Hematology Exam 3 Flashcards
What is one of the largest organs in the body?
Bone marrow
What percentage of our body weight is bone marrow?
4%
Where is bone marrow found in infants?
All bones
Where is bone marrow found in adults?
Flat bones
Where are RBCs located in bone marrow?
Inside the sinus around a macrophage
Where are megakaryocytes located in bone marrow?
Near the sinus wall
Ratio of fat to tissue in normal bone marrow
50:50
Job of macrophages in bone marrow
To incorporate iron into the red cells
What forms the foundation or support of bone marrow?
Meshwork of stromal cells
Cells unique to bone marrow
Osteoclasts - bone destroying/breakdown
Osteoblasts - bone forming
Name the cells
Osteoblasts
Name the cells
Osteoclasts
What is circled? (BM)
Spicules in bone marrow
What does seeing spicules tell you?
You have a good aspirate
Where does the core biopsy go in the lab?
Histology
Lifespan of RBCs
120 days
Lifespan of WBCs
anywhere from 7 hours to 20 days depending on the type of WBC
Function of bone marrow
Supplies mature cells for circulation in steady state or for increased demand
What maintains the self-renewal of bone marrow?
Pluripotential stem cells
What are some examples of stimuli received to create cells in the bone marrow?
- Thrombopoietin
- Erythropoietin
- Colony stimulating factors
- Interleukins
What is produced by stromal cells, fibroblasts, endothelial cells, and macrophages?
Growth factors
What colony stimulating factors go in to the myeloid line?
- CSF-Spleen
- CSF-GEMM
Anemia, polycythemia, leukopenia, and thrombocytopenia are all diseases that affect what in bone marrow?
Blood production of bone marrow
How do the following systemic diseases affect bone marrow?:
- Solid metastasizing tumors that spread to the marrow such as cancer and Hodgkin’s lymphoma
- Fever of Unknown Origin (FUO)
They affect blood production in bone marrow
Type of hereditary diseases that can affect bone marrow
Storage pool diseases such as Gauchers
Usual location a bone marrow aspirate is performed on adults
Posterior superior iliac crest
Usual location a bone marrow aspirate is done on children and infants
Top of tibia below the knee
Type of needle used for bone marrow aspirate
Jamshidi needle
Amount needed for bone marrow aspirate
0.5 - 1.5mL for hematology and an additional 5cc for other departments
2 diseases that could cause a “dry tap” (no aspirate)
- Myelofibrosis
- Aplastic anemia
Reasons an aspirate may not be collected
- Dry tap (Myelofibrosis or aplastic anemia)
- Not in the bone marrow
- Tumor
Preservative used for biopsy
Formalin
Marrow slide examination:
Childhood cellularity percentage
80%
Marrow slide examination:
Age 30-70 cellularity percentage
50%
Marrow slide examination:
How do you calculate the cellularity percentage for ages >70?
100 - patient age = cellularity +/- 10%
Bone marrow cellularity
What would be the expected cellularity for an 82 year old patient?
100 - 82 = 18
8 - 28%
(18 +/-10%)
Under oil immersion, how many cells are counted during a bone marrow differential? What cells are counted?
500 to 1000 both red and white cells
What cells are not included in the M:E ratio?
Lymphs, monos, and plasma cells
What percentage of the bone marrow differential count will be comprised of neutrophilic myelocytes, metamyelocytes, bands, and segmented neutrophils?
50%
M:E Ratio:
350 neutrophilic blasts >segs, eos, baso
75 lymphs, monocytes, and plasma cells
75 erythroid cells (blasts>meta)
What is the M:E ratio?
350 / 75 = 4.7:1
Normal M:E ratio
3:1
How would myeloid hypoplasia effect the M:E ratio?
Myeloid cells would be decreased causing the M:E to be < 3:1
How would erythroid hyperplasia effect the M:E ratio?
Erythroid hyperplasia would increase the red cells count causing the M:E ratio to be 1:1
What stains are performed on each bone marrow aspirate?
- Wright’s stain
- Iron stain
Iron that is stored in the bone marrow is in what form?
Hemosiderin
What is hemosiderin composed of?
Iron and protein
Stain used to stain iron
Prussian Blue
Symptoms of anemia
- Tachycardia
- Shortness of breath
- Headaches
- Pallor
- Fatigue
TRUE or FALSE
Typical CBC results in anemia include:
-Decreased hemoglobin, hematocrit, and RBC count
TRUE
TRUE or FALSE
With most anemia, the M:E ratio is 1:1
TRUE
What MCV classifies as microcytic anemia?
< 80fL
What MCV classifies as a macrocytic anemia?
> 100 fL
What MCV classifies as a normocytic anemia?
80 - 100 fL
What is the cause of Microcytic, hypochromic anemias?
Inadequate production of some part of hemoglobin (iron, heme, globin)
Thalassemias have what abnormality?
Globin abnormality
2 Etiologic categories of macrocytic anemias
- Megaloblastic
- Non-Megaloblastic
Cause of megaloblastic anemias
Abnormal DNA synthesis
Cause of non-megaloblastic anemia
Increase in membrane lipids
TRUE or FALSE
Non-megaloblastic anemia will have an MCV > 110
FALSE
Non-megaloblastic anemia will have an MCV > 100 fL but < 110 fL
This anemia is due to a slowdown in DNA synthesis in developing cells causing a shorter life span in the deficient cells
Megaloblastic anemia
What causes the defect in DNA replication that is seen in megaloblastic anemia?
A depletion of thymidine triphosphate, an immediate DNA precursor
If there is an increase in _______________ , it tells us there is possibly a B12 deficiency
Methylmalonyl Coenzyme A
(MMA)
Being deficient in this causes slowed nuclear maturation and mitosis resulting in asynchrony in cells
Thymidine triphosphate
When the nucleus of a cell is immature and the cytoplasm is matured, this is referred to as what?
