identical antigen binding domains known as idiotypes. It

is easy to generate large quantities of MoAbs for diagnostic use.

2 Cell populations from e.g. PB or BM samples are incubated with a

panel of MoAbs e.g. anti-CD4, anti-CD34 which are directly or indi-

rectly bound to a fluorescent marker antibody e.g. FITC.

2 Sample is passed through a fluorescence-activated cell sorter (FACS)

machine.

2 FACS instruments assign cells to a graphical plot by virtue of cell size

and granularity detected as forward and side light scatter by the laser.

2 Allows subpopulations of cells e.g. mononuclear cells in blood sample

to be selected.

2 The reactivity of this cell subpopulation to the MoAb panel can then

be determined by fluorescence for each MoAb.

2 A typical result for a CD4 T-lymphocyte population is shown:

CD3, CD4 +ve; CD8, CD13, CD34, CD19 -ve.

Common diagnostic profiles

AML

CD13+, CD33+, ± CD 34, ± CD14 +ve.

cALL

CD10 and TdT +ve.

T-ALL

CD3, CD7, TdT +ve.

637

B-ALL

CD10, CD19, surface Ig +ve.

CLL

CD5, CD19, CD23, weak surface Ig +ve.

Clonality assessment

Particularly useful in determining whether there is a monoclonal B cell or

plasma cell population.

Monoclonal B cells from e.g. NHL will have surface expression of or

light chains but not both.

Polyclonal B cells from e.g. patient with infectious mononucleosis will

have both and expression.

Cytogenetics

Acquired somatic chromosomal abnormalities are common in haemato-

logical malignancies. Determination of patterns of cytogenetic abnormali-

ties is known as karyotyping.

Uses

2 Aid diagnosis and classification of haematological malignancy.

2 Assess clonality.

2 Identify prognostic groups.

2 Monitor minimal residual disease (MRD).

2 Determine engraftment and chimerism post-allogeneic transplant.

Terminology

2 Normal somatic cell has 46 chromosomes; 22 pairs and XX or XY.

2 Numbered 1-22 in decreasing size order.

2 2 arms meet at centromere —short arm denoted p, long arm denoted q.

2 Usually only visible during condensation at metaphase.

2 Stimulants and cell culture used —colchicine to arrest cells in

metaphase.

2 Stained to identify regions and bands e.g. p1, q3.

Common abnormalities

2 Whole chromosome gain e.g. trisomy 8 (+8).

2 Whole chromosome loss e.g. monosomy 7 (-7).

2 Partial gain e.g. 9q+ or partial loss e.g. 5q- .

2 Translocation—material repositioned to another chromosome; usually

reciprocal e.g. t(9;22)—the Philadelphia translocation.

2 Inversion—part of chromosome runs in opposite direction e.g. inv(16)

in M4Eo.

2 Many translocations involve point mutations known as oncogenes, e.g.

BCR, ras, myc, bcl-2.

Molecular cytogenetics

2 Molecular revolution is further refining the specific abnormalities in the

genesis of haematological malignancies.

2 Techniques such as FISH (fluorescence in situ hybridisation) and PCR

(polymerase chain reaction) can detect tiny amounts of abnormal

638

genes.

2 BCR-ABL probes are now used in diagnosis and monitoring of treat-

ment response in CML.

2 IgH and T-cell receptor (TCR) genes are useful in determining clonality

of suspected B and T cell tumours respectively.

2 Specific probes may be used in diagnosis and monitoring of subtypes of

AML e.g. PML-RARA in AML M3.

Haematological investigations

Common karyotypic abnormalities

CML

t(9;22)

Philadelphia chromosome translocation creates BCR-ABL

chimeric gene.

AML

t(8;21)

AML M2, involves AML-ETO genes—has better prognosis.

t(15;17)

AML M3 involves PML-RARA genes—has better prognosis.

inv(16)

AML M4Eo—has better prognosis.

–5, -7

Complex abnormalities have poor prognosis.

MDS

-7, +8, +11

Poor prognosis.

5q- syndrome

Associated with refractory anaemia and better prognosis.

MPD

20q- and +8

Common associations.

ALL

t(9;22)

Philadelphia translocation, poor prognosis.

t(4;11)

Poor prognosis.

Hyperdiploidy

Increase in total chromosome number—good prognosis.

Hypodiploidy

Decrease in total chromosome number—bad prognosis.

T-ALL

t(1;14)

Involves tal-1 oncogene.

B-ALL and Burkitt’s lymphoma

t(8;14)

Involves myc and IgH genes, poor prognosis.

CLL

+12, t(11;14)

ATLL

14q11

639

NHL

t(14;18)

Follicular lymphoma, involves bcl-2 oncogene.

t(11;14)

Small cell lymphocytic lymphoma, involves bcl-1 oncogene.

t(8;14)

Burkitt’s lymphoma, involves myc and IgH genes.

HLA typing

HLA (human leucocyte antigen) system or MHC (major histocompatibility

complex) is the name given to the highly polymorphic gene cluster region

on chromosome 6 which codes for cell surface proteins involved in

immune recognition.

The gene complex is subdivided into 2 regions

Class 1

The A, B and C loci.

These proteins are found on most nucleated cells and interact

with CD8+ T lymphocytes.

Class 2

Comprising of DR, DP, DQ loci present only on B lymphocytes,

monocytes, macrophages and activated T lymphocytes. Interact

with CD4+ T lymphocytes.

2 Class 1 and 2 genes are closely linked so one set of gene loci is usually

inherited from each parent though there is a small amount of cross-

over.

2 There is ~1:4 chance of 2 siblings being HLA identical.

2 There are other histocompatibility loci apart from the HLA system but

these appear less important generally except during HLA matched

stem cell transplantation when even differences in these minor systems

may cause GvHD.

Typing methods

Class 1 and 2 antigens were originally defined by serological reactivity with

maternal antisera containing pregnancy-induced HLA antibodies. Many

problems with technique and too insensitive to detect many polymor-

phisms. Molecular techniques are increasingly employed such as SSP.

