UNE HEMATOLOGY SECTION

CLINICAL PEDIATRIC HEMATOLOGY

December, 2008

An Introduction

Pediatric Hematology-Oncology, 1984-98 Hospice & Palliative Care Medicine Medical Director, The Jason Program, 1998 -

2008

Gary Allegretta, MD

Pediatric Hematology Outline

Section 1: The Red Cell Section 2: Leukocytes & Marrow

Failure Section 3: Coagulation Section 4: Hematopoietic Malignancies Section 5: Hematologic Manifestations

of Systemic DiseaseTake-Home pointTake-Home point

Section I : The Red Cell

General Physiology Developmental Physiology Definition & Effects of Anemia Formulating a Differential Dx Specific Conditions

Newborns Children & Adolescents

Bilirubin Metabolism

Intravascular

Extravascular

Free Hgb+

Haptoglobin

Fe + Transferrin

Free Hgb

Red cells contain SGOT

& LDH

All Fe is recycled

Effects on Health & Disease

Developmental RBC Physiology

Newborn Blood Values

Age Hgb g/dl Hct% MCV Retic WBC Plts EPO

Term 14.5-22.5 48-69 95-121 0.4-6 9-30 84-478 35.6 mU/ml

3 days Same 44-72 Gradual Change

Gradual Change

150-400

2 weeks Gradual Change

Gradual Change

1-1.2 No Change

1 month 1-2.4 5-19

2 months 9-14 28-42 0.1-2.9 Gradual Change

11.5 mU/ml

6 months 70-86 0.1-1.3 18.8 mU/ml

Fetal Marrow Development

Primitive megaloblastic blood formationstarts at 18th day - recurs with

illness

Kleihauer-Betke Smear

Adult (Maternal) RBC

Fetal type RBC

Acid removes adult hemoglobin, but not fetal hemoglobin

Megaloblastic Condition

Primary cause: results from inhibition of DNA synthesis in red blood cell production B12 and/ or Folate deficiency Pernicious Anemia

Hematological findings Increased MCV Multi-segmented Neutrophils Howell-Jolly bodies

Megaloblastic Disease

Pre-Leukemia: Myelodysplastic Disease – Elevated MCV

Fanconi Anemia People with FA may also have physical findings, which are highly

variable, and may include short stature, upper limb differences, kidney, cardiac, and gastrointestinal problems, brown-pigmented spots on the skin, hearing loss, and developmental delay.

Fetal Marrow Development

Normoblastic = 90% @ 10th week Liver is 1o site from 3rd-6th month Marrow is 1o site from 6th month Myeloid development starts ~4th

month Blood is rich in progenitors –

Cord blood transplants

Human Hemoglobins

Hgb Chain Production

Gestational Age 0 3 6 Birth 3

ß- Adultγ- Fetal (high O2 affinity)

є- Embryonic

ά- Adult

Fetal Hemoglobin

Oxygenated placental bloodOxygenated placental blood

Lower extremity bloodLower extremity blood

Fetal Brain PerfusionFetal Brain Perfusion

Fetal Circulation

Prenatal Fetal Circulation Video Postnatal

Severe anemia - Parvovirus

O2O2

Blood VesselBlood Vessel

Vascular WallVascular Wall

Cardiac Compensation to HypoxiaCardiac Compensation to Hypoxia

Hypoxia: Damaged RBC; Less RBC; Less Oxygen Delivery

High Output Heart Failure Cardiac Output = SV X HR Hypoxia requires increased

cardiac output HR increases first SV increases by Starling’s LawIntravascular

VolumeIntravascular

Volume

ContractilityContractility

Better Worse

Pleural EffusionPleural EffusionNormal LungNormal Lung

CardiomegalyCardiomegaly

Hydrops Fetalis RadiographHydrops Fetalis Radiograph

Infant with Hydrops FetalisInfant with Hydrops Fetalis

Malignancy until proven otherwise after first week of life

Leukoerythroblastic Blood Smear

“Unusual” Definition of Normal

Possible Sepsis Day of Birth: WBC 30K Next Day: WBC 34 K Peripheral Smear:

Leukoerythroblastic

Dx: Normal

Newborn Iron Acquisition

Physiology Review Fetus rapidly accumulates Hgb & Fe

Newborn will have normal Hgb & ferritin even if mother has mild-moderate iron deficiency - May cause of prematurity, LBW

Fe content at birth = ~ 75 mg/kg Varies with cord clamping technique Fe deficiency rare before 4 mos of age Neither human nor cow’s milk has iron Fe absorption better with human (lactoferrin)

Umbilical Cord Management

Placental vessels contain 75-125 ml of blood, ~ 25-30% fetal blood volume

Umbilical arteries constrict after birth Umbilical veins remain open gravity

flow Vaginal birth: ~ ½ placental volume

transfused 1 minute C-Section: keep infant below placenta

20 seconds prior to clamping the cord

Postnatal Erythropoiesis

RBC production 10X during 1st week Mechanism unknown -- EPO level = 0 Increases from wk 2 - 3 months Consequence = “physiologic anemia” Marked increase from 4 mos - 12 mos

due to body mass growth

Normal Infant Hgb Values

Lower Normal - TermLower Normal - Term

Lower Normal - PretermLower Normal - Preterm

RBC-Related Conditions of the Infant

Fetal Blood Loss (rare) Jaundice (very common) Newborn Immune Hemolysis (occasional) Congenital RBC Aplasia (rare)

Fetal-Maternal Blood Loss

Occurs through the placenta Causes: trauma, iatrogenic, idiopathic Cause of fetal death if >20% fetal

blood volume is lost Dx: Test maternal blood for fetal cells

Kleihauer-Betke Smear

Fetal-Fetal Blood Loss

Occurs in 70% of identical twins Significant if Hgb > 5 g/dl Chronic –

weight > 20% of larger twin Donor: SGA

Acute – weight < 20% of larger twin Donor: volume & rbc depleted

Fetal-Placental Loss

Placental Accidents Abruption Previa Multilobar placenta Rupture of a cord aneurysm Iatrogenic during C-section

Jaundice in the Newborn Fundamentals of physiology

Bilirubin produced by rbc breakdown Newborn liver conjugates poorly Lab: T/D Direct bili = conjugated Indirect bili = unconjugated

Common: indirect bilirubin (1/0.2) Physiologic; breast milk; rbc destruction;

Uncommon: direct bilirubin Cholestasis (abnormal ducts; sepsis;

mass)

Potential Consequences

Bilirubin toxicity Kernicterus –

deafness, retardation Caused by staining of basal ganglia

Risk level: > 20 if hemolysis

Jaundice Evaluation

Clinical – sick vs. well / normal color vs. orange

Jaundice Evaluation - Continued Examination for hepatomegaly Labs :

Bili T/D ?Hemolysis - SGOT, SGPT, LDH, Retic, CO-Hgb Maternal ABO Liver Function Studies

Management

Hydration Phototherapy

Isomerize unconjugated bilirubin

Degrades bilirubin to biliverdin

Exchange transfusion

Newborn Isoimmune Hemolysis - Rh

Anti-D (Rh) Setup -

mother Rh-, IgG Antibody + infant is Rh+

Mechanism – Maternal anti-D IgG crosses placenta, binds

fetal rbcs, fetal macrophages destroy rbcs Consequences –

jaundice, anemia, CHF

Rh-Rh-

Rh+Rh+

Maternal Anti-DMaternal Anti-D

MotherMother

BabyBaby

Prevention and Treatment

Prevention Administer Rhogam (IM anti-D antibody) at

28 weeks & at delivery Treatment (anti-D + mother)

Follow anti-D levels Amniocentesis (bilirubin) Fetal ultrasound – scalp edema

transfusion Infant – Exchange transfusions

Isoimmune Hemolysis - ABO

ABO Incompatibility Setup:

mother type O Mechanism:

Same Antibody is usually anti-A isohemaglutinnin

Infant: Jaundice before anemia Spherocytes – rbc membrane destruction

O +/-O +/-

A+ A+

Anti A & BAnti A & B

MotherMother

BabyBaby

Congenital Hypoplastic Anemia

Blackfan-Diamond Anemia Fault in one of the early steps of red

blood cell production 25% have a gene called RPS19

(short for 'small ribosomal protein 19') Symptoms

Fatigue, pallor, “open mouth” facies, protruding scapulae,web neck, cardiac abnormalities

Congenital Hypoplastic Anemia Dx:

Infantile normochromic, macrocytic anemia Reticulocytopenia Normocellular marrow with deficiency of rbc

precursors Nl or sl wbc Nl or sl platelets

Rx: Transfusions, steroids, marrow transplant

Common Anemias - Children & Adolescents

Iron Deficiency Lead poisoning Destructive Anemias

All Ages Anemia Definition Numerical -- Reduction in Hgb Level

> 2 S.D. Below the Population Mean

10

11

12

13

14

15

0.5-4yrs

5-7yrs

8-11yrs

12-14yrs

15-17yrs

18-50yrs

Hgb-Female

Hgb-Male

Clinical Definition

Generic Multisystem failure; Global CNS

depression Infants

Poor Feeding; Tachypnea; Apnea; Irritability

Children Poor Growth; Learning difficulties; Fatigue

Teens Headache; Fatigue; Poor school and

athletic performance

Tissue O2

Reasons for Investigating

General Health -- Sxs: Fatigue, headache, cardiac

failure Sign of Underlying Illness

Malnutrition; Lead poisoning; Marrow disease; Hypothyroid

Genetic Counseling

Evaluating an Anemia

Destruction Production Loss

Immune

Not Immune

GI

Marrow Disease

Marrow Invasion

Increased Destruction

Immune Not Immune

ABO

Rh

AIHA

EBV

SLE

Intrinsic Extrinsic

Enzyme

Membrane

HGB

DIC & Sepsis

Burns & Heat

Toxins

Heart Valve

Decreased Production

Marrow Disease Marrow Invasion

Nutritional Iron; Copper; FolateMetabolic Thyroid; B-12;Failure Aplastic Anemia Myelodysplasia InfectionCongenital Fanconi; BFD

Malignant Leukemia Neuroblastoma Lymphoma Solid TumorNon-Malignant Histiocytosis Storage Disease

Anemia Toolkit

First Step – History, family history, ROS Labs:

CBC – define anemia; rbc morphology; Retic – Helps with RBC destruction/production RBC Destruction – LDH, ALT(normal),AST( ),

CO, Haptoglobin ( in intravascular hemolysis) Urtinalysis – Hematuria Detailed tests then based on mechanism/sxs

Iron Deficiency

Physical Performance & Growth Restless Leg Syndrome Weakness, Dyspnea, Sexual dysfunctions Headaches

Intellectual Performance & Growth Attention Deficit Disorder, Cognitive or behavioral

dysfunction, fatigue, depression GI: pica, anorexia, headache, burning tongue, Endocrine: increased menstrual blood Immune: Increased severity of infections Skin: pruritis, paresthesias, pallor

Glossitis

Angular Chelitis

Koilonychia

Stages of Iron Deficiency

1. Decreased stores ( ferritin)2. Transferrin saturation3. Morphologic Changes

1. Anisocytosis2. Normochromic, normocytic anemia3. Hgb, MCV, MCHC; thrombocytosis

4. Bone marrow depletion

Causes

Blood loss GI: Cow’s milk in infants, Celiac disease Menses: 20% teenage girls are deficient Respiratory loss is rare

Dietary Nursing: 1 mg/kg/day required for term

infants starting at 4 months of age Children who drink a lot of milk Age 1-2 years; Female 14-30; Pregnancy; Males > 12 are OK (low requirement;

carnivorous)

Laboratory Dx

CBC terminology Peripheral Smear Iron Studies

Normal Blood Smear

Iron Deficiency Smear

Iron Studies

IronIron

IronVaries

TIBC NL

TIBC TIBC Varies

Normal Fe Deficient Chronic Disease

•Iron

•TIBC (transferrin)•Ferritin

Normal Fe Deficient ??? Chronic disease

Serum Ferritin

Generally correlates with iron stores Nl ferritin @ 6 mos-15 years lower than

other ages Taking Fe increases ferritin Normal Ferritin

Newborn: 25-200 ng/ml or SI units 1st month: 200-600 2-5 months: 50-200 > 5 months: 7-140 Adult Male: 20-250 Adult female: 10-120

Soluble Transferrin Receptor

Using TF Receptor

The concentration of cell surface transferrin receptor is regulated according to the internal iron content of the cell and its iron requirements.

