Exam 2 Exam 1

Question 1

• Anatomy of bone marrow and How to do bone marrow biopsy
• Anatomy of lymph node (4 parts)
• what is immunophenotyping and what do you see; LCA? immature? (2) Myeloid? (5) B cell? (4) T cell (6)? langerhan cells? other (6)?
• Hypocellular vs hyper cellular neutropenia (kostmann syndrome is from which?)
• Common etiologies of neutropenia based on patient age
• Consequences of neutopenis

Answer 1

Bone marow biopsy is performed at the iliac crest; You take some cortical bone with you. Bone marrow consist of stroma (matrix of proteins, stromal cells that help with hematopoiesis regulation and cell differentiation) and hematopoietic cells (stem cells self renew and differentiate and commited precursors differentiate)

Lymph node consist of;

• Sinuses - macrophages, DC.
• Cortex - B cells.
• Paracortex - T cells.
• Medulla - plasma cells.

Immunophenotyping; utilize flow cytometry to interrogate the cells. **Flow cytometry and imunohistochemistry •Leukocyte Common Antigen (LCA) – CD4 •Immature - CD34, TdT •Myeloid - CD13, CD33, MPO, CD14, NSE •B cell - CD19, CD20, kappa and lambda light chains •T cell - CD2, CD3, CD4, CD8, CD5, CD7 •Langerhans cell – CD1a •Other - CD10, CD15, CD30, CD103, CD25, CD11c

Hypocellular neutropenia (inadequate production) from

• 1) Suppression of stem cell - affect all cell lines (aplastic anemia).
• 2) supress granulocytic precursors (infection, large granular lymphocytic leukemia, drugs - chemo).
• 3) Inherited conditions with gene defects; KOSTMANN SYNDROME - genetic defects impair maturation.

Hypercellular neutropenia (ineffective production problem); 1) Nutritional deficiency; B12/folate, copper. 2) Myelodysplastic syndromes

Hypercellular neutropenia (accelerated removal/destruction); BM is hypercellular becuase it is trying to compensate for peripheral loss. 1) Immune mediated destruction - DRUGS. 2) Splenomegaly 3) Increased peripheral utilization - overwelming infections

Main causes of neutropenia; Neonates - Infection. Children - infection. Adults - drugs.

Main Clinical Consequence of neutropenia; INFECTIONS

Question 2

• Identify Normal CBC levels (differential vs absolute)
• Identify Normal peripheral blood lymphocytes? what is lymphopenia usually due to?

Answer 2

• Normal CBC - Table
• Normal peripheral blood lymphocytes; 80% T cells and 20% polyclonal B cells - •CD3/CD4+ •CD3/CD8+ •NK cells (CD3 negative). Lymphopenia usually due to decrease in CD4+ T cells (<1.0 K/cmm)

Question 3

•Understand Etiologies of Leukocytosis ( 3 main cause of leukocytosis)

• Learn how to differentiate a reactive process from a neoplastic one

Answer 3

***Main cause of leukocytosis - lymphocytosis - 1) Transient STRESS; MI, seizure, trauma. 2) Drugs 3) Acute viral illness especially in children - EBV - mononucleosis (monospot positive), CMV (monospot negative), pertussis.

1. Reactive process; polyclonality (different origin). a reactive process is when you see mature heterogeneity instead of homogeneity. e.g mononucleosis neg. EBV pos.
2. Neoplastic process; immature monotonous. Homogeneity.

Question 4

• Common causes of reactive leukocytosis
• Common causes of neoplastic leukocytosis

Answer 4

Reactive; heterogeneity

• Reactive lymphocytosis; acute viral state
• Reactive neutrophilia; Left shift. Heterogeneity whether reactive or immature
• Reactive eosinphilia; NAACP - Allergic response, Medications/drug hypersensitivity, parasitic infection - fungal infection, skin disease, vasculitis and some endocrine disorders.
• Reactive monocytosis; 1) Chronic infections (TB, rickettsia, viral, fungus). 2) Inflammatory disorders - SLE (lupus), rheumatoid arthritis, ulcerative colitis 3) Sarcoidosis 4) Some malignancies.

Neoplastic; homogeneity

• Neoplastic lymphocytocis; ALL, CLL
• Neoplastic neutrophilia; Heterogeneity whether reactive or immature
• Neoplastic eosinophilia; 1) Myeloid and lymphoid neoplasms with - PDGFRA, PDGFRB, FGFR1, JAK2 rearrangement. 2) Chronic Eosinophilic leukemia, NOS
• Neoplastic monocytosis; AML, CML, CMML

Question 5

Know how to differentiate a mature from an immature, neoplastic leukocytosis

Answer 5

***In both mature and immature neoplastic leukocytosis; you see the same rotten cells (monotony/homogeneity)

Reactive vs. Neoplastic Leukocytosis

• •Overall clinical picture must be kept in mind!!
• •Lymphocytosis: – acute viral states vs. neoplastic (ALL, CLL, etc)
• •Neutrophilia with left shift – Leukemoid reaction (acute bacterial infections) vs. Neoplastic process (CML or other myeloproliferative neoplasm)

Question 6

Lymphadenopathy vs lymphadenitis

•Understand Etiologies of Lymphadenopathy (5); 3 examples

• ly,phadenitis and types

Know the difference between Hodgkin (HL) and Non Hodgkin Lymphomas (NHL) in regards to cell type seen

Answer 6

Lymphadenopathy is lymph node enlargment (tender or non-tender) while lymphadenitis is lymph node inflammation due to benign reactive process like an infection

Etiologies of lymphadenopathy

• Infections; •Viral (EBV) •Bacterial (Bartonella) •Protozoal (Toxoplasma) •Fungal (Histoplasma)
• Autoimmune disorders; •Rheumatoid arthritis •SLE •Sjogren syndrome
• Iatrogenic; drugs and silicone
• Maignant; metastatic disease and lymphoma
• Other; sarcoid and dermatosis
• Examples of lymphadenopathy
• Follicular hyperplasia; due to stimuli that stimulate B cells (humoral immune response). Enlarged germinal centers and mantle zones mostly from nonspecific things and bactrial infections. can be confused with follicular lymphoma
• Paracortical hyperplasia; stimuli that stimulate cellular immune response. T cell area expansion mostly from viral infections (mono) and drugs (dilantin). confused with T-cell lymphoma
• Sinus histocytosis; Nonspecific and prominent in nodes draining area. •thought to represent the host response to the malignant cells or their products •Numerous macrophages within sinuses

Examples of lymphadenitis

• Acute nonspecific lymphadenitis; most common in kids. TENDER, enlarged, red, soft nodes. Follicular hyperplasia with large germinal center +/- neutrophils in sinuses. Due to drainage of infection.
• Chronic nonspecific lymphadenitis; NON-TENDER. Due to chronic immunologic stimulation
• Hemaphagocytic lymphohistiocytosis

Question 7

• summarize neoplasm with examples

•Know key points of the various B cell NHL’s and the emphasized T cell NHL’s

Answer 7

Lymphoid Neoplasms; NHL and HL

• Precursor; B cell and T cell
  
  • Precusor B cell; B-ALL (acute lymphoblastic leukemia)
  • Precursor T cell; T-ALL
• Mature Non-Hodgkin Lymphoma (NHL)
  
  • B cell
  • T cell
  • NK cell
• Hodgkin Lymphoma (HL) – Reed Sternberg cells

Myeloid Neoplasm

• •Acute Myeloid Leukemias (AML)
• •Myeloproliferative Neoplasms (MPN)
• •Myelodysplastic Syndromes (MDS)

Question 8

•Understand Hodgkin Lymphoma (classic feature)

Answer 8

•Hodgkin Lymphoma (HL) – Reed Sternberg cells

Question 9

•Memorize Common Genetic Abnormalities and Their Associated Diseases

• chromosomal abnormalities in lymphoid neoplasm? (precursor vs mature), Myeloid neoplasm? (MDS, MPN, AML (imparied proliferation), AML and MPN(proliferationa survival)

**specific translocations associated with pecific diseases - follicular lymphoma? burkitt lymphoma? mantle cell lymphoma? acute primyelocytic leukemia? chornic myelogenous leukemia?

Answer 9

Chromosomal abnormalities

• Lymphoid Neoplasm
  
  • Precursor cells
    
    • •normally, a V(D)J recombinase cuts DNA at specific sites in Ig or T-cell receptor loci
    • •inappropriate joining of these sites next to proto-oncogenes can result in neoplasm
  • Mature cells ; •Mutations occur most often in germinal center B cells when they are undergoing antibody diversification
    
    • •Class Switch - IgM to a different constant chain (IgG, etc)
    • •Somatic hypermutaton - point mutations that increase antibody affinity for antigen
  • Myeloid neoplasm
    
    • ​Gains or losses of chromosome material - MDS
    • Activation of tyrosine kinases - MPN; •BCR/ABL1 [t(9;22) dx of CML] , PDGFR
    • Impaired maturation of neoplastic clone - (AML’s); •RARA [t(15;17) dx of APL], RUNX1, NPM1
    • Proliferation and survival of neoplastic clone - (AMLs, MPNs); •FLT3 , JAK2, KIT

Translocations

• t(14;18) - Follicular lymphoma
• t(8;14) - Burkitt lymphoma
• t(11;14) - Mantle Cell lymphoma
• t(15;17) - Acute Promyelocytic Leukemia
• t(9;22) - Chronic Myelogenous Leukemia

Question 10

How do cell become neoplastic (6). identify rish of the different neoplasms with the following risk factors

1. Chromosome translocations/mutations (already discussed)
2. Inherited genetic factros
3. Viruses
4. Environmental factors
5. Iatrogenic fectors
6. Smoking

Answer 10

• 1. Chromosome translocations/mutations (already discussed)
     * Genes involved normally play imprtant role in regulation of cell maturation or survival
     * Result ONCOPROTEIN will; block normal maturation (acute leukemia), stimulate self-renewal or protect cell from apoptosis
     * Multiple hit required for malignancy to occur
• 2. Inherited genetic factros; increase risk of acute leukemia
     * Genetic diseases like; Fanconi anemia, bloom syndrome, ataxia - telangiectasia
     * Down syndrome and NF1 (Neurofibromatosis I) increase risk in childhoon acute leukemia
• 3. Viruses
     * HTLV-1 - Adult T cell leukemia/lymphoma
     * HHV8 - Pleural Effusion Lymphoma
     * EBV
     
     • - Burkitt Lymphoma
     • - Hodgkin lymphoma (some)
     • - Immunodeficiency associated B cell lymphomas
• 4. Environmental factors and chronic inflammation factors
     * Chemotherapy and radiation therapy
     * Chronic inflammation/Immune dysregulation
     
     • •HIV – T cell dysregulation/immunodeficiency results in increased risk of B cell lymphomas
     • •H. pylori – Gastric lymphomas
     • •Celiac Disease – Enteropathy associated T cell lymphoma
• 6. Smoking; AML
     * •up to 2x increase risk for AML due to carcinogens in tobacco smoke (benzene, etc)

Question 11

Differentiate Lymphoma vs leukemia

**Both caused by what type of cell

Lymphoid neoplasm

• Clinical presentation
• presntation of lymphoma (non-tender adneopathy vs extranodal tissue)
• clinical history (what are B sysmptoms? why bleeding? why infection? why abd pain? why bone pain?
• Physical exam

Answer 11

Lymphoma vs leukemia

• •Lymphoma
  
  • •Mostly solid organ/tissue involvement
• •Leukemia
  
  • •Mostly blood and/or bone marrow involvement
    
    • •Acute (blasts) vs Chronic (mature cells

•The disease is caused by the neoplastic cells which are the same, regardless of where they are in the body

Lymphoid neoplasm

• Clincal presentation
  
  • Destruction and disruption of both tissue architecture and functions; unexplained organomegaly and lymphadenopathy, infections (loss of immune function), autoimmunity (loss of immune tolerance)
  • B type symptoms; occur in some patients and used in clinical stagings. fever, weight loss, night sweats
• Leukemia​
  
  • •bone marrow involved so symptoms are related to signs of BM failure; anemia, thrombocytopenia
  • •can involve liver or spleen (hepatomegaly, splenomegaly)
• Lymphoma
  
  • 2/3 present with non-tender adenpathy
  • 1/3 present with extranodal tissue involvement
• •Clinical History
  
  • •B Symptoms – fatigue (anemia), weight loss, fever, night sweats
  • •Bruising/bleeding (thrombocytopenia)
  • •Frequent/unresolving infections (leukopenia, neutopenia)
  • •Early satiety, abdominal pain (spenomegaly)
  • •Bone pain (compression of nerve endings)
  • •Unexplained, persistant “lumps”
• •Physical Exam
  
  • •Skin and conjunctival pallor – anemia
  • •Unexplained bruising, mucosal bleeding – thrombocytopenia
  • •Thrush – leukopenia
  • •Hepatosplenomegaly
  • •Lymphadenopathy

Question 12

•Understand Plasma Cell Neoplasms

Answer 12

Plasma Cell Neoplasms

• terminally differentiated B cells
• commonly arise in bone marrow; rarely involve lymph nodes
• result in bony destruction (lytic lesions)

Clinical History

• B Symptoms – fatigue (anemia), weight loss, fever, night sweats
• Bruising/bleeding (thrombocytopenia)
• Frequent/unresolving infections (leukopenia, neutopenia)
• Early satiety, abdominal pain (spenomegaly)
• Bone pain (compression of nerve endings)
• Unexplained, persistant “lumps”

Question 13

• 2 functions of hemostasis
• regulated by what 3 concepts

Answer 13

Normal hemostasis

• Maintenance of blood in a fluid, clot-free state in normal vessels (blood flows when it should)
• Induction of a rapid and localized hemostatic plug at a site of vascular injury (blood clots when it should)

Regulated by three general components

• Endothelium (vascular wall); endothelial cells have prothrombic and antithrombic properties
• Platelets; 3As (adherence, activation and aggregation)
• Coagulation cascade

Question 14

Sequence of events in hemostasis

Answer 14

1. Vasoconstriction of arterioles due to reflex mechanisms and endothelin
2. Primary hemostasis; a) Platelet adhesion – to ECM with help of von Willebrand factor (vWF), produced by endothelium. b) Platelet activation - shape change and release secretory granules which recruit more platelets., c) Platelet aggregation - recruited platelets form a plug.
3. Secondary hemostasis; a) tissue factor (activates extrinsic pathway in coaglation cascade). b) thrombin (activated fibrinogen to fibrin). c) Cross- linked fibrin (holds aggregated platelets together in nice clot - form permanent plug)

Question 15

Role of platelets in hemostasis

1. adhesion
   - what factor works here by bridging a respector and exposed collagen
   - what is receptor called?
2. Activation
   - what occurs after adhesion ? initiated by?
   - what acts as sites for coagulation cascade
3. aggregation
   - what amplifies aggregation?
   - what promotes aggregation

Answer 15

3 A’s

Adhesion; vWF bridges platelet surface receptor Glycoprotein Ib and exposed collagen

Activation;

• Shape change (increase surface area).
• Secretion (release reaction) •Degranulation occurs after adhesion •Initiated by agonists binding platelet surface receptors. alpha granules - P-selectin, fibrinogen, factor V and VIII, platelet factor 4 (HIT), PDGF, Transforming growth factor -beta. delta granules - ADP, ATP, fibronectin, calcium, histamine, serotonin, epinephrine
• Phospholipids appear on surface of activated platelets, bind Ca2+ and act as sites for the coagulation cascade

Aggregation (reversible point)

• ADP and thromboxane A2 (TxA2; a prostaglandin produced by activated platelets) amplify aggregation forming primary hemostatic plug
• Thrombin binds to protease-activated receptor (PAR) on platelet membrane and with ADP and TxA2 causes further aggregation

Aggregation (Irreversible point)

• Platelet contraction – fused mass of platelets occurs forming the secondary hemostatic plug
• Thrombin converts fibrinogen to fibrin cementing the platelet plug in place
• Fibrinogen binds GpIIIa/IIb receptors on activated platelets promoting aggregation

Question 16

Hemostasis - Coagulation Cascade

Answer 16

• A series of enzymatic conversions turning inactive proenzymes into active enzymes, culminating in formation of fibrin
• Occurs on negatively charged surface of activated platelets
• Divided into extrinsic and intrinsic pathways converging to a common pathway
• Extrinsic pathway activated by tissue factor
• In vivo pathway is also activated by tissue factor exposed at site of endothelial injury
• Size of the ultimate clot is moderated by a fibrinolytic cascade
• Plasmin cleaves fibrin to fibrin split products
• Fibrin split products can be measured to diagnose abnormal clotting (DIC, DVT, PE)

Question 17

2 roles of endothelial cells in hemostasis

Answer 17

1. Anti-thrombotic properties; Inhibit platelet adherence and blood clotting in the absence of injury. In the presence of an injury, restrict coagulation to site of vascular injury

• Antiplatelet effects;
• Antithrombotic properties;

2. Pro-thrombotic properties

Question 18

Endothelial cells in hemostatis (prothrombotic and antithrombotic properties). 2 effects of antithrombotic properties are (anti-thrombotic and anti-platelet effects)

• Describe 2 functions/effects of anti-thrombotic endothelial cells

**3 components of antiplatlet vs 4 components of antithrombotic

Answer 18

Anti-platelet effects;

• Nonactivated platelets don’t adhere to intact endothelium
• PGI2 and NO are vasodilators and interfere with platelet adhesion and aggregation
• ADPase inhibits platelet aggregation by breaking down ADP

Anti-thrombotic properties;

1) Thrombomodulin

Binds thrombin

Thrombin-thrombomodulin activates protein C

Protein C with protein S inactivates factors Va and VIIIa

2) Anti-thrombin III

• Activated by binding to heparin-like molecules on endothelial cells
• Inhibits the activity of thrombin (and other proteases from coagulation cascade: factors IXa, Xa, XIa, and XIIa)

3) TFPI (tissue factor pathway inhibitor)

•Inhibits factors VIIa and Xa

4) Tissue-type Plasminogen Activator (t-PA) – converts plasminogen to plasmin
- Plasmin cleaves fibrin, degrading thrombi

Question 19

Pro- thrombotic properties of endothelial cells in hemostasis

** platelet effects? procoagulant effects?

Answer 19

Pro-thrombotic properties; Are stimulated by injury to endothelial cells. Augment local clot formation

Platelet effects; von Willebrand factor. Cofactor in binding platelets to ECM exposed during endothelial injury

Procoagulant effect;

• Thrombomodulin. Expression is downregulated by activated endothelial cells
• Tissue factor;
• Activates extrinsic and in vivo coagulation cascade
• Synthesis is stimulated by TNF, IL-1, bacterial endotoxins and others

Anti-fibrinolytic effects

• Plasminogen Activator Inhibitor (PAI) – secreted by endothelial cells, limiting fibrinolysis

Question 20

How does EDTA work

Answer 20

Chelatin agent

• bind to ions
• bind to calcium

Question 21

Identify condition; most common cancer in children

• Neoplastic population of immature lymphocytes = lymphoblasts
• MOST ALL’s ARE PRE-B; Pre-B ALL usually leukemic (blood and BM) - lead to bone marrow failure
• Pre-T ALL usually lymphomic – mediastinal mass (thymus)
• Overlap does exist between the two

**Identify clinical features

Answer 21

ALL - acute lymphoblastic leukemia/lymphoma (hispanic>white>black)

• Clinical features; Bone marrow failure (neoplastic cells crowd out normal marow cells). Abrupt stormy onset. Pre - B mostly in kids. Pre-T mostly in adults. BONE PAIN (DDx of bone pain in kids must include ALL. generalized adenopathy, hepatosplenomegaly. Pre-T associated with airway compression (mediastinal mass) or testicular involvement. CNS sx (headache, vomiting, nerve palsies; meningeal spread)
• Diagnosis; ALL and AML look very similar. Effacement of normal architecture. Small cells with high N:C ratio, irregular nuclear contours, immature nuclear chromatin, +/- nucleoli; “hand mirror”. No peroxidase granules (MPO negative) - this will only be seen with neutrophils. Diagnostic is when you see lots of tear drop cells and BLASTS (monotonous, mononuclear cells with irregular contours and high nucleus/cytoplasm ratio)
• ALL Phenotype; •CD34 and TdT positive; CD45 dim – negative; surface light chain negative; MPO negative
• Pre-B; Early B cell antigens: CD19, CD22, CD10
• Pre-T; Early T cell antigens: CD2, cCD3, CD5, CD7
• Other T antigens: CD4, CD8
• ALL cytogenetics; dysregulated expression and function of transcription factors needed for normal maturation and differentiation.