Molecular characterisation is detecting vast Class 2 polymorphism.

Importance of HLA typing

2 Matching donor/recipient pairs for renal, cardiac and marrow stem cell

transplantation.

2 Degree of matching more critical for stem cell than solid organ trans-

plants.

2 Sibling HLA matched stem cell transplantation is now treatment of

choice for many malignancies.

640

2 Unrelated donor stem cell transplants are increasingly performed but

outcome is poorer due to HLA disparity. As molecular matching

advances, improved accuracy will enable closer matches to be found

and results should improve.

Functional tests of donor/recipient compatibility

2 MLC (mixed lymphocyte culture)—now rarely used.

2 CTLp (cytotoxic T lymphocyte precursor assays)—determine the fre-

quency of cytotoxic T lymphocytes in the donor directed against the

recipient—provides an assessment of GvHD occurring.

HLA related transfusion issues

2 HLA on WBC and platelets may cause immunisation in recipients of

blood and platelet transfusions.

2 May cause refractoriness and/or febrile reactions to platelet transfu-

sions.

Using the blood transfusion laboratory

Requests for compatibility testing or blood grouping

Transfusion samples and forms must be clearly identified and clerical

details match exactly. The form and sample should be signed by the

person taking the sample as vouching for the identity of the potential

recipient.

2 3 points of identification are required: patient’s full name, date of birth,

hospital number.

2 Requests must be legible and clearly labelled with the name of the

responsible clinician.

2 Indication for transfusion should be specified.

2 Indicate time for planned surgery.

2 For major elective surgery where transfusion is usual with the proce-

dure the laboratory should receive a G&S sample in advance (7

days)—allows identification of alloantibodies - the lab will arrange for

appropriate blood units to be available.

2 In genuine haemorrhagic emergencies ABO ± Rh (D) group compat-

ible blood can be given without matching as the slight risk of this action

far outweighs the immediate risk of death from exsanguination.

2 Unmatched O Rh (D) -ve blood should only be used in extreme emer-

gency when the patient’s blood group is unknown or, if known, blood

of the same ABO and Rh type is unavailable. Emergency grouping can

be conducted in ~15 min; full laboratory compatibility testing can be

completed in ≤1h. Can be ~20 min in emergencies (sending G&S

sample to laboratory may save valuable time).

Hazards

2 Most serious is ABO mismatch—almost invariably arises through cler-

ical errors (at time of sampling) or when blood given to patient.

2 The blood transfusion laboratory groups the blood sample received

and assumes the sample has been correctly identified at the time of

collection.

Issue and administration of blood and blood products

1. Units of blood are labelled as being matched for an individual patient.

2. Before administering the patient/recipient identity must be checked

(see 3 point identity above).

3. Label details are rechecked by trained nursing staff at the bedside

644

immediately prior to the transfusion any discrepancies identified must be

referred urgently to the blood bank and the clinician responsible for the

patient - transfusion of that unit cannot proceed until any ambiguity about

identity has been resolved.

4. Unit of blood must be given within its expiry date.

5. Check for damage to the pack, discolouration of the contained red

cells, or evidence of haemolysis.

6. Administration of the unit must commence <30 min after leaving the

blood bank and be completed within 4h of commencing infusion.

7. Administration of blood products must be recorded in the case notes.

8. The unique number of given RBCs or blood products should be

entered in the notes.

9. If given warm, ensure a safe approved warming procedure is used.

Maximum surgical blood ordering

schedule (MSBOS)

A system of tailoring blood requirements to particular elective surgical

procedures, including—importantly—procedures which do not usually

require blood cover.

The ABO group and Rh (D) type of the patient is determined on dupli-

cate samples, and the serum screened for significant RBC (‘atypical’)

antibodies. If there are no antibodies, the serum is kept available

(‘saved’) for a determined period (usually a week)—this is the ‘Group,

Screen and Save’ (G&S) procedure.

If there are no atypical antibodies, and the planned surgery is likely to

need peri-operative transfusion, the required number of red cell units

are matched by routine tests, labelled and set aside in an accessible

refrigerator. Storage conditions must meet certain standards (contin-

uous recording of appropriate temperature, alarms, etc).

If more blood is required than anticipated, extra units must be readily

available. If the need is urgent, suitable arrangements—such as rapid

matching (using the ‘saved’ serum) and despatch procedures—must

enable the timely supply of blood.

If there are atypical antibodies, which may occur in up to 10% patients,

their specificity must be determined and, if clinically significant, suffi-

cient (extra) red cell units lacking the relevant antigen provided and

matched by detailed techniques. (These are often referred to as ‘phe-

notyped red cells’.)

If there is no ‘MSBOS’ more units must be matched than are usually

required for transfusion, in order to give rapid access if extra blood is

needed. Matched ‘bespoke’ blood is therefore unavailable for other

patients for the 2-3 days set aside.

A good MSBOS gives better access to blood stocks and enables more

efficient use, in particular of O Rh(D) -ve blood. There is no good

reason for regarding O Rh(D) -ve blood as a ‘universal’ donation type.

It can be antigenic; and it is a precious resource, being available from

<8% of the population.

The surgical team must be confident in the system, and the blood bank

staff committed to ‘minimal barriers’. The cross-match : transfusion

ratio of a blood bank may well become lower than 2 (i.e. overall <2

646

units matched for every unit transfused) which is an indication of effi-

cient practices. It could even be nearer to 1 than to 2.

MSBOS schedules will vary between hospitals—depending on demo-

graphic factors, general layout, access to the blood bank refrigerators,

types of surgery etc.

Transfusion of red blood cells

Used acutely in the management of ‘significant’ blood loss following

trauma or surgery or electively to manage anaemia which is not correctable

by other means, e.g. correction of iron deficiency is by giving iron supple-

ments, not by blood transfusion.

Indications for red cell transfusion

Blood loss

Massive/acute

Bone marrow failure

Post-chemotherapy, leukaemias, etc.

