HEMATOLOGY 1 Flashcards
Homogenous, continuous, aqueous solution in the cytoplasmic matrix
Cytosol
Macromolecular complexes composed of small and large subunit of rRNA and many accessory ribosomal proteins.
Ribosomes
are found free in the cytoplasm or on the surface of rough endoplasmic reticulum
Ribosomes
serves as the site of protein synthesis
Ribosomes
Synthesizes phopholipids and steroids
Smooth endoplasmic reticulum
Detoxifies drugs
Smooth endoplasmic reticulum
Stores calcium
Smooth endoplasmic reticulum
Synthesizes most membrane-bound proteins
Rough endoplasmic reticulum
• Term used for the non-mitosis stages of the cell cycle, that is, G1, S, and G2. Mitosis – M phase
Interphase
• Two identical daughter cells are produced, each of which receives one entire set of the DNA that was replicated during the S phase
Interphase
Interphase
• Duration: _____
• Also known as: Gap 1 phase
- Interphase – G1 phase
• Cell grows rapidly and performs its cellular functions
- Interphase – G1 phase
• Period of cell growth and synthesis of components necessary for replication.
- Interphase – G1 phase
- Interphase – G1 phase
• Duration: ____
• Also known as: Synthesis phase
- Interphase – S phase
• DNA is replicated
- Interphase – S phase
• An exact copy of each chromosome is produced and they pair together as sister chromatids.
- Interphase – S phase
• The centrosome is also duplicated during the S stage.
- Interphase – S phase
- Interphase – S phase
• Duration: ____
• Also known as: Gap 2 phase
- Interphase – G2 phase
• Period when the cell produces materials essential for cell division
- Interphase – G2 phase
• Tetraploid DNA is checked for proper replication and damage
- Interphase – G2 phase
- Interphase – G2 phase
• Duration: ____
G0 phase • Also known as: ____________
• Cells are not active in cell cycle
G0 phase
• Some cells may enter this phase after G1 phase
G0 phase
• Normally do not re-enter the cell cycle and remain alive performing their function until apoptosis occurs
G0 phase
• Occur at the end of G1 phase
• Before DNA replication in S phase
• At the end of G2 phase before M phase
The chromosomes condense, the duplicated centrosomes begin to separate, and mitotic spindle fibers appear.
The nuclear envelope disassembles, the centrosomes move to opposite poles of the cell and serve as a point of origin of the mitotic spindle fibers.
The sister chromatids (chromosome pairs) attach to the mitotic spindle fibers.
The sister chromatids align on the mitotic spindle fibers at a location equidistant from the centrosome poles.
The sister chromatids separate and move on the mitotic spindles toward the centrosomes on opposite poles
The nuclear membrane reassembles around each set of chromosomes and the mitotic spindle fibers disappear.
The cell divides into two identical daughter cells
• Present in small numbers in the bone marrow (<1% cells in the bone marrow)
Stem Cells
Types of Human Stem Cells
- Totipotent hematopoietic stem cell (THSC)
- Pluripotential or Multipotential stem cell
- Unipotential Stem cell
• These cells are present in the first few hours after an ovum is fertilized.
- Totipotent hematopoietic stem cell (THSC)
• Can develop into any human cell type, including development from embryo into fetus.
- Totipotent hematopoietic stem cell (THSC)
• The most versatile type of stem cell.
- Totipotent hematopoietic stem cell (THSC)
• Give rise to all cell lineage
- Totipotent hematopoietic stem cell (THSC)
• Gives rise to CFU-S and CFU-L
- Totipotent hematopoietic stem cell (THSC)
• Can develop into any human cell type, including development from embryo into fetus.
- Totipotent hematopoietic stem cell (THSC)
• These cells are capable of giving rise to multiple lineages of blood cells
- Pluripotential or Multipotential stem cell
• Example: CFU-S and CFU-L
- Pluripotential or Multipotential stem cell
• Gives rise to single lineage of blood cell Identification
- Unipotential Stem cell
• The identification and origin of stem cells can be determined by
immunophenotypic analysis using flow cytometry
Characteristic of stem cell
1. Capable of [?]
2. Give rise to [?]
3. Able to reconstitute the hematopoietic system of a [?]
self-renewal
differentiated progeny
lethally irradiated host
Fate of Hematopoietic Stem Cell (HSC)
- Self-renewal
- Differentiation
- Apoptosis
• Glycoprotein
• Encoded on Chromosome 1q
• Stem cell marker
General cell size (diameter) ; Nuclear-cytoplasmic ratio
Decreases with maturity
Chromatin pattern
Becomes more condensed
Presence of nucleoli
Not visible in mature cells
Cytoplasmic characteristics: Color
Progresses from darker blue to lighter blue, blue-gray, or pink
Cytoplasmic characteristics: Granulation
Progresses from no granules to non-specific to specific granules
Cytoplasmic characteristics: Vacuoles
Increase with age
• Is a continuous, regulated process of blood cell production that includes cell renewal, proliferation, differentiation, and maturation. (Rodak)
Hematopoiesis
• Is a collective term used to describe the process involved in the production of blood cells from human stem cells (HSCs) with subsequent cellular differentiation and development. (Turgeon)
Hematopoiesis
• These processes result in the formation, development, and specialization of all of the functional blood cells that are released from the bone marrow to the circulation.
Hematopoiesis
• In healthy adults, it is restricted primarily to the bone marrow.
Hematopoiesis
• Consists of bone marrow, liver, spleen, lymph nodes, and thymus.
Hematopoiesis
• In fetus, hematopoiesis takes place at various intervals in the liver, spleen, thymus, bone marrow, and lymph nodes. At birth, and continuing into adulthood
Hematopoiesis
• Takes place in a unique microenvironment in the marrow consisting of stromal cells and extracellular matrix.
Hematopoiesis
Hematopoiesis Major locations
• Yolk sac, aorta-gonad-mesonephros (AGM) region, fetal liver, bone marrow, and thymus.
• Lymphocytes:
Spleen and lymph nodes of the secondary lymphoid tissues.
Hematopoiesis Types
- P___________________________
- D___________________________
• Occurs during the mesoblastic phase
• Begins during the fetal hepatic phase and continuous through adult life
Site of hematopoiesis in Adult bone
• Large, nucleated cells
Primitive erythrocytes
• Contain embryonic hemoglobins: Gower 1, Gower 2 and Portland
Primitive erythrocytes
• Occurs in distinct anatomical sites called erythropoietic islands
Erythropoiesis
account for 5% to 38% of nucleated cells in normal bone marrow
• Erythroid cells
account for 23% to 85% of the nucleated cells in normal bone marrow
• Myeloid cells
• Neutrophils in the bone marrow reside in the proliferating pool and the maturation storage pool
Granulopoiesis
• Maturing cells spend an average of 3 to 6 days in the proliferating pool
Granulopoiesis
• If needed, cells from the storage pool can exit into the circulation rapidly and will have an average life span of 6 to 10 hours.
Granulopoiesis
• Unlike other cell lines, lymphocytes and plasma cells are produced in lymphoid follicles.
Lymphopoiesis
account for 1% to 5% of the nucleated cells in the normal bone marrow.
• Lymphoid cells
• takes place adjacent to the sinus endothelium
Megakaryopoiesis
• protrude through the vascular wall as small cytoplasmic processes to deliver platelets into the sinusoidal blood.
Megakaryocytes
• develop into platelets in approximately 5 days.
