Hematology Part 2 PDF

Hematology Part (2) “Dr. Gillan El-Kimary” White Blood Cell Disorders “Quantitative Leukocyte Disorders” Granulocytosis Agranulocytosis “ neutropenia “ Leukemias Lymphomas Multiple Myeloma...

Hematology Part (2) “Dr. Gillan El-Kimary” White Blood Cell Disorders “Quantitative Leukocyte Disorders” Granulocytosis Agranulocytosis “ neutropenia “ Leukemias Lymphomas Multiple Myeloma Granulocytosis Granulocytosis is an abnormally large number of granulocytes in the blood, most commonly associated with an increase in neutrophils. Neutrophilia is a total WBC count >11,000/μL with an absolute neutrophil count (ANC) >7,700/μL Etiology Infection, stress, smoking, pregnancy, and myeloproliferative disorders Noninfectious causes include burns, postoperative states, acute myocardial infarction, acute glomerulonephritis, and hypersensitivity reactions. metabolic conditions (diabetic ketoacidosis, preeclampsia, uremia), poisoning (with lead, mercury, …) rapidly growing neoplasms “ Neutropenia, Granulocytopenia” The 2 terms are commonly used interchangeably to note a reduced quantity of leukocytes. (ANC < 1,000/ μL) -----> increased susceptibility to infections Etiology Transient marrow suppression associated with viral infections such as Epstein Barr virus (EBV) Drug induced, either due to myelosuppression or antibody-mediated destruction (antineoplastics agents, antibiotics (sulfonamides, penicillins), anticonvulsants, anti- inflammatories, antithyroid agents ,diuretics. Autoimmune disorders such as rheumatoid arthritis, lupus erythematosus 1  Oral Health Considerations Prophylactic antibiotics prior to dental extractions Physician consultation Cyclic Neutropenia Inherited autosomal dominant disorder due to mutations in the gene for neutrophil elastase (ELA-2 ) , characterized by repetitive episodes of fever, mouth ulcers, and infections. Neutropenia recurs with a regular 21-day intervals, persists for 3 to 5 days Clinical and Oral Manifestations Periodic oscillations of neutrophil counts associated with fever and mouth ulcers , lymphadenopathy and infections are the key clinical hallmarks Recurrent aphthous stomatitis (RAS) “ the most common presenting symptoms” recurrent gingivitis, and periodontitis Leukemia Leukemia results from the proliferation of a clone of abnormal hematopoietic cells with impaired differentiation, regulation, and programmed cell death (apoptosis) It is defined by a rapid disease course which progresses over weeks to months. Leukemic cells multiply at the expense of normal hematopoietic cell lines, resulting in marrow failure, altered blood cell counts, and, when untreated, death from infection, bleeding, or both. Classification Acute leukemia 1. Acute Lymphocytic Leukemia( ALL) 2. Acute Myeloid Leukemia(AML) Chronic leukemia 1. Chronic Myelocytic Leukemia 2. Chronic Lymphocytic Leukemia Acute Leukemia Acute leukemia occur at any age (ALL) is commonly found in children (AML) is more frequently in adults The signs and symptoms results from either bone marrow suppression or infiltration of leukemic cells into other organs Gingival hyperplasia secondary to leukemia cell infiltration may be a first sign Clinical manifestations Anemia: fatigue, malaise, pallor, Thrombocytopenia: mucosal bleeding, petechiae Decrease leukocytic function: fever, local infections (infection of lung, urinary tract skin…), Lymphadenopathy Localized tumors consisting of leukemic cell infiltrate. Muscle/joints pain , laryngeal pain Chemotherapy-induced mucositis and infection, including herpes simplex ulcers and oral candidiasis, are commonly observed complications 2  Oral manifestations Pallor of oral mucosa, Atrophy of tongue coating Oral & gingival bleeding petechiae & ecchymosis Gingival Enlargement ,gingivitis ,periodontitis ,cheilitis Oral ulceration -->Ulcers large, deep irregular, No inflammatory halo Mucositis due to Chemotherapy Infection(Viral, Bacterial, Fungal) “ PHGS, RHL, candidiasis” Oral Health Considerations Prechemotherapy dental assessment, maintenance of oral hygiene, and management of periodontal infection to prevent oral and systemic complications during treatment. Symptomatic treatment for oral ulcers & candidiasis. Analgesic for pain. Antifungal, antiviral for oral lesions. Drainage of abscessed tooth. No surgery except in emergency “patient should be hospitalized” Spontaneous gingival bleeding: remove gross local factors, place subgingivally under pressure absorbable gelatin saturated + thrombin Chronic Leukemia Characterized by the presence of large number of well differentiated cells in the bone marrow. This distinguish chronic leukemia from acute leukemia in which immature cells predominate and the untreated clinical course leads to death in months. less pronounced marrow failure than acute leukemias. Staging is based on the extent of lymph node, liver, or spleen involvement and anemia, thrombocytopenia, or both Patients in late-stage disease, with severe thrombocytopenia (60 yrs) Etiology : unknown ( genetic and environmental factors, including EBV may be involved ) Clinical and Oral Manifestations The first sign is typically an asymptomatic enlargement of a supradiaphragmatic lymph node, often in the neck LNs enlarged causing pressure on organs. night sweats, fever, and weight loss, generalized pruritis involvement of Waldeyer’s ring structures may occur Imaging tests are key diagnostic aid ( CT and PET scan ) 3  Oral health consideration Patients who receive radiation in fields involving the cervical nodes will invariably have their salivary glands in the field and are at risk for xerostomia. Radiation induced caries (topical fluoride varnish, gel, or fluoride toothpaste can be used for caries prevention) risk of osteoradionecrosis (inferior border and angle of the mandible) Multiple Myeloma (MM) is a neoplastic plasma cell disorder that is characterized by clonal proliferation of malignant plasma cells in the bone marrow microenvironment, monoclonal protein in the blood or urine, and associated organ dysfunction Men - >45 yrs Etiology : genetic mutation It's called multiple myeloma as the cancer often affects several areas of the body, such as the spine, skull, pelvis and ribs Symptoms include fatigue, weakness, weight loss, bone pain, and recurrent infections focal osteolytic bone lesions, diffuse osteopenia, and pathologic fractures (result from increased osteoclast formation, osteoblast inhibition induced by MM cells) oral lesions that mimic common dental pathologies such as periapical or periodontal abscess, gingivitis, periodontitis, or other gingival enlargement or masses - pain, paresthesia of the inferior alveolar and mental nerves swelling, tooth mobility, and radiolucency - Radiographic changes in patients with MM include typical “osteolytic” lesions in the skull from the focal proliferation of plasma cells inside the bone marrow and jaw bone (mandible > maxilla) involvement Oral Health Considerations - Osteonecrosis of the jaw, resulting in symptomatic exposed nonhealing areas of the maxilla and mandible (as a complication of bisphosphonates therapy) - MM patients requiring dental surgery is the risk of hemorrhage. - Pre-dental surgical assessments should include radiographic assessment for plasma cell tumors of the jaw and CBC and coagulation studies. - Prevention of hemorrhage should be managed by consultation with the patient’s hematologist Thank you 4