DRAFT Flashcards
– continuous, regulated process of blood cell production that includes cell renewal, proliferation, differentiation, and maturation.
Hematopoiesis
Hematopoiesis Types:
Primitive hematopoiesis Definitive hematopoiesis
Site of hematopoiesis:
ribs
sternum
skull
scapula
vertebrae
pelvic bones
proximal ends of the long bones
Yolk sac
Mesoblastic phase
Liver (main), spleen
Hepatic phase
Bone marrow
Myeloid phase
Gower I, Gower II, Portland
Mesoblastic phase
Hb F (major), Hb A1, Hb A2
Hepatic phase
Hb A1 (major), Hb A2, Hb F
Myeloid phase
Primitive erythroblasts
Mesoblastic phase
Erythroblasts Granulocytes Monocytes Megakaryocytes
Hepatic phase
All blood cells
Myeloid phase
Start: 19-20th day
End: 8-12th week
Mesoblastic phase
Start: 5th to 7th week
End: 1st to 2nd week (after birth)
Hepatic phase
Start: 5th month of gestation *Lifetime
Myeloid phase
the spleen, liver, and the lymph nodes revert back to produce immature blood cells in certain abnormal conditions where the bone marrow cannot produce sufficient number of hematopoietic cells
extramedullary hematopoiesis
are frequently noted on physical examination
✓ Hepatomegaly and splenomegaly
Hematopoietic hormones
▪ Erythropoietin
▪ Thrombopoietin
− produced by the kidneys (90%) and the liver (10%)
▪ Erythropoietin
prevents the apoptosis of erythroid precursors
▪ Erythropoietin
Stimulates Hb synthesis
▪ Erythropoietin
Serves as differentiation factor causing the CFU-E to differentiate into pronormoblasts
▪ Erythropoietin
− Also known as mpL kit ligand
▪ Thrombopoietin
− Synthesized by the liver
▪ Thrombopoietin
Note: the primary source of erythropoietin among the newborns is the
liver
Adult Hematopoietic tissue
▪ Bone marrow ▪ Liver ▪ Spleen
− hematopoietically active marrow
Red marrow
− consists of developing blood cells and their progenitors
Red marrow
− hematopoietically inactive
Yellow marrow
− composed primarily of adipocytes
Yellow marrow
− under physiologic stress, it will revert back to active marrow
Yellow marrow
: the process of replacing the active marrow by adipocytes
Retrogression
- the primary site of hematopoiesis during the hepatic phase of hematopoiesis
▪ Liver
Responsible for splenic culling/pitting of RBCs
▪ Spleen
Removes senescent RBCs Stores
▪ Spleen
1/3 of platelets
▪ Spleen
▪ Refers to RBC production
Erythropoiesis
Erythropoiesis
▪ Occurs in distinct anatomical sites called erythropoietic islands where each island consists of a macrophage surrounded by a cluster of erythroblasts
(suckling pig phenomenon)
− a condition where oxygen content decreases within the tissues
▪ Tissue hypoxia
− primary stimulus for the production of RBCs
▪ Tissue hypoxia
− produces a dramatic increase in the production of EPO
▪ Tissue hypoxia
Erythroblastic
Proerythroblast
Basophilic erythroblast
Polychromatophilic erythroblast
Orthochromic erythroblast
Polychromatophilic erythrocyte/Reticulocyte
Erythrocyte
Rubriblastic
Rubriblast
Prorubricyte
Rubricyte
Metarubricyte
Polychromatophilic erythrocyte/Reticulocyte
Erythrocyte
Normoblastic
Pronormoblast
Basophilic normoblast
Polychromatophilic normoblast
Orthochromic normoblast
Polychromatophilic erythrocyte/Reticulocyte
Erythrocyte
RBC Maturation Series:
▪ Earliest recognizable RBC precursor
Pronormoblast
▪ Fine and uniform chromatin pattern
Pronormoblast
▪ It takes approximately 3 days for the pronormoblast to develop into orthochromic normoblast
Pronormoblast
▪ Nuclear chromatin becomes more clumped
Basophilic normoblast
▪ Last stage with nucleolus (last stage of RNA synthesis)
Basophilic normoblast
▪ Note: Hb is produced in this stage but not detected in light microscopy but in EM (Rodak)
Basophilic normoblast
▪ Hb production begins during this stage
Polychromatophilic normoblast
▪ Characterized by muddy, light gray appearance of cell due to variable amounts of pink coloration mixed w/ basophilia
Polychromatophilic normoblast
▪ Last stage capable of mitosis
Polychromatophilic normoblast
▪ Nucleus is tightly condensed and described as pyknotic
Orthochromic normoblast
▪ Last stage w/ nucleus
Orthochromic normoblast
▪ Part of this stage occurs in the bone marrow (2 days), and the later part of this stage takes place in the circulation (1 day)
Polychromatophilic erythrocyte
▪ Anucleate
Polychromatophilic erythrocyte
▪ When stained with supravital stain = reticulocyte
Polychromatophilic erythrocyte
▪ Last stage capable of Hb synthesis
Polychromatophilic erythrocyte
Earliest recognizable precursor
Pronormoblast/Proerythroblast/Rubriblast
Last stage capable of mitosis
Polychromatophilic normoblast/Polychromatophilic erythroblast/Rubricyte
Last stage with a nucleolus
Basophilic normoblast/Prorubricyte
Last stage with nucleus
Orthochromic normoblast/Metarubricyte
Last stage that can synthesize hemoglobin
Reticulocyte
Caused by increased number of reticulocytes that are prematurely released from the bone marrow under the stimulus of EPO because of certain conditions (e.g., hypoxia, acute bleeding)
Stress or shift retics
An elevated reticulocyte count accompanied w/ a shortened RBC survival
Polychromatophilia/Reticulocytosis
▪ Anaerobic glycolysis
Embden-Meyerhof pathway
▪ Supplies 90-95% ATP
Embden-Meyerhof pathway
▪ G6PD and glutathione are generated in this pathway
Hexose Monophosphate Shunt
▪ Purpose: prevents oxidative denaturation of hemoglobin
Hexose Monophosphate Shunt
▪ Maintains the iron present in the Hb in a functional reduced state (Ferrous iron) for oxygen transport
Methemoglobin Reductase pathway
▪ Generates 2,3-DPG
Rapoport-Luebering shunt
▪ Alcohol intoxication
Acanthocyte Thorny cells Spur cell Spike cell
▪ PK deficiency
Acanthocyte Thorny cells Spur cell Spike cell
▪ Congenital abetalipoproteinemia (neuroacanthocytosis)
Acanthocyte Thorny cells Spur cell Spike cell
▪ Severe liver disease (spur cell anemia)
Acanthocyte Thorny cells Spur cell Spike cell
▪ Vitamin E deficiency
Acanthocyte Thorny cells Spur cell Spike cell
▪ Lipid metabolism disorder
Acanthocyte Thorny cells Spur cell Spike cell
▪ Hereditary stomatocytosis
Stomatocytes Mouth cell
▪ Electrolyte imbalance
Stomatocytes Mouth cell
▪ Liver disease, alcoholism
Stomatocytes Mouth cell
▪ Rh null syndrome
Stomatocytes Mouth cell
▪ Hydroxyurea therapy
Stomatocytes Mouth cell
▪ Hemoglobinopathies (Hb CC, Hb SS, Hb SC)
Target cells Codocyte Mexican hat cell Platycyte Leptocyte Greek helmet cell Bull’s eye cell
▪ Liver disease (flattened surface)
Target cells Codocyte Mexican hat cell Platycyte Leptocyte Greek helmet cell Bull’s eye cell
▪ MDS
Ovalocytes/Elliptocytes Egg shape
▪ Thalassemia
Ovalocytes/Elliptocytes Egg shape
▪ Megaloblastic process
Ovalocytes/Elliptocytes Egg shape
▪ IDA
Ovalocytes/Elliptocytes Pencil shape
▪ Hereditary elliptocytosis
Ovalocytes/Elliptocytes Pencil shape
▪ Idiopathic myelofibrosis
Ovalocytes/Elliptocytes Pencil shape
▪ associated with hemolytic process
Spherocytes Bronze cell
▪ ABO HDN
Spherocytes Bronze cell
▪ Immune hemolytic anemia
Spherocytes Bronze cell
▪ Hereditary spherocytosis
Spherocytes Bronze cell
▪ Severe burns
Spherocytes Bronze cell
▪ Others: normal aging process, storage phenomenon
Spherocytes Bronze cell
▪ Artifact
Echinocytes (Evenly distributed uniformly sized blunt)
▪ Seen in old specimen
Echinocytes (Evenly distributed uniformly sized blunt)
▪ Associated w/ renal insufficiency
Burr cells (Irregularly sized and unevenly spaced spicules)
▪ Dehydration
Burr cells (Irregularly sized and unevenly spaced spicules)
▪ Azotemia
Burr cells (Irregularly sized and unevenly spaced spicules)
▪ Hallmark of hemolytic anemia
Schistocytes Schizocytes Helmet cells Triangular cells Keratocytes
▪ MAHA (DIC, TTP, HUS)
Schistocytes Schizocytes Helmet cells Triangular cells Keratocytes
▪ Exposure of RBCs to heat or mechanical trauma
Schistocytes Schizocytes Helmet cells Triangular cells Keratocytes
▪ Prosthetic heart valve
Schistocytes Schizocytes Helmet cells Triangular cells Keratocytes
▪ Clostridial infection
Schistocytes Schizocytes Helmet cells Triangular cells Keratocytes
▪ Removal of Heinz bodies
Keratocytes Bite cell Degmacyte Horned cell
▪ Seen in G6PD deficiency
Keratocytes Bite cell Degmacyte Horned cell
▪ Overt hemolysis
Semilunar bodies
▪ Associated with malaria
Semilunar bodies
▪ Myelofibrosis w/ myeloid metaplasia
Teardrop cells Dacryocytes
▪ Myelophthisic anemia
Teardrop cells Dacryocytes
▪ Pernicious anemia
Teardrop cells Dacryocytes
▪ Beta-Thalassemia
Teardrop cells Dacryocytes
▪ Hypersplenism
Teardrop cells Dacryocytes
▪ Severe burns
Pyropoikilocytes
▪ Hereditary pyropoikilocytosis
Pyropoikilocytes
▪ Sickle cell anemia
Drepanocyte Sickle cell
▪ Hb SC disease
Drepanocyte Sickle cell
▪ Hb C disease
Folded cell Biscuit cell
▪ Hb SC disease
Folded cell Biscuit cell
Small round reddish-blue fragments of nucleus
Howell-Jolly bodies
(+) Feulgen stain
Howell-Jolly bodies
DNA
Howell-Jolly bodies
Accelerated or abnormal erythropoiesis
Megaloblastic anemia
Alcoholism
Howell-Jolly bodies
Reddish violet, thin ringlike, figure of eight, loop-shaped appearance
Cabot rings
Mitotic spindle
Cabot rings
Megaloblastic anemia
Lead poisoning
Homozygous thalassemia
Severe anemia
Cabot rings
Small faint basophilic coccoid bodies near the periphery of RBCs
Pappenheimer bodies (Wright’s stain)
Siderotic granules (Prussian blue)
Iron
Pappenheimer bodies (Wright’s stain)
Siderotic granules (Prussian blue)
Refractory anemia
Sideroblastic anemia
Iron overload (hemosiderosis, hemochromatosis)
Thalassemia
Hemoglobinopathies
Pappenheimer bodies (Wright’s stain)
Siderotic granules (Prussian blue)
Multiple, uniform, evenly distributed dark blue granules
Basophilic stippling
RNA
Basophilic stippling
▪ Megaloblastic anemia
▪ Thalassemia
▪ Hemoglobinopathies
▪ Alcoholism
▪ Pyrimidine-5nucleotidase deficiency
Basophilic stippling Fine
▪ Lead poisoning
Basophilic stippling Coarse
Single or multiple purplish inclusions on the RBC periphery
Heinz bodies
Supravital stains: CV, BCB
Heinz bodies
Precipitated Hb
Heinz bodies
G6PD deficiency (favism)
Naphthalene ball ingestion
Hemoglobinopathies
Thalassemia major
Sulfonamides
Hb Koln and Hb Zurich
Post-splenectomy
Heinz bodies
Small-greenish blue
Hb H inclusions
“Pitted gold ball appearance”
Hb H inclusions
Supravital stain: BCB
Hb H inclusions
Fingerlike or quartz like crystal of dense Hb protruding from the RBC membrane
Hb SC crystal
Hexagonal crystal of dense Hb
Hb C crystal
Also known as hemozoin/hematin
Malarial inclusions
Plasmodium spp.