Megakaryocytes
START: 19 or 20 day of gestation
- Mesoblastic Phase
END: 8 to 12 week of gestation
- Mesoblastic Phase
Mesodermal cells of the yolk sac and later to aortagonad mesonephros (AGM)
- Mesoblastic Phase
RBCs (Primitive erythroblasts)
- Mesoblastic Phase
START: 5 to 7 gestational week (RODAK) 5 to 6th week of gestation(STEININGER)
- Hepatic Phase
Peak: 3rd month of fetal life (Turgeon)
- Hepatic Phase
END: 1 to 2 weeks after birth
- Hepatic Phase
Main: Liver
- Hepatic Phase
Minor: Spleen, Thymus, Lymph nodes
- Hepatic Phase
RBC, Granulocytes, Monocytes, Megakaryocytes/Platelets
- Hepatic Phase
Stem Cells:
Phases of Hematopoiesis:
Hematopoietic Hormones:
- Thrombopoietin (TPO) • Also known as ________________________
• Synthesized in the liver
- Thrombopoietin (TPO)
• Produced primarily by the kidneys (85 to 90%), and the liver (10 to 15%)
- Erythropoietin (EPO)
• Primary source of erythropoietin in the newborn: liver
- Erythropoietin (EPO)
• Molecular weight: 34,000 Daltons or 34 kD
- Erythropoietin (EPO)
• Produced in the renal peritubular interstitial cells or renal tubular cells
- Erythropoietin (EPO)
• Prevents the apoptosis of erythroid precursors
- Erythropoietin (EPO)
• Induces hemoglobin synthesis and serves as differentiation factor causing the CFU-E to differentiate into Pronormoblasts
- Erythropoietin (EPO)
• First human hematopoietic growth factor to be identified
- Erythropoietin (EPO)
• Encoded on Chromosome 7
- Erythropoietin (EPO)
• Major hematopoietic organ, and a primary lymphoid tissues.
Bone Marrow
• One of the body’s largest organs
Bone Marrow
• Represents approximately 3.5% to 6% of total body weight
Bone Marrow
• Averages 1,500 grams in adults
Bone Marrow
Bone Marrow • Predominant cell:
Metamyelocyte (Juvenile)
Bone Marrow • Consist of:
Hematopoietic cells (Erythroid, Myeloid, Lymphoid, and Megakaryocyte), Fat (adipose tissue), osteoblasts, osteoclasts, and stroma.
• During infancy and early adulthood, all the bones in the body contain primarily red (active) marrow.
Bone Marrow
Bone Marrow • Between [?], adipocytes become more abundant and begin to occupy the spaces in the long bones previously dominated by active marrow.
5 and 7 years old
• Hematopoietically inactive [?] is scattered throughout the red marrow so that in adults, there is approximately equal amounts of red and yellow marrow in these areas.
yellow marrow
is capable of reverting back to active marrow in cases of increased demand on the bone marrow, such as in excessive blood loss or hemolysis.
Yellow marrow
Bone Marrow Types:
- Red Marrow
- Yellow Marrow
• Hematopoietically active marrow
- Red Marrow
• Consists of developing blood cells and their progenitors
- Red Marrow
• By age 18, found only in the vertebrae, ribs, sternum, skull bones, pelvis, proximal epiphyses of femur and humerus.
- Red Marrow
• Hematopoietically inactive marrow
- Yellow Marrow
• Composed primarily of adipocytes (fat cells), with undifferentiated mesenchymal cells and macrophages
- Yellow Marrow
• Under physiological stress, yellow marrow will revert to active red marrow
- Yellow Marrow
• Process of replacing the active marrow by adipocytes (yellow marrow) during development.
Retrogression
• Results in restriction of the active marrow in the adult to the sternum, vertebrae, scapulae, pelvis, ribs, skull, proximal portion of the long bones.
Retrogression
• In certain abnormal circumstances, the spleen and liver revert back to producing immature blood cells as extramedullary sites. In these cases, enlargement of spleen and liver, hepatosplenomegaly, is frequently noted on physical examination. This situation suggests that undifferentiated primitive blood cells are present in these areas and are able to proliferate if an appropriate stimulus is present.
Extramedullary Hematopoiesis
• In certain disease states, the bone marrow is unable to produce sufficient numbers of hematopoietic cells, and the liver and spleen may then become the sites of extramedullary hematopoiesis.
Extramedullary Hematopoiesis
• This can occur in hemolytic anemias, where there is increased demand placed on the bone marrow.
Extramedullary Hematopoiesis
• However, in cases of aplastic anemia and the leukemias, blood cells are not produced because of the fibrotic nature of the bone marrow or infiltration with malignant cells.
Extramedullary Hematopoiesis
Conditions where extramedullary hematopoiesis takes place:
- When the bone marrow becomes dysfunctional in cases such as aplastic anemia, infiltration by malignant cells, or overproliferation of a cell line (?)
- When the bone marrow is unable to meet the demands placed on it, as in the [?]
leukemia
hemolytic anemias
Other Adult Hematopoietic Tissue:
• Main site of hematopoiesis during the Hepatic phase
- Liver
• Main site of production of thrombopoietin (TPO) Liver
- Liver
• is often involved in blood-related diseases.
- Liver
• In porphyrias, hereditary or acquired defects in the enzymes involved in heme biosynthesis result in the accumulation of the various intermediary porphyrins that damage hepatocytes, erythrocyte precursors, and other tissues.
- Liver
• In severe hemolytic anemias, the liver increases the conjugation of bilirubin and the storage of iron.
- Liver
• sequesters membrane-damaged RBCs and removes them from the circulation.
- Liver
• can maintain hematopoietic stem and progenitor cells to produce various blood cells (called extramedullary hematopoiesis) as a response to infectious agents or in pathologic myelofibrosis of the bone marrow.
- Liver
Largest lymphoid organ
• Filters the circulating blood
• Stores 1/3 of platelet
- Play a role in the formation of new lymphocytes from the germinal centers
- Lymph Node
- Involved in the processing of specific immunoglobulins
- Lymph Node
- Filter particulate matter, debris, and bacteria entering the lymph node via the lymph
- Lymph Node
• Maturation site of T-lymphocyte
- Thymus
• First fully developed organ in fetus
- Thymus
• Term used to describe the process of RBC production
Erythropoiesis
• Occurs in distinct anatomical sites called erythropoietic islands
Erythropoiesis
• Each island consists of a macrophage surrounded by a cluster of erythroblasts.
Erythropoiesis
• The macrophage serves to supply the developing red cells with iron for hemoglobin synthesis.
Erythropoiesis
• Erythroid cells account for 5% to 38% of nucleated cells in normal bone.
Erythropoiesis
• Literally means decrease in oxygen content within the tissues
• Produces a dramatic increase in the production of erythropoietin
• Primary stimulus for the production of RBCs
• Refers to all of the stages of erythrocyte development encompassing the earliest precursor cells in the bone marrow to the mature RBCs in the circulating, peripheral blood and the vascular areas of organs such as the spleen.
Erythron
Basic substances needed for normal erythrocyte and hemoglobin production
• Amino acids (protein)
• Iron
• Vitamin B12
• Vitamin B6
• Folic acid (member of B2 complex)
• Trace minerals (Cobalt and nickel)
• Produced primarily by the kidneys (80% to 90%), liver (10 to 15%)
Erythropoietin (EPO)
• Primary source of EPO in the unborn:
Liver
• Site of EPO production in kidneys:
Peritubular cells
• Glycoprotein hormone
Erythropoietin (EPO)
Erythropoietin (EPO) • MW:
46,000 daltons
• First human hematopoietic growth factor to be identified
Erythropoietin (EPO)
• Blood levels is inversely related to tissue oxygenation
Erythropoietin (EPO)
Erythropoietin (EPO)• Level can increase up to [?] in response to anemia or arterial hypoxemia
20,000 mU/mL
: Produces dramatic increase in the production of EPO.
• Tissue hypoxia
• prevents erythroid cell apoptosis
Erythropoietin (EPO)
Erythropoietin (EPO) General Characteristics of Maturation and Development
• Maturation through nucleated cell stages in [?]
• Bone marrow reticulocytes: [?]