Supportive therapy with concentrated cells

Inherited RBC disorders Homozygous b-thalassaemia

Red cell aplasia, etc.

Hb SS (some circumstances)

Acquired RBC disorders Myelofibrosis

Myelodysplasia

Some chronic disorder anaemias

Selected use in renal failure

Neonatal &

Haemolytic disease of the newborn

exchange transfusions

Meningococcal septicaemia

Falciparum malaria

RBC transfusion is contraindicated in chronic iron deficiency anaemia; iron

supplements will raise the haemoglobin in a safer and less costly manner.

If patients are suffering marked anaemic symptoms then use of 2 units of

concentrated cells will deal with this problem pending a response to iron.

In severe megaloblastic anaemias RBCs should not be used; a rapid

response to haematinics is expected. Transfusion can precipitate severe

cardiac failure.

● Red cells have a shelf life of 35 days at 4°C and are supplied as con-

centrated red cells with PCV between 0.55 and 0.75. Most units in the

UK are supplied in ‘optimal additive solution’, SAG-M*, which allows

removal of all the plasma for preparation of other blood components

648

and results in a less viscous product. The volume of a unit of concen-

trated cells is 280 ± 20mL. With adequate venous access it will flow

easily through a standard blood giving set.

● In acute blood loss concentrated RBCs are adequate (whole blood not

currently available in practice). Concentrated RBCs allow maintenance

of oxygen delivery, and are often infused at the same time as other

colloids.

● All blood in UK is leucodepleted at source.

● Irradiated RBCs are indicated to stop transfusion transmitted graft

versus host disease e.g. following total body irradiation, bone marrow

allografting or therapy with purine analogues (fludarabine, 2-CDA).

● Frozen RBCs similarly have plasma and some other constituents

removed. They are expensive to process, store and handle; they must

Blood transfusion

be used within 24h after thawing. Clinical usage is restricted to patients

with extremely rare blood groups or with highly problematic blood

group alloantibodies.

In autoimmune haemolytic disorders transfusion can be lifesaving as a

short term support pending a response to immunosuppression. As a

general rule, most otherwise fit adult patients with chronic anaemia will

tolerate Hb levels around

9.0-10.0g/dL without major problems.

Transfusion therapy is more likely to be needed below this level

Transfusion procedure

Although fussy, strictly laid down hospital protocols must be followed for

administration of blood and blood products. Errors carry the potential

for major morbidity or fatality.

Identity of label on each matched unit must match EXACTLY with the

patient’s identity.

The ABO and Rh groups on the blood pack and the compatibility

report must correspond as must the donor number on the pack and

compatibility form.

Units must show no sign of leakage or damage and be used within

their expiry period.

The prescription of blood must be made by a registered medical prac-

titioner and details of the product’s administration must be recorded

in the case record.

An IV line should be established and flushed with 0.9% saline solution

before the pack is opened.

No drug or other infusion solution should be added to any blood

component.

Monitoring of the patient involves recording temperature, pulse and

blood pressure before transfusion, every 15 min for the first hour and

hourly until transfusion is finished.

Adverse events should be recorded meticulously.

Major reactions require immediate cessation of the transfusion

and instigation of a full investigative protocol

(see Emergencies:

Transfusion reactions, p 502-504).

10.

Minor febrile reactions are not uncommon, their occurrence should

649

be recorded, simple measures such as slowing the rate of infusion or

administration of an antihistamine may deal with the problem; if not

transfusion of the specific unit should be stopped.

11.

An RBC pack should be given within 30 min of removal from the

blood bank; the target infusion time for an individual unit should be

≤4h.

Platelet transfusion

May be given as prophylaxis against bleeding e.g. in patients undergoing

intensive chemotherapy or to arrest overt haemorrhage e.g. in DIC.

Platelets may be required to cover surgery and dentistry.

Indications for platelet transfusion

5 production due to

Acute and chronic leukaemias

BM failure/infiltration

Myelodysplasia

Myeloproliferative disorders and myelofibrosis

Marrow infiltration with other malignant tumours

Post-chemotherapy or TBI

Aplastic anaemia

4 platelet destruction

Hypersplenism 2° splenic infiltration or portal

in peripheral circulation

hypertension

Consumptive coagulopathies e.g. DIC

Avoid in TTP (p530)

Acute and chronic ITP (in emergencies only)

Alloimmune thrombocytopenias e.g. PTP and

perinatal thrombocytopenia (need to be HPA typed)

Sepsis

Drug induced

Platelet function

Aspirin and NSAIDs

abnormalities

Myelodysplasia

Rare congenital disorders e.g. Bernard-Soulier

Dilutional

Massive blood transfusion—in practice not usually

required unless some other haemostatic

abnormality (e.g. consumption)

Cardiac bypass

Dilution and damage to platelets in extracorporeal

circulation.

Indications for irradiated platelets

Recommended in immunosuppressed patients and haemopoietic stem cell

transplant recipients to prevent transfusion-associated GvHD.

Indications for CMV negative platelets

650

1. Where CMV transmission may cause disease.

2. BM and PBSCT recipients who are CMV -ve.

3. Solid organ transplant recipients who are CMV -ve.

4. In utero and neonatal transfusion.

5. Aplastic anaemia.

6. GvHD.

7. Primary immunodeficiency syndromes.

Fresh frozen plasma (FFP)

FFP is prepared by removing plasma from a single donor unit by centrifu-

gation within 8h of donation, snap frozen at -80°C and maintained deep

frozen until use. Serological testing excludes HBV, HCV, HIV and the

product is ABO and Rh (D) grouped. Group AB Rh (D) -ve FFP is suitable

for all groups since it lacks anti-A and B, and will not sensitise Rh(D) -ve

patients to Rh(D).

Factor

VII

Range (u/dL)

53-121

41-140

32-102

61-150

Median

82.5

92.0

61.0

90.5

Indications for use

2 Warfarin overdose—see p522.

2 DIC (common causes include obstetric haemorrhage, postoperative

complications, following trauma, severe infection, septicaemic shock,

acute blood loss—see p512).

