Download Haematological changes in systemic disease

Table 28.1 Causes of anaemia of chronic
disorders.
Chronic inflammatory diseases
Infectious (e.g. pulmonary abscess,
tuberculosis, osteomyelitis, pneumonia,
bacterial endocarditis)
Non-infectious (e.g. rheumatoid arthritis,
systemic lupus erythematosus and other
connective tissue diseases, sarcoid, Crohn’s
disease, cirrhosis)
Malignant disease
(e.g. carcinoma, lymphoma, sarcoma, myeloma)
Table 28.2 Haematological abnormalities in malignant disease.
Haematological abnormality
Pancytopenia
Marrow hypoplasia
Myelodysplasia
Leucoerythroblastic
Megaloblastic
Tumour or treatment associated
Chemotherapy, radiotherapy
Chemotherapy, radiotherapy
Metastases in marrow
Folate deficiency
B12 deficiency (carcinoma of stomach)
Red cells
Anaemia of chronic disorders
Iron deficiency anaemia
Pure red cell aplasia
Immune haemolytic anaemia
Microangiopathic haemolytic anaemia
Polycythaemia
Most forms
Especially gastrointestinal, uterine
Thymoma
Lymphoma, ovary, other tumours
Mucin-secreting carcinoma
Kidney, liver, cerebellum, uterus
White cells
Neutrophil leucocytosis
Leukaemoid reaction
Eosinophilia
Monocytosis
Most forms
Disseminated tumours, those with necrosis
Hodgkin lymphoma, others
Various tumours
Platelets and coagulation
Thrombocytosis
Disseminated intravascular coagulation
Activation of fibrinolysis
Acquired inhibitors of coagulation
Paraprotein interfering with platelet function
Tumour cell procoagulants – tissue factor and cancer
procoagulant (activates factor X)
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Gastrointestinal tumours with bleeding, others
Mucin-secreting carcinoma, prostate
Prostate
Most forms
Lymphomas, myeloma
Especially ovarian, pancreas, brain, colon
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Table 28.3 Haematological abnormalities in
renal failure.
Anaemia
Reduced erythropoietin production
Aluminium excess in dialysis patients
Anaemia of chronic disorders
Iron deficiency
blood loss (e.g. dialysis, venesection, defective
platelet function)
Folate deficiency
chronic haemodialysis without replacement
therapy
Abnormal platelet function
Thrombocytopenia
Immune complex-mediated (e.g. systemic lupus
erythematosus, polyarteritis nodosa)
Some cases of acute nephritis and following
allograft
Haemolytic uraemic syndrome and thrombotic
thrombocytopenic purpura
Thrombosis
Some cases of the nephrotic syndrome
Polycythaemia
In renal allograft recipients
Rarely in renal cell carcinoma, cysts, arterial
disease
Table 28.4 Haematological abnormalities in
liver disease.
Liver failure ± obstructive jaundice ± portal
hypertension
Refractory anaemia– usually mildly macrocytic,
often with target cells; may be associated with:
Blood loss and iron deficiency
Alcohol (± ring sideroblastic change)
Folate deficiency
Haemolysis (e.g. Zieve’s syndrome, Wilson’s
disease, immune hypersplenism from portal
hypertension)
Bleeding tendency
Deficiency of vitamin K-dependent factors; also of
factor V and fibrinogen
Thrombocytopenia hypersplenism, immune
platelet function defects
Functional abnormalities of fibrinogen
Increased fibrinolysis
Portal hypertension – haemorrhage from varices
Viral hepatitis
Aplastic anaemia
Tumours
Polycythaemia
Neutrophil leucocytosis and leukaemoid reactions
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Table 28.5 Blood abnormalities associated with infections.
Haematological abnormality
Anaemia
Anaemia of chronic disorders
Aplastic anaemia
Transient red cell aplasia
Marrow fibrosis
Immune haemolytic anaemia
Direct red cell damage or microangiopathic
Hypersplenism
White cell changes
Neutrophil leucocytosis
Leukaemoid reactions
Eosinophilia
Monocytosis
Neutropenia
Lymphocytosis
Lymphopenia
Thrombocytopenia
Megakaryocytic depression, immune complexmediated and direct interaction with platelets
Prothrombotic state
Infection associated
Chronic infections especially tuberculosis
Viral hepatitis
Human parvovirus
Tuberculosis
Infectious mononucleosis, Mycoplasma
pneumoniae
Bacterial septicaemia (associated DIC),
Clostridium perfringens, malaria, bartonellosis
Viruses – haemolytic uraemic syndrome and TTP
Chronic malaria, tropical splenomegaly
syndrome, leishmaniasis, schistosomiasis
Acute bacterial infections
Severe bacterial infections particularly in infants
Tuberculosis
Parasitic diseases (e.g. hookworm, filariasis,
schistosomiasis, trichinosis)
Recovery from acute infections
Chronic bacterial infections: tuberculosis,
brucellosis, bacterial endocarditis, typhoid
Viral infections – HIV, hepatitis, influenza
Fulminant bacterial infections (e.g. typhoid,
miliary tuberculosis)
Infectious mononucleosis, toxoplasmosis,
cytomegalovirus, rubella, viral hepatitis,
pertussis, tuberculosis, brucellosis
HIV infection
Legionella pneumophila
Acute viral infections particularly in children (e.g.
measles, varicella, rubella, malaria, severe
bacterial infection)
All with prolonged inflammation
DIC, disseminated intravascular coagulation; HIV, human immunodeficiency virus; TTP, thrombotic thrombocytopenic purpura.
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Table 28.6 Advantages and disadvantages of
the tests used to monitor the acute phase
response.
Advantages
CRP*
Specific test of acute
phase protein
Disadvantages
More than one protein
required to measure
acute (CRP) and
chronic inflammation
Costly when assayed
in small numbers
Fast response (6
hours) to change in
disease activity
High sensitivity – owing Sophisticated
to large incremental
equipment and
change
antisera required
Can be measured on
stored serum
Small sample
volumes
Automated analysis
ESR and plasma viscosity
Useful in chronic
Not sensitive to acute
disease
changes (<24 hours)
ESR inexpensive,
Not specific for acute
easy, no electrical
phase response
power required
Plasma viscosity –
Slow to change with
alteration in disease
result obtained
activity and
quickly (15 min)
insensitive to small
changes in activity
Plasma viscosity not
Fresh samples (<2
affected by anaemia
hours) required for
ESR
ESR, erythrocyte sedimentation rate.
* C-reactive protein (CRP) is normally present in low
concentrations (<5 mg/L). Levels are not influenced by
anaemia, pregnancy or heart failure. During severe acute
infection the plasma concentration may rise 100-fold.
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