Asynchrony
Another name for B12
Cyanocobalamin
How is B12 absorbed in the body?
Through the intestine by Intrinsic Factor (IF)
Where is Intrinsic Factor produced?
Parietal cells of the stomach
What do the IF-B12 complexes attach for absorption?
To receptors on the ileal mucosal cells
What does B12 attach to after being absorbed?
Transcobalamin II
Where does the B12-transcobalamin II complex go?
Bone marrow
or
Liver for storage
(large amount is stored)
Where do we get B12 from in our diet?
Meat
Eggs
Dairy products
Liver
Where does folic acid come from in our diets?
- Leafy greens
- Meat
- Some fruits
What carries folate after it is absorbed?
Albumin
Where does albumin take folate in the body?
Bone marrow
or
Liver
(only a small amount is stored)
Once absorbed and transported, what 2 cofactors play an important role in DNA synthesis?
Folate and Vitamin B12
Any cell actively dividing or replicating will have a defective nucleus when either of what 2 cofactors are deficient?
B12 and Folate
A lack of intrinsic factor causes what anemia?
Pernicious Anemia
What tapeworm can cause a B12 deficiency?
Diphyllobothium latum - fish tapeworm
TRUE or FALSE
In pernicious anemia, folate cannot be absorbed
FALSE
Vitamin B12 cannot be absorbed properly due to a lack of intrinsic factor
An autoimmune disorder with autoantibodies produced by parietal cells causes what type of anemia?
Pernicious anemia
Pernicious anemia is typically found in which descent of people?
Northern European
How is pernicious anemia treated?
Vitamin B12 injections
Which is more common and why?
B12 deficiency
or
Folate deficiency
Folate deficiency because little to none is stored in the body
Clinical features of megaloblastic anemia
- Typical signs of anemia
- Lemon-yellow pallor
-Smooth, sore tongue
Clinical features of B12 deficient megaloblastic anemia
Neurologic manifestations from degeneration of myelin:
- tingling and numbness of extremities
- gait abnormalities
- psychosis due to defective methyl group metabolism
Key diagnostic features seen in the peripheral blood smear of megaloblastic anemia
- Hypersegmented neutrophils
- Macro-ovalocytes
Identify the anemia:
- Decreased retic
- Hypercellular bone marrow
- MCV >110
- Decreased RBC, WBC, and PLT counts
- Macro-ovalocytes
- Hypersegmented neutrophils
Megaloblastic anemia
-either B12 or Folate deficiency but cannot distinguish without further testing
What is the term for a pyknotic cell causing a fragmented nucleus?
Karyorrhexis
Giant bands and giant metamyelocytes are a key findings in the bone marrow of which anemia?
Megaloblastic anemia
What is the term used to describe the cell the arrow is pointing to?
Karyorrhexis
What chemistry tests are elevated due to hemolysis with megaloblastic anemia?
LD and Bilirubin
Test that is used to differentiate between Pernicious Anemia and other B12 deficiencies
Schilling Test
Non-megaloblastic conditions (3)
- Liver disease
- Alcoholism
- Reticulocytosis
MCV will increase 1 fL for each ___% of retics
MCV will increase 1 fL for each 1% of retics
What can cause the MCV to appear macrocytic?
- Cold agglutinin
- High WBC count
- High glucose causing cells to swell
The following morphologic characteristics are seen in what class of anemia?:
- MCV <80
- MCH and MCHC are decreased
- RDW is generally normal
Microcytic, hypochromic anemia
Where does most of the iron required by the cells come from?
Broken down RBCs
How much iron is needed for each mL of RBCs?
1mg
What regulates the absorption of iron in the body?
Mucosal cells in the GI tract
How much of the daily intake of iron from diet is actually absorbed?
10%
What enhances iron absorption?
Ascorbic acid (vitamin C) and using cast iron pots/skillets
What decreases iron absorption in the body?
Antacids
All of the following affect what?
- Type of iron in the food
- Other food that is ingested
- Acidity of stomach
- Availability of iron stores
Absorption of iron
Iron is transported from mucosal cells to the blood in what state?
Ferrous state (Fe2+)
What is the dietary form of iron?
Ferric (Fe3+)
What protein transports the ferric iron?
Transferrin
Number of iron atoms that transferrin can bind to at once
2 iron atoms per 1 transferrin molecule
Where are the 2 places transferrin will transport iron?
- Bone marrow
- Liver
Iron is stored as this in the liver
Ferritin
Transferrin can bind ____ - ____ mg of iron
240 - 280 mg
About what percentage of transferrin is bound with iron?
30%
How does celiac disease cause iron deficiency?
Celiac disease doesn’t allow iron to absorb properly
What is significant about having an inherited mutation with matripase 2 protein?
It causes impaired absorption of iron leading to iron deficiency anemia
Most common cause of iron deficiency anemia
Increased blood loss
Sequence of development of iron deficient anemia
- Iron storage depleted
- Transport iron depleted
- Functional iron depletion
Iron is required for _____ synthesis
Iron is required for heme synthesis
Stage of Iron depletion:
- Normal hemoglobin
- Normal serum iron
- Normal TIBC
- Decreased ferritin
Stage 1
Storage Iron Depletion
Stage of Iron depletion:
- Normal hemoglobin
- Decreased serum iron
- Increased TIBC
- Decreased ferritin
Stage 2
Transport Iron Depletion
Stage of Iron depletion:
- Decreased hemoglobin
- Decreased serum iron
- Increased TIBC
- Decreased ferritin
Stage 3
Functional Iron Depletion
Normal range for serum iron
50 - 160 ug/dL
Normal range for TIBC
250-400 ug/dL
What is TIBC?