• Reticulocytes in circulation: [?] (represents 0.5% to 1% of the circulating erythrocytes)
4 or 5 days
2.5 days
1 day
• One technique used in nuclear medicine to identify sites of erythropoiesis as well as other physiologic characteristics and tumors
Radioactive imaging
• After radioisotope injection, total body surface counts are done with an external probe, which shows the location of radioactivity in the body
Radioactive imaging
Radioisotopes used
- Iron-59
- Iron-52
- Technetium-99m sulfur colloid
• Ingested iron normally is bound to transferrin in the blood, carried to sites of erythrocyte production, and incorporated into the erythrocyte to be used in hemoglobin production
Iron-59 and Iron-52
• Has long half-life (45 days), thus exposes the patient to long-term radiation
Iron-59
• Does not permit good image production
Iron-59
• Has an ideal half-life (8.2 hours)
Iron-52
• Excellent for imaging
Iron-52
Most widely used radioisotope in clinical imaging
• Refers to the total production of red blood cells
Total Erythropoiesis
• Production of red blood cells that reach the circulation or peripheral blood
Effective Erythropoiesis (RBCS that reach the circulation)
• Uses radioactive 59Fe intravenously to measure rate of disappearance
Plasma Iron turnover
• Measures total erythropoiesis
Plasma Iron turnover
• Measures effective erythropoiesis
Red cell turnover
• Measures 59Fe radioactivity for 2-3 weeks
Red cell turnover
Pronormoblast
Proerythroblast Rubriblast
Basophilic normoblast
Basophilic erythroblast Prorubricyte
Polychromatophilic normoblast or Polychromatic normoblast
Polychromatophilic erythroblast or Polychromatic erythroblast Rubricyte
Orthochromic normoblast
Orthochromic erythroblast Metarubricyte
Polychromatophilic erythrocyte or Polychromatic erythrocyte/Diffusely Basophilic Erythrocyte or Reticulocyte (Supravital stain)
Erythrocyte
• Also known as Rubriblast, Proerythroblast
• N:C ratio is 8:1
• Fine and uniform chromatin pattern and stains intensely
• It takes approximately 3 days for the pronormoblast to develop into the orthochromic normoblast
• Earliest recognizable RBC precursor in light microscopy
• Also known as Prorubricyte, Basophilic erythroblast
• Slightly smaller than rubriblast
• N:C ratio is 4:1
• Nuclear chromatin becomes more clumped
• Last stage with nucleolus
• Cytoplasm is less but intensely basophilic (due to RNA)
• Also known as Rubricyte, Polychromatophilic erythroblast
• Hemoglobin appear for the first time
• N:C ratio is 1:1
• Muddy, light gray appearance of cell due to variable amounts of pink coloration mixed with basophilia
• Last stage capable of mitosis
• Also known as Metarubricyte, Orthochromic erythroblast
• Nucleus is tightly condensed and described as pyknotic (dense or compact)
• In the later period of this stage, the nucleus will be extruded from the cell
• Last stage with nucleus
• Eight reticulocytes are normally produced from one pronormoblast
• Reticulocytes synthesize hemoglobin for approximately 1 day after leaving the marrow
• Residual ribosomes, mitochondria, and other organelles are removed in the spleen or are internally dissolved.
• Part of this phase occurs in the bone marrow, and the later part of the stage takes place in the circulating blood
• Anuclear
• In supravital stain: Reticulocyte
• Last stage capable of hemoglobin synthesis
• After nuclear expulsion, reticulocytes retained in the marrow for 2 to 3 days
• Same color with mature RBC
• Increased numbers of reticulocytes are prematurely released from the bone marrow under the stimulus of erythropoietin because of such conditions as acute bleeding.
Stress or shift reticulocyte
• When stained with a supravital stain, stress reticulocytes exhibit a much denser meshlike network
Stress or shift reticulocyte
• An elevated reticulocyte count accompanies a shortened RBC survival
Polychromatophilia, polychromasia, reticulocytosis
- Mature erythrocyte
Earliest recognizable
Last stage capable of mitosis
Last stage with a nucleolus
Last stage with nucleus
Last stage that can synthesize hemoglobin
• Anaerobic glycolysis
• 90 to 95% of ATP
• 2 ATP is produced for every glucose molecule broken down to lactic acid
• ATP is used to control the flow of sodium and potassium into and out of the RBC, maintain the biconcave shape of the cell, and protect membrane lipids
• Important enzyme: Pyruvate kinase
• Also known as Pentose phosphate pathway
• Decreased activity of an enzyme in this pathway results in oxidized hemoglobin, which denatures and precipitates as Heinz bodies
• Important enzymes: G6PD, Glutathione
- Prevent oxidative denaturation of hemoglobin by hydrogen peroxide
- Aerobic glycolysis (5 to 10%)
• Maintains the iron present in the hemoglobin molecule in a functional reduced state (Fe2+) for oxygen transport
• Enzyme: Methemoglobin reductase or Cytochrome b5 reductase
• Allows the production of 2,3 diphosphoglycerate (2,3 DPG)
• The 2,3 DPG combines reversibly with the deoxygenated hemoglobin, decreasing the affinity of hemoglobin for oxygen.
RBC Membrane • Shape:
Biconcave disk
RBC Membrane • Cell membrane:
50% protein, 40% lipid, 10% carbohydrate (BROWN) /52% proteins, 40% lipids, and 8% carbohydrates (RODAK)
2 classes of proteins in the membrane
- Integral/ Transmembrane protein 2. Peripheral/Cytoskeletal/Skeletal protein
• In-contact with both the inner and outer surfaces of the membrane
Integral/ Transmembrane protein
• Carry various antigens on the membrane surface, while some antigens are also attached to the glycolipid portions of the membrane surface
Integral/ Transmembrane protein
• Serve as transport and adhesion sites and signaling receptors
Integral/ Transmembrane protein
• Any disruption in transport protein function changes the osmotic tension of the cytoplasm, which leads to a rise in viscosity and loss of deformability
Integral/ Transmembrane protein
• Proteins: protein 4.1, ankyrin, and Glycophorin A
Integral/ Transmembrane protein
• Responsible of the negative charge of the red blood cell surface
Glycophorin A (M, N antigen)
• Proteins: α-spectrin, β-spectrin, and Actin
Peripheral/Cytoskeletal/Skeletal protein
• Do not penetrate the bilayer
Peripheral/Cytoskeletal/Skeletal protein
= Consists of an α and a β chain in a helix circular pattern like a spring
Peripheral/Cytoskeletal/Skeletal protein • Spectrin
= contractile protein that contributes to the deformability of the RBC
Peripheral/Cytoskeletal/Skeletal protein • Actin
Variation in shape
Variation in size
Variation in hemoglobin content
• Variation in hemoglobin contents of red blood cells
RBC with a normal hemoglobin content have a clear pallor that occupies about 1/3 of the cell diameter
Decreased hemoglobin concentration and increase central pallor
• Do not have an area of central pallor because of its increased thickness
• Seen in spherocytes, sickle cell, Hb CC and Hb SC
RBC shift
Shift to the left=
Shift to the right =
Shift to the left= Microcytosis
Shift to the right = Macrocytosis
WBC shift
Shift to the left =
Shift to the right =
Shift to the left = Hyposegmented neutrophil
Shift to the right = Hypersegmented neutrophil
Oxygen dissociation curve
Shift to the left =
Shift to the right =
Shift to the left = Increased oxygen affinity
Shift to the right = Decreased oxygen affinity
• Spherical in shape
• Do not have central pallor
• Decreased surface membrane area to volume ratio
• Increased MCHC
• MCHC between 36 and 38 g/dL
• Centrally stained area with a thin outer rim of hemoglobin
• Increases in cholesterol and phospholipid may be one cause of target cells
• Slit-like (rectangular) area of central pallor
• Lost the indentation on one side
Red blood cell fragments
RBC with a single pointed extension resembling a teardrop or pear
RBC fragment in shape of a helmet
RBC in the shape of a sickle or crescent due to the formation of rod-like polymers of hemoglobin S within the cells
Elliptical (cigar-shaped), Oval (egg-shaped) RBC
• Crenated red blood cells
• Have blunt spicules evenly distributed over the surface of the RBC
• RBC with irregularly spaced projections
• These spicules vary in width but usually contain a bulbous, rounded end
• RBC with membrane folded over
• RBC with one or more semicircular portions removed from the cell margin
• RBC with just a thin rim of hemoglobin and a large clear central area
• RBC with just a thin rim of hemoglobin and a large clear central area
“Poker-chip” stacking of RBCs
Associated with hemolytic anemia
ABO HDN
Hereditary spherocytosis
Liver disease
Hemoglobinopathies (Sickle cell anemia, hemoglobin CC, hemoglobin E, and hemoglobin SC)
Acquired stomatocytosis (Liver disease, Alcoholism)
Electrolyte imbalance
Hereditary stomatocytosis
Artifact
Rh deficiency syndrome/Rh null
Microangiopathic hemolytic anemia (DIC, TTP, HUS)
Uremia
Severe burns
Myelofibrosis
Pernicious anemia
Myeloid metaplasia
Thalassemia
Microangiopathic hemolytic anemia
Sickle cell anemia
Hemoglobin SC disease
Hereditary elliptocytosis or ovalocytosis
Iron deficiency anemia
Thalassemia major
Myelophthisic anemia
Uremia
Severe burns
Pyruvate kinase deficiency
Neuroacanthocytosis (Abetalipoproteinemia)
Severe liver disease (Spur cell anemia)
Lipid metabolism disorder
Hemoglobin C disease
Hemoglobin SC disease
G6PD Deficiency
Artifact
Cold agglutinins
Feulgen stain (DNA stain): Positive
Howell-Jolly bodies
Small, reddish-blue fragments of nucleus
Howell-Jolly bodies
Round, solid-staining, dark-blue to purple inclusions, 1 to 2 mm in size.
