Hematology Flashcards by KM Guntayon

includes erythrocytes, leukocytes, platelets, and plasma
when centrifuged, leukocytes and platelets make up the buffy coat

whole blood

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small white layer of cells lying between the packed red blood cells and the plasma

buffy coat

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liquid potion of unclotted blood
composed of 90% water and contains proteins, enzymes, hormones, lipids and salts
normally appears hazy and pale yellow

plasma

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fluid that remains after coagulation has occurred and a clot has formed
appears clear and straw colored (lacks fibrinogen group coagulation proteins)

serum

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body’s tendency to move toward physiological stability

homeostasis

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body/cellular water concentration, composed of 0.85% sodium chloride

osmotic concentration

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lesser amount of water in relationship to greater amounts of solutes
so the water leaves the cell, the cell may crenate

hypertonic solution

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pH reference range in venous blood

7.36-7.41

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pH reference range in arterial blood

7.38-7.44

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normal size range of thrombocytes

2-4micrometers

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normal size range of erythrocytes

6-8micrometers

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normal size range of lymphocytes

6-9micrometers

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normal size range of reactive lymphocytes

10-22micrometers

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normal size range of basophils

10-15micrometers

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normal size range of segmented neutrophils

10-15micrometers

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normal size range of band neutrophils

10-15micrometers

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normal size range of eosinophils

12-16micrometers

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normal size range of monocytes

12-20micrometers

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indicator of the average / mean volume of erythrocytes
increased in megaloblastic anemia, hemolytic anemia with reticulocytosis, liver disease and normal newborn
decreased in iron deficiency anemia, thalassemia, sideroblastic anemia and lead poisoning

mean corpuscular volume (mcv)

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reference range for mcv

80-100fL

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mcv calculation

(% hgb x 10) / rbc count (x 10^12/L)

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indicator of the average weight of hemoglobin in individual rbcs
increased in microcytic anemia
decreased in microcytic, hypochromic anemia

mean corpuscular hemoglobin (mch)

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reference range for mch

26-34pg

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mch calculation

(hgb in g/dl x 10) / rbc count ( x 10^12/L)

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measure of the average concentration of hemoglobin in grams per deciliter

mean corpuscular hemoglobin concentration (mchc)

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reference range for mchc (normochromic rbcs)

32-37 g/dL

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what level of mchc indicates hyprochromic rbcs, which is seen in ida and thalassemia

<32g/dL

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what level of mchc indicates a possible error in rbc or hemoglobin measurement of the presence of spherocytes

> 37g/dL

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determined from the rbc histogram
increased proprotional to the degree of anisocytosis
coefficient of variation of the mean corpuscular volume

rbc distribution width (rdw)

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reference range for rdw

11.5-14.5%

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this is seen post-transfusion, post treatment (iron, b12 or folic acid therapy), idiopathic sideroblastic anemia, in the presence of two concurrent deficiencies (iron and folic acid deficiencies)

high rdw

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percentage of rbcs in a given volume of whole blood
age and sex dependent

hematocrit (hct)

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reference range of hct in males

41-53%

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reference range of hct in females

36-46%

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how to calculate hct

(mcv x rbc in 10^12/L) /10

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reference range of hgb in males

13.5-17.5 g/dL

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reference range of hgb in females

12.0-16.0 g/dL

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reference manual method for determining hct

spun microhematrocrit

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reference range for platelets

150-450 x 10^9/L

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reference range for mean platelet volume

6.8-10.2fL

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amount of a cell type in relation to other blood components

relative count

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increase in the percentage of lymphocytes
frequently associated with neutropenia

relative lymphocytosis

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rbcs appear increased due to a decreased plasma volumne

relative polycythemia

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actual number of each cell type without respect to other blood components

absolute count

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most commonly used routine peripheral blood smear stain

wright’s strain

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wright’s stain contains ___, a basic dye, which stains acidic cellular components (dna and rna) blue, and ___, an acidic dye, which stains basic components (hemoglobin and eosinophilic cytoplasmic granules) red orange

methylene blue
eosin

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used in the staining process to fix the cells to the slide

methanol fixative

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romanowsky staining does not begin until a ___ is added

phosphate buffer (pH between 6.4-6.8)

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causes of rbcs too red and wbc nuclei poorly stained

buffer or stain below pH 6.4
excess buffer
decreased staining time
increased washing time
thin smear
expired stains

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causes of rbcs and wbc nuclei too blue

buffer or stain above 6.8
too little buffer
increased staining time
poor washing
thick smear
increased protein
heparinized blood sample

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used for staining specific cellular components

non vital monochrome stains

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contains potassium ferrocyanide, HCl, and a safranin counterstain
used to visualize iron granules in rbcs (siderotic iron granules), histiocytes and urine epithelial cells

prussian blue

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used to stain specific cellular components
no fixatives are used int he staining process

supravital (living cell) monochrome stain

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used to precipitate rna in reticulocytes
measure of bone marrow erythropoiesis

new methylene blue

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used to visualize heinz bodies

neutral red with brilliant cresyl green

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clinical disorders associated with heinz bodies

g6pd deficiency
unstable hemoglobin disorders

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production and differentiation of blood cells

hematopoiesis

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blood cell production, maturation and death occur in organs of the ___
functions in hematopoiesis, phagocytosis and immune defense

reticulo-endothelial system

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res includes these organs

bone marrow
spleen
liver
thymus
lymph nodes

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intrauterine hematopoiesis includes three phases

mesoblastic (yolk sac) phase
hepatic (liver) phase
myeloid/medullary phase

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phase of intrauterine hematopoiesis:
begins around the fifth month of gestation, with the bone marrow producing mainly granulocytes
M:E ratio approaches the adult level of 3:1
alpha- and gamma-globin chain production predominates at birth, forming Hgb E, Hgb A1 and A2 are also present

myeloid/medullary phase

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phase of intrauterine hematopoiesis:
begins at ~19 days gestation
yolk sac is located outside the developing embryo
alpha-globin chain production begins at this phase and continues throughout life

mesoblastic phase

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first cell to be produced during the mesoblastic phase of hematopoiesis

primitive nucleated erythroblast

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primitive nucleated erythroblast produces which embryoni chemoglobins

portland
gower I
gower II

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phase of intrauterine hematopoiesis:
begins at 6 week gestation with production of mainly red blood cells but also granulocytes, monocytes, and megakaryocytes
alpha- and gamma-globin chain production predominates forming Hgb F
detectable Hgb A and A2 are also present

hepatic (liver) phase

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in young adult, 60% of bone marrow is active, hematopoiesis is confined to the _____

proximal ends of large flat bones, pelvis and sternum

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in newborn, 80-90% of bone marrow is active ____

red marrow

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ratio of marrow cells to fat

cellularity

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marrow has 30-70% hematopoietic cells

normocellular

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marrow >70% hematopoietic cells

hypercelullar/hyperplastic

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marrow <30% hematopoietic cells

hypocellular/hypoplastic

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marrow has few or no hematopoietic cells

aplastic

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ratio of granulocytes and their precursors to nucleated erythroid precursors

myeloid:erythroid ratio

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normal M:E ratio

3:1 and 4:1

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involves the production of pluripotential stem cells that develop into committed progenitor cells and finally mature blood cells

hematopoiesis

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differentiate into either b or t lymphocytes in response to cytokines / lymphokines / csfs / growth factors

lymphoid progenitor cells

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gives rise to the multipotential progenitor cfu-gemm, which will differentiate into committed progenitor cells and finally mature blood cells in response to cytokines / interleukins / colony stimulating factor / growth factors

myeloid progenitor cells

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thrombocytes: committed progenitor cells and growth factors / interleukins

cfu-meg
thrombopoietin, gm-csf

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monocytes: committed progenitor cells and growth factors / interleukins

cfu-gm, cfu-m
gm-csf, m-csf, il-3

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site of pre-B cell differentiation

bone marrow

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primary lymphoid tissues

bone marrow
thymus

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site of pre-T cell differentiation

thymus

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second lymphoid tissues

lymph nodes
spleen
gut-associated tissue (Peyer’s patches)

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classifications of leukocytes

phagocyte
immunocytes

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reference range of WBCs

4.0-11.0 x 10^9/L

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include neutrophils, eosinophils, and basophils

granulocytes

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first to reach the tissues and phagocytize bacteria

neutrophils

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differentiate into macrophages, and they work in the tissues to phagocytize foreign bodies
they arrive at the site of inflammation after neutrophils and do not die in the process

monocytes

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provide cellular immunity
they represent 80% of lymphocytes in the blood
when activated, they proliferate and produce cytokiens/interleukins

t lymphocytes

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destroy tumor cells and cells infected with viruses
large granular lymphocytes

nk lymphocytes

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develop into plasma cells in the tissue and produce antibodies needed for humoral immunity
represent 20% of the lymphocytes in the blood

b lymphocytes

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modulate the allergic responses caused by basophil degranulation

eosinophils

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mediate immediate hypersensitivity reactions (type I, anaphylactic)

basophils

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surface proteins expressed by specific cell lines at different maturation stages

cd markers

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cd2, cd3

lymphoid, all t cells

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cd4

helper/inducer t cells

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cd8

suppressor/cytotoxic t cells

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cd13

all myeloid

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cd11c, cd14

monocytes

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cd19, cd20

lymphoid, all b cells

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cd33

all myeloid

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cd34

stem cell marker (lymphoid and myeloid precursor)

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cd16, cd56

nk cells

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blood cell production within the bone marrow
begins in the fifth month of gestation and continues throughout life

medullary hematopoiesis

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blood cell production outside the bone marrow
occurs when the bone marrow cannot meet body requirements
occurs mainly in the liver and spleen; hepatomegaly and/or splenomegaly often accompany this

extramedullary hematopoiesis

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this is where antigen-independent lymphopoiesis occurs

primary lymphoid tissue

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this is where antigen-dependent lymphopoiesis occurs

secondary lymphoid tissue

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composition of nucleus

chromatin
nucleolus

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rich in rna

nucleolus

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composed of dna and proteins

chromatin

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forms lysosomes

golgi complex

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contain hydrolytic enzymes that participate in phagocytosis

lysosomes

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assemble amino acids into protein

ribosomes

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furnish the cell with energy (ATP)

mitochondria

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system of interconnected tubes for protein and lipid transport

endoplasmic reticulum

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characteristics of immature cells
size:
nucleoli:
chromatin:
nucleus:
cytoplasm:
N:C ratio:

size: large
nucleoli: present
chromatin: fine and delicate
nucleus: round
cytoplasm: dark blue (rich in rna)
N:C ratio: high