Total Iron Binding Capacity = transferrin related test
Normal range for % transferrin saturation
20 - 55%
Normal range for ferritin for males
40 - 400 ng/mL
Normal range for ferritin for females
12 - 160 ng/mL
Classify the type of anemia
(size and pallor)
Hypochromic, microcytic
What is iron overload also known as?
Hemosiderosis
The following may cause what?:
- Hemolytic anemia with massive transfusions
- Disorders of erythropoiesis where cells cannot be made and iron builds up
Hemosiderosis
What is the term for a more severe form of hemosiderosis
Hemochromatosis
What is the cause of Hereditary hemochromatosis?
A gene mutation (hereditary iron or transferrin receptor protein)
The following results are seen in what disorder?
- Abnormal AST and ALT (LFTs)
- Increased serum iron
- Increased % transferrin saturation
- Increased serum ferritin
- Increased hgb
- Increased HCT
Hemochromatosis
How is hereditary hemosiderosis treated?
Therapeutic phlebotomy
How is transfusion related hemosiderosis treated?
Chelation therapy
Patient is given desferrioxamine which binds to iron and gets excreted in urine
Thalassemia, Anemia of Chronic Disease/Inflammation, Lead poisoning, and Sideroblastic Anemia are all examples of what type of anemia?
Microcytic anemia
An inherited disorder in which the globin chain is not produced in adequate amounts
Thalassemia
This is the most common anemia among hospitalized patients
Anemia of Chronic Disease/Inflammation
This hormone is an acute phase reactant that regulates the absorption of iron in the intestines and also the release of iron from macrophages.
Hepcidin
What produces hepcidin?
The liver
This acute phase reactant is an iron binding protein located in the granules of neutrophils. It is involved in preventing phagocytized bacteria from using intracellular iron for their own metabolic processes
Lactoferrin
The following lab results are seen with which type of anemia?:
- Decreased serum iron
- Decreased TIBC
- Increased serum ferritin
- normal soluble transferrin receptors (sTfRs) - newer test
Anemia of Chronic Disease/Inflammation
Treatment of Anemia of Chronic Inflammation
- Treat with erythropoietin, given with iron b/c the body’s stored iron remains unavailable
- Alleviate the causative condition
Lead poisoning is caused by lead blocking the production of what in several spots?
Lead poisoning blocks heme production
This microcytic anemia causes:
-Interference in the conversion of aminolevulinic acid (ALA) to porphobilinogen (PBG)
and
-Interference in the incorporation of iron into protoporphyrin IX by ferrochetalase
Lead poisoning
This microcytic anemia will interfere with the breakdown of ribosomal RNA creating coares basophilic stippling and a low MCV
Lead poisoning
TRUE or FALSE
Basophilic stippling is diagnostic for lead poisoning
FALSE
In this microcytic anemia the following occurs:
- Cells cannot use available iron
- The iron is trapped in the cell
- Iron will form pappenheimer bodies in mature cells
Sideroblastic anemia
This picture depicts a hallmark representation of what microcytic anemia?
Sideroblastic anemia
What is considered “hallmark” for sideroblastic anemia?
Dimorphic RBCs and ringed sideroblasts
MCV, MCH, and MCHC are lowest with which microcytic anemia?
Thalassemia
Will the RDW be normal, elevated, or decreased with iron deficiency anemia?
Elevated
Will RDW be normal, elevated, or decreased with Thalassemia?
Normal
What is included in iron studies?
- Serum iron
- Total Iron Binding Capacity (TIBC)
- % Transferrin Saturation
- Serum Ferritin
What is measured in serum iron?
The amount of iron bound to transferrin in circulation
What does TIBC measure?
The amount of transferrin bound and unbound with iron
It is measuring the binding ability of transferrin
How is % transferrin saturation calculated?
Serum iron / TIBC x 100
Normal range for soluble transferrin receptors
1.15 - 2.75 mg/L
The amount measured in this test is based on intracellular iron and is an indicator of functional iron available in cells
Soluble transferrin receptors (sTfR)
TRUE of FALSE
sTfR is increased in Anemia of Chronic Inflammation
FALSE
Normal in Anemia of Chronic Inflammation
TRUE or FALSE
sTfR is increased in IDA
TRUE
When does free erythrocyte protoporphyrin accumulate?
When iron is NOT available
Free erythrocyte protoporphyrin will be increased, decreased, or normal in IDA?
Increased
With which anemia is knowing the value of free erythrocyte protoporphyrin is most valuable?
Lead poisoning due to ferrochelatase impairment
Normal value of free erythrocyte protoporphyrin
< 80 ug/dL
A storage form of iron mostly found in bone marrow
Hemosiderin
Red cells having a “shaggy” cytoplasm is seen with what anemia?
Iron deficiency anemia
Name the hypochromic, microcytic anemia
Iron Deficiency Anemia
Name the hypochromic, microcytic anemia
Thalassemia
Name the hypochromic, microcytic anemia
Anemia of Chronic Inflammation/Disease
Name the hypochromic, microcytic anemia
Sideroblastic anemia
Name the hypochromic, microcytic anemia
Lead poisoning
Free erythropoietin is also known as
Zinc protoporphyrin (ZPP)
What are the 3 types of normocytic, normochromic anemia?
- Hemolytic
- Aplastic Anemia
- Acute Blood loss
In this category of N/N anemia cells are not made. The building blocks are present and RBCs look normal but there just aren’t enough of them.
