Hematology Exam 2

Rare CMPD characterized by marked thrombocytosis and abnormal platelet functions.

ET Essential thrombocythemia

• Clonal multipotential stem cell, mostly megakaryocytes
• Hypersensitivity of megakaryocytes to cytokines and thrombopoietin
• Absence of identifiable causes of reactive thrombocytosis
• Absence of Philadelphia chromosome
• Hgb no higher than 13 g/dL
• Absence of significant marrow fibrosis
• Consumption of coag factors- Acute hemorrhage
• Presence of stainable iron in BM

• bone marrow fibrosis
• proliferation of megakaryocytic and granulocytic cells
• extramedullary hematopoiesis-splenomegaly
• Chromosomal abnormalities (no philly)

Myelofibrosis with Myeloid Metaplasia

• Teardrop RBCs
• Normochromic normocytic anemia
• Leukoerythroblastosis
• Giant platelets
• Many nRBCs

Myelofibrosis with myeloid metaplasia

• Chronic Lymphocytic Leukemia (CLL)
• Hairy Cell Leukemia
• Sezary Syndrome
• Prolymphocytic Leukemia- younger lymphs
• Hodgkin’s and Non- Hodgkin’s lymphoma
• Multiple Myeloma
• Waldenstrom’s Macroglobulinemia

Clonal B proliferation-chromosomes 11, 12, and 13, especially trisomy 12

CLL

• Lymphadenopathy
• Many white counts are >100,000 x 109/L
• Peripheral smear shows exclusively small lymphocytes intermixed with few lymphoblasts
• Smudge cells
• nRBCs and spherocytes may be present if autoimmune hemolytic

• CLL Fragile small lymphocytes
• Smudge cells

• Splenomegaly & Lymphadenopathy- lymphs accumulating in nodes and spleen
• Anemia, Neutropenia, & Thrombocytopenia-Lymph production crowds out other cell proliferation
• Autoimmune hemolytic anemia- caused by altered immune function

CLL

B-cell malignancy

• Fragile mononuclear cell
• Hair-like projections of the cytoplasm
• Spongy appearance of chromatin
• Stain with TRAP- tartrate-resistant acid phosphatase
• Thrombocytopenia
• Pancytopenia
• Massive spleen
• Infection

Hairy Cell Leukemia

• T-cell lymphoma with mycosis fungoides
• Infiltration of Lymphocytes on skin

• Large cells (8 - 20 mm)
• Ovoid, convoluted, cerebriform nucleus
• May be mistaken for monocytes
• Folded, brain-like
• Clefted
• Clover pattern
• Blue cytoplasm

Sezary Syndrome-cutatneous T-cell lymphoma

Variant of chronic lymphocytic leukemia

• Splenic enlargement
• Liver involvement
• Escalating white counts
• Prolymphocytes have more abundant cytoplasm than mature lymphocytes

PLL

People exposed to EBV or environmental hazards are at increased risk.

• Single cervical lymph node becomes firm to the touch and does not disappear
• Low-grade fever
• Weight loss
• In lymph nodes - Presence of Reed-Sternberg cell
• Diagnosis via lymph biopsy

• Reed-Sternberg Cell
• Hodgekin's Lymphoma

Hodgekin's Lymphoma

• May present as painless cervical lymph node involvement
• Lymphoma cells may be seen in peripheral smear
• Disease can spread

• Plasma Cells-Evolve from B-lymphocytes
• Medium-sized cell
• Have an eccentric nucleus
• Have well-defined Golgi apparatus
• Cytoplasm has distinct sea blue/cornflower color
• Chromatin organized in a pinwheel structure
• Make immunoglobulins

• Disorder of Plasma Cells
• Accumulation of plasma cells in BM and other locations
• Exposure to atomic radiation
• Work involving organic solvents
• Toxins within the textile industry
• Occupations with exposure to chemicals, pesticides, or herbicides
• Chromosome 13 abnormalities
• Caused by cytokine IL-6

Multiple Myeloma

• Acceleration of plasma cells in the bone marrow
• Activation of bone resorption factors or osteoclasts
• Production of an abnormal monoclonal protein

• Inclusions called Russell bodies or other crystalline inclusions
• Flame cells may be seen in IgA myeloma -Deep pink cytoplasm
• Monoclonal gammopathy
• Increased osteoclast activity -Serum calcium increased
• Rouleaux formation
• Bence-Jones protein found in urine of patients with multiple myeloma
• ESR usually elevated due to increased settling
• "Punched-out” lesions on initial radiography

