HEMATOLOGY Hot Topics and Morphology

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HEMATOLOGYHot Topics and Morphology

• BCSLS Telehealth Broadcast
• June 16, 2005
• Kin Cheng
• higbc_at_yahoo.ca

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CASE 1

• 76 year old female
• Previously well
• Acute back pain and vomiting after mowing the
  lawn

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• Physical (1000 PM)
• Afebrile P-108 BP 139/69
• Alert and oriented but deathly ill looking
• Soft, non-tender abdomen with bowel sounds

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MCHC gt365

• Hematocrit RBC x MCV
• MCH Hgb / RBC
• MCHC Hgb / Hct
• 3 x RBC Hgb
• 3 x Hgb Hct

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MCHC gt365 Handling

• Cold agglutinin Warm sample
• Lipemic, icteric, hemolysed Saline replacement
• Protein Warm specimen, rerun
• Spherocytes

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SPUN SAMPLE
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Spun Hct 0.11
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Pre Post Saline Replacement
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Manual Differential

• Neuts 5.0
• Lymphs 2.7
• Eos 0.1
• NRBC 5 / 100 WBC

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Agar Plate
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Histogram
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• Intubated at 0130
• Hypotensive post-intubation
• ICU bed found at referral centre (0400)
• Arrested in transit (0430)

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• Autopsy
• green discoloration of skin with skin slippage
  and advanced organ autolysis
• No identifiable source of sepsis

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Clostridial Gas Gangrene

• 6/150 species capable of causing gas gangrene
• Toxin and gas producing bacteria
• Lethal
• Necrotize soft tissues
• Clostridial myonecrosis Common surgical
  infection if poor surgical technique

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Clostridial gas gangrene

• Anerobic, gram pos bacilli (Hematology stain is
  NOT gram stain)
• Spore forming bacteria
• Found in soil, contaminated raw meat and poultry,
  normal skin, colon flora

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Clostridial infection

• 80 caused by C. perfringens
• 20
• C. novyi
• C. septicum
• C. bifermentans
• C. histolyticum
• C. fallax

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Clostridium perfringens (welchii)

• Produce 12 types of toxins (lecithinase)
• Extraordinary spectrum of clinical manifestations
  from transient bacteremia to gas gangrene or
  sepsis with hemolysis
• Rate of myonecrosis 2 cm/hr
• Fatal within 12 hours.

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C. perfringens

• Introduction of bacteria into tissues
• Bacterial proliferation in low (lt30) oxygen
  environment
• Incubation period 1 12 hrs
• Release exotoxin

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C. perfringens

• gt17 Exotoxins
• Lecihinase
• Collagenase
• Hyaluronidase
• Fibrinolysinhemolysin

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C. perfringens

• Alpha toxin lecithinase
• Destroys red cell membranes, muscle cells,
  platelets and WBC
• Induces platelet aggregation and clot formatioin
• Kappa toxin destroys connective tissues
• Theta toxin Destroys WBC and disarms
  inflammatory responses.

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Clostridium spp
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C. perfringens

• Massive intravascular hemolysis
• Hb-emia, Hb-uria, hyperkalemia
• Renal failure, coagulopathy
• Often fully conscious with normal BP
• Shock and death 70-100 mortality
• Survival measured in hours

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C. perfringens

• Elderly and immunocompromized
• Cancer patients with mucosal disruption
• Chemotherapy radiotherapy
• Tumor infiltration
• Malnutrition
• Hepatobilliary disease, liver abscess, colonic
  perforation, trauma or surgery
• Septic abortion / ruptured ectopic pregnancy

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Case 1

• Despite absence of effective RBC mass patients
  transiently maintain normal BP and mentation
  presumably due to free Hb
• Maintenance of intravascular oncotic pressure
• Maintenance of adequate tissue oxygenation

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Questions??

• higbc_at_yahoo.ca
• kin.cheng_at_fraserhealth.ca