A 62-year-old man presents with lethargy. A full blood count is taken and is reported
as follows:
Hb 102 g/L Male:
(135-180)
Female:
(115 - 160)
Platelets 330 * 109/L (150 - 400)
WBC 15.2 * 109/L (4.0 - 11.0)
Blood film Leucoerythroblastic picture.
Tear-drop poikilocytes seen
1. What is the most likely diagnosis?
Myelodysplasia 1
7
%
Chronic lymphocytic leukaemia 8
%
Myelofibrosis 6
4
%
Chronic myeloid leukaemia 8
%
Post-splenectomy 3
%
Myelofibrosis is associated with 'tear drop' poikilocytes on blood film
The correct answer is Myelofibrosis. The key features in this case pointing towards
myelofibrosis are the presence of a leucoerythroblastic blood picture (immature white
cells and nucleated red cells in the peripheral blood) and tear-drop poikilocytes,
which are characteristically seen in this condition. Myelofibrosis is a
myeloproliferative neoplasm characterised by bone marrow fibrosis, leading to
extramedullary haematopoiesis. The anaemia and leucocytosis seen in this case are
also consistent with myelofibrosis.
, Myelodysplasia typically presents with cytopenias (low blood counts) rather than the
raised white cell count seen here. While anaemia may be present, the characteristic
blood film findings of leucoerythroblastic picture and tear-drop poikilocytes are not
typical features of myelodysplasia.
Chronic lymphocytic leukaemia would show a marked lymphocytosis with
mature-appearing lymphocytes on the blood film. The leucoerythroblastic picture and
tear-drop poikilocytes are not features of CLL. Additionally, CLL typically shows a
much higher white cell count.
Chronic myeloid leukaemia typically presents with a much higher white cell count,
often >50 x 10^9/L, and shows a characteristic left shift with immature granulocytes
but not typically a leucoerythroblastic picture. The blood film would show
predominantly neutrophils and myelocytes rather than tear-drop poikilocytes.
Post-splenectomy blood films typically show Howell-Jolly bodies and target cells
rather than tear-drop poikilocytes. While there may be a mild leucocytosis
post-splenectomy, a leucoerythroblastic picture would not be expected.
2. A 64-year-old female is referred to rheumatology out-patients by her GP with
a history of arthritis in both hands.
Which one of the following x-ray findings would most favour a diagnosis of rheumatoid
arthritis over other possible causes?
A. Loss of joint space 9%
B. Periarticular osteopenia 61%
C. Subchondral sclerosis 18%
D. Osteophytes 5%
E. Subchondral cysts
Rheumatoid arthritis: x-ray changes
Early x-ray findings
● loss of joint space
● juxta-articular osteoporosis
● soft-tissue swelling
● periarticular erosions
● subluxation
,●
3. A 19-year-old man presents with dysuria associated with a watery discharge
from his urethral meatus. A urethral swab shows non-specific urethritis and
urine is sent for Chlamydia/gonococcus.
What is the most appropriate antibiotic to use?
Erythromycin
Ciprofloxacin
Metronidazole
Doxycycline
Azithromycin
Chlamydia - treat with doxycycline
The management of non-specific urethritis is similar to that of Chlamydia, with
doxycycline being preferred to azithromycin, partly due to increasing levels of
macrolide resistance in Mycoplasma genitalium.
Chlamydia
Chlamydia is the most prevalent sexually transmitted infection in the UK and
is caused by Chlamydia trachomatis, an obligate intracellular pathogen.
Approximately 1 in 10 young women in the UK have Chlamydia. The
incubation period is around 7-21 days, although it should be remembered a
large percentage of cases are asymptomatic
Features
● asymptomatic in around 70% of women and 50% of men
● women: cervicitis (discharge, bleeding), dysuria
● men: urethral discharge, dysuria
Potential complications
● epididymitis
● pelvic inflammatory disease
● endometritis
● increased incidence of ectopic pregnancies
● infertility
● reactive arthritis
● perihepatitis (Fitz-Hugh-Curtis syndrome)
, Investigation
● traditional cell culture is no longer widely used
● nuclear acid amplification tests (NAATs) are now the investigation of choice
● urine (first void urine sample), vulvovaginal swab or cervical swab may be tested
using the NAAT technique
● for women: the vulvovaginal swab is first-line
● for men: the urine test is first-line
● Chlamydiatesting should be carried out two weeks after a possible exposure
Screening
● in England the National Chlamydia Screening Programme is open to all men and
women aged 15-24 years
● the 2009 SIGN guidelines support this approach, suggesting screening all sexually
active patients aged 15-24 years
● relies heavily on opportunistic testing
© Image used on
license from
PathoPic
Pap smear demonstrating infected endocervical cells. Red inclusion bodies are typical
Management
● doxycycline (7 day course) if first-line
○ this is now preferred to azithromycin due to concerns about Mycoplasma
genitalium. This infection is often coexistant in patients with Chlamydia and
as follows:
Hb 102 g/L Male:
(135-180)
Female:
(115 - 160)
Platelets 330 * 109/L (150 - 400)
WBC 15.2 * 109/L (4.0 - 11.0)
Blood film Leucoerythroblastic picture.
