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Classification of anemia
Microcytic, hypochromic anemia e.g. iron deficiency anemia
Normochromic, normocytic anemia e.g. recent blood loss
Macrocytic anemia e.g. folic acid deficiency, vitamin B12 deficiency
Treatment
Petchrod,Thanat 2
Role of iron
- essential metallic component of heme
- heme combined with appropriate globin chains forms hemoglobin (Hb)
Pharmacokinetics: Absorption
Iron is best absorbed in ferrous form (Fe2+)
Absorption is maximum in duodenum because acid medium of stomach and mucopolysaccharide
chelator substances that prevent iron from precipitating maintain iron in soluble form
Food interferes with iron absorption therefore it should be administered 1 hr or more before meal
Iron must be taken with food if patients experience nuasea and diarrhea when taking on empty
stomach
At alkaline pH, iron tend to form insoluble complex (unavailable for absorption)
Antacid or medication that reduce stomach acid production impairs iron absorption
Clinical use
Treatment or prevention of iron deficiency anemia
ferro
us
sulfat
eferro
300
mgus
fumar
ferrou
ate
s
200
gluco
mg
nate
300
mg
Iron toxicity
Acute toxicity
- most common in children & usually occurs as a result of accidental ingestion of iron therapy
- urgent treatment is necessary lavage with carbonate solutions, desferoxamine, deferiprone
(licensed in UK)
Adverse effect
is a cofactor in the transfer of one-carbon units (step necessary for DNA synthesis)
essential nutrient for hematopoiesis, maintenance of myelin in the nervous system, and production of
epithelial cell
Frequent cause of Vit.B12 deficiency is atrophic gastritis leading to lack of intrinsic factor
Besides megaloblastic anemia, damage to mucosal linings and degeneration of myelin sheats with
neurologic sequelae will occur (pernicious anemia)
Clinical use
- oral cyanocobalamin is well absorbed (peak serum conc.being reached 8-12 hr after ingestion)
Folic acid
is necessary for synthesis of purines & for the formation of thymidylic acid
body store is very low, so a decrease in dietary intake is followed by anemia within a few months
Folates are found in fresh foods but rapidly destroyed by heating during food preparation
Cause of deficient
Insufficient intake
Malabsorption in GI diseases
Increased requirement during pregnancy
Antiepileptis drugs (phenytoin, primidone, phenobarbital) may decrease FA absorption
Clinical use
Megaloblastic anemias
Folic acid deficiency due to malabsorption syndrome and due to continuous use of anticonvulsants,
particular primidone and phenytoin
Erythropoietin
Colony-stimulating factors
Thrombopoietin
Petchrod,Thanat 6
Erythropoietin
Regulates red cell production
2 forms of recombinant human erythropoietin: epoetin alfa and epoetin beta (similar activity)
Given iv.,sc. or ip.
Greatest response with sc.injection
Fastest response with iv.injection
Clinical uses
Anemia of chronic renal failure
Petchrod,Thanat 7
Colony-stimulating factors
Stimulate committed progenitor cells and cause irreversible differentiation
GM-CSF: granulocyte-macrophage colony-stimulating factors
G-CSF: granulocyte colony-stimulating factors
Given sc. or iv.
