-
Total volume of blood in average adult
-
Blood collection for CBC
Purple top = anticoagulant EDTA
-
Distinguishing feature of immature cells
Big nucleus (-BLAST)
- -in bone marrow only
- -should never be in periphery
-
Hematopoiesis
process by which immature precursor cells develop into mature blood cells
-
blood formation before birth
liver
-
blood formation mid-fetal life
spleen & lymph nodes
-
blood formation after birth
initially: RBCs from mother
after 1y/o: bone marrow
-
cells in peripheral blood
- -Erythrocytes (RBCs)
- -Lymphocytes
- -Monocytes
- -Platelets
- -Granulocytes (neutrophils, segmented/banded, eosinophils, basophils)
-
Erythropoiesis
RBC formation
- -Rubriblast-Reticulocyte (used as indicator of RBC production w/anemia)
-
Regulation of erythropoiesis
with EPO and renal oxygen tension
-EPO released from kidney and travels to bone marrow to produce more RBCs
(renal disorders can lead to anemia)
-
Hemoglobin
1/3 of RBC
-oxygen carrying molecule
-
Hemoglobin variants
changes in molecule shape = decreased O2 carried
Hemoglobin S = Sickle cell
Carboxyhemoglobin = carbon monoxide poisoning
-
Red Blood Cells
- -life span of 120 days
- -new RBCs released into circulatory system every day
- -Reusable components = iron & protein
- (stored in body)
- -Waste products = converted to bilirubin and eliminated from from body (urine/feces)
-
Quality control for CBC
Hct = Hb x 3 (+-2)
*CBC must be repeated if this does not correlate
-
MCV
Mean Cell Volume
- -volume/size of average RBC
- -macrocyctic, normocytic, microcytic
*most important w/MCHC
-
-
MCHC
Mean Cell Hemoglobin Concentration
-cell color
*most important w/MCV
-
RDW
Red Cell Distribution Width
-degree variability
-
Components of CBC
- WBC count
- RBC count
- Hb
- Hct
- Platelets
-
RBC morphology
Size = macrocytosis, microcytosis
Shape = ovalocytes, spherocytes, schistocytes
Inclusions = Pappenheimer bodies, malaria
-
Anemia
Decreased RBC, Hct, Hb
- -implies a decline in oxygen-carrying capacity
- -etiology & morphology
- 1. losing blood (RBC loss)
- 2. bone marrow not producing
- 3. body destroing RBCs
-
Anemia critical levels
- Transfusion:
- Hb <6.0 = heart failure, death
- Hct <20%
- Clotting:
- Hb >20.0 = hemoconcentration and capillary clogging
- Hct >60% = spontaneous clotting
-
Anemia patient presentation
- -fatigue
- -HA
- -vertigo
- -dyspnea
- -pica
- -chest pain
- -hematuria
- -dark stools
-
Anemia physical findings
- -Hepatomegaly
- -Spleenomegaly
- -heart abnormalities
- -skin pallor
- -neurological changes
- -esophageal webs
-
Considerations for diagnosing Anemia
- -Rate of onset
- -Severity
- -Age
- -Sex (males Hb > females)
- -Geographic location (malaria, high altitude)
-
Etiologic Classification of Anemia
Causes of erythrocyte and Hb depletion
- 1. Impaired RBC production
- 2. Excessive destruction
- 3. Blood loss
-
Morphological Classification of Anemia
- Characteristic changes in RBC size, shape, color
- -use RBC indicies (MCV) (size)
- 1. Macrocytic (increased mean cell volume) large
- 2. Microcytic (decreased MCV) small
- 3. Normocytic (normal MCV) medium
-
Anemia: Impaired RBC Production
Etiological classification
- 1. Abnormal bone marrow-aplastic anemia
- -leukemia, cancer metastasis
- 2. Essential factors deficiency-deficient in iron, B12, folic acid
- -anemia w/renal disease: EPO
- 3. Stimulation factor deficiency-chronic disease (autoimmune)
- -hypopituitarism
- -hypothyroidism
-
Anemia: Excessive destruction of RBCs
(intracorpuscular)
Etiological classification
- 1. Hemolytic anemia: Intracorpuscular defect
- (inside the cell)
- -Membrane: hereditary spherocytosis, ovalocytosis, etc
- -Enzyme: G-6PD deficiency
- -Hb: thalassemia (wrong Ab); hemoglobinopathies
-
G-6PD
Enzyme
-causes Hemolytic Intracorpuscular anemia when deficient
- -etiological classification: Excessive RBC destruction