Howell-Jolly bodies
If present, cells contain only one or two
Howell-Jolly bodies
Represent nuclear remnants predominantly composed of DNA (from karyorrhexis or nuclear disintegration
Howell-Jolly bodies
Megaloblastic anemia
Alcoholism
Hemolytic anemias
Pernicious anemia
Post-splenectomy
Physiological atrophy of th spleen
Howell-Jolly bodies
Reddish-violet, thin ringlike, figure eight, loopshaped appearance
Cabot rings
• Megaloblastic anemia
• Lead poisoning
Cabot rings
• Small, irregular, dark-staining granules that appear near the periphery of a young RBC
Pappenheimer bodies (Wright stain) / Siderotic granules (Prussian blue)
• Resembles basophilic stippling and must be differentiated by Prussian blue stain
Pappenheimer bodies (Wright stain) / Siderotic granules (Prussian blue)
• Refractory anemia
• Sideroblastic anemia
• Iron overload (Hemosiderosis, Hemochromatosis)
Pappenheimer bodies (Wright stain) / Siderotic granules (Prussian blue)
• Purple-staining granules in the RBC
Basophilic stippling
• Composed of RNA Basophilic stippling
Basophilic stippling
• Resembles pappenheimer bodies and must be differentiated by Prussian blue stain
Basophilic stippling
• Type: Fine or Coarse (Punctuate basophilia)
Basophilic stippling
Fine
• Megaloblastic anemia
• Alcoholism
• Thalassemia
Coarse
Lead poisoning
Basophilic stippling
Wright stain: Not visible
Heinz bodies
Hemoglobin H
• Composed of Hemoglobin
Heinz bodies
• Round, refractile inclusions and are attached to RBC membrane
Heinz bodies
• Multiple Heinz bodies = Pitted Golf Ball Appearance
Heinz bodies
• G6PD deficiency
• Unstable hemoglobin
• Oxidant drug and chemicals
• Favism (Fava beans)
• Acetylphenylhydrazine/ phenylhydrazine
Heinz bodies
• Small greenish-blue inclusion bodies
Hemoglobin H
• Composed of tetramer of β globin
Hemoglobin H
• “Golf ball” appearance of RBCs
Hemoglobin H
Hemoglobin H disease
Hemoglobin H
Fingerlike or quartzlike crystal of dense hemoglobin protruding from the RBC membrane
Hemoglobin SC
Hemoglobin SC disease
Hemoglobin SC
Hexagonal crystal of dense hemoglobin
Hemoglobin C
Hemoglobin C disease
Hemoglobin C
Malarial Pigment: Hemozoin (GREGORIUS)/Hematin (BELIZARIO)
Malarial stippling
Malaria
Malarial stippling
Maltese cross/ Tetrads
Babesia inclusion
Mistaken as Plasmodium falciparum
Babesia inclusion
Vector: Hard Tick/Black Legged Tick/Deer Tick/Ixodes scapularis
Babesia inclusion
Babesiosis/Piroplasmosis/Malarialike infection
Babesia inclusion
Plasmodium falciparum
Plasmodium ovale
Plasmodium vivax
Plasmodium malariae
Plasmodium falciparum
Plasmodium ovale
Plasmodium vivax
Plasmodium malariae
Malignant tertian malaria
Plasmodium falciparum
Black water fever (Cerebral malaria)
Plasmodium falciparum
Benign tertian malignant
Plasmodium ovale Plasmodium vivax
Quartan malaria
Plasmodium malariae
• Crescent, banana or sausage shaped Gametocyte
Plasmodium falciparum
• Maurer’s dot or Christopher’s dot
Plasmodium falciparum
• Applique
Plasmodium falciparum
• Most severe malaria
Plasmodium falciparum
• James dot/Schuffner’s dot
Plasmodium ovale
• RBCs are oval and enlarged
Plasmodium ovale
• Malarial relapse
Plasmodium ovale/vivax
• Schuffner’s dot
Plasmodium vivax
• Enlarged RBC
Plasmodium vivax
• Ameboid ring trophozoite
Plasmodium vivax
• Ziemann’s dot
Plasmodium malariae
• Fruit pie
Plasmodium malariae
• Band form trophozoite
Plasmodium malariae
Other name
Erythrocyte, Red corpuscle, Red cell, RBC, Discocyte
Color (Wright stain)
Lifespan
Size
Thickness
Surface area
Shape
Function
Volume (Normocytic)
Zeta potential
Site of production
Site of destruction
• As a nonnucleated cell, the mature RBC is unable to generate new proteins, such as enzymes, so as its cellular functions decline, the cell ultimately approaches death
RBC Destruction
• The average RBC has sufficient enzyme function to live 120 days.
RBC Destruction
• Because RBCs lack mitochondria, they rely on glycolysis for production of ATP
RBC Destruction
• The loss of glycolytic enzymes is central to this process of aging, called senescence, which results in phagocytosis by macrophages
RBC Destruction
• Macrophage-mediated hemolysis
Extravascular hemolysis
• Occurs in the spleen
Extravascular hemolysis
• 90% of RBC destroyed
Extravascular hemolysis
• Mechanical hemolysis
Intravascular hemolysis
• Although most natural RBC deaths occur in the spleen, a small portion of RBCs rupture, normally intravascularly (within the lumen of blood vessels)
Intravascular hemolysis
• Extremely damaged cells lyse within the circulation before they reach the liver or spleen
Intravascular hemolysis
• 10% of RBC destroyed
Intravascular hemolysis
• Removal of senescent(old) and damaged RBC in the spleen
• Removal of RBC inclusion bodies in the spleen
• Results to the formation of bite cell
Hemoglobin • Identified by __________ in 1862
• Major function is to transport oxygen to the tissues and carbon dioxide from the tissues to the lungs
Hemoglobin
• Composed of 4 subunits, each containing heme and the protein, globin
Hemoglobin
• Every heme group is capable of carrying 1 mole of oxygen, therefore each hemoglobin molecule is able to transport 4 mole of oxygen.