2 Liver disease and biopsy.

2 Massive blood transfusion—use of prophylactic FFP (1-2 units FFP/10

units of blood) and platelets is not supported by documented clinical

benefit. Give as dictated by coagulation tests.

2 Isolated coagulation deficiencies where no specific concentrate is

readily available.

2 Treatment of thrombotic thrombocytopenia purpura/haemolytic

uraemic syndrome (see p468, 530).

2 Non-specific haemostatic failure in a bleeding patient e.g. following

surgery, in intensive care with disturbed coagulation tests where no

definite diagnosis is made.

Instructions for use

The average volume of 1 unit is 220-250mL.

Half-life of infused coagulation factors in FFP

<12h

Factors V, VII, VIII, and protein C

>12 <24h

Factor IX and protein S

>24 <48h

Factor X

652

>48h

Fibrinogen, factors XI, XII, XIII, ATIII

2 Defrost the bag in a waterbath (5 min) or at room temperature (20

min).

2 Give as soon as possible and at least within the hour through a filter

needle.

2 Must be group compatible; if blood group not known, give ‘all groups’.

2 If recipient Rh (D) -ve 3 of child bearing age given Rh (D) +ve plasma

give anti-D (250u).

2 Dose 10-15mL/kg body wt (usual starting dose in an adult = 2-4 units

depending on the PT).

Cryoprecipitate

2 Prepared by slow thawing of FFP at 4-6°C. Fresh plasma taken from a

single donor is snap frozen then thawed at 4°C and a cryoprecipitate

forms.

2 Precipitate formed is cryoprecipitate which is then stored at -30°C.

2 Rich in factors VIII, XIII, fibrinogen and von Willebrand factor.

Per unit (bag):

- Factor VIII and vWF ~80-100iu.

- Fibrinogen ~250mg.

- Factor XIII and fibronectin.

- Does not contain other coagulation factors.

- May contain anti-A and anti-B blood group antibodies.

2 Formerly (but no longer) used for management of bleeding in factor

VIII deficiency and von Willebrand’s disease.

2 Main clinical use for cryoprecipitate is as additional support for the

clotting defects induced by massive transfusion and DIC.

2 All donations are screened for HIV, HBV and HCV.

Indications for use

2 Haemophilia A and vWD not treatment of choice where virally inacti-

vated concentrates are available. May still have a role in acquired vWD

when purified factor VIII products are ineffective.

2 Hypo/dysfibrinogenaemia e.g. in DIC and liver disease/liver transplanta-

tion is used to treat and prevent bleeding.

2 Of no proven value as empirical treatment in post-op or uraemic

bleeding.

Instructions for use

2 Keep frozen until required.

2 Thaw at room temperature/37°C (takes 5-10 min); use immediately.

2 ABO compatibility not required.

2 Give through filter needle.

2 Dose depends on the indications for use and desired increment

- Hypofibrinogenaemia:

severe 2-4 bags/10kg body wt

less severe 1-2 bags.

2 Aim to keep fibrinogen >1g/L.

2 Factor VIII minimum adult dose 5 bags.

Complications

654

Viral transmission —rare but reported. Reactions, fever, chills, allergic

reactions.

Intravenous immunoglobulin

Used as antibody replacement in 1° and 2° antibody deficiency states, and

as immune modulator.

Preparations of intravenous IgG (IVIg)

2 Contain predominantly IgG (with small amounts of IgA and IgM).

2 Prepared from large pool of normal donors e.g. >1000.

2 Contain all subclasses of IgG encountered in normal population.

Uses

Antibody replacement

1° immune deficiency

2° immune deficiency

Transient hypogammaglobulinaemia

CLL

of infancy

Non-Hodgkin’s lymphoma

Common variable immune deficiency

Multiple myeloma

Sex-linked hypogammaglobulinaemia

Post-BMT

Late-onset hypogammaglobulinaemia

Hypogammaglobulinaemia + thymoma

Immune modulation

Autoimmune diseases

Antiviral activity

ITP

Prophylaxis/treatment of CMV

Autoimmune haemolytic anaemia

in BMT patients

Autoimmune neutropenia

B19-induced red cell aplasia

Red cell aplasia

Haemophagocytic syndromes (viral)

Coagulation factor inhibitors

Post-transfusion purpura (PTP)

Neonatal platelet alloimmunisation

Thrombocytopenia in pregnancy

Mechanisms of action

Not fully understood: natural anti-idiotypic antibodies suppress antibody

production in patient; F_c receptor blockade on macrophages (thereby

blocking RE function) and T/B lymphocytes (inhibits autoantibody produc-

tion); suppression of production of inflammatory mediators (e.g. TNF-a,

656

IL-1) produced by macrophages.

Administration

Usual dose 0.4g/kg/d ¥ 5d (e.g. ITP, etc) or 0.2-0.4g/d ¥ 1 day monthly

(CLL, myeloma, etc). Check TPR and BP pre-infusion. With first infusion

check TPR and BP ¹⁄2 hourly for the first hour only. Side effects are more

likely at the start of an infusion and in the first hour. (See pack insert and

BNF for details.)

Complications

2 Fevers, chills.

2 Backache.

2 Myalgic symptoms.

2 Flushing.

Autologous blood transfusion

Allows patient to be transfused with his/her own red cells, avoiding

(some) problems associated with transfusion of allogeneic (i.e. donor)

blood, e.g. immunological incompatibility, risks of transmission of infec-

tion, and transfusion reactions. Useful for patients who wish not to receive

allogeneic blood or who have irregular antibodies that make cross-

matching difficult. Can be pre-deposit or intraoperative red cell salvage.

Pre-deposit system

Involves collection of 2-4 units of blood: the first unit is collected ~2

weeks before the operation and the second is taken 7-10d prior to

surgery. Iron replacement usually given. Some pre-deposit programmes

use Epo (enables a larger number of units to be collected but expensive).