Aplastic anemia
In this category of N/N cells are broken down at an increased rate
Hemolytic anemias
N/N anemia:
- Cellular areas of bone marrow are replaced by fat cells
- Caused by toxic, radiant, or immunologic injury to pluripotential cells
Aplastic anemia
Normocytic/Normocytic anemias are categorized based on increased, decreased, or normal ______
Reticulocyte count
TRUE or FALSE
Aplastic anemia is always permanent and requires a bone marrow transplant - but this may not always work
FALSE
It can be permanent but only if all of the pluripotential cells are damaged.
Types of congenital aplastic anemia
- Fanconi anemia
- Dyskeratosis Congenita
- Scwachman-Bodian-Diamond Syndrome
This inherited aplastic anemia is an autosomal recessive chromosomal instability disorder
Fanconi Anemia
In this aplastic anemia you will see:
-Pancytopenia, a decrease in reticulocytes, hypocellular bone marrow
as well as
-Skin pigmentation, short stature, and hypogonadism
Fanconi Anemia
This inherited aplastic anemia is a bone marrow failure disease
Dyskeratosis Congenita
With this inherited aplastic anemia you will see:
- Abnormal skin pigmentation (dark spots with white dots in them)
- Dystrophic nails (look almost like a fungal infection)
- Oral leukoplakia (very white thrush-looking tongue)
- Bone marrow failure
Dyskeratosis Congenita
This inherited aplastic anemia resembles cystic fibrosis
Shwachman-Bodian-Diamond Syndrome
Name the inherited aplastic anemia:
- Pancreatic insufficiency
- Cytopenia
- Skeletal abnormalities
- Predisposition for hematologic malignancies
- Neutropenia and immune dysfunction
- Normal sweat chloride (will differentiate it from cystic fibrosis)
Shwachman-Bodian-Diamond Syndrome
What percentage of aplastic anemia is diagnosed as idiopathic?
50-75%
Secondary aplastic anemia accounts for what percentage of cases?
25%
Causes of secondary aplastic anemia
- Chloramphenicol, an old antibiotic
- Industrial chemicals such as benzene
- Insecticides such as DDT
What can cause acquired aplastic anemia?
- Radiation exposure
- Infections such as hepatitis, HIV, Epstein-Barr, or TB
TRUE or FALSE
You will see pancytopenia and increased infections with aplastic anemia
TRUE
What is the survival rate for aplastic anemia after bone marrow transplant?
80%
What anemia is this bone marrow indicative of?
Aplastic anemia
This is a selective decrease in the red cell commited stem cells resulting in a temporary reduction in RBC production. It often follows a parvovirus infection.
Pure Red Cell Aplasia
What does parvovirus infection cause in children?
Fifth Disease
What is due to clonal proliferation of pluripotential stem cells with incomplete maturation of marrow precursors?
Myelodysplastic syndromes
These disorders are due to a chromosomal defect in stem cells from oncogenes, environmental elements, or secondary to chemotherapy and radiation from previous cancers
Myelodysplastic disorders
(MDS)
In ____, apoptosis appears to be increased early in the disease
MDS
This anemia is usually resistant to any therapy. Pancytopenia including reticulocytopenia, is present. The bone marrow is normo- or hypercellular with increased iron stores.
Refractory anemia
In this anemia, erythroid hyperplasia with nuclear budding in erythroid precursors can be seen in the bone marrow
Refractory Anemia
TRUE or FALSE
Refractory anemia can be cured with hematopoietic stem cell transplant
TRUE
The cause of this NC/NC anemia is mostly due to decreased erythropoietin
Anemia of renal disease
How is anemia of renal disease treated?
Erythropoietin therapy
What other organs may contribute to anemia of renal disease disorder?
Thyroid and liver
Anemia of chronic disorders is the most common anemia of what type of people?
Hospitalized patients
What anemia is observed with infections, autoimmune disorders (SLE, RA), and malignancies?
Anemia of chronic disorders
Name the anemia:
- Cytokines are produced by the immune system in response to immune or tumor stimulus
- Erythropoietin is inhibited
- Macrophages become stimulated and will not release iron after normal RBC breakdown in the spleen
- Hepcidin protein is involved
Anemia of chronic disorders
Acute phase reactant that increases in inflammation/infection
- Iron regulator produced by hepatocytes
- Increased in anemia of chronic disorder
Hepcidin
This anemia results from marrow infiltration with subsequent damage to hematopoietic microenvironment and replacement of normal cells.
-Due to metastatic carcinoma whereby primary cancer cells go to bone marrow and start to proliferate
Myelophthisic anemia
Extramedullary hematopoiesis occurs with this anemia producing less functional cells.
Myelophthisic anemia
What anemia is depicted in this picture?
- Tear drop RBCs
- Leukoerythroblastic cells
- NRBCs
Myelophthisic anemia
This NC/NC anemia leads to cardiovascular collapse and shock
Acute blood loss
What percentage of blood loss will result in shock and death?
50%
What percentage of blood loss with result in major symptoms?
30-40%
What are the 2 major categories of NC/NC anemia?
Aplastic and hemolytic
With normocytic/normochromic anemias, what CBC results are normal and what results are decreased?
Normal: indices (MCV, MCH, MCHC)
Decreased: Hgb, HCT, RBC count
What are the classifications of hemolytic anemia? (6)
- Intrinsic
- Extrinsic
- Acquired
- Inherited
- Acute
- Chronic
This classification of hemolytic anemia is intracellular - due to a defect of the cell
Intrinsic
This classification of hemolytic anemia is extracellular - due to a defect outside the cell.
Extrinsic
Classification of hemolytic anemia that is sudden and/or episodic
Acute
Classification of hemolytic anemia that occurs over time and may not be evident if the bone marrow is able to compensate.