Tear-drop poikilocytes seen
1. What is the most likely diagnosis?
Myelodysplasia 1
7
%
Chronic lymphocytic leukaemia 8
%
Myelofibrosis 6
4
%
Chronic myeloid leukaemia 8
%
Post-splenectomy 3
%
Myelofibrosis is associated with 'tear drop' poikilocytes on blood film
The correct answer is Myelofibrosis. The key features in this case pointing towards
myelofibrosis are the presence of a leucoerythroblastic blood picture (immature white
cells and nucleated red cells in the peripheral blood) and tear-drop poikilocytes,
which are characteristically seen in this condition. Myelofibrosis is a
myeloproliferative neoplasm characterised by bone marrow fibrosis, leading to
extramedullary haematopoiesis. The anaemia and leucocytosis seen in this case are
also consistent with myelofibrosis.
, Myelodysplasia typically presents with cytopenias (low blood counts) rather than the
raised white cell count seen here. While anaemia may be present, the characteristic
blood film findings of leucoerythroblastic picture and tear-drop poikilocytes are not
typical features of myelodysplasia.
Chronic lymphocytic leukaemia would show a marked lymphocytosis with
mature-appearing lymphocytes on the blood film. The leucoerythroblastic picture and
tear-drop poikilocytes are not features of CLL. Additionally, CLL typically shows a
much higher white cell count.
Chronic myeloid leukaemia typically presents with a much higher white cell count,
often >50 x 10^9/L, and shows a characteristic left shift with immature granulocytes
but not typically a leucoerythroblastic picture. The blood film would show
predominantly neutrophils and myelocytes rather than tear-drop poikilocytes.
Post-splenectomy blood films typically show Howell-Jolly bodies and target cells
rather than tear-drop poikilocytes. While there may be a mild leucocytosis
post-splenectomy, a leucoerythroblastic picture would not be expected.
2. A 64-year-old female is referred to rheumatology out-patients by her GP with
a history of arthritis in both hands.
Which one of the following x-ray findings would most favour a diagnosis of rheumatoid
arthritis over other possible causes?
A. Loss of joint space 9%
B. Periarticular osteopenia 61%
C. Subchondral sclerosis 18%
D. Osteophytes 5%
E. Subchondral cysts
Rheumatoid arthritis: x-ray changes
Early x-ray findings
● loss of joint space
● juxta-articular osteoporosis
● soft-tissue swelling
● periarticular erosions
● subluxation
,●
3. A 19-year-old man presents with dysuria associated with a watery discharge
from his urethral meatus. A urethral swab shows non-specific urethritis and
urine is sent for Chlamydia/gonococcus.
What is the most appropriate antibiotic to use?
Erythromycin
Ciprofloxacin
Metronidazole
Doxycycline
Azithromycin
Chlamydia - treat with doxycycline
The management of non-specific urethritis is similar to that of Chlamydia, with
doxycycline being preferred to azithromycin, partly due to increasing levels of
macrolide resistance in Mycoplasma genitalium.
Chlamydia
Chlamydia is the most prevalent sexually transmitted infection in the UK and
is caused by Chlamydia trachomatis, an obligate intracellular pathogen.
Approximately 1 in 10 young women in the UK have Chlamydia. The
incubation period is around 7-21 days, although it should be remembered a
large percentage of cases are asymptomatic
Features
● asymptomatic in around 70% of women and 50% of men
● women: cervicitis (discharge, bleeding), dysuria
● men: urethral discharge, dysuria
Potential complications
● epididymitis
● pelvic inflammatory disease
● endometritis
● increased incidence of ectopic pregnancies
● infertility
● reactive arthritis
● perihepatitis (Fitz-Hugh-Curtis syndrome)
, Investigation
● traditional cell culture is no longer widely used
● nuclear acid amplification tests (NAATs) are now the investigation of choice
● urine (first void urine sample), vulvovaginal swab or cervical swab may be tested
using the NAAT technique
● for women: the vulvovaginal swab is first-line
● for men: the urine test is first-line
● Chlamydiatesting should be carried out two weeks after a possible exposure
Screening
● in England the National Chlamydia Screening Programme is open to all men and
women aged 15-24 years
● the 2009 SIGN guidelines support this approach, suggesting screening all sexually
active patients aged 15-24 years
● relies heavily on opportunistic testing
© Image used on
license from
PathoPic
Pap smear demonstrating infected endocervical cells. Red inclusion bodies are typical
Management
● doxycycline (7 day course) if first-line
○ this is now preferred to azithromycin due to concerns about Mycoplasma
genitalium. This infection is often coexistant in patients with Chlamydia and