Russell Body in Multiple Myeloma

• Anemia
• Thrombocytopenia
• Neutropenia
• Can Spread in body as plasmacytomas
• Fatigue
• Bone Fractures

Overproduction of IgM caused by abnormal B lymphocytes

• IgM interferes with coagulation factors by coating platelets and impeding their function
• Peripheral smear may show rouleaux and plasmacytoid lymphocytes
• Cryoglobulins-May lead to Raynaud’s phenomenon(Cold, tingeling, fingers and toes); Causes bleeding; Cold agglutenins

• Pronormoblast
• Basophilic Normoblast
• Polychromatophilic normoblast
• Orthochromic normoblast (NRBC)
• Reticulocyte (requires stain)
• Erythrocyte

• Rubriblast
• Prorubricyte
• Rubricyte
• Metarubricyte
• Diffusely Basophilic Erythrocyte
• Erythrocyte

Target Cells

Excessive plasma chol. can lead to excessive membrane chol. and cause cell to become heavier and thicker, displacing the Hgb. Surface area to volume ratio increases, cell is less fragile.

• Glycophorin A (Glycophorins are proteins
• containing carbohydrates)
• Spectrin
• Ankyrin

Spherocytes

• Embden-Meyerof
• Hexose Monophosphate Shunt
• Methemoglobin Reductase

• Glycolytic
• Generates 2,3 diphosphoglycerate-unloading of Oxygen
• 90% of cell metabolism
• Anareobic

• Embden-Meyerhoff pathway
• Aids in unloading of oxygen

• Produces NADPH
• Protects against oxidative damage

Hexose Monophosphate shunt

• Then - Heinz Bodies
• Bite Cells
• Cause- G6PD deficiency

Caused by Denaturing of Hgb- precipitation in form of Heinz Bodies. HMS-G6PD deficiency

Heinz Bodies

Bite Cell

• Keeps heme in ferrous (+2) state
• If deficient, cannot bind oxygen

• –Normal 6-8µm
• –MCV 80- 100 fL
• –MCHC 32% -36%

• Iron Def Anemia -IDA
• Anemia of Inflammation-AoI
• Thalassemia
• Iron Overload Disorders

• Megaloblastic-Folic acid or Vit. B-12 def
• Liver Disease
• MCV > 110fL

• Gray/Blue Color
• Retic released - BM response to anemic stress

Polychromatic RBC

• Mean Corpuscular Volume
• 80-100fL, HCT/RBC x10

• Mean Corpuscular Hgb
• 27-31pg
• Hgb/RBC x10

• Mean Corpuscular Hgb Concentration
• 32-36%
• Hgb/HTC x100

• RedCell Distribution Width
• 11.5-14.5%
• Anisocytosis

• 14-18 Males
• 12-16 Females
• g/dL

• 42-52% Males
• 37-47% Females

4-11 x10^9g/L

• 4.7-6.1 Males
• 4.2-5.4 Females
• x10^12/L

• MCHC
• Normochromic- 32-36%
• Hypochromic- <32%

• MCV
• Microcytic- <80fL
• Normocytic- 80-100fL
• Macrocytic- >100fL

• Seen in
• Hemoglobin C disease
• Liver Disease
• Iron Deficiency
• Hgb abnormalities
• Thalassemia
• or artifact

• Increased MCHC, no central pallor
• Loss of RBC membrane
• Ab and complement coated cells get their membranes shreard in splenic circulation
• Also hereditary

• Slit like central pallor
• Increased fragility

• ATP and 2,3-DPG decreased
• Ovalocytes-myelodysplastic syndromes, thalassemias, megaloblastic processes
• Eliptocytes-seen in hereditary elliptocytosis, ideopathic myelofibrosis and iron deficiency

Ovalocytes and Elliptocytes

• Seen in:
• abetalipoproteinemia (a lipid disorder)
• anorexia nervosa
• lecithin cholestrol acyltransferase deficiency
• alcohol intoxication
• pyruvate kinase deficiency
• vit E deficiency
• post splenectomy
• MCHC normal

Acanthocytes

• RBC inclusion is “pitted” as cell passes through the spleen. A “tail” is left and RBC membrane does not reform discocyte shape.
• Large cells have to squeeze through microvasculature of the spleen
• Seen in ideopathic myelofibrosis with myeloid metaplasia, thalassemia syndromes, iron deficiency, inclusion bodies (the things that get “pitted” see later in lecture)

Tear Drop Cells

• Helmet Cells
• Burr Cells
• Shistocytes

• •Howell Jolly Bodies–remnants of DNA
• •Siderotic Granules/ Pappenheimer bodies–iron
• •Basophilic stippling–RNA and mitochondrial remnants
• •Heinz Bodies–denatured hemoglobin

• Denatured and precipitated Hgb
• Use crystal violet or brilliant cresyl blue stain.
• α thalassemic syndromes, G6PD, unstable Hgb syndromes, RBC injury from chemical insult

• figure 8 shaped stippling
• Made of arginine-rich histones and non-hemoblobin iron
• Seen in megaloblastic anemias, homozygous thalassemic syndromes, post splenectomy

Cabot Ring

• •Granules of non-heme iron
• •Seen in iron excess, sideroblastic anemia, hemochromatosis, hemosiderosis, sickle cell, thalassemia, post splenectomy

Pappenheimer bodies

• Multiple myeloma
• Waldenstrom’s macroglobulinemia
• Chronic inflammatory disorders
• Some lymphomas

• Iron deficiency anemia
• Sideroblastic anemia
• Thalassemia
• Anemia of inflammation

• Decreased red count
• Decreased hemoglobin
• Decreased hematocrit
• Decreased MCV
• Decreased MCHC
• Decreased serum iron
• Decreased serum ferritin
• Increased TIBC
• Decreased transferrin sat.

• Red cell count, hemoglobin, and hematocrit all borderline
• MCHC normal
• MCV slightly low
• Serum iron low
• Serum ferritin normal or increased
• TIBC decreased-holding onto iron

• 5-aminolevulinic synthetase is deficient, Protoporphyrin ring cannot be formed
• Iron accumulates in the mitochondria, because it cannot be incorporated into heme
• Dimorphic blood picture
• Pappenheimer bodies
• Siderocytes and ringed sideroblasts with Prussian blue (BM)
• Increased serum ferritin
• Increased serum iron
• TIBC is normal or low

• (NOT AN ANEMIA!)
• accumulation of excess iron in reticuloendothelial cells in various
• tissues
• Causes tissue damage
• Increase in intestinal iron absorption due to mutation in the HFE gene on chromosome 6

• increased % transferrin saturation is a hallmark
• presence of HFE gene
• Elevated serum iron
• Elevated serum ferritin
• Elevated transferrin saturation
• Normal serum transferrin
• Normal TIBC

• Globin chain disorders
• Microcytic process
• Hemolytic anemias
• Normal iron status
• Not enough Hgb A chains produced

• 0, 1 or 2 functional genes.
• Also a carrier state with 3 functional genes
• Gene Deletions

• Inherit defective beta genes
• Heterozygotes or homozygotes
• Many mutations

H-Bodies w. supravital stain

• Used to screen for carrier states of thalassemia
• (and also hereditary spherocytosis)
• Normal RBC’s lyse at .45% NaCl
• HE spherocytes (decreased SA:volume) lyse at .65% NaCl
• Beta thal and alpha thal trait lyse at < .45% NaCl

• Little or no beta-chains (therefore little or nohemoglobin A)
• Low hemoglobin levels (6 - 9 g/dl)

• 1 abnormal beta gene
• Microcytic, hypochromic anemia
• Hemoglobin A2 increased to 5-10% Alpha/Delta combos

• Hb F
• Normal cells = ghost
• HGB F cells-stained

• Macrocytic Megaloblastic Anemias
• –Vit B 12 or Folic Acid Deficiencies
• Macrocytic Non-Megaloblastic Anemias
• –Liver Dz. or drug induced

• Macrocytic normochromic anemia
• Defective nuclear maturation due to impaired DNA synthesis
• N:C asynchrony
• Cause -Vit B 12 or Folic acid deficiency
• MCH is increased, but MCHC is normal

• Megaloblasts = large RBC precursors
• Large granulocyte precursors including large bands and giant metamyelocytes
• “sievelike“ chromatin

• Macrocytes and macro-ovalocytes
• Schistocytes, tear drops, spherocytes, targets
• HJ bodies, Cabot rings, basophilic stippling
• Absolute retic is low, RPI is <2 indicating ineffective erythropoeisis

Corrected retic% = (retic% X Patient hct)/Normal hct* based on age and sex

• Reticulocyte Production Index
• RPI = corrected retic / maturation time in days