Chronic
Classification of hemolytic anemia that is passed to offspring by parents and is due to a mutant gene
Inherited
Hemolytic anemia classification that is developed in individuals who were previously normal but exposed to a chemical/agent/ or condition
Acquired
Hemolytic anemias:
Most intrinsic defects are ______, while most extrinsic defects are _______.
Most intrinsic defects are inherited, while most extrinsic defects are acquired.
What hemolytic anemia is intrinsic but acquired instead of inherited?
Paroxysmal Nocturnal Hemoglobinuria
Examples of acute hemolytic anemia
- Paroxysmal Nocturnal Hemoglobinuria
- Hemolytic Transfusion Reaction
Examples of chronic hemolytic anemia
-G6PD deficiency
All of the following are examples of what classification of hemolytic anemia?:
- Abnormalities of the RBC membrane
- Defective enzymatic pathways
- Defective hemoglobin molecule
Intrinsic hemolytic anemia
All of the following are examples of what classification of hemolytic anemia?:
- Malaria parasitic infection
- Antibodies to an RBC antigen
Extrinsic hemolytic anemia
Term that means the cell is destroyed by the spleen
Extravascular
Term that means the cells is destroyed in the vessel
Intravascular
Percentage of cell destruction that is intravascular
10%
Percentage of cell destruction that is extravascular
90%
Compensated or uncompensated?:
-Little to no anemia
Compensated
Compensated or Uncompensated?:
Red cell life span is usually only 15-20 days
Uncompensated
In compensated bone marrow response, the bone marrow is able to increase its output how much?
6x - 8x
(six-fold to eight-fold)
-Autosomal dominant
- Defects in proteins that disrupt the vertical interactions between transmembrane proteins and cytoskeleton proteins of red cells
- Ankrin and Spectrin
-Results in a destabilization of the lipid bilayer allowing lipids to escape
Hereditary spherocytosis
In this disorder the cell is not able to deform due to decreased surface-to-volume ratio so macrophages in the spleen will remove the cell.
The disorder is more common in northern European descent
Hereditary spherocytosis
Clinical symptoms of this disorder include:
- Mild jaundice
- Anemia
- Splenomegaly
Lab Findings:
- MCV normal or slightly decreased
- MCH elevated
- MCHC >36% (hallmark)
- Increased LD and Bilirubin
- Increased osmotic fragility
- Reticulocytosis
Hereditary spherocytosis
Measures the surface-to-volume ratio of RBCs
- Cells are placed in graded hypotonic salt (saline) solutions
- Water enters cell, cell swells, and bursts
Osmotic fragility
What is represented by A
Target cells and elliptocytes
What does B represent?
Normal cells
What does C represent?
Spherocytes
Normal range of osmotic fragility
Hemolysis begins at 0.45% NaCl
100% hemolysis occurs between 0.35-0.30%
When does hemolysis begin for hereditary spherocytosis in osmotic fragility?
0.65% NaCl
Treatment for hereditary spherocytosis
Splenectomy in severe cases
Autosomal dominant hereditary membrane defect involving the horizontal bonds on the skeleton of RBCs
Hereditary elliptocytosis
This membrane defect is caused by an imbalance of cations and is more commonly acquired due to acute alcoholism, malignancy, or medications.
Stomatocytes
This membrane defect condition is rare and usually inherited. Fragmentation, microspherocytosis, and elliptocytosis are seen. RBCs show a marked thermal sensitivity- incubated cells between 41C-45C will fragment.
Pyropoikilocytosis
This membrane defect is observed in:
-Acquired liver disease
and
- Congenital abetalipoproteinemia (rare)
- No LDL/VLDL
- Fat malabsorption, ataxia, neuropathy, retinitis pigmentosa, acanthocytosis
Acanthocytes
This deficiency is transmitted a by sex-linked, mutant gene and is more common in males
G-6-PD Deficiency
When this is deficient NADP cannot be converted to NADPH, glutathione is reduced, hemoglobin aggregates or precipitates (Heinz Bodies), and premature destruction of red cells occurs.
G-6-PD
Relatively common disorder in African American males and Asians. Most people never suffer any clinical manifestations because the bone marrow will compensate.
G-6-PD deficiency
If you have this, you will have a sensitivity to fava beans and primaquine (an anti-malarial drug) could induce a hemolytic episode
G-6-PD deficiency
Qualitative test for G-6-PD deficiency
Fluorescent Spot Test
Second most common enzyme deficiency
-Involved in Embden-Meyerhoff pathway
Pyruvate Kinase Deficiency
Acquired intracellular defect with intravascular hemolysis
Paroxysmal Nocturnal Hemoglobinuria
In PNH, what is deficient?
CD 55 - Decay Accelerating Factor
CD 59 - Membrane inhibiting of Reactive Lysis (MIRL)
These proteins prevent normal cells from complement destruction
Screening test for PNH
Sugar Water Test
-promotes binding of complement to red cell membrane; complement-sensitive PNH red cells are lysed while normal cells are unaffected
Confirmation test for PNH
Ham’s Test (Acidified serum lysis test)
PNH treatment
- Treat symptoms - support therapy
- Treat complications
Average survival period for PNH
10 years
-May become AML
What causes autoimmune hemolytic anemia?
Primary - idiopathic
Secondary to autoimmune disorder or cancer- SLE, RA, CLL, lymphoma
2 types of autoimmune hemolytic anemias
- Warm-reactive antibodies (IgG)
- Cold-reactive antibodies (IgM)
70% of all cases of autoimmune hemolytic anemias are due to this autoantibody
Warm-reactive (IgG)
What will differentiate warm-reactive autoantibodies from spherocytosis?
