Hematology - WBC Flashcards
WBC development steps
Myeloblast - Promyelocyte - Myelocyte - Metamyelocyte - Band cells - Mature WBC
Stain used to see visualise all WBC cells
Wright stain
Most abundant WBC cells
Neutrophils (50-70%)
Nuclear lobes in neutrophils
2-5 nuclear lobes
Neutrophils levels are increased in
Bacterial infection
Acute inflammation
Sterile inflammation
Burns
Normal lymphocytes percentage
20-40%
Nucleus in Lymphocytes
Round nucleus
Lymphocytes levels are increased in
Viral infections (CMV,EBV)
Chronic Inflammatory conditions
Borditella pertusis infection
Biggest WBC in human body
Monocytes
Which WBC levels usually increases with Lymphocytes
Monocytes
Monocytes levels increases in
Chronic inflammation
Autoimmune disorders
IBD
TB, Malaria
Ricketssiae
Nuclear lobes in Eosinophil
2 nuclear lobes
Eosinophil levels increases in
Parasitic/worm infections
Allergy
Hodgkin’s lymphoma
Athero-embolism - Eosinophils in urine
Least WBC found in Blood
Basophils (1-2%)
Basophils levels increases in
Allergic conditions
Chronic myelogenous leukemia
Nucleus shape of Band neutrophils
Horse shoe shaped nucleus
Band neutrophils seen in peripheral blood due to
When there is increased stimulation of BM
Shift to left means
Increased leukocytes count in blood
Normal WBC levels
4,000-11,000 WBCs per microliter
Condition when WBC levels are more than 40-50k WBCs per microliter
Leukemoid reaction
Leukemoid reaction means
Increased no. Of matured Wbc cells
LAP score in Leukemoid reaction
Increases
Leukemoid reaction is usually seen in
Pneumonia
Infectious endocarditis
Septicimea
Leukemia means
Increased involvement of Bone marrow and surrounding blood vessels
Lymphoma means
Infiltration of Cancer cells in different organs of body via lymph nodes
In leukemia
Cancer cells in BM - Can suppress normal cells leads to
Decreased RBC - Anemia
Decreased WBC - Fever
Decreased platelets - Increased risk of bleeding
In leukemia
Cancer cells in BM - Can suppress normal cells leads to
Decreased RBC - Anemia
Decreased WBC - Fever
Decreased platelets - Increased risk of bleeding
WHO Classification of lymphoid neoplasms
1) Precursor B cell neoplasm
2) Peripheral B cell neoplasm
3) Precursor T cell neoplasm
4) Peripheral T cell neoplasm
5) Hodgkin’s lymphoma
WHO Classification of Myeloid Neoplasm
1) Acute myeloid leukemia
2) Myelodysplastic Syndrome
3) Myeloproliferative neoplasms
WHO classification of Macrophages
Langerhans cell histiocytosis
Cancers arising from precursors cells are usually
Multiply very rapid
Very rapid onset of symptoms
Cancers arising from Peripheral cells are usually
Slow growing
Chronic leukemia
Symptoms onset can take months to years
Risk factors Of Acute leukemia
Ionising radiation
Chemicals
Genetic factors
Infectious organisms
Chemicals having risk of Acute leukemia
Smoking
Benzene
Drugs - Anticancer drugs (Alkylating agents, Topoisomerase inhibitors)
Genetic factors responsible for acute leukemia
Down Syndrome (Trisomy 21) - ALL (MC), AML
Klinefelter’s syndrome
Neurofibromatosis
Fanconi’s anemia
Ataxia telangectasia
Infectious organisms responsible for acute leukemia
EBV (Epstien barr virus)
HTLV-1
HHV-8
Due to blocking of differentiation in acute leukemia
There is increased no. Of immature cells
Clinical symptoms of acute leukemia
Acute/sudden onset of action
Weakness, fever
Lymph nodes enlargement
Bleeding
Abdominal fullness
Blood exam in acute leukemia shows
TLC increased
Percentage of immature Wbc cells in normal person on BM Aspiration
5%
In case of Acute leukemia percentage of immature Wbc cells is
More than 20% of lymphoblasts or myeloblasts
If Lymphoblast >20%
Acute lymphoblastic leukemia(ALL)
Stain used to identify Lymphoblasts
TdT(Terminal deoxynucleotide transferase)
PAS (Periodic acid-Schiff)
If Myeloblast >20%
Acute myeloid leukemia (AML)
Stain used to identify Myeloblast cells
Myeloperoxidase
Non specific esterase
Flow cytometry is used to
See absence or presence of CD Molecules
Precursor cell of Acute Myelogenous leukemia (AML)