Malarial inclusions
Malaria
Malarial inclusions
Resembles maltese cross/tetrads
Babesia inclusion
Babesia spp.
Babesia inclusion
Babesiosis/Piroplasmosis
Babesia inclusion
− Macrophage-mediated hemolysis
Extravascular hemolysis
− Occurs in the spleen
Extravascular hemolysis
− 90% of RBCs are destroyed
Extravascular hemolysis
− Mechanical hemolysis
Intravascular hemolysis
− Occurs within the lumen of blood vessels
Intravascular hemolysis
− Extremely damaged cells are being destroyed within the circulation before they reach the liver or the spleen
Intravascular hemolysis
− 10% of RBCs are destroyed
Intravascular hemolysis
− Removal of senescent and damaged red blood cells in the spleen
▪ Splenic culling
▪− Removal of RBC inclusion bodies in the spleen
Splenic pitting
NOTE: when red blood cells are destroyed, only the [?]are recycled for reuse
iron and globin chains
▪ Function: to transport oxygen to the tissue and carbon dioxide from tissues to the lungs
Hemoglobin
Hemoglobin Composition:
4 heme
4 globin
– consists of protoporphyrin IX and ferrous iron
4 heme
– consists of 2 identical pairs of unlike polypeptide chains
4 globin
✓ every heme group is capable of carrying [?] of oxygen, therefore each Hb molecule is able to transport [?] of oxygen
1 mole
4 moles
✓ 1 gram Hb = can carry [?] of oxygen
1.34 mL
✓ 1 gram Hb = can carry [?] of iron
3.47 mg
✓ there are 4 pyrrole rings for every [?] of iron
1 molecule
: occurs in the mitochondria
▪ Heme synthesis
: occurs in the ribosomes
▪ Globin synthesis
Alpha
141
Zeta
Beta
Gamma
Delta
Epsilon
146
Alpha
Zeta
Ch 16
Beta
Gamma
Delta
Epsilon
Ch 11
2 alpha, 2 beta
A1
> 95%
A1
Predominant Hb among the adults
A1
2 alpha, 2 delta
A2
<3%
A2
2 alpha, 2 gamma
F
1-2%
F
Predominant Hb during the hepatic phase
F
Major Hb of newborn
F
Embryonal hemoglobin
2 zeta, 2 epsilon
Gower I
2 alpha, 2 epsilon
Gower II
2 zeta, 2 gamma
Portland
Cherry red
Carboxyhemoglobin
Chocolate brown
Methemoglobin
Mauve lavender
Sulfhemoglobin
Reversible
Carboxyhemoglobin Methemoglobin
Not Reversible
Sulfhemoglobin
Hb bounded with CO
Carboxyhemoglobin
Hb that contains iron in oxidized or ferric state (Fe3+)
Methemoglobin
Hb bounded with sulfur
Sulfhemoglobin
The affinity of hemoglobin to CO is 200 times greater than oxygen
Carboxyhemoglobin
Cannot transport oxygen
Methemoglobin
Once formed, it will stay in the RBC during its entire 120day lifespan
Sulfhemoglobin
Associated with C. perfringens infection
Sulfhemoglobin
Formation is caused by oxidizing drugs (acetanilid, phenacetin, and sulfonamides)
Sulfhemoglobin
▪ Graphically describe the relationship between oxygen content and partial pressure of oxygen
Oxygen Dissociation Curve
▪ Shape of the curve:
sigmoid (affected by 2,3-DPG and oxygen)
(Hb won’t let go its oxygen)
Increase in oxygen affinity – hemoglobin has increased affinity for oxygen
(Hb releases oxygen)
Decrease in oxygen affinity – hemoglobin has decreased affinity for oxygen
– increased oxygen affinity
▪ Shift to the left
– decreased oxygen affinity
▪ Shift to the right
– hemoglobin’s affinity for oxygen is influenced by pH
▪ Bohr effect
– hemoglobin’s affinity for oxygen is influenced by carbon dioxide
▪ Haldane effect
Carbon Dioxide
Increased:
Decreased:
shift to the R ; shift to the L
pH
Increased:
Decreased:
shift to the L ; shift to the R
2,3-DPG
Increased:
Decreased:
shift to the R ; shift to the L
Exercise
Increased:
shift to the R (due to lactic acid)
Temperature
Increased:
Decreased:
shift to the R ; shift to the L
Hb F:
shift to the L
Hb Chesapeake:
shift to the L
Hb Kansas:
shift to the R
▪ Together with protoporphrin IX, [?] is important for the synthesis of heme
iron
– functional, absorbable form in the intestine
▪ Ferrous iron
▪ Normal adult iron level – approximately [?] (60% in the circulation; 40% in the storage form)
400 mg
▪ Storage form of iron
o – short-term storage form of iron
o – long-term storage form of iron
Ferritin
Hemosiderin
o Also known as siderophilin
▪ Transferrin
o Transport protein of iron
▪ Transferrin
o Produced by the liver
▪ Hepcidin
o Negative regulator of intestinal iron absorption
▪ Hepcidin
o Suppresses the release of iron from macrophage
▪ Hepcidin
o Plays an important role in anemia of chronic inflammation
▪ Hepcidin
▪ Storage site of iron in the body
o Liver (major) o Bone marrow o Spleen
▪ Main function: primary defense against foreign invaders such as bacteria, viruses and other foreign antigens
White blood cells
White blood cells Compartments in the body:
bone marrow, peripheral blood, tissues
: most valuable and reliable criterion for deciding whether a cell is mature or immature
Nuclear chromatin pattern
According to granularity
According to segmentation
According to function
Granulocytes
Neutrophil Basophil Eosinophil
Agranulocytes
Monocyte Lymphocyte
Polymorphonuclear cells
Neutrophil Basophil Eosinophil
Mononuclear cells
Monocyte Lymphocyte
Phagocytes
Neutrophil Monocyte Eosinophil
Immunocytes
Lymphocyte
▪ Earliest recognizable blast
Myeloblast
▪ No visible granules
Myeloblast
▪ The nucleus is made up of a smooth, delicate, uniformly distributed chromatin pattern (lacy chromatin pattern)
Myeloblast
▪ First appearance of primary granules (azurophilic/non-specific granules)
Promyelocyte
▪ Appearance of secondary or specific granules
Myelocyte
▪ Dawn of neutrophilia
Myelocyte
▪ Also known as Juvenile cells
Metamyelocyte
▪ Appearance of tertiary granules
Metamyelocyte
▪ Nucleus: kidney bean or peanut shaped
Metamyelocyte
▪ Indentation of the nucleus: <50% of the width of the nucleus
Metamyelocyte
▪ Also known as Stab cell/Staff cell
Band cell
▪ Appearance of secretory granules
Band cell
▪ Nucleus: sausage-shaped
Band cell
▪ Indentation of the nucleus: >50% of the width of the nucleus
Band cell
▪ First immature WBC to be released in the circulation
Band cell
▪ Youngest cell in the granulocytic series to normally appear in the peripheral blood
Band cell
▪ Most common WBC in normal peripheral blood
Neutrophil
Neutrophil Two forms in the peripheral blood:
Segmenters and Bands
Neutrophil Lifespan:
o 9-10 days (Steininger)
o 5 days (Brown)
o Tissue neutrophil
Ferrata cell
o Associated with subacute bacterial endocarditis
Ferrata cell
: o Described as drumstick
▪ Barr body
o Described as drumstick
▪ Barr body
o Represents the second X chromosome in females and may be seen in 2-3% of the neutrophils in females
▪ Barr body
Pools of neutrophils in the Bone marrow:
Mitotic/Proliferating pool
Storage/Maturation pool
− Myeloblasts, Promyelocytes, Myelocytes
Mitotic/Proliferating pool
− Cells undergoing cell division
Mitotic/Proliferating pool
− Metamyelocytes, Bands, Segmented neutrophils
Storage/Maturation pool
− Cells no longer undergoing cell division but progressively maturing
Storage/Maturation pool
o Pools of neutrophils in the circulation:
Circulating pool (50%)
Marginating pool (50%)
Azurophilic/nonspecific granules
Primary granules
Produced by Promyelocytes
Primary granules
Primary granules:
▪ MPO
▪ Cathepsins
▪ Acid beta-glycerophosphatase
▪ Defensins
▪ Elastase
▪ Proteinase-3
Specific granules
Secondary granules
Produced by Myelocyte
Secondary granules
Secondary granules:
▪ Lactoferrin
▪ Collagenase
▪ Gelatinase
▪ beta-2 microglobulin
▪ Lipocalin
Produced by metamyelocyte
Tertiary granules
▪ Gelatinase
▪ Collagenase
▪ Lysozyme
▪ Acetyltransferase
▪ Beta-2 microglobulin
Tertiary granules
Also known as secretory vesicles
Secretory granules
Produced by Band cell
Secretory granules
Secretory granules:
▪ ALP
▪ Vesicle-associated membrane-2
▪ CD13, CD10, CD14, CD16, CD18
▪ Plays a major role in defense against parasitic invasion and in hypersensitivity reaction
Eosinophil
▪ Eosinophil Important products:
MBP and Charcot-Leyden crystals
– an arginine-rich protein that plays an important role in the eosinophil’s ability to damage parasites
▪ Major Basic Protein
: − Hexagonal pyramidal crystals
▪ Charcot-Leyden crystals
− Found in the nasal mucus of patients with allergic asthma, pleural fluid of patients w/ pulmonary eosinophilic infiltrates, and stool of patients w/ parasitic infections
▪ Charcot-Leyden crystals
▪ Mediator of Immediate hypersensitivity reaction
Basophil
cells have specific receptor for IgE
▪ Basophils and mast
▪ Basophils Important products:
Histamine and Heparin
Main function: phagocytosis
▪ Monocyte
Slightly immature cells whose ultimate goal is to enter the tissues and mature into macrophages
▪ Monocyte
Size: 15-20 um
▪ Monocyte
o Chromatin pattern: lacelike
Monocyte
o Nucleus: horseshoe or tulip shape
Monocyte
o Cytoplasm: blue-gray with fine azure granules often referred to as azure dust or a ground glass appearance
Monocyte
▪ Monocyte Maturation series:
monoblast → promonocyte → monocyte → macrophage
o There is no storage pool in the bone marrow
Monocyte
o Proliferation in the bone marrow: 55 hours
Monocyte
spends about 12 hours in the peripheral blood before going to the tissues
Monocyte
o The marginal pool in the peripheral blood is 3.5 times greater than the circulating pool
Monocyte
▪ Main function: immune response
Lymphocyte
▪ Serves as a “marker cell” for estimating the size of surrounding cells
Lymphocyte
– most small lymphocytes
▪ T-lymphocytes
– most large lymphocytes
▪ B-lymphocytes
– third population of lymphocytes
▪ NK cells
▪ Lifespan: several months to years
Lymphocyte
▪ Mononuclear cells with round or oval and smooth or irregular margins
Plasma cells
▪ The eccentrically located nucleus is composed of blocks of heterochromatin resembling a tortoise shell
Plasma cells
▪ Nucleus exhibits a cartwheel pattern
Plasma cells
▪ The area next to the nucleus containing the Golgi apparatus is unstained (Hof)
Plasma cells
: located on the cytoplasm that may contain round, discrete globules that appear paleclue, or occasionally red which contains immunoglobulins
▪ Russel bodies