•B – ALL; •Hypodiploidy or hyperdiploidy •t(12;21) ETV6 and RUNX1 genes – disturb differentiation and maturation •t(9;22) BCR and ABL1 genes – tyrosine kinase activity

•T – ALL; •NOTCH1 gene mutation – essential for normal T cell development

• ALL prognosis; Kid have higher remission rates and survive more than adults. Favorable prognosis include; - age 2-10 - low WBC count - early Pre-B phenotype (CD19/CD10) - favorable cytogenetics (hyperdiploidy - trisomies of 4,7,10 - t(12;21))

•MRD = minimal residual disease - molecular detection after therapy is associated with worse outcome. Other poor prognosis include; - <2 years old (association with MLL gene on 11q) - adolescence or adult presentation - Peripheral Blast count > 100K. - t(9;22) in Pre-B ALL – considered poor prognostic factor but BCR- ABL Tyrosine kinase inhibitor therapy has improved prognosis for this subtype​

Question 22

Diagnosis of lymphoid neoplasm

**non hodgkin vs hodgkin

**polyclonal vs monoclonal

Answer 22

Non Hodgkin Lymphoma vs Hodgkin Lymphoma

• treatment and prognosis is different
• distribution, type, and number of neoplastic cells is different
• NHL - at diagnosis, most are disseminated on a molecular level
• HL - spreads in a systematic fashion

Polyclonal vs Monoclonal

• normal immune response is polyclonal
• neoplastic process is monoclonal
• easier to identify clonality with B cell process than T cell

Other facts

85% of lymphomas are B cell origin

Neoplastic cells like to reside where their normal counterparts do - helpful when looking at the histology

Can clinically suspect lymphoma, but diagnosis requires fresh tissue

• for histology, immunophenotyping, cytogenetic, and/or molecular testing

Question 23

How to stage lymphoma

Answer 23

Ann Arbor Classification

I – one node region

II – 2 node regions, same side of diaphragm

III – both sides of diaphragm

IV – disseminated

A or B = without/with systemic sx (night sweats, fever, weight loss)

Question 24

Identify the 2 cancers

1) most common leukemia of adults in western world. Leukocytosis and absolute mature lymphocyte
2) 4% of adult NHL

**Identify clinical features

**What syndrome is a complication of these cancers*****

Answer 24

CLL/SLL; chronic lymphocytic leukemia/small lymphocytic lymphoma

• Clinical features; > 50 years (asymptomatic, non specific sx, insidious onset, •WBC counts are variable depending on disease presentation •+/- small monoclonal serum spike. •immune disruption; •infections = hypogammaglobulinemia •hemolytic anemia or thrombocytopenia = autoantibodies created by non-neoplastic B-cells due to immune dysregulation
• CLL Morphology; •PB: increased small mature lymphs with hyperclumped nuclear chromatin; smudge cells.
• SLL Morphology; •node architecture effaced diffusely by small round cells; proliferation centers mimic germinal centers – BM: lymphoid aggregates, or interstitial or diffuse pattern – Spleen/Liver = red and white pulp; portal tracts
• CLL/SLL immunophenotype;

–CD19/CD5/CD23

– CD20 - dim

– surface light chain restricted - dim

• CLL/SLL genetics;

•Deletions and trisomy (FISH); inorder of decreasing prognosis ; •del13q tri12 del11q del17p13 (p53) •Somatic hypermutation of IGHV gene •Mutated •Unmutated •Positive for CD38 by flow and ZAP70

• CLL/SLL prognosis; •Richter syndrome; •Transformation to Diffuse Large B cell Lymphoma •Rapidly enlarging lymph node and/or spleen •Ominous, most patients survive < 1 year •Unmutated IGHV (CD38 and ZAP70 positive) •Del17p13 (p53) •Complex karyotype

Question 25

Identify cancer

‒second most common NHL

‒ 40% of adult lymphomas in US

‒Architecturally, mimics the normal lymphoid follicles

‒strongly associated with translocations involving BCL2

Answer 25

Follicular Lymphoma

​Clinical features; •painless adenopathy, generalized or localized •BM almost always involved – Stage 4 •Rarely PB involvement

​Morphology;

• –LN: nodular or nodular and diffuse pattern
• •2 cell types; •centrocytes - small cleaved cells •centroblasts – larger cells; count for grading •Low grade •High grade
• – BM: paratrabecular aggregates; seen in 85%
• – Spleen/Liver = white pulp; portal tracts

Diagnosis; Immunophenotyping - CD19/CD20/CD10 - surface light chain restriction

• •BCL2 expression; •anti-apoptosis protein •normally shut off in germinal center to allow for normal lymphocyte maturation
• •BCL6 expression; •DNA-binding zinc-finger transcription repressor required for normal germinal center formation and regulation •3q27
• •Genetics – t(14;18); •14 – IGH; 18 – BCL2

Prognosis; •incurable, but indolent; high dose chemotherapy not effective •Transformation/progression to higher grade occurs in 20% at 8 years •Grade 1-2 —- Grade 3 •DLBCL

Question 26

Follicular hyperplasia vs follicular lymphoma

Answer 26

Question 27

Identify cancer types

Clinical features; ‒painless, generalized lymphadenopathy ‒involvement of PB varies from a few cells to a leukemic picture ‒BM involvement in most ‒Lymphomatoid Polyposis = GI involvement ‒multifocal mucosal involvement of small and large bowel

Diagnosis;

‒Morphology; ‒nodular or diffuse pattern ‒homogeneous population of small round to slightly irregular lymphs ‒surround and infiltrate normal germinal center ‒blastoid variant is more aggressive

Immunophenotype;

‒CD19/CD20/CD5

‒bright surface light chain

‒typically CD23 negative

Cytogenetics;

‒t(11;14) Cyclin D1 (11) with IgH (14)

‒Cyclin D1 not normally expressed in lymphocytes or myeloid cells

‒increased cyclin D1 expression = progression of cell cycle from G1 to S

Prognosis; incurable

Answer 27

Mantle cell Lymphoma

Clinical features; ‒painless, generalized lymphadenopathy ‒involvement of PB varies from a few cells to a leukemic picture ‒BM involvement in most ‒Lymphomatoid Polyposis = GI involvement ‒multifocal mucosal involvement of small and large bowel

Diagnosis;

• ‒Morphology; ‒nodular or diffuse pattern ‒homogeneous population of small round to slightly irregular lymphs ‒surround and infiltrate normal germinal center ‒blastoid variant is more aggressive
• Immunophenotype;

‒CD19/CD20/CD5

‒bright surface light chain

‒typically CD23 negative

• Cytogenetics;

‒t(11;14) Cyclin D1 (11) with IgH (14)

‒Cyclin D1 not normally expressed in lymphocytes or myeloid cells

‒increased cyclin D1 expression = progression of cell cycle from G1 to S

Prognosis; incurable

Question 28

identify NHL cancer

Diagnosis

• Morphology

• •small B-cells and plasmacytoid cells with destructive infiltration of host tissue
• • Immunophenotype
• •nothing specific; CD19/CD20/surface light chain

Answer 28

Marginal Zone Lymphoma - MZL

–extranodal (e – mzl) vs. nodal vs. splenic in origin

– 7- 8% of B cell NHL

E-MZL

• •MALT = mucosal associated lymphoid tissue •Permeable mucosal sites are vulnerable to pathogens and antigens; Peyers patches (terminal ileum) and tonsils (nasopharynx) are examples of MALT •MALT exists to protect the mucosa
• •MZL = neoplastic proliferation of cells that destructively mimic the normal marginal zone of MALT

Clinical Features

‒most cases arise in tissue that don’t normally have MALT, but instead are involved by a chronic inflammatory process

‒stomach – H. pylori

‒thyroid – Hashimotos

‒parotid – Sjogren disease

polyclonal to oligoclonal to monoclonal theory

• •reactive polyclonal inflammatory reaction
• •mutations are acquired over time with the eventual emergence of an oligoclonal or monoclonal population that is still dependent on reactive T cells for growth and survival
• •acquisition of t(11;18) or t(1;14) with upregulation of BCL10 or MALT1 leading to a neoplastic population that no longer responds to antibiotics
• •growth now independent of extrinsic stimuli

Question 29

Identify cancer

• high grade; heterogeneous group
• most common type of NHL
• most patient lack a specific risk factor, but can occur in immunodeficient patients (where it is associated with EBV)

Answer 29

Diffuse Large B cell lymphoma (DLBCL)

1) Clinical Features; •rapidly enlarging, symptomatic mass

•nodal or extranodal site •“B-type” symptoms present in many patients •BM involvement occurs late in disease

2) Morphology; •diffuse effacement of architecture by large lymphocytes •convoluted nuclear contours, 1-3 nucleoli, pale cytoplasm, indistinct cell borders, mitotically active

3) Diagnosis

• Immunophenotype
  
  • ‒CD19/CD20
  • ‒ +/- CD10, rare CD5
  • ‒ surface light chain restriction
• GCB vs ABC
  
  • ‒Based on expression of CD10, bcl6 and MUM1 antigens
  • ‒ABC subtype is poor prognostic indicator
• cytogenetics
  
  • – BCL6 (3q27) mutation – 30%
    
    • – required for normal germinal center formation
    • – mutation represses normal B-cell differentiation, growth arrest and apoptosis
  • – BCL2 (18) mutation – 20%
    
    • •may be associated with t(14;18) and be a transformed follicular lymphoma
    • •de-novo rearrangement
    • •usually lack bcl6
• – MYC (8) mutation – 5%

4) prognosis

• ‒aggressive and fatal if untreated
• ‒Combination chemotherapy (R-CHOP) can result in remission for 60%
• ‒limited disease does better than widespread bulky disease

Question 30

Identify cancer

•High grade (the highest)

• Subtypes
• African (endemic in malaria belt)
• 100% EBV associated
• Sporadic (US children)
• 20% EBV associated
• Immunodeficiency associated (HIV)
• 25% EBV associated

Answer 30

Burkitt Lymphoma

Clinical Features:

• •30% of childhood NHL •BM and PB involvement unusual •Usually extranodal a) Sporadic – abdominal mass (ileocecum) b) Endemic – mandibular mass or abdominal viscera
• •Tumor Lysis Syndrome; -rapid cell turnover -tumor cell death releases uric acid, potassium, calcium -medical emergency requiring hydration, binding agents for electrolytes, and in some cases, hemodialysis
• •CNS disease occurs in most patients

Morphology

Why it grows so fast? (WARBURG EFFECT);

• •translocation involving MYC gene = increased myc protein
• •myc increases expression of genes needed for glycolysis; •tumor cells can constantly be using glucose and glutamine to make all building blocks for growth and division (Warburg effect)

Diagnosis

• Immunophenotype
  
  • – CD19/CD20/CD10 – surface light chain restriction – bcl6 – myc – No bcl2, CD34, TdT – Ki67 - >99%
• Cytogenetics; translocation involving ; t(8;14)
  
  • ‒ translocation involving MYC (8) ‒t(8;14) ‒t(2;8) ‒t(8;22)

Prognosis; •aggressive, but responds well to intensive systemic chemotherapy with intrathecal CNS chemotherapy

Question 31

What is thrombosis

Describe/summarize steps in thrombosis (pathogenesis)

Answer 31

Thrombosis is a clot in the cardiovascular system

1. Endothelial injury
2. Abnormal blood flow
3. Hypercoagulability

Question 32

Identify thrombosis pathogenesis

Most important influence for thrombus formation in heart and arteries

Loss of endothelium

• •Exposes ECM
• •Platelet adhesion
• •Tissue factor release (starts in vivo coagulation cascade)
• •Depletion of PGI2 and Pas (depleting these will promote thrombosis)

Answer 32

Endothelial Injury

Dysfunction of endothelium

• Etiology – htn, turbulent flow, bacterial endotoxins
• Increased procoagulant factors, decreased anticoagulant effectors

Question 33

step in thrombosis

• Turbulence and stasis
• Disrupt laminar flow
• Prevent dilution of clotting factors
• Slows inflow of clotting factor inhibitors
• Promote endothelial activation
• Clinical
• Turbulence – atherosclerotic plaques
• Stasis – aneurysms, flaccid myocardium post MI, heart chamber dilation, a-fib etc.

Answer 33

Abnormal blood flow

Question 34

In hypercoagulability, what 2 conditions exist •

Answer 34

Hypercoagulability - PRIMARY and SECONDARY condition

Primary (Genetic)

• •Common: Mutations: Factor V, prothrombin gene, MTHFR gene (increases homocysteinemia)
• •Rare: Deficiencies: antithrombin III, protein C, protein S. Antithrombin III activated by binding to heparin-like molecules then inactivates thrombin and multiple coagulation factors

Secondary (acquired)

• •High risk; •Prolonged immobilization •Myocardial infarction, a-fib, prosthetic cardiac valves •Tissue damage •Cancer •DIC •Heparin-induced thrombocytopenia (HIT) •Antiphospholipid antibody syndrome
• Antiphospholipid antibody syndrome
• Lower risk; •cardiomyopathy, nephrotic syndrome, hyperestrogenic states (pregnancy), oral contraceptive use, sickle cell anemia, advancing age (decreases endothelial PGI2 production), cigarette smoking, obesity

Combined States

• •Homozygous mutations •Concurrent inheritance of different mutations (combined heterozygosity) •Mutations plus acquired risk factors •Pts under age of 50 with venous thrombosis should be checked for genetic risk factors even in setting of acquired risk factors

Question 35

Describe primary hypercoagulability

Answer 35

Inherited hypercoagulable state; Factor V Leiden - Mutant Factor V is resistant to cleavage by protein C

Factor V Leiden

• •Arg→Glu substitution at a.a. residue 506 •Mutant factor V is resistant to cleavage by protein C •2-15% of Caucasians carry the mutation •Heterozygotes have 5X relative risk of venous thrombosis •Homozygotes have 50X relative risk of venous thrombosis •60% of patients with recurrent DVTs have this mutation

Prothrombin gene; •1-2% of population carry the mutation •Mutation causes elevated prothrombin levels •3X relative risk of venous thrombosis

MTHFR gene (increases homocystenemia); •5 – 15% of white and East Asians carry the mutation •Variant of 5,10-methylenetetrahydrofolate reductase •Causes a modest elevation of homocysteine •Homocysteine may inhibit antithrombin III and endothelial thrombomodulin

Deficiencies (rare); antithrombin III, protein C, protein S. Antithrombin III binds to heparin-like molecule, inactivates heparin

Question 36

Describe secondary hypercoagulability

Answer 36

•Secondary (Acquired)

•High risk; •Prolonged immobilization •Myocardial infarction, a-fib, prosthetic cardiac valves •Tissue damage •Cancer •DIC •Heparin-induced thrombocytopenia (HIT)

•Antiphospholipid antibody syndrome

• •Antiphospholipid antibody syndrome (formerly lupus anticoagulant syndrome)
• •Antibodies bind to protein epitopes exposed by phospholipids
• •Mechanism by which hypercoagulability is induced is unknown

•Antiphospholipid antibody syndrome

•Two categories of patients:

• Pts with autoimmune disease (secondary)
• Pts without autoimmune disease (primary)
• Clinical: recurrent thrombi and miscarriages, cardiac valve vegetations, thrombocytopenia, prolonged PTT
• Treatment: chronic anticoagulation, immunosuppression

•Lower risk: cardiomyopathy, nephrotic syndrome, hyperestrogenic states, oral contraceptive use, sickle cell anemia, advancing age (decreases endothelial PGI2 production), cigarette smoking, obesity

Question 37

Combined states of hypercoagulability

Answer 37

Combined states

• Homozygous mutations
• Concurrent inheritance of different mutations (combined heterozygosity)
• Mutations plus acquired risk factors
• Pts under age of 50 with venous thrombosis should be checked for genetic risk factors even in setting of acquired risk factors

Question 38

Thrombosis - Morphology

• where do they form?
• what you see?
• attach where?
• types of thrombi

Answer 38

• Anywhere in circulatory system
• Laminations (Lines of Zahn)
• •Pale layers are platelets
• •Darker layers are fibrin and RBCs
• •Indicate thrombus is formed in flowing blood
• •More prominent in arterial thrombi
• Attach to underlying heart or vessel wall
• Types of thrombi
• •Arterial system
• •Venous system
• •Post-mortem

Question 39

Identify the type of thrombi

**Describe the system (arterial, venous or post mortem?)

Answer 39

Coronary artery recent thrombosis - occlusive. The while strips are cholesterol plaques

Arterial thrombi

• •Usually occlusive
• •Coronary, cerebral, femoral
• •Usually overlies atherosclerotic plaque
• •Gray-white, friable mesh of platelets, fibrin, rbcs, wbcs
• •Grows retrograde to blood flow (toward the heart)

Question 40

Identify type of thrombi

• •Essentially always occlusive
• •Lower extremities (90% of cases), then upper extremities, ovarian and prostatic plexuses, uterine, portal and hepatic veins, dural sinuses
• •Red – containing more RBCs
• •Grow in direction of blood flow (toward heart), propagating tail not well attached, prone to embolization

Answer 40

Venous Thrombi

Question 41

Identify type of thrombi

• Usually not attached
• Dependent portion is dark red
• Supernatant is yellow, gelatinous like chicken fat

Answer 41

Post-Mortem clots

Question 42

Thrombosis - fate of thrombus (4)

Answer 42

1) Propagation
2) Embolization
3) Dissolution – esp. recent thrombi
4) Organization and recanalizaton +/-incorporation

• •Endothelial cells, fibroblasts, smooth muscle cells grow into clot
• •Small channels develop through clot
• •Clot may incorporate into vessel wall

Question 43

Thrombosis clinical correlations - Obstruction and Embolization

Identify type of thrombosis based on clinical correlations

1) •Rarely embolize •Cause edema distal to obstruction, predispose overlying skin to injury, infection, ulceration

2) •At or above knee most likely to embolize •Sx of pain and edema may be relieved by collateral circulation •50% asymptomatic •Diagnosis: ultrasound or angiogram •Treatment: anticoagulation •Below the knee: monitor for 1-2 wks for propagation above the knee (~25%)

Answer 43

1) Venous thrombosis; Superficial venous thrombosis
2) Deep Venous thrombosis (DVT)

Question 44

Thrombosis - clinical correlation; arterial and cardiac thrombosis

Answer 44

• Coronary artery thrombosis – MI
• Cerebral artery thrombosis – stroke, TIA
• Femoral artery thrombosis – gangrene
• Atrial mural thrombus – secondary to a-fib or mitral valve stenosis, can embolize
• Ventricular mural thrombus – secondary to MI, cardiomyopathy, can embolize

Question 45

•Definition – A detached intravascular solid, liquid, or gaseous mass that is carried by the blood to a site distant from its point of origin

**Identify types

Answer 45

EMBOLISM

• Pulmoary thromboembolism
• Systemic thromboembolism
• Less common sources of embolism; Fat embolism, Air embolism, Amniotic fluid embolism

Question 46

Identify type of emboli based on clinical presentation

• •Most are clinically silent
• •If > 60% of pulmonary circulation is obstructed then may cause sudden death, right heart failure (cor pulmonale) or cardiovascular collapse
• •Obstruction of medium-sized arteries may cause hemorrhage but not infarction due to dual circulation
• •Obstruction of end-arterioles: infarction

Answer 46

Pulmonary thromboembolism

• •200,000 deaths per year in US
• •Source is DVT in lower extremity in 90-95% of cases
• •Often occurs as multiple emboli, sequentially or shower

Question 47

Identify type of emboli

• •80% come from the heart (intracardiac mural thrombi)
• •Others from aortic aneurysm, atherosclerosis, valvular vegetations
• •Few from paradoxical embolism – from right side (usually dvt), bypasses pulmonary circulation to systemic circulation through interchamber defect or other R – to – L shunt

Answer 47

Systemic thromboembolism

• •Go to various sites: Lower extremities (75%), brain (10%), intestines, kidneys, spleen, upper extremities
• •Ischemia or infarction of tissue distal to embolism depends on extent of collateral or dual circulation

Question 48

Identify less common source of embolism

• •Microscopic fat globules may be found in circulation after fracture of long bones
• •90% of pts with severe skeletal injury have fat emboli, 10% have clinical finding

**Identify syndrome****

Answer 48

FAT EMBOLI

Fat embolism syndrome – 1-3 days post injury

• •Pulmonary insufficiency
• •Neurologic effects
• •Anemia and thrombocytopenia (what do you see clinically?); pallor and petechiae
• •Etiology – obstruction of pulmonary and cerebral microvasculature, toxic injury from release of free fatty acids

Question 49

Identify less common source of embolism

• •Obstruction of circulation by large or coalesced gas bubbles (>100 cc) is similar to thrombotic obstruction
• •Sources; Neck and chest injuries, obstetric procedures, thoracentesis, hemodialysis, decompression sickness

**How does decompression sickness cause this embolism

Answer 49

Air Embolism

•Decompression sickness

• •Air breathed at high pressure increases amount of air that dissolves in the blood
• •Gas bubbles out of the blood during rapid depressurization forming emboli
• •Gas bubbles in muscle and tissue around joints is painful, “the bends”
• •Treatment: 100% O2, compression chamber

Question 50

Identify less common source of embolism

• •Initial sx: sudden severe dyspnea, cyanosis, hypotensive shock, then seizures, coma
• •Late sx (in survivors) pulmonary edema, DIC
• •Rare, mortality 20-40% (pregnant woman)

Answer 50

Amniotic fluid embolism

•Infusion of amniotic fluid or fetal tissue into maternal circulation at delivery

Question 51

Define (list the different categories)

• •A condition of profound hemodynamic and metabolic disturbance characterized by failure of the circulatory system to maintain an appropriate blood supply to the microcirculation with consequent inadequate perfusion of vital organs”
• •Final common pathway for a number of potentially lethal clinical events: massive hemorrhage, extensive trauma and burns, massive MI, massive PE, bacterial sepsis
• •Hypoperfusion and cellular hypoxia result in injury that is initially reversible but eventually irreversible culminating in death of the patient

Answer 51

SHOCK

• •Cardiogenic shock
• •Hypovolemic shock (loss of blood volume)
• •Septic shock
• •Anaphylactic shock
• •Neurogenic shock (damage to nervous system)

Question 52

Development of Septic Shock - identify

• •Exaggerated and generalized manifestation of a local inflammatory reaction, often fatal
• •Massive inflammatory reaction due to release of cytokines (most important: TNF, IL-1, IL-6 and PAF)

**How is this diagnosed?

Answer 52

Systemic Inflammatory Response Syndrome (SIRS)

• Diagnosed by two or more signs of systemic inflammation (fever, tachycardia, tachypnea, leukocytosis or leukopenia):
• Temperature >100.4°F (38°C) or <95°F (35°C).
• HR >90 bpm.
• RR >20 breaths per minute.
• WBC >12,000/µl or <4000/µl (immature - bands)
• >10% immature WBCs is also significant.

Question 53

Sepsis vs septic shock

Answer 53

•Sepsis is SIRS with a culture-proven infection or obvious infection

•Septic shock is clinical sepsis severe enough to lead to organ dysfunction and hypotension

Question 54

Septic shock

Epidemiology

Triggers (most common agent?)

Major pathophysiologic factors

Answer 54

Epidemiology

• •Mortality rate is 20%
• •200,000 deaths per year in US
• •Number 1 cause of death in ICUs

Triggers

• •Gram-positive bacterial infections – most common
• •Gram-negative bacterial and fungal infections

Major pathophysiologic factors

• •Inflammatory mediators
• •Endothelial cell activation and injury
• •Metabolic abnormalities
• •Immune suppression
• •Organ dysfunction

Question 55

Identify major pathophysiologic factor of septic shock

• •Toll-like receptors (TLRs) on leukocytes recognize microbial elements and trigger responses that start sepsis
• •TNF, IL-1, IFN-γ, IL-12, IL-18 + others create a pro-inflammatory state
• •Prostaglandins and PAF activate endothelial cells, causing adhesion molecule synthesis and a pro-coagulant state
• •Complement cascade activated by microbial components contributes to the hyperinflammatory state

Answer 55

Inflammatory mediators

Question 56

Identify mahor pathophysiologic factor of septic shock

• •Activation is by microbial components and inflammatory mediators
• Activation has 3 major consequences
• •Thrombosis (DIC)
• •Increased vascular permeability
• •Vasodilation

Answer 56

Endothelial cell activation

Thrombosis; DIC (up to 50% of pts with septic shock)

• •Inflammatory mediators stimulate tissue factor and PAI-1 production
• •Decreased production of tissue factor pathway inhibitor, thrombomodulin and protein C
• •Decreased blood flow producing stasis

Increased vascular permeability; causes “3rd spacing” and edema which increases interstitial fluid pressure which impedes blood flow into the tissues = tissue hypoperfusion and stasis

Vasodilation – Increased NO synthesis + vasoactive inflammatory mediators lead to vasodilation, hypotension and tissue hypoperfusion

Question 57

Identify major pathophysiologic factor of septic shock

• •Cytokines, stress-hormones and catecholamines drive gluconeogenesis
• •Pro-inflammatory cytokines suppress insulin release and promote insulin-resistance
• •Resulting hyperglycemia decreases neutrophil function

Answer 57

Metabolic abnormalities – hyperglycemia and insulin-resistance

Question 58

Identify major pathophysiologic factor of septic shock

• •Hyperinflammatory state can activate counter-regulatory immunosuppressive mechanisms
• •Whether immunosuppressive mediators are helpful or harmful in sepsis is uncertain

Answer 58

Immune suppression

Question 59

Identify major pathophysiologic factor of septic shock

• •Tissue hypoperfusion (resulting from hypotension, edema and small vessel thrombosis) starves organs of oxygen and nutrients
• •Changes in cellular metabolism interfere with tissues utilizing nutrients
• •Myocardial contractility is weakened by cytokines and secondary mediators decreasing cardiac output

Answer 59

Organ dysfunction

• •Decreased cardiac output, increased vascular permeability and endothelial injury can damage the lungs resulting in adult respiratory distress syndrome (ARDS)
• •Organs are affected by the changes that take place in septic shock particularly kidneys, liver, lungs and heart

Question 60

Identify stages of shock (3)

Answer 60

• •Nonprogressive phase – reflex mechanisms compensate and tissue perfusion is maintained (SIRS)
• •Progressive stage – tissue hypoperfusion ensues with worsening circulatory and metabolic imbalances including acidosis
• •Irreversible state – extent of cellular and tissue injury is so great that death is inevitable even with infection control and hemodynamic correction

Question 61

Treatment and outcome of septic shock

Answer 61

•Treatment

• •Control infection
• •Fluid resuscitation and vasopressor drugs to maintain systemic pressures
• •Insulin therapy for hyperglycemia
• •Corticosteroids at physiologic doses
• •Anti-inflammatory tx to control inflammation has not been successful
• •Activated protein C to reduce coagulation and inflammation is still controversial

Clinical Outcome (depends on the cause)

• •Initial threat of shock is from the underlying cause: MI, hemorrhage, infection etc.
• •Rapidly the secondary complications of tissue hypoperfusion exacerbate the situation
• •Prognosis varies with origin of shock, duration, and underlying comorbidities of the patient

Question 62

1. 75 y.o man suffered MI with left ventricular failure and cardiogenic shock. He died 2 days later. What is the most importnat consequence of shock? (cerebral edema, cyanosis, tissue hypoxia, hypotension)
2. 52 y.o man, asplenic from trauma 20 years previous. Gun shot wound. Source of infection not apparent. Pt has hypotension and develop respiratory failure requiring intubation with mechanical ventilation and vasopressors to support BP. blood pressure grow Strep pneumonia. Gangrene develops despite all treatment in all 4 extremity. Poor prognosis (die or amputate)

Answer 62

1) TISSUE HYPOXIA
2) Amputated all extremities

Question 63

Lecture WBC PPT part 2 (cont’d)

General concepts of plasma cell neoplasms

Answer 63

•Group of diseases caused by a clonal plasma cell proliferation

• •M component/protein = monoclonal protein secreted by the plasma cell and identified in the blood
• •Bence Jones protein = the monoclonal free light chain found in the urine
• •A spectrum of diseases, ranging in severity
  
  • •Multiple myeloma
  • •Plasmacytoma
  • •MGUS

Question 64

Define cancer type

clonal plasma cells secrete M-protein that is identified in blood (or urine) and cause end organ damage (CRAB)

**Identify pathogenesis? pathophysiology?

Answer 64

Multiple myeloma

Pathogenesis

• •Genetic alterations; translocations involving IgH and Cyclins, deletions of 17p (TP53) and rearrangements involving MYC
• •tumor cells produce IL6 which is a growth factor for the tumor cell; •can monitor serum levels of IL6 in patients
• •tumor cells influence:
  
  • •activation of osteoclasts
  • •inhibition of osteoblast

Pathophysiology

• Marrow infiltration by the plasma cells - pathologic fractures and bone pain (hypercalcemia)
• Monoclonal protein production
  
  • •IgG > IgA > IgM, IgE, IgD
  • •Most patients have both increased monoclonal Ig in the blood and Bence Jones proteins in the urine
• Inadequate normal immunoglobulin production

Question 65

Identify cancer based on clinical presentation and labs

• • weakness, fatigue (anemia)
• • recurrent infections (decreased normal Ig’s)
• • polyuria, constipation, confusion (hypercalcemia)
• • bone pain, pathologic fractures (tumor load/plasma cells)
• • renal insufficiency (Bence Jones protein)
• • amyloidosis (light chain deposition in organs)

Answer 65

Multiple Myeloma

Abnormal labs

• • CBC: anemia, sometimes pancytopenia
• • Metabolic Panel: hypercalcemia, increased creatinine
• • Quantitative Immunoglobulins
    
    • • IgG > IgA >>> IgM, IgE, IgD
    • • one class will be elevated (monoclonal protein); the rest will be decreased

•Serum and Urine Protein Electrophoresis and Immunofixation

• •identifies, specifies and quantitates increased proteins in the gamma region
• •Bence Jones Proteinuria = excess free light chains in the urine…toxic to renal tubules

•Serum Free Light Chain Immunoassay

• •baseline quantity and ratio important prognostic indicator for every type of plasma cell neoplasm
• •free light chain kappa;lambda ratio is powerful determinant of disease activity

Radiology; skeletal survey identifies bony lytic lesions (vertebral column, ribs, skull, pelvis)

Question 66

Pathology of multiple myeloma

****what happens due to increased proteins****

increase in serum immunoglobulins cause RBC adhesion resulting in??

Answer 66

– disease is patchy - requires adequate BM aspirate and biopsy

• •Plasmacytosis (>10%), groups and sheets
• •inclusions can be seen
• •multinucleation
• •immature features = worse prognosis

– Flow cytometry: clonal light chain restricted plasma cells

• –Often have aberrant antigen expression (as compared to normal)

–PB ***rouleux*** due to increased protein

– PB plasma cell leukemia = end stage

Peripheral blood findings in MM;

• -excess immunoglobulins are acidic and take up the basophilic stain
• • increase in serum immunoglobulins cause RBC adhesion resulting in “rouleaux formation

Question 67

Identify cancer type

• •>10% clonal bone marrow plasma cells
• •Monoclonal protein at myeloma levels
• •>30 g/L (serum)
• •ABSENCE of end organ damage
• •Importance: more likely to progress to symptomatic myeloma (50% at 5 years)

Answer 67

Smoldering Myeloma

Treatment and Prognosis

• •Prognosis related to extent of disease burden, cytogenetics
• •Morbidity/mortality related to infections, renal failure
• •Chemotherapy, radiation therapy, and stem cell transplant (prolong life, but not yet curative)

Question 68

Identify

• •the most common cause of monoclonal gammopathy
• •1% per year progress to MM; cannot predict who
• •exclude all other causes of monoclonal gammopathy
  
  • •smoldering MM
  • •other lymphomas
• •often same chromosomal aberrations as in MM
• •periodic assessment of BJ protein and serum M protein levels warranted to check for progression to MM

Answer 68

MGUS (monoclonal gammopathy of undetermined significance)

Question 69

Identify cancer type

• •solitary bone or soft tissue clonal plasma cell masses with no evidence of marrow or organ disease
  
  • •spine is most common bone site
  • •lung and oronasopharynx most common soft tissue site
• •Osseous
  
  • •can recur or progress to myeloma (10-20 yrs)
• •Extraosseous
  
  • •cured by resection
• •Excision and local field radiation therapy

Answer 69

Plasmacytoma

Question 70

Cancer type

• •resembles SLL, but many of the neoplastic cells are plasma cells
• •secrete monoclonal IgM in large amounts (>3gm/dL) causing a hyperviscosity syndrome known as Waldenstrom macroglobulinemia (explain this)
• •balance of secretion of light chains and heavy chains so NO light chain deposition disease sx (no renal failure or amyloid)
• • NO bony lesions

**Identify mutation

Answer 70

Lymphoplasmacytic Lymphoma (LPL)

Waldenstrom’s macroglobulinemia

• •IgM is the largest of the heavy chains so increased levels increase the blood viscosity
  
  • •Visual sx
  • •Neurologic sx
  • •Bleeding – interference with coag factors and platelets
  • •Cryoglobulinemia – IgM precipitates at low temps (fingers/toes)
• •autoimmune hemolytic anemia (10%)
  
  • •due to cold agglutinins (IgM) that bind to RBC’s at temps <37C
• •Plasmapheresis alleviates sx by removing the large amounts of IgM

•Acquired mutation of MYD88; a gene that when mutated ultimately promotes the growth and survival of tumor cells

Question 71

identify cancer type

• –2% of NHL
• –older male with splenomegaly and pancytopenia
• –“hairy” B-cells involving the PB, BM, and splenic red pulp; look like “fried eggs”
• –BRAF mutation

Answer 71

Hairy Cell Leukemia (HCL)

Clinical Features

• ‒symptoms related to cytopenias and splenomegaly
  
  • ‒ infections
  • ‒fatigue, weakness
  • ‒early satiety
• ‒spleen and BM involvement
• ‒PB involvement but due to pancytopenia, sometimes hard to find the cells
• ‒monocytopenia

Question 72

How to diagnose HCL (hairy cell leukemia) - 2

**Identify prognosis (is treatment same as other NHL)

Answer 72

•Morphology

• •diffuse “fried eggs” in BM
• •round to reniform nuclei with moderate amount of pale blue cytoplasm which has “hairs”
• •cells incite reticulin fibrosis = dry tap of BM
• •splenic red pulp involvement with obliteration of white pulp

Immunophenotype

• •CD19/CD20/surface light chain restriction
• •CD11c/CD25/CD103

Prognosis

• •indolent course
• •treatment differs from other NHL because the neoplastic cells are very sensitive to a different type of chemo (purine analogs) = long remissions
• •BRAF inhibitors used in patients that have failed chemotherapy

Question 73

identify type of neoplasms

• • (15% of NHL in US)
• • aberrant T cell phenotype (flow or IHC)
• • PCR required to id monoclonal rearrangements of at least one TCR locus

Answer 73

Mature T cell Neoplasms

T cells do not have light chains but you can interrogate the T cell antigens with flow or immunohistochemistry. you will see some aberration

Question 74

identify type of mature T cell neoplasms

Definition - the T cell counterpart of DLBCL

Clinical Features

• -generalized lymphadenopathy
• -eosinophilia
• -pruritis, fever, weight loss

Prognosis

• • worse prognosis than B cell counterpart

Answer 74

Peripheral T cell Lymphoma, not otherwise specified

(PTCL-NOS)

Question 75

Identify mature T cell neoplasm

Definition

- Translocation involving ALK gene on 2p23

• •ALK fusion proteins behave as tyrosine kinases
• •can identify protein with immunohistochemistry ALK

Clinical Presentation

• - advanced stage with adenopathy, extranodal infiltrates, and BM involvement
• - up to 30% of childhood lymphomas

Answer 75

ALCL (Anaplastic large cell lymphoma)

*** 3 cancers in kids; ALL, burkitt and ALCL

Diagnosis

•Morphology

• •hallmark cells = large anaplastic appearing cells with horseshoe or wreath shaped nuclei
• •Sinusoidal pattern
  
  • • neoplastic cells often congregate around venules and in sinuses of node. (DDx = metastatic ca)

Prognosis

• ‒ kids - lymphoma is ALK (+)
• ‒prognosis is good with 75-80% cure rate with chemo
• ‒ adults - lymphoma ALK (+) or negative; ALK negative less favorable

Question 76

Identify T cell neoplasms

Definition

• CD4 + T-cells infected with the retrovirus HTLV 1 (human T-cell leukemia virus)

Clinical Features

• –HTLV-1 is endemic in Caribbean basin, Japan, W. Africa
• –generalized adenopathy, skin lesions, HSM, PB lymphocytosis, hypercalcemia
• –different presentations and prognosis
• –leukemic = rapidly progressive
• –skin localized = less aggressive

Answer 76

Adult T-cell leukemia/lymphoma (ATCL)

Question 77

Identify condition? clinical features? morphology?

•different manifestations of a tumor of CD4+ helper T cells that home to the skin

**Skin shows infiltration of epidermis and upper dermis

Prognosis

• – indolent; if limited to <10% of the skin, lifespan unaffected
• – when extensive, coexisting internal organ involvement occurs
• –morbidity/mortality due to immunodeficiency

Answer 77

Mycosis fungoides/Sezary syndrome
(MF/SS)

Clinical Features

–MF – 3 stages: patch, plaque, and tumor

–SS

• –generalized exfoliative erythroderma plus leukemia
• –Disease can spread to involve nodes and BM

Morphology - MF

• • Skin – infiltration of epidermis and upper dermis
• • Neoplastic cell = cerebriform nuclear contours

Morphology – SS

• • - Skin – looks same as MF
• •Sezary cell = neoplastic cell in blood

Question 78

Identify cancer type (syndrome and treatment)

•+/- lymphocytosis due to LGL’s

• •T cell type
• •NK cell type

•Minimal BM infiltration but neutropenia and anemia

• •Unclear why; myeloid maturation is decreased

•STAT3 mutations

Answer 78

Large Granular Lymphocytic Leukemia

•Felty Syndrome

• •Rheumatoid arthritis – autoimmunity provoked by the neoplastic cells
• •Neutropenia
• •Splenomegaly – infiltrates in the spleen

•Treatment is supportive

Question 79

Identify types of hogkin lymphoma

Answer 79

•Classical – Reed Sternberg cell

• –Nodular Sclerosing
• –Mixed Cellularity
• –Lymphocyte Rich
• –Lymphocyte Depleted

•Nodular Lymphocyte Predominance (NLPHL)

• – L&H cell (popcorn cell)

Question 80

Identify differences in hodkin lymphoma compared to NHL

• origin?
• what fashion does it spread?

***what cell is diagnostic of hodgkin lymphoma

Answer 80

Hodgkin Lymphoma

1) arises in a single node or chain of nodes

2) spreads in a contiguous fashion

• •Stage rather than histologic type is most important prognostic factor
• •usually curable with radiation and chemotherapy
  
  • •Stage I and II – 90%
  • •Stage III and IV – 70%

3) Reed-Sternberg cell – the malignant cell

• •make up the minority of the cell population
• •most cells are reactive cells that have been recruited by cytokines secreted by the RS cell
• •cross-talk occurs between the reactive cells and the RS to support growth of RS cells
• large, 15-45 um ( RBC is 6-7um)
• Large, inclusion-like nucleolus
• sometimes “mummify” in classical subtypes

Question 81

identify component of hodgkin lymphoma

• large, 15-45 um ( RBC is 6-7um)
• Large, inclusion-like nucleolus
• sometimes “mummify” in classical subtypes

**Identify variants

Answer 81

Hodgkin Lymphoma - Reed Sternberg cell variants (clasical vs NLPHL)

1) Classical

• •Diagnostic; •Bilobed to multilobed nucleus
• •Mononuclear; •Single lobe nucleus
• •Lacunar; •Above, with pale cytoplasm that has been disrupted by fixation; looks like it’s sitting in a hole
• Classic RC cell immunophenotype;
  
  • –CD30 + CD15 +
  • – CD45, B and T cell antigen negative

2) NLPHL

• •L&H; Popcorn cell; polypoid nucleus with inconspicuous nucleoli
• •NLPHL L&H cell immunophenotype

– CD20 + CD45 +

– CD15, CD30 negative

Question 82

Clinical course of hodgkin lymphoma

Answer 82

• •Bimodal (classical) – young; >55
• •painless localized or generalized adenopathy
• •+/- B sx
• •mediastinal adenopathy with enlarged mediastinum is common presentation
• •long term survivors have increased risk of secondary malignancies (alkylating chemotherapy)

Question 83

identify types of classical hodgkin lymphoma

1)

• –70% of cases
• –cervical, supraclavicular, and mediastinal nodes
• –rare EBV association
• –lacunar cell and bands of polarizing fibrosis
• –polymorphous background
• –RS cells vary in number

2)

• –25% of cases
• – EBV associated
• – older age, B-sx, advanced stage
• – diffuse effacement by heterogeneous infiltrate
• – RS cells plentiful

Answer 83

1. NSHL (nodular sclerosing HL)
2. MCHL (mixed cellularity HL)

Question 84

differentiate normal vs abnormal hematopoiesis

Answer 84

•Normal hematopoiesis is fine tuned by various cytokines and growth factors

• •this is deranged in marrows involved by myeloid neoplastic cells which have escaped the control factors

•Abnormal hematopoiesis - the characteristics of the neoplasm depend on:

• –the stage at which the cell escapes from control
• –the effect this stage has on differentiation
  
  • •may be blocked
  • •may be shunted toward one lineage at the expense of the others

Question 85

Identify 3 types of myeloid neoplasms

Answer 85

Myeloid Neoplasms

• MPN (myeloproliferative Neoplasms); e.g CML
• MDS
• AML

Question 86

identify subclassification of Myeloproliferative Neoplasms (4)

Answer 86

MPN (Myeloproliferative Neoplasm)

• •CML-BCR-ABL1 positive (chronic myeloid leukemia)
• •PV polycythemia vera)
• •ET (essential thrombocytosis)
• •PM (primary myelofibrosis)

Question 87

General concepts of MPN (myeloproliferative neoplasms)

• hemotopoiesis?
• mutipotent stem cell? (exception)
• neoplastic stem cell?
• overlap in categories

genetic abnormality?

Answer 87

•effective hematopoiesis, just too much of it

• •marrow hypercellularity with associated increased peripheral counts; no dysplasia

•Multipotent stem cell is neoplastic cell, thus capable of giving rise to all myeloid lines

• •exception is CML in which the neoplastic cell is a pluripotent stem cell, so it can give rise to myeloid and lymphoid lines

– neoplastic stem cell can circulate and home to secondary hematopoietic organs (spleen and liver) to give rise to EMH

– there is a considerable degree of overlap between the subcategories

– Genetic abnormalities have tyrosine kinase activity (cell growth)

• •t(9;22) = BCR – ABL1 = philadelphia chromosome = CML
• •JAK-2
• •MPL
• •CALR

Question 88

Identify cancer type

• •pluripotent stem cell abnormality
• •t(9;22)(q34;q11) = BCR-ABL fusion gene aka Philadelphia chromosome
• –tyrosine kinase activity
• –reciprocal translocation in 95%
• –cryptic in minority, thus need FISH or PCR to ID

**Identify morphology

Answer 88

CML (Chronic Myeloid Leukemia)

Morphology (peripheral blood, bone marrow, spleen/liver)

• •Peripheral Blood
  
  • –marked leukocytosis with left shift
  • –eosinophilia and basophilia
  • –thrombocytosis in 50%
• •Bone Marrow
  
  • –packed marrow with prominent granulocytic hyperplasia; no dysplasia
  • –sea- blue histiocytes – due to increased cell turnover; not specific
• •Spleen/Liver
  
  • –Splenomegaly and/or hepatomegaly due to extramedullary hematopoiesis

Question 90

Identify clinical features and treatment of CML

*

Answer 90

Clinical features

• –middle age
• – often incidental finding
• – EMH – LUQ pain/fullness
• – Slow progression without treatment
• – chronic phase to accelerated phase to blast phase (defined criteria)

Treatment; Tyrosine kinase inhibitors

• •Gleevac (Imantinib)
• • inhibits bcr-abl kinase activity, thus suppressing the clone
• •does not eliminate the clone, thus patient may eventually accelerate
• •resistance can occur
  
  • •subclones with mutations that alter the efficacy with which the TKI binds to the BCR-ABL1 protein
  • •new generation of TKI’s now available

Question 91

Identify Hodgkin lymphoma type

• •Late middle age
• •Increased Hgb and decreased serum erythropoietin
• •JAK-2 point mutation in > 95% of cases
• •multipotent stem cell abnormality
  
  • •erythrocytosis, leukocytosis, thrombocytosis (panmyelosis) in PB and BM

***Identify epo/epo- like substance

Answer 91

PV (polycythemia Vera)

Secondary polycythemia; increased epo/epo-like substance

• –Physiologically Appropriate
  
  • •High altitude
  • •Chronic hypoxic disorders
  • •Hemoglobinopathies
• –Physiologically Inappropriate
  
  • •Dysregulated epo production (renal transplant, cystic disease, or hydronephrosis)
  • •Abnormal production of epo-like substance by neoplasm
  • –Uterine leiomyoma –Renal cell carcinoma –Cerebellar hemangioblastoma –Ovarian carcinoma –Hepatoma –Pheochromocytoma

Question 92

Identify mutation in PV?

***What S&S will you see

Answer 92

PV (Polycythermia Vera)

•JAK2 mutation – hematopoietic cell lines not responsive to growth factor regulation

• •Increased RBC mass
• •Abnormally functioning platelets
• • in up to 15% of patients, symptoms can occur before abnormal blood parameters; may have JAK2 mutation.
• •hyperuricemia with gout due to high cell turnover

Question 93

Identify manifestation of PV

• •abnormal blood flow in low pressure venous side
  
  • leads to
• •stagnation
  
  • causing
• •deoxygenation of blood
  
  • resulting in
• •headache, dizziness, hypertension, GI ulcers and bleeding

***identify 25% initial presentation of PV

Answer 93

PV - increased RBC mass

•Bleeding and thrombosis 25%, initial presentation

• – Thrombi involving major arteries or veins
  
  • –DVT MI
  • –Hepatic, Portal, Splenic and Mesenteric vein thrombosis
  • –CNS venous sinus thrombosis leading to stroke
• – Acquired von Willebrand syndrome
  
  • – abnormal platelet function
• Bleeding can lead to iron deficiency which can mask diagnostic polycythemia Hgb/Hct levels

Question 94

Morphology of PV (3)

Treatment (2)

Answer 94

Morphology of PV

• Peripheral Blood
  
  • –erythrocytosis, leukocytosis, thrombocytosis
  • –basophilia
• Bone Marrow
  
  • –hypercellular with trilineage hyperplasia
  • –no dysplasia
  • –minimal reticulin fibrosis, EMH
• Disease progression
  
  • •Marrow failure with fibrosis and EMH – most common
  • •Transformation to AML

Treatment of PV

• –Phlebotomy and aspirin to keep Hct below 45%
• –JAK2 inhibitors

Question 95

Identify hodgkin lymphoma (diagnosis and clinical findings)

• •older patient (>60) usually
• •platelet count of > 450 K/uL with abnormal large platelets
  
  • – Sustained thrombocytosis in blood
  • – Increased large mature megs in the marrow
• •JAK-2 point mutations in 60%
  
  • •CALR and MPL can be seen; all mutually exclusive

Answer 95

ET (Essential thrombocytosis)

• •diagnosis of exclusion – R/O:
  
  • – reactive thrombocytosis
  • – iron deficiency anemia
  • – inflammatory processes
  • – asplenism
  • – other MPN, especially CML

Clinical findings

• •asx in 50%; discovered by abnormal CBC
• •Thrombosis
  
  • •Like PV: DVT, MI, Stroke, Portal or Splenic vein thrombosis
  • •Microcirculatory sx: headaches, dizziness, blurred vision, erythromelagia (burning and reddness due to ischemia of distal digits)
• •Bleeding – less common; due to acquired von Willebrand’s syndrome
• •Treatment with myelosuppressive agent like Hydroxyurea to lower platelet count

Question 96

Morphology of ET (essential thrombocytosis)

Answer 96

Blood

• –Thrombocytosis ( > 450K/ul)
  
  • •giant forms to small forms
  • •Circulating micromegs and megakaryocyte fragments
• –WBC normal to mildly elevated (30K/ul)
  
  • •Basophilia or eosinophilia not typically seen
• –Normal RBC’s

Bone Marrow

• • mildly hypercellular
• • Megakaryocyte clustering
• •Large hyperlobated megs
• •Minimal Reticulin fibrosis
  
  • •if present think of other MPN
• • Mild erythroid and granulocytic proliferation; no increase in blasts

Question 97

Identify hogkin lymphoma (clinical features and morphology)

• – neoplastic megs release PDGF and TGF-b which are fibroblast mitogen
  
  • – eventually, increased reticulin and collagen fibrosis resulting in a spent marrow and EMH
• – EMH
  
  • –blood cell production is disordered and ineffective so that cytopenias persist
• – JAK-2 mutations seen in 50%
  
  • – CALR and MPL can also be seen; mutually exclusive

Answer 97

PM (Primary myelofibrosis)

Clinical features

• •Older patient (> 60 yrs)
• •Two Disease phases
  
  • •Pre –fibrotic; •Marked thrombocytosis (differential dx is reactive vs ET)
  • •Fibrotic; •Anemia, leukoerythroblastosis and splenomegaly •Fatigue, early satiety

Morphology

•Early: Pre-Fibrotic stage

• – Hypercellular marrow with prominent neutrophil proliferation
• – Markedly atypical megakaryocytes, both architecturally and cytologically
• – Minimal fibrosis

•Progression: Fibrotic stage

• –hypocellular marrow with replacement by fibrosis
• –still see atypical clusters of megs
• –intra-sinusoidal hematopoiesis
• –osteosclerosis
• –EMH
• –Peripheral Blood
  
  • •leukoerythroblastosis with marked erythrocyte anisopoikilocytosis

Question 98

Identify cell type

• Biconcave disc with central pallor
• About 7-8 micrometers in diameter
• Must be strong as well as deformable to allow passage through:
  
  • Capillaries (3 micrometers diameter)
  • Splenic fenestrations (2 micrometers diameter)

Answer 98

RBC (on electron microscopy) / erythrocyte (peripheral smear)

**come from myeloid progenitor stem cell

Question 100

• •Definition: a reduction in amount of circulating Hb, in total number of RBCs, or circulating RBC mass
• •Robbins: Reduction of total red cell mass below normal limits (p. 629)
  
  • •Practical definition:
  • •<13.6 or 12 g/dL Hgb
  • •< 39 or 33 % Hct

**2 main types

***Clinical manifestations

Answer 100

Anemia

• •Acute anemia = 3x increase in RBC production within 7 – 10 days
• •Chronic hemolytic anemia = up to 6x – 8x RBC production

**•Bone marrow = factory. When bone marrow erythropoiesis cannot compensate for blood loss (through various mechanisms) –> anemia results

• •Anemia is about tissue hypoxia; •Inadequate perfusion of vital organs
• •Manifests as: (when Hgb < 7 – 8 g/dl in younger, 10 – 12 g/dl in older persons)
  
  • •Easy fatigue
  • •Dyspnea
  • •Pallor* (sign not a symptom)
  • •Syncope
  • •Postural hypotension
  • •Angina

Question 101

identify condition

• •Acute blood loss
  
  • •> 30% blood volume within 12 hrs -> hypovolemia, hypoxia
  • •> 40% blood volume -> hypovolemic shock
• •Compensatory mechanisms by the cardiovascular system in more gradual dev’t of anemia lead to:
  
  • •Heart murmurs
  • •More forceful apical impulse, palpitations
  • •Tachycardia
  • •Congestive heart failure

Answer 101

Anemia

Question 102

What lab test is frequently ordered to detect anemia

Answer 102

CBC (Complete blood count)

• •Frequently ordered; very good screening test (any abnormalities warrant microscopic exam)
• •Measures: (with *electronic blood counter)
  
  • •Hemoglobin concentration, Hb
  • •Hematocrit (plasma cell volume)
  • •RBC indices (see later)
  • •WBC (sometimes a differential white count also ordered)
• •Average adult blood volume = 5 liters: 3 liters of plasma + 2 liters of blood cells

Question 103

What do you see in RBC indices (of CBC) -6

**Identify normal values (in men and women)

Answer 103

• •Hb^* = Hemoglobin concentration (g/L)
• •Hematocrit* (Hct, “crit”, packed red cell volume,%)
• •RBC count (millions of RBCs per picoliter [10-12 of a liter]
• •MCV* (mean corpuscular volume, fl) = average size of a RBC
  
  • •Normal = 80 - 100 fl
  • •Low MCV = microcytic
  • •High MCV = macrocytic
  • •Normal MCV = normal sized RBCs
• MCH* (mean corpuscular hemoglobin, pg) = average amount/mass of Hb in a RBC

= Hb/RBC count

Normal = 27 - 31 pg/ml

• MCHC (mean corpuscular hemoglobin concentration, %) = proportion of each red cell taken up by Hb

= [Hb/Hct] x 100

Normal = 32 - 36 g/dL

• RDW* (red cell distribution width) = coefficient of variation of RBC volume; variation in cell size

High RDW = anisocytosis

Question 104

RBC indices - what is useful in classfying anemia

Answer 104

Reticulocyte count

• •Helps classify anemia. (It is very important to classify anemia type and underlying cause e.g bleeding, vit deficiency, genetic disease). **Remember though anemia is a diagnosis, it is most often a sign
• •Reticulocyte = young RBC with residual rRNA, stainable; also polychromasia on smear
• •Normal = 1 % (0.6 – 2.0 %). RBC lifespan is 120 days
• •Increases in patients w/ normal renal (epo) and bone marrow functions
• •Reticulocyte count can be falsely elevated in anemia.
• •Corrected Retic= Retic (Hct/45)
• •>3% indicates good compensatory response.

Question 105

identify classification of anemia

**What factor deficiencies cause anemia

Answer 105

1) According to pathophysiologic mechanism

• Depletion of RBCs (hemorrhage)
• Excessive destruction of RBCs - hemolysis
• Production of abnormal RBCs; Due to factor deficiency (vitamin B12, folate, iron)
• Underproduction of RBCs; Due to marrow disease (neoplasia, fibrosis, aplasia, infection etc

2) Accrding to morphology - most common (low MCV)

• •Microcytic, hypochromic anemia
  
  • •Iron deficiency, thalassemias,
  • •Decreased MCV, MCH, MCHC
• Normocytic, normochromic anemia
  
  • Acute blood loss, and associated with chronic disease
  • Normal MCV, MCH, MCHC
• Macrocytic anemia
  
  • Vitamin B12 and folate deficiencies
  • Increased MCV, variable MCH and MCHC

Anemia due to factor deficiency

• Iron deficiency anemia
• Vitamin B12, folate deficiencies

Question 106

identify condition

• •One of most common diseases worldwide
• •US = excessive milk intake by babies
• •Microcytic, hypochromic anemia, anisopoikilocytosis
  
  • •decreased MCV (due to extra division during maturation)
  • •decreased MCH, MCHC
  • •increased RDW
  • •major cause of microcytic anemia
• •One of most commmon causes of thrombocytosis (high platelet levels - not sure why)
• •Chronic blood loss leads to IDA

Answer 106

IRON DEFICIENCY ANEMIA (peripheral film) - Hypochromic, microcytic, anisopoikilocytic RBCs

Question 107

Iron deficiency anemia

• mechanism
• cycle
• absorption

Answer 107

Mechanism

• Production defect in hemoglobin due to deficient iron
  
  • nIron needed for formation of heme and other enzymes
• Iron cycle
  
  • Iron mostly in Hb (80%), then hemosiderin, ferritin
  • 1 mg/day lost thru exfoliated skin, mucosal cells but no natural mechanism for excretion

Iron cycle: Tight control by 3 proteins:

• •transferrin = delivers iron to cells; duodenum
• •transferrin receptor = binds, absorbs iron-laden transferrin at cell surface
• •ferritin = binds iron for storage in cells and circulation
• •Total body iron: 2 – 4 g:
  
  • •50 mg/kg, men
  • •35 mg/kg, women
• •70-90% iron in hemoglobin in RBCs (200 – 400 mg in myoglobin, nonheme enzymes

***POOR ABSORPTION

Question 108

How is iron regulated

**describe protein responsible for this

Answer 108

Iron Regulation

• •Iron absorption is regulated by hepcidin.
• •Hepcidin is a small circulating peptidethat is synthesized in the liver.
• •Released from the liver in response to increases in intrahepatic iron levels.

Hepcidin

• •Hepcidin inhibits iron transfer from the enterocyte to plasma by binding to feroportin and causing it to be endocytosed and degraded
• •As hepcidin levels rise iron becomes trapped in duodenal cells in the form of mucosal ferritin lost through cells sloughing.
• •When body is replete with iron, high hepcidin levels inhibit iron absorbtion into blood.
• When body stores of iron are low , hepcidin synthesis falls and iron absorbtion is facilitated.
• Hepcidin inhibits feroportin.(duodenum)

Question 109

identify condition

• •Mutated TMPRSS6
• •Hepatic transmembrane serine protease that normally supresses hepcidin production when iron stores are low.
• •Affected patients have high hepcidin levels, resulting in reduced iron absorbtion.
• •Failure to respond to iron therapy.

Answer 109

Rare non-iron responsive microcytic anemia

Question 110

Identify causes of iron deficiency anemia

Answer 110

• •Nutritional/deficient diet
  
  • •Excessive milk-fed infant
• •Malabsorption
  
  • •Gastrointestinal surgery, enteritis, celiac sprue
• •Blood loss
  
  • •Menstrual loss = in women of reproductive age
  • •Occult gastrointestinal bleeding = tumors, ulcers in men, postmenopausal women
  • •Hookworm infection •Aspririn •Chronic hemolysis (PNH, etc.) •Traumatic hemolysis (cardiac prosthesis) •States requiring increased iron intake •Infancy •Adolescence •Pregnancy (esp. repeated) •Lactation

Question 111

identify condition

• •Clinical history
• •Clinical signs and symptoms
  
  • •Pallor
  • •Koilonychia (“spoon nails”)
  • •Esophageal webs
  • •Pagophagia, pica (craving for dirt, etc.; for ice)
• •Peripheral blood film = microcytic, hypochromic anemia, anisopoikilocytosis
• •RBC Indices: MCV < 80 fl, MCH < 27 pg, RDW increased

Answer 111

Iron deficiency Anemia

• •Serum iron studies:
  
  • •Serum iron [Fe]
  • •TIBC (total iron-binding capacity)
  • •Serum ferritin
  • •Serum transferrin saturation
  • •(If do bone marrow exam, marrow stores are decreased/depleted.)
• •[ Normal values
  
  • •serum iron = 120 mg/dl (men); 100 mg/dl (women)
  • •total iron-binding capacity (TIBC) = 300 to 350 mg/dl
  • •serum ferritin = 100 mg/L
  • •serum transferrin saturation = 33% ]
• •Serum iron [Fe], ferritin, TIBC and transferrin saturation
  
  • •Low serum iron [Fe] (measured)
  • •High TIBC (total iron-binding capacity; measured )
  • •Low serum ferritin (measured) < 12 mcg/L
  • •Thus, low serum transferrin saturation (TRF) (calculated)
  • [Fe] / TIBC = TRF (transferrin saturation)

​

Question 112

Identify common cause of IDA (iron deficiency anemia) in males vs females

Answer 112

Casues of IDA

Males and postmenopausal females- GI occult bleeding

Females - menstrual loss

• Note: Iron deficiency anemia in all males and all postmenopausal females requires investigation into etiology
• Due to occult bleeding, such as gastrointestinal lesions (ulcers, tumors), gynecologic lesions (tumors), etc.
• May also be due to chronic hemolytic states (see later lectures)
• Treatment: giving iron supplements will correct anemia, but need to find out source of bleeding

Question 114

Identify condition

• •Second only to iron deficiency anemia in incidence
• •a.k.a. anemia of chronic inflammation / infection
• •Most common anemia in hospitalized patients
• •Peripheral blood: Normocytic, normochromic anemia (normal MCV, MCH, RDW)
• •RBCs have shortened life span
  
  • •Increased phagocytosis
  • •Factors released by damaged tissues
  • •Physical damage during passage of red cells through tissues

Answer 114

Anemia of Chronic Disease

Bone marrow unable to compensate for anemia

• •Suppression of bone marrow response to erythropoietin by inflammatory cytokines (TNF, IL-1)
• •Defective reutilization of iron salvaged from old RBCs
  
  • •Iron sequestered in phagocytes
  • •Inflammatory cytokines increase phagocytic uptake of iron
• •Iron stores
  
  • •low serum iron
  • •normal to low transferrin
  • •low transferrin saturation
  • •high serum ferritin (tissue stores)
  • •Increased hepcidin production.
• •Increased bone marrow iron stores
  
  • •Mostly in macrophages (hepcidin)
  • •Surpressed EPO (hepcidin)

Question 115

Identify chronic diseases associated with anemia (2)

Answer 115

• •Chronic renal failure
  
  • •Chronic bleeding, hemolysis, decreased erythropoietin, hematosuppression
• •Chronic disease
  
  • •Diabetes mellitus (poor absorption, renal insufficiency, chronic blood loss)
  • •Inflammation (endocarditis, autoimmune dz)
  • •Cancer
  • •Liver disease
• •Alcoholism - complex effects
  
  • •Alcohol directly toxic
  • •Nutritional deficiencies
  • •Bleeding (gastritis)
  • •Congestive splenomegaly, portal hypertension
  • •Lipoprotein abnormalities: acanthocytes

•

Question 116

Identify anemia type

*** 2 most common causes

**what does CBC show

• peripheral blood smear?
• bone marrow?

Answer 116

Megaloblastic anemias

• •Two most common causes:
  
  • •Vitamin B12 deficiency
  • •Folate deficiency
• •CBC: pancytopenia
  
  • •Decreased RBC counts, WBC counts, platelet counts
• Peripheral blood smear
  
  • Macrocytic anemia
  • Macro-ovalocytes (MCV usually > 115 fl)
  • Anisopoikilocytosis
  • Hypersegmented neutrophils
• Bone marrow (in megaloblastic anemias)
  
  • Giant bands, nuclear-cytoplasmic asynchrony

Question 118

Identify anemia type

Answer 118

Megaloblastic anemia

•Clinical signs and symptoms in B12, folate deficiencies

• •Anemia
• •Atrophic glossitis (smooth tongue with no contour)
• •Gastric gland atrophy
• •Neurologic deficits ( only in vitamin B12 deficiency, not in folate deficiency)
  
  • •Due to demyelination; •degeneration of white matter (brain) and of dorsolateral columns (spinal cord)

Question 119

Identify condition

• •GI surgery, disease
• •Rarely due to dietary insufficiency
  
  • •Body stores of B12 last several years
  • •Except in strict vegans
• •States requiring increased intake
  
  • •Pregnancy
  • •Disseminated cancer
  • •Hyperthyroidism

Answer 119

Vitamin B12 deficiency;

•Pernicious anemia most common cause = malabsorption

• •Starvation amidst plenty”
• •Due to absent intrinsic factor (IF) or IF antibodies which binds vitamin B12
• •Genetic predisposition, rarely manifests before age 35y

***Need to give IV injection of vit B12 because they cannot absorb oral vit B12

Question 120

Identify condition

Autoimmune diease

• •Autoantibodies in serum, gastric juice (90%)
  
  • •Type I (blocking) block binding of B12 to IF
  • •Type II (binding) bind B12-IF complex
  • Type III - associated with gastritis (not specific to PA

Answer 120

Pernicious anemia

• •Associated with autoimmune diseases
  
  • •Hashimoto’s thyroiditis
  • •Adrenalitis (Addison’s disease)
  • •Grave’s disease
• •Chronic atrophic gastritis
  
  • •Parietal cells lost
• •Schilling test – radiolabeled B12

Question 121

identify condition form megalobalstic anemia

• •Usually due to dietary insufficiency
  
  • •Sources; •green, leafy veggies, citrus fruits, eggs, milk, liver, yeast
  • •Liver stores can be depleted in 3-6 months
  • •Folate is heat-labile

***are there neurologic defects?

Answer 121

Folate deficiency

•Clinical picture as in vitamin B12 deficiency, but without neurologic deficits

Question 122

How to diagnose megaloblstic anemias

Answer 122

Serum levels

• Low vitamin B12 (cobalamin)
  
  • <170 pg/mL, symptoms when <100 (normal >240 pg/mL)
• Low serum and RBC folate
  
  • <150 ng/mL RBC folate
• High methylmalonic acid (B12 def.) and homocysteine (both in folic acid def.)
• Autoantibodies (PA)
  
  • Antiparietal cell
  • Anti-IF, anti-cobalamin/IF complex
• Clinical trial – give B12 IM - reticulocytosis
• Schilling test: for absorption of B12; •Rarely used today, difficult to do

Question 123

treatment of megaloblastic anemia

Answer 123

• •Vitamin B12 = intramuscular injections
  
  • •Corrects anemia, reverses neurologic deficits (if less than 6 months’ duration)
• •Folate supplements
  
  • •Passively absorbed even with SI malabsorption
• •Folate treatment partially corrects vitamin B12 deficiency, but does not affect neurologic deficits

Question 124

Identify other causes of macrocytic anemia (aside from folate and B12 deficiency) - 5

Answer 124

• •Chemotherapy/Drugs (AZT)
• •Alcoholism
• •Hypothyroidism
• •Liver disease
• •Myelodysplastic syndromes (cancer of bone marrow with poor prognosis)

Question 125

Identify type of anemia

**when bone marrow is underproducing

Answer 125

Production Defect Anemias

• •The “factory” = bone marrow = is underproducing
• •Aplastic anemia
  
  • •Acquired
  • •Hereditary
• •Pure red cell aplasia
  
  • •Diamond-Blackfan syndrome

***No abnormal cells (just underporducing)

Question 126

Identify condition (clinical presentation)

• •Stem cell injury/suppression
• •Peripheral blood
  
  • •Pancytopenia (also on CBC)
  • •Normocytic, normochromic anemia
  • •No reticulocytosis
• •Bone marrow
  
  • •Hypocellular bone marrow = “dry tap”, no cells on aspiration
  • •No abnormal cells

Answer 126

Aplastic Anemia (from damage to stem cell so bone marrow is underproducing)

• Clinically:
  
  • Anemic (weakness, pallor, dyspnea etc.)
  • Prone to infections (neutropenia)
  • Prone to bleeding - petechiae, ecchymosis (thrombocytopenia)
  • No splenomegaly (no hemolysis) or lymphadenopathy

Question 127

Identify 2 forms aplastic anemia exists

Answer 127

1. Acquired

• Chemicals, toxins, drugs
  
  • Benzene, alcohol, myelotoxic drugs, chloramphenicol, nonsteroidal anti-inflammatory drugs (NSAIDs)
• Radiotherapy/irradiation
• •Viral infections
  
  • •Hepatitis, Epstein-Barr virus, HIV, parvovirus
• •Systemic lupus erythematosus, rarely
• •Most common cause: autoimmune suppression by a T cell-mediated cell mechanism
• •Half are idiopathic

2. Genetics (fanconi’s anemia)

• •Autosomal recessive
• •Defects in DNA repair mechanism = chromosomal instability
• •Congenital anomalies (hypoplastic radii, thumbs, organs)
• •May be pre-malignant: evolve into myelodysplasia, acute and chronic myeloid leukemias

Question 128

Identify treatment of Aplastic anemia

Answer 128

Aplastic anemia treatment

• •Supportive – transfusions, antibiotics
• •Severe (<500 neutros/microL, platelets <20K, retics <1%, <20% BM cellularity) - need to raise blood cell count - •Immunosuppression
  
  • •ATG, Steroids, Rituxan, IVIG
  • •High-dose with cyclophosphamide in refractory cases
  • •If no suitable BM donors
• •Bone marrow transplantation (< 50 y.o.)

Question 129

Idetify condition (identify 2 forms)

• As name implies, only erythroid (RBC) cell line affected; myeloid and platelet lines normal
• Chronic, severe anemia
• Peripheral blood
  
  • Normocytic or slightly macrocytic
  • No reticulocytosis
• Bone marrow
  
  • Few to absent erythroid (RBC) precursors (erythroblasts)
• •Autoimmune disease mediated by T-lymphs or IgG antibody vs. red cell precursors
• •Associated with: •Systemic lupus erythematosus, CLL, lymphomas, thymomas
• •Drugs (chloramphenicol)

Answer 129

Pure Red Cell Aplasia (2 forms)

• •Primary form
  
  • •Diamond-Blackfan syndrome; • Severe anemia first year of life, with congenital anomalies
• •Secondary forms;
  
  • •Infections: parvovirus B19
  • •Solid tumors
  • •Rheumatic diseases; •Sjogren’s syndrome, lupus erythematosus
  • •Medication; •Phenytoin, azathioprine, isoniazid
• •Idiopathic

Treatment of pure red cell aplasia

• •Stop offending drugs
• •Thymoma resection sometimes ameliorates anemia
• •High-dose IV immunoglobulin (parvo)
• •Immunosuppression – ATG + cyclosporine

Question 130

A 68-year-old man presents with weakness and

pallor. His lab work shows a total iron binding

capacity (TIBC) of 450 microgm/dL (ref range: 300-350

ug/dL), MCV of 72 fL (rr: 80-100 fL), MCH of 24 pg

(rr: 26-34 pg), and hematocrit of 30% (rr: 33-43%).

The causative lesion is most likely located in the :

• (A) bone marrow
• (B) gastrointestinal tract
• (C) kidney
• (D) liver
• (E) lung

Answer 130

GI TRACT

Question 131

ientify anemia type

• nRare; heterogeneous group
• nFailure to incorporate heme into protoporphyrin to form hemoglobin
• nMild anemia
  
  • nDimorphic (micro-/macrocytic) red cells in peripheral blood
  • nHypochromia
  • nIneffective erythropoiesis

Answer 131

Sideroblatsic anemia; Ringed sideroblasts in bone marrow: Cells with iron granules around nucleus (Prussian blue stain).

Question 132

Identify anemia type (what causes this?) - hereditary form? acquired form?

• •Pathophysiology: adequate iron stores, but defective utilization of iron within mitochondria of red blood cell
• •Iron indices:
  
  • •High serum iron
  • •High ferritin
  • •High transferrin saturation
• •Can get iron overload (secondary hemochromatosis)

Answer 132

Sideroblastic anemias

• nHereditary form is X-linked recessive; Due to defects in amino-levulonic acid synthase (ALA synthase), rate-limiting enzyme in heme synthesis
  
  • nInsufficient hemoglobin produced
  • nIron in mitochondria

•Acquired forms: etiologies

• •Myelodysplasia
• •Drugs
• •Alcohol, isoniazid/INH, chloramphenicol)
• •Toxins; •Lead, zinc)
• •Nutritional deficiency; •Pyridoxine, copper

•Treatment:

• •Pyridoxine (vitamin B6) treatment seems to help
• Treat underlying condition, remove exposure to toxins, etc

Question 134

1) identify anemia type

• Trauma
• Acute hemolysis
• Massive gastrointestinal bleed, peripartum bleed

2) identifY anemia type

• Gastrointestinal lesions (ulcers, tumors, parasites)
• Menstrual losses
• Chronic hemolysis
• Excessive blood sampling

Answer 134

1) Anemia due to blood loss (Acute blood loss)
2) Anemia due to blood loss (Chronic blood loss)

Question 135

Describe anemia type with examples

• Erythropoiesis can be increased up to 6-8 times normal with chronic bleeding or hemolysis.
• Anemia develops when rate of loss exceeds rate of erythropoiesis.

**2 types

**what is found with lab findings and peripheral smear

Answer 135

Hemolytic Anemias

• •Due to increased rate of RBC destruction, or premature RBC destruction
• •Acute
  
  • •Fatigue, fever, pallor, jaundice, low back pain, splenomegaly, congestive heart failure
• •Chronic
  
  • •In addition to above: gallstones, abnormal bone growth, fractures
• •Lab findings
  
  • •Increased unconjugated bilirubin
  • •Decreased serum haptoglobin conc. (which take up free Hb)
  • •Increased serum LDH / lactate dehydrogenase (RBC enzyme released)
  • •Reticulocytosis
• •Peripheral smear = spherocytes, schistocytes (RBC fragments that look like helmets), reticulocytosis, polychromasia (like reticulocytosis)

Question 136

Most forms of hemolysis are classified predominantly extravascular or intravascular. Many are mixed. Identify the one below.

• Occurs outside bloodstream, in the reticuloendothelial system
  
  • Spleen, liver, bone marrow macrophages
• Usually occurs in association with intrinsic/inherited hemolytic anemias (hemaglobinopathy, red cell disorders)
  
  • Defects in hemoglobins, RBC membrane, RBC enzymes

**What do labs show?

Answer 136

Extravascular Hemolysis

•Lab

• •Increased unconjugated serum bilirubin
• •Normal or slightly decreased haptoglobins (due to some leakage of Hb into plasma) - because it’s not occuring in the circulatory system
• •Spherocytes in peripheral blood (cells getting smaller - helmet like - RBC fragments)

Question 137

Most forms of hemolysis are classified predominantly extravascular or intravascular. Many are mixed. Identify the one below.

• RBC destruction within the circulation
• Free hemoglobin released
  
  • Haptoglobins
    
    • Excessive free Hb = hemoglobinuria, hemosiderinuria
    • Expect decreased serum haptoglobin concentration
• Usually occurs in association with extrinsic/acquired hemolytic anemias
  
  • Immune hemolytic, microangiopathic anemias, infection, burns, hypersplenism

Answer 137

Intravascular Hemolysis

Question 138

Describe anemia due to extravascular hemolysis

**3 defects

Answer 138

Intrinsic (Inherited, Hereditary) Hemolytic Anemias

• •Predominantly extravascular hemolysis
• •Defects in hemoglobin
  
  • •Quantitative defect = Thalassemias
  • •Qualitative defect = Hemoglobinopathies
• •Defects in RBC membrane
  
  • •Hereditary spherocytosis etc.
• •Defects in RBC enzymes
  
  • •Glucose-6-phosphate dehydrogenase deficiency etc.

Question 139

Identify condition in bold (and types)

• •Normal adult hemoglobin
• •Made up of alphd beta (or beta-related) subunits, 2 chains of each
  
  • •Hemoglobin A (a2 b2) ~ 96%
  • •Hemoglobin A2 (a2 d2) ~ 3%
  • •Hemoglobin F (a2 g2) ~ 1%
• reduced production of one or more globin chains****???

Answer 139

Thalassemias

• •Beta thalassemia = beta-globin chains deficient
  
  • •Common in people of Mediterranean origin
• •Alpha thalassemia = alpha-globin chains deficient
  
  • •Common in people from Southeast Asia, China

Question 140

Identify condition

• •Decreased production of HbA
• •Beta-globin gene affected
• •Beta-globin gene on chromosome 11 (two copies in each genome)
  
  • •Point mutations, partial deletions (unlike total deletions of alpha thalassemia)
• •Promoter mutations = transcription
• •Coding region, splice site, termination codon mutations = RNA processing and translation

**What is abnormal? (functions?)

**2 forms ?

Answer 140

Beta thalasemia Major

• •Normal allele = b (beta)
• •Both alleles abnormal in beta thalassemia major
• •Two possible abnormal beta globin alleles, beta 0 and beta+ :
  
  • •beta 0 produces NO beta-globin at all (abnormal messenger RNA degraded)
  • •beta+ produces reduced beta-globin

2 forms

• •Homozygous –
  
  • =beta 0 / beta 0 = no normal beta globin synthesis
  • =beta + / beta + = reduced beta globin
• •Or compound heterozygous
  
  • =beta + / beta 0 = reduced beta globin

Question 141

Identify condition (and clinical features and treatment)

• •Onset 6 - 9 months after birth
  
  • •switch from HbF a2 g2 (2 alpha+2 gamma) to Hb A a2 b2 (2 alpha+2 beta)
• •Severe anemia (3-6 g/dl Hb)
• •Compensatory changes for ineffective erythropoiesis
  
  • •Abnormal bone growth
  • •Hepatosplenomegaly
  • •Damage to organs

Answer 141

Beta Thalassemia Major ; distorted faces, hepatosplenomegaly and growth retardation, X-ray show crew cut skull, smear show HOWELL-JOLLY BODY

• •Transfusion-dependent for survival
• •Clinical findings in survivors
  
  • •Growth retardation, distorted facies
  • •Hepatosplenomegaly
  • •Death from anemia, complications of iron overload
• •Peripheral blood (see pic)
  
  • •Microcytosis, hypochromia, anisopoikilocytosis, target cells, teardrop cells, nucleated RBCs
• •Hb electrophoresis or HPLC
  
  • •Compensatory increase in Hb A2 and Hb F, variable Hb A

Question 142

Identify condition

• One normal and one abnormal gene of beta-globin
  
  • b/b+ or b/b0
  • (beta/beta+ or beta/beta0 )
• Microcytic, hypochromic anemia (mild)

**differentiate from iron deficiency anemia

Answer 142

Beta Thalassemia Minor

• •Important to differentiate beta-thalassemia minor from iron deficiency anemia
  
  • •Iron therapy improves iron deficiency anemia, worsens beta-thalassemia
  • •Increased or normal serum iron and bone marrow iron in thalassemia

Question 143

Identify the condition and severity

• •Alpha-globin genes affected: Four alpha-globin genes, two from each parent make: two alpha-globin chains, a1 and a2
• •Complete deletion of genes is defect (unlike mutations and partial deletions in Beta Thalassemia)
• •Severity of syndrome depends on the number of alpha-globin genes lost
• •Unpaired gamma chains in fetus and beta chains in children and adults = g and b tetramers result
• •Peripheral blood film shows microcytic, hypochromic red cells with target forms and basophilic stippling

Answer 143

Alpha thalassemia

Severity of disease related to # genes lost:

• •Loss of all 4 a genes
  
  • •Fetal death-in-utero, no HbA, HbF or HbA2 at all
  • •Hemoglobin Bart = g4 = excess, unpaired tetrameric gamma chains (of fetal hemoglobin, HbF); very high O2 affinity, does not release O2
• •Loss of 3 a genes
  
  • •Hemoglobin H, HbH = b4 = excess, unpaired tetrameric beta chains
  • •Unstable, can precipitate, has high affinity for oxygen
  • •Precipitated HbH results in inclusions in RBC, which are “bitten off” by splenic macrophages
  • •After splenectomy, can see precipitated HbH as Heinz bodies on staining with crystal violet/cresyl blue
• Loss of 2 a genes = Alpha Thalassemia Trait
• Two types:
• •Alpha-thal-1: –/aa (deletion of both genes on same chromosome)
  
  • •Hb Bart g4 (from HbF, fetal Hgb) present at birth
  • •HbH inclusions (from HbA-related excess beta chain tetramers b4) in peripheral blood during life
• •Alpha-thal-2: -a/-a (deletion of one gene on each chromosome)
  
  • •Hb Bart g4 (from HbF, fetal Hgb) present at birth
  • •No HbH inclusions detected afterwards, cannot screen with staining, need gene mapping to confirm condition

Question 144

Summarize conditions that occur in intrinsic (inherited, hereditary) hemolytic anemia

Answer 144

Intrinsic (Inherited, Hereditary) Hemolytic Anemias

• •Predominantly extravascular hemolysis
• •Defects in hemoglobin
  
  • •Quantitative defect = Thalassemias
  • •Qualitative defect = Sickle cell disease, other hemoglobinopathies like Hb C disease
• •Defects in RBC membrane
  
  • •Hereditary spherocytosis etc.
• •Defects in RBC enzymes
  
  • Glucose-6-phosphate dehydrogenase deficiency etc

Question 145

Identify condition

Answer 145

•Sickle cell disease

Sickled cells = dense, dehydrated, crescent-shaped, not easily deformable

• •Viscosity of blood increased
• •Obstruction in microcirculation
• •Infarction (tissue death) results

•Initially reversible, later irreversible with repeated, rapid sickling/unsickling

• •Cytoskeletal damage: spectrin now dimers instead of normal tetramers
• •Up to 30 - 40% RBCs can be irreversibly sickled
• •Life span of 20 days only (instead of 120 days)

Question 146

**Identify complications in the following condition (12)

• •Best example of hemoglobinopathy (structurally abnormal hemoglobin is produced)
• •Hemoglobin S, HbS
  
  • •Valine replaces amino acid glutamic acid in position 6 of beta-globin chain
  • •Abnormal intermolecular bonding between adjacent HbS molecules with low oxygen tension
  • •Aggregation of HbS => polymerization => sickling
• •Homozygous for HbS (a2,b26 Glu Val; val. substitutes for glu. on beta chain amino acid 6 )
  
  • •HbF ~ 10% (normal is only 1%; a2,g2, fetal gamma gene more active to produce HbF)
• •Affects 0.25% of African Americans
• •Chronic hemolysis and vaso-occlusive crises
• •Extravascular hemolysis with some intravascular also

Answer 146

Sicle Cell Anemia

• •Expanded bone marrow due to increased hematopoiesis
• •Extramedullary hematopoiesis
• •Autosplenectomy
  
  • •Congestion, then infarction, fibrosis
  • •Salmonella osteomyelitis
  • •Influenza can cause death
• •Chronic leg ulcers

Vaso-occlusive crises

• •Musculoskeletal “painful” crises (like “the bends”)
• •Hand and foot syndrome (dactylitis = swollen fingers) in infants
• •Avascular necrosis of femoral head can cripple (surface of right is flattened)

•Acute Chest syndrome

• •Dangerous microvascular occlusive crisis in lung.
• •Fever cough chest pain pulmonary infiltrates.
• •CVA
• •Infection/sepsis with encapsulated organisms incusing Streptococcus & Haemophilus
• •Prophylactic ABX

Aplastic crises (parvovirus bone marrow suppression)

Splenic sequestration crises

• Rapid splenomegaly and hypovolemia

Priapism in males

Organ infarction

• Renal papillary necrosis
• Pulmonary infarction, cor pulmonale
• Cerebral infarction
• Abdominal, hepatic, splenic infarction

General growth/development impaired

•Gallstone formation

• •(from chronic extravascular hemolysis)

•Severe anemia (Hb of 8 g/dl, Hct of 18 - 30%)

•Peripheral blood

• •Crescent-shaped sickle cells (up to 5 - 15% of cells), anisocytosis, basophilic stippling, Howell-Jolly bodies

Question 147

How do you diagnose sickle cell anemia

Answer 147

• •Peripheral blood film - sickle cells
• •Sickling test
  
  • •Reducing agents like metabisulfate added to blood to induce sickling
• •Hemoglobin electrophoresis (separates the various hemoglobins according to rate of migration in gel) or HPLC (high-performance liquid chromatography)
• •Molecular analysis for gene defect
  
  • •Prenatal diagnosis possible

Question 148

1) What factors affect the tendency to sickling (part 1)
2) Identify condition (in picture below)
3) Factors affecting tendency to sickling (part 2)
4) therapy of sickle cell (life expectancy)

Answer 148

1) Factors affecting tendency to sickling

• •Interaction with other hemoglobins
  
  • •HbA = weak interaction, need severe hypoxia to sickle
  • •HbF = inhibits polymerization, can moderate severity
  • •HbD = intermediate affinity between HbA and HbC

2) Hemoglobin C; SC disease is less severe than SS

• •Variant Hemoglobin in which lysine is substituted forglutamic acid in position 6 of the beta globin chain.
• •Hemoglobin SC disease is a sickling disorder but clinically less severe than SS

3) Factors affecting tendency to sickling

• •Hemoglobin concentration
  
  • •Dehydration increases MCHC, promoting sickling
  • •Thalassemia
• •Low pH, increase in temperature promote sickling

4) Sickle cell therapy

• •Hydroxyurea increases HbF
• •Transfusions
• •Pain management
• •Social support
• •90% survive to age 20
• •50% survive beyond 5th decade
• •Prophylactic ABX
• •Folate

Question 149

Identify type of Intrinsic (Inherited, Hereditary) Hemolytic Anemias

**Defect in RBC membrane

• Autosomal dominant, common in N. Europeans
• Usually presents in childhood
• RBCs normal at first, but lose bits of membrane as they pass thru spleen -> become spherocytes
• Splenic sequestration, destruction of spherocytes = shortened RBC survival

Answer 149

Hereditary spherocytosis

• Mutation in RBC membrane skeleton protein gene, ankyrin
  
  • Weakened anchor for lipid bilayer; Deficiency of spectrin (membrane protein)
    
    • Due to mutations in ankyrin gene (codes for the anchor)
    • Causes a decreased interaction between membrane cytoskeleton and the overlying lipid bilayer
  • Results in spherical shape, which is less deformable

Question 150

Identify clinical features, diagnosis and treatment of hereditary spherocytosis

Answer 150

Clinical picture

• Usually chronically compensated, mild-moderate hemolytic anemia
• Jaundice, splenomegaly (extravascular hemolysis)
• Gallstones
• Anemic crises (parvovirus infection, hematosuppression, folate deficiency)
• Fever- and infection-induced crises

Diagnosis

• Ppossible iron overload from multiple transfusions
• Diagnosis
  
  • Osmotic fragility test (see next slide)
  • Only notable disease with microcytosis and increased MCHC (36 g/dL)
  • Reticulocytosis
  • Negative DAT (Coombs test), + family history

Treatment

• Folic acid supplements
• Splenectomy – treatment of choice
  
  • Does not correct membrane defect or spherocytosis, but -
  • Eliminates the site of hemolysis (spleen)

Question 152

Summarize conditons with Intrinsic (Inherited, Hereditary) Hemolytic Anemias

Answer 152

Predominantly extravascular hemolysis

• Defects in hemoglobin
  
  • Quantitative defect = Thalassemias
  • Qualitative defect = Sickle cell disease, other hemoglobinopathies like Hb C disease
• Defects in RBC membrane (discussed earlier)
  
  • Hereditary spherocytosis etc.
• Defects in RBC enzymes
  
  • Glucose-6-phosphate dehydrogenase deficiency

Question 153

Identfiy condition (and variants)

• Example of anemia due to defective red cell enzyme
• 100 million affected worldwide, many asymptomatic
• Recessive, X-linked Trait
• May protect from falciparum malaria
• Episodic hemolysis with oxidant stress.

Answer 153

Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency

• In oxygen-carrying RBC, G6PD gives red cell antioxidant protection
  
  • Hemoglobin becomes denatured during times of oxidant stress without G6PD
  • Due to inadequate production of NADPH
  • NADPH needed to maintain GSH levels
• Heinz bodies formed – denatured hemoglobin
• Induced by drugs, infections, certain food substances in absence of G6PD

Variants

• Mediterranean variant = severe decrease; in Middle Eastern populations; less than 10% activity
• G6PD- (10% American Blacks, Moderately reduced G6PD Activity)

Question 154

Identify clinical findings and precipitating factors ofthe condition in the picture peripheral smear

Answer 154

G6PD - Glucose 6 phosphate deficiency

Clinical findings: hemolysis of stressed RBCs

• Intravascular hemolysis due to Heinz bodies
  
  • Chills, fever, hemoglobinemia, hemoglobinuria
• Extravascular hemolysis
  
  • Destruction of affected RBCs in spleen

Precipitating factors

• Infections
  
  • Viral hepatitis, typhoid fever, pneumonia
• Oxidant drugs
  
  • Antimalarials paraquine, chloroquine, sulfonamides, nitrofurantoin, chloramphenicol etc.)
• Fresh fava beans (“favism”)
  
  • Occurs 5 - 24 hrs after ingestion
  • Can also occur with canned, cooked, frozen beans, however!

Self-limited acute attacks

• Only older RBCs affected; reticulocytes have normal activity
• Stability of enzyme is the functional defect

Between attacks, peripheral blood smear is normal

Question 155

Summarize examples of Extrinsic (Acquired) Hemolytic Anemias

Answer 155

• Immune hemolytic anemias
  
  • Autoimmune hemolytic anemias (autoantibodies)
  • Alloimmune (transfusion) hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn)
• Non-immune hemolytic anemias
  
  • Microangiopathy, infections, drugs, acquired membrane defects, mechanical/physical factors

Question 156

Extrinsic (acquired) hemolytic anemias

1) Identify types of immune hemolytic anemias
2) identify specific type (and classification)

• Bulk of immune hemolytic anemias
• Autoantibodies: anti-RBC antibodies attach to red cells
  
  • Detected by the Coombs test (Direct Antiglobulin Test, DAT)
  • Antiglobulin is used to detect red cells coated with antibodies via agglutination of cells

Answer 156

1) Immune hemolytic anemias

• Based on the antigen that stimulates antibody or complement-mediated RBC destruction
• Autoimmune hemolytic anemias
• Alloimmune hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn)

2) Autoimmune Hemolytic Anemias (AHA); Antiglobulin used to detect antibody-coated red cells via agglutination of these cells.

• Classification according to thermal reactivity of antibody: “warm” and “cold” AIHA
  
  • Warm antibody hemolytic anemia (WAHA)
  • Cold aggutinin hemolytic anemia (CAHA)

Question 157

Identify classifications of autoimmune hemolytic anemia

• More common
• Antibodies reactive at body temperature (“warm”)
• Mostly due to IgG autoantibodies (90%)
• Spleen eliminates IgG-coated cells: macrophage Fc receptors bind to protruding Fc (rear) ends of IgG antibodies
  
  • Extravascular hemolysis

***Identify causes and disorders asociated and treatment

Answer 157

1) Warm Antibody Hemolytic Anemia

• Drug-induced WAHA models well-studied
  
  • Methyldopa (L-dopa) = antibody against Rh blood group antigen
  • Penicillin-hapten = antibody against drug, which is bound to the red cell
  • Tetracyclines, cephalosporins, tolbutamide
• Disorders associated with WAHA
  
  • nLymphatic malignancies (CLL, etc.)
  • nAutoimmune disorders
    
    • nsystemic lupus erythematosus,
    • nrheumatoid arthritis,
    • nulcerative colitis
• Treatment
  
  • nTreat underlying condition
  • nCorticosteroids
  • nBlood transfusion, gammaglobulins, plasmapheresis
  • nSplenectomy

**WAHA may antedate the onset of disease by months or years!

Question 158

Identfy type of Autoimmune Hemolytic Anemias

• Monoclonal IgMs (large antibodies) are induced at colder temperatures (below 30oC)
• Destruction of RBCs by agglutination or serum complement activation
• Precipitated by exposure to cold temperatures (even cold food, drinks),

***describe specific types

Answer 158

Cold Agglutinin Immune Hemolytic Anemia (Cold Agglutinin Disease)

• nIgMs
  
  • n target blood group antigens (like A, B, O) : I (big I), and i (little i)
  • nFix complement C3
  • nC3-coated red cells are eliminated by the spleen (extravascular hemolysis), but no splenomegaly
• nCan also present with acrocyanosis

Acute type:

• An acute, self-limited hemolysis
  
  • Atypical pneumonia (Mycoplasma pneumoniae); Cold agglutinins against I (“big I”).
• Infectious mononucleosis; Cold agglutinins against i (“little I”)

Chronic type :

• Due to lymphoid malignancy or idiopathic
• May be unremitting

Treatment

• Warm environment
• Treat underlying condition (atypical pneumonia, lymphoma, infxs mono…)

Question 159

Identify condition

• IgG autoantibody (Donath-Landsteiner antibody) = biphasic hemolysis
  
  • at low temperatures binds to cells without causing hemolysis,
  • warming binds complement -> intravascular hemolysis

[Note: CAD has IgM]

• A rare, acquired hemolytic anemia characterized by biphasic nature of hemolysis (cold => warm=> hemolysis)
• For ex., hemolysis occurs after skiing, when patient voids dark urine = hemoglobinuria

Answer 159

Paroxysmal Cold Hemoglobinuria

• Associated with recovery from viral infections (similar to CAD)
  
  • Mycoplasma pneumonia
  • Infectious mononucleosis
  • (Historically, syphilis)
• No jaundice or splenomegaly
• Difference = biphasic intravascular hemolysis, hemoglobinuria

Diagnosis

• Test for Donath-Landsteiner antibody = differentiates PCH from CAIHA/cold agglutinin hemolytic anemia
  
  • Mix patient’s serum (with antibodies) with test RBCs
  • First chill, then warm to 38oC
  • Lysis of RBCs indicates PCH

Treatment: keep patient warm

Question 160

summarize extrinsic (acquired) hemolytic anemia

Answer 160

• Immune hemolytic anemias
  
  • Autoimmune hemolytic anemias (autoantibodies)
  • Alloimmune (transfusion) hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn)
• Non-immune hemolytic anemias
  
  • Microangiopathy, infections, drugs, acquired membrane defects, mechanical/physical factors

Question 161

2 types of alloimmune (transfusion) hemolytic anemias

Answer 161

Hemolytic transfusion reactions

• Administration of ABO-incompatible red blood cells (usually clerical error) e.g., giving A RBCs to an O recipient
• Acute reaction
  
  • Brisk, severe intravascular hemolysis of donor red cells in recipient via complement fixation
  • Fever, chills, dyspnea, hypotension, low back pain, hemoglobinuria, jaundice, oliguria (even renal shutdown), shock
• nTest for hemolysis

nCoombs test/direct antiglobulin test/DAT

nSerum haptoglobin, LDH, serum bilirubin, serum and urine hemoglobin

nStop transfusion immediately

nBlood bank to repeat blood group typing, antibody screen, cross-match to investigate source of error

Hemolytic disease of the newborn (HDN) - picture below

• a.k.a erythroblastosis fetalis = hemolysis of newborn’s RBCs
• Due to transplacental transmission of maternal antibodies (anti-Rh or -D) directed against Rh-positive fetal RBCs
• Can happen when mom is Rh-, baby Rh+
• nMaternal immunization (produces anti-Rh antibodies) can result from:
  
  • nPrevious blood transfusion
  • nPrevious pregnancy, delivery (due to fetal-maternal hemorrhage)

Question 162

identify Extrinsic (acquired) Hemolytic anemia based on below examples

• Microangiopathy
• infections, drugs,
• acquired membrane defects
  
  • Alcoholic liver disease
  • Paroxysmal Nocturnal Hemoglobinuria (PNH)
• mechanical/physical factors

Answer 162

Non-immune hemolytic anemias

Question 163

Identify type of non-immune hemolytic anemia

• Due to abnormalities in microcirculation -> fibrin deposition, vessel narrowing
  
  • Disseminated intravascular coagulopathy (DIC)
  • Hemolytic-uremic syndrome (HUS)
  • Thrombotic-thrombocytopenic purpura (TTP)
  • Preeclampsia, HELLP syndrome (hemolysis, elev. liver enzymes, low platelets)

Answer 163

Microangiopathic Hemolytic Anemias

Question 164

identify Non - immune hemolytic anemia

**type of acquired RBC membrane disorders

Answer 164

Alcoholic liver disease (acquired membrane disorders)

• Acanthocytes or “spur” cells, target cells
• Due to abnormal lipid in red cell membrane

Question 165

identify Non - immune hemolytic anemia

**type of acquired RBC membrane disorders

• Rare, acquired and clonal disorder
• Mutation in pig-A / PIGA (phosphatidyl inositol glycan class A) gene
  
  • Synthesis of glycosyl phosphatidyl inositol (GPI) anchor in cell membrane
  • Some membrane proteins (CD14, CD16, CD59 and CD55) need GPI anchor
• Screening test (activate C’-mediated lysis)
  • Sucrose lysis test
• Diagnosis
  • Ham’s test
  • Now, flow cytometry

Answer 165

Paroxysmal Nocturnal Hemoglobinuria

• Abnormal sensitivity of RBCs to lysis by complement
• Complement-regulating proteins CD59 and CD55 absent

Paroxysmal and nocturnal hemolysis in 25% (chronic form more common)

• Blood smear non-diagnostic (micro- or macrocytic)
• Intravascular hemolysis, hemosiderinuria, pancytopenia
• Iron deficiency anemia may result later
• Recurrent thrombosis (hepatic, portal, cerebral)

Clonal disorder, may later evolve into:

• Aplastic anemia
• Myelodysplasia
• Acute myeloblastic leukemia (AML)

Treatment

• Iron supplements
• Prednisone/Immune supression
• Eculizamab (Soliris) monoclonal antibody – complement inhibitor.
• Bone marrow transplant

Question 166

Identify non-immune hemolytic anemia

Answer 166

Mechanical and Physical Factors (Non-immune hemolytic anemia)

Prosthetic heart valves

• Artificial more than porcine valves
• Mild compensated anemia to severe, hemolytic anemia; Iron deficiency later
• Peripheral blood smear: Hemolysis (schistocytes, burr cells, polychromasia)
• Lab findings of hemolysis

March hemoglobinuria

• Marching, marathon running, drum-beating
• Hemoglobinuria after exercise
• Normal peripheral blood smear, anemia rare

Burn injury

• microsperocytes, barbell shapes, rod shape

Question 167

You examine a peripheral blood smear and notice many spherocytes. What test would be most useful in differentiating between hereditary spherocytosis and immune hemolytic anemia as possible causes for this finding?

(a) Hemoglobin electrophoresis
(b) Coombs test
(c) Flow cytometry
(d) Bone marrow examination
(e) Schilling test

Answer 167

(b) Coombs test

The answer is (b), Coombs test, or the antiglobulin test.

• Immune hemolytic anemia would be Coombs positive, and HS would be negative.

Question 168

Summary of lab diagnosis of anemia

1. Peripheral blood tests
2. Reticulocyte counts
3. Iron indices
4. Serum and red cell folate, vit. B12 concentrations
5. Plasma unconjugated bilirubin and haptoglobin concentrations
6. Gel electrophoresis, HPLC
7. Coombs test

Answer 168

Lab diagnosis of anemia

1. Peripheral blood tests; (CBC, peripheral blood smears) usually suffice to determine a cause of isolated anemia (meaning, only RBCs are decreased).
   
   • However, if thrombocytopenia and/or granulocytopenia are also present, marrow is likely to be affected-> bone marrow examination is warranted.
2. Reticulocyte counts; to differentiate between hemolysis (RBC destruction) and marrow failure (decreased RBC production as in aplastic anemia) as cause of anemia.
3. Iron indices; to differentiate hypochromic, microcytic anemias due to iron deficiency, anemia of chronic disease, thalassemia minor.
4. Serum and red cell folate, vit. B12 concentrations
   
   • to determine cause of megaloblastic anemia.
5. Plasma unconjugated bilirubin and haptoglobin concentrations
   
   • to support diagnosis of hemolytic anemia.
6. Gel electrophoresis, HPLC
   
   • to detect abnormal hemoglobins (HbS, etc.).
7. Coombs test
   
   • to detect autoimmune hemolytic anemias.

Question 169

1) Identify causes of excessive bleeding (3)
2) compare and contract bleeding due to what 3 things

Answer 169

1) Causes of excessive bleeding (3)

• Increased vessel fragility
• Platelet deficiency or dysfunction
• Derangement of coagulation

2) bleeding due to

• Vascular defect (localized or generalized)
• Platelet defect
• Coagulation defect

Question 170

Identify lab coagulation tests in primary (3) vs secondary hemostatis (4)

Answer 170

Primary hemostasis

• Platelet count
  
  • •Normal range: 150,000 – 400,000/uL
  • •False lows: platelet clumps/fibrin strands (traumatic draw)
• Bleeding time (BT) ; Not standardized
• Platelet function analysis (PFA)
  
  • •Simulates in vivo conditions – high shear stress
  • •Utilizes platelet agonists (collagen/ADP and collagen/EPI) to interrogate platelet function
  • •Interpretation (picture)

Secondary hemostatis

• PTT (partial thromboplastin time in seconds); test is heparin is adequate for agglutination
  
  • Kaolin + cephalin + Ca2+ + pt plasma → clot
  • Tests intrinsic (XII, XI, IX, VIII) and common pathway (X, V, II, Fibrinogen, XIII)
• PT (prothrombin time in seconds); test warfarin effectiveness
  
  • Tissue thromboplastin + Ca2+ + pt plasma → clot
  • Tests extrinsic (VII) and common pathway (X, V, II, Fibrinogen, XIII)
• Mixing study; Pt serum + pooled sera – check PTT (or PT)
  
  • •If PTT normal (corrects) then factor deficiency
  • •If PTT abnormal (no correction) then inhibitor present in patient’s serum
• Clotting factors
  
  • •Known specific factor-poor plasma + pt plasma
  • •Run either PT or PTT depending on which factor being evaluated

Question 171

One of the causes of excess bleeding is vessel fragility.

Abnormalities of the vessel wall

**Identify clinical picture (2), coag test result (normal or abnormal?) and etiologies/causes of fragile vessels (6)

Answer 171

Abnormalities of vessel wall

Clinical picture; petechae and purpura

Coag test resuts are normal

Causes

• Drugs
  
  • •Drug-induced immune complexes deposit in the vascular wall leading to leukocytoclastic vasculitis
• Impaired collagen support
  
  • •Scurvy – vitamin C deficiency – required for hydroxylation of procollagens
  • •Ehlers-Danlos syndrome – inherited collagen abnormality
  • •Elderly
  • •Cushing syndrome: Excessive steroid → protein wasting → loss of vascular support
• Henoch-Schönlein Purpura (covered in renal section)
  
  • •Systemic hypersensitivity disease in which circulating immune complexes deposit in the vessels
  • •Unknown etiology
  • •Colicky abdominal pain, polyarthralgias, acute glomerulonephritis
• Hereditary Hemorrhagic Telangiectasia
  
  • •AD
  • •Dilated tortuous vessels with thin walls
• Amyloid infiltration; weakens vessel wall.
  
  • Amyloid deposits in vessel wall (alzheimer disease)
• DIC

Question 172

One of causes of excessive bleeding is platelet deficiency or dysfunctiom

Thrombocytopenia

**Identify clinical findings, coag test results and etiologies

Answer 172

Clinical Findings:

• • Normal platelet count: 150,000 – 400,000
• • Typically not a problem unless counts <50,000
• • Post-traumatic bleeding – 20,000 – 50,000
• • Spontaneous bleeding of small vessels at <20,000
• • Skin, mucus membranes, GI, GU, intracranial

Coag Test Results:

• • Platelet count decreased; BT and PFA prolonged if Platelet <75K
• • Normal PT and PTT

Etiologies

• Decreased Production (bone marrow)
  
  • Neoplastic; •Non-hematopoietic neoplasms infiltrating marrow (prostate, breast, neuroblastoma, etc) •Hematopoietic neoplasms (AML, ALL, MDS, lymphoma, etc)
  • non-neoplastic; Infections, drugs, EtOH/toxins, B12/folate deficiency
• •Increased Peripheral destruction/decreased survival
  
  • Non-immune
  • All-immune condition (transfusion-related)
  • Auto immune conditions; ITP, HIT, HIV, TTP/HUS
  • Non-immune; •Sequestration – splenomegaly (hypersplenism) •Mechanical damage – prosthetic heart valves, malignant hypertension
• •Sequestration;
• •Dilutional Effect secondary to Massive Transfusions

Question 173

Identify type of auto-immune thrombocytopenia (and types)

• •Primary
  
  • •Idiopathic autoimmune platelet destruction
• •Secondary
  
  • •Identifiable etiology causing autoimmune platelet destruction

Answer 173

Immune Thrombocytopenic Purpura (ITP)

• Chronic ITP
  
  • •Adults, generally
  • •Insidious onset of symptoms
  • •Secondary etiologies include SLE, HIV, drugs, other viruses
  • •Peripheral blood shows thrombocytopenia with giant platelets reflected by increased MPV
• Acute ITP
  
  • ​•Kids
  • •Abrupt onset of thrombocytopenia
  • •Preceded by viral illness (2 wks)
  • •Self-limited, resolves in 6 mos.
  • •20% of kids will persist beyond 6 mo (chronic ITP similar to adults)

Question 174

Identify type of auto-immune thrombocytopenia

**mechanism, BM examination and treatment

**is spleen normal sized?

Answer 174

Chronic ITP

• •IgG autoAb against platelet antigens (Gp IIb-IIIa or Gp Ib-IX)
• •Ab bind to plts, plts are then opsonized and removed by reticuloendothelial system (spleen)
• •Spleen – normal size; congestion of sinusoids, macrophages prominent, splenic follicular hyperplasia, occasional megakaryocytes

•BM examination

• •done only if pt not responsive to therapy, to exclude other etiologies of thrombocytopenia
• •shows increased #’s of megakaryocytes with left shifted maturation

•Treatment

• •Immunosuppression with steroids
• •Splenectomy
• •IVIg, Rituximab (CD20 antibody)

Question 175

identify types of auto-immune thrombocytopenia

1)

• •Most common
• •Moderate thrombocytopenia, clinically insignificant
• •Occurs within a few days of heparin use
• •Due to direct platelet aggregation caused by heparin

2)

• •5-14 days after heparin is started (or sooner if pt has been previously sensitized with heparin)
• •Moderate to severe drop in platelets
• •Antibodies directed against the heparin-platelet factor 4 complex result in direct platelet activation

3) Identify third type - paradoxical thrombosis

Answer 175

Heparin Induced Thrombocytopenia (HIT); never give any form of Heparin to patient with HIT. For bed ridden patient without HIT, you can use lovenox - not heparin (levonix) will decrease the risk HIT)******** KNOW FOR EXAM

1) HIT Type I

2) HIT Type II
3) HIT Type III

• •Paradoxical thrombosis due to systemic platelet activation
• •Life threatening – must d/c heparin and use alternative anticoagulation
• •If pt has history of HIT, Lovenox/enoxaparin (low molecular weight heparin) is also contraindicated
• •BUT risk of developing HIT is less with LMW heparin

Question 176

Identify condition

• •Common problem
• •CD4 is present on surface of megakaryocytes
  
  • •Direct infection of megas by HIV → impaired megas → low production of platelets
• •HIV results in dysregulation and hyperplasia of B cells
  
  • •AutoAb production towards plt Gp IIb-IIIa

Answer 176

Auto-immune thrombocytopenia - HIV associated

Question 177

Identify condition

• •Hyaline thrombi (platelet aggregates) form
• •Platelet consumption → thrombocytopenia
• •Red cell trapping in microthrombi → microangiopathic hemolytic anemia (schistocytes)
• •Organ dysfunction

***Identify pathogenesis

• what deficiency?
• treatment?

Answer 177

TTP - Thrombotic Microangiopathies

•ADAMTS 13 deficiency

• •A metalloprotease that degrades HMW multimers of vWF
• •Deficiency results in accumulation of HMW multimers which can promote platelet microaggregation
• •Acquired – autoAb against ADAMTS 13
• •Inherited – inactivating mutation in gene
• Endothelial cell injury due to secondary cause can exacerbate
• Treatment of TTP is total plasma exchange to remove auto-Ab and replenish normal levels of ADAMTS 13

•Platelet transfusions are contraindicated – worsen the thrombi

Question 178

identify type of auto-imune thrombocytopenia

• •Presents with bloody diarrhea and subsequent renal failure
• •Often associated with E. coli strain 0157-H7
• •Kids
• •Normal levels of ADAMTS 13 enzyme.
• •Treatment is supportive care +/– plasma exchange
• •May suffer irreversible renal damage

Answer 178

HUS (Hemolytic Uremic Syndrome)

*** Pathogenesis is related to E coli strain not ADAMTS 13. ADAMTS 13 is normal.

Question 179

Thrombotic microangiopathies

TTP vs HUS

Answer 179

Thrombotic microangiopathies - TTP (thrombotic throbocytopenic purpura) vs HUS (hemolytic uremic syndrome)

TTP - ADAMTS 13 deficiency

HUS - Ecoli O157

Question 180

completion of WBC cancers

Identify group of disorders (according to range in severity)

• •clonal stem cell abnormality resulting in ineffective hematopoiesis with dysplasia
• •cytopenic older patient
• •chromosomal abnormalities seen in about 60% at diagnosis

Answer 180

MDS - Myelodysplastic syndromes

• •MDS single lineage dysplasia
• •MDS with ringed sideroblasts
• •MDS with multilineage dysplasia
• •MDS with excess blasts

Question 181

MDS morphlogy

what do you see in peripheral blood? BM? cytogenetics

Answer 181

MDS morphology

• •Peripheral Blood
  
  • –cytopenic with anemia, usually macrocytic
  • –dysplastic neutrophils, platelets
• •BM
  
  • –Hypercellular marrow, usually
  • –trilineage hyperplasia with dysplasia in at least one line
  • –increased storage iron
  • –blasts < 20% ( greater than 20% is acute leukemia)
• Cytogenetics; gains or loss of chromosomes
  
  • – Monosomy 5, 7******
  • – del5q del7q
  • – tri 8, del20q – no longer MDS defining; can be seen with aging, non-MDS causes of cytopenias (aplastic anemia, ITP)
  • – > 50% of cases are normal at the cytogenetic level

Question 182

MDS - clinical course and treatment

Answer 182

MDS - clinical course

• •Prognosis dependent on the Revised International Prognosis Scoring System (IPSS-R):
  
  • – % blasts
  • – Cytogenetics
  • – Hemoglobin
  • – ANC
  • – Platelets

MDS - Treatment

• Dependent on patient and severity of MDS
  
  • • supportive care with transfusions, antibiotics, etc
  • • Vidaza (pyrimadine analog)
  • -Allo-stem cell transplant

Question 183

Identify cancer type based on morphology

Morphology

• – Myeloblast
  
  • •Auer rods = abnormal azurophilic (primary) granules
  • •CD34 CD13 CD33
  • •Myeloperoxidase (MPO) positive
  • •Nonspecific esterase (NSE) negative
• – Monoblast
  
  • •CD11b CD14 CD33 CD64
  • •MPO negative
  • •NSE positive

**Diagnostic; >20% blasts in PB (peripheral blasts) or BM (bone marrow) •Some patients present pancytopenic because marrow is packed, but blasts are not yet spilling into PB

Answer 183

Acute Myeloid Leukemia (AML) - pathophysiology

****• >20% blasts in PB (peripheral blasts) or BM (bone marrow) •Some patients present pancytopenic because marrow is packed, but blasts are not yet spilling into PB

• • acquired genetic alteration causes impaired maturation
  
  • §RUNX1, RARA, NPM1
• • mutation in genes involved in signal transduction allow for survival/proliferation advantage
  
  • §FLT3, JAK2, KIT
• • neoplastic cells repress normal hematopoiesis by physical replacement as well as other unknown mechanisms

Question 184

identify condition and classification

• •Sx are similar to ALL – Bone marrow failure
  
  • •Fatigue, pallor, SOB – anemia
  • •Bruising and mucosal bleeding – thrombocytopenia
  • •Infections – neutropenia
  • •May have splenomegaly or soft tissue mass
• –Opportunistic infections
• – can have infiltration of soft tissues by blasts forming a mass, especially if blasts are monocytic
• – Granulocytic sarcoma = tissue mass of blasts in the absence of PB or BM involvement; if left untreated it will progress to AML

Answer 184

AML

• •WHO Classification 2016
  
  • –With recurrent genetic abnormalities (8)
  • –With gene mutations (3)
  • –With myelodysplasia related changes
  • –Therapy related Myeloid Neoplasms
  • –Not otherwise specified (NOS); •Based on morphology/cell lineage

Question 185

Identify cancer types

• •Specific translocation or mutation that defines the leukemia
• •Some qualify as leukemia regardless of blast percentage
• •Prognostic and/or therapeutic implications
  
  • •t(8;21) RUNX1 – RUNX1T1
  • •in(16) or t(16;16) CBFB – MYH11
  • •APL with PML – RARA, most commonly t(15;17)
  • •t(9;11) KMT2A/MLL – MLLT3
  • •t(6;9) DEK – NUP214
  • •in(3) or t(3;3) GATA2, MECOM
  • •t(1;22) RBM15 – MKL1
  • •AML with BCR – ABL1

Answer 185

AML - with recurrent cytogenetic abnormalities

Question 186

Identify cancer type

• •PML gene (15) fuses to RARA gene (17)
• •PML/RARA fusion protein blocks myeloid differentiation at the level of the promyelocyte
• •Association with DIC due to the release of procoagulants and fibrinolytics by the malignant cells
• •In adults who achieve complete remission, prognosis is better than any other AML
• •Treatment is different than other AML’s
  
  • •Blasts very sensitive to anthracycline based chemotherapy and differentiate in response to ATRA and arsenic trioxide

Answer 186

AML - with recurrent cytogenetic abnormalities

Acute Promyelocytic Leukemia

Question 187

Identify 3 gene mutations related to AML

Answer 187

AML with gene mutations

• •With NPM1 mutation
  
  • •50% of adult AML’s with normal karyotype
  • •Often female patient; often monocytic morphology
  • •Favorable prognosis; Unless there is also a mutation in FLT3 – ITD; seen in 40% of cases
• •With biallelic mutations of CEBPA
• •With mutated RUNX1

Question 188

Identify classficiations of AML

1) Defined as AML with:

• •History of MDS or MDS related cytogenetics
• •AND NO prior cytotoxic therapy or AML defining cytogenetics
• •Prognosis is poor

2) Defined as:

• •AML or MDS neoplasms that occur in a patient with a history of chemotherapy or radiation therapy
• •Considered a single disease entity regardless of whether it morphologically looks like an AML or a MDS
• •Prognosis is poor

3) Defined as;

• •Cases that do not fulfill criteria for other AML’s
• •Classified based on their morphology – M0 – M7
• •Account for 40% of AML’s
• •Have an intermediate prognosis

Answer 188

1) AML with myelodysplasia related change

2) Therapy Related Myeloid Neoplasms

3) AML, NOS

Question 189

Spleen

Identify conditions of the spleen

Answer 189

1. Splenomegaly
   
   1. Nonspecific acute splenitis
   2. HLH (Hemophagocytic Lymphohistiocytosis)
   3. Congestive splenomegaly
2. Splenic infarcts
3. Neoplasms; rare except of the hematopoietic system. Can see hemangiomas or fibromas
   
   • HCL
   • HL
   • NHL
   • MPN
4. Congenital anomalies
   
   • complete absence
   • hypoplaia
   • accessory spleen
5. Splenic rupture

Question 190

Identify condition (where do you see it)

• •LUQ dragging sensation
• •Discomfort after eating
• •“Hypersplenism”
  
  • •splenomegaly
  • •pancytopenia or cytopenia with associated marrow hyperplasia of affected line
  • •correction of cytopenia by splenectomy

Answer 190

Splenomegaly

Seen in; nonspecific acute splenitis, HLH, congestuve splenomegaly

Question 191

identify condition in splenomegaly

• –Can occur with any blood-borne infection
• –Splenomegaly (200-400gm)
  
  • •Softness
  • •Congestion of red pulp
  • •+/- necrosis

Answer 191

Nonspecific Acute Splenitis

Question 192

Identify condition in splenomegaly

• •Systemic activation of macrophages and CD8 cytotoxic T cells
• •Familial (auto-recessive) or
• •Secondary
  
  • •Infections (EBV)
  • •Malignancy
  • •Rheumatologic/inflammatory disorders

***What does diagnosis require?

Answer 192

Splenomegaly – Hemophagocytic Lymphohistiocytosis aka HLH; For HLH diagnosis, you need to have 5 of the 8 signs in bold

• •Activated macrophages
  
  • •HEMOPHAGOCYTOSIS - phagocytize blood cells in the periphery (spleen, liver, nodes,etc) and in the bone marrow
    
    • •CYTOPENIAS
    • •HEPATOSPLENOMEGALY and lymphadenopathy
• •Cytokine release
  
  • •Cytokine storm—-Severe inflammation
  • •FEVER
  • •HIGH FERRITIN
  • •HIGH SOLUBLE INTERLEUKON-2 RECEPTOR (IL2 aka CD25)
  • •DECREASED NK CELL FUNCTION
• •HYPERTRIGLYCERIDEMIA or HYPOFIBRINOGENEMIA

Question 194

Treatment of HLH - splenmegaly

Answer 194

• •High index of suspicion with prompt treatment required
  
  • •Immunosuppressives and gentle chemotherapy
  • •Stem cell transplant if familial, persistent or recurrent
  • •Approximately 50% survival
• •Without treatment – grim prognosis with <2 month survival

Question 195

Identify condition

• •Intrahepatic etiology
  
  • – Right heart failure; •chronic passive congestion of liver and eventually spleen
  • – Hepatic cirrhosis; •chronic alcoholic or viral hepatitis
• •Extrahepatic etiology

Answer 195

Congestive splenomegaly

Pathologc findings

• •You will see different things grossly and microscopically, depending on duration of the congestion
• • Firmness (due to progressive fibrosis of the sinusoids) will increase over time
  
  • • means less efficient passage of the blood with more time for macrophages to destroy cells
  • •increased pressure = intraparenchymal hemorrhage

Question 196

Identify condition in spleen

• •due to sterile or infectious emboli
• •infarcts are pale, wedge shaped and subcapsular in location
• •if associated with an infective endocarditis, there can be subsequent abscess formation
• •common in enlarged spleens because blood supply cannot keep up with the demands of the organ

Answer 196

Splenic infarcts

Question 197

Identify congenital anomalies of the spleen (3)

Answer 197

• •Complete absence – rare
• •Hypoplasia
• •Accessory spleen
  
  • – Gastrosplenic ligament, tail of pancreas, omentum, large/small bowel mesenteries
  • – Of no clinical significance; •unless patient is having a therapeutic splenectomy for condition such as idiopathic thrombocytopenia pupura or hereditary spherocytosis – then the overlooked accessory will begin to function as the dominant spleen

Question 198

Identify condition of the spleen

• •usually precipitated by trauma
• •infectious mononucleosis
• •lymphoid neoplasm
• •massive, rapid, intraperitoneal hemorrhage

Answer 198

Splenic Rupture

Question 199

Conditiosn of the thymus

Answer 199

1. Thymic hyperplasia
   
   • •refers to the appearance of secondary follicles (B cells)
   • •associated with Myasthenia gravis
   • •also associated with Graves disease, SLE, RA, and other autoimmune disorders
2. Thymomas

• •tumors of thymic epithelial cells with a background of immature T cells
• •anterior superior mediastinum of adults; ‒also a good location for NSHL
• •firm gray-white mass up to 20 cm in size
  
  • ‒ may have areas of cystic necrosis and calcification
  • ‒ mixture of epithelial cells and non-neoplastic lymphocytes

Question 200

Identify types of tymomas

Answer 200

• •Benign, encapsulated
  
  • –50%
  • –Medullary or mixed medullary and cortical epithelial cells
• Malignant – 2 types
  
  • •Cytologically benign, but invasive – 20-25%
    
    • –Epithelial cells are usually of the cortical type
  • •Cytologically malignant - <5%
    
    • –Squamous cell carcinoma
    • –Lymphoepithelioma-like carcinoma – EBV associated in 50%

Question 201

Identify condition ( 3 types)

• Neoplastic process
  
  • •BRAF mutation (60%)
• Tumor cells are derived from dendritic cells
  
  • •Express HLA-DR, S-100, CD1a
  • •Contain Birbeck granules
    
    • –“tennis rackets”
    • –seen by electron microscopy

Answer 201

LCH - LANGERHANS CELL HISTIOCYTOSIS

3 types

• Multifocal multisystem - letter siwe disease
  
  • •Usually < 2 yrs of age
  • •Seborrheic appearing cutaneous lesions of trunk and scalp
  • •Hepatosplenomegaly, lymphadenopathy, pulmonary lesions
  • •Extensive marrow infiltration = cytopenias
  • •Untreated = fatal
  • •Intensive chemotherapy = 50% ofpatients will survive 5 years
• Unifocal and Multifocal Unisystem = Eosinophilic Granuloma
  
  • •Langerhans cells plus chronic inflammatory cells, most notably, eosinophils
  • •Usually affects bones
  • •Unifocal – indolent with spontaneous healing or treatment by local excision or radiation
  • •Multifocal – young children with multiple erosive bony masses
  • •Hand – Schuller – Christian triad = calvarial bone defects, diabetes insipidus, and exophthalmos (due to erosion into the posterior pituitary)
• Pulmonary LCH
  
  • Adult smokers
  • Lesions may regress with smoking cessation

Question 202

Independent learning (transfusion medicine)

1.Know and understand ABO blood groups and Rh blood groups

Answer 202

ABO Blood groups (4); the difference between O,A and B is one sugar - carbohydrate chain). Most common are type O and A. least common is type AB. •If patient has antigen, there will be no antibody •If patient lacks antigen, there will be an antibody against the antigen

• Type A
  
  • RBC antigens; A
  • Plasma antibodies; Anti-B
• Type B
  
  • RBC antigen; B
  • Plasma antibodies; Anti-A
• Type AB
  
  • RBC antigen; A and B
  • Plasma antibodies; NONE
• Type O
  
  • RBC antigen; None
  • Plasma antibodies; Anti A and Anti B

Rh blood groups

• Rh positive (D positive) ; 85%
• Rh negative (D negative)
• •Can give Rh-negative blood to Rh positive patient
• •Can safely give Rh+ blood to Rh neg patients if compatible (patient has no Anti-D)
  
  • •Only do in selected situations
  • •Rh neg recipients of Rh+ blood may make anti-Rh (Anti-D)
• •O neg female: Pregnancy exposure to D+ fetus:
  
  • •Mother may make Anti-D
• •Anti-D can cause
  
  • –Hemolytic Disease of the Newborn
  • –Acute hemolytic transfusion reactions

Question 203

Be able to select compatible plasma and RBC in;

• Type O
• Type A
• Type B
• Type AB

**Who is universal donor vs recipient

Answer 203

• •UNIVERSAL DONOR: Group O
  
  • •If recipient has Anti-A or anti-B, the O RBC lacks these antigens
  • •Can give group O RBCs to any recipient
• •UNIVERSAL RECIPIENT: Group AB
  
  • •Can receive RBCs from any ABO group
  • •Lacks any Anti-A or Anti-B
• •AB plasma can be used on any blood group because lacks anti-A and anti-B

Question 204

Understand the direct and indirect antiglobulin test

Answer 204

•DIRECT ANTIGLOBULIN TEST (DAT)

• •Test patient RBC for attached IgG or compliment
• •Not done as part of TS or TC

•Positive

• 1.Autoantibodies against patient RBC
• •Autoimmune anemia is DAT positive
• 2.Transfused incompatible RBC; patient has antibody against donor RBC
• •Hemolytic transfusion reaction
• •Patient antibody on transfused RBC
• 3.Passive transfusion of antibodies attach to RBC, eg IVIG; FFP
• •Negative
• –Rules out majority of autoimmune anemias and acute hemolytic transfusion reactions

•INDIRECT ANTIGLOBULIN TEST (IAT OR ANTIBODY SCREEN)

• •Test patient serum for antibodies
• •Test is done for TS and TC

•Positive:

• 1.Alloantibody against foreign RBC antigens
• •Main indication for test; done in all type and screens
• •Acquired eg Anti-D in an Rh-negative patient
• •Passive eg IVIG
• 2.Autoantibody can sometimes be detected
• •eg autoimmune anemia

•Negative:

• •No alloantibodies

Question 205

Understand the type and screen versus type and crossmatch

Answer 205

•TYPE AND SCREEN (TS):

• –Check for historical prior blood type
• –Patient blood type completed
• –Patient antibody screen completed (See IAT below)
  
  • •If negative: no further action taken; No dedicated units set aside for patient
  • •If positive, blood is cross matched
• •NO units of blood set aside and dedicated for patient
• •Can convert to crossmatch rapidly

•TYPE AND CROSS (CROSSMATCH or TC):

• –Type and screen (see above)
• –Test donor cells against patient plasma
• –Compatible dedicated units set aside for patient

•Both good for 72 hours, must be repeated after that

Question 206

1.Know the indications for:

• 1.PRBC
• 2.Frozen RBC
• 3.Washed RBC
• 4.Platelets
• 5.Frozen plasma: FFP or FP24
• 6.Cryoprecipitate
• 7.Four factor prothrombin complex (4-PCC)
• 8.Factor VIII
• 9.Albumen
• 10.Rh immunoglobulin

Answer 206

• 1.PRBC
• 2.Frozen RBC
• 3.Washed RBC
• 4.Platelets
• 5.Frozen plasma: FFP or FP24
• 6.Cryoprecipitate
• 7.Four factor prothrombin complex (4-PCC)
• 8.Factor VIII
• 9.Albumen
• 10.Rh immunoglobulin

Question 207

Know causes of platelet refractories

Answer 207

• Patient does not increase platelets after transfusion (expect ↑ 30K for 6 random)
• Causes:
• •Splenomegaly (sequestration)
• •Accelerated consumption eg DIC, sepsis, bleeding
• •Alloimmunization: eg Anti-HLA antibodies destroy platelets

Question 208

Know advantages of leukocyte reduced platelets and PRBC

Answer 208

• Processing greatly reduces WBC content
• Many blood banks use only leukocyte-reduced PRBC and platelets
• •Decreased incidence of alloimmunization against WBC antigens (eg HLA)
• •Decreased risk of CMV transmission
• •Decreased risk of febrile nonhemolytic transfusion reaction (see below)

Question 209

Know basic tenants of blood administration

Answer 209

• •ALWAYS FOLLOW THE PROCEDURE TO THE LETTER; most common cause of fatal acute hemolytic reaction is failure to follow procedure!!!!
• •PATIENT IDENTIFICATION WHEN DRAW BLOOD
• •PATIENT IDENTIFICATION WHEN ADMINISTER BLOOD
• •INFORMED CONSENT
• •Only use Normal Saline to mix with blood
• •Only used approved blood warmers
• •Use blood filter
• •Observe patient carefully when first beginning and periodically during transfusion for transfusion reactions

Question 210

Know how to recognize, prevent and treat transfusion reactions

•Transfusion reactions can be divided into categories

• •Hemolytic vs nonhemolytic
• •Acute vs Delayed
• •Febrile vs nonfebrile

Answer 210

•HEMOLYTIC

• –Acute hemolytic transfusion reaction (AHTR)
• –Delayed hemolytic transfusion reaction

•NON-HEMOLYTIC

• –Transfusion related acute lung injury (TRALI)
• –Transfusion associated circulatory overload (TACO)
• –Febrile non-hemolytic transfusion reaction
• –Graft vs Host Disease
• –Urticaria
• –Anaphylaxis
• –Hypotension
• –Iron overload
• –Infection

•FEBRILE

• –Acute:
  
  • •Acute hemolytic transfusion reaction
  • •Febrile non-hemolytic transfusion reaction
  • •Infection: sepsis from bacterial contaminated unit
  • •Transfusion-related acute lung injury (TRALI)
• –Delayed
  
  • •Delayed hemolytic transfusion reaction
  • •Graft vs Host Disease (GVHD)
  • •Infection

•NON-FEBRILE

• –Acute:
  
  • •Anaphylaxis
  • •Urticaria
  • •TACO
  • •Hypotension
• –Delayed:
  
  • •Iron overload
  • •Infection

Question 211

List possible infectious complications of a transfusion

• •Viruses
• •Bacteria
• •Parasites
• •Prion disease

Answer 211

• •Viruses
  
  • •HIV*
  • •HTLV*
  • •HBV*
  • •HCV*
  • •West Nile Virus*
  • •Herpesvirus [eg Cytomegalovirus (CMV)*, Human Herpes Virus (HHV), Ebstein-Barr Virus (EBV)]
  • •Parvo B19
  • * Currently tested for by blood donor centers
• •Bacteria
  
  • •Acute infections*: See above
  • •Others:
  • •Syphilis**
  • * Units are checked for evidence of bacterial conatimination
  • ** Currently tested for by blood donor centers
• •Parasites
  
  • •Any blood born parasite
  • •Chagas’ Disease: Trypanosoma cruzi**
  • •Malaria
  • •Babesiosis
  • •Leshmaniasis
  • •Toxoplasmosis
  • •Microfilaria
  • ** Depending on donor center location, some donor centers test for this
• •Prion disease
  
  • •Variant CJD (“Mad cow disease”)

Question 212

Be familiar with selected aspects of blood donation

• allogenic blood
• autologous blood
• therapeutic donor
• 2 safety processes
• donor reactions

Answer 212

• •Allogeneic blood:
  
  • •Volunteer donor: Almost all blood is volunteer
  • •Paid donor
  • •Directed donor: Unit donated for specific person
• •Autologous blood: Donated for self
• •Therapeutic donor: A treatment (“blood letting”); not used for transfusion
  
  • •Hemochromatosis (to reduce iron stores)
  • •Polycythemia (HCT to high; reduces viscosity)
• •Two safety processes
  
  • –Protect the recipient: eg infectious disease questions and testing, temperature
  • –Protect the donor: eg Hgb, history
• •Donor reactions:
  
  • –Vasovagal reaction (“pass out”)
  • –Hematoma/thrombosis/infection
  • –Arterial puncture
  • –Nerve injury

Question 213

1. Describe the pathogenesis of edema and give examples associated with the four main causes of non-inflammatory edema.

Answer 213

• •Increased fluid in interstitial tissue spaces, body cavities, sometimes cells
• •Inflammatory edema: ↑ vascular permeability, results in protein-rich exudate (sp.gr. >1.020)
• •Non-inflammatory edema: protein-poor transudate (sp.gr. < 1.012)

causes of noninflammatory edema

• 1. Increased hydrostatic pressure
• 2. Reduced plasma osmotic/oncotic
• pressure (hypoproteinemia)
• 3. Lymphatic obstruction
• 4. Sodium and water retention

Question 214

2. Compare edema of the subcutaneous tissue, the lungs, and the brain on the basis of pathogenesis, morphologic changes, and clinical effects.

Answer 214

•Subcutaneous edema may be diffuse or dependent

• •Diffuse – affects all parts of body
• Example: Periorbital edema seen in renal failure
• •Dependent edema – legs of mobile pts, sacrum of bed-ridden pt
• •Pitting edema: Finger pressure leaves depression

•Pulmonary edema

• •Seen in left-sided heart failure, renal failure etc.
• •Lungs 2-3x normal wt and sectioning shows frothy, blood-tinged fluid

•Cerebral edema

• •May be local or general
• •Some causes:
• Infection
• Neoplasm
• Hypertensive crisis
• Venous obstruction

Question 215

3. Compare and contrast active hyperemia and passive congestion, in terms of mechanisms of development and clinically important examples.

Answer 215

Question 216

4. Recognize the patterns of subcutaneous hemorrhage.

Answer 216

•Seen in a variety of patterns

• •Petechiae: pinpoint hemorrhage, 1 – 2 mm
• •Purpura: hemorrhage measuring > 3mm
• •Ecchymoses: subcutaneous hematomas (bruises) larger than 1 – 2 cm
• •Progress of healing of ecchymosis:
  
  • •RBCs are phagocytosed by macrophages
  • •Hemoglobin (red-blue) is converted to bilirubin (blue-green) then to hemosiderin (gold-brown)

Question 217

5. Compare rapid and slow hemorrhage in terms of common causes and clinical manifestations.

Answer 217

• •The extravasation of blood due to vessel rupture most often from trauma, atherosclerosis, or erosion from inflammation or neoplasm
• •May be external or internal
• •Within a tissue then known as hematoma
• •Large accumulations of blood in body cavities are called hemothorax, hemopericardium, hemoperitoneum, hemarthrosis
• •Adults may tolerate rapid loss of up to 20% of blood volume
• •>20% loss may result in hemorrhagic (hypovolemic) shock

Question 218

Completion of bleeding disorders

Identify abnormalities (3 causes)

I. Clinical Findings: prolonged bleeding after cuts/trauma
II. Coag Test Results:
A. PT, PTT, Plt count normal
B. PFA (platelet function assay) – abnormal
C. Platelet Aggregation Studies; examines the functionality of platelets when stimulated with various agonists: collagen, ADP, Epi, Thrombin, Ristocetin

Answer 218

Platelet function abnormalities (acquired vs congenital)

A. Acquired

• 1. drugs – ASA, NSAIDS, many others
• 2. uremia – unknown pathogenesis

B. Congenital

• 1. Platelet adhesion defect
• a. Bernard-Soulier - AR
  
  • • Deficient platelet Gp Ib-IX complex where vWF needs to bind
  • • vWF links platelets and endothelium
  • • Giant platelets
  • • Platelet Aggregation Test: everything works but ristocetin (doesn’t work)
• 2. Platelet aggregation defect
• a. Glanzmann’s thrombasthenia – AR
  
  • • Deficient Gp IIb-IIIa which is the place where fibrinogen crosslinks between platelets
  • • Platelet Aggregation Test: nothing works but ristocetin (works)

Question 219

congenital platelet function abnormalities

congenital

**differentiate Bernard-Soulier (AR) vs Glanzmann’s thrombasthenia (AR)

Answer 219

1. Platelet adhesion defect

a. Bernard-Soulier - AR

• Deficient platelet Gp Ib-IX complex where vWF needs to bind
• vWF links platelets and endothelium
• Giant platelets
• Platelet Aggregation Test: everything works but ristocetin (doesn’t work)
  2. Platelet aggregation defect

a. Glanzmann’s thrombasthenia – AR

• Deficient Gp IIb-IIIa which is the place where fibrinogen crosslinks between platelets
• Platelet Aggregation Test: nothing works but ristocetin (works)

Question 220

Identify abnormalities (4 conditions)

Clinical Findings:
- prolonged bleeding after laceration, trauma, or surgery
- bleeding into GI/GU tract
- bleeding into weight bearing joints
Coag Test Results: depends on which factor is deficient

Answer 220

Clotting factor abnormalities

• Von Willebrand disease
• Factor VIII deficiency (Hemophilia A)
• Factor IX deficiency (Hemophilia B, Christmas disease)
• Acquired deficiencies; Vit K deficiency, Liver disease, DIC

Question 221

Identify clotting factor abnormality

A. prolonged bleeding from cuts, menorrhagia, mucous membrane
bleeding
B. abnormal PFA and PTT; normal platelet count
C. AD usually; 1% of the population
D. different subtypes with severity of symptoms dependent on which subtype

**identify 3 subtypes

Answer 221

Von Willebrand disease

1. Type 1 - AD (70%)

• a. quantitative decrease in vWF - <50% activity
• b. mutation type is not well defined and varies
• c. reduced penetrance and variable expression thus symptoms vary among type 1 patients
• d. patients generally do not require treatment, but DDAVP can be given during procedures/surgery, if needed

2. Type 2 – AD (25%)

• a. qualitative vWF abnormality
• b. several subtypes – 2A is the most common
• c. abnormal vWF results in defective multimer assembly with absence of intermediate and large multimers

3. Type 3 – AR (rare)

• a. quantitative decrease in vWF - < 5-10% activity
• b. gene deletions and frameshift mutations
• c. symptoms are severe and because vWF carries VIII, the symptoms often reflect VIII deficiency as well
• d. patients require replacement therapy (Humate P)

Question 222

Identify clotting factor abnormality

B. X-linked recessive

• 1. males and homozygous females
• 2. heterozygous females can be symptomatic due to unfavorable lyonization

C. 30% of families have no family history – new mutations

Answer 222

Factor VIII deficiency (Hemophilia A)

A. VIII is the cofactor for IX

D. Clinical symptoms correlated with VIII level

• <1% activity = severe
• 2. 2-5% activity = moderate
• 3. 6-50% activity = mild

E. different mutation types explain the variability of VIII levels

• 1. rarely, mutations result in abnormal function of normal levels

F. Symptoms;

• 1. easy bruising, massive hemorrhage after surgery/trauma
• 2. spontaneous hemorrhage into large joints = hemarthroses
• 3. no mucous membrane bleeding or petechiae

Question 223

In factor VIII deficiency (hemophilia A), identify diagnosis and treatment

**Why do symptoms occur if only one arm of cascade is knocked out?

Answer 223

G. Diagnosis:

• 1. Prolonged PTT
• 2. Normal PFA, platelet count, PT
• 3. Factor VIII assay (functional)

H. Treatment = Humate P (purified plasma derived) or recombinant (Kogenate)

• 1. purified and recombinant VIII virtually eliminates infectious risk
• 2. inhibitor development is still a risk of replacement therapy

Why do symptoms occur if only one arm of cascade is knocked out?

• 1. tests may not reflect true in-vivo reality
• 2. fibrin formation/deposition is inadequate to maintain clot
     * a. extrinsic role is the burst to get the cascade moving; intrinsic pathway maintains it

3. inappropriate fibrinolysis
   * a. high levels of thrombin needed to activate TAFI (inhibits fibrinolysis); this does not occur with only one pathway working

Question 224

Identify clotting abnormality

X-linked recessive with variable clinical severity
C. 14% of pt have normal levels of IX, but abnormal function
D. Diagnosis:
1. prolonged PTT
2. Normal PT, PFA, Plt count
3. Factor IX assay (functional)

Answer 224

Factor IX Deficiency (Hemophilia B, Christmas Disease)
A. clinically identical to VIII deficiency (remember, VIII and IX work together to activate X)

***Treatment: recombinant factor IX

Question 225

Clotting abnormality

**Identify 3 acquired deficiencies

Answer 225

A. Vitamin K deficiency (II, VII, IX, X, Protein C)

• • this is how Coumadin works

B. Liver Disease

• • majority of coagulation cascade proteins are made in liver

C. DIC

Question 226

identify clotting condition (identify 4 etiologies?)

I. Not a Primary Disease – a physiologic consequence of diseases

• A. Thrombohemorrhagic disorder (bleeding and clotting)
• B. Pathologic activation of the coagulation cascade systemically in the microvasculature
• C. Signs/symptoms related to tissue hypoxia and infarction and/or hemorrhage due to consumption of coagulation factors

II. Coag Tests:

• A. prolonged PT, PTT
• B. decreased plt
• C. decreasing fibrinogen
• D. increased d-dimer, fibrin-split products

Answer 226

DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC)

Etiologies
A. Obstetric complications

• 1. Placental abruption
• 2. retained products
• 3. septic abortion

B. Infections

• 1. gram negative sepsis
• 2. meningococcemia

C. Neoplasms

• 1. APL (AML-M3)
• 2. Adenocarcinoma

D. Massive Tissue Injury

Question 227

Identify mechanisms and consequences of DIC

both bleeding and clotting

Answer 227

Mechanisms
A. Tissue Factor release into the blood

• 1. obstetric complications
• 2. substance released by blasts of APL
• 3. mucin of adenocarcinoma released into blood directly activating X
• 4. gram negative sepsis with bacterial endotoxins result in release of IL1 and TNF which increase the TF on endothelial cells, and

B. Wide spread endothelial cell injury

• 1. infectious etiologies via TNF production
     * a. increases leukocyte adhesion and free radical formation which damages endothelium
• 2. antigen/antibody complex deposition (SLE)
• 3. heat stoke, burns

Consequences

A. Widespread fibrin deposition in microvasculature
1. ischemia of associated organs

• a. ischemic bowel
• b. renal failure
• c. hepatic necrosis
• d. skin/digit necrosis

2. hemolytic anemia
   * a. microangiopathic; schistocytes on smear

• *B. Hemorrhagic diathesis**
  1. factor and platelet consumption faster than production
  2. plasminogen activation - fibrinolysis results in increased d-dimer/FDP’s which inhibit platelet aggregation and have antithrombin activity

Question 228

Identify clotting condition based on morphology

A. thrombi in brain, heart, lungs, kidney, adrenals, spleen, and liver
B. CNS micro-infarcts/hemorrhage with associated symptoms
C. Waterhouse-Friderichsen Syndrome

• 1. massive bilateral adrenal hemorrhage associated with meningococcus

D. Sheehan Syndrome – postpartum pituitary necrosis
E. Toxemia of pregnancy – microthrombi in placenta

****Clinical course and prognosis (acute vs chronic vs presentation vs coagulation findings vs peripheral smear

Answer 228

DIC

• A. Acute, fulminent – typically presents with bleeding
  
  • 1. endotoxic shock, trauma
  • 2. obstetric complications
  • 3. APL
• B. Chronic, insidious – typically presents with thrombosis
  
  • 1. carcinomatosis
• C. Presentation
  
  • 1. microangiopathic hemolytic anemia
  • 2. dyspnea, cyanosis, respiratory failure
  • 3. convulsions, coma
  • 4. oliguria, acute renal failure
  • 5. circulatory shock
• D. Coag findings
  
  • 1. decreased platelets
  • 2. prolonged PT and PTT
  • 3. decreasing fibrinogen
• E. Peripheral smear:
  
  • 1. schistocytes with compensatory increase in retics/nRBCs if marrow stores available
  • 2. leukocytosis and neutrophilia, sometimes with left shift; toxic changes
  • 3. decreased numbers of plts; giant platelets
• E. Treatment
  
  • 1. treat underlying problem/illness
  • 2. supportive care

Question 229

NORTON REVIEW

**Normal PT and PTT indicate what is not a problem?

1. condition with Ecoli 0517

**fever and neurologic symptoms indicate what

**Will factor VIII deficiency have prolonged PTT?

2. what condition does ristocetin work but everything else doesn’t work
3. Schistocytes, thrombocytopenia, adult, fever, high BUN, PT/PTT is normal. what deficiency?
4. pregnant woman with petechiae and intravascular clotting

Answer 229

Normal PT and PTT – shows it is not a coagulation factor problem

1. HUS (hemolytic uremic syndrome) – Ecoli 0517.

Fever and neurologic symptoms – TTP (both kids and adults)

Factor VIII deficiency – prolonged PTT

Bernard-Soulier; ristocetin doesn’t work due to deficient glycoprotein Ib-IX complex where vWF needs to bind

1. thrombasthenia; ristocetin works but everything else doesn’t
2. Schistocytes, thrombocytopenia, adult, fever, high BUN, PT/PTT is normal; ADAMTS 13 deficiency (TTP)
3. Pregnanct woman – petechiae, intravascular clotting (fibrin degradation products), increased PT and PTT; DIC (disseminated intravascular coagulopathy)

Question 230

CASE 1

30 y.o woman with diabetes insipidus and pituitary tumor develop gum, vaginal and skin infiltrates. Dx – langerhan cell histiocytosis. Platelet getting progressively low, pulmonary emboli, massive swelling and pain and subclavian thrombi. Gave heparin and platlet dropped down to 19,000

• Diagnosis?
• Treatment (immediate and discharge med)

Answer 230

• Diagnosis; Type II HIT (heparin induced thrombocytopenia)
• Treatment; Anticoagulant – direct thrombin inhibitor (Argatroban) started and then patient was discharged on Coumadin (prevent factors II, VII, IX, X). THESE WILL PREVENT BLOOD CLOTTING

Question 231

CASE 2; 65 y.o man presents to ER with 4 hour history of severe chest pain radiate to left arm. Given treatment and then aspirin once daily.

• what lyse clot?
• what cause arterial thrombosis?
• Number 1 cause of venous thrombosis
• What cause SOB in this patient (why?)
• How does this type of edema that the patient has differ from acute type of edema
• most common source of clinically significant pulmonary emboli?
• Most common symptom associated with venous thrombi
• most common symptom of PE

Answer 231

• What lyse the clot? tPA (ALTEPLASE) – cause fibrinolysis
• What cause arterial thrombosis; artthleroscolrosis
• Number 1 cause of Venous thrombosis? STASIS
• What causes SOB in patient; pulmonary edema – from heart attack in left ventricle (left ventricle failure) – increased hydrostatic pressure.
• How does this edema differ from acute type edema; TRANSUDATE SEEN
• Most common source of clinically significant pulmonary emboli? CLOT FROM THE LEG (DVT)
• Most common symptom associated with venous thrombi? ASYMPTOMATIC (until they have pulmonary embolism)
• Most common symptom of PE; ASYMPTOMATIC. Others are; SOB, chest pain

Question 232

Case 3 and case 4

2 y.o oozing blood from mouth. Alert no distress. IF PATIENT HAS Joint swelling – hemarthrosis (factor deficiency)

• Increased PTT differential (3)
• results of vWF structural gel analysis; codnitions when vWF is absent? reduced quantity? reduced quality?

CASE 4

• Hemarthrosis is what type of hemostasis
• Factor VIII deficiency at risk for what?

Answer 232

Case 3

• Increased PTT differential; von willebrand disease, Factor VIII and IX (hemophilia A and B)
• Tests; vWF structural gel analysis; vWF absent (Type III), vWF reduced (Type I), qualitative defect (Type II)

Case 4; Factor VIII deficiency

• Hemarthrosis (joint swelling); secondary hemostasis
• Factor VIII deficiency at risk for INTRAMUSCULAR HEMORRHAGE