Haematological examination
Peter Farkas MD
Semmelweis University
3rd Department of Internal Medicine
30.11.2010.
Haematological examination
• Physical examination – inspection
• Lymphadenopathy
• Splenomegaly
• Special haematological examinations
Physical examination – Inspection
• Skin and its appendices
– Paleness: anaemia
– Plethoric aspect: polyglobulia
– Jaundice: haemolytic anaemia, pernicous
anaemia
– Thrombocytopenic purpura (petechia,
ecchymosis, suffusion): thrombocytopenia
– Skin infections: neutropenia (lack of pus!)
– Iron deficiency: dry skin, koilonychia, brittle
hair and nail, hair loss, itching
Physical examination – Inspection
• Oral cavity, mucous membranes
– Plummer-Vinson sy.: mucous membrane atrophy in
iron deficient anaemia
– Hunter’s glossitis: vitamin B
12
deficiency
– Petechia: thrombocytopenia
– Gingiva hypertrophy: leukaemia
– Aphthosus stomatitis, angina: agranulocytosis,
leukaemia
– Confluent tonsillitis: mononucleosis sy.
Lymphadenopathy
• Palpable – non-palpable
• Regional – generalized
• Size (soliter, conglomerate), speed of development
• Tenderness, pain
• Soft, thicken, hard
• Relation to the surrounding tissues (fixed pr mobile)
• Fluctuation, abscess/fistula formation
• „Mass effect” (VCS sy., tracheal/bronchial obstruction,
bowel obstruction, DVT)
Palpable lymphadenopathy
Most common causes of lymphadenopathia based on its location
Cervical
- Bacterial infection
- Mononucleosis sy.
- Rubella
- Tuberculosis
- Lymphoma (frequently unilateral)
- Head-neck tumors (frequently unilateral)
Supraclavicular
- Lung, retroperitoneal or gastrointestinal tumors
- Lymphoma
- Chest or retroperitoneal bacterial or fungal infection
Axillary
- Bacterial infection, trauma of upper extremity
- Cat scratch disease
- Lymphoma
- Breast cancer
- Brucellosis
- Melanoma
Inguinal
- Bacterial infections of lower extremity, genitals or parianal region
- Lymphoma
- Pelvic tumors
- Venereal diseases (lymphogranuloma venereum, syphilis I.)
Non-palpable and generalized
lymphadenopathy
Hilar
- Sarcoidosis
- Tuberculosis
- Lung cancer
Mediastinal
- Mononucleosis sy.
- Sarcoidosis
- Tuberculosis
- Histoplasmosis
- Lung cancer
- Lymphoma
Abdominal/retroperitoneal
- Tuberculosis
- Lymphoma
- Germinal tumors/seminoma
- Other tumors
Generalized lymphadenopathy
- Infection (EBV, CMV, toxoplasmosis, tuberculosis, hepatitis, syphilis, HIV/AIDS, histoplasmosis)
- Haematological malignancies: lymphomas, CLL, myeloid disorders: acut and chronic myelomonocytic leukaemia
- Drug reactions
- Other
Lymphadenopathy
Causes of lymphadenopathy
I. Infectious
- Viruses: mononucleosis sy.(EBV, CMV, HIV), hepatitis infectiosa, herpes simplex, rubella
- Bacterias: Streptococcus, Staphylococcus, Brucella, Francisella tularensis, Treponema pallidum, Chlamydia,
mycobacterias
- Fungi: histoplasmosis, coccidiomycosis
- Parazites: toxoplasmosis, leishmaniasis, trypanosomiasis
II. Malignant disorders
- Primary hematoligical disorders: lymphomas; myeloid disorders (acute and chronic myelomonocytic leukaemia)
- Solid tumor metastases
III. Disorders with immunpatomechanism
- Autoimmun disorders: SLE, RA, MCTD, Sjögren-sy., vasculitis
- Sarcoidosis
IV. Storage diseases Gaucher, Niemann–Pick-, Fabry-, Tangier-disease
V. Endocrin disorders (lymphoid hyperplasia)
Hyperthyreosis
VI. Other rare disorders
- Castleman disease
- Kikuchi disease
- Histiocytosis
- Dermatopathic lymphadenitis
- Mucocutan lymphnode sy.(Kawasaki disease)
Splenomegaly
• Palpation, percussion, auscultation
• Size, tenderness, pain
• Soft, thicken, hard
• „Hypersplenism” – pancytopenia due to
sequestration
Splenomegaly
• Portal hypertension
– Liver cirrhosis
– Hepatic, portal or splenic vein thrombosis
• Storage disorders
– Gaucher, Niemann-Pick
• Systemic diseases
– Sarcoidosis, amyloidosis, RA
• Infections
– Acute
• Sepsis, IE, typhus abdominalis, Mononucleosis sy.
– Chronic
• Tuberculosis, brucellosis, syphilis, malaria, leishmaniasis,
schistosomiasis
Splenomegaly
• Haematological disorders
– Haemolysis (RES hyperplasia): thalassaemia
major and intermedia, sickle cell anaemia,
any type of haemolytic anaemia
– Malignancies
• Lymphoid: CLL, HCL, Lymphoma, ALL
• Myeloid: CML, MF, PRV, AML
• (Metastases of solid tumors)
Useful laboratory tests
General
•
CBC, reticulocyte
•
Peripheral blood smear MGG: cytomorhology
•
ESR, CRP
•
EPO
Iron deficiency
•
SeFe, Tf, Sat, SolTfR, Ferritin
Megaloblastic anaemia
•
B
12
, folsav
Haemolysis
•
SeBi, LDH
•
Direct Coombs, irregular antibodies
•
Haptoglobin, plasma free haemoglobin
•
HgbELFO
•
RBC enzyme activity
Blood loss
•
Stool benzidin test, urine sediment
Plasma cell dyscrasia
•
Total protein, ELFO, immunelfo, quantitative Ig
Useful haematopathological exams
• Bone marrow aspiration, biopsy & Lymphnode
biopsy
– Cytomorhology, histology
– Immunehistochemistry
– Flow cytometry
– Cytogenetics (metaphase analysis, FISH)
– Molecular genetic
FNAB of lympnodes is not recommended!
Sometimes other organs (skin, stomach, bowel, spleen) for these
examinations
Imaging techniques
• Xray (bone laesions of MM)
• US
• CT
• MRI
• Gallium scan
• PET/CT