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gives rise to a committed progenitor cell that is acted on by growth factors to form granulocytes

myeloid progenitor cell

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characteristics of mature cells
size:
nucleoli:
chromatin:
nucleus:
cytoplasm:
N:C ratio:

size: small
nucleoli: absent
chromatin: coarse and clumped
nucleus: round, lobulated or segmented
cytoplasm: light blue (less rna)
N:C ratio:

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earliest recognizable granulocyte precursor

myeloblast

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morphology of myeloblast
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
% in BM:

size: 14-20 micrometers
NC ratio: 7:1-4:1
nucleus: round/oval with fine reddish-purple staining chromatin
nucleoli: 2-5
cytoplasm: dark blue
% in BM: 1% of the nucleated cells

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morphology of promyelocyte
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
% in BM:

size: 15-21 micrometers
NC ratio: 6:1
nucleus: round/oval with slightly coarsening chromatin
nucleoli: 1-3
cytoplasm: large, non specific/primary granules containing myeloperoxidase
% in BM: 2-5% of the nucleated cells

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morphology of myelocyte
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
% in BM:

size: 12-18 micrometers
NC ratio: 2:1
nucleus: round with coarse chromatin
nucleoli: visible in early myelocytes
cytoplasm: light blue to light pink, prominent golgi apparatus, cytoplasm has specific/secondary granules that contain hydrolytic enzymes, including phosphatase and lysozyme
% in BM: 13% of the nucleated cells

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morphology of metamyelocyte
size:
NC ratio:
nucleus:
nuclear indent:
cytoplasm:
granules:
% in BM:

size: 10-18 micrometers
NC ratio: 1.5:1
nucleus: indented in a kidney bean shape, has coarse clumped chromatin
nuclear indent: less than half the width of a hypothetical round nucleus
cytoplasm: pink and filled with pale blue to pink specific/secondary granules
granules: nonspecific/primary present but do not stain
% in BM: 16%

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morphology of band neutrophil
size:
NC ratio:
nucleus:
nuclear indent:
cytoplasm:
granules:
% in BM:

size: 10-15 micrometers
NC ratio: 1:2
nucleus: C or S-shaped with coarse, clumped chromatin lacking segmentation
nuclear indent: greater than half the width of a hypothetical round nucleus
cytoplasm: pink and filled with pale blue to pink specific/secondary granules
granules: present but do not usually stain
% in BM: 12%

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morphology of segmented neutrophil (PMN)
size:
NC ratio:
nucleus:
cytoplasm:
granules:
% in BM:

size: 10-15 micrometers
NC ratio: 1:3
nucleus: coarse, clumped chromatin with 3-5 lobes connected by thin filaments
cytoplasm: pink, filled with small, pale blue to pink specific/secondary granules
granules: nonspecific/primary granules are present but usually do not stain unless in response to infection or growth factor
% in BM: 12%

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morphology of eosinophil
size:
nucleus:
cytoplasm:
% in BM:

size: 12-16 micrometers
nucleus: bilobed
cytoplasm: large, bright red-orange, secondary granules that contain enzymes and proteins
% in BM: <1%

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morphology of basophil
size:
nucleus:
cytoplasm:
% in BM:

size: 10-15 micrometers
nucleus:
cytoplasm: contains heparin and histamine, granules may be numerous and obscure the nucleus, and leave empty areas
% in BM: <0.1%

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neutrophils: those in the bone marrow mitotic pool 3-6 days and that is where they divide

blasts
promyelocytes
myelocytes

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neutrophils: those in the bone marrow post-mitotic pool about 6 days and that is where they mature

metamyelocyte
bands
segmented neutrophils

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diapedeses into the tissue from the marginating pool in response to antigenic stimulation

neutrophils

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attract the neutrophil to the site of inflammation and include complements, bacterial products, injured tissue, hemostatic components

chemotactic factors

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help neutrophils recognize a substance as foreign
IgG and complement component C3b

opsonins

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involves neutrophil attachment to the foreign object, formation of a vacuole around it and neutrophilic degranulation to release lytic enzymes (respiratory burst) in effort to kill the organism

phagocytosis

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induced by extracellular forces such as lethal chemical, biological, or physical events

necrosis

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programmed cell death due to extracellular or intracellular processes that depend on a signal

apoptosis

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neutrophils: associated with bacterial infection or growth factor therapy

toxic changes

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neutrophils: prominent granulation due to persistent staining or primary granules

toxic granulation

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neutrophils: colorless areas in the cytoplasm that indicate phagocytosis and degranulation have occurred

toxic vacuolation

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neutrophils: small oval inclusions located in the cytoplasm stain light blue

double bodies

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neutrophils: increased number of myelocytes, metamyelocyte, and/or bands in the peripheral blood
associated with either increased, or decreased, WBC counts

shift to the left

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neutrophils: an appropriate bone marrow response to increased demand for neutrophils
seen in infection or in other physiological or pathological conditions requiring neutrophils; most common type of left shift; wbc count above the reference range

regenerative shift to the left

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neutrophils: seen after an overwhelming infection in which bone marrow production cannot keep up with increased need for neutrophils; associated with a poor prognosis; wbc count below the reference range

degenerative shift to the left

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found in the blood, only a few hours before seeking a tissue site such as nasal passages, skin or urinary tract
can degranulate, express Fc receptors for Ig as a response to parasitic infections
release substances that can neutralize products released by basophils and mast cells, and modulate the allergic response

eosinophils

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found in the blood only a few hours before migrating to the site of inflammation int he tissues
express membrane receptors for IgE
release a chemotactic factor that attracts eosinophils to the site

basophils

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released by degranulation of basophils which initiates the classic signs of immediate hypersensitivity reaction (type I)

histamine

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redistribution of the blood pools causes a short-term increase in the total wbc count and in the absolute number of neutrophils in the circulating granulocyte pool
caused by exercise, stress, pain, pregnancy
not a response to tissue damage

shift/physiologic/pseudoneutrophilia

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neutrophils leave the circulating fool, enter the marginating pool and the move to the tissues in response to tissue damage
bone marrow reserves are released into the blood to replenish the circulating pool

pathologic neutrophilia

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blood picture mimics that seen in chronic myelogenous leukemia
benign, extreme response to a specific agent or stimulus
wbc count can increase to between 50.0-100.0 x 10^9/L, and there is a shift to the left with toxic changes to neutrophils

neutrophilic leukemoid reaction

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presence of immature leukocytes and immature (nucleated) erythrocytes in the blood
occurs in marrow replacement disorders, such as myelofibrosis

leukoerythblastic reaction

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decrease in absolute number of neutrophils, which increases the risk of infection
due to bone marrow production defects

neutropenia

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causes of bone marrow production defects

chronic or severe infection
hypersplenism
bone marrow injury/infiltration/suppression
dna synthesis defects (vitamin b12, b9)
viral infections

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increase in the absolute number of eosinophils

eosinophilia

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associated with eosinophilia

parasitic infections
allergic reactions
chronic inflammation
chronic myelogenous leukemia
hodgkin disease
tumors

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decrease in the absolute number of eosinophils

eosinopenia

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associated with eosinopenia

acute inflammation and inflammatory reactions that cause release of glucocorticoids and epinephrine

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increase in the absolute number of basophils

basophilia

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can cause basophilia

type 1 hypersensitivity reactions
chronic myelogenous leukemia including early maturation stages
polycythemia vera

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can be seen in patients with hematopoietic growth factors

relative transient basophils

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decrease in the absolute number of basophils associated with inflammatory states and following immunologic reactions; difficult to diagnose because of their normally low reference range

basopenia

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both sex-linked and autosomal inheritance with the ratio of affected males to females being 6:1
morphologically normal but functionally abnormal because of enzyme deficiency that results in an inability to degranulate, which causes inhibited bacterial function
fatal early in life

chronic granulomatous disease

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autosomal recessive disorder causes large, gray-green, peroxidase positive granules in the cytoplasm of leukocytes; abnormal fusion of primary and secondary neutrophilic granules
both morphologically and functionally abnormal leukocytes, wbcs unable to degranulate and kill invading bacteria
patients will present with photophobia and skin hypopigmentation
fata early in life

chediak-higashi syndrome

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characterized by 5 or more lobes in the neutrophil; associated with megaloblastic anemia (due to vit b12 or folic acid deficiencies)

hypersegmentation

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refers to a tendency in neutrophils to have 1-2 lobes; may indicate an anomaly or a shift to the left

hyposegmentation

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autosomal dominant inheritance
nucleus is hyperclumped, and it does not mature past the 2-fold stage
nucleus dumbbell or peanut shaped; referred to as pince-nez
morphologically abnormal but functionally normal
must differentiate from a shift to the left associated with an infection (toxic changes)

pelger-huet anomaly

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acquired abnormally associated with myeloproliferative disorders and myelodysplastic syndromes; can also be drug-induced
nucleus is usually round instead of the dumbbell shaped that is seen in the anomaly
frequently accompanied by hypogranulation

pseudo pelger-huet

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autosomal dominant inheritance
large, crystalline, Dohle-like inclusions in the cytoplasm of neutrophils on wright’s stain, gray-blue and spindle (cigar) shaped
morphologically abnormal but functionally normal
giant platelets, thrombocytopenia, and clinical bleeding are also associated with this anomaly

may-hegglin anomaly

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autosomal recessive
large azurophilic granules appear in the cytoplasm of all or only one cell line, granules contain degraded mucopolysaccharide due to an enzyme defect
morphologically abnormal but functionally normal
must differentiate from toxic granulation present in neutrophils only in infectious condition

alder-reilly anomaly

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macrophages in peripheral blood

monocytes

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macrophages in liver

kupffer cells

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macrophages in central nervous system

microglial cells

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macrophages in bone

osteoclasts

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macrophages in skin

langerhan’s cells

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macrophages in lungs

alveolar cells

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earliest recognizable monocyte precursor
12-18 micrometers; nc ratio 4:1
round/oval eccentric nucleus with fine chromatin; 1-2 nucleoli
dark blue cytoplasm; may have a gray tint, no cytoplasmic granules

monoblast

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12-20 micrometers
irregularly shaped indented nucleus with fine chromatin; 0-1 nucleoli
blue to gray cytoplasm; fine azurophilic granules

promonotye

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12-20 micrometers
horseshoe or kidney-bean-shaped nucleus, often with brain-like convolutions
fine lacy chromatin
blue-gray cytoplasm; may have pseudopods and vacuoles
many fine azurophilic granules give the appearance of “ground glass”
transitional cell because it migrates into the tissue and becomes a fixed or free macrophage

monocyte

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15-80 micrometers
indented, elongated or egg-shaped nucleus with fine chromatin
blue-gray cytoplasm with many vacuoles and coarse azurophilic granules; may contain ingested material

macrophage

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granules of monocytes which contain hydrolytic enzymes, including peroxidase and acid phosphatase

lysosomes

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highly motile cell that migrates against vessel walls and into the tissues
reference range is 2-100% in the peripheral blood

monocyte

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play a major role in initiating the regulating the immune response
process ingested material and antigenic information, which is relayed to the T-helper lymphocytes
very efficient phagocytic cells with receptors for IgG or complement-coated organisms

monocyte
macrophage

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ingest antigen-antibody complexes and activated clotting factors limiting the coagulation response

blood monocytes

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remove old/damaged rbcs and conserve iron for recycling

splenic macrophages

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remove fibrin degradation products

liver macrophages

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remove abnormal rbcs, ingest bare megakaryocyte nuclei or extruded rbc nuclei, and store and supply iron for hemoglobin synthesis

bone marrow marophages

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released by monocytes

cytokines/interleukins
tumor necrosis factor

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increase in the absolute number of monocytes

monocytosis

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monocytosis is associated with:

recovery stage from acute bacterial infections and marrow suppression by drugs
tuberculosis
syphilis
subacute bacterial endocarditis
AI disorders

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most common lipid storage disorder and has an autosomal recessive inheritance pattern

gaucher disease

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deficiency of this enzyme lead to accumulation of _____ in macrophages of the bone marrow, spleen and liver, with Gaucher cells more commonly seen in the bone marrow

glucocerebrosidase
glucocerebroside

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autosomal recessive pattern
accumulation of sphingomyelin to accumulate in macrophages in multiple organs and bone marrow

niemann-pick disease

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deficiency in niemann-pick disease

sphingomyelinase

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caused by unknown deficiency
sea-blue macrophages are found in the spleen and bone marrow

sea-blue histiocytosis

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lipid storage diseases: deficiency of alpha-galactosidase

fabry’s disease

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lipid storage diseases: deficiency of galactosidase

GM-1 gangliosidosis

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lipid storage diseases: deficiency of beta glucosidase (crumpled tissue paper appearance of macrophages/monocytes)

gaucher

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lipid storage diseases: deficiency of cerebroside beta galactosidase

krabbe

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lipid storage diseases: deficiency of sphingomyelinase (foamy appearance of macrophages/monocytes)

niemann pick

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lipid storage diseases: deficiency of arylsulfatase A

metachromatic leukodystrophy

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lipid storage diseases: deficiency of total hexosaminidase (hexosaminidase A and B)

sandhoff

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lipid storage diseases: deficiency of hexosaminidase A

tay sach

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decrease in the absolute number of monocytes
associated with stem cell disorders such as aplastic anemia

monocytopenia

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primary lymphoid tissues

bone marrow
thymus

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earliest recognizable lymphocyte precursor

lymphoblast

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morphology of lymphoblast
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
cytoplasmic granules:

morphology of lymphoblast
size: 10-18 micrometers
NC ratio: 4:1
nucleus: round/oval eccentric, with fine chromatin
nucleoli: one or more
cytoplasm: dark blue
cytoplasmic granules: none

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morphology of prolymphocyte
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
cytoplasmic granules:

morphology of prolymphocyte
size: 9-18 micrometers
NC ratio: 3:1
nucleus: round or indented, with coarsening chromatin
nucleoli: 0-1
cytoplasm: basophilic
cytoplasmic granules: none

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morphology of lymphocyte
size:
NC ratio:
nucleus:
nucleoli:
cytoplasm:
cytoplasmic granules:

morphology of lymphocyte
size: 9-18 micrometers
NC ratio: -
nucleus: round, oval or slightly indented with condensed chromatin
nucleoli: -
cytoplasm: scant to moderate amount of blue
cytoplasmic granules: few azurophilic

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have become activated as part of the immune response
associated with lymphocytosis can show the following characteristics:
1. generally larger cell with increased amount of dark blue cytoplasm
2. fine chromatin pattern with nucleoli
3. irregular shape to the nucleus
4. irregular shape to the cytoplasm (tags, sharp ridges); indented by red cells

reactive lymphocytes

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become immunocompetent in the secondary lymphoid tissue; dependent on antigenic stimulation
acquire specific receptors for antigens
make up 80% of the peripheral blood lymphocytes

T lymphocytes

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membrane markers of T-lymphocytes

cd2, cd3

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provide cellular immunity

T lymphocytes

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responsible for graft rejections and lysis of neoplastic cells

T lymphocytes

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attack and destroy viral and fungal organisms

T lymphocytes

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t lymphocytes obtain their antigenic information from these cells

monocytes

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regulate humoral response by helping antigen activate b cells

T lymphocytes

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t cell subsets that are involved in the immune response and are differentiated by cluster designation markers

t helper/inducer cell
t suppressor cells
cytotoxic t cell

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identified by cd4 membrane marker
promotes activation of b cells by antigens

t helper/inducer cells

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identified by cd8 membrane marker
suppresses activation of b cells by antigens

t suppressor cells

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identified by chd8 membrane marker
functions in viral infections and organ reactions

cytotoxic t cells

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normal T4:T8 ratio in circulating blood

2:1

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become immunocompetent in the secondary lymphoid tissue
dependent on antigenic stimulation
require specific receptors for antigens
make up 20% of the peripheral blood lymphocytes
identified by membrane makers CD19, CD20

b lymphocytes

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large cells with low NC ratio, large cytoplasmic granules, and pale blue cytoplasm
lack b cell or t cell membrane markers
CD16, CD56 positive
responsible for surveillance of cells for surface alterations such as tumor cells or cells infected with viruses
activated by IL-2 to express non specific cytotoxic functions
attacks antigens with attached IgG, called antibody-dependent cytotoxic cells

natural killer (nk) cells

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pathogen causing infectious mononucleosis
infects b cells

epstein-barr virus

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nonmalignant lymphocytosis associated with viral infections
common in the 14-24 age group
malaise, fever, pharyngitis, lymphadenopathy, splenomegaly through nasopharyngeal secretions
lymphocytes usually >50% of the wbcs, with 20% being reactive t lymphocytes attacking affected b lymphocytes
(+) heterophile antibody test

infectious mononucleosis

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nonmalignant lymphocytosis associated with viral infections
symptoms similar to IM
transmission by blood transfusion and saliva exchange
90% of lymphocytes can be reactive
(-) heterophile antibody test

cytomegalovirus

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nonmalignant lymphocytosis associated with viral infections
associated with adenovirus and coxsackie a virus
contagious disease mostly affecting young children
after a 12-21 day incubation period symptoms appear and include vomiting, fever, rash, diarrhea and possible cns involvement
no reactive lymphocytes

infectious lymphocytosis

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viral infections associated with lymphocytosis

hepatitis
influenza
mumps
measles
rubella
varicella

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bacterial infections associated with lymphocytosis

bordetella pertussis
brucellosis
toxoplasmosis

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malignant clone of cells proliferate that do not respond to normal regulatory mechanisms
originates in the bone marrow and is initially systemic

leukemia

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malignant clone of cells proliferate that do not respond to normal regulatory mechanisms
originates in lymphoid tissue and is initially localized

lymphoma

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acute or chronic proliferative of the cells of the lymphoid series

lymphoproliferative disorders

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acute or chronic proliferation of the cells of the myeloid series

myeloproliferative disorders

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most commonly used for bone marrow examination

posterior superior iliac crest

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predominant cell type in acute leukemias

immature/blast cells

predominant cell type in chronic leukemias

maturing or mature cells

clinical manifestations and laboratory findings in acute leukemias

weakness and fatigue due to anemia
petechiae and bruising due to thrombocytopenia
fever and infection due to neutropenia
variable leukocyte count
marrow blasts ≥ 20% based on WHO classification or ≥ 30% on FAB classification with cellularity > 70%

clinical manifestations and laboratory findings in chronic leukemias

anemia mild or absent
normal to slightly increased platelet count
wbc count usually high
marrow cellularity > 70%

classification based on cellular morphology and cytochemical stain results

french-american-british (fab) classification

classification based on cellular morphology and cytochemical stains, but also utilizes information obtained from immunologic probes of cell markers, cytogenetics, molecular abnormalities, and clinical syndrome

world health organization (who)

fab defines acute leukemia as ___ bone marrow blasts

> 30%

who defines acute leukemia as __ bone marrow blasts

≥20%

cells of the granulocytic series and to a lesser degree the monocytic series contain the enzyme peroxidase in their granules that is detected by this stain
used to differentiate blasts of acute myelogenous leukemia from acute lymphoblastic leukemias

myeloperoxidase (mpo)

auer rods in mpo tests

(+)

lymphocytic cells in mpo tests

(-)

stains phospholipids and lipoproteins
used to differentiate blasts of aml from aml

sudan black b

sudan black b: auer rods and granulocytic cells

(+)
blue-black granulation

sudan black b: lymphocytic cells

(-)

specific esterase stain
detects esterase enzyme present in primary granules of granulocytic cells

naphthol AS-D chloroacetate esterase stain

negative for naphthol AS-D chloroacetate esterase stain

monocytic cells

nonspecific esterase stain
detects esterase enzyme present in monocytic cells

alpha-naphthyl acetate
alpha-naphthyl butyrate

negative for nonspecific esterase stain

granulocytic cells

stains intracellular glycogen bright pink
useful in diagnosis of erythroleukemia and acute lymphoblastic leukemia

periodic acid schiff

positive with PAS

immature lymphoid cells
malignant erythroblasts
megakaryocytic cells

negative with PAS

myeloblasts
normal erythrocytic cells

detects alkaline phosphatase enzyme activity in primary granules of neutrophils
used to differentiate chronic myelogenous leukemia from a neutrophilic leukemoid reaction
positive stain will dark precipitate

leukocyte alkaline phosphatase (lap)

100 neutrophils are graded on a scale from 0 to 4+ based on stain intensity and size of granules, results are added together

lap score

reference range in lap score

30-185

lap grading: 0

no staining

lap grading: 1+

faint and diffuse staining

lap grading: 2+

pale with a moderate amount of blue staining

lap grading: 3+

strong blue precipitated staining

lap grading: 4+

deep blue or brilliant staining with no visible cytoplasm

clinical significance of decreased lap score

cml
paroxysmal nocturnal hemoglobinuria

clinical significance of normal lap score

cml in remission or with infection
hodgkin lymphoma in remission
secondary polycythemia

clinical significance of increased lap score

neutrophilic leukomoid reaction
polycythemia vera
cml
in blast crisis
late trimester pregnancy

chronic granulocytic leukemia
splenomegaly:
lap score:
phosphatase:
basophilic/eosinophilic:

(+)
decreased
(+)
normal to increased

leukemoid reaction
splenomegaly:
lap score:
phosphatase:
basophilic/eosinophilic:

(-)
normal to increased
(-)
normal

almost all blood cells contain the acid phosphatase enzyme and show positivity with acid phosphatase stain, hence this is administered so that staining is inhibited in most cells
only hairy cells from hairy cell leukemia are resistant

tartrate-resistant acid phosphatase stain (TRAP)

free iron precipitates into small blue/green granules in mature erythrocytes

perl’s prussian blue stain

iron inclusions when visible with wright’s stain

siderotic granules
pappenheimer bodies

nucleated rbcs in bone marrow that contain iron granules; normal

sideroblasts

contain iron that encircles the nucleus; abnormal

ringed sideroblasts

unregulated proliferation of the lymphoid stem cell
classified morphogically using FAB criteria or immunologically using CD markers to determine cell lineage (t or b cell)
s/sx: fever, bone/joint pain, bleeding, hepatosplenomegaly
lab: neutropenia, anemia, thrombocytopenia, variable wbc count, hypercellular marrow with bone marrow blasts > 20% (who) or >30% (fab)

acute lymphoproliferative disorders

ALD: most common childhood leukemia (2-to-10 year peak); also found in young adults
small lymphoblasts, homogenous appearance
best prognosis
most t-cell ALLs

FAB L1

ALD: most common in adults
large lymphoblasts, heterogenous appearance

FAB L2

ALD: leukemic phase of burkitt lymphoma
seen in both adults and children
lymphoblasts are large and uniform with prominent nucleoli; cytoplasm stains deeply basophilic and may show vacuoles
poor prognosis
b-cell lineage

FAB L3

ALD: high-grade non-hodgkin lymphoma phase of FAB L3 leukemia
endemic in east africa with high association with EB virus; children preset with jaw or facial bone tumors
US variant seen in children and young adults; present with abdominal mass

burkitt lymphoma

CD marker of progenitor b cell ALL

cd19(+)
cd34(+)
terminal deoxynucleotidyl transferase (+)
cd10(CALLA) (-)

CD marker of early-pre-B cells ALL

cd10(CALLA)(+)
cd19(+)
cd34(+)
TdT (+)

CD marker of pre-b cells ALL

cd10(CALLA)(+)
cd19(+)
cd20(+)
TdT(+)

CD marker of b cells ALL

cd19(+)
cd20(+)
TdT(-)

least mature b cell

progenitor b cells

most common subtype of b cell

early pre-b cells

second most common subtype of b cell

pre-b cells

most mature b cell and the least common subtype

b cells

immature t cells are tdt ___

positive

t cells markers include

cd2
cd3
cd5
cd7

ALL cell type that occurs most often in males
mediastinal mass is a common fiding

t cell

genetic translocations in FAB L3 / burkitt lymphoma

t(8;14) with a rearrangement of the myc oncogene

genetic translocations in pre-b cell ALL

t(9;22)

genetic translocations in b cell ALL

t(4;11)

genetic translocations in t cell ALL

t(7;11)

chronic lymphoproliferative disorders

chronic lymphocytic leukemia
hairy cell leukemia
prolymphocytic leukemia

chronic lymphoproliferative disorders: found in adults over 60 years old, more common in males (2:1), survival rate of 5-10 years
b cell malignancy
often asymptomatic and diagnosed secondary to other conditions
lab: bone marrow hypercellular, blood shows absolute lymphocytosis of >5.0 x 10^9, homogenous, small hyperclumped lymphocytes and smudge cells
anemia is not usually present unless secondary to warm ai hemolytic anemia

chronic lymphocytic leukemia (CLL)

lymphoma phase of CLL

small lymphocyte lymphomas

chronic lymphoproliferative disorders: found in adults over 50 years old, more common in males (7:1)
b cell malignancy
massive splenomegaly
extensive bone marrow involvement
lab: pancytopenia, cytoplasm of lymphocytes show hair-like projections; TRAP stain positive

hairy cell leukemia (HCL)

chronic lymphoproliferative disorders: found in adult; more common in males
can be either b cell (most common) or t cell malignancy
marked splenomegaly
lab: characterized by lymphocytosis with many prolymphocytes, anemia and thrombocytopenia
both b and t cell types are aggressive and respond poorly to treatment

prolymphocytic leukemia (PLL)

monoclonal gammopathy causes b cell production of excessive IgG or IgA with decreased production of other globulins
found in adults over 60 years old
incidence higher in males
multiple skeletal system tumors or plasma cells cause lytic bone lesions and hypercalcemia
lab: bone marrow plasma cell, marked rouleaux, increased erythrocyte sedimentation rate, blue background on blood smear, plasma cells and lymphocyte blood smear

multiple myeloma

found in the urine of patients with multiple myeloma
toxic to tubular epithelial cells and cause kidney damage

bence jones proteins

proliferation of malignant cells in solid lymphatic tissue
initially localized; may spread to bone marrow and blood
clinical symptom; lymphadenopathy
dx: tissue biopsy, cd surface markers, cytogenetics, dna analysis

lymphoma

WHO groups the lymphomas into:

hodgkin
b cell non hodgkin
t/nk cell non hodgkin

40% of lymphomas
seen in patients between 15-35 years of age and over 55 years of age
seen more frequently in males certain subtypes have an EB virus association
lab: mild anemia, eosinophilia and monocytosis, increased LAP and ESR during active disease

hodgkin lymphoma

found in lymph node biopsy
large, multinucleated cells each with prominent, large nucleoli, b cell lineage

reed-sternberg cells

WHO classification of hodgkin lymphoma subtypes

nodular sclerosis
mixed cellularity
lymphocyte rich
lymphocyte depleted

hodgkin lymphoma subtype: 70%; lowest EBV association

nodular sclerosis

hodgkin lymphoma subtype: 20%; highest EBV association

mixed cellularity

60% of lymphomas; seen in patients over 50 years of age; seen more frequently in males
enlarged lymph nodes or GI tumors
cells can be small and mature or large and primitive
can be slow growing or very aggressive
b cell neoplasms are more common

non hodgkin lymphoma

classified by WHO as T/NK cell neoplasm
seen in patients over 50 years of age
cutaneous lymphoma causes skin itching, leading to ulcerative tumors
cd2, cd3, cd4 (+)

mycosis fungoides

variant of mycosis fungoides
presents as disseminated disease with widespread skin involvement and circulating lymphoma cells

sezary syndrome

unregulated proliferation of the myeloid stem cell
classified using morphology, cytochemical stains, cd markers, cytogenetics
platelets, erythrocyte, granulocytes and/or monocytes can be affected
found mainly in middle-aged adults, also children <1 yar old
clinical s/sx: fever, malaise, weight loss, petechiae, bruises, mild hepatosplenomegaly
lab: neutropenia, anemia, thrombocytopenia, variable wbc count; hypercellular marrow with bone marrow blasts

acute myeloproliferative disorders

acute myelogenous leukemia: blasts exhibit myeloid markers (cd13, cd33 and cd34 but stain negatively with the usual cytochemical stains, myeloperoxidase, sudan black), constitute 5% of AML

FAB M0

acute myelogenous leukemia: shows 90% or more marrow myeloblasts; may have auer rods (fused primary granules)

FAB M1

aml with maturation
shows <90% marrow myeloblasts; may have auer rods; chromosome abnormality t(8;21)

FAM M2

characterized by >30% marrow promyelocytes with bundles of auer rods( faggot cells) heavy azurophilic granulation
clinical symptoms: severe bleeding, hepatomegaly, and disseminated intravascular coagulation (promyelocytes have procoagulant activity)
accounts for 5% of the amls
sbb, mpo and specific esterase (+), cd13 (+), cd33(+), diagnostic chromosome abnormality t(15;17); pml/rara oncogene involved

acute promyelocytic leukemia (apl, FAB M3)

characterized by >20% (who) or <30% FAB marrow myeloblasts with >20% cells of monocytic origin may have auer rods
proliferation of unipotential stem cell cfu cm that gives rise to both granulocytes and monocytes
accounts for 30% of the amls
increased urine/serum lysozyme
sbe, mpo and specific and non specific esterase (+)
cd13 (+), cd33 (+) and cd14(+)

acute myelomonocytic leukemia (amml, FAB M4)

subclass of amml that presents with eosinophilia

M4Eo

characterized by >20% (who) or >30%(fab) marrow monoblasts
accounts for 10% of the amls
nonspecific esterase (+), cd14(+)
contains two variants

acute monocytic leukemia (AMoL, FAB M5)

AMoL variants: seen in children with >80% monoblasts in the bone marrow

M5a

AMoL variants: seen in middle-aged adults with >80% monoblasts in the bone marrow