Advantages

2 Can store RBCs up to 5 weeks at 4°C.

2 May donate 2-4 units pre-op.

2 Avoids many problems associated with allogeneic blood transfusion.

Disadvantages

2 Generally requires Hb ≥11.0g/dL.

2 Patients must be ‘fit’ for pre-donation programme (e.g. to donate

450mL 2-4

¥ pre-op) and live near transfusion centre.

2 Requires close coordination between surgeon, patient and transfusion

lab and fixed date for surgery.

2 Little/no reduction in workload—blood must be treated in same way

as regular donor units (including microbiological screening, grouping,

compatibility testing, etc).

2 Cost is high.

2 Transfusion should be to donor only.

2 Bacterial contamination of blood units may still occur.

2 Patient may still require additional allogeneic units.

2 Blood may be wasted if operation cancelled.

2 Patients with epilepsy excluded (risk of seizures).

Intraoperative blood salvage

Allows blood lost during surgery to be reinfused into patients using

suction catheters and filtration systems. Expensive and not widely used in

the UK at present. Intraoperative blood salvage useful in cardiovascular

658

surgery but may be used for almost any surgical procedure (provided no

faecal contamination or risk of tumour dissemination).

1. Single use disposable canisters (e.g. Solcotrans^™) where the patient is

heparinised and anticoagulated blood is collected into ACD anticoagu-

lant in the canister. Red cells reinfused after filtration through a

microaggregate filter.

2. Automated or semi-automated salvage (e.g. Hemonetics Cell Saver^™).

Blood is collected, washed centrifugally, filtered and red cells held for

reinfusion.

Other physical methods—pre-operative haemodilution

Involves reducing the Hb concentration prior to surgery. Reduces blood

viscosity and red cell loss (through reduced haematocrit). Provides a bank

of freshly collected autologous whole blood for return later.

Jehovah’s Witnesses

2 Religious sect numbering 120,000 in the UK.

2 Pose ethical and management difficulties due to their refusal of blood

transfusion, derived from a literal interpretation of a number of biblical

passages (Acts 15:28-29).

2 Jehovah’s Witnesses still die during both elective and emergency surgery

due to their beliefs.

Elective surgery—discuss

1. Risks of surgery and the specific risk of refusing blood.

2. Extent of religious belief (preferably alone to prevent any external

pressure).

3. What blood derived products they personally are willing to accept e.g.

albumin, FFP, platelets, etc?

If the surgeon agrees to an operation, communication then becomes para-

mount and the Jehovah’s Witness should be referred to both an anaesthetist

and haematologist—preferably when the patient is placed on the waiting list

to allow time for any optimisation and for further counselling with their family.

Pre-operative considerations

2 Timing (e.g. liver transplantation before clotting function deteriorates).

2 Autologous blood transfusion—not permitted but may be acceptable

to some.

2 Morning list —to allow post-op observations during ‘office hours’.

2 Admission to ITU for invasive monitoring if required.

2 Stop anticoagulants and NSAIDs.

2 Optimise Hb —nutrition, B₁₂, folate, Fe, Epo.

Operative considerations

2 Surgeon

Consultant

Positioning of patient—to prevent venous congestion

Tourniquets if possible

Speed

Meticulous haemostasis

2 Anaesthetist

Consultant

Regional blocks

Hypotensive anaesthesia

Hypothermia

660

Isovolaemic haemodilution - permitted as long as

blood remains linked to circulation

Hypervolaemic haemodilution

Intraoperative blood scavenging e.g. cellsavers

Blood substitutes (fluorocarbons)

Pharmacological methods to improve clotting e.g.

DDAVP, tranexamic acid, aprotinin

2 Post-operative

Observation for re-bleed—HDU, senior surgeon

considerations review

Optimise Hb —nutrition enteral or parenteral

feeding, B₁₂, folate, Fe, erythropoietin

Severe anaemia - IPPV to reduce oxygen demand

Reduce phlebotomy and use paediatric vials

Acid suppression to reduce GIT bleeding.

CancerBACUP

A major British cancer information and support charity; aims to provide

clear, accurate, up-to-date information as well as sensitive and confidential

support for patients and their families. Also provides assistance to health

care professionals with specific enquiries relating to patients in their care.

CancerBACUP services for patient’s and their families

2 A national freephone cancer information service (tel 0808 800 1234),

staffed by specialist oncology nurses.

2 Cancer counselling service offering people the chance to talk through

their concerns face to face (tel 0207 696 9003; fax 0207 696 9002)

2 CancerBACUP produces excellent written information e.g. booklets

on specific cancers, treatments and aspects of living with cancer and

fact sheets on specific chemotherapy drugs, hormonal therapies, brain

tumours and rare tumours. Available from CancerBACUP’s administra-

tion (tel 0207 696 9003).

CancerBACUP services for health professionals

Medical Advisory Committee Statements produced by an expert panel on

controversial or complex oncology issues including

2 Clinical trials.

2 Cancer screening—cervical, breast, prostate, colorectal and ovarian

cancer.

2 Breast cancer, the pill and hormone replacement therapy.

2 Information on

Support groups

Sources of help

2 Lists of booklets and factsheets.

Internet

CancerBACUP web site: www.cancerbacup.org.uk

664

Leukaemia Research Fund (LRF)

The LRF is one of the major UK based research charities in the field of

leukaemia and related conditions. It supports leukaemia research in major

academic institutions; work supported ranges from basic science relating

to the molecular genetics of leukaemogenesis to extensive case controlled

studies into epidemiology of leukaemia and related disorders.

In addition to funding major research it provides information booklets on

a range of (mainly) malignant blood disorders which are suitable for

patients, their relatives and carers and also appropriate for non-specialist

professional staff who become involved in specific aspects of the clinical

care of the patient with leukaemia or a related disorder.

The stated aim of the fund is to improve treatments, find cures and

prevent all forms of leukaemia and related cancers through a programme

of nationally funded, high calibre research activities.