Hemoglobin
• Conjugated globular protein
Hemoglobin
• First protein whose structure was described using x-ray crystallography
Hemoglobin
• Main cytoplasmic component of erythrocytes
Hemoglobin
Hemoglobin Composition
a. 4 Heme
b. 4 Globin
• Consists of protoporphyrin IX and Ferrous iron (Fe2+)
a. 4 Heme
• Each heme contains 1 ferrous iron and 4 pyrrole rings
a. 4 Heme
• Consist of 2 identical pairs of unlike polypeptide chains, 141 to 146 amino acids each
b. 4 Globin
1 gram hemoglobin
• Can carry __________ of oxygen
• Carries ________ iron
Secreted by endothelial cells
Nitric oxide
• It relaxes the vascular wall smooth muscle and vasodilation
Nitric oxide
• Dysfunctional hemoglobins that are unable to transport oxygen
Dyshemoglobins
Dyshemoglobins:
• Methemoglobin, sulfhemoglobin, carboxyhemoglobin
Hemoglobin Molecular weight
• 64,000 Daltons or 64 kD
Molecules for production
- Amino acid
- Iron
- Vitamins: Vitamin B12, Vitamin B6, and Folic acid (member of vitamin B2 complex)
- Trace Minerals: Cobalt and Nickel Hemoglobin Biosynthesis
- Vitamins:
Vitamin B12, Vitamin B6, and Folic acid (member of vitamin B2 complex)
- Trace Minerals:
Cobalt and Nickel
Hemoglobin Biosynthesis
• [?]of the cytoplasmic hemoglobin is synthesized before the nucleus is extruded
65%
Hemoglobin Biosynthesis
•[?] is synthesized in the early reticulocyte
35%
= Conformation of the hemoglobin molecule in the deoxygenated form
• Tense state
= Conformation of the hemoglobin molecule in the oxygenated form
• Relaxed state
• Heme pigment found in striated muscle
Myoglobin
• 17,000 Daltons
Myoglobin
• Requires amino acid, iron, and protoporphyrin IX as raw materials
Myoglobin
• Occurs in the M_____________
Heme biosynthesis
• Occurs in the R_____________
Globin biosynthesis
• Does not begin until the 20th week of prenatal life
Beta globin
• Increased in some β-thalassemias and in iron deficiency anemia (Hubbard)
Hemoglobin A2
• Minor component of adult hemoglobin on chromatography analysis
Hemoglobin A1c
• Hemoglobin with a glucose irreversibly attached
Hemoglobin A1c
• Older RBCs have a higher level of HbA1c than young RBCs
Hemoglobin A1c
• Blood concentrations of glucose>400 mg/dL significantly increase levels of HbA1c.
Hemoglobin A1c
Alpha
Number of Amino Acids:
Chromosome:
Zeta
Number of Amino Acids:
Chromosome:
Beta
Number of Amino Acids:
Chromosome:
Gamma
Number of Amino Acids:
Chromosome:
Delta
Number of Amino Acids:
Chromosome:
Epsilon
Number of Amino Acids:
Chromosome:
A1
A2
F
Gower-1
Gower-2
Portland
> 95%
A1
Predominant hemoglobin in adult
A1
<3.5%
A2
A2
1-2%
F
• Predominant hemoglobin during the hepatic phase
F
• Predominant hemoglobin in newborn
F
Gower-1
Seen only in mesoblastic phase
Gower-1
Gower-2
Portland
Gower-2
Portland
Graphically describe the relationship between oxygen content (percent of saturation) and partial pressure of oxygen (pO2)
Oxygen Dissociation Curve
• 26.52 or 27 mmHg for whole blood under accepted standard conditions of pH 7.4 and temperature of 37.5oC
P50 value
• Represents hemoglobin’s affinity for oxygen and is used to designate the partial pressure of oxygen at which the hemoglobin molecule is 50% saturated with oxygen
P50 value
Increased oxygen affinity
Shift to the left
Decreased oxygen affinity
Shift to the right
Shape of the curve
Term for hemoglobin’s affinity for oxygen as influenced by the pH
Bohr effect
Decreased carbon dioxide
Haldane effect
Factors affecting oxygen dissociation curve
“CADET”
- Carbon dioxide
• Increased carbon dioxide = Shift to the ________
• Decreased carbon dioxide = Shift to the ________
- Acidity (pH)
• Increased pH = Shift to the ________
• Decreased pH = Shift to the ________
- DPG
• Increased 2,3 DPG = Shift to the ________
• Decreased 2,3 DPG = Shift to the ________
- Exercise
• Increased exercise =
increased acidity (due to lactic acid), increased temperature
- Temperature
• Increased temperature = Shift to the ________
• Decreased temperature = Shift to the ________
- Hemoglobin present
• Hemoglobin F and Hemoglobin Chesapeake = Shift to the ________
• Hemoglobin Kansas = Shift to the ________
= It won’t hold tight, decreased oxygen affinity, loose binding
Shift to the right = Increased CADET
= Increased oxygen affinity, tight binding
Shift to the left = Decreased CADET
• Hemoglobin in ferrous (Fe2+) form bounded with carbon dioxide
Deoxyhemoglobin
• Color of blood: Purplish-red
Deoxyhemoglobin
• Hemoglobin bound to oxygen
Oxyhemoglobin
• Color of blood: Bright red
Oxyhemoglobin
Cherry red
- Carboxyhemoglobin
Chocolate brown
- Methemoglobin
Mauve lavender
- Sulfhemoglobin
Reversible
- Carboxyhemoglobin 2. Methemoglobin
Irreversible
- Sulfhemoglobin
Hemoglobin bounded with carbon monoxide
- Carboxyhemoglobin
Hemoglobin that contains iron in oxidized or ferric (Fe3+) state
- Methemoglobin
Hemoglobin bounded with sulfur
- Sulfhemoglobin
• Carbon monoxide is an insidious by-product of incomplete hydrocarbon combustion, is generated in toxic amounts from fossil fuels
- Carboxyhemoglobin
• Affinity of hemoglobin to carbon monoxide is 200 to 240 times than oxygen
- Carboxyhemoglobin
• Also known as hemiglobin (Hi), ferrihemoglobin, and oxidized hemoglobin
- Methemoglobin
• Cannot transport oxygen
- Methemoglobin
• Cannot transport oxygen
- Sulfhemoglobin
• Once formed, sulfhemoglobin stays in the erythrocyte during its entire 120-day life span.
- Sulfhemoglobin
• Can combine with carbon monoxide to form carboxysulfhemoglobin
- Sulfhemoglobin
• Can be formed by oxidizing drugs such as acetanilid, phenacetin and sulfonamides, in cases of bacteremia with Clostridium welchii, and in enterogenous cyanosis
- Sulfhemoglobin
• In vitro, sulfhemoglobin forms when hydrogen sulfide (H2S) is added to hemoglobin
- Sulfhemoglobin
• Absorption at 620 nm
- Sulfhemoglobin
Succinyl Coenzyme A + Glycine
Pyridoxal phosphate (Vitamin B6) ↓ Delta-Aminolevulinic acid synthetase
Delta-Aminolevulinic acid
↓ Delta-Amino levulinic acid dehydrase
Porphobilinogen
↓ Uroporphyrinogen III Cosynthetase
Uroporphyrinogen III
↓ Uroporphyrinogen Decarboxylase
Coproporphyrinogen III
↓ Coproporphyrinogen oxidase
Protoporphyrinogen IX
↓ Protoporphyrinogen oxidase
Protoporphyrin IX
Fe2+ ↓ Ferrochelatase or heme synthetase Heme molecule
• Atom is located in the center of the heme structure and, in the ferrous (Fe2+) state to bind oxygen
Iron
• Iron of each heme is directly bonded to a [?] of a histidine side chain.
nitrogen atom
• This histidine is known as the [?] and functions to increase the oxygen affinity of the heme ring.
proximal histidine
• Most abundant transition metal in the body
Iron
• In the duodenum, dietary free iron is reduced to [?] and taken up from the intestinal lumen into the enterocytes by the iron transport protein divalent metal transporter 1 (DMT1)
ferrous iron
is instrumental in the uptake of iron by erythropoietic cells as well
• DMT1
• Once absorbed, iron may be stored as [?] in the enterocytes or exported into the circulation by another iron transport protein, [?].
ferritin
ferroportin 1 (fpn1)
is important as the last step in intestinal iron absorption
• Ferroportin
exports iron into plasma from absorptive enterocytes, from macrophages that recycle the iron of senescent RBCs, and from hepatocytes that store iron
• Ferroportin
allows macrophages in the liver, spleen, and bone marrow from damaged or senescent RBCs back into the circulation for reuse
• Hepcidin synthesis
exports iron into plasma from absorptive enterocytes, from macrophages that recycle the iron, and from hepatocytes that store iron.
• Ferroportin
• In the plasma, ferric iron binds to transferrin, which is delivered into cells by binding to transmembrane glycoprotein,[?]
transferrin receptors (TfR)
• Functional
Ferrous (Fe2+) iron
• Absorbable form in the intestine
Ferrous (Fe2+) iron
Non-Functional
Ferric (Fe3+) iron
Normal adult iron level
• About [?]
• [?] in circulation, [?] in Ferritin/Hemosiderin
4,000 mg (3 to 4 g)
60%; 40%
1 mg Iron
1 mL RBC
Storage form of iron
- Ferritin
- Hemosiderin
• Short-term storage form of iron
- Ferritin
= protein component of ferritin molecule without iron
• Apoferritin
• Long-term storage form of iron
- Hemosiderin
• Also known as siderophilin
Transferrin
• Carries two atoms of iron in the ferric (Fe3+) state
Transferrin
Absorption site in the small intestine
• Produced in the liver
• Negative regulator of intestinal iron absorption
• Suppresses release of iron from macrophage
• Has a role in anemia of chronic inflammation
• Normal absorption rate of iron
• Daily loss of iron in adult (Turgeon)
• Total iron in the human body
Storage site of iron in the body
- Liver (major)
- Bone marrow
- Spleen
• Under normal conditions, red cell production and the circulating red cell mass (RCM) remain at constant level regulated by the erythropoietic mechanism, which functions to meet the body’s oxygen requirement
RBC Abnormalities
• If the RCM is excessively either decreased or increased, significant problems occur
RBC Abnormalities
RBC Abnormalities Classification
A. Increased RCM ➢ Polycythemia or Erythrocytosis
B. Decreased RCM ➢ Anemia
• Other name: Erythrocytosis
Polycythemia
• Associated with increased RBC count, hemoglobin, hematocrit
Polycythemia
• A hematocrit >52% in men and >50% in women is often used as the diagnostic criterion
Polycythemia
• Maybe classified as relative or absolute
Polycythemia
• Due to decrease in the fluid (plasma) portion of the blood that gives the appearance of an increased RCM in relation to total blood volume rather than a true increase in RCM
Relative Polycythemia
• Actual number of RBC in the blood is not increased, but the number of cells per unit volume of blood is increased
Relative Polycythemia
• Not a hematologic disorder
Relative Polycythemia
• RCM is normal
Relative Polycythemia
Relative Polycythemia Causes
a. Dehydration secondary to diarrhea, vomiting, excessive sweating, increased vascular permeability (burns or anaphylaxis), or the use of diuretics
b. Anxiety and stress
c. Tobacco smoking (Tobacco polycythemia)
d. Gaisbock’s syndrome
➢ Also known as Spurious polycythemia or Stress syndrome
Gaisbock’s syndrome
➢ Affected individuals are usually middle-aged, overweight men complaining of headaches, dizziness, and fatigue
Gaisbock’s syndrome
➢ Associated with smoking, cardiovascular problems, hypertension, and diuretic therapy
Gaisbock’s syndrome
• Refers to true increase in RCM and is associated with various causes
Absolute Polycythemia
Absolute Polycythemia Classification:
- Absolute Primary Polycythemia
- Absolute Secondary Polycythemia
• Also known as Polycythemia rubravera/Vaquez Osler disease/Panmyelosis
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Characterized by uncontrolled proliferation of bone marrow elements
Absolute Primary Polycythemia - Polycythemia vera (PV)
• A chronic myeloproliferative disorder
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Absolute increased in RBC, WBC and platelets (Pancytosis)
Absolute Primary Polycythemia - Polycythemia vera (PV)
• The bone marrow is hypercellular showing an overall increase in granulocytic, erythroid, megakaryocytic cells (Panhyperplasia)
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Results to 2 to 3 times increased in blood volume
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Blood is very viscous due to increased RBCs
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Erythrocyte sedimentation rate(ESR) is decreased
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Erythropoietin is decreased
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Leukocyte alkaline phosphatase is increased
Absolute Primary Polycythemia - Polycythemia vera (PV)
• Due to increased level of erythropoietin(EPO) in the blood
Absolute Secondary Polycythemia
• This may occur as a normal response to hypoxia or as a result of inappropriate EPO production
Absolute Secondary Polycythemia
• This may occur as a normal response to hypoxia or as a result of inappropriate EPO production
Absolute Secondary Polycythemia
Absolute Secondary Polycythemia Causes:
- Residence at high altitudes
- Chronic pulmonary disease
- Chronic congestive heart failure
- Heavy smoking
- Methemoglobinemia
Chronic effects of smoking
• Increased RBC count, WBC count, MCV and Hemoglobin
• A decrease in RBCs, hemoglobin, and hematocrit below the reference range for healthy individuals of the same age, sex, and race, under similar environmental conditions
Anemia
• Mild anemic states of cause no symptoms because of the body’s ability to compensate
Anemia
is the term for marrow erythroid proliferative activity
• Erythropoiesis
• Normal erythropoiesis occurs in the
bone marrow
• When[?] is effective, the bone marrow is able to produce the functional RBCs that leave the marrow and supply the peripheral circulation with adequate numbers of cells
erythropoiesis
• Production may be impaired due to:
- Ineffective erythropoiesis 2. Insufficient erythropoiesis
• Refers to the production of erythroid progenitor cells that are defective
- Ineffective erythropoiesis
• The defective progenitors are often destroyed in the bone marrow before their maturation and release into the peripheral circulation
- Ineffective erythropoiesis
• The effective production rate is considerably less than the total production rate, which results in a decreased number of normal circulating RBCs
- Ineffective erythropoiesis
- Ineffective erythropoiesis Condition : “SMT” S______________________
M______________________
T______________________
• Refers to a decrease in the number of erythroid precursors in the bone marrow, resulting in decreased RBC production and anemia
- Insufficient erythropoiesis
• Anemia can develop as a result of [?] (such as traumatic injury) or premature hemolysis in a shortened RBC life span
acute blood loss
• With [?] and excessive hemolysis, the bone marrow is able to increase production of RBCs, but the level of response is inadequate to compensate for the excessive RBC loss
acute blood loss
B. Destruction and Loss Causes:
a. Intrinsic defects in the RBC membrane, enzyme, or hemoglobin
b. Extrinsic causes such as antibody-mediated processes, mechanical fragmentation, or infection related
Test for Accelerated RBC Destruction
Lactate dehydrogenase
Indirect bilirubin
Glycated hemoglobin
Chromium radioisotope
Enzyme that is release into the blood upon hemolysis
Lactate dehydrogenase
Also known as B1
Indirect bilirubin
• Also known as Hemoglobin A1C
Glycated hemoglobin
• Increases over the life of the cell as it is exposed to plasma glucose
Glycated hemoglobin
• Decreased in chronic hemolytic disease the cells have less exposure to plasma glucose before lysis
Glycated hemoglobin
Reference method for RBC survival studies by International Committee for Standardization in Hematology (ICSH)
Chromium radioisotope
Laboratory Diagnosis of Anemia
Complete blood count(CBC) and RBC Indices
Peripheral blood film examination
Bone marrow examination
Hemoglobin and Hematocrit
Complete blood count(CBC) and RBC Indices
- RBC count
- H and H (Hematocrit and Hemoglobin)
- RBC indices (MCV, MCH, MCHC)
- WBC count
- Platelet count
- Red cell distribution width (RDW)
- Relative and absolute reticulocyte count
• Obtain from automated analyzers
- Red cell distribution width (RDW)
• Indicates variation in size (Anisocytosis)
- Red cell distribution width (RDW)
• Should be done when anemia is found
- Relative and absolute reticulocyte count
• Serves as an important tool to assess the bone marrow’s ability to increase RBC production in response to the anemia
- Relative and absolute reticulocyte count
• Should examine RBC diameter, shape, color, and inclusions
Peripheral blood film examination
• Indicated for a patient with an unexplained anemia associated with or without other cytopenia, fever of unknown origin, or suspected hematologic malignancy
Bone marrow examination
• Widely used tests for anemia
Hemoglobin and Hematocrit
Morphologic Classification of Anemia
Normocytic normochromic
Microcytic normochromic
Microcytic hypochromic
Macrocytic normochromic
Macrocytic hypochromic
• Blood picture shows red cells that are normal in size and normal in hemogobin contents
Normocytic normochromic
• Normal MCV, MCH, MCHC
Normocytic normochromic
• Condition: Hemodilution, hemorrhage, hemolytic anemia, and aplastic anemia
Normocytic normochromic
• Blood picture shows small red cells with normal hemoglobin contents
Microcytic normochromic
• Normal MCHC
Microcytic normochromic
• Decreased MCV and MCH
Microcytic normochromic
• Condition: Chronic inflammations
Microcytic normochromic
• Blood picture shows small red cells that are pale in color due to decreased hemoglobin contents
Microcytic hypochromic
• Decreased MCV, MCH, MCHC
Microcytic hypochromic
• Condition: Thalassemia, and severe iron deficiency anemia
Microcytic hypochromic
• Blood picture shows red cells that are larger than normal
Macrocytic normochromic
• Although they contain a larger than normal weight of hemoglobin, the MCHC is normal so that the cells therefore, are normochromic
Macrocytic normochromic
• Increased MCV, MCH
Macrocytic normochromic
• Normal MCHC
Macrocytic normochromic
• Condition: Pernicious anemia
Macrocytic normochromic
• Blood picture shows red cells that are larger than normal but are hypochromic due to decreased MCHC.
Macrocytic hypochromic
• Increased MCV
Macrocytic hypochromic
• Decreased MCH and MCHC
Macrocytic hypochromic
Anemia of Bone Marrow Failure
Aplastic anemia
Hereditary Aplastic Anemia
Fanconi Anemia (FA)
Diamond-Blackfan Anemia (DBA)
Acquired Aplastic Anemia
Myelophthisic anemia
Anemia of Chronic Kidney Disease (CKD)
• Is a condition in which there is a peripheral blood pancytopenia
Aplastic anemia
• Pancytopenia is a decrease in all blood cells (RBC, WBC, Platelet)
Aplastic anemia
• ↓ Reticulocytes
Aplastic anemia
• Lymphocytes are the cells predominant in the peripheral blood because it has a longer life span
Aplastic anemia
Aplastic anemia Clinical
• Bleeding =
• Anemia =
• Infection =
• No [?]
• No [?]
↓ platelets
↓ RBCs
↓ WBCs
splenomegaly
lymphadenopathy
Anemia of Bone Marrow Failure Causes
• Genetic defect
• Ionizing radiation
• Chemicals
• Viruses (Parvovirus B19)
• Benzene
• Trinitrotoluene
• Insecticides and weed killers
• Chloramphenicol = most common cause
• Inorganic arsenic
Anemia of Bone Marrow Failure Types
Hereditary • Fanconi Anemia (FA) • Diamond-Blackfan Anemia (DBA)
Acquired • Myelophthisic anemia • Chronic kidney disease
• Also known as Congenital Aplastic Anemia
Fanconi Anemia (FA)
• Rare, inherited form of aplastic anemia
Fanconi Anemia (FA)
• Inheritance is Autosomal Recessive (AR)
Fanconi Anemia (FA)
• Total decreased in RBC, WBC, and platelets in the peripheral blood (Pancytopenia)
Fanconi Anemia (FA)
• Type of anemia: Normocytic
Fanconi Anemia (FA)
Diamond-Blackfan Anemia (DBA)
Myelophthisic anemia
• Low birth weight <2,500g
Fanconi Anemia (FA)
• Skin hyperpigmentation (cafe au lait spots)
Fanconi Anemia (FA)
• Short stature
Fanconi Anemia (FA)
• Skeletal disorders
Fanconi Anemia (FA)
• Renal malformations
Fanconi Anemia (FA)
• Microcephaly
Fanconi Anemia (FA)
• Hypogonadism
Fanconi Anemia (FA)
• Mental retardation
Fanconi Anemia (FA)
• Strabismus
Fanconi Anemia (FA)
• Also known as Congenital Pure Red Cell Aplasia, Congenital erythroid hypoplasia
Diamond-Blackfan Anemia (DBA)
• Defective/reduced CFU-E
Diamond-Blackfan Anemia (DBA)
• Rare, congenital disorder
Diamond-Blackfan Anemia (DBA)
• Normocytic, normochromic anemia with normal leukocyte and platelet count and a marked decrease in marrow erythroblasts
Diamond-Blackfan Anemia (DBA)
• Cause: Congenital mutation in R______________
Diamond-Blackfan Anemia (DBA)
• Also known as leukoerythroblastic anemia, leukoerythroblastosis, and myelopathic anemia
Myelophthisic anemia
• Common finding in patients with carcinoma
Myelophthisic anemia
• Results when the bone marrow is replaced by abnormal cells such as metastatic tumor cells (particularly from lung, breast, and prostate), leukemic cells, fibroblasts, and inflammatory cells (found in miliary tuberculosis and fungal infections)
Myelophthisic anemia
• If the infiltration and proliferation of the abnormal cells disrupts the normal bone marrow architecture, premature release of immature cells from the bone marrow occurs
Myelophthisic anemia
• Because of the unfavorable bone marrow environment, stem and progenitor cells migrate to the spleen and liver and establish extramedullary hematopoietic sites
Myelophthisic anemia
= invasion of abnormal cells
• Myelophthisis
• ↓Reticulocyte, Teardrop cell, NRBCs, Immature myeloid cells in the peripheral blood, presence of abnormal cells in the bone marrow
Myelophthisic anemia
Anemia is due to inadequate production of erythropoietin by the kidneys
Anemia of Chronic Kidney Disease (CKD) •
•• Without erythropoietin, the bone marrow is unable to increase RBC production in response to tissue hypoxia
Anemia of Chronic Kidney Disease (CKD)
•• ↓ EPO, presence of Burr cells (Due to uremia)
Anemia of Chronic Kidney Disease (CKD)
affects all rapidly dividing cells of the body, including the skin, gastrointestinal tract, and bone marrow
• Impaired DNA synthesis
are integral components in DNA synthesis, without normal DNA synthesis, megaloblastic erythropoiesis results
• Vitamin B12 and Folate
• Deficiencies of either vitamin impair DNA replication, halt cell division, and increase apoptosis, which results in ineffective erythropoiesis and megaloblastic morphology
• Vitamin B12 and Folate
Anemia of Abnormal Nuclear Development MCV:
100 to 150 fL (Usually greater than 120 fL)
• The root cause of megaloblastic anemia is impaired DNA synthesis
Megaloblastic anemia
• The anemia is named for the very large cells of the bone marrow that develop a distinctive morphology due to a reduction in the number of cell divisions
Megaloblastic anemia
• MCH is increased because the hemoglobin content is increased in proportion to cell size
Megaloblastic anemia
• MCH is increased because the hemoglobin content is increased in proportion to cell size
Megaloblastic anemia
• MCV is increased
Megaloblastic anemia
• MCHC is normal
Megaloblastic anemia
• As the megaloblastic anemia becomes more severe, the peripheral blood gradually reflects pancytopenia and a decreased reticulocyte count, even though the bone marrow is generally hypercellular, as a result of ineffective erythropoiesis and intramarrow RBC destruction
Megaloblastic anemia
Causes of Megaloblastic anemia
- Vitamin B12 deficiency
- Folate deficiency
- Megaloblastoid maturation
- Other cause
Increased LDH and fecal urobilinogen
Hemolytic anemia (intravascular)
Ineffective erythropoiesis (megaloblastic anemia)
is produced by microorganisms and certain molds
• Vitamin B12
• Its dietary sources include animal protein products such as meat, fish eggs, and milk.
• Vitamin B12
• It is not found in vegetables or fruit
• Vitamin B12
• The liver stores adequate amount of vitamin B12 for several years if no more is ingested
Vitamin B12 Deficiency
• Absorption in the gastrointestinal tract requires several factors
Vitamin B12 Deficiency
• Absorption in the gastrointestinal tract requires several factors
Vitamin B12 Deficiency
• First, the vitamin must be released from foods by peptic digestion in the stomach, which is facilitated by hydrochloric acid (HCl) released from the gastric parietal cells
Vitamin B12 Deficiency
also secrete an important protein called intrinsic factor (IF)
• Parietal cells
• In the stomach, intrinsic factor forms a protective complex with vitamin B12 that is transported down the GI tract
Vitamin B12 Deficiency
• Upon reaching the ileum, the complex attaches to mucosal receptors, B12 is released from IF and absorption takes place
Vitamin B12 Deficiency
Causes of Vitamin B12 deficiency
- Inadequate intake
- Increased need
- Impaired absorption
• Patients who are strict vegetarian who do not eat meat, eggs, or dairy products
- Inadequate intake
• Vitamin B12 is essential vitamin for animals, plant cannot synthesize vitamin B12
- Inadequate intake
• Occurs during pregnancy, lactation, and growth
- Increased need
• Vitamin B12 in food is released from food proteins primarily in the acid environment of the stomach, aided by pepsin, and is subsequently bound by a specific salivary protein, haptocorrin (also known as R-binder protein)
- Impaired absorption
• In the small intestine, vitamin B12 is released from haptocorrin by the action of trypsin
- Impaired absorption
• It is then bound by intrinsic factor, produced by the gastric parietal cells
- Impaired absorption
• It is then bound by intrinsic factor, produced by the gastric parietal cells
- Impaired absorption
• Vitamin B12 binding to IF is required for absorption by the ileal cells (enterocytes) that possess receptors for the complex
- Impaired absorption
Causes of impaired absorption:
a. Failure to separate vitamin B12 from food proteins
b. Lack of intrinsic factor
Causes of impaired absorption:
a. Failure to separate vitamin B12 from food proteins
b. Lack of intrinsic factor
o A condition known as “food-cobalamin malabsorption” is characterized by hypochlorhydria and the resulting inability of the body to release vitamin B12 from food or intestinal transport proteins for subsequent binding to intrinsic factor
a. Failure to separate vitamin B12 from food proteins
o Lack of intrinsic factor constitutes a significant cause of impaired vitamin B12 absorption
b. Lack of intrinsic factor
constitutes a significant cause of impaired vitamin B12 absorption
b. Lack of intrinsic factor
o It is most commonly due to autoimmune disease, as in pernicious anemia, but can also result from the loss of parietal cells with Helicobacter pylori infection, total or partial gastrectomy, or hereditary intrinsic factor deficiency
b. Lack of intrinsic factor
o It is most commonly due to autoimmune disease, as in pernicious anemia, but can also result from the loss of parietal cells with Helicobacter pylori infection, total or partial gastrectomy, or hereditary intrinsic factor deficiency
b. Lack of intrinsic factor
▪ Autoimmune disorder characterized by impaired absorption of vitamin B12 due to lack of intrinsic factor ▪ Production of antibodies to intrinsic factor and gastric parietal cells
Pernicious anemia
▪ Persons older than 60 years of age are at higher risk
Pernicious anemia
▪ Persons older than 60 years of age are at higher risk
Pernicious anemia
▪ Most common form of vitamin B12 deficiency in adults
Pernicious anemia
▪ Most common form of vitamin B12 deficiency in adults
Pernicious anemia
▪ More common in people with blood group A
Pernicious anemia
▪ More common in people with blood group A
Pernicious anemia
▪ Able to split vitamin B12 from intrinsic factor, rendering the vitamin unavailable for host absorption
Diphyllobothrium latum (Broadfish tapeworm) infection
▪ Portions of the intestines that are stenotic (narrow) as a result of surgery or inflammation, can become overgrown with intestinal bacteria that compete effectively with the host for available vitamin B12
Blind loops
▪ Portions of the intestines that are stenotic (narrow) as a result of surgery or inflammation, can become overgrown with intestinal bacteria that compete effectively with the host for available vitamin B12
Blind loops
▪ Portions of the intestines that are stenotic (narrow) as a result of surgery or inflammation, can become overgrown with intestinal bacteria that compete effectively with the host for available vitamin B12
Blind loops
▪ It causes vitamin B12 malabsorption
Imerslund-Grasbeck syndrome
▪ Malabsorption is not related to IF deficiency or defect
Imerslund-Grasbeck syndrome
▪ Inheritance is autosomal recessive (AR)
Imerslund-Grasbeck syndrome
▪ Inheritance is autosomal recessive (AR)
Imerslund-Grasbeck syndrome
▪ Inheritance is autosomal recessive (AR)
Imerslund-Grasbeck syndrome
▪ Inheritance is autosomal recessive (AR)
Imerslund-Grasbeck syndrome
Cause: Defect in cubilin/amnionless receptor (Henry’s)
Imerslund-Grasbeck syndrome
• Provides a measure of body’s ability to secrete viable IF and absorb orally administered 57Co-labeled B12 in the ileum
Schilling test
• Along with the 57Co B12, excessive amounts of unlabeled B12 are administered to the patient to fill all tissue binding sites
Schilling test
• Normal absorption of vitamin B12 under such circumstances is reflected by a minimum level of urinary excretion of radiolabeled B12
Schilling test
Schilling test Specimen and Patient Requirements
• The patient should fast [?]
• A [?] is begun immediately upon administration of the labeled B12 by mouth
overnight
24-hour urine collection
Schilling test Procedure
• A physiologic dose of 57Co-labeled vitamin B12 is given by mouth, followed by a “flushing dose” of unlabeled B12 injected intramuscularly within the next [?]
• The flushing dose is given to saturate the liver and tissue binding sites so that, if the labeled B12 is absorbed it will not be completely bound in B12-depleted tissues and some will be excreted in the [?]
• If results of the initial test are abnormal, the test is repeated [?] later
• In this phase, IF is administered with the 57Co B12, to eliminate IF as a variable and to determine whether provision of IF allows for normal [?]
• The results allow for distinguishing between a deficiency of or a defect in IF and a malabsorption syndrome such as that caused [?]
1 to 2 hours
urine
2 to 3 days
B12 absorption
ileal disease or fish tapeworm
Schilling test Interpretation:
- Phase 1 (Radiolabeled B12 without IF)
• Urine:
o >7% of labeled B12 is excreted = __________________________
o <7% of labeled B12 is excreted = __________________________ - Phase 2 (Radiolabeled B12 with IF)
• Urine:
o >7% of labeled B12 is excreted = __________________________
o <7% of labeled B12 is excreted = __________________________
Sources of Folate
Green leafy vegetables, liver, kidney, whole grain cereals, yeast, and fruits(especially oranges)
Cause of Folate deficiency
a. Inadequate intake
b. Increased need
c. Impaired absorption
d. Impaired use due to drugs
e. Excessive loss with renal dialysis
f. Alcohol (It interferes with folate metabolism)