M5b

characterized by >20% (who) or >30% (fab) marrow myeloblasts and >50% dysplastic marrow normoblasts
accounts for 5% of the amls
malignant normoblasts are PAS (+), cd45(+), cd71/glycophorin A(+)
myeloblasts are sbb (+), mpo(+), cd13(+), cd(+15), cd33(+)

acute erythroleukemia (ael, digulgliemo syndrome, FAB M6)

characterized by proliferation, of megakaryoblasts and atypical megakaryocytes in the bone marrow; blasts may have cytoplasmic blebs
accounts for <1% of the amls
marrow aspiration results in dry tap; blood shows pancytopenia
difficult to diagnose with cytochemical stains
cd41, cd42, cd61 (platelet markers) positive

acute megakaryocytic leukemia

contain two cell populations: one expresses myeloid antigens and the other expresses lymphoid antigens

bilineage leukemias

occur when myeloid and lymphoid antigens are expressed on the same cell; poor prognosis

biphenotypic leukemias

characterized by hypercellular marrow, erythrocytosis, granulocytosis, thrombocytosis
defect on myeloid stem cell
named for the cell line most greatly affected
all may terminate in acute leukemia

chronic myeloproliferative disorders

implicated in polycythemia vera (80%), chronic idiopathic myelofibrosis (50%) and essential thrombocytopenia (40%)

jak2 oncogene

associated with chronic myelogenous leukemia

bcr/abl

presents with proliferation of granulocytes
found mainly in adults 45 years of age and older, often diagnosed secondary to other conditions
clinical s/sx: weight loss, splenomegaly, fever, night sweats, and malaise
bone marrow has an increased M:E ratio
lab: blood findings include mild anemia and wbc between 50 and 500x10^9 with all stages of granulocyte production
, including early forms of eosinophils and basophils, myelocyte predominate, may have a few circulating blasts
can mimic neutrophilic leukemoid reaction
philadelphia chromosome is present in virtually all patients

chronic myelogenous leukemia

translocation in the philadelphia chromosome

t(9;22)

cml: can last up to 5 years

chronic phase

cml: ultimately leads to acute leukemia in most patients

accelerated phase (blast crisis)

malignant hyperplasia of the multipotential myeloid stem cell causes increases in all cell lines; erythrocytes most greatly increased despite decreased erythropoietin
high blood viscosity can cause high blood pressure, stroke and heart attack
found in adults 50 years old and older

polycythemia vera

characterized by proliferation of megakaryocytes
found mainly in adults 60 years of age and older
lab: platelets commonly greater than 1000 x 10^9/L, giant forms, platelet function abnormalities, leukocytosis
must differentiate from reactive thrombocytosis and polycythemia vera

essential thrombocythemia

increase in rbc mass is an appropriate response to increased erythropoiesis or tissue hypoxia
plasma volume, leukocyte count, and platelet count are normal
can be caused by smoking, emphysema, or high altitude

secondary polycythemia

decreased plasma volume with a normal rbc mass caused by dehydration
increased hemoglobin, normal leukocyte and platelet count, normal epo

relative polycythemia

myeloid stem cell disorder characterized by proliferation of erythroid, granulocytic and megakaryocytic precursors in the marrow with dyspoiesis
progressive marrow fibrosis
found in adults 50 years of age and older
clinical symptoms: bleeding due to abnormal platelet function; extramedullary hematopoiesis, splenomegaly and hepatomegaly
lab: anisocytosis, poikilocytosis with teardrop cells, leukoerythroblastic anemia, abnormal morphology associated with all cell lines

chronic idiopathic myelofibrosis

immature neutrophils and nucleated rbcs in circulation

leukoerythroblastic anemia

group of acquired clonal disorders affecting the pluripotential stem cell
characterized by progressive blood cytopenias despite bone marrow hyperplasia
can be triggered by chemotherapy, radiation and chemicals
found in older adults, rarely found in children and young adult
five subgroups using the FAB classification scheme; up to 30% blasts in the marrow

myelodysplastic syndromes (mds)

anemia that is not responsive to therapy
lab: oval macrocytes, reticulocytopenia, dyserythropoiesis; bone marrow blasts <5% and peripheral blood blasts <1%

refractory anemia (ra)

ringed sideroblasts comprise more than 15% of bone marrow nucleated cells, signs of dyserythropoiesis and neuetropenia
lab: oval macrocytes, reticulocytopenia, dyserythropoiesis; bone marrow blasts <5% and peripheral blood blasts <1%, dimorphic erythrocytes
primary/idiopathic sideroblastic anemia discussed with the anemia

refractory anemia with ringed sideroblasts (rars)

trilineage cytopenias common
lab: bone marrow blasts 5-20% and peripheral blood blasts <5%; no absolute monocytosis
the higher the blast percent, the worse the prognosis

refractory anemia with excess blasts (raeb)

mds that usually presents with leukocytosis
lab: one marrow blasts 5-20% and peripheral blood blasts <5%; absolute monocytosis greater than 1.0x10^9/L

chronic myelomonocytic leukemia (cmml)

lab: bone marrow blasts >20% but less than 30% peripheral blood blasts > 5%
who classification reassigns this as an acute leukemia instead of a mds because fo the bone marrow blast percent

refractory anemia with excess blasts in transformation (raeb-t)

serves as oxygen transport, removal of metabolic waste
loss of nucleus is required for function

rbc

normal life span of erythrocyte

120 days

produced mainly by the kidneys
growth factor that stimulates erythrocytes production from myeloid progenitor cells; influences colony-forming unit-erythrocytes (cfu-es) to differentiate into erythroblasts

erythropoietin

earliest rbc, size up to 20 micrometers, with an NC ratio of f8:1
1-3 nucleoli, nucleus has dark areas of dna
chromatin is fine and uniform and stains intensely
deep blue cytoplasm with no granules

pronormoblast (rubriblast)

size up to 16 micrometers with an NC ratio of 6:1
centrally located nucleus with 0-1 nucleoli
chromatin coarsening
cytoplasm is less blue intensely basophilic

basophilic normoblast (prorubricyte)

size up to 12 micrometers with an NC ratio of 4:1
eccentric nucleus with no nucleoli
chromatin shows significant clumping
begins to produce hemoglobin resulting, in reddish-blue cytoplasm

polychromatophilic normoblast (rubricyte)

size up to 10 micrometers with an NC raio of 0.5:1
eccentric nucleus with small, fully condensed (pyknotic) nucleus; no nucleoli
pale blue to salmon cytoplasm
hemoglobin synthesis decreases

orthochromatic normoblast (metarubricyte)

size up to 10 micrometers
contains no nucleus but has mitochondrial and ribosomes
last stage to synthesize hemoglobin
last stage in bone marrow before release to the blood
reference ranges are 0.5-1.5% for adults and 2.5-6.5% for newborns, with a slightly increased ranges at higher altitudes

reticulocyte

used to enumerate for reticulocyte

supravital stain

one of the best indicators of bone marrow function

reticulocyte count

young cells released from bone marrow after older reticulocytes have been released

stress reticulocytes

size range is 6-8 micrometers
round, biconcave discocyte
salmon with central pallor when a blood smear is wright’s stained

erythrocyte

rbc reference range in females

4.0-5.4 x 10^12/L

rbc reference range in males

4.6-6.0 x 10^12/L

produced in the kidney
regulates erythropoiesis, hypoxia due to high altitude, heart or lung dysfunction, anemia, and androgens and hemolytic anemias

erythropoietin

early rbcs’ source of energy

oxidative phosphorylation

mechanism that keeps sodium outside and potassium inside the wall

cation pump

iron should be in this state to transport oxygen

ferrous state

amino acids needed for erythropoiesis

globin-chain sythesis

needed for dna replication or cell division during eyrthropoiesis

folic acid/vitamin b12

rbcs greater than 8 micrometers
MCV greater than 100fL
seen in megaloblastic anemia, such as B12/folate deficiency
seen in liver disease or accelerated erythropoiesis; also seen in normal newborns

macrocytes

normal erythrocytes that are approximately the same size as the nucleus of a small lymphocyte

normocyte

rbcs less than 6 micrometers in diameter
mcv less than 80fL
see in iron deficiency anemia, thalassemia, sideroblasic anemia and anemia of chronic disease

microcytes

variation in rbc size, indicating a heterogenous rbc population
correlates with rdw, especially when the rdw exceeds 15%
seen post transfusion, post treatment for a deficiency, presence of two concurrent deficiencies, and idiopathic sideroblastic anemia

anisocytosis

general term to describe variation in shape
associated with a variety of pathologic conditions

poikilocytosis

have evenly spaced round projections; central pallor area present
see in liver disease, uremia, heparin therapy, pyruvate kinase deficiency, or an an artifact
caused by changes in osmotic pressure

echinocytes

have unevenly spaced pointed projections; lack a central pallor area
associated with alcoholic liver disease, post-splenomegaly, and abetalipoproteinemia
caused by excessive cholesterol in the membrane

acanthocytes (spur cells)

show a central area of hemoglobin surrounded by a colorless ring and a peripheral ring of hemoglobin; cells have an increased surface-to-volume ratio
seen in liver disease, hemoglobinopathies, thalassemia, iron deficiency anemia
caused by excessive cholesterol in the membrane or a hemoglobin distribution imbalance

target cells (codocytes or mexican hat cells)

disk-shaped cell with a smaller volume than a normal erythrocyte; cells have a decreased surface
lack a central pallor area
associated with defects of the red cell membrane proteins
mchc may be >37% increased osmotic fragility
damaged rbc, seen in hereditary spherocytosis, g6pd deficiency and immune hemolytic anemia
microspherocytes <4micrometers are frequently seen in severe thermal injury

spherocytes

pear-shaped cell with one blunt projection
seen in megaloblastic anemias, thalassemia and extramedullary hematopoiesis

teardrops (dacryocytes)

shapes vary but show thin, elongated, pointed ends and will appear crescent shaped; usually lack a central pallor area
contain polymers of abnormal hemoglobin S
seen in hemoglobinopathies SS, SC, SD and S/beta-thalassemia
cell shape is caused by cell membrane alterations due to an amino acid substitution

sickle cell (drepanocytes)

interior portion of cell is hollow, resembling a horn or helmet
seen in macroangiopathic hemolytic anemias

helmet cells (horn cells or keratocytes)

damaged rbc fragments of various sizes and shapes are present
often with pointed projections
seen in microangiopathic hemolytic anemias, thermal injury, renal transplant rejection, and g6pd deficiency

schistocytes (rbc fragments)

characterized by an elongated or slit-like area of central pallor
seen in liver disease, hereditary stomatocytosis or as artifact
caused by osmotic changes due to cation imbalance

stomatocytes (mouth cells)

usually orthochromic normoblasts, metarubricytes but can appear in any erythrocytic stage of maturation
indicate bone marrow stimulation or increased erythropoiesis
associated with thalassemia jamor, sickle cell aenima, and tother hemolytic anemias, erythroleukemia and myeloproliferative disorders
normal newborns can have a few
healthy individuals should have none on a peripheral blood smear

nucleated rbcs

cigar- to egg-shaped erythrocytes
associated with defects of the red cell membrane proteins
seen in hereditary elliptocytosis, iron-deficiency anemia, pencil forms, megaloblastic anemia, (macro-ovalocytes), thalassemia major

elliptocytes (ovalocytes)

small round dna fragments, usually one per cell, but can be multiple
stain dark purple to black with wright’s stain
not seen in normal erythrocytes; normally pitted by splenic macrophages
seen in sickle cell anemia, beta thalassemia major, and other severe hemolytic anemias, megaloblastic anemia, alcoholism, post-splenomegaly

howell-jolly bodies

multiple, tiny, fine and coarse inclusions (ribosomal rna remnants) evenly dispersed throughout the cell; “blueberry bage” appearance
stain dark blue with wright’s stain
seen in thalassemia, megaloblastic anemias, sideroblastic anemia, lead poisoning, and alcoholism

basophilic stippling

small, irregular, dark staining iron granules usually clumped together at periphery of the cells
stain with perl’s prussian blue stain: appear dark violet with wright’s stain
caused by an accumulation of ribosomes, mitochondria and iron fragments
seen in sideroblastic anemia, hemoglobinopathies, thalassemia, megaloblastic anemia, myelodysplastic syndrome

pappenheimer bodies

thin, red-violet, single to multiple ringlike structures that may appear in loop or figure-eight shapes
seen in megaloblastic anemia, myelodysplastic syndromes, lead poisoning
composed of fragments of nuclear material

cabot rings

condensed, intracellular, rod-shaped crystal
seen in hemoglobin C or SC disease, but not in trait

hemoglobin c crystals

1-2 blunt, finger-like projections extending from the cell membrane
seen in hemoglobin SC disease

hemoglobin SC crystals (washington monument)

multiple inclusions ranging in size from 0.3-2.0 micrometers
invisible with wright’s stain; must use a supravital stain to visualize
seen in g6pd deficiency, beta thalassemia major, hgb h disease, unstables hemoglobinopathies, drug-induced anemias

heinz bodies

central pallor area is greater than one-third the diameter of the cell
mch and mchc usually decreased
often associated with microcytosis
seen in iron-deficiency anemia, thalassemia, anemia of chronic disorder, sideroblastic anemia, myelodysplastic syndromes

hypochromasia

rbcs that have normal one-third clear, central pallor area

normochromasia

variation in hemoglobin content showing a slight blue tinge when stained with wright’s stain residual rna
indicates reticulocytosis; supravital reticulocyte stain to enumerate
usually slightly macrocytic

polychromasia

rbcs lacking a central pallor area

spherocyte

staking or coining pattern of rbcs due to abnormal or increased plasma protein
may see excessively blue color to smear macroscopically and microscopically
seen in hyperproteinemia, multiple myeloma, waldenstrom macroglobulinemia, and conditions that produce increased fibrinogen
may be artifact; considered normal n thicker area of the peripheral smear

rouleaux

characterized by clumping of erythrocytes with no pattern
occurs when erythrocytes are coated with igm antibodies and complement
seen in cold autoimmune hemolytic anemia
warm blood to 37degC to correct a false low rbc and hematocrit and falsely high mchc when using an automated cell counting instrument

agglutination

oxygen-transporting protein contained within erythrocytes
heme portion gives characteristic red color

hemoglobin

four identical heme groups, each containing a protoporphyrin ring and ferrous iron
alpha chains have 141 amino acids while the beta, gamma and delta chains have 146 amino acids

hemoglobin

heme synthesis occurs in _____ of normoblasts

mitochondria

heme synthesis is dependent on these

glycine
succinyl coenzyme A
aminolevulinic acid synthetase
vitamin b6

hemoglobin: globin synthesis occurs in ____

ribosomes

hemoglobin synthesis: globin synthesis is controlled on ___ for alpha chain and ____ for all other chains

chromosome 16
chromosome 11

occurs when hemoglobin breaks down in the blood and free hemoglobin is released into plasma
lab: increased plasma hemoglobin, serum bilirubin, serum ld and urine urobilinogen, hemoglobinuria, and hemosiderinuria present, decreased serum haptoglobin

intravascular hemolysis (10%)

in intravascular hemolysis: free hemoglobin binds to ___, ____ and ___ and is phagocytized by _____

haptoglobin, hemopexin, albumin
liver macrophages

occurs when senescent/old rbcs are phagocytized by macrophages in the liver or spleen

extravascular hemolysis (90%)

protoporphyrin ring metabolized to ___, and excreted in urine and feces

bilirubin and urobilinogen

extravascular hemolysis: iron binds to ____ and is transported to bone marrow for new rbc production, or it is stored for future use in the form of _____

transferrin
ferritin or hemosiderin

measures the amount of fe3+ bound to transferrin

serum iron

measures the total amount of iron that transferrin can bind when fully saturated

total iron binding capacity

indirect measurement of storage iron in tissues and bone marrow

serum ferritin

contains two alpha- and two gamma globin chains
functions in a reduced oxygen environment
predominates at birth (80%)
compensatory hemoglobin and can be increased in homozygous hemoglobinopathies and beta thalassemia major
lab: alkali denaturation test and kleihauer-betke acid elution stain, column chromatography, radial immunodiffusion

hgb F

in adult blood, this contains 2 alpha and 2 beta globin chains
subdivided into glycosylated fractions

HgbA

this fraction reflects the glucose levels in the blood
used to monitor individuals with DM

HbA1c

in adult blood, this contains 2 alpha and 2 delta-globin chains

HgbA2

reference range for a normal adult:
HbA, HbA2 and HbF

97%
2%
1%

normal human embryonic hemoglobin

portland
gower 1
gower 2

normal newborn and adult hemoglobin

fetal
A1
A2

globin chain types: portland

2 zeta
2 gamma

globin chain types: gower 1

2 zeta
2 epsilon

globin chain types: gower 2

2 alpha
2 epsilon

globin chain types: fetal

2 alpha
2 gamma

globin chain types: a1

2 alpha
2 beta

globin chain types: a2

2 alpha
2 delta

hemoglobin with ferrous iron bound to oxygen, seen in arterial circulation

oxyhemoglobin

hemoglobin with ferrous iron but no oxygen, seen in venous circulation

deoxyhemoglobin

hemoglobin with ferrous iron and carbon monoxide
can result in death but reversible if given pure O2

carboxyhemoglobin

hemoglobin with sulfhydryl group; cannot transport oxygen; seldom reaches fatal levels; caused by drugs and chemicals, irreversible, not measured by the cyanmethemoglobin mehod

sulfhemoglobin

hemoglobin with iron on the ferric state, cannot transport oxygen, increased levels causes cyanosis and uremia

methemoglobin

ability of hemoglobin to bind or release oxygen
expressed in terms of the oxygen tension at which hemoglobin is 50% saturated with oxygen

oxygen affinity

oxygen dissociation curve: decreases oxygen affinity; more oxygen release to the tissues due to high 2,3-biphosphoglycerate level or increased body temperature, decreased body pH

right shift

oxygen dissociation curve: increases oxygen affinity, less oxygen release to the tissues due to low 2,3-DPG level or decreased body temperature

left shift

oxygen dissociation curve: inc. blood temp

right

oxygen dissociation curve: inc. pH

left

oxygen dissociation curve: inc. 2,3 DPG

right

oxygen dissociation curve: inc. carbon dioxide

right

oxygen dissociation curve: inc. HgbF

left

oxygen dissociation curve: dec. blood temp

left

oxygen dissociation curve: dec. pH

right

oxygen dissociation curve: dec. 2,3 DPG

left

oxygen dissociation curve: dec. carbon dioxide

left

decrease in erythrocytes and hemoglobin, resulting in decreased oxygen delivery to the tissues
can be classified morphologically or based on etiology/cause

anemia

rbc mass is normal, but plasma volume is increased
secondary to an unrelated condition and can be transient in nature
causes include conditions that result in hemodilution, such as pregnancy and volume overload

relative (pseudo) anemia

rbc mass is decreased, but plasma volume is normal
indicative of a true decrease in erythrocytes and hemoglobin

absolute anemia

most common form of anemia
prevalent in infants, children, pregnancy, excessive menstrual flow, elderly with poor diets, malabsorption syndromes, chronic blood loss
s/sx: fatigue, dizziness, pica, stomatitis, glossitis, koilonychias

iron-deficiency anemia

laboratory:
serum iron, ferritin, hemoglobin/hematocrit, rbc indices and reticulocyte counts are low
rdw and total iron binding capaicty high
smear shows ovalocytes/pencil forms

iron-deficiency anemia

cracks in the corners of the mouth

stomatitits

spooning of the nails

koilonychias

due to an inability to use available iron for hemoglobin production
impaired release of storage iron associated with increased hepcidin levels
associated with persistent infection, chronic inflammatory disorders (SLE, rheumatoid arthritis, hodgkin lymphoma, cancer)
second common cause of anemia

anemia of chronic disease

liver hormone and a positive acute phase reactant
plays a major role in body iron regulation by influencing intestinal iron absorption and release of storage iron from macrophages
level increase is triggered by inflammation and infection
decreases release of iron from stores

hepcidin

laboratory: increased esr
normal to increased ferritin
low serum iron and tibc

normocytic/monochromic anemia

caused by blocks in the protoporphyrin pathway resulting in defective hemoglobin synthesis and iron overload

sideroblastic anemia

excess irons accumulates in the mitochondrial region of the immature erythrocytes in the bone marrow and encircles the nucleus; cells are called ____

ringed sideroblasts

excess iron accumulates in the mitochondrial region of the mature erythrocytes in the circulation; cells are called ____, best demonstrated using ___

siderocytes
perl’s prussian blue stain

inclusions of siderocytes are called ___ which are ____ on wright’s stained smear

siderotic granules
pappenheimer bodies

types of sideroblastic anemia: irreversible; cause of the blocks unknown
2 rbc populations (dimorphic) are seen
this is one of the myelodysplastic syndromes - refractory anemia with ringed sideroblasts

primary

types of sideroblastic anemia: reversible, causes include alcohol, anti-tuberculosis drugs, chloramphenicol

secondary

laboratory: microcytic/hypochromic anemia with increased ferritin and serum iron, tibc is decreased

sideroblastic anemia

multiple blocks in the protoporphyrin pathway affect heme synthesis
seen mostly in children
s/sx: abdominal pain, muscle weakness, and a gum lead line that forms from blue/black deposits of lead sulfate
lab: normocytic/normochromic anemia with characteristics coarse basophilic stippling

lead poisoning

group of inherited disorders characterized by a block in the protophorphyrin pathway of heme synthesis
heme precursors accumulate in the tissues, and large amounts are excreted in the urine and/or feces
s/sx: photosensitivity, abdominal pains, cns disorders
hematologic findings are insignificant

porphyrias

defective dna synthesis causes abnormal nuclear maturation
rna synthesis is normal, so the cytoplasm is not affected
nucleus matures slower than the cytoplasm
caused by either a vitamin b12 or b9 deficiency, malabsorption syndromes, d. latum tapeworm infection, total gastrectomy, intestinal blind loops and total vegetarian diet
lab: pancytopenia, macrocytic/normochromic anemia with oval macrocytes and teardrops, hypersegmented neutrophils

megaloblastic anemia

secreted by parietal cells and is needed to bind vitamin b12 for absorption into the intestines

intrinsic factor

caused by deficiency of intrinsic factor, antibodies to intrinsic factor or antibodies to parietal cells

pernicious anemia

prevalent in older adults of english, irish and scandinavian descent
characterized by achlorhydria and atrophy of gastric parietal cells

vitamin b12 deficiency

causes a megaloblastic anemia with a blood picture and clinical symptoms similar to vitamin b12 except that there is no cns involvement
associated with poor diet, pregnancy, or chemotherapeutic anti-folic acid drugs such as methotrexate

folic acid deficiency

bone marrow failure causes pancytopenia
lab: decrease in hemoglobin/hematocrit and reticulocytes; normocytic/normochromic anemia; no response to erythropoietin
most commonly affects people around the age of 50 and above
poor prognosis with complications that include bleeding, infection and iron overload due to frequent transfusion needs
treatment includes bone marrow or stem cell transplant and immunosuppression

aplastic anemia

autosomal recessive trait
dwarfism, renal disease, mental retardation
strong association with malignancy development, especially acute lymphoblastic leukemia

fanconi anemia

causes of secondary aplastic anemia: antibiotics

chloramphenicol
sulfonamides

causes of secondary aplastic anemia: chemicals

benzene
herbicides

causes of secondary aplastic anemia: viruses

parvovirus secondary to hepatitis
measles
cmv
epstein-barr virus

true red cell aplasia (leukocytes and platelets normal in number)
autosomal inheritance

diamond-blackfan anemia

difference between diamond blackfan anemia vs. fanconi anemia: hematologic classification

d: congenital pure rede cell aplasia
f: congenital aplastic anemia

difference between diamond blackfan anemia vs. fanconi anemia: brown skin pigmentation

d: uncommon
f: common

difference between diamond blackfan anemia vs. fanconi anemia: thumb abnormalities

d: uncommon
f: common

difference between diamond blackfan anemia vs. fanconi anemia: renal abnormalities

d: uncommon
f: common

difference between diamond blackfan anemia vs. fanconi anemia: onset of hematologic abnormalities

d: <1 year of age
f: 5-10 years of age

difference between diamond blackfan anemia vs. fanconi anemia: bone marrow biopsy

d: cellular
f: hypoplastic to aplastic

difference between diamond blackfan anemia vs. fanconi anemia: bone marrow aspirate

d: marked decrease only in erythroid precursors
f: pancytopenia

difference between diamond blackfan anemia vs. fanconi anemia: peripheral blood

d: decrease in rbc, normal wbc and platelets
f: pancytopenia

difference between diamond blackfan anemia vs. fanconi anemia: cytogenetics

d: no associated abnormalities
f: multiple chromosomal abnormalities in many tissues

hypoproliferative anemia caused by replacement of bone marrow hematopoietic cells by malignant cells or fibrotic tissue
associated with cancers (breast, prostrate, lung, melanoma) with bone metastasis
lab: normocytic, normochromic anemia; leukoerythroblastic blood picture

myelophthisic (marrow replacement) anemia

characterized by a sudden loss of blood resulting from trauma or other severe forms of injury
s/sx: hypovolemia, rapid pulse, low blood pressure, pallor
lab: normocytic normochromic anemia; initially normal reticulocyte count, hemoglobin/hematocrit; in a few hours, increase in platelet count and leukocytosis with a left shift, drop in hemoglobin and hematocrit and rbc, reticulocysotis in 3-5 days

acute blood loss anemia

characterized by a gradual, long-term loss of blood; often caused by gi bleeding
lab: initially normocytic, normochromic anemia that over time causes a decrease in hemoglobin/hematocrit; gradual loss of iron causes microcytic/hypochromic anemia

chronic blood loss anemia

all cause a normocytic/normochromic anemia
usually hereditary with reticulocytosis due to accelerated destruction

hemolytic anemias due to intrinsic defects

most common membrane defect
autosomal dominant
characterized by splenomegaly, variable degree of anemia, spherocytes on the pbs
increased permeability of the membrane to sodium
results in loss of membrane fragments; erythrocytes have decreased surface area-to-volume ratio; rigid spherocytes culled/removed by splenic macrophages
lab: spherocytes, mchc may be >37g/dl, increased osmotic fragility and increased serum bilirubin

hereditary spherocytes

autosomal dominant
most are asymptomatic due to normal erythrocytes life span
> 25% ovalocytes on pbs
membrane defects is caused by polarization of cholesterol at the ends of the cell rather than around pallor area

hereditary elliptocytosis (ovalocytosis)

autosomal dominant
variable degree of anemia
up to 50% stomatocytes on the blood smear
membrane defect due to abnormal permeability both to sodium and potassium
causes erythrocyte swelling

hereditary stomatocytosis

autosomal recessive
mild anemia associated with steatorrhea, neurological and retinal abnormalities
50-100% of erythrocytes are acanthocytes
increased cholesterol:lecithin ratio in the membrane due to abnormal lipid concentrations
absence of serum beta-lipoprotein needed for transport

hereditary acanthocytosis

sex-linked enzyme defect
most common enzyme deficiency in the hexose monophosphate shunt
reduced glutathione levels are not maintained because of decreased nadph generation
results in oxidation of hemoglobin to methemoglobin, and denatures to form heinz bodies
usually nonanemic until oxidatively challenged
severe hemolytic anemia with reticulocytosis

g6pd deficiency

autosomal recessive
most common enzyme deficiency in embden-meyerhof pathway
lack of atp causes impairment of the cation pump that controls intracellular sodium and potassium levels
decreased erythrocyte deformability reduces their life span
severe hemolytic anemia with reticulocytosis and echnicytosis

pyruvate kinase deficiency

an acquired membrane defect in which the red cell membranes has an increased sensitivity for complement binding as compared to normal rbcs
unknown etiology
all cells are abnormally sensitive to lysis by complement
pancytopenia, chronic intravascular hemolysis cause hemoglobinuria and hemosiderinuria at an acid ph at night
low leukocyte alkaline phosphatase score
ham’s and sugar water tests used in diagnosis
increased incidence of acute leukemia

paroxysmal nocturnal hemoglobinuria

all cause a normocytic/normochromic anemia due to defects extrinsic to rbc
all are acquired disorders that cause accelerated destruction with reticulocytosis

hemolytic anemia due to extrinsic/immune defects

rbcs are coated with igg and/or complement
macrophages phagocytize these rbcs, or they may remove the antibody or complement from the rbcs surface, causing membrane loss and spherocytes
60% of cases are idiopathic
other cases are secondary to disease that alter the immune response
lab: spherocytes, mchc may be >37g/dL, increased osmotic fragility, bilirubin, reticulocyte count, occasional nRBCs present

warm autoimmune hemolytic anemia

rbcs are coated with igm and complement at temperatures <37degC
rbs are lysed by complement or phagocytized by macrophages
can be idiopathic, or secondary to mycoplasma pneumoniae, lymphoma or infectious mononucleosis
lab: seasonal symptoms, rbc clumping can be seen both macroscopically and microscopically, mchc >37g/dL, increased bilirubin, reticulocyte count, positive DAT detects complement coated rbcs

cold autoimmune hemolytic anemia

an igg biphasic donath-landsteiner antibody with p specificity fixes complement to rbcs in the cold
the complement coated pbcs lyse when warmed to 37degC
can be idiopathic or secondary to viral infections and non hodgkin lymphoma
lab: variable anemia following hemolytic process, increased bilirubin and plasma hemoglobin, decreased haptoglobin, DAT may be positive

paroxysmal cold hemoglobinuria

recipient has antibodies to antigens on donor rbcs
donor cells are destroyed
abo incompatibility causes and immediate with massive intravascular hemolysis that is complement induced
usually igm antibodies
can trigger dic due to release of tissue factor from lysed rbcs
lab: positive DAT, increased plasma hemoglobin

hemolytic transfusion reaction

may be due to Rh incompatibility
Rh (-) woman is exposed to Rh Ag from fetus and forms IgG Ab, which then cross the placenta and destroy rbcs of the next fetus that is Rh (+)
lab: severe anemia, nRBCs, positive DAT, very high bilirubin levels cause kernicterus leading to brain damage
exchange transfusions in utero or shortly after birth
no longer a common problem with the use of Rh Ig
may be due to ABO incompatibility

hemolytic disease of the newborn

all cause a normocytic/normochromic anemia caused by trauma to the rbc
all are acquired disorders that cause intravascular hemolysis with schistocytes and thrombocytopenia

hemolytic anemia due to extrinsic/non-immune defects

systemic clotting is initiated by the activation of the coagulation cascade due to toxins or conditions that trigger release of procoagulants (tissue factor)
multiple organ failure can occur due to clotting
fibrin is deposited in small vessels, causing rbc fragmentation

disseminated intravascular coagulation

occurs most often in children following gastrointestinal infection
clots form, causing renal damage

hemolytic uremic syndrome

occurs most often in adults
it is likely due to a deficiency of the enzyme ADAMTS 13 causing multimers not being broken down, thereby causing for clots to form leading to rbc fragmentation and cns impairment

thrombotic thrombocytopenic purpura

transient hemolytic anemia that occurs after a forceful contact of the body with hard surfaces

march hemoglobinuria

group of inherited disorders causing structurally abnormal globin chain synthesis due to amino acid substitution
associated with target cells

hemoglobinopathies

most common type of hemoglobinopathies

HgbS

second most common type of hemoglobinopathies

HgbC

third most common type of hemoglobinopathies

Hbg E

responsible for breaking down large von willebrand factor multimers

ADAMTS 13

caused when valine replaces glutamic acid at position 6 on both beta chains
results in a decrease in hemoglobin solubility and function
defect is inherited from both parents
occurs most commonly in african-america
no hgbA is produced
erythrocytes become rigid and trapped in capillaries; blood flow restriction causes lack of oxygen to the tissues, resulting in tissue necrosis
all organs are affected, with kidney failure being a common outcome

sickle cell disease

those with sickle cell disease/sickle cell trait have apparent immunity to ___

plasmodium falciparum

valine replaces glutamic acid at position 6 on one beta chain
defect is inherited from one parent
most common hemoglobinopathy in the US
produces no clinical symptoms
(+) Hgb solubility screening test

sickle cell trait

caused when lysine replaces glutamic acid at position 6 on both beta chains
occurs in the african-american and african populations
no hgbA is produced
lab: normochromic/normocytic anemia with target cells
characterized by intracellular rod-like C crystals

HgbC disease

double heterozygous condition where an abnormal sickle gene from one parent and an abnormal C gene from the other parent is inherited
seen in african, mediterranean and middle eastern populations; symptoms less severe than sickle cell anemia but more severe than hbgC disease
no hbgA is produced
lab: moderate to severe normocytic/normochromic anemia with target cells characterized by SC crystals; may see rare sickle cells or C crystals; positive hemoglobin solubility screening test

Hbg SC disease

caused when lysine replaces glutamic acid at position 26 on the beta chain
found more commonly in southeast asian, african and african-american population
homozygous condition results in mild anemia with microcytes and target cells
hgb@ migrates with hemoglobins A2, C and O on alkaline electrophoresis

hemoglobin E

caused when glycine replaces glutamic acid at position 121 on the beta chain
found more commonly middle eastern and indian populations
both homozygous and heterozygous conditions are asymptomatic
Hgb D migrates with HgbS and HgbG during alkaline electrophoresis

hemoglobin D

group of inherited disorders causing decreased rate of synthesis of a structurally normal globin chain (quantitative defect)
characterized by microcytic/hypochromic rbcs and target cells
classified according to the globin chain affected
found in mediterranean, asian, and african population

thalassemias

group of inherited disorders causing decreased rate of synthesis of a structurally normal globin chain (quantitative defect)
causes severe anemia, either no alpha or beta chains produced

thalassemia major

group of inherited disorders causing decreased rate of synthesis of a structurally normal globin chain (quantitative defect)
causes mild anemia, sufficient alpha and beta chains produced to make hemoglobins A, A2, and F, but may be in abnormal

thalassemia minor

markedly decreased rate of synthesis of both beta chains results in an excess of alpha chains
no hgbA can be produced
compensate with up to 90% hgb F
excess alpha chains precipitate on the rbc membrane, form heinz bodies, and cause rigidity destroyed in the bone marrow or removed by the spleen
symptomatic by 6 month of age
lab: severe microcytic/hypochromic anemia, target cells, teardrops, many nrbcs, basophilic stippling, howell-jolly bodies, pappenheimer bodies, heinz bodies, increased serum iron and increased bilirubin reflect the hemolysis

beta-thalassemia major/homozygous (cooley anemia)

decreased rate of synthesis of one of the beta chains; other beta chain normal
lab: mild microcytic/hypochromic anemia, with a normal or slightly elevated rbc count; target cells, basophilic stippling
hgbA is slightly decreased but hgbA2 is slightly increased to compensate

beta-thalassemia minor/hetozygous

all four alpha genes are deleted
no normal hemoglobins are produced
80% hemoglobin barts produced, cannot carry oxygen, incompatible with life

alpha-thalassemia major (hydrops fetalis)

3 alpha genes are deleted; decrease in alpha chains leads to beta chain excess
heinz bodies form and rigid RBCs are destroyed in the spleen
moderate microcytic/hypochromic anemia

alpha-thalassemia hgb H disease

2 alpha genes are deleted
patients are usually asymptomatic and discovered accidentally
up to 6% bart’s in newborns may be helpful in diagnosis, absent by 3 months of age
mild microcytic/hypochromic anemia often with a rbc count and target cells

alpha-thalassemia minor/trait

one alpha gene is deleted
patients are asymptomatic and are often not diagnosed unless gene analysis is done
borderline low mcv may be the only sign

alpha-thalassemia silent carrier

caused by inheritance of a thalassemia gene from one parent and a hemoglobin variant genre from other parent
severity and symptoms depend on the specific interactions
common interactions include hgbS, hgbC, hgbE

thalassemia/hemaglobinopathy interactions

manual wbc count using a hemocytometer: dilute a well-mixed, edta, whole blood sample 1:20 with ____, allow 10 minutes for complete ___

3% glacial acetate
rbc lysis

formula for manual wbc count using a hematocytometer

wbcs/mm3 = (total wbcs counted x dilution) / (total area counted in mm2 x depth)

formula for presence of nucleated rbcs

corrected wbcs/mm3 = {uncorrected wbcs x 100) / #nRBCs per 100 WBCs + 100)

platelet count: dilute a well-mixed EDTA whole sample 1:100 with _____; allow 10 minutes for complete rbc lysis; fill both sides of hemocytometer and allow 10 minutes for complete settling in a humidified chamber to prevent evaporation

1% ammonium oxalate

formula for platelet count

plt count/mm3 = (total platelets counted x dilution)/(total area counted x depth)

blood cell enumeration - automation methods: cells pass through an aperture with an electrical current flowing through simultaneously. cells do not conduct current but rather they change electrical resistance, which is then counted as voltage pulses

electrical impedance

this is used in electrical impedance to reduce cell coincidence in electrical impedance

hydrodynamic focusing

blood cell enumeration - automation methods: uses flow cytometer with laser to measure light scattering properties of cells

light scattering optical method

light scattering optical method: measures cell size

forward angle light scatter

light scattering optical method: provides information on cell granularity and lobularity

side angle light scatter

utilizes impedance technology, and it is a representation of cell number versus one measured property

histogram

WBC histogram: reference size range of wbcs

35-450fL

WBC histogram: range for lymphocytes

35-90fL (1st peak)

WBC histogram: range for mononuclear cells

90-160fL (2nd peak)

WBC histogram: range for granulocytes

160-450fL (3rd peak)

abnormal wbc histogram: population before 35fL may indicate ____

nucleated rbcs
giant or clumped platelets

abnormal wbc histogram: peak overlap at 90fL may indicate ___

reactive lymphocytes or blast cells

abnormal wbc histogram: peak overlap at 160fL may indicate ___

increase in bands, immature neutrophils, eosinophils or basophils

abnormal wbc histogram: population after 450fL may indicate ___

a high granulocyte count

RBC histogram: reference size range for rbcs

36fL and above

normal RBC histogram

single peak between 70 and 110fL that will correlate with the mcv

abnormal rbc histogram: two peaks

dimorphic erythrocyte population

RBC histogram: increased curve width

increased rdw (anisocytosis)

RBC histogram: shift to the right

increased mcv (macrocytic)

RBC histogram: shift to the left

decreased mcv (microcytic)

platelet histogram: reference range for platelets

2-20fL

platelet histogram: <2fL

electrical interference

platelet histogram: >20fL

microcytic rbcs or schistocytes, giant or clumped platelets

two-dimensional representative of two or more cell properties or characteristics plotted against each other

scatterplot/scattergrams

scatterplot/scattergrams: methodologies

radio frequency
fluorescence
cytochemistry

measures functional hemoglobin

blood oxygen capacity

blood oxygen capacity formula

oxygen capacity in mL/dL blood / 1.34 = gram of hgb/dL blood

reference method for measuring hemoglobin by measuring all hgb except for sulfhemoglobin
read spectrophotometrically at 540nm

cyanmethemoglobin method

cyanmethemoglobin method: what reagent is used to lyse rbcs and convert heme iron to the ferric state forming the methemoglobin

drabkin reagent (potassium ferricyanide and KCN)

converts methemoglobin to cyanmethemoglobin

KCN

used to demonstrate reticulum in reticulocytes

reticulocyte counts

retic formulas: relative count

retics in 1% = (# of retics / 1000 rbcs observed) x 100

retic formulas: absolute count

absolute retics (x10^9/L) = retics in % x rbc count (x 10^12/L)/100

calculated to account for the degree of anemia by using a standard normal hematocrit of 45% expressed in SI units

corrected reticulocyte counts (CRC)

instrument calculated parameter that indicates the ratio of immature reticulocytes to total reticulocytes

immature reticulocyte fraction

measures degree of settling of rbcs in plasma in an anticoagulated specimen during a specific time, usually 1 hour

erythrocyte sedimentation rate

increases esr

high fibrinogen or protein levels

esr: reference range

0-20mm/hr

esr is increased in these conditions

chronic inflammatory conditions (rheumatoid arthritis and pregnancy)
bacterial infection
malignancy
tissue damage
multiple myeloma
waldenstrom macroglobulinemia
severe anemia

westergren tube specifications

300mm in length
200mm graduations/markings
5.5 ± 0.5mm external bore diameter
2.65 ± 0.15 mm internal bore diameter

wintrobe tube specifications

115mm in lenth
100mm graduation/markings
3mm internal bore
no external bore

wintrobe tube: used for esr, red markings, left side of the tube

top 0 to bottom 100

wintrobe tube: used for hematocrit, white markings, right side of the tube

top 100 to bottom 0

does not require correction for anemia
makes use of specially capillary and zetafuge

zeta sedimentation ratio

count dense-staining hbg F cells and the number of the ghost cells containing hbg A to obtain percentage
used to detect presence of fetal cells in the maternal circulation during problem pregnancies because hgb F in fetal cells resists acid elution
differentiates hereditary persistance of fetal hemoglobin from other conditions associated with high hgb f levels

kleihauer betke method

normal newborns have ___ hgb F levels

70-90%

insoluble when combined with a reducing agent, which will then crystallize and give a turbid appearance of the solution
will not differentiate homozygous from heterozygous sickle cell

hemoglobin s

procedure for the identification of normal and abnormal hemoglobin s
base don net negative charges, which cause hemoglobins to migrate from the negative region toward the positive region
distance at particulat hemoglobin molecule migrates is due to its net electrical charge
migration of hemoglobin is dependent on net negative charge and buffer pH

hemoglobin electrophoresis

two of hemoglobin electrophoresis

cellulose acetate at pH 8.6
citrate agar at pH 6.2

hemoglobin electrophoresis: at pH 8.6, ___ migrates the fastest and ___ migrate the slowest

hgb A
hgb A2, C, E, and O

citrate agar (pH 6.2) hemoglobin electrophoresis: hgbS is differentiated from ___

hgbD and G

citrate agar (pH 6.2) hemoglobin electrophoresis: hgbC is differentiated from ___

hgb A2, E, O

cells in a suspension of buffered solution are labeled with one to several fluorescent compound
this cell suspension is run under high pressure and in a single, narrow stream through a laser, causing excitation of the fluorescence compounds and resulting in the emission of light energy
this energy is detected by a photomultiplier tube and is subsequently converted into computerized data, which upon analysis provides information regarding number, size, and cellular composition of the population assayed

flow cytometry

major components of a flow cytometer: flow chamber for a single cell separation, sheath fluid, and hydrodynamic focusing

fluidics

major components of a flow cytometer: excitation light sources include lasers or lamps; light is separated by dichronic mirrors and filters

optics

major components of a flow cytometer: photomultiplier tube detects light energy, then converts this to voltage pulses, computers translates pulses into datafiles

electronics

flow cytometry: hydrodynamic focusing uses ___ to line the cells up single file

laminar flow

flow cytometry: light is scattered at ___ or forward

90 degrees

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Hematology Flashcards

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