Iron-deficient cells contain increased numbers of receptors, while receptor numbers are downregulated in iron-replete cells

Reference intervals: 3.5– 8.5 mg/L

Diagnoses with TR

Serum concentrations of transferrin receptor increase in iron-deficiency anemia

Transferrin receptor concentrations do not increase in anemia secondary to inflammatory disorders

Treatment

Iron replacement 3mg/kg elemental Fe daily X 3 months Poor compliance is main reason for failure Retics increase after 3 days; Hgb by 1

week GI absorptive defect very rare -

use intravenous Fe (not IM) Transfusion needed only if anemia is

hemodynamically very significant

Lead Poisoning

• Physiology – Absorbed like iron from air, paint, dirt, dust– Inhibits 1st and last steps in Hgb production– -ala and EPP basal ganglia damage– Disrupt CNS heme synthesis

Sources

Homes built before 1960 Ongoing home renovation Lead in water pipes Nearby industry Old furniture, toys, art supplies

Acute Neurological: hyperactivity or lethargy; increased

sleep; ataxia; coma, seizures, respiratory arrest Renal: Fanconi nephropathy

Chronic Neurological: behavioral changes, peripheral

neuropathy with pain & weakness of extensors, deteriorating cognitive function - even with mildly elevated Lead levels of ~ 20 mcg/dl

GI: abdominal pain, vomiting, malaise, constipation

Skeletal: Lead lines

Symptoms

Diagnosis

Increased serum lead level (veinipuncture)

CBC with microcytosis and basophilic stippling

X-ray: dense metaphyseal bands

Basophilic Stippling

Dense Metaphyseal Bands

Treatment

Asymptomatic: level 20-44 - consider chelation Level 45-69 - urgent chelation Level > 70 - emergency chelation

Symptomatic children require immediate supportive care and aggressive chelation

Identify the Source of Lead Quarantine the house Follow-up closely The state of Maine will help with all of this

Anemia of Increased Destruction

Intrinsic Hemoglobin disorders

Hgb SS Thalassemia

Membrane HS -- Stiff membrane

Metabolic PK

Extrinsic Autoimmune, mechanical, DIC

Laboratory Findings

Heme: retics; anemia; abnl smear Chem: LDH, AST (SGPT); haptoglobin Urine: Hgb (vs. myoglobin)

Sickle Cell Anemia

Pathophysiology Clinical

Autosplenectomy & OPSI Acute splenic sequestration Aplastic Crisis Vaso-occlusive crisis Stroke Endocrinopathies

Pain with Sickle Cell Disease

The most common symptom is pain Pain crises –people go to the emergency room

to get treated Pains seem to come from the bones, usually in the

arms, hands, legs, feet, or back acute chest syndrome Some have been accused of being addicted to pain

meds Prevention – avoid dehydration, excess exercise Rx – pain meds; hydration; steroids

-Thalassemia

1o problem is ineffective hematopoiesis -thal trait

Asymptomatic Low MCV, +/- mild anemia

-thal major Severe disease-some recommend BMT Severe anemia (hgb ~ 5) Progressive Fe overload causes morbidity &

mortality - cardiac, endocrine, liver Rx: Support; BMT

Hereditary Sphereocytosis

Defective membrane (stiff) Intrasplenic hemolysis Clinical

Varying degrees of severity Aplastic crises Anemia Increased MCHC Cholelithiasis WHY? Folate deficiency

Blood SmearSpherocytes

Osmotic Fragility

[NaCl] % Lysis % Lysis

1.0% NS (plasma) 0 0

.75% NS 10 20

.50% NS 30 60

.25% NS 70 90

.00% NS (water) 100100

•Normal •HS

Management

Follow infant Hgb & bilirubin closely Follow reticulocyte counts when well Follow growth & “wellness” Folic acid supplementation Rx aplastic crises with patience and

transfusion or steroids if necessary Splenectomy based on clinical course

Case Studies EndCase Studies End

Spherocytosis Case

7 year old boy, + OF and family history Taking folic acid daily 2 years of difficulty keeping up with

peers Retics ~ 15%, Hgb 9 mg/dl PE: Thin, short; spleen 8 cm below LCM

What needs to be done?

New labs show normal thyroid, celiac, growth hormone.

Options?……

Childhood Hemolytic Anemia

Autoimmune - antibody mediated Idiopathic Drug-Induced Disease-related

Infections - Viral (EBV, HIV), mycoplasma Autoimmune - SLE, RA, Thyroid, UC Immunodeficiency - all of them Cancer - Hodgkin’s, ALL, NHL, etc.