– cluster of Russel bodies
▪ Morula cell/grape cell/Mott cells
Associated with increased RBC count, hemoglobin, hematocrit
Polycythemia
May be classified as relative or absolute
Polycythemia
NOTE: A hematocrit value of [?] in men and [?] in
women is often diagnostic of Polycythemia
> 52%
> 50%
Refers to true increase in red cell mass
ABSOLUTE POLYCYTHEMIA
– due to bone marrow defect
▪ Primary Polycythemia
Refers to true increase in red cell mass
ABSOLUTE POLYCYTHEMIA
– due to kidney defect
▪ Secondary Polycythemia
▪ Chronic myeloproliferative disorder
Absolute Primary Polycythemia
▪ Due to mutation of JAK2 gene
Absolute Primary Polycythemia
▪ Pancytosis: absolute increased in RBC, WBC, platelets Absolute
Absolute Primary Polycythemia
▪ Panhyperplasia: the bone marrow is hypercellular showing an overall increase
Absolute Primary Polycythemia
Characterized by hyperviscous blood (due to increased RBCs)
Absolute Primary Polycythemia
▪ Prone to IDA (therapeutic phlebotomy)
Absolute Primary Polycythemia
▪ Hallmark of PV:
plethora
Absolute Primary Polycythemia Clinical features:
▪ ESR is decreased
▪ EPO is decreased
▪ LAP is increased
▪ Dacryocyte in PBS is a common finding
▪ Due to increased level of EPO
Absolute Secondary Polycythemia
▪ Residence at high altitudes
Absolute Secondary Polycythemia
▪ Chronic pulmonary disease
▪
Absolute Secondary Polycythemia
CHF
Absolute Secondary Polycythemia
▪ Heavy smoking
Absolute Secondary Polycythemia
▪ Methemoglobinemia
Absolute Secondary Polycythemia
▪ Tumor of the kidneys
Absolute Secondary Polycythemia
▪ Due to decrease in the fluid (plasma) portion of the blood that gives the appearance of an increased red cell mass in relation to total blood volume rather than a true increase in red cell mass
RELATIVE POLYCYTHEMIA
▪ NOT a hematologic disorder
RELATIVE POLYCYTHEMIA
▪ Actual number of RBC in the blood is not increased, but the number of cells per unit volume of blood is increased
RELATIVE POLYCYTHEMIA
- Dehydration secondary to diarrhea, vomiting, excessive sweating, burns, anaphylaxis, and diuretics
RELATIVE POLYCYTHEMIA
- Anxiety and stress
RELATIVE POLYCYTHEMIA
- Tobacco smoking
RELATIVE POLYCYTHEMIA
- Gaisbock’s syndrome
RELATIVE POLYCYTHEMIA
− also known as Spurious polycythemia or Stress syndrome
Gaisbock’s syndrome
− Associated with smoking, CVD, hypertension, and diuretic therapy
Gaisbock’s syndrome
A decrease in red blood cells, hemoglobin, and hematocrit below the reference range for healthy individuals of the same age, sex, and race, under similar environmental conditions
Anemia
Mechanisms of Anemia
A. Due to Production B. Due to Destruction
A. Due to Production
▪ Ineffective erythropoiesis
▪ Insufficient erythropoiesis
B. Due to Destruction
▪ Intrinsic defects in the RBC membrane, enzyme, or hemoglobin
▪ Extrinsic causes such as antibody-mediated process, mechanical fragmentation, or infectionrelated
Test for Accelerated RBC destruction
- Lactate dehydrogenase
- Indirect bilirubin
- Chromium Radioisotope: the reference method for RBC survival studies by ICSH
Laboratory Diagnosis of Anemia
- CBC and RBC indices
- Reticulocyte count
- Peripheral Blood Smear Examination
- Bone Marrow Examination
- H/H
– serves as an important tool to assess the bone marrow’s ability to increase RBC production in response to anemia
- Reticulocyte count
– indicated for a patient with an unexplained anemia, fever of unknown origin, or suspected hematologic malignancy
- Bone Marrow Examination
– widely used tests for anemia
- H/H
▪ A condition in which there is a peripheral blood pancytopenia
Aplastic Anemia
▪ Pancytopenia: dec RBC, WBC, Platelets, Reticulocytes
Aplastic Anemia
▪ Lymphocytes are the predominant cell in the peripheral blood (less affected)
Aplastic Anemia
Clinical Features:
▪ Bleeding
▪ Infection
▪ Anemia
▪ No splenomegaly
▪ No lymphadenopathy
Aplastic Anemia
▪ Genetic defect
Aplastic Anemia
▪ Ionizing radiation
Aplastic Anemia
▪ Chemicals
Aplastic Anemia
▪ Parvovirus B19
Aplastic Anemia
▪ Benzene
Aplastic Anemia
▪ Chloramphenicol (most common cause)
Aplastic Anemia
▪ Trinitrotoluene
Aplastic Anemia
▪ Arsenic
Aplastic Anemia
▪ Fanconi Anemia
Hereditary Aplastic Anemia
▪ Diamond-Blackfan anemia
Hereditary Aplastic Anemia
▪ Chronic Kidney Disease
Acquired Aplastic Anemia
▪ Myelophthisic anemia
Acquired Aplastic Anemia
▪ Also known as Congenital Aplastic Anemia
Fanconi Anemia
▪ Autosomal recessive
Fanconi Anemia
▪ Pancytopenia
Fanconi Anemia
▪ Normocytic anemia
Fanconi Anemia
▪ Low birth weight (<2,500 gram)
Fanconi Anemia
▪ Skin hyperpigmentation (café au lait spots)
Fanconi Anemia
▪ Short stature
Fanconi Anemia
▪ Renal malformations
Fanconi Anemia
▪ Microcephaly
Fanconi Anemia
▪ Mental retardation
Fanconi Anemia
▪ Hypogonadism
Fanconi Anemia
▪ Strabismus
Fanconi Anemia
▪ Also known as Congenital Pure Red Cell Aplasia
Diamond-Blackfan Anemia
▪ Defective/reduced CFU-E
Diamond-Blackfan Anemia
▪ Caused by a mutation in RPS19 gene; idiopathic (Steininger)
Diamond-Blackfan Anemia
▪ Normocytic anemia w/ normal leukocyte and platelet count and a marked decrease in marrow erythroblasts
Diamond-Blackfan Anemia
▪ Also known as leucoerythroblastic anemia
Myelophthisic Anemia
▪ Common finding in patients with carcinoma
Myelophthisic Anemia
▪ Results when the bone marrow is replaced by abnormal cells such as metastatic tumor cells, leukemic cells, fibroblasts, and inflammatory cells (found in miliary TB and fungal infections)
Myelophthisic Anemia
= invasion of abnormal cell
▪ Myelophthisis
Myelophthisic Anemia Lab Picture:
▪ Normocytic anemia
▪ Normocytic anemia
▪ Reticulocyte, Teardrop cells, nRBCs, immature myeloid cells in the peripheral blood, presence of abnormal cells in the bone marrow Anemia of Chronic Kidney Disease
▪ Anemia is due to inadequate production of EPO by the kidneys
▪ EPO, presence of Burr cells (Uremia)
Myelophthisic Anemia
▪ dec Reticulocyte, Teardrop cells, nRBCs, immature myeloid cells in the peripheral blood, presence of abnormal cells in the bone marrow
Myelophthisic Anemia
▪ Anemia is due to inadequate production of EPO by the kidneys
Anemia of Chronic Kidney Disease
▪ dec EPO, presence of Burr cells (Uremia)
Anemia of Chronic Kidney Disease
▪ Impaired DNA synthesis affects all rapidly dividing cells of the body, including the skin, GIT, and bone marrow
ANEMIA OF ABNORMAL NUCLEAR DEVELOPMENT
▪ Vitamin B12 and Folate are essential in DNA synthesis
ANEMIA OF ABNORMAL NUCLEAR DEVELOPMENT
▪ Deficiencies of either vitamin impair DNA replication, halt cell division, and increase apoptosis, which results in ineffective erythropoiesis and megaloblastic morphology
ANEMIA OF ABNORMAL NUCLEAR DEVELOPMENT
▪ Dietary source: meat
Vitamin B12 Deficiency
▪ The liver stores adequate amount of Vitamin B12 for several years if no more is ingested
Vitamin B12 Deficiency
: forms a protective complex with Vitamin B12 that is transported down the GIT
▪ Intrinsic factor
▪ Vitamin B12 is maximally absorbed in the
ileum
Vitamin B12 Deficiency Causes:
▪ Inadequate intake
▪ Increased need
▪ Impaired absorption
▪ Autoimmune disorder characterized by impaired absorption of vitamin B12 due to lack of IF
Pernicious Anemia
▪ Most common form of Vitamin B12 deficiency
Pernicious Anemia
▪ More common in people with blood type A
Pernicious Anemia
▪ The organism has the ability to split vitamin B12 from IF, rendering the vitamin unavailable for host absorption
D. latum infection
▪ Portions of the intestines becomes stenotic as a result of surgery or inflammation
Blind loop syndrome
▪ These sites can become overgrown with intestinal bacteria that compete effectively with the host for available vitamin B12
Blind loop syndrome
▪ Causes Vitamin B12 malabsorption
Imerslund-Grasbeck syndrome
▪ Not related to IF deficiency/defect
Imerslund-Grasbeck syndrome
▪ Defect in cubilin/amnionless receptor (Henry’s)
Imerslund-Grasbeck syndrome
▪ Provides a measure of body’s ability to secrete viable IF and absorb orally administered 57Co-labeled B12 in the ileum
Schilling Test (Classical Test)
Schilling Test (Classical Test) Specimen requirement
▪ Fasting specimen
▪ A 24-hour urine collection is begun immediately upon administration of the labeled B12 by mouth Interpretation
Schilling Test (Classical Test)
Phase 1 (radiolabeled B12 w/o IF)
▪ >7% of labeled B12 is excreted =
▪ <7% of labeled B12 is excreted =
Dietary B12 deficiency
Proceed to Phase 2
Schilling Test (Classical Test)
Phase 2 (radiolabeled B12 w/IF)
▪ >7% of labeled B12 is excreted =
▪ <7% of labeled B12 is excreted =
Pernicious anemia
Malabsorption syndrome (Tropical Sprue, D. latum, Blind Loop syndrome)
Sources of Folate:
green leafy vegetables
▪ Inadequate intake
Folate Deficiency
▪ Increased need
Folate Deficiency
▪ Impaired absorption
Folate Deficiency
▪ Excessive loss due to renal dialysis
Folate Deficiency
▪ Alcohol (alcohol interferes with folate metabolism)
Folate Deficiency
▪ Lacks hypersegmented neutrophil and oval macrocytes in the peripheral blood and megaloblasts in the bone marrow
Macrocytic Non-Megaloblastic Anemia
Macrocytic Non-Megaloblastic Anemia ▪ Physiologic cause:
newborn
Macrocytic Non-Megaloblastic Anemia ▪ Pathologic cause:
liver disease, chronic alcoholism, bone marrow failure
CBC Folate deficiency Vitamin B12 deficiency
Pancytopenia ([?]RBC, WBC, Platelet count)
[?] MCV, MCH
[?] RDW
[?] Reticulocyte count
Dec
Inc
Inc
Dec
PBS examination Folate deficiency Vitamin B12 deficiency:
Macroovalocytosis
Teardrop cells
nRBCs
Hypersegmented neutrophils
Bone marrow examination Folate deficiency Vitamin B12 deficiency:
Presence of megaloblasts
Inc M:E ratio
Hypercellular bone marrow
(+) anti-parietal cells, anti-IF
Vitamin B12 deficiency
Achlorhydria
Vitamin B12 deficiency
(+) D. latum eggs
Vitamin B12 deficiency
Gastric analysis NORMAL
Folate deficiency
Anemia of Iron and Heme Metabolism Mechanisms:
1. Deficiency of[?]
2. Defective release of[?] from macrophages (Anemia of Chronic Inflammation)
3. Defective utilization of[?] within the erythroblast (SDA, lead poisoning)
raw material (e.g., iron)
stored iron
iron
Tests used to differentiate iron metabolism disorders:
- Serum Ferritin
- Serum Iron
- FEP
- TIBC
- Transferrin saturation
- Zinc Erythrocyte Porphyrin
▪ Reflects the body’s tissue iron stores
Serum Ferritin
▪ A good indicator of iron storage status
Serum Ferritin
▪ First laboratory test to become abnormal when iron stores begin to decrease
Serum Ferritin
▪ Decreased only in IDA
Serum Ferritin
▪ Helpful in cases where the diagnosis is not obvious from other laboratory tests
Serum Iron
▪ Normally, red cells produced slightly more protoporphyrin than is needed
FEP
▪ However, when iron is deficient, protoporphyrin levels builds up in RBCs than the normal level
FEP
▪ Indirect measurement of transferrin concentration
TIBC
▪ Measures the binding site
TIBC
▪ (dec Anemia of chronic inflammation; inc IDA)
TIBC
▪ Obtained through the measurements of serum iron and TIBC
Transferrin saturation
%Transferrin saturation =
serum iron/TIBC x 100
▪ Measures unused protoporphyrin
Zinc Erythrocyte Porphyrin Test
▪ Increased in IDA, Lead poisoning, and Porphyria
Zinc Erythrocyte Porphyrin Test
▪ Most common form of anemia
Iron Deficiency Anemia
▪ The individual may not exhibit signs or symptoms until the appearance of Frank anemia
Iron Deficiency Anemia
▪ Microcytic, hypochromic anemia
Iron Deficiency Anemia
Iron Deficiency Anemia
▪ [?] Iron
▪ [?] TIBC and FEP
▪ Normal Reticulocyte count
▪ [?] Reticulocytes after iron therapy
Dec
Inc
Inc
Iron Deficiency Anemia Causes
Inadequate intake
Increased body demand (pregnancy, growing children)
Impaired absorption
Chronic blood loss due to infection (Hookworm infection)
Marching anemia: develops when RBCs are hemolyzed by footpounding trauma and iron is lost (hemoglobinuria is a common finding)
Chronic blood loss due to infection (?)
Hookworm infection
Chronic blood loss due to infection (?)
Hookworm infection
: develops when RBCs are hemolyzed by footpounding trauma and iron is lost (hemoglobinuria is a common finding)
Marching anemia
Stages of iron loss
▪ Stage 1 – progressive loss of storage iron
▪ Stage 2 – exhaustion of the storage pool of iron
▪ Stage 3 – Frank anemia (storage pool and circulatory iron is depleted)
Stages of iron loss
▪ Stage 1 – progressive loss of storage iron
▪ Stage 2 – exhaustion of the storage pool of iron
▪ Stage 3 – Frank anemia (storage pool and circulatory iron is depleted)
– progressive loss of storage iron
▪ Stage 1
– exhaustion of the storage pool of iron
▪ Stage 2
– exhaustion of the storage pool of iron
▪ Stage 2
– Frank anemia (storage pool and circulatory iron is depleted)
▪ Stage 3
▪ Glossitis
Iron Deficiency Anemia
▪ Glossitis
Iron Deficiency Anemia
▪ Angular cheilosis
Iron Deficiency Anemia
– inflamed cracks at the corner of the mouth
Angular cheilosis
– inflamed cracks at the corner of the mouth
Angular cheilosis
▪ Koilonychia
Iron Deficiency Anemia
▪ Koilonychia
Iron Deficiency Anemia
– spooning of the fingernails
Koilonychia
▪ Pica
Iron Deficiency Anemia
▪ Pagophagia
Iron Deficiency Anemia
▪ Decreased: RBC count, H/H, MCV, MCH, MCHC
Iron Deficiency Anemia
▪ Increased RDW (anisocytosis)
Iron Deficiency Anemia
▪ Increased RDW (anisocytosis)
Iron Deficiency Anemia
are iron-containing normoblasts found in a normal bone marrow
Sideroblastic Anemia ▪ Sideroblasts
▪ The iron deposits are identified using Prussian blue stain, and the resulting abnormal cells are identified as ringed sideroblasts
Sideroblastic Anemia
▪ Caused by: defective iron loading (accumulation of erythroid precursor in the mitochondria) due to deficiency of ALA synthetase
Sideroblastic Anemia
Sideroblastic Anemia Hereditary:
▪ Hereditary Sideroblastic Anemia
Sideroblastic Anemia Acquired:
▪ Refractory Anemia w/ Ringed Sideroblasts
▪ Idiopathic Acquired Sideroblastic Anemia
▪ Primary Idiopathic Sideroblastic Anemia
▪ Secondary Sideroblastic Anemia
▪ Severe anemia (Hct = <20%)
Hereditary Sideroblastic Anemia
▪ Dimorphic population of RBCs:
✓ Normocytic, normochromic
✓ Microcytic, hypochromic
Hereditary Sideroblastic Anemia
▪ (+) Target cells and basophilic stippling
Hereditary Sideroblastic Anemia
▪ inc iron and % transferrin saturation
Hereditary Sideroblastic Anemia
▪ More common SDA
Primary Idiopathic SDA
▪ Moderate anemia (Hct = 25-30%)
Primary Idiopathic SDA
▪ (+) normocytes and macrocytes w/ few microcytes
Primary Idiopathic SDA
▪ Erythroid hyperplasia w/ ringed sideroblasts in all stages of development
Primary Idiopathic SDA
▪ Due to toxins and drugs that interfere w/ heme synthesis
Secondary SDA
▪ Alcoholism, lead poisoning, TB drugs, and chloramphenicol
Secondary SDA
▪ Second most common anemia
Anemia of Chronic Inflammation
▪ Associated with infections, inflammatory, or malignant diseases of more than 1 or 2 months of duration
Anemia of Chronic Inflammation
▪ Most common anemia among hospitalized patients
Anemia of Chronic Inflammation
▪ Iron appears to be trapped in macrophages; therefore iron is not made available for reutilization in normoblasts
Anemia of Chronic Inflammation
▪ The anemia is often corrected when the primary disease is resolved
Anemia of Chronic Inflammation
▪ dec Transferrin (due to being a negative APR)
Anemia of Chronic Inflammation
▪ Tuberculosis
Anemia of Chronic Inflammation
▪ Lung abscess
Anemia of Chronic Inflammation
▪ Bacterial endocarditis
Anemia of Chronic Inflammation
▪ Neoplasms
Anemia of Chronic Inflammation
▪ RA
Anemia of Chronic Inflammation
▪ Rheumatic fever
Anemia of Chronic Inflammation
▪ SLE
Anemia of Chronic Inflammation
▪ Chronic liver disease
Anemia of Chronic Inflammation
▪ Hormone produced by the liver to regulate body iron levels particularly absorption of iron in the intestine and release of iron from macrophages
Hepcidin
▪ Iron-binding protein in the granules of the neutrophils
Lactoferrin
▪ Prevents phagocytized bacteria from using intracellular iron
Lactoferrin
▪ During infection and inflammation, inflammation is released into the plasma
Lactoferrin
▪ Binds iron
Ferritin
▪ Because developing RBCs do not have a ferritin receptor, this iron is unavailable for incorporation into hemoglobin
Ferritin
▪ Because developing RBCs do not have a ferritin receptor, this iron is unavailable for incorporation into hemoglobin
Ferritin
▪ A form of acquired porphyria and acquired Sideroblastic Anemia
Lead Poisoning
▪ Children may be exposed to lead secondary to ingestion of leadcontaining paint
Lead Poisoning
▪ Also associated with the use of improperly glazed pottery for cooking or eating
Lead Poisoning
▪ Similar to Sideroblastic anemia (lead inhibits several enzymes needed in heme biosynthesis)
Lead Poisoning
▪ Anemia, when present in lead poisoning, is most often normocytic and normochromic; however, with a chronic exposure to lead, a microcytic hypochromic clinical picture may be seen
Lead Poisoning
▪ (+) Coarse basophilic stippling
Lead Poisoning
Inherited disorder of defective heme synthesis
Porphyria
Accumulation of porphyrin precursors
Porphyria
Rare autosomal recessive disorder common in males
Hemochromatosis
Abnormal iron deposition in the tissues causing “bronze skin pigmentation”
Hemochromatosis
Associated with Bronze diabetes
Hemochromatosis
Normal H/H
Inc Iron and transferrin saturation
Dec Transferrin
Hemochromatosis
Caused by qualitative structural abnormalities of the globin chains that result from alteration of genetic sequence
Hemoglobinopathies
Quantitative defect/reduction in globin chain synthesis
Thalassemia
High incidence in Mediterranean descent
Thalassemia
= sickle cell anemia
▪ Homozygous SS
= sickle cell trait
▪ Heterozygous SS
▪ Autosomal codominant
Sickle Cell Anemia
▪ When fully oxygenated, hemoglobin S is fully soluble (reversible)
Sickle Cell Anemia
▪ Sickling occurs when oxygen decreases at the tissue level
Sickle Cell Anemia
▪ Provides resistance against P. falciparum
Sickle Cell Anemia
▪ When oxygen is released from the molecule, a conformational change occurs, which results in polymerization of Hb molecule leading to the formation of tactoids or crystals which causes the cells to become rigid
Sickle Cell Anemia
Any situation that produces excessive deoxygenation of the RBC may cause painful sickle cell crises (e.g., infection, dehydration, strenuous exercise, obstetric delivery and high altitudes)
Sickle cell crises
▪ Occur when rigid sickle cells increase the blood viscosity
Vaso occlusive crises
▪ Occur when rigid sickle cells increase the blood viscosity
Vaso occlusive crises
▪ Associated with the development of microthrombi, vascular occlusions, and microinfarction in the joints and extremities as well as in the major organs, which can cause organ failure
Vaso occlusive crises
▪ Associated with the development of microthrombi, vascular occlusions, and microinfarction in the joints and extremities as well as in the major organs, which can cause organ failure
Vaso occlusive crises
▪ Primary cause of death of patients with sickle cell anemia
Infectious crises
▪ Causative agent: S. pneumoniae (common in children) ▪
Infectious crises
▪ Also known as dactylitis
Hand-Foot syndrome
▪ First sites affected by decreased blood flow are the small bones of hands and feet
Hand-Foot syndrome
▪ Normocytic, normochromic anemia
Sickle Cell Anemia
▪ (+) Sickle cell, Target cell, Ovalocyte, Schistocyte, Polychromasia, nRBC
Sickle Cell Anemia
Sickle Cell Anemia
▪ [?] RDW
▪ [?] OFT, ESR
▪ [?] M:E ratio
Inc
Dec
Inc
occurs when sickle cells become trapped in the splenic microcirculation.
