4.4 Blood and Lymphatic Diseases

4.4 Blood and Lymphatic Diseases

Quick Answer: Blood and lymphatic vignettes test recognition of systemic disease behind vague complaints — fatigue and pallor suggest anemia; petechiae and gum bleeding with fever suggest acute leukemia; painless persistent lymphadenopathy with night sweats suggests lymphoma; thrombocytopenia causes mucosal bleeding; sickle cell crisis causes severe pain that may mimic musculoskeletal injury. Chiropractors who treat "tired patients" and palpate lymph nodes must form these impressions before routine adjustment.

Why Hematologic Disease Appears on Part II

Fatigue is among the most common complaints in outpatient care, including chiropractic offices. General Diagnosis asks whether you can move beyond "patient is tired" to a specific clinical impression — iron deficiency anemia from chronic GI blood loss, B12 deficiency with neuropathy, or leukemia with pancytopenia. Lymphatic disease appears when patients have "swollen glands" in the neck that may be reactive, infectious, or malignant. Missing hematologic malignancy or severe cytopenia before manipulation exposes patients to infection, bleeding, and splenic rupture risks.

Anemia: Mechanism-Based Impressions

Anemia is reduced hemoglobin or hematocrit — a lab finding with mechanistic subtypes Part II expects you to distinguish.

Iron deficiency anemia — most common worldwide:

• Causes: chronic blood loss (menorrhagia, GI malignancy, peptic ulcer, colon cancer in older adults), inadequate intake, malabsorption (celiac)
• Presentation: fatigue, weakness, pallor, exertional dyspnea, pica (ice craving), koilonychia (spoon nails), glossitis
• Labs: low hemoglobin, low MCV (microcytic), low ferritin, low serum iron, high TIBC
• Chiropractic relevance: new iron deficiency in a man over 50 or postmenopausal woman should trigger medical referral for GI source workup — not just spinal adjusting for fatigue

Vitamin B12 (cobalamin) deficiency:

• Causes: pernicious anemia (anti-parietal cell antibodies), strict vegan diet, gastrectomy, metformin long-term use
• Presentation: fatigue, neurologic signs (peripheral neuropathy, subacute combined degeneration — spastic paresis, ataxia), smooth beefy red tongue, dementia
• Labs: low hemoglobin, high MCV (macrocytic), low B12, elevated methylmalonic acid
• Distinguish from folate deficiency (macrocytic without neurologic unless very severe) — giving folate alone in B12 deficiency can worsen neurologic injury

Folate deficiency — poor diet, alcoholism, pregnancy, methotrexate; macrocytic anemia without early neurologic deficit.

Anemia of chronic disease — inflammation (RA, malignancy, chronic infection) elevates hepcidin; normocytic or mildly microcytic anemia with low iron but normal or high ferritin.

Hemolytic anemia — shortened RBC survival; jaundice, dark urine, elevated LDH, low haptoglobin, splenomegaly. Sickle cell disease is a hemolytic subtype with vaso-occlusive crises.

Aplastic anemia — marrow failure; pancytopenia with low reticulocyte count.

When Part II gives microcytic anemia plus guaiac-positive stool in an elderly patient, the impression chain is iron deficiency from GI blood loss — colonoscopy referral, not iron tablets alone without evaluation.

Leukemia and Myeloproliferative Disorders

Acute leukemia (AML, ALL) — rapid proliferation of malignant immature cells crowding marrow:

• Presentation: fatigue, fever (infection due to neutropenia), bleeding (thrombocytopenia — gum bleeding, petechiae, epistaxis), bone pain, hepatosplenomegaly, lymphadenopathy
• Labs: pancytopenia with circulating blasts on smear
• Impression: medical emergency — induction chemotherapy; patient is immunocompromised and thrombocytopenic — no manipulation of fragile tissues, no NSAIDs without medical guidance

Chronic leukemia — CLL (older adult, massively elevated WBC, smudge cells, lymphocytosis) and CML (Philadelphia chromosome, leukocytosis with left shift, splenomegaly).

Multiple myeloma — elderly, bone pain (especially back), anemia, hypercalcemia, renal failure, rouleaux on smear. Spinal compression from plasmacytoma is manipulation contraindication until malignancy is ruled out in unexplained back pain with anemia in older adults.

Red flag cluster for Part II: young adult with weeks of fatigue, recurrent infections, gum bleeding, and scattered petechiae — impression is acute leukemia until proven otherwise.

Lymphoma and Lymphoproliferative Disease

Lymphoma (Hodgkin and non-Hodgkin) — malignant proliferation of lymphocytes:

• Painless lymphadenopathy — cervical, supraclavicular, axillary, or mediastinal (Hodgkin may present with mediastinal mass in young adult)
• B symptoms: fever, night sweats, weight loss greater than 10% body weight
• Hodgkin lymphoma: Reed-Sternberg cells; may have alcohol-induced pain in involved nodes (classic Part II association)
• Non-Hodgkin lymphoma: more heterogeneous; associated with HIV, immunosuppression, autoimmune disease

Impression vs reactive nodes: reactive nodes from URI are tender, mobile, and resolve in weeks. Malignant nodes are often firm, non-tender, fixed, and persistent beyond 4–6 weeks.

Supraclavicular lymphadenopathy — left (Virchow node) suggests abdominal malignancy; right suggests thoracic malignancy. Always refer before palpating aggressively or applying cervical HVLA near pathologic nodes.

Chiropractors frequently palpate cervical lymph nodes during exam. Document size, mobility, tenderness, and duration. New fixed supraclavicular mass is not a subluxation — it is a lymphoma or metastasis workup.

Platelet Disorders and Coagulopathy

Thrombocytopenia (low platelets) — bleeding risk:

• Petechiae, ecchymoses, mucosal bleeding (gums, GI), prolonged bleeding from minor cuts
• Causes: ITP (immune destruction), DIC (consumption in sepsis), HIT, marrow failure, hypersplenism, drug effect (heparin, chemotherapy)

Immune thrombocytopenic purpura (ITP) — isolated low platelets after viral illness; children often self-resolve; adults may need steroids or rituximab.

Thrombotic thrombocytopenic purpura (TTP) — pentad: fever, thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal failure. Emergency plasma exchange.

Heparin-induced thrombocytopenia (HIT) — paradoxical: thrombosis (not bleeding) after heparin exposure with falling platelets. Part II trap: low platelets usually suggest bleeding, but HIT causes clotting — stop heparin, alternative anticoagulation.

von Willebrand disease — most common inherited bleeding disorder; mucosal bleeding, menorrhagia, normal platelet count but abnormal platelet function.

Disseminated intravascular coagulation (DIC) — widespread clotting with consumption of platelets and factors — bleeding and thrombosis simultaneously in sepsis, trauma, obstetric catastrophe.

Before soft-tissue techniques in patients with known thrombocytopenia or active bleeding diathesis, obtain medical clearance. Petechiae on intake should halt aggressive work until platelet count is known.

Sickle Cell Disease and Hemoglobinopathy

Sickle cell disease (HbSS) — homozygous hemoglobin S polymerization under deoxygenation:

• Vaso-occlusive crisis — severe pain in bones, back, chest (can mimic MI — "acute chest syndrome"), abdomen
• Triggers: infection, dehydration, cold, hypoxia
• Acute chest syndrome — chest pain, fever, hypoxia, new pulmonary infiltrate — emergency
• Splenic sequestration in children — sudden enlargement, shock
• Aplastic crisis with parvovirus B19

Chiropractic patients with sickle cell may seek care for musculoskeletal pain during crises. Do not apply aggressive manipulation during acute vaso-occlusive crisis — pain is ischemic, not primarily mechanical. Hydration, medical pain management, and infection treatment take priority. Know the diagnosis on intake — HbSS patients need gentle care, infection precautions, and low threshold for emergency referral if chest symptoms develop.

Sickle cell trait — usually asymptomatic except rare complications (exertional rhabdomyolysis, altitude).

Lymphadenopathy: Systematic Evaluation

When evaluating lymphadenopathy, Part II rewards localization and pattern recognition:

Duration rule: nodes persisting more than 4–6 weeks without explanation need biopsy imaging referral.

Size: nodes greater than 1 cm in cervical chain are notable; supraclavicular nodes of any size are suspicious.

Chiropractors should not repeatedly manipulate through enlarged lymph node regions without diagnosis — inflammation may worsen, and undiagnosed malignancy may be disturbed.

Splenomegaly and Manipulation Risk

Splenomegaly accompanies leukemia, lymphoma, portal hypertension, infectious mononucleosis, and hemolytic anemia. An enlarged spleen is vulnerable to rupture with trauma — contact sports and deep abdominal or thoracic manipulation are contraindicated in acute mono and unknown splenomegaly. Part II may link mono, splenomegaly, and avoidance of abdominal compression.

Coagulation Factor Deficiencies (Recognition)

Hemophilia A (factor VIII) and Hemophilia B (factor IX) — X-linked; deep tissue bleeding, hemarthrosis, prolonged bleeding after minor trauma. Not primarily petechiae (platelet problem). Joint swelling from hemarthrosis may bring patients to chiropractors mistaken for joint injury.

Vitamin K deficiency — bleeding in newborns (prophylactic vitamin K given at birth) or adults with biliary disease and malabsorption; prolongs PT.

Integrating Blood/Lymph Impressions with Chiropractic Care

Screening questions that support hematologic impressions: unexplained weight loss, night sweats, bleeding gums, easy bruising, recurrent infections, alcohol use, dietary restrictions, family history of anemia or clotting disorder, prior cancer treatment.

Lab patterns Part II may state directly:

• Low Hgb, low MCV, low ferritin → iron deficiency
• Low Hgb, high MCV, low B12 → B12 deficiency
• Low WBC, low Hgb, low platelets → marrow failure or leukemia
• High WBC with blasts → acute leukemia

Action hierarchy:

1. Emergency — acute leukemia with fever and neutropenia, TTP, DIC, sickle acute chest syndrome
2. Urgent referral — unexplained pancytopenia, fixed supraclavicular mass, iron deficiency in high-risk GI malignancy age group
3. Co-management — stable chronic anemia on treatment, known sickle cell between crises
4. Routine care — reactive tender nodes resolving with URI, mild iron deficiency in menstruating woman with clear source

Part II clinical reasoning pairs the most likely impression with the most appropriate next step — when petechiae and gum bleeding accompany fatigue in a young adult, the answer is leukemia workup, not cervical adjustment for fatigue.