Booklets are available on the acute and chronic leukaemias, lymphomas

including Hodgkin’s disease, myeloma and related disorders, myelodys-

plasia myeloproliferative disorders and aplastic anaemia. A revised series

of booklets was produced in 1997. Availability of such information on the

wards or in the clinic is vary helpful to patients and their carers.

Address for the Leukaemia Research Fund

43 Great Ormond Street, London WC1N 3JJ

Telephone 0207 405 0101

e-mail: info@leukaemia.research.org.uk

www.leukres.demon.co.uk/lrfhome.htm

666

NCRI Leukaemia Trials

Birmingham Clinical Trials Unit (BCTU)

For randomisation/entry of AML patients into MRC trials

(AML14, AMLHR and AML15 trials).

Contacts:

BCTU

Park Grange

1 Somerset Road

Edgbaston

Birmingham B15 2RR

tel

0121 687 2310

fax 0121 687 2313

bctu@bham.ac.uk or H.Travers@bham.ac.uk

M.Nixon@bham.ac.uk or N.H.Hilken@bham.ac.uk

www.bctu.bham.ac.uk

CTSU

For randomisation into: CLL4, CLL5, PT1, UKALL XII and

childhood ALL

CTSU

Harkness Building

Radcliffe Infirmary

Oxford OX2 6HE

tel

01865 240972

fax 01865 404849

Randomisation@ctsu.ox.ac.uk

www.ctsu.ox.ac.uk

Northern and Yorkshire Clinical Trials

668

and Research Unit

For randomisation in: myeloma IX

NYCTRU

17 Springfield Mount

University of Leeds

Leeds

LS2 9NG

Haematology on-line

There are many Internet resources available for haematology, including

organisations, journals, atlases, conference proceedings and newsgroups.

The main difficulty with Internet resources is that they change so fre-

quently and they are constantly being updated and outdated.

It would be impossible to list every known site, and we have provided only

URLs for those we think are of most value.

General websites

Bloodline

www.bloodline.net

BloodMed

www.bloodmed.com

Hematologic Diseases (CliniWeb: Oregon Health Sciences University)

www.ohsu.edu/cliniweb/C15/C15.378.html

Hematology Case Studies (UC Davis School of Medicine)

medocs.ucdavis.edu/IMD/420A/course.htm

International Medical News

www.internationalmedicalnews.com

Medical Matrix

www.medmatrix.org/Index.asp

Meducation

www.meducation.com/

Medweb

www.medweb.emory.edu/medweb

MRC Molecular Haematology Unit

www.imm.ox.ac.uk/groups/mrc_molhaem

National Library of Medicine

www.nlm.nih.gov

Oncolink

www.oncolink.com

Oxford Haemophilia Centre

www.medicine.ox.ac.uk/ohc/

Oxford Regional Blood Club

www.btinternet.com/~phm/BloodClub.html

672

Sickle Hut

www.sicklehut.com

The Hematology Site

www.geocities.com/HotSprings/5340/

Atlases

Atlas of Hematology

www.medic.bgu.ac.il/mirrors/pathy/Pictures/atoras.html

Haematology on-line

Atlas of Hematology (Nagoya)

pathy.med.nagoya-u.ac.jp/atlas/doc/atlas.html

Cells of the blood (University of Leicester: Department of Microbiology

and Immunology)

www-micro.msb.le.ac.uk/MBChB/bloodmap/Blood.html

Digital Image Study Sets (UC Davis School of Medicine)

medocs.ucdavis.edu/IMD/420A/dib

Hematology Image Atlas

www.hms.medweb.harvard.edu/HSHeme/AtlasTOC.htm

Introduction to Blood Morphology

www.hslib.washington.edu/courses/blood/intro.html

Journals and books

ASH Education Book

www.asheducationbook.org

Blood

www.bloodjournal.org/

Blood Cells, Molecules and Disease

www.scripps.edu/bcmd

British Journal of Haematology

www.blackwellpublishing.com/journals/bjh

British Medical Journal

bmj.bmjjournals.com

Cancer

caonline.amcancersoc.org

Haematologica

www.haematologica.it

Lancet

www.thelancet.com/

Nature

www.nature.com/

New England Journal of Medicine

content.nejm.org

673

Science

www.sciencemag.org

Societies and organisations

American Association of Blood Banks (AABB)

www.aabb.org

American Medical Association

www.ama-assn.org

American Society of Hematology

www.hematology.org/

Aplastic Anemia Foundation of America

www.medic.uth.tmc.edu/ptnt/00001045.htm

Bloodline

www.bloodline.net

British Blood Transfusion Society (BBTS)

www.bbts.org.uk

British Committee for Standards in Haematology

www.bcshguidelines.com

British Society for Haematology

www.b-s-h.org.uk

CancerBACUP

www.cancerbacup.org.uk/

European Bone Marrow Transplant Association

www.embt.org

Imperial Cancer Research Fund

www.cancerresearchuk.org

International Histiocytosis Organization

(Histiocytosis

Association

America)

www.histio.org

Leukemia Research Fund

dspace.dial.pipex.com/lrf-/

Leukemia Society of America

www.leukemia.org

Medical Research Council

www.mrc.ac.uk

National Blood Service

www.blood.co.uk

National Guidelines Clearinghouse

www.guidelines.gov

National Heart, Lung, and Blood Institute

www.nhlbi.nih.gov/

National Institutes of Health

674

www.nih.gov

NHS Centre for Reviews and Dissemination

www.york.ac.uk/inst/crd/

Royal College of Pathologists

www.rcpath.org

Haematology on-line

Royal College of Physicians

www.rcplondon.ac.uk

Royal Society of Medicine

www.roysocmed.ac.uk

Sickle Cell Information Centre Home

www.scinfo.org

Society for Hematopathology (Dartmouth College)

www.dartmouth.edu/~nlevy/wwwx.html

The Cochrane Library

www.update-software.com/cochrane/

UK NEQAS Schemes

www.ukneqas.org.uk

Wellcome Trust

www.wellcome.ac.uk/

World Federation of Hemophilia

www.wfh.org/

Guidelines and trials

cancerTrials (National Cancer Institute)