Splenic sequestration
▪ The spleen enlarges as more cells are trapped leading to [?] which may cause shock and death
hypovolemia
▪ 2nd most common Hb variant
Hemoglobin C
▪ tends to crystallize when dehydrated
Hemoglobin CC
▪ Note: the cells most vulnerable to intracellular crystallization are[?] because they tend to lose water as they age
older RBCs
▪ in MCHC
▪ Normocytic, normochromic anemia
▪ (+) Target cell, Spherocyte
▪ (+) Hb CC or SC crystal
Hemoglobin C disease
▪ in MCHC
▪ Normocytic, normochromic anemia
▪ (+) Target cell, Spherocyte
▪ (+) Hb CC or SC crystal
Hemoglobin C disease
▪ Caused by deletion of all four alpha globin genes (–/–) resulting in the production of hemoglobin Barts (γ4)
Bart’s Hydrops Fetalis
▪ has high affinity for oxygen
Bart’s Hydrops Fetalis
▪ The disorder is lethal; infants are usually stillborn or die within hours of birth
Bart’s Hydrops Fetalis
▪ Hb Barts has high affinity for oxygen
Bart’s Hydrops Fetalis
▪ Hb Barts has high affinity for oxygen
Bart’s Hydrops Fetalis
▪ The disorder is lethal; infants are usually stillborn or die within hours of birth
Bart’s Hydrops Fetalis
▪ Caused by deletion of 3 out of 4 alpha globin genes (–/-a)
Hb H Disease
▪ This disorder results from the decreased synthesis of alpha chains and the resultant formation of the unstable hemoglobin, Hb H (β4)
Hb H Disease
Hb H Disease ▪ At birth =
Inc Hb Barts (due to the presence of gamma globin chains)
▪ Also known as alpha thalassemia trait
Alpha Thalassemia minor
Hb H Disease ▪ Adult =
Inc Hb H (due to availability of beta globin and replaces Barts Hb
▪ Caused by deletion of 2 out of 4 alpha globin genes
Alpha Thalassemia minor
▪ Caused by deletion of 2 out of 4 alpha globin genes
Alpha Thalassemia minor
▪ Heterozygous a0 (–/aa)
▪ Homozygous a+ (a-/a-)
Alpha Thalassemia minor
▪ Also known as heterozygous alpha thalassemia
Silent carrier
▪ Caused by deletion of 1 out of 4 alpha globin genes (-a/aa)
Silent carrier
▪ Benign, and often discovered only during family studies
Silent carrier
Results to reduced production of beta globin chains → excess production of alpha chain (unstable)
Beta Thalassemia
▪ Also known as Cooley’s anemia/Mediterranean anemia
Thalassemia major
▪ Beta globin chain synthesis is impaired
Thalassemia major
▪ inc Hb A2
Thalassemia major
Marked skeletal deformities with frontal bossing, cheek bone and jaw protrusion
Beta Thalassemia
Characterized by increased levels of Hb F in adults in the absence of the usual hematologic features of thalassemia
Hereditary Persistence of Hemoglobin F
1st most common Enzymopathies
G6PD Deficiency
Most common RBC enzymopathy
G6PD Deficiency
Produced in: HMP
G6PD Deficiency
Triggers of hemolysis: antimalarial drugs, fava beans
G6PD Deficiency
Classical finding: Heinz bodies
G6PD Deficiency
2nd most common Enzymopathies
PK Deficiency
Produced: EMP
PK Deficiency
can lead to hemolytic anemia
PK deficiency
Deficiency 3rd most common Enzymopathies
Pyrimidine-5-nucleotidase
Substitution of glutamic acid to lysine at 6th position of the β-chain
Hemoglobin C
Substitution of glutamic acid to lysine at 26th position of the β -chain
Hemoglobin E
Substitution of asparagine to threonine at 102nd position of the β-chain
Hemoglobin Kansas
Substitution of glutamic acid to lysine at 121st position of the β-chain
Hemoglobin O-Arab
Also known as D-Punjab Substitution of glutamic acid to glycine at 121st position of the β-chain
Hemoglobin D-Los Angeles
Also known as C-Georgetown
Hemoglobin C-Harlem
Caused by two amino acid substitutions
Hemoglobin C-Harlem
Substitution of glutamic acid to valine at 6th position and aspartic acid to asparagine at 73rd position of the β-chain
Hemoglobin C-Harlem
Substitution of asparagine to lysine at 68th position of the alpha chain
Hemoglobin G-Philadelphia
Substitution of arginine to leucine at 92nd position of the alpha chain
Hemoglobin Chesapeake
Addition of 31 amino acids in the alpha chain
Hemoglobin Constant Spring
Amino acid deletion
Hemoglobin Gun Hill
Unstable hemoglobin
Hemoglobin Koln
Protein 4.1 and Spectrin deficiency
Hereditary Spherocytosis
(+) Autohemolysis test
Hereditary Spherocytosis
Inc OFT
Hereditary Spherocytosis
Protein 4.1 deficiency
Hereditary Elliptocytosis
Spectrin deficiency
Hereditary Pyropoikilocytosis
Commonly seen in burn patients
Hereditary Pyropoikilocytosis
Band 3 deficiency
Southeast Asian Ovalocytosis
Hemolytic anemia with dehydrated red blood cells
Hereditary Xerocytosis
(+) stomatocytes, target cells, macrocytes
Hereditary Xerocytosis
Also known as hydrocytosis
Hereditary Stomatocytosis
Characterized by neurologic impairment and acanthocytes on the PBS
Neuroacanthocytosis
Also known as hereditary acanthocytosis
Abetalipoproteinemia (Bassen-Kornzweig Syndrome)
Due to absence of β-lipoprotein
Abetalipoproteinemia (Bassen-Kornzweig Syndrome)
Characterized by malabsorption of fat, retinitis pigmentosa, neurologic damage and acanthocytosis
Abetalipoproteinemia (Bassen-Kornzweig Syndrome)
Characterized by chorea, hyperkinesia, cognitive impairment, and neuropsychiatric symptoms
Chorea Acanthocytosis
Due to KX gene mutation
McLeod syndrome
– precursor for the production of Kell antigen
Kx substance
▪ Also known as Marchiafava-Micheli syndrome
Paroxysmal Nocturnal Hemoglobinuria
▪ Hemoglobinuria occurs at night when blood pH falls (acidic)
Paroxysmal Nocturnal Hemoglobinuria
▪ Complication of PNH may progress to aplastic anemia
Paroxysmal Nocturnal Hemoglobinuria
▪ Cause: stem cell mutation that results in circulating blood cells that lack CD55 and CD59
Paroxysmal Nocturnal Hemoglobinuria
Paroxysmal Nocturnal Hemoglobinuria
▪ = DAF
▪ = MIRL
CD55
CD59
are complement-inhibiting regulator proteins
▪ CD55 and CD59
Paroxysmal Nocturnal Hemoglobinuria ▪ Screening test:
Sugar water test or sucrose hemolysis test
Paroxysmal Nocturnal Hemoglobinuria ▪ Confirmatory test:
Acidified Serum Test (Ham’s test)
▪ Dec LAP
Paroxysmal Nocturnal Hemoglobinuria
Due to severe liver disease that develop a hemolytic anemia with acanthocyte
Spur cell anemia
A disease of small blood vessels
Microangiopathic Hemolytic Anemia
Can be a complication of one of several conditions in which there is a disturbance of the microvascular environment (DIC, TTP, HUS)
Microangiopathic Hemolytic Anemia
▪ When there is extensive damage to vessel endothelium or exposure to compounds to initiate clotting (thromboplastic substances that encourage coagulation), DIC may follow
DIC
▪ As a direct result of fibrin deposition along and across the vessel lumen, RBCs can be fragmented or destroyed as they are pushed through the vessel by the action of blood pressure and rapidly flowing circulation
DIC
▪ (+) Schistocyte
DIC
▪ (+) D-dimer
DIC
▪ Also known as Moschkovitz syndrome
TTP
▪ Due to ADAMTS13 deficiency
TTP
▪ Most common in children
HUS
▪ Involves acute intravascular hemolysis and renal failure
HUS
▪ Causative agent: E. coli O157:H7
HUS
▪ EHEC produces Shiga-like toxin
HUS
▪ (+) Shistocytes, Burr cells, polychromasia
HUS
▪ Inc BUN, Creatinine
HUS
Autoimmune Hemolytic Anemia
WAIHA
CAIHA
PCH
Alloimmune Hemolytic Anemia
HDN
HTR
DIHA
Caused by Autoanti-P (biphasic hemolysin)
Paroxysmal Cold Hemoglobinuria
Paroxysmal Cold Hemoglobinuria Diagnostic test:
Donath-Landsteiner Test
Infection
Leishmaniasis Malaria Babesiosis B. bacilliformis
Also known as Chronic Myeloproliferative Disorders
MYELOPROLIFERATIVE DISORDERS
Splenomegaly is a common finding (extramedullary hematopoiesis)
MYELOPROLIFERATIVE DISORDERS
Examples:
Polycythemia vera
Essential Thrombocythemia
Primary Myelofibrosis
CML
MYELOPROLIFERATIVE DISORDERS
▪ Also known as Primary Thrombocytosis, Idiopathic Thrombocytosis
Essential Thrombocythemia
▪ Characterized by a thrombocytosis of 1000 x 109/L with spontaneous aggregation of functionally abnormal platelets
Essential Thrombocythemia
▪ Must be differentiated from secondary or reactive thrombocytosis
Essential Thrombocythemia
▪ Due to mutation of JAK2 gene
Essential Thrombocythemia
▪ Markedly increased platelet count
Essential Thrombocythemia
▪ Bone marrow examination: megakaryocytes stick together (Glued together appearance)
Essential Thrombocythemia
▪ Characterized by fibrosis and granulocytic hyperplasia of the bone marrow, with granulocytic and megakaryocytic proliferation in the liver and spleen
Primary Myelofibrosis Description
▪ Hepatomegaly and splenomegaly are common (extramedullary hematopoiesis)
Primary Myelofibrosis
▪ Due to mutation of JAK2 gene
Primary Myelofibrosis
▪ Normocytic, normochromic anemia
Primary Myelofibrosis
▪ Inc Reticulocyte count
▪ Inc WBC
Primary Myelofibrosis
▪ PBS: Teardrop cell, Polychromatophilia, NRBC
Primary Myelofibrosis
▪ Bone marrow examination: “dry tap” → presence of fibrotic tissues
Primary Myelofibrosis
▪ A stem cell disorder affecting the granulocytic, monocytic, erythrocytic, and megakaryocytic cell lines
Chronic Myelogenous Leukemia
▪ Common in adults (between ages of 30 and 50)
Chronic Myelogenous Leukemia
▪ A WBC count of 50,000-300,000/uL is often diagnostic of CML
Chronic Myelogenous Leukemia
▪ Cause: translocation between the long arms of chromosome 9 and 22
Chronic Myelogenous Leukemia
▪ Philadelphia chromosome: indicates good prognosis
Chronic Myelogenous Leukemia
▪ Must be differentiated from Leukemoid reaction using LAP test
Chronic Myelogenous Leukemia
▪ Inc RBC, WBC, and Platelet count
Chronic Myelogenous Leukemia
▪ BM Examination: hypercellular bone marrow
Chronic Myelogenous Leukemia
▪ Inc M:E ratio ▪ Inc LAP
