What is the recommended workup and initial treatment for a newly admitted hematology (hema) patient?

Initial Workup for Newly Admitted Hematology Patients

All newly admitted hematology patients require a standardized diagnostic workup including complete blood count with differential, peripheral blood smear review, bone marrow evaluation when indicated, and comprehensive infectious disease screening, with the specific tests guided by the suspected diagnosis and clinical presentation.

Essential Clinical Information to Obtain

The treating clinician must provide or ensure accessibility of the following data to the pathologist 1:

• Patient demographics: Age, sex, ethnicity 1
• Hematologic history: Any prior hematologic disorders, known predisposing conditions or syndromes, prior malignancies 1
• Treatment exposures: Prior cytotoxic therapy, immunotherapy, radiotherapy, or toxic substance exposure 1
• Confounding factors: Recent growth factor therapy, transfusions, or medications that might obscure diagnostic features 1
• Family history: Hematologic disorders or malignancies in family members 1
• Physical examination findings: Neurologic examination, presence of tumor masses (mediastinal), tissue lesions (cutaneous), organomegaly 1

Core Laboratory Workup

Initial Blood Work (All Patients)

• Complete blood count (CBC) with differential and leukocyte differential 1
• Peripheral blood smear review by pathologist 1
• Reticulocyte count 1
• Coagulation studies: PT, PTT, INR, fibrinogen 1

Bone Marrow Evaluation

Bone marrow aspiration and biopsy should be performed when 1:

• Abnormalities exist in initial testing requiring further investigation for diagnosis
• Other cell lines are affected with concern for aplastic anemia
• Peripheral blood findings suggest acute leukemia or other hematologic malignancy 1

The pathologist must review bone marrow specimens and provide morphologic, immunophenotypic, and cytochemical data on which the diagnosis is based 1.

Infectious Disease Screening

Mandatory Screening Tests

All newly admitted hematology patients should undergo 1:

• HIV testing (if not already done)
• Hepatitis B virus (HBV) screening
• Hepatitis C virus (HCV) screening
• Helicobacter pylori testing (particularly for ITP patients)

Additional Infectious Workup for Immunocompromised Patients

For patients on or anticipated to receive immunosuppressive therapy 1:

• CMV screening
• EBV testing if evidence of lymphadenopathy, hepatitis, fevers, or hemolysis suggesting lymphoproliferative disease
• Initiate Pneumocystis jirovecii prophylaxis
• Initiate Mycobacterium avium complex prophylaxis

Specialized Testing Based on Suspected Diagnosis

For Suspected Acute Leukemia

Multicolor flow cytometry (8-10 colors) to distinguish myeloid, lymphoid, or mixed lineage blast origin 1

Cytogenetic analysis 1:

• Conventional karyotyping
• FISH (fluorescence in situ hybridization)
• PCR techniques for specific mutations
• NGS (next-generation sequencing) when available for risk stratification

Molecular testing should be performed to identify prognostic markers and guide treatment stratification 1.

For Suspected Immune Thrombocytopenia (ITP)

• Direct antiglobulin test (DAT) to rule out concurrent Evans syndrome 1
• HIV, HCV, HBV, H. pylori testing 1
• Nutritional evaluation 1

For Suspected Autoimmune Hemolytic Anemia

• Monospecific direct antiglobulin test (mandatory in diagnostic workup) 2
• Evaluation for secondary causes of AIHA 2

Admission Criteria and Urgency Assessment

Immediate Admission Required

Adults with newly diagnosed ITP and platelet count <20 × 10^9/L who are asymptomatic or have minor mucocutaneous bleeding should be admitted rather than managed as outpatients 3, 4.

Additional admission criteria include 4:

• Significant mucosal bleeding regardless of platelet count
• Social concerns or uncertainty about diagnosis
• Significant comorbidities with bleeding risk
• Patients on anticoagulant or antiplatelet medications
• Limited access to follow-up care

Outpatient Management Acceptable

Adults with established ITP and platelet count <20 × 10^9/L who are asymptomatic or have minor mucocutaneous bleeding can be managed as outpatients with expedited hematology follow-up 3.

Patients with platelet counts ≥30 × 10^9/L who are asymptomatic can be observed without corticosteroid treatment 4.

Hematology Consultation Requirements

Urgent Consultation (24-72 hours)

• Newly diagnosed ITP with platelet count <20 × 10^9/L 3, 5
• Established ITP with platelet count <20 × 10^9/L 3, 5
• Suspected acute leukemia (AML, ALL) 3
• Unexplained cytopenias in any cell line 3
• Abnormal peripheral blood smear showing immature myeloid cells or dysplastic features 3

Standard Consultation

• ITP patients corticosteroid-dependent or unresponsive after ≥3 months 3
• Suspected myelodysplastic syndromes or myeloproliferative neoplasms 3

Reporting and Documentation

The pathologist should issue a comprehensive report including 1:

• Morphologic, immunophenotypic, and cytochemical data
• List of pending tests
• Addenda/amended reports when additional test results become available
• Sample source, adequacy, and collection information

All test results for classification, management, prognosis prediction, and disease monitoring must be entered into the patient's medical records 1.

Final reports should use current WHO terminology for diagnosis and classification 1.

Complete reporting including major risk and stratification factors should be available within 2 weeks of diagnosis 1.

Common Pitfalls to Avoid

• Failing to ensure timely hematology follow-up within 24-72 hours for urgent conditions 3, 5
• Not providing adequate patient education about warning signs requiring emergency care for outpatients 5, 4
• Inadequate infectious disease screening before initiating immunosuppressive therapy 1
• Performing bone marrow biopsy without first reviewing peripheral blood smear and basic laboratory tests 1
• Delaying molecular and cytogenetic testing in suspected acute leukemia, as these results guide initial treatment decisions 1