Direct antiglobulin test
- Positive with warm auto
- Negative with spherocytosis
When treating a patient with a warm autoantibody, what is done only as a last resort?
Transfusion
Cold-reactive autoantibodies are most often observed when?
Secondary to an infection such as:
-Mycoplasma pneumonia
or
-Infectious mononucleosis
Clinical findings of cold autoantibodies
Acrocyanosis- cyanosis in extremities
Anemia symptoms
With this autoimmune hemolytic anemia the specimen will agglutinate as it cools to room temperature and you will observe agglutinated red cells on the peripheral blood smear
Cold autoantibody
Non-immune hemolytic anemia also referred to as sports anemia. Caused by trauma to cells from physical disruptions
March hemoglobinuria
This non-immuno hemolytic anemia is a serious life-threatening disease in which cells are fragmented by fibrin in the vessels or a defective heart valve.
Microangiopathic anemia
Non-immune hemolytic anemia can be caused by what chemical or physical agents?
- Copper
- Water (drowning)
- Insect venom
- Drugs
- Chemicals
- Heat stroke
What microorganisms can cause a non-immune hemolytic anemia?
- Malaria
- other bateria and viruses producing toxins
This microorganism is the most common cause on non-immune hemolytic anemia in the world
Malaria
Will the following be increased, decreased, or normal in hemolytic anemias?:
- Unconjugated bilirubin
- LD
- Reticulocytes
- MCV
- Red cells
- Haptoglobin
- HCT
- Urine urobilinogen
Increased:
- unconjugated bilirubin
- LD
- Reticulocytes
- Urine urobilinogen
- Bone marrow red cells
- MCV slightly if retic % is increased
Decreased:
- Red cells in peripheral blood
- Haptoglobin
- HCT
Normal:
-MCV if retic % is normal
Urine hemoglobin and hemosiderin are increased in what type of hemolysis?
Intravascular hemolysis
What test is specific for autoimmune hemolytic anemia?
Direct antiglobulin test (DAT)
What test is specific for hemoglobinopathies?
Hemoglobin electrophoresis
What test is specific for G6PD deficiency?
Heinz bodies
and
G6PD assay when patient is not in a crisis
Test that is specific for hereditary spherocytosis and elliptocytosis
Osmotic fragility
What test is specific for PNH?
Sucrose hemolysis (screening)
and
Ham Test (confirmation)
What is hemoglobin A comprised of?
2 Alpha chains and 2 Beta chains
Percentage of adult hemoglobin that is Hgb A
95%
What is Hemoglobin A2 comprised of?
2 Alpha chains and 2 Delta chains
Percentage of hemoglobin that is A2
~3%
What is hemoglobin F comprised of?
2 Alpha chains and 2 Gamma chains
Percentage of hemoglobin that if F
~1%
A chronic hemolytic anemia resulting from an inherited alteration of the globin chain.
Valine is substituted for glutamic acid on the sixth position of the Beta chain
Sickle Cell anemia
Why do the red cells form sickle shapes in sickle cell anemia?
Valine is insoluble and hydrophobic
-so when the red cell is deoxygenated, polymerization occurs causing the hemoglobin molecules to combine and “flatten”
- Autosomal recessive
- 7-8% of African Americans have the trait
- .25% of African Americans have homozygous disease
- Disease is found in Africa, Middle East, and USA
- Associated with malaria
Sickle Cell Anemia
Screening tool for Hemoglobin S
Solubility test
A turbid result of the solubility test is _____ for hgb S
Positive
What can cause a false negative on a sickle solubility test?
- Increased levels of hgb F
- If the patient is very anemic (<7.0 g/dL hgb)–add 50ul of blood to the reducing agent–
False positive sickle solubility
- Too much sample
- Hyperlipidemia
Order of movement for hemoglobin on cellulose acetate agar
(from cathode to anode)
- (cathode)
origin
Hgb C
Hgb S
Hgb F
Hgb A
+ (anode)
What is the pH of cellulose acetate agar?
8.4 pH
pH of citrate agar
6.0-6.2 pH
What is citrate agar used for in hemoglobin electrophoresis?
To verify Hgb S or C from other variants
Mild chronic hemolytic anemia with splenomegaly resulting from glutamic acid being substituted by lysine on the sixth position of the Beta chain. Found in 2-3% of African Americans
Hemoglobin C
What are the arrows pointing at?
Hemoglobin S - Sickle cells
What is the arrow pointing to in the picture?
Hemoglobin C crystals
What are the arrows pointing to?
Hemoglobin SC
This hemoglobin variant causes a splice site, causing transcription of mRNA which results is both qualitative and quantitative defects. A mild chronic hemoltic anemia forms as a result.
Hemoglobin E
A beta chain variant (a2B2)26Glu->Lys causes this hemoglobin variant which is commonly found in Southeast Asian descent
Hemoglobin E
This is the most common single gene disorder in humans
Thalassemia
Due to a reduced rate of a globin chain
Thalassemia
What is the term used to describe the area in which thalassemia is most often found
“Thalassemia belt”
Having a thalassemia minor means you’re ____________
(heterozygous/homozygous)
Heterozygous
Thalassemia major is _______
(homozygous/heterogous)
Homozygous
Genetic disorder resulting in abnormal amount or function of mRNA, producing reduced or absent beta globin chains
Beta thalassemia
Found in people from Mediterranean region, Saudi Arabia, Southeast Asia, and Africa
Beta thalassemia
Heterzygous state of beta thalassemia with no hematologic abnormalities or clinical symptoms
Beta thalassemia silent carrier
Heterzygous state of beta thalassemia with mild hemolytic anemia, microcytic/hypochromic RBCs, no clinical symptoms
Beta thalassemia minor
Homozygous state of beta thalassemia with severe hemolytic anemia, microcytic/hypochromic RBCs, severe clinical symptoms, and transfusion dependent
Beta thalassemia major
Type of beta thalassemia: Mild to moderate hemolytic anemia, microcytic/hypchromic RBCs, moderate clinical symptoms, transfusion independence
Beta thalassemia intermedia
This Thalassemia has:
- No Hgb A
- Most of the Hgb is Hgb F with increased Hgb A2
- Hgb value is very low; 3-7 g/dL
- Marked expansion of marrow spaces due to ineffective erythropoiesis
- Extreme skeletal changes
- Marked aniso, poik, mciro, and hypo
- Target cells, NRBCs, and basophilic stippling are seen on peripheral blood smear
Beta Thalassemia Major
aka
Homozygous Beta Thalassemia
What thalassemia is depicted in these pictures?