Chronic Myelogenous Leukemia
Formerly known as Refractory anemia
Myelodysplastic Syndrome
Caused by proliferation of abnormal stem cells
Myelodysplastic Syndrome
Poikilocytosis, Basophilic stippling, Howell-Jolly bodies, and Siderocytes
Myelodysplastic Syndrome
French-American-British Classification of MDS
- RARS 2. RAEB-t 3. RAEB 4. CMML
An abnormal, uncontrolled proliferation and accumulation of one or more of the hematopoietic cells
Leukemia
A disease of the blood forming tissues and the bone marrow
Leukemia
Classification of Leukemia
Based on duration of the untreated disease
Based on number of WBC present
Based on WBC type involved
Based on duration of the untreated disease
▪ Acute leukemia:
▪ Subacute leukemia:
▪ Chronic leukemia:
several days to 6 months
2 to 6 months
1-2 years
Based on number of WBC present
▪ Leukemic leukemia:
▪ Subleukemic leukemia:
▪ Aleukemic leukemia:
> 15,000/uL
<15,000/uL w/ immature WBCs
<15,000/uL
Based on WBC type involved
▪ Acute leukemia:
▪ Chronic leukemia:
predominance of blasts
predominance of mature WBCs
Small cell, homogenous
L1
Most common acute leukemia in children
L1
Best prognosis
L1
Large cell, heterogenous
L2
Burkitt type
L3
Large lymphocytes w/ basophilic cytoplasm and numerous vacuoles
L3
Poor prognosis
L3
Acute myeloblastic leukemia, minimally differentiated
M0
Acute myeloblastic leukemia without maturation
M1
Acute myeloblastic leukemia with maturation
M2
Acute promyelocytic leukemia
M3
Characterized by the presence of bowtie/butterfly appearance of nucleus
M3
DIC is common
M3
(+) FSP
(+) Faggot cells
PT and APTT: prolonged
Dec Fibrinogen
M3
Acute myelomonocytic leukemia
M4
Also known as Naegeli monocytic leukemia
M4
Acute monocytic leukemia
M5
Also known as Schilling leukemia
M5
: ▪ Poorly differentiated leukemia
M5a
▪ Nucleus: lacy chromatin w/ nucleoli
M5a
▪ Well differentiated leukemia
M5b
▪ Nucleus: cerebriform shape with nucleoli
M5b
▪ Presence of all stages of monocytes in the peripheral blood
M5b
Erythroleukemia
M6
Also known as Di Guglielmo’s syndrome
M6
Predominance of myeloblasts and erythroblasts in the peripheral blood
M6
Acute megakaryocytic leukemia
M7
Predominance of megakaryocytes
M7
(+) PAS, ACP, platelet peroxidase
M7
M1, M2, M3, M4
MPO
SBB
Specific esterase (Naphthyl AS-D chloroacetate)
M1, M2, M3, M4
MPO
SBB
Specific esterase (Naphthyl AS-D chloroacetate)
M4, M5, M6
Nonspecific esterase (Naphthyl Acetate and Butyrate)
M5, M6, M7
PAS
ALL: +
AML: -
Terminal deoxynucleotidyl transferase
PAS
Oil Red O
ALL: -
AML: +
MPO
SBB
Most affected lymphocytes are B-cells
Chronic Lymphocytic Leukemia
Characterized by fragile lymphocytes
Chronic Lymphocytic Leukemia
Smudge cells (formed during film preparation, thumbprint appearance)
Chronic Lymphocytic Leukemia
(+) PAS
Chronic Lymphocytic Leukemia
▪ A stem cell disorder affecting the granulocytic, monocytic, erythrocytic, and megakaryocytic cell lines
Chronic Myelocytic Leukemia
▪ Common in adults (between ages of 30 and 50)
Chronic Myelocytic Leukemia
▪ A WBC count of 50,000-300,000/uL is often diagnostic of CML
Chronic Myelocytic Leukemia
▪ Cause: translocation between the long arms of chromosome 9 and 22
Chronic Myelocytic Leukemia
▪ Philadelphia chromosome: indicates good prognosis
Chronic Myelocytic Leukemia
▪ Must be differentiated from Leukemoid reaction using LAP test
Chronic Myelocytic Leukemia
▪ Inc RBC, WBC, and Platelet count
▪ BM Examination: hypercellular bone marrow
▪ Inc M:E ratio
▪ Dec LAP
▪ Chronic Myelocytic Leukemia
▪ (+) Basket cells
Chronic Myelocytic Leukemia
= nuclear remnants of granulocytic cells w/ netlike chromatin pattern
Basket cells
= nuclear remnants of granulocytic cells w/ netlike chromatin pattern
Basket cells
= nuclear remnants of granulocytic cells w/ netlike chromatin pattern
Basket cells
Also known as Leukemic Reticuloendotheliosis
Hairy Cell Leukemia
: lymphocyte w/ hairlike projections around the outer border
Hairy cell
(+) TRAP
HCL
A group of malignant tumors of the lymphoid tissue
Lymphoma
Usually, blood and bone marrow are not involved
Lymphoma
Lymphoma Classification:
Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, Miscellaneous lymphoma
Starts in one lymph node group and spreads in a predictable fashion to adjacent lymph nodes (unifocal)
Hodgkin’s Lymphoma
Hodgkin’s Lymphoma Definitive diagnostic test:
Lymph node biopsy
= classifies the different types of Hodgkin’s lymphoma
▪ Rye Classification
= used to formulate the treatment plan
▪ Ann Arbor staging system
Types of Hodgkin’s Lymphoma:
a. Nodular lymphocyte-predominant Hodgkin lymphoma
b. Classical Hodgkin lymphoma
-predominant Hodgkin lymphoma
a. Nodular lymphocyte
− presence of popcorn cell
a. Nodular lymphocyte
Classical Hodgkin lymphoma − types:
✓ Lymphocytic predominant (best prognosis)
✓ Lymphocyte depleted (worst prognosis)
✓ Mixed cellularity
✓ Nodular sclerosis (most common type)
− presence of Reed-Sternberg cell
b. Classical Hodgkin lymphoma
Spreads in a much less predictable way
Non-Hodgkin’s Lymphoma
Classified under Rappaport system (replaced by NCI)
Non-Hodgkin’s Lymphoma
Non-Hodgkin’s Lymphoma Types:
✓ Well differentiated lymphocytic lymphoma
✓ Poorly-differentiated lymphocytic lymphoma
✓ Histiocytic lymphoma
✓ Mixed histiocytic-lymphocytic lymphoma
▪ Caused by neoplastic T-cells that migrate into the skin
Mycosis fungoides
▪ Affects primarily the T-cells
Mycosis fungoides
▪ Classic symptoms: pruritus
Mycosis fungoides
▪ Pautrier’s microabscesses = cluster of lymphocytes in the epidermis
Mycosis fungoides
▪ NOTE: fungal infection is not present
Mycosis fungoides
▪ Leukemic phase of mycosis fungoides
Sezary syndrome
▪ (+) Sezary cells
Sezary syndrome
▪ Prognosis is worst at this stage
Sezary syndrome
▪ Also known as Kahler’s disease
Multiple Myeloma
▪ Caused by excessive production of IgG
Multiple Myeloma
▪ The homogenous protein synthesized by the abnormal clone may be complete immunoglobulins or light chains (kappa and lambda)
Multiple Myeloma
▪ The homogenous protein synthesized by the abnormal clone may be complete immunoglobulins or light chains (kappa and lambda)
Multiple Myeloma
▪ Idiopathic
Multiple Myeloma
▪ Clonal proliferation begins in the bone marrow and multiple tumors appear as patchy infiltrates in skeletal structures producing osteoporosis and lytic bone disease
Multiple Myeloma
▪ As the neoplastic mass grows, pathologic bone fractures and vertebral collapse may occur
Multiple Myeloma
▪ (+) Bence Jones proteins in urine
Multiple Myeloma
▪ PBS: Rouleaux formation, Dutcher bodies, Russell bodies
Multiple Myeloma
▪ Caused by excessive production of IgM
Waldenstrom’s Macroglobulinemia
▪ Monoclonal IgM may exhibit cryoglobulin activity demonstrated by precipitation or gel formation during refrigeration at 4’C and dissolve when heated
Waldenstrom’s Macroglobulinemia
▪ May result to renal damage caused by deposition of IgM complexes
Waldenstrom’s Macroglobulinemia
▪ Characterized by a WBC count of greater than 50,000/uL
Leukemoid Reaction
▪ Resembles CML
Leukemoid Reaction
Leukemoid Reaction ▪ Differential test:
LAP score
▪ Inc LAP
Leukemoid Reaction
▪ Also known as Leukoerythroblastic anemia
Leukoerythroblastic Reaction
▪ (+) NRBCs and immature neutrophils in peripheral blood smear
Leukoerythroblastic Reaction
▪ Caused by space-occupying disturbances of the bone marrow
Leukoerythroblastic Reaction
▪ Caused by space-occupying disturbances of the bone marrow
Leukoerythroblastic Reaction
Causes:
▪ Myelofibrosis w/ myeloid metaplasia
▪ Metastatic carcinoma
▪ Leukemia
▪ Multiple myeloma
▪ Gaucher disease
Leukoerythroblastic Reaction
▪ Hyposegmented neutrophils (bilobed)
Pelger-Huet anomaly
▪ The bilobed nuclei are commonly described as “pince-nez spectacles” or peanut or dumbbell shape
Pelger-Huet anomaly
Pelger-Huet anomaly
▪ Homozygous =
▪ Heterozygous =
round nucleus
pince-nez nucleus (more common)
▪ Also known as hereditary hypersegmentation of neutrophils
Undritz anomaly
▪ Characterized by leukopenia, thrombocytopenia, giant platelets, and presence of gray-blue spindle-shaped inclusions in the cytoplasm of granulocytes and monocytes
May-Hegglin anomaly
▪ NOTE: the cytoplasmic inclusion resembles Dohle bodies
May-Hegglin anomaly
▪ Characterized by the presence of abnormally large azurophilic granules resembling severe toxic granulation in the cytoplasm of granulocyte, lymphocyte and monocyte
Alder-Reilly anomaly
▪ Associated with mucopolysaccharidoses
Alder-Reilly anomaly
▪ Random movement of phagocytes is normal, but chemotaxis (directional motility) is impaired
Job’s syndrome
▪ As a result, bacteria have more time to multiply in the tissues
Job’s syndrome
▪ Both random and directed movement of the phagocytes are impaired
Lazy Leukocyte syndrome
▪ Presence of giant cytoplasmic granules in the phagocytes and lymphocytes
Chediak Higashi anomaly
▪ Inability of phagocytes to produce superoxide and ROS
Chronic Granulomatous Disease
▪ Due to NADPH oxidase
Chronic Granulomatous Disease
▪ Diagnostic test: (-) NBT dye test
Chronic Granulomatous Disease
▪ Also known as Alius-Grignaschi Anomaly
Myeloperoxidase deficiency
Most common form of neutrophil abnormality
Myeloperoxidase deficiency
▪ Function abnormality is not severe
Myeloperoxidase deficiency
Neutrophil that contains a large spherical body in its cytoplasm ; SLE
LE cell
Formed during LE cell preparation (May be confused with LE cell) ; Unknown
Tart cell
Crumpled tissue paper appearance
Macrophage with swollen cytoplasm composed of numerous small, uniform lipid droplets ; Niemann-Pick disease
Foam cell
Abnormal plasma cell with immunoglobulin trapped in endoplasmic reticulum ; Plasma cell myeloma
Morula cell
Nuclear remnants of granulocytic cells with netlike chromatin pattern Formed during blood film preparation ; CML
Basket cell
Nuclear remnants of lymphocytes Formed during blood film preparation Thumbprint appearance ; CLL
Smudge cell
Large lymphoid cells with a bilobed nucleus with prominent eosinophilic nucleoli and abundant cytoplasm (owl’s eye appearance) ; Hodgkin’s lymphoma
Reed-Sternberg cell
Large lymphoid cells with abundant cytoplasm and vesicular multilobed nuclei ; Nodular Lymphocyte ; Predominant-Hodgkin’s lymphoma
Popcorn cell
Plasma cell with abundant cytoplasm with a reddish tinge of ribosomal protein ; IgA myeloma
Flame cell
Lymphocyte with hairlike projections around the outer border ; HCL
Hairy cell
Contains bundles of Auer rods in the cytoplasm ; AML M3/APL
Faggot cell
Also known as Reactive lymphocytes, atypical lymphocytes, stress lymphocytes, virocytes, variant lymphocytes, transformed lymphocytes ; Non-malignant reactive disorders
Downey cells
✓ Type 1 –
Turk’s cell (also known as plasmacytoid lymphocyte, Turk’s irritation cell)
✓ Type 2 –
Infectious mononucleosis cell (Flared skirt appearance)
✓ Type 3 –
Transformed/Reticular lymphocytes
▪ Pale blue, round or elongated bodies
Dohle bodies
▪ Consists of rRNA
Dohle bodies
▪ Found in neutrophils
Dohle bodies
▪ Associated with pregnancy, infection, poisoning, burn and surgery
Dohle bodies
▪ Resembles May-Hegglin bodies
Dohle bodies
▪ Larger than Dohle bodies
May-Hegglin bodies
▪ Consists of mRNA
May-Hegglin bodies
▪ Found in granulocytes and monocytes
May-Hegglin bodies
▪ Heavy, coarse, blue-black granulation of the leukocytes
Alder-Reilly bodies
▪ Resembles toxic granules
Alder-Reilly bodies
▪ Associated with Hurler’s and Hunter’s syndrome and Alder-Reilly Anomaly
Alder-Reilly bodies
▪ Dark blue-black cytoplasmic granules in the neutrophil
Toxic granules
▪ Composed of primary granules
Toxic granules
▪ Associated with severe infection
Toxic granules
▪ Results when the degenerating cytoplasm begins to acquire holes or as the result of active phagocytosis
Vacuolation
▪ Associated with infection
Vacuolation
▪ Rod-like bodies representing aggregated primary granules that stain a reddish purple
Auer rods
▪ Associated with AML
Auer rods
▪ Stimulates vasodilation
Prostacyclin (PGI2)
Adenosine
Reduces blood flow rate
Prostacyclin (PGI2)
Adenosine
Inhibits platelet activation
Prostacyclin (PGI2)
Anticoagulant
Prostacyclin (PGI2)
Thrombomodulin
Heparan sulfate
Fibrinolytic
Thrombomodulin
tPA
Coagulation
von Willebrand factor
▪ Endothelial receptor for thrombin
Thrombomodulin
▪ Binds and inactivates thrombin and enhances anticoagulant and fibrinolytic action of Protein C
Thrombomodulin
▪ Coats the endothelial cell surface and weakly enhances the activity of antithrombin-III
Heparan sulfate
▪ Converts plasminogen to plasmin which plays an important role in fibrinolysis
tPA
▪ NOTE: released only on appropriate stimulus, such as vessel injury, to prevent excessive clot formation at the site of tissue injury
tPA
tPA ▪ NOTE: released only on appropriate stimulus, such as vessel injury, to prevent excessive clot formation at the site of tissue injury
▪ Secreted by endothelium
von Willebrand factor
▪ Required for platelet adhesion
von Willebrand factor
✓ Synthesized by endothelial cells, and megakaryocytes
von Willebrand Factor
✓ Stored in endothelial cells (Weibel-Palade bodies) and platelets
von Willebrand Factor
: entire molecule as it circulates in the plasma
✓ VIII/vWF
– portion of molecule responsible for binding to endothelium and supporting normal platelet adhesion and function
✓ VIII:vWF
– portion of molecule participating in intrinsic pathway
✓ VIII:C
✓ Labile factors:
V and VIII
✓ Activated by cold temperature:
VII and XI
✓ Fibrinogen is the most abundant clotting factor with a normal value of
200-400 mg/dL
✓ Serine protease:
II, X, VII, IX, XII, XI, and PK
✓ Prothrombinase:
Xa-Va
Intrinsic Tenase:
VIII-IX
Extrinsic Tenase:
VII-III-IV
: central regulatory component of coagulation (can inhibit or accelerate coagulation)
Thrombin (IIa)
▪ Extrinsic pathway:
III and VII
▪ Intrinsic pathway:
XII, XI, IX, VIII
▪ Common pathway:
I, II, V, X
▪ Fibrinogen group:
I, V, VIII, XIII
▪ Prothrombin group (Vitamin K dependent):
II, VII, IX, X
▪ Contact group:
XI, XII, PK, HMWK
▪ A transmembrane receptor for Factor VIIa
Tissue factor (thromboplastin)
= mixture of tissue factor and phospholipid
▪ Tissue thromboplastin
▪ Found on extravascular cells such as fibroblasts and smooth muscle cells (not found in endothelial cells under normal conditions)
Tissue factor (thromboplastin)
▪ High levels are found in brain, lung, heart, kidneys, and testes
Tissue factor (thromboplastin)
▪ Produced by B. fragilis and E. coli
Vitamin K
▪ Found in green leafy vegetables
Vitamin K
▪ Catalyzes an essential post-translational modification of the prothrombin group proteins
Vitamin K
▪ Vitamin K dependent factors:
o II, VII, IX, X
o Protein C, S, Z
▪ Participates in platelet adhesion and transports Factor VIII
von Willebrand Factor
▪ Large multimeric glycoprotein
von Willebrand Factor
▪ Composed of multiple subunits of 240,000 Da each
von Willebrand Factor
▪ The subunits are produced by endothelial cells and megakaryocytes, where they combine to form multimers that range from 600,000 to 20,000,000 Da
von Willebrand Factor
▪ Once released into the plasma, they are normally degraded into small-multimers by vWF-cleaving protease called ADAMTS13 (a disintegrin-like metalloprotease with a thrombospondin type 1 motif, member 13)
von Willebrand Factor
= associated with abnormally large vWF
▪ TTP
= associated with abnormally large vWF
▪ TTP
▪ Required for the assembly of coagulation complexes
Calcium
▪ Expressed by vascular endothelial cells
Thrombomodulin
▪ Cofactor of thrombin
Thrombomodulin
= activates Protein C
▪ Thrombomodulin + Thrombin
: a coagulation inhibitory protein, and thrombin activatable fibrinolysis inhibitor (TAFI)
▪ Protein C
▪ Once thrombin is bound to thrombomodulin, it loses its procoagulant ability to activate factors V and VII, and through the activation of Protein C, leads to the destruction of factors V and VII, thus suppressing further generation of thrombin
Thrombomodulin
▪ Considered as the key protease of coagulation pathway
Thrombin
▪ Primary function is to cleave fibrinopeptidases A and B from the alpha and beta chains of fibrinogen molecule, triggering spontaneous polymerization
Thrombin
✓ Activates cofactors V, VIII, and IX
Thrombin
✓ Activates factor XIII
Thrombin
✓ Initiates platelet aggregation
Thrombin
✓ Activates TAFI to suppress fibrinolysis
Thrombin
Principal regulator of tissue factor pathway
Tissue factor pathway inhibitor
→ Protein C → Activated Protein C
Thrombin + Thrombomodulin
→ inactivates factor Va and VIIIa
Protein S
Antithrombin and other serine protease inhibitors (Serpins)
Antithrombin
Heparin cofactor II
Protein Z-dependent protease inhibitor (ZPI)
Protein C inhibitor
a1-antitrypsin
a2-macroglobulin
a-2-antiplasmin
PAI-1
Inhibits thrombin
Antithrombin III
Synthesized by the liver
Antithrombin III
SERPIN
Antithrombin III
Heparin cofactor II
Inactivates thrombin
Heparin cofactor II
Potent inhibitor of factor Xa
Protein Z-dependent protease inhibitor (ZPI)
Final stage of coagulation
Fibrinolysis
Dependent on plasmin
Fibrinolysis
Destroys fibrinogen, fibrin, factor V, and factor VIII
Plasmin
Not normally present in the blood in an active form
Plasmin
Zymogen of plasmin
Plasminogen
Normally present in the plasma
Plasminogen
Homologous to Lp (a)
Plasminogen
Released in vivo by endothelial cell damage
Tissue plasminogen activator
Activates plasminogen
Tissue plasminogen activator
Activates plasmin
Urokinase plasminogen activator
May be administered to a patient to activate plasminogen
Urokinase plasminogen activator
Activates plasminogen
Streptokinase
Early degradation products:
FDP/FSP
X, Y
Late degradation products:
FDP/FSP
D (D-dimer) and E
Indicates fibrin degradation products
D-dimer
Marker of thrombosis and fibrinolysis
D-dimer
Produced by digestion of either fibrin or fibrinogen by plasmin
Fragment X, Y, E
o Purplish red, pinpoint hemorrhagic spots caused by loss of capillary ability to withstand normal blood pressure and trauma
▪ Petechiae
o Size: <3 mm
▪ Petechiae
o Produced by hemorrhage of blood into small areas of skin, mucous membrane, and other tissues
▪ Purpura
▪ o Size: <1 cm
Purpura
o Form of purpura in which blood escapes into large areas of the skin or mucous membrane but not into deep tissues
▪ Ecchymosis
o Size: >3 cm
▪ Ecchymosis
▪ Autosomal Dominant
Ehlers-Danlos Syndrome
Hereditary hemorrhagic telangiectasia
Gray Platelet Syndrome
▪ Characterized by hyperextensible joints and hyperelastic skin
Ehlers-Danlos Syndrome
▪ Autosomal Recessive
Pseudoxanthoma elasticum
Bernard-Soulier Syndrome
Glanzmann’s Thrombasthenia
Hermansky-Pudlak Syndrome
Chediak-Higashi Anomaly
Thrombocytopenia w/ absent Radii
▪ The connective tissue elastic fibers in small arteries are calcified and structurally abnormal
Pseudoxanthoma elasticum
▪ Also known as Rendu-Osler-Weber syndrome
Hereditary hemorrhagic telangiectasia
▪ Characterized by vascular malformations and skin lesions called telangiectasias
Hereditary hemorrhagic telangiectasia
▪ Also known as Kasabach-Merritt syndrome
