Haematological and Oncological Emergencies




(1)
Royal Free NHS Foundation Trust, London, UK

 




Causes of neutropenia

(total neutrophil count <1 × 10/L regardless of total white cell count)



  • Infections: bacterial; viral; rickettsial; parasitic


  • Drugs: antibiotics; chemotherapy agents; anti-metabolites; antipsychotics; anti-thyroid drugs; anti-epileptic drugs; heavy metals


  • Ionizing radiation


  • Haematopoeitic disease: leukaemia; aplastic anaemia


  • Autoimmune: SLE


  • Hypersplenism


  • Nutritional: alcoholism; B12/folate deficiency

Neutropenic sepsis should be considered with presentations within 6 weeks of last administration of chemotherapy or radiotherapy for cancer.


Evaluation of neutropenic sepsis

(febrile neutropenia is defined as a single oral temperature greater than 38.3 degrees Centigrade, or a temperature greater than 38.0 degrees Centigrade sustained over 1 h, in association with a neutrophil count <0.5 × 109/L)



  • Inspect intravenous access sites


  • Skin sepsis


  • Oropharyngeal sepsis: gums; pharynx


  • Palpate maxillary and frontal sinuses


  • Chest auscultation; chest xray


  • Inspect perianal area for cellulitis and abscess; avoid rectal examination as may cause bacteraemia


  • Urine dipstick analysis


  • Cultures from each intravenous port and from peripheral blood


Causes of neutrophilia





  • Infections: bacterial; parasitic; viral; fungal


  • Inflammation


  • Drugs: glucocorticoids; lithium


  • Haemorrhage


  • Burns


  • Gangrene


  • Myelo-proliferative disorders: leukaemia; polycythaemia rubra vera


  • Physiological: exercise, stress; menstruation


  • Metabolic: diabetic ketoacidosis; acute kidney injury


Causes of leukaemoid reactions

(WBC count >50,000/cu mm)



  • Haemorrhage


  • Drugs: glucocorticoids; all-trans retinoic acid


  • Infections: tuberculosis; pertussis; infectious mononucleosis


  • Asplenia


  • Acute haemolysis


  • Diabetic ketoacidosis


  • Organ necrosis: ischaemic colitis


Causes of eosinophilia

(eosinophil count >500/μl)



  • Allergic/atopic disease: asthma; allergic rhinitis; urticaria


  • Parasitic infestations: helminths (ascariasis); filariasis; toxocara; trichinella; strongyloides; visceral larva migrans; ankylostomiasis


  • Fungal disease


  • Drug reaction with eosinophilia and systemic symptoms (DRESS)


  • Skin disease: dermatitis herpetiformis


  • Pulmonary infiltration with eosinophilia (eosinophilic pulmonary infiltration with peripheral blood eosinophilia): Loeffler’s syndrome; tropical eosinophilia; Churg-Strauss syndrome (eosinophilic granuloma with polyangiitis); nitrofurantoin lung


  • Myeloproliferative disease: chronic myeloid leukaemia; polycythaemia vera


  • Lymphoproliferative disease: acute lymphoblastic leukaemia; lymphoma (Hodgkin; non-Hodgkin; T-cell); mycosis fungoides


Hypereosinophilic syndrome

is characterized by:



  • Eosinophil count >1500/μl for longer than 6 months


  • Signs of end-organ involvement attributable to eosinophilic infiltration


  • No identifiable cause


Causes of lymphocytosis

(lymphocyte count >5,000/μl)



  • Transient, reactive: acute viral infections (infectious mononucleosis; CMV; hepatitis); acute bacterial infections (pertussis; typhoid)


  • Chronic intracellular bacterial infection (tuberculosis; brucellosis); secondary syphilis


  • Protozoal infection: toxoplasmosis; American trypanosomiasis (Chagas disease)


  • Haematological malignancy: chronic lymphocytic leukaemia; lymphoma (non-Hodgkin); acute lymphoblastic leukaemia


Causes of lymphocytopenia

(lymphocyte count <1500/μl)



  • Reduced production: aplastic anaemia; thymic dysplasia; ataxia telangiectasia; Wiskott-Aldrich syndrome


  • Increased destruction: radiation therapy; cancer chemotherapy (alkylating agents); glucocorticoids


  • Increased loss: intestinal lymphangiectasia (protein-losing enteropathy); impaired intestinal lymphatic drainage (Whipple disease); thoracic duct leak


Causes of thrombocytopenia





  • Artifactual: platelet clumping


  • Reduced production of platelets



    • Diminished or absent megakaryoctes in bone marrow: aplastic anaemia; leukaemia or other infiltrative bone marrow disease; dose-dependent bone marrow suppression (chemotherapeutic agents); paroxysmal nocturnal haemoglobinuria


    • Diminished platelet production despite the presence of megakaryocytes in bone marrow: alcohol-induced thrombocytopenia; HIV-associated thrombocytopenia; B12 or folate deficiency


  • Altered distribution: platelet sequestration in enlarged spleen (hypersplenism)



    • Cirrhosis with portal hypertension and congestive splenomegaly


    • Myelofibrosis with myeloid metaplasia


  • Increased destruction of platelets


    1. (a)


      Immunological



      • Idiopathic thrombocytopenic purpura


      • Systemic lupus erythematosus


      • Anti-phospholipid syndrome


      • Post-transfusion purpura (allo-immune)


      • Drug-mediated: immune-mediated platelet destruction (heparin-heparin dependent IgG antibodies bind to heparin/platelet factor 4 complexes; falling platelet count during or following heparin treatment, with or without thrombosis-venous or arterial), trimethoprim


      • Lymphoproliferative disorders

       

    2. (b)


      Non-immunological



      • Systemic infections (hepatitis; Epstein-Barr virus, cytomegalovirus)


      • Disseminated intravascular coagulation


      • Sepsis


      • Pregnancy (gestational thrombocytopenia)


      • Thrombotic microangiopathies associated with consumptive thrombocytopenia, microangiopathic haemolytic anaemia, and thrombosis: thrombotic thrombocytopenic purpura; haemolytic uraemic syndrome; disseminated intravascular coagulation

       


  • Dilution



    • Massive red blood cell replacement or exchange transfusion


Causes of multiple bruising





  • Purpura simplex


  • Alcohol abuse


  • Non-accidental injury; elder abuse


  • Senile purpura: transient red to purple patches on the forearms and dorsal aspects of hands


  • Vitamin C deficiency


  • Cushing’s syndrome


  • Connective tissue disease: Ehlers-Danlos syndrome


  • Medication: aspirin, clopidogrel, oral anticoagulants, NSAIDs


Features of non-accidental bruising in children





  • Children not independently mobile


  • Babies


  • Away from bony prominences


  • Bruises on the face, back, abdomen, arms, buttocks, ears, hands


  • Multiple bruises in clusters


  • Multiple bruises of uniform shape


  • Bruises carrying the imprint of the implement used (linear marks from sticks or belts) or ligature marks


  • Symmetrical bruising


  • Human bite marks


Features of acute idiopathic thrombocytopenic purpura



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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Haematological and Oncological Emergencies

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