Beta Thalassemia Major
(Homozygous Beta Thalassemia)
What is the treatment for Beta thalassmeia major?
- Blood transfusions throughout lifetime
- Hematopoietic stem cell transplant
- Possible gene therapy
This beta thalassemia causes a mild microcytic, hypochromic anemia with target cells and basophilic stippling. Patients have few symptoms except during pregnancy.
-May resemble IDA
Beta thalassemia trait/minor
Which thalassemia is depicted in the picture?
Beta thalassemia trait/minor
What chromosome contains the genes that control beta, gamma, and delta chains?
Chromosome 11
What chromosome comtains the genes that control alpha chains?
Chromosome 16
Number of genes on chromosome 11 that control beta, gamma, and delta chains
2
Number of genes on chromosome 16 that control alpha chains
4
Alpha Thalassemia:
What number of gene deletions has no clinical symptoms, normal hematology values, and affects 30% of all African Americans?
1 gene deletion
Alpha Thalassemia:
What number of gene deletions has no clinical symptoms, creates a slight hypo, micro anemia, and affects Asians?
2 gene deletions cis
This alpha thalassemia is a 2 gene deletion in which the deletions are on the same chromosome
2 gene deletion cis
Alpha Thalassemia:
What number of gene deletions has no clinical symptoms, creates a slight hypo/micro anemia, and affects mostly Blacks?
2 gene deletion trans
This alpha thalassemia is a 2 gene deletion in which the deletions are on opposite chromosomes
2 gene deletion alpha thalassemia trans
Alpha Thalassemia:
This number of gene deletions causes:
- Severe hemolytic anemia
- Is name Hgb H disease, causes patients to have mostly Hgb H (tetramer of beta chains)
- Is observed in Asians
3 gene deletions
Alpha Thalassemia:
This number of gene deletions causes:
- Hydrops Fetalis
- Always fatal
- No Hgb A, A2, or F
- All Hgb is Bart’s Hgb (tetramer of gamma chains)
- Observed in Asian descent
4 gene deletion
With this disorder, there is no switch from fetal hgb to adult hgb. Beta chains are not produced. Homozygous individuals have 100% Hgb F. Carriers have 15-35% Hgb F.
Hereditary Persistence of Fetal Hemoglobin
HPFH
This test is used to visualize Hgb F in peripheral smears
Kleihauer Betke Test
In the Kleihauer Betke test, how will RBCs containing adult hemoglobin appear?
as “ghost” RBCs
Constant Spring, M Hemoglobin, Hemoglobin Lepore, Hgb Hammersmith, and Hgb Gun Hill are all examples of what?
Abnormal hemoglobins
Increased or Decreased:
This oxygen affinity is ovserved in erythrocytosis (such as PV) because hemoglobin does not released O2 to the tissues.
-Causes erythropoietin to be activated due to decreased oxygen tension in the blood
Increased oxygen affinity
Increased or Decreased:
This oxygen affinity is due to more oxygen being released to the tissue so erythropoietin is not activated causing a slight anemia.
Decreased oxygen affinity
Hgb Kempsey is an example of _________ oxygen affinity causing a left shift in the oxygen dissociation curve.
Increased
Hgb Kansas is an example of ________ oxygen affinity causing a right shift in the oxygen dissociation curve.
Decreased
What is caused due to an abnormality in the globin chains in the hemoglobin molecule?
Hemoglobinopathies
How do we identify hemoglobinopathies?
Hemoglobin electrophoresis
How do you calculate the relative reticulocyte count?
Normal range for relative retic count
0.5 - 2.5%
How do you calculate the absolute reticulocyte count?
Normal range for absolute retic count
20,000 - 115,000/uL
How do you calculate the corrected retic count to adjust for anemia?
Patients with a hematocrit of 35% should have what corrected retic value?
2-3%
Patients with a hematocrit < 25% should have what corrected retic value?
3-5%
This calculation adjusts for prolonged peripheral maturation time for reticulocytes
Reticulocyte production index (RPI)
What are the calculations for the reticulocyte production index?
What RPI value indicates adequate bone marrow response?
RPI > 3
What RPI value indicates inadequate erythropoietic response?
RPI < 2
Fat to cell ration seen with aplastic bone marrow
90: 10
- normal = 50:50
Most anemias will have what type of cell hyperplasia in the bone marrow?
Erythroid hyperplasia
(RBCs)
What would you expect to see in a bone marrow smear for possible megaloblastic anemia?
- Asynchrony
- Hypersegmented neutrophils
- Giant metamyelocytes and bands
What tests will help distinguish the different microcytic anemias?
