Haematology

Top Ten Tips for ‘not quite right’ Haematology

As a general rule, patients with:
– Lymphadenopathy or Splenomegaly
– Weight loss/fevers/night sweats
– Other FBC abnormalities
– Hx of thrombosis Need to be referred to Haematology

If none of the above, usually recommend repeating test in 4-6 weeks with blood film Extend monitoring to 3 months, then 6 or 12 monthly. Non-progression is reassuring.

 

1. Polycythaemia

• Hb >147/166, raised haematocrit >0.44/0.48

Have confidence in trying to normalise the sample.

Hydration. Tourniquet free! Smoking. Alcohol. Anabolic steroids. Apnoea. Thiazides etc…

2. Anaemia

• Hb <13.5 in males, <11.5 females

Trial oral iron if patients have anaemia with hypochromia/microcytosis but ferritin normal.

Consider iron studies, but normal circulating iron/ferritin doesn’t exclude cellular deficiency.

3. Macrocytosis

• MCV >96

There is little of haematological concern UNLESS other FBC abnormalities present

Perform immunoglobulins and reticulocytes

Refer if persistently and inexplicably >104

Many may only need 6-12 monthly monitoring

4. Thrombocytosis

• Platelets >450

Think about iron deficiency anaemia

Think about CXR

If platelets >450 but <600 can consider 6 monthly monitoring in preference to referral

5. Thrombocytopenia

• Platelets <150

Worth bearing in mind most surgical procedures can be performed with platelets >50

Liver disease/alcohol – strong contenders. And PPIs!

Refer if persistently, inexplicably less than 80 – don’t worry too much if above 80 and stable without other cell line abnormalities

6. Leucocytosis

• Refer if over 20
• Eosinophilia = eosinophils >0.5
• Usually reactive to something rather than haematological cause
• Refer if inexplicably >1 for >3 months or >2 for >6 weeks
• Monocytosis
• Refer if chronically >1

7. Neutrophils

• Neutrophilia = neutrophils >6.5
• Consider metabolic syndrome
• Refer if >15
• Neutropenia = Neutrophils <2 (or <1 depending on ethnicity)

Infection risk increases greatly <0.5

PPIs!

Repeat at 4-6/52

Refer if inexplicably remains 1-1.5

8. Lymphocytes

• Lymphocytosis = lymphocytes >3
• Yes it may be CLL but can grumble on for years and don’t need to be seen until >10
• Consider metabolic syndrome
• Lymphopenia = lymphocytes <1
• Usually transient. Repeat!
• Common in elderly
• Viral infections, consider BBV screen

9. Paraproteinaemia

• Only interested in raised immunoglobulins if there’s an associated paraprotein band

Polyclonal gammopathy isn’t concerning from a haematology point of view

• Implies a non-specific immune reaction

10. The PRESS portal

All Sheffield CCG referral guidelines can be found here

Haematology presentation from PLI 05/2/20

Sheffield PRESS Portal Haematology (sheffieldccgportal.co.uk), includes GP guidance for the following presentations:

Anaemia guidelines

Eosinophilia

Leucocytosis Guidelines

Lymphadenopathy Guidelines

Lymphocytosis Guidelines

Macrocytosis Guidelines

MGUS Guidelines

Neutropenia Guidelines

Paraproteins Guidelines

Polycythaemia Guidelines

Thrombocytopenia Guidelines

Thrombocytosis Guidelines

Lab test online Patient Education on Blood, Urine, and Other Lab Tests | Lab Tests Online-UK, particularly for interpreting iron studies Iron Studies (labtestsonline.org.uk).

NB concerns regarding possible haemochromatosis should be directed to Gastroenterology, not Haematology.

A summary of the changes in iron tests seen in various diseases of iron status[1]:

[1] Iron Studies (labtestsonline.org.uk)

Disease	Iron	TIBC/Transferrin	UIBC	% Transferrin Saturation	Ferritin
Iron Deficiency	Low	High	High	Low	Low
Haemochromatosis	High	Low	Low	High	High
Chronic Illness	Low	Low	Low/Normal	Low	Normal/High
Iron Poisoning	High	Normal	Low	High	Normal

 

GP Notebook General Practice notebook (gpnotebook.com), particularly for immunoglobulin queries.

IgA immunoglobulins (IgA (summary and causes of reduced and increased levels)) – General Practice notebook (gpnotebook.com)

IgG immunoglobulins (IgG (summary and causes of increased and reduced levels)) – General Practice notebook (gpnotebook.com)

IgE immunoglobulins (IgE (summary and causes of increased and reduced levels)) – General Practice notebook (gpnotebook.com)

IgM immunoglobulins (IgE (summary and causes of increased and reduced levels)) – General Practice notebook (gpnotebook.com)

Appropriate primary care considerations/investigations for immunoglobulin abnormalities would include:

• Repeat at > 6-8 weeks (changes can be transient)
• Serum electrophoresis and assessment for B-symptoms (if no abnormalities found then an underlying haematological cause is unlikely and ongoing concerns are best directed to immunology)
• Urinalysis for protein and other signs of protein loss such as oedema, hypoalbuminaemia
• Liver function tests and signs/symptoms of, or risk factors for, liver disease
• Autoimmune screen and assessment for signs/symptoms of autoimmune conditions
• History for severe, persistent, unexplained or recurrent (SPUR) infections

Sheffield Laboratory Medicine Sheffield Laboratory Medicine Tests, details of all tests performed by STH labs including indications, sample requirements and test request forms for tests advised by CASES peer reviewers that may not be available on ICE.