Congenital hemangiomathrombocytopenia syndrome
▪ Associated with tumors composed of vessels that commonly swell and bleed at the surface
Congenital hemangiomathrombocytopenia syndrome
▪ Formation of fibrin clots, platelet consumption, and RBC destruction secondary to vascular obstruction occur at the site of tumor
Congenital hemangiomathrombocytopenia syndrome
▪ Also known as Scurvy
Vitamin C deficiency
▪ Vitamin C is required for the formation of intact structure of the vascular basement membrane
Vitamin C deficiency
▪ Gingival bleeding and hemorrhage into subcutaneous tissues and muscles are common finding
Vitamin C deficiency
▪ Acquired and chronic disorder of the elderly causing abnormalities in connective tissues
Senile Purpura
▪ The aging process brings about a degeneration of collagen, elastin, and subcutaneous fat
Senile Purpura
▪ Common in elderly men
Senile Purpura
▪ Purpura associated with abdominal pain secondary to GIT bleeding
Henoch-Schonlein Purpura
▪ Abdominal and joint pain related to allergic purpura
Henoch-Schonlein Purpura
▪ Common in children
Henoch-Schonlein Purpura
▪ Caused by lack of expression of Gp Ib/IX complex on the platelet surface
Bernard-Soulier Syndrome
▪ Characterized by large platelets
Bernard-Soulier Syndrome
Lab Findings:
▪ Giant platelets
▪ BT: Prolonged
▪ Platelet Aggregation studies: Ristocetin is abnormal
Bernard-Soulier Syndrome
▪ Lacks vWF
von Willebrand Disease
Lab Findings:
▪ APTT, BT, TT, CT = Prolonged
▪ Platelet Aggregation studies: Ristocetin is abnormal
▪ Treatment of choice: cryoprecipitate, DDAVP
von Willebrand Disease
▪ Lacks Gp IIb-IIIa
Glanzmann’s Thrombasthenia
▪ Clot Retraction: Abnormal
Glanzmann’s Thrombasthenia
▪ BT: Prolonged
Glanzmann’s Thrombasthenia
▪ Platelet aggregation studies: ADP, Collagen, and Epinephrine are abnormal
Glanzmann’s Thrombasthenia
▪ Lacks alpha granules
Gray Platelet Syndrome
▪ Giant platelets
Gray Platelet Syndrome
▪ Platelets are gray or blue-gray
Gray Platelet Syndrome
▪ Lacks dense granules
Hermansky-Pudlak Syndrome
▪ Triad of oculocutaneous albinism, bleeding tendency associated with abnormal platelet function, and accumulation of ceroid-like pigment in macrophages
Hermansky-Pudlak Syndrome
▪ Lacks dense granules
Chediak-Higashi Anomaly
▪ Characterized by albinism, recurrent infection, and giant lysosomes
Chediak-Higashi Anomaly
▪ Decreased delta granules
Wiskott-Aldrich Syndrome
▪ Platelets are small
Wiskott-Aldrich Syndrome
▪ Triad of thrombocytopenia, recurrent infection and eczema
Wiskott-Aldrich Syndrome
▪ X-linked recessive
Wiskott-Aldrich Syndrome
▪ Platelets have structural defects in delta granules
Thrombocytopenia w/ absent Radii
▪ Characterized by congenital absence of the radial bones
Thrombocytopenia w/ absent Radii
inhibits the synthesis of cyclooxygenase
Aspirin
inhibits platelet aggregation
Aspirin
most common acquired platelet disorder
Aspirin
▪ Autoimmune disorder
ITP
▪ Develops after transfusion of platelet containing blood products
PTP
▪ Also known as Moschowitz syndrome
TTP
▪ Characterized by triad of microangiopathic hemolytic anemia, thrombocytopenia, and neurologic abnormalities
TTP
▪ Due to ADAMTS13 deficiency
TTP
− Inherited TTP − Severe
Upshaw-Schulman Syndrome
− Caused by mutation in the ADAMTS13 gene
Upshaw-Schulman Syndrome
− Caused by autoantibodies
Idiopathic TTP
− triggered by infections, pregnancy, surgery, trauma, inflammation, and disseminated malignancy
Secondary TTP
− Trimethoprim, Ticlopidine, Quinine drugs
Secondary TTP
▪ Resembles TTP
HUS
▪ Common in children
HUS
▪ Due to E. coli infection
HUS
▪ Similar to TTP
DIC
▪ Thrombi are primarily composed of platelets and fibrinogen
DIC
▪ (+) D-dimer
DIC
▪ Due to massive blood transfusion (effect is temporary)
Dilutional
▪ Rationale: stored blood contains platelets whose viability is severely impaired by the effects of storage and temperature. Under these conditions, the damaged platelets are rapidly sequestered by the RES of the patient resulting to thrombocytopenia
Dilutional
Due to uncontrolled proliferation of platelets (e.g., PV, ET)
Primary Thrombocytosis
Splenectomy
Secondary Thrombocytosis (Reactive)
▪ Do not demonstrate clinical bleeding
PK deficiency
▪ May be vulnerable to thrombotic tendencies
PK deficiency
▪ Prolonged APTT
PK deficiency
HMWK deficiency
Factor XII deficiency
Factor XI deficiency
Factor VIII deficiency
▪ Prolonged APTT, PT, Stypven time
Factor X deficiency
▪ Prolonged APTT and PT
Factor IX deficiency
Factor V deficiency
Factor II deficiency
Factor I deficiency
▪ 5M Urea: Abnormal
Factor XIII deficiency
▪ Do not manifest bleeding disorder
Factor XII deficiency
▪ May be vulnerable to thrombosis
Factor XII deficiency
Confirmatory test: Factor XII assay
Factor XII deficiency
▪ Hemophilia C
Factor XI deficiency
▪ Also known as Hemophilia B, Christmas Disease, Rosenthal syndrome
Factor IX deficiency
▪ Also known as Hemophilia A or Classic hemophilia or Royal disease
Factor VIII deficiency
▪ X-linked disorder (males are affected)
Factor VIII deficiency
▪ Also known as Owren’s disease or Parahemophilia
Factor V deficiency
▪ Screening test for primary hemostasis
Bleeding Time
▪ Principle: the time it takes for a standard wound to stop bleeding
Bleeding Time
▪ NV: 2 to 4 minutes
Bleeding Time
– earlobe was punctured (not accurate, obsolete)
▪ Duke’s method
– uses blood pressure cuff (40 mmHg)
▪ Ivy method
– standardization of wound
▪ Mielke
▪ For primary hemostasis
Whole Blood Clotting Time
▪ Principle: when venous blood is put into a foreign surface, it will form a solid clot
Whole Blood Clotting Time
▪ Lee and White method
Whole Blood Clotting Time
NV: 5-15 minutes
Whole Blood Clotting Time
Uses 75 x 100 mm test tube
Whole Blood Clotting Time
Visual detection of fibrin clot formation
▪ Tilt tube method
▪ Also known as Capillary Fragility Test ; Used to measure capillary fragility
Tourniquet Test
(+) result: formation of petechiae
Tourniquet Test ▪
Tourniquet Test ▪ Grading:
1+ =
2+ =
3+ =
4+ =
few petechiae on the anterior part of the forearm
many petechiae on the anterior part of the forearm
multiple petechiae over the whole arm and back of the arm
confluent petechiae on the arm and back of the hand
▪ For platelet aggregation in vitro
Platelet aggregometry
▪ Reagents used: ADP, Collagen, Epinephrine, Ristocetin
Platelet aggregometry
▪ For extrinsic and common pathway
Prothrombin Time
▪ Used to monitor oral anticoagulants (Warfarin, Coumadin, Coumarin)
Prothrombin Time
prolonged if fibrinogen level is <80 mg/dL
Prothrombin Time
▪ PT reagent:
Thromboplastin (rabbit brain or lung tissue)
Calcium chloride (CaCl2)
Calculation made to standardize PT ; It is based on ratio of patient’s PT and normal mean PT
ISI – assigned by the manufacturer
Prothrombin Time ▪ INR
▪ NV: 10-14 seconds
Prothrombin Time
▪ For intrinsic and common pathway
Activated Partial Thromboplastin Time
▪ Used to monitor heparin therapy
Activated Partial Thromboplastin Time
▪ APTT Reagent:
Platelet substitute (phospholipid)
Activator (Kaolin, Celite, Silica, Ellagic acid)
▪ NV: 20-45 seconds
Activated Partial Thromboplastin Time
▪ Also known as Russell’s viper venom time
Stypven Time
▪ For common pathway
Stypven Time
Stypven Time ▪ Reagent:
Russell’s viper venom is obtained from the snake Vipera russelli
▪ For fibrinogen
Thrombin Time
▪ NOTE: affected by heparin therapy
Thrombin Time
▪ Sensitive test in detecting heparin inhibition
Thrombin Time
▪ Prolonged Thrombin time is noted when fibrinogen level is below
75 to 100 mg/dL
▪ For fibrinogen
Reptilase Time
▪ NOTE: NOT affected by heparin therapy
Reptilase Time
is an enzyme found in the venom of Bothrops atrox snake
▪ Reptilase
▪ Also known as Plasma Clotting Time
Plasma Recalcification Time
▪ For intrinsic pathway
Plasma Recalcification Time
▪ For Factor XIII
Duckert’s test
▪ Reagent: 5M Urea and 1% Monochloroacetic acid
Duckert’s test
▪ (+) Factor XIII deficiency: the clot is dissolved in the presence of 5M Urea
Duckert’s test
▪ NOTE: a clot that has not stabilized by Factor XIII is soluble to 5M Urea
Duckert’s test
▪ Screening test for DIC
Fibrinosticon
▪ The presence of crosslinked D-dimer indicates that a stable fibrin clot has been lysed
Fibrinosticon
▪ Screening test for DIC
Ethanol Gelation Test
▪ Used to detect fibrin monomers in the plasma
Ethanol Gelation Test
▪ Used to differentiate DIC from primary fibrinolysis
Ethanol Gelation Test
Principle: ▪ During the process of DIC, the level of fibrin monomer (product of fibrinogen conversion to fibrin) in the blood increases
Ethanol Gelation Test
▪ NaOH is added in the plasma to increase the pH to 7.70 (if pH is below 7.70, this will cause precipitation of fibrinogen instead of fibrin monomer)
Ethanol Gelation Test
▪ Ethyl alcohol will cause precipitation of any fibrin monomers
Ethanol Gelation Test
▪ Used to detect the presence of fibrin monomers
Protamine Sulfate
▪ NOTE: normally, there should be no fibrin monomers present in the plasma
Protamine Sulfate
▪ Screening test for fibrinolytic activity
Euglobulin clot lysis time
▪ Clot lysis in less than 1 hour indicates abnormal fibrinolytic activity
Euglobulin clot lysis time
▪ Used for the detection of lupus anticoagulant
Platelet neutralization test
▪ Also known as Mixing studies
Substitution Test
Used to identify specific factor deficiency
▪ Substitution Test
▪ A specific factor deficiency may be identified by mixing correction reagents with a patient’s plasma and then performing PT and APTT (1:1 dilution)
Substitution Test
