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HEMATOLOGY Hot Topics and Morphology

HEMATOLOGY Hot Topics and Morphology. BCSLS Telehealth Broadcast June 16, 2005 Kin Cheng higbc@yahoo.ca. 76 year old female Previously well Acute back pain and vomiting after mowing the lawn. CASE # 1. Physical (10:00 PM): Afebrile P-108; BP 139/69

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HEMATOLOGY Hot Topics and Morphology

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  1. HEMATOLOGYHot Topics and Morphology BCSLS Telehealth Broadcast June 16, 2005 Kin Cheng higbc@yahoo.ca

  2. 76 year old female Previously well Acute back pain and vomiting after mowing the lawn CASE # 1

  3. Physical (10:00 PM): • Afebrile P-108; BP 139/69 • Alert and oriented but “deathly ill looking” • Soft, non-tender abdomen with bowel sounds

  4. MCHC >365 • Hematocrit: RBC x MCV • MCH = Hgb / RBC • MCHC = Hgb / Hct • 3 x RBC = Hgb • 3 x Hgb = Hct

  5. MCHC >365 Handling • Cold agglutinin : Warm sample • Lipemic, icteric, hemolysed: Saline replacement • Protein: Warm specimen, rerun • Spherocytes

  6. SPUN SAMPLE

  7. Spun Hct: 0.11

  8. Pre & Post Saline Replacement

  9. Manual Differential • Neuts: 5.0 • Lymphs: 2.7 • Eos: 0.1 • NRBC: 5 / 100 WBC

  10. Agar Plate

  11. Histogram

  12. Intubated at 01:30 Hypotensive post-intubation ICU bed found at referral centre (04:00) Arrested in transit (04:30)

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

  14. 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

  15. 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

  16. Clostridial infection • 80% caused by C. perfringens • 20%: • C. novyi • C. septicum • C. bifermentans • C. histolyticum • C. fallax

  17. 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.

  18. C. perfringens • Introduction of bacteria into tissues • Bacterial proliferation in low (<30%) oxygen environment • Incubation period: 1 – 12 hrs • Release exotoxin

  19. C. perfringens • >17 Exotoxins: • Lecihinase • Collagenase • Hyaluronidase • Fibrinolysin’hemolysin

  20. 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.

  21. Clostridium spp

  22. 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

  23. 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

  24. 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

  25. Questions?? • higbc@yahoo.ca • kin.cheng@fraserhealth.ca

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