www.cancertrials.nci.nih.gov

Clinical practice guidelines: hematology (Canadian Medical Association)

www.cma.ca/cpgs/hema.htm

Clinical trials: hematology (CenterWatch)

www.centerwatch.com

Comprehensive Sickle Cell Center at Grady Health System

www.scinfo.org

National Guideline Clearinghouse (Agency for Health Care Policy and

Research (AHCPR))

www.guidelines.gov

675

Karnofsky performance status

Normal, no complaints; no evidence of disease

100%

Able to carry on normal activity; minor signs or symptoms of disease

90%

Normal activity with effort; some signs or symptoms of disease

80%

Cares for self; unable to carry on normal activity or to do active work

70%

Requires occasional assistance but is able to care for most of his/her needs

60%

Requires considerable assistance and frequent medical care

50%

Disabled; requires special care and assistance

40%

Severely disabled; hospitalisation is indicated although death not imminent

30%

Very sick; hospitalisation necessary

20%

Moribund; fatal processes progressing rapidly

10%

Dead

WHO/ECOG performance status

Fully active; able to carry on all pre-disease performance without restriction.

Restricted in physically strenuous activity, but ambulatory and able to carry out

work of a light or sedentary nature, e.g. light housework, office work.

Ambulatory and capable of all self-care but unable to carry out any work

activities; up and about more than 50% of waking hours.

Capable of only limited self care, confined to bed or chair more than 50% of

waking hours.

Completely disabled; cannot carry on any self care; totally confined to bed or

chair.

Oken, M.M. et al. (1982) Toxicity and response criteria of the Eastern Cooperative Oncology

678

Group Am J Clin Oncol, 5 649.

Normal ranges (adults)

Haematology

Haemoglobin

13.0-18.0g/dL

(9)

11.5-16.5g/dL

(3)

Haematocrit

0.40-0.52

(9)

0.36-0.47

(3)

RCC

4.5-6.5

¥ 10¹²/L

(9)

3.8-5.8

¥ 10¹²/L

(3)

MCV

77-95 fL

MCH

27.0-32.0pg

MCHC

32.0-36.0g/dL

WBC

4.0-11.0

¥ 10⁹/L

Neutrophils

2.0-7.5

¥ 10⁹/L

Lymphocytes

1.5-4.5

¥ 10⁹/L

Eosinophils

0.04-0.4

¥ 10⁹/L

Basophils

0.0-0.1

¥ 10⁹/L

Monocytes

0.2-0.8

¥ 10⁹/L

Platelets

150-400

¥ 10⁹/L

Reticulocytes

0.5-2.5% (or 50-100

¥ 10⁹/L)

ESR

2-12 mm/1st hour (Westergren)

Red cell mass

25-35mL/kg

(9)

20-30mL/kg

(3)

Serum B₁₂

150-700ng/L

Serum folate

2.0-11.0µg/L

Red cell folate

150-700µg/L

Serum ferritin

15-300µg/L (varies with sex and age)

14-200µg/L (premenopausal female)

INR

0.8-1.2

12.0-14.0s

APTT ratio

0.8-1.2

APTT

26.0-33.5s

Fibrinogen

2.0-4.0g/L

Thrombin time

± 3s of control

XDPs

<250µg/L

D-dimer

<500ng/mL

Factors II, V, VII, VIII, IX, X, XI, XII

50-150iu/dL

RiCoF

45-150iu/dL

vWF: Ag

50-150iu/dL

Protein C

80-135u/dL

Protein S

80-135u/dL

Antithrombin III

80-120u/dL

APCR

2.12-4.0

688

Bleeding time

3-9min

Normal ranges

Biochemistry and immunology

Serum urea

3.0-6.5mmol/L

11.5-16.5g/dL

Serum creatinine

60-125µmol/L

Serum sodium

135-145mmol/L

Serum potassium

3.5-5.0mmol/v

Serum albumin

32-50g/L

Serum bilirubin

<17µmol/L

Serum alk phos

100-300iu/L

Serum calcium

2.15-2.55mmol/L

Serum LDH

200-450iu/L

Serum phosphate

0.7-1.5mmol/L

Serum total protein

63-80g/L

Serum urate

0.18-0.42mmol/L

Serum g-GT

10-46iu/l

Serum iron

14-33µmol/L

(9)

11-28µmol/L

(3)

Serum TIBC

45-75µmol/L

Serum ALT

5-42iu/L

Serum AST

5-42iu/L

Serum free T4

9-24pmol/L

Serum TSH

0.35-5.5mU/L

Immunology

IgG

5.3-16.5g/L

IgA

0.8-4.0g/L

IgM

0.5-2.0g/L

Complement

0.89-2.09g/L

0.12-0.53g/L

C1 esterase

0.11-0.36g/L

CH₅₀

80-120%

C-reactive protein

<6mg/L

Serum b₂-microglobulin

1.2-2.4mg/L

CSF proteins

IgG

0.013-0.035g/l

Albumin

0.170-0.238g/L

Urine proteins

Total protein

<150mg/24h

689

Albumin (24h)

<20mg/24h

Paediatric normal ranges

Full blood count

Age

Hb (g/dL) MCV (fL) Neuts

Lymph

Platelets

Birth

14.9-23.7

100-125

2.7-14.4

2-7.3

150-450

2 weeks

13.4-19.8

88-110

1.5-5.4

2.8-9.1

170-500

2 months

9.4-13.0

84-98

0.7-4.8

3.3-10.3

210-650

6 months

10.0-13.0

73-84

1-6

3.3-11.5

210-560

1 year

10.1-13.0

70-82

1-8

3.4-10.5

200-550

2-6 years

11.5-13.8

72-87

1.5-8.5

1.8-8.4

210-490

6-12 years 11.1-14.7

76-90

1.5-8

1.5-5

170-450

Adult 9

12.1-16.6

77-92

1.5-6

1.5-4.5

180-430

Adult 3

12.1-15.1

77-94

1.5-6

1.5-4.5

180-430

Neuts, neutrophils; lymph, lymphocytes and platelets (all ¥ 10⁹/L)