Clinical uses of CSFs
To reduce severity and duration of neutropenia induced by cytotoxic drugs during
To stimulate release into circulation of progenitor cells
To expand the number of harvested cells ex vivo before re-infusing them
For persistent neutropenia in advanced HIV infection
Aplastic anemia
Adverse effects
GM-CSF can cause:fever, skin rashes, muscle pain, hypotension, GI symptoms, and arterial oxygen desaturation
Thrombopoietin
Stimulate proliferation of progenitor cells of platelets
Recombinant thrombopoietin is being tested clinically
Petchrod,Thanat 8
LYMPHOID NEOPLASMS
• Lymphoma
• Hodgkin lymphoma
• Acute leukemia
• Acute lymphoblastic leukemia
• Acute myeloid leukemia
• Chronic leukemia
• Chronic lymphocytic leukemia
• Chronic myeloid leukemia
Lymphoid Neoplasms
B-cell neoplasms
• Precursor B-cell neoplasms
• Mature B-cell neoplasms
T-cell and NK-cell neoplasms
• Precursor T-cell and NK-cell neoplasms
• Mature T-cell and NK-cell neoplasms
Lymphoma
NON-HODGKIN LYMPHOMAS
Clinical Features
Nodal Extranodal
Painless lymphadenopathy Upper respiratory tract : nasal cavity
B-symptoms Gastrointestinal tract
o Fever > 38 °C Skin
o Night sweat
o Weight loss > 10% of body
weight
Classification
Rappaport classification
Lukes and Collins classification
Keil/Lennert classification
Working formulation
REAL classification
WHO classification
Working formulation
Petchrod,Thanat 11
WHO classification
à Morphology
à Immunophenotype
à Genetics
à Clinical informations
Precursor cells : immature cells
Peripheral cells : mature cells
Petchrod,Thanat 12
B-cells
T-cells and NK-cells
• Precursor B-cell neoplasms
Acute lymphoblastic leukemia/lymphoma
• Precursor T-cell neoplasms
Acute lymphoblastic leukemia/lymphoma
Follicular lymphoma
Burkitt lymphoma/leukemia
Petchrod,Thanat 15
HODGKIN LYMPHOMAS
Clinical Features
Nodal
Painless lymphadenopathy : cervical region
B-symptoms (25%)
Extranodal
Rare
Splenomegaly
• Lymphocytes
• Eosinophils
• Plasma cells
• Neutrophils
WHO classification
• Nodular lymphocyte predominance Hodgkin lymphoma (nLPHL)
PLASMA CELL
NEOPLASMS
• Immunosecretory disorders
• Expansion of single clone of immuno-secreting B-cells
• Secrete single homogeneous immunoglobulin à M-component or monoclonal component
Classification
WHO classification of Plasma cell neoplasm
• Plasma cell myeloma (multiple myeloma : MM)
• Plasmacytoma
• Immunoglobulin deposition disease
• Osteosclerotic myeloma (POEMS syndrome)
• Heavy chain disease
• Alpha-globulin
Alpha1-globulin : Alpha1-antitrpsin
Alpha2-globulin : Haptoglobin
• Beta-globulin
Lipoprotein, Transferrin, Plasminogen and complement
• Gamma-globulin
Immunoglobulin
Petchrod,Thanat 19
• Hypercalcemia
• Renal insufficiency
M-component (IgD, Bence Jones protein)
Hypercalcemia
Dehydration
Hyperuricemia
Nephrotoxic dugs
• Infection
LYMPHADENOPATHIES
Lymph nodes enlargement
• Reactive lymphadenopathy
• Reactive hyperplasia
• Atypical hyperplasia
• Lymphadenopathy associated with clinical syndrome
• Infection
• Neoplasm : lymphoma, leukemia, metastatic tumor
REACTIVE LYMPHADENOPATHY
Reactive lymphoid hyperplasia (reactive hyperplasia
• Increased cellularity of lymph nodes
• Palpable mass ~ 1 cm.
• Axilla, inguinal, cervical and supratrochlear
Atypical lymphoid hyperplasia (atypical hyperplasia)
• Condition between benign and malignant condition
à Reactive condition
à Malignant lymphoma
Petchrod,Thanat 21
Dermatopathic lymphadenopathy
• Associated with chronic skin lesion
Petchrod,Thanat 22
Kimura lymphadenopathy
• Asian
• Female > male, 27-40 yrs
• Slowly lymph node enlergement
• Head and neck à auricular area
• Eosinophilia
• Increased serum level of IgE
Kikuchi-Fugimoto lymphadenopathy
• Asian, female
• Painless cervical lymphadenopahty with fever and myalgia
Petchrod,Thanat 23
INFECTIOUS LYMPHADENITIS
• Bacterial lymphadenitis
• Ordinary bacterial lymphadenitis
• Mycobacterium lymphadenitis
• Mycobacterium avium-intracellulare lymphadenitis
• Cat-scratch disease
• Fungal lymphadenitis
• Viral lymphadenitis
• HIV lymphadenitis
• Infectious mononucleosis lymphadenitis
• Protozoal lymphadenitis
HIV lymphadenitis
Petchrod,Thanat 24
Cat-scratch disease
• Rochalimaea hensalae
• Incubation period ~ 3 weeks
• Self-limited lymphadenopathy
Petchrod,Thanat 25