Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
Can a patient still have primary HLH even in the absence of any HLH associated genetic mutations?
Yes, a patient can still have primary Hemophagocytic Lymphohistiocytosis (HLH) even in the absence of identified HLH-associated genetic mutations.Primary HLH, also known as familial HLH, is typically linked to mutations in genes related to the immune system, such as PRF1, UNC13D, STX11, STXBP2, and ...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...
How do you modify the hemoglobin goal and ESA dosing for patients with sickle cell anemia and ESKD on hemodialysis?
In sickle cell patients, I coordinate care with the patient's hematologist. I will reduce the hemoglobin goal to 8-10 g/dl, and if patients have a history of crises, closer to 10 g/dl, I may choose 7-9 g/dl. ESA requirements seem to be higher in sickle cell patients, so I would start with 100 units/...
Do you use anti-microbial prophylaxis when you prescribe ibrutinib?
Traditionally, H.Zoster and PJP prophylaxis was more routinely administered in CLL patients receiving chemoimmunotherapy as these regimens were typically more myelosuppressive as well as immunosuppressive. In the era of the novel BCR receptor agents with the approval of ibrutinib and idelalisib and ...
What is the optimal management of a patient with refractory TTP who has had poor response to plasma exchange, steroids, rituximab, especially when caplacizumab is unavailable?
Caplacizumab would obviously be the best thing right now, but if unavailable, there are some data with cyclosporine as well as bortezomib and cyclophosphamide to help with more refractory disease. These measures, unfortunately though, will take some time to have an effect. Intensification of plasma ...
What is your preferred treatment for refractory warm autoimmune hemolytic anemia with autoimmune neutropenia?
For immunomodulation, have you trialed IVIG? If not, this would be worth a trial. For immunosuppression, I prefer to utilize a more T cell-directed agent after failure of steroids/rituximab. Thus, a trial of MMF or cyclophosphamide may be reasonable. I think MMF may take too long to work in a situat...