Haemostasis

Parameter

Neonate

Adult level

Platelet count

150-400

¥ 10⁹/L

as adult

Prothrombin time

few sec longer than adult

up to 1 week

APTT

up to 25% increase

by 2-9 months

Thrombin time

as adult

Bleeding time

2-10 min

as adult

Fibrinogen

2.0-4.0g/L

as adult

Vit K factors

Factor II

30-50% adult level

up to 6 months

Factor VII

30-50% adult level

by 1 month

Factor IX

20-50% adult level

up to 6 months

Factor X

30-50% adult level

up to 6 months

Factor V

as adult

Factor VIII

Variable: 50-200% adult level

vW factor

usually raised (up to 3

¥ adult level)

Factor XI

20-50% adult level

6-12 months

Factor XII

20-50% adult level

3-6 months

Factor XIII

50-100% adult level

1 month

FDP/XDP

up to twice adult level

by 7 days

50-80% adult level

6-12 months

Protein C

30-50% adult level

up to 24 months

Protein S

30-50% adult level

3-6 months

690

Plasminogen

30-80% adult level

2 weeks

Index

5HT₃ antagonists 574

lineage infidelity 153

³²P therapy 252-3

molecular analysis 154

A-β-lipoproteinaemia 114

prognosis 157

ABO

prognostic factors 157

haemolytic disease of the newborn

relapse management 157

441

specific treatment 156-7

incompatibility 316-17

supportive treatment 155

abortion, recurrent 401

World Health Organisation

acanthocytosis 114

classification 151-2

hereditary 97

addresses 664-9

acquired

adenosine deaminase deficiency 408-9

conditions 114

adrenal disorders 48

-immune haemolytic syndromes 68,

adriamycin 594, 596, 620, 622, 624

(doxorubicin), BCNU (carmustine)

megaloblastic anaemia 64

cyclophosphamide,

neutrophil function disorders 464

melphalan (ABCM) 278, 620

-non-immune haemolytic

(doxorubicin), bleomycin,

syndromes 68, 69

vinblastine, dacarbazine

activated protein C resistance 396

(ABVD) 596, 602

acute lymphoblastic leukaemia

aggregants 370

158-63, 576

albumin 425

aetiology 158

alkalinisation 560

-allo and autografts 310

allergic reactions 585

clinical features 159

allogeneic transplants 336

cytogenetic analysis 159

allografts 337

emergency treatment 161

alloimmune thrombocytopenia,

immunological classification 158

neonatal 448-9

immunophenotyping 158

allopurinol 258, 560

incidence 158

amniotic fluid 442

investigations and diagnosis 159-60

amphotericin 330

minimal residual disease detection

amyloidosis (primary systemic) 32,

162

288-91

prognosis/prognostic factors 162,

anaemia 278, 456-7

163

aplastic 122-3

relapse management 163

autoimmune haemolytic 116-17

specific treatment 161-2

of chronic disorders 50-1

supportive treatment 161

congenital dyserythropoietic 450-1

acute myeloblastic leukaemia (AML)

dilutional 34

150-7

drug related 52

aetiology 150

drug-induced haemolytic 108

biphenotypic leukaemias 153

in endocrine disease 48

clinical features 154-5

in gastrointestinal disease 52

cytochemistry 151

haemolytic of the neonate 434

cytogenetic analysis 153-4

hereditary 130

diagnosis 150

iron deficiency 56-8

emergency treatment 155

in joint disease 50-1

immunophenotyping 152

large bowel 52

incidence 150

leucoerythroblastic 120

anaemia (continued)

antiplatelet antibodies 378, 380

in liver disease 54

antithrombin

megaloblastic 64

concentrate 398

microangiopathic haemolytic

III deficiency 397

(MAHA) 112, 438

antiviral

neonatal 430-1

prophylaxis 550

oesophageal 52

therapy 418

pancreas 52

apheresis 584

and peripheral blood film 44

aplasia

pernicious 60

acquired red cell 454-5

in pregnancy 34

congenital red cell 452-3

of prematurity 432

pure red cell 126

pure sideroblastic 228

aplastic crises 73

refractory 220, 486

argatroban 521

in renal disease 46

arthropathy, chronic 353

sickle cell 72

aspirin 244, 253, 378-9

small bowel 52

ataxia telangiectasia 410

unexplained 10-11

atypical organisms 556

anagrelide 244, 252

autohaemolysis test 98

analgesics 258, 538-9, 569, 585

autoimmune disorders 32, 582

simple non-opioid 538

azacytidine 76

aniline dyes 496

azo compounds 496

ankylostoma 495

Ann Arbor stating classification

(Cotswolds modification) 210,

213

antenatal diagnosis 355

anti-arrhythmics 585

B cells 408, 410

antibacterial prophylaxis 550

B lineage 158

antibiotics

babesiosis 96

intravenous 552-3

bacteriology 302, 544

prophylactic 569

basopenia 142

antibodies 69, 441

basophilia 142

antiplatelet 378, 380

BEAM (BCNU, etoposide, cytarabine

anticoagulation 402

(ara-C), melphalan) 610,

acquired 366-8

612-13

heparin 588-9

benzodiazepines 574, 585

lupus 400

beta blockers 585

oral 590

bilirubin 320

post-partum 404-5

biochemistry 302, 471, 544, 689

prophylactic 401, 588-9

bird-headed dwarfism 460

therapeutic 588

Birmingham Clinical Trials Unit 668

anti-D prophylaxis 390, 441

bisphosphonates 279

antidepressants 585

bleeding 51, 360-1, 588

antiemetics 574, 574-5

active 365

antiepileptics 585

disorders 344

antifungal

neonate 448-9

prophylaxis 550

prolonged after surgery 38-9

therapy 330-2

vWF-related 348-50

anti-infective therapy 230