- -Normocytic Anemia
-
Anemia: Excessive destruction of RBCs
(extracorpuscular)
Etiological classification
- 1. Hemolytic anemia: Extracorpuscular defect
- (outside the cell)
- -Mechanical: Microangiopathic HA (MAHA)(schistocytes)
- -Chemical/physical
- -Infection: clostridium tetani
- -Antibodies: SLE
- -Hyperspleenism: enlarged spleen
-
Anemia: Blood loss
Etiological classification
- 1. Acute blood loss-accident, GI bleed (hemocult test)
- 2. Chronic blood loss-Hypermenorrhea
- -parasitic infection
-
Normocytic Anemia
- MCV 82-92
- (normal cells, just decreased #s)
- 1. Acute hemorrhage
- 2. Increased plasma volume (pregnancy, overhydration)
- 3. Hypoplastic marrow
- 4. Infiltrate BM (leukemia, mult. myeloma)
- 5. Abnormal endocrine (hypothyroid, adrenal insuf)
- 6. Kidney disease
- 7. Hemolytic anemia (depends of cause)
-
Normocytic Anemia additional diagnostic studies
- -Bone marrow biopsy:
- 1. normal cells, decreased production (bone marrow infiltration w/leukemia, aplastic anemia)
- 2. non-competent/functioning marrow (if reticulocyte count is decreased)
- -Urobiligen: hemolysis (?)
- -RBC enzymes: G-6-PD deficiency
- -RBC morphology: abnormal shapes, spherocytes, schistocytes
- -AHG (Coombs) test
-
Microcytic Anemia
- 1. Iron deficiency (chronic blood loss, inadequate diet, malabsorption)
- 2. Chronic disease (autoimmune)
- 3. Defective heme or globin production
- -Hemoglobinopathy: sickle cell, Hb C disease
- -Thalassemia
- -Lead poisoning: interferes with heme production
-
Hemoglobinopathy
- -defective globin production; causes increased RBC destruction and decreased heme production
- -sickle cell; Hb C disease
- -Mycrocytic Anemia (MCV <80)
- -Excessive destruction of RBCs (intracorpuscular hemolytic anemia)
-
Thalassemia
-decreased globin production, alpha or beta chains, creates wrong Ab
- -Intracorpuscular hemolytic anemia (excessive destruction of RBCs)
- -Microcytic Anemia (MCV <80)
-
Lead poisoning: Anemia
Mycrocytic Anemia
- -lead interferes with heme production
- -children under 5 y/o high-risk
- (live in old house, candy from other countries, underserved populations)
-
Mycrocytic Anemia additional diagnostic tests
- Iron studies:
- -TIBC (capacity of plasma to carry more iron)
- -Transferrin (protein that carries iron)
- -Ferritin (reflects marrow iron stores)
- -Lead levels
- -Hb electrophoresis (for hemoglobinopathies)
- Microcytic Anemia w/iron deficiency =
- 1. Iron and ferritin decreased
- 2. TIBC and transferrin increased
-
Macrocytic Anemia
- MCV > 94
- (large cells, large nucleus)
- 1. Megalobastic dyspoiesis
- -Vit B12 deficiency: Pernicious anemia
- -Folic acid deficieny: Nutritional megaloblastic anemia, sprue, malabsorption
- -Abnormal DNA synthesis: chemotherapy, anticonvulsant, ETOH, liver disease, cirrhosis
-
Pernicious Anemia
- Macrocytic anemia
- -megaloblastic dyspoiesis
-cause by Vit. B12 deficiency
-
Macrocytic Anemia additional diagnostic tests
- -B12 levels
- -Folate levels
- -Intrinsic factor
-
Polycythemia
Increased RBC, Hb, Hct
Relative: decreased plasma volume (can result from dehydration)
Absolute: total RBC mass increases
- Primary: independent of erythropoietin stimulation
- (malignant hematologic d/o: Polycythemia vera)
- Secondary: lowered oxygen tension
- (smokers, respiratory d/o)
-
Erythrocyte Sedimentation Rate
Rate at which RBCs fall
- -non-specific test for inflammatory conditions
- (increased levels bc of fats, proteins, other factors in blood from inflammation)
-measure to look for presence and severity of pathologic process( RA, lupus, gout, carcinoma)
-
Granulopoiesis
Process by which WBCs mature
- -Myeloblast
- -Myelocytic cell line produces:
- 1. Granulocytic -neutrophils, eosiniphils, basophils
- 2. Monocytic -monocyte, tissue macrophage
-
Granulocytes