-Hemoglobin electrophoresis to detect:
~Thalassemia, Sickle, Hgb C
~If no Hgb A, disease is homozygous
~Kleihauer Betke stain to detect increased fetal hgb in thalassemia or HPFH
-Ferritin, iron, TIBC to detect IDA
Tests used to distingiush normocytic anemias
- Sickle solubility test: cannot distinguish disease from trait
- Direct antiglobulin test (DAT): for AIHA
- Osmotic fragility: will diagnose hereditary spherocytosis or elliptocytosis
- Enzyme deficienes: G6PD deficiency will have Heinz Bodies and a deficient G6PG screen
- Sucrose hemolysis, Ham test, and Flow cytometry for PNH: lysis positive
- Haptoglobin, urine hemosiderin, urine urobilinogen: determines intravascular vs extravascular hemolysis
- Reticulocytes: indicates if hemolysis or hypoproliferative disorder
- Bilirubin and LD: increased in hemolytic anemia
Tests used to distinguish macrocytic anemia
- B12 and folate levels
- Erythropoietin level increased: intramedullary hemolysis
- Schilling test: detects Pernicious Anemia
- Liver enzymes increased in liver disease
- Bone marrow for myelodysplasia: pre-leukemia
Red cell inclusions:
- DNA
- Seen in post-splenectomy
- Megaloblastic anemias and some hemolytic anemias
- Small single, deep blue, round granule at periphery of cell
Howell Jolly Body
Red cell inclusions:
- RNA
- Associated with decreased RBC survival/hemorrhage, erythroid hyperplastic marrow
- Polychromasia with Wright’s stain
Reticulocyte
Red cell inclusions:
- Iron
- Seen in sideroblastic anemia and thalassemia
- Subtle pale dots near periphery of cell
Pappenheimer body
Red cell inclusions:
- Precipitated hemoglobin
- Seen in G6PD deficiency
- Can only be seen with supravital stain
Heinz Body
Red cell inclusions:
-Crystallized hemoglobin
C crystal
Red cell inclusions:
- Iron
- Nucleated red blood cell precursor with at least five granules that circle at least 1/3 of the nucleus
Ringed sideroblast
Red cell inclusions:
- RNA aggregates
- Seen in thalassemia (fine) and lead poisoning (coarse)
Basophilic stippling
Red cell inclusions:
- DNA
- Usually a metarubricyte
- Always abnormal in adult peripheral blood
NRBC
How do is the automated hematocrit calculated?
Common cause for Folate deficiency
Diet
What is increased in hemochromatosis?
Iron
What anemia is found in mononucleosis?
Cold agglutinin (IgM)
What globin chains are in Hgb A?
2 Alpha
2 Beta
What globin chains are in Hgb A2?
2 Alpha
2 Delta
What chains are in Hgb F?
2 Alpha
2 Gamma
What chains are in Hgb H?
4 Beta
What chains are in Bart’s Hemoglobin?
4 Gamma
Percentage of transferrin bound to iron
30%
How are intravascular and extravascular hemolysis distinguised?
Urine hemosiderin
(increased with intravascular)
Tests utilized in the detection of hemolytic anemia
- Bilirubin: increased
- LD: increased
- Haptoglobin: decreased
- Urine hemosiderin: increased
What is the reticulocyte value for hemolytic anemias?
Increased
What is the reticulocyte value for anemias due to nutritional deficiencies?
Decreased until the nutritional need is met
Which of the anemias are life threatening?
- Alpha Thalassemia major (4 gene deletion)
- Microangiopathic Anemia (DIC, HUS, TTP)
How can Hgb A with Hgb S be confirmed?
Hemoglobin electrophoresis using citrate agar
How can IDA and anemia of chronic disease be differentiated?
Ferritin and TIBC
IDA: Ferritin is decreased and TIBC is increased
Anemia of chronic disease: Ferritin and TIBC are decreased
What’s the purpose of the Schilling test?
Detects malabsorption of B12 found in Pernicious Anemia
What is the breakdown product of hemoglobin?
Urobilinogen
What are the products of heme synthesis?
- Protoporphyrin
- Uroporphyrin
- Coproporphyrin
Which thalassemia is more serious?
Alpha thalassemia major
What microscopic power is used to view bone marrow megakaryocytes?
10X, low power
What do karyorrhexis and asynchrony indicate?
Defective DNA synthesis
At what point do normal RBCs lyse in osmotic fragility?
~ 0.45 - 0.5% NaCl with complete hemolysis by 0.3%
Which anemia type is found in liver disease?
Macrocytic
Which chemistry tests are elevated in hemolytic anemia?
Bilirubin and LD
Which group of anemias has the most polychromasia?
Hemolytic anemias
Ringed sideroblasts on an iron stain indicate what?
Sideroblastic anemia
Are hyper-segmented neutrophils reported?
Yes
What is the bone marrow fat to cell ratio in aplastic anemia?
90:10
If the wrong type of blood is transfused, what type of hemolysis is found?
Intravascular
Fetal hemoglobin content for newborns
60-90%
Fetal hemoglobin content for HPFH heterozygous
15 - 35%
Fetal hemoglobin content for HPFH homozygous
100%
Fetal hemoglobin content for sickle cell trait
Normal, ~1%
What is the M:E ratio for erythroid hyperplasia?
1:1
Calculate the M:E ratio-
-During a bone marrow analysis, 370 myeloid cells are counted, 130 erythroid cells are counted.
370 myeloid : 130 erythroid
2.8 : 1
What is the normal M:E ratio?
3:1
What is the M:E ratio in anemia?
1:1
What percentage of white blood cells are the more mature cells in normal bone marrow?
50% of neutrophils are myelocytes, metamyelocytes, bands, and segs
What is an advantage of using automated instruments?
Increased precision
When is basophilic stippling observed?
- Thalassemia
- Lead poisoning
- Megaloblastic anemia
- Sickle Cell anemia