Clinical Course

Age usually < 4 yrs Acute onset - rapid Hgb fall 0-4 days Course can be acute (3-6 mos) or

chronic Mortality 9-19% Clinical: pallor, jaundice, dark urine,

fever, abdominal pain, hepatosplenomegaly, CHF

Diagnosis

Evidence of hemolysis Blood Smear: spherocytes; retics DAT - Direct antibody test

Macro (> 1000 IgG molecules/rbc) Micro (detects > 100 molecules/rbc)

Treatment

Observation Corticosteroids Intravenous Immunoglobulin (IVIG) Transfusion -- need a good lab Exchange transfusion - severe CHF Plasmapheresis Splenectomy Rituximab: anti-CD20 (new & cool)

Mechanical Destruction

DIC Sepsis, coagulopathy, tissue necrosis

Thermal burns, heatstroke

Infection Hardware

heart valve, thrombosed CVL Surgery - cardiac

Case Studies

Case 1 12 hr old black male term infant with jaundice Mother is 25 yrs. Old, G2P1001, O-, serology

-, uncomplicated pregnancy, received Rhogam @ 28 weeks

Infant is clinically well, has not voided or stooled

Labs: Bilirubin 16/0.5 CBC: WBC 21,000 60p/5b/27lymphs Hgb 16/ Hct 50; Platelets 165 K Peripheral Smear Type & Coombs: A+; DAT +; IAT + (anti-A)

Blood Smear

Case 2

5 yr old white male with a 4 mo. hx of irritability and inattention at school

Social hx: Lives with parents and 2 siblings in an old apartment that is under repair.

Family hx: “We all fed our babies whole milk, and nobody ever had a problem!”

Past hx: mild developmental delay. PE: hyperactivity; pale conjunctivae;

hyperreflexia;

Case 2 Labs

CBC-WBC 9,000, normal differentialHgb 9.0/Hct 27, MCV 72, Platelets 220 KSmear

Retics: 1%Lead: 21 mcg/dlFerritin: 5Fe low; TIBC elevated

High Power

Low Power

A Different Scenario

PE: grade II systolic murmur; no CHF Hgb: 4.9 MCV: 63 Retics: 0.5% WBC 6000, 10 polys, 90 lymphs Platelets: 1,300,000

Management Options

Dx: Fe Deficiency

Consider Hospitalization

Rx: Fe, 3-6 mg/kg/day

Folate, 1 mg/day

Retic in 3 Day Hgb in 1 Week

? Transfusion Continue Fe & Folate X 3 mos

Case 8

3 year old child presents for WCC. Parents note 2 months of increasing pallor & fatigue. No medical care since 4 months of age. Several recent colds.

Both parents are of Italian descent. Apartment is 80 years old & under repair.

PE: slightly pale. No dysmorphic features. Grade III SEM, no gallop. Liver down 2 cm.

Case 8 Labs CBC:

WBC 8,000 40 polys, 60 lymphs Hgb 3.8 Hct 11.9 MCV 80 Platelets 190 K Smear Retics: 0.5% Lead: 15 mcg/dl Ferritin: 50 Hgb Electrophoresis: A1= 97%; A2= 2%;

F=1% Bone marrow: decreased rbc precursors

Another Scenario

CBC- WBC 8,000 with a normal differential Hgb 3.8 Hct 11.9 MCV 100 Platelets 400,000 Smear: 2+ polychromasia, 1+ nrbcs Retics: 5% Bone marrow: increased RBC

precursors

Case 12 CC: 4 yr. old girl, 1 week of pallor & jaundice HX: Started with fever, malaise, congestion Progressive pallor, fatigue, abdominal

pain PE: Vitals: HR 130; RR 27; obvious pallor HEENT: Scleral icterus Cardiac: Grade II systolic murmur Abdomen: Spleen 5 cm below RCM

More History

Neonatal jaundice Transfused once in infancy Several similar episodes in past

Family History

Mother “always” anemic Mother and her sister with

cholecystectomy in early 20’s Mother’s Father had splenectomy “many

years ago”

Lab Tests

Hgb: 5.5 gm/dl MCHC: 32 Retic: 0.1% WBC & Platelets: Normal Coombs: Negative Smear

Break Time!

Grazing Horse, Freeport

Bilirubin MetabolismBilirubin Metabolism

Intravascular

Extravascular

Free Hgb+

Haptoglobin

Fe + Transferrin

Free Hgb

Red cells contain SGOT

& LDH

All Fe is recycled

The CBC - Definitions

WBC : Total leukocytes per mm3

ANC: Total # neutrophils per mm3

Hgb: Grams Hgb/dl Hct: % rbcs in a spun tube of blood MCV: mean rbc volume MCHC: mean Hgb concentration Platelets: # per MPV: mean platelet volume

Spun Capillary Tube

Blood Smear

Normal