Neutrophils: highly mobile, eat small particles, defend from infection, inflammatory rxn
Eosinophils: immediate hypersensitivity and allergic response, destruction of opsonized tissue
Basophils: immediate hypersensitivity rxns, inflammation, histamine release
-
Monocytes
- Promonocyte
- Monocyte
(similar to lymphocytes but with vacuoles)- Macrophage:
phagocytic cells; destroy larger tissue than compared to neutrophils
-
Lymphopoiesis
Produces mature cells in the lymphocytic line
- T lymphocytes
- B lymphocytes
-
Lymphocytes
- -Normally found in peripheral blood
- -Participate in Ab production; particularly viral infections
- T lymphocytes: thymus; cell mediated immunity
- B lymphocytes: bone marrow; humoral immunity and Ab production
-
Neutrophils vs. Lymphocytes
Neutrophils = bacterial (granulocytes)
Lymphocytes = viral
-
Leukocytosis
increased WBC count
- -Non-malignant, quantitative
- Neutrophilia, eosinophilia, basophilia, monocytosis, lymphocytosis
-
Neutrophilia
non-malignant, quantitative leukocytosis
- -Bacterial infection
- -Toxic response
- -Tissue destruction/injury
-
Eosinophilia
non-malignant, quantitative leukocytosis
- -Allergic rxns
- -Parasite tissue infiltration
- -Chronic skin disorders
-
Basophilia
non-malignant, quantitative leukocytosis
-Active allergic responses
-
Monocytosis
non-malignant, quantitative leukocytosis
-Recovery phase of infections
-
Lymphocytosis
non-malignant, quantitative leukocytosis
- -Viral infection
- -Infectious mononucleosis (monspot, heterophile Ab)
- -CMV
- -Pertussis (culture)
- -Toxoplasmosis (immunologic testing)
-
Non-malignant Qualitative WBC d/o
Can have normal to low WBCs in conjunction with abnormal appearance
-nuclear abnormalities: Pelger-Huet Anomaly (benign)
-
-
Neutropenia
- 1. Decreased WBC production:
- -compromised bone marrow
- -toxicity
- -malignancy
- 2. Decreased survival/increased destruction:
- -overwhelming chronic infection
-
Lymphopenia
Decreased WBC count
- -briefly after onset of viral infections
- (measles, mumps, VZV, hepatitis, roseola)
- -bone marrow suppresion; primary bone marrow d/os
- -distribution: steroid therapy, morphine
-
Malignant WBC disorders
- Clonal disorders
- -primary defect occurs in stem cell or precursor cell
- -leukemias: acute or chronic
-
Acute leukemia
Blast cells
- -increased, decreased, normal WBC count
- -Anemia
- -Thrombocytopenia
- -Erythroleukemia: Red cell line involved
- -Megakaryoblastic leukemia: platelets involved
- -Myelogenous leukemia: AML
- -Lymphocytic leukemia: ALL
Presentation: fever, lethargy, infection
-
AML
Acute myelogenous leukemia
-
ALL
Acute lymphocytic leukemia
special tests: Bone marrow, CD markers, cytogenetics
-
Chronic leukemia
Mature cells
-Increased WBC (most typical) - -Anemia
- -Thrombocytopenia
- -few or no blast seen in periphery
- -Myeloproliferative leukemia: CML
- -Lymphocytic leukemia: CLL
- -Hairy cell leukemia: HCL
Presentation: fever, lethargy, infection
-
Malignant WBC d/o additional diagnostics
- -Bone marrow
- -Cytochemical stain (on bone marrow cells)
- -Cytogenetics
- -Flow cytometry
-
CML
Chronic myeloproliferative leukemia
- -common in middle-age
- -Philadelphia chromosome (gold standard, cytogenetics)
-
CLL
Chronic lymphocytic leukemia
-common in geriatrics
-
HCL
Hairy cell leukemia
- -Chronic
- -TRAP (+)
- (tartrate resistant acid phosphatase; cytochemical stain)
-
Plasma cell dyscracias
Multiple Myeloma
- -increased plama cells in peripheral blood (B cell line)
- -relative lymphocytosis (decreased plasma volume, non-malignant quantitative)
- -Anemia
- -Increased sed rate
- -presence of Bence Jones protein in urine
- (gold standard)
-
Lymphoma
- Solid tumor of lymphoid cells
- -B/T cells
- -Hodgkin's lymphoma = REED-stenberg cells
- -Non-Hodgkin's lymphoma
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