HAEMATOLOGY
Questions&Answers
Q-1
A 35 year old first time donor suddenly passes out as she is donating blood. She
is not known to have any medical problems in the past. Which of the following
steps would be the least useful in managing this adverse event?
A. Ensure donor is adequately hydrated and has not skipped a meal
B. Elevating the donor’s legs as this is usually due to a vasovagal syncope
C. Ensure haemoglobin of the donor meets the minimum requirements for
donation
D. The donation is continued along with simultaneous normal saline infusion
E. The donor should be encouraged to mobilise after they have recovered
ANSWER:
The donation is continued along with simultaneous normal saline infusion
EXPLANATION:
This question may seem tricky, but it is actually really simple. You need to read the
question well; it states, ‘which would be the LEAST useful in managing the adverse
event’
A is correct. Blood donors should ensure they are well hydrated and have eaten well
before donating blood.
B is correct. Elevation of the legs would cause more blood to return to the heart and
hence more blood to be pumped to the brain.
C is correct. People should not donate blood if their haemoglobin level is below the
lower limit of normal.
E is correct. The donor should be encouraged to eat, rest and continue their normal
activities as soon as possible after the donation.
This leaves us with D. If a donor faints whilst giving blood, YOU IMMEDIATELY STOP
THE DONATION. You should never continue bleeding the donor if an adverse event
,has occurred or is about to occur.
In general, you should not take more than 30 seconds to answer these types of
questions.
Q-2
A 13 year old girl has mucosal bleeding and petechial rashes. She has been
feeling tired lately. She looks pale. A blood count shows:
Haemoglobin 74 g/L
White cell count 1.9 x 109/L
Neutrophils 0.1 x 109/L
Platelets 24 x 109/L
Blood film morphology was unremarkable. Reticulocytes are absent. A bone
marrow aspirate shows a gross reduction in all haematopoietic tissue that is
replaced by fat spaces. What is the SINGLE most likely underlying diagnosis?
A. Pernicious anaemia
B. Chronic myeloid leukaemia
C. Aplastic anaemia
D. Acute myeloid leukaemia
E. Acute lymphoblastic leukaemia
ANSWER:
Aplastic anaemia
EXPLANATION:
She has signs and symptoms of anaemia. The blood picture showspancytopenia which
rules out pernicious anaemia as an underlying cause.
Normal morphology rules out the possibility of acute myeloid leukaemia,and acute
lymphoblastic leukaemia.
From the age alone we can exclude chronic myeloid leukaemia as it usuallypresents at
age 40 to 50 years old (middle-age)
A bone marrow aspirate that shows a gross reduction in all haemopoietictissue that is
replaced by fat spaces is seen classically in aplastic anaemia.Absent reticulocytes
support the diagnosis.
Aplastic anaemia
Aplastic anaemia is a rare, potentially life-threatening failure ofhaemopoiesis
characterised by pancytopenia and hypoplastic marrow (themarrow stops making cells).
Causes
,Most cases are autoimmune, triggered by drugs (viruses, eg parvovirus,hepatitis) or
irradiation.
Presentation
Aplastic anaemia can present abruptly over, or insidiously over, weeks tomonths.
Clinical manifestations are proportional to the peripheral-blood cytopeniasand include:
• Symptoms of anaemia (pallor, headache, palpitations, dyspnoea,fatigue, or ankle
oedema) Note: Anaemic symptoms are usually lesssevere due to the chronic onset
• Symptoms of thrombocytopenia (skin or mucosal haemorrhage,visual disturbance due
to retinal haemorrhage, petechial rashes)
• Infection (a less common presentation) particularly upper and lowerrespiratory tracts,
skin, mouth, and peri-anal
• There is no lymphadenopathy or hepatosplenomegaly (in theabsence of infection).
Diagnostic tests:
Marrow examination is needed for the diagnosis
Note: To define aplastic anaemia based on FBC and bone marrow findings,
at least two of the following must be present:
• Haemoglobin <10 g/dL
• Platelet count < 50 x 109/L
• Neutrophil count <1.5 x 109/L
It is also important to note that the blood film morphology is unremarkable
which differentiates it from some other types of leukaemias.
Q-3
A 5 year old child presents with fever and pallor. His parents say he always feels
tired and is not as active as the other children around his age. On examination,
splenomegaly was noted. Blood results show:
Hb 7 g/dL
WCC 2 x 109/L
Platelets 42 x 109/L
What is the SINGLE most likely diagnosis?
A. Acute myeloid leukaemia
B. Acute lymphoblastic leukaemia
C. Chronic myeloid leukaemia
D. Chronic lymphocytic leukaemia
E. Hodgkin’s lymphoma
ANSWER:
Acute lymphoblastic leukaemia
, EXPLANATION:
Acute lymphoblastic leukaemia (ALL)
Aetiology
Most cases of acute leukaemia arise with no apparent cause. There areseveral well
known associations with the development of acute leukaemiathat are sometimes
present. These include radiation exposure,chemotherapeutic agents, as well as some
retroviruses.
Clinical Presentation
The most common presentation results from the effects of the leukaemicblast cells
crowding out the normal marrow cells, resulting in symptoms ofpancytopenia even if the
total white blood cell count is normal.
• Fatigue from anaemia is the most common presenting complaint.
• Bleeding, petechiae, purpura or ecchymoses (due tothrombocytopenia)
• Recurrent and severe infections (oral, throat, skin, perianalinfections commonly). This
is because of the underproduction orabnormal function of white blood cells.
• Left upper quadrant fullness and early satiety due to splenomegaly(10-20%)
Acute lymphocytic leukaemia (ALL) is more common in children, and
acutemyelogenous leukaemia (AML) is more common in adults, but they
areindistinguishable clinically. This means you cannot determine the diagnosisonly from
the clinical presentation.
ALL is more often associated with infiltration of other organs, but AML cando it as well.
Enlargement of the liver, spleen, and lymph nodes and bonepain are common at
presentation.
Diagnosis
The FBC is the first clue to the diagnosis. Depression of all three cell lines is
common at presentation.
FBC
• Anaemia is usual and Hb may be below 5 g/L
• The white cell count can be low, normal, or elevated
• Thrombocytopenia
Many other disorders can present as pancytopenia similar to leukaemiasuch as aplastic
anaemia, infections involving the marrow, metastaticcancer involving the marrow,
vitamin B12 deficiency, SLE, hypersplenism,and myelofibrosis. However, none of these
will have leukaemic blastscirculating in the peripheral blood. Although pancytopenia can
cause all ofthe above, in PLAB, when pancytopenia is in the options, it is
usuallyleukaemia, or aplastic anaemia.
A bone marrow biopsy showing numerous blasts confirms the diagnosis ofacute
leukaemia.
Questions&Answers
Q-1
A 35 year old first time donor suddenly passes out as she is donating blood. She
is not known to have any medical problems in the past. Which of the following
steps would be the least useful in managing this adverse event?
A. Ensure donor is adequately hydrated and has not skipped a meal
B. Elevating the donor’s legs as this is usually due to a vasovagal syncope
C. Ensure haemoglobin of the donor meets the minimum requirements for
donation
D. The donation is continued along with simultaneous normal saline infusion
E. The donor should be encouraged to mobilise after they have recovered
ANSWER:
The donation is continued along with simultaneous normal saline infusion
EXPLANATION:
This question may seem tricky, but it is actually really simple. You need to read the
question well; it states, ‘which would be the LEAST useful in managing the adverse
event’
A is correct. Blood donors should ensure they are well hydrated and have eaten well
before donating blood.
B is correct. Elevation of the legs would cause more blood to return to the heart and
hence more blood to be pumped to the brain.
C is correct. People should not donate blood if their haemoglobin level is below the
lower limit of normal.
E is correct. The donor should be encouraged to eat, rest and continue their normal
activities as soon as possible after the donation.
This leaves us with D. If a donor faints whilst giving blood, YOU IMMEDIATELY STOP
THE DONATION. You should never continue bleeding the donor if an adverse event
,has occurred or is about to occur.
In general, you should not take more than 30 seconds to answer these types of
questions.
Q-2
A 13 year old girl has mucosal bleeding and petechial rashes. She has been
feeling tired lately. She looks pale. A blood count shows:
Haemoglobin 74 g/L
White cell count 1.9 x 109/L
Neutrophils 0.1 x 109/L
Platelets 24 x 109/L
Blood film morphology was unremarkable. Reticulocytes are absent. A bone
marrow aspirate shows a gross reduction in all haematopoietic tissue that is
replaced by fat spaces. What is the SINGLE most likely underlying diagnosis?
A. Pernicious anaemia
B. Chronic myeloid leukaemia
C. Aplastic anaemia
D. Acute myeloid leukaemia
E. Acute lymphoblastic leukaemia
ANSWER:
Aplastic anaemia
EXPLANATION:
She has signs and symptoms of anaemia. The blood picture showspancytopenia which
rules out pernicious anaemia as an underlying cause.
Normal morphology rules out the possibility of acute myeloid leukaemia,and acute
lymphoblastic leukaemia.
From the age alone we can exclude chronic myeloid leukaemia as it usuallypresents at
age 40 to 50 years old (middle-age)
A bone marrow aspirate that shows a gross reduction in all haemopoietictissue that is
replaced by fat spaces is seen classically in aplastic anaemia.Absent reticulocytes
support the diagnosis.
Aplastic anaemia
Aplastic anaemia is a rare, potentially life-threatening failure ofhaemopoiesis
characterised by pancytopenia and hypoplastic marrow (themarrow stops making cells).
Causes
,Most cases are autoimmune, triggered by drugs (viruses, eg parvovirus,hepatitis) or
irradiation.
Presentation
Aplastic anaemia can present abruptly over, or insidiously over, weeks tomonths.
Clinical manifestations are proportional to the peripheral-blood cytopeniasand include:
• Symptoms of anaemia (pallor, headache, palpitations, dyspnoea,fatigue, or ankle
oedema) Note: Anaemic symptoms are usually lesssevere due to the chronic onset
• Symptoms of thrombocytopenia (skin or mucosal haemorrhage,visual disturbance due
to retinal haemorrhage, petechial rashes)
• Infection (a less common presentation) particularly upper and lowerrespiratory tracts,
skin, mouth, and peri-anal
• There is no lymphadenopathy or hepatosplenomegaly (in theabsence of infection).
Diagnostic tests:
Marrow examination is needed for the diagnosis
Note: To define aplastic anaemia based on FBC and bone marrow findings,
at least two of the following must be present:
• Haemoglobin <10 g/dL
• Platelet count < 50 x 109/L
• Neutrophil count <1.5 x 109/L
It is also important to note that the blood film morphology is unremarkable
which differentiates it from some other types of leukaemias.
Q-3
A 5 year old child presents with fever and pallor. His parents say he always feels
tired and is not as active as the other children around his age. On examination,
splenomegaly was noted. Blood results show:
Hb 7 g/dL
WCC 2 x 109/L
Platelets 42 x 109/L
What is the SINGLE most likely diagnosis?
A. Acute myeloid leukaemia
B. Acute lymphoblastic leukaemia
C. Chronic myeloid leukaemia
D. Chronic lymphocytic leukaemia
E. Hodgkin’s lymphoma
ANSWER:
Acute lymphoblastic leukaemia
, EXPLANATION:
Acute lymphoblastic leukaemia (ALL)
Aetiology
Most cases of acute leukaemia arise with no apparent cause. There areseveral well
known associations with the development of acute leukaemiathat are sometimes
present. These include radiation exposure,chemotherapeutic agents, as well as some
retroviruses.
Clinical Presentation
The most common presentation results from the effects of the leukaemicblast cells
crowding out the normal marrow cells, resulting in symptoms ofpancytopenia even if the
total white blood cell count is normal.
• Fatigue from anaemia is the most common presenting complaint.
• Bleeding, petechiae, purpura or ecchymoses (due tothrombocytopenia)
• Recurrent and severe infections (oral, throat, skin, perianalinfections commonly). This
is because of the underproduction orabnormal function of white blood cells.
• Left upper quadrant fullness and early satiety due to splenomegaly(10-20%)
Acute lymphocytic leukaemia (ALL) is more common in children, and
acutemyelogenous leukaemia (AML) is more common in adults, but they
areindistinguishable clinically. This means you cannot determine the diagnosisonly from
the clinical presentation.
ALL is more often associated with infiltration of other organs, but AML cando it as well.
Enlargement of the liver, spleen, and lymph nodes and bonepain are common at
presentation.
Diagnosis
The FBC is the first clue to the diagnosis. Depression of all three cell lines is
common at presentation.
FBC
• Anaemia is usual and Hb may be below 5 g/L
• The white cell count can be low, normal, or elevated
• Thrombocytopenia
Many other disorders can present as pancytopenia similar to leukaemiasuch as aplastic
anaemia, infections involving the marrow, metastaticcancer involving the marrow,
vitamin B12 deficiency, SLE, hypersplenism,and myelofibrosis. However, none of these
will have leukaemic blastscirculating in the peripheral blood. Although pancytopenia can
cause all ofthe above, in PLAB, when pancytopenia is in the options, it is
usuallyleukaemia, or aplastic anaemia.
A bone marrow biopsy showing numerous blasts confirms the diagnosis ofacute
leukaemia.
