Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Is there any indication for hydroxyurea in patients with sickle cell trait?
No. Of course, be sure it is the correct diagnosis and not HgA + HgS (beta+) which, as you know, shows HgA and HgS on electrophoresis and can/will be called trait if not looked at by someone experienced to note if A> S or if S > A. If MCV is low. If HgA2 is up. HgF up etc... If indirect Bili/LDH/AST...
Would you start anticoagulation in a patient with provoked blood clot in the past now with labs done for rheumatological reasons showing triple positive APLA?
The short answer is that I would probably not anticoagulate this patient as a history of prior thrombosis is hard to connect to the currently positive APL antibodies. I would certainly obtain a second set for future risk stratification. However, there are several variables that could influence the ...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
How do you manage patients with embolic stroke of an undetermined source and a papillary fibroelastoma found on an echocardiogram?
The definitive treatment is surgical, and the only way of knowing for certain that the lesion is a fibroelastoma is to perform surgery and obtain pathology. If a patient is not a candidate for heart surgery, anticoagulation could be tried.
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
How do you manage mild Type 1 von Willebrand disease undergoing wisdom teeth removal?
This depends on the patient's past personal and family bleeding history with past challenges and on the VWF levels. If past challenges are known and no bleeding has occurred, and if the VWF levels are 30 IU/dL or greater, I would give only EACA p.o. pre and post. Intranasal DDAVP 2 hours prior and 4...
Is there a correlation between spleen size and degree of thrombocytopenia?
In a normal individual, approximately 1/3 of total body platelets are sequestered in the spleen at any given time. As the size of the spleen increases, so too does the proportion of platelets in the spleen increase. This is due to the total volume of the spleen, not just longitudinal measurement. It...
Would you consider continuing or re-trialing hydroxyurea for sickle cell patients after development of a leg ulcer?
I do not think HU is the cause of leg ulcers, neither does ASJ. Habibi et al., Blood 2023 Most cases of ulcers are multifactorial and studies have also included patients with thrombocytosis (even myeloproliferative disorders!!). Low nitric oxide is part of the cause of leg ulcers in most cases. HU r...
How do you manage severe lenalidomide-associated drug rash in a transplant-eligible patient with multiple myeloma?
A rash with lenalidomide occurs in up to a third of patients exposed, and it's likely that dose corresponds directly with rash severity. While excellent desensitization protocols appear effective (PMID 31400463), most of us want to be able to deal with this with a phone call or text message that inc...
Is a very rapidly rising WBC count ever an indication for the upfront treatment of CLL?
This situation, fortunately, does not arise frequently in CLL. But, when it does occur, it is a vexing question. According to the recommendations and guidelines of iwCLL, in absolute terms, the answer (to this question which is worded very carefully) is "NO". But, in my view, there is room for some ...