Myeloblast
Precursor cell of Acute Myelogenous leukemia (AML)
Myeloblast
Moat commonly affected population in AML
Elderly population (60yrs)
Affected myeloid cells in AML
Erythroblast
Megakaryoblast
Myeloblast
Clinical signs of AML
Sudden onset
Fatigue
Fever
Anorexia
Weight loss
AML-FAB Classification
M0 to M7
M0
Minimally differentiated AML
M1
AML without maturation
M2
AML With maturation
M3
Acute Promyelocytic Leukemia
M4
Acute Myelomonocytic leukemia
M5
Acute monocytic leukemia
M6
Acute erythroleukemia
M7
Acute Megakaryocytic leukemia
M1 to M4 AML are identified by
Myeloperoxidase
M5 AML identified by
Non specific esterase
M6 AML are identified by
PAS +ve
M7 AML is identified by
CD41
CD61
Myeloblast are stained by
Myeloperoxidase
Non specific esterase
PAS +ve
Special markers used to identify Myeloblast
CD41 and CD61
Most common AML
M2 - AML with maturation
Translocation seen in AML with maturation
t(8;21)
AML with maturation also known as
Granulocytic sarcoma
Myeloblastoma
In AMl With maturation cell deposits in
Retroorbital tissues - Pushes eyeball forward - Development of Proptosis
Markers used for AML with Maturation
CD45, Lysosome+ve
CD43
Translocation seen in Acute Promyelocytic Leukemia (M3)
t(15;17)
In M3, Due to t(15;17) there is fusion of
PML protein + Retinoic acid receptor fusion - can lead to vitamin A defeciency
In M3 AML, there is high risk of development of
DIC - because tumor cells release mucin - leads to extensive damage of endothelial cells
Aeur rods are seen in
Acute Promyelocytic Leukemia (M3)
20-30 Aeur rods together termed as
Faggot cell (Bundle of stick appearance)
Translocation seen in Acute myelomonocytic leukemia (M4)
t(16;16)
Gum hypertrophy and leukemia cutis are seen in
Acute Myelomonocytic leukemia (M4) and Acute monocytic leukemia(M5)
AML most commonly associated with Down Syndrome
Acute Megakaryocytic leukemia (M7)
WHO classification of AML
AML with specific genetic defetcs
AML with Myelodysplasia related changes
AML (Therapy related)
AML not otherwise specified
Myeloid sarcoma
Myeloid profileration related to Down Syndrome
AML with Specific genetic defetcs includes
t(8;21)
t(16;16)
PML-Retinoic acid receptor fusion (M3)
Nucleophosmin mutation
t(11;v)
Good prognosis
AML with Myelodysplasia related changes includes
Abnormal proliferation of myeloid cells
Monosomy 5 and 7
Intermediate prognosis
AML (Therapy related) includes
Alkylating agents
Topoisomerase inhibitors
Very bad prognosis
Myeloid proliferation related to sown Syndrome includes
GATA1 Mutations
Transient abnormal myelopoiesis
Myeloid leukemia associated with Down Syndrome
Most common AML subtype in Infants
M5
Most common AML Subtype in childrens
M7
Diagnosis of AML
Peripheral blood smear
BM Examination
Flow cytometry
Cytogenetics
Molecular study
Investigation of choice in AML
Flow cytometry
Most common leukemia in childrens
Acute Lymphoblastic leukemia (ALL)
Clinical features of ALL
Sudden onset
Fatigue
Pallor
Increased risk of infection - Fever
Increased bleeding - petechiae, purpura, gum bleeding
Splenomegaly, hepatomegaly
Lymphadenopathy
Sternal tenderness
In male - enlarged testicular mass
Cytogenetic abnormality seen in B cell ALL
Hyperploidy (Presence of more than 50 chromosomes)
Translocations seen in B cell ALL
t(12;21) , t(9;22) , t(1;19)
Prognosis of B cell ALL in Hyperploidy and t(12;21)
Good prognosis
Prognosis of B cell ALL in hypoploidy and t(9;22) , t(1;19)
Bad Prognosis
EBF and PAX-5 is required for
Proper B cell differentiation
Mutations in EBF AND PAX-5 can leads to
Loss of function - proliferation of undifferentiated cells
Mutations seen in T cell ALL
NOTCH Mutation - Gain of function mutation
NOTCH Mutation is associated with
Excessive proliferation of tumor cells
Diagnosis of ALL
Peripheral blood smear
BM Aspiration - greater no. Of precursor cells (Lymphoblasts)
More common ALL
Pre B cell ALL
In Pre B cell ALL which organ is involved
Bone marrow
In Pre T cell ALL which organ is involved
Thymus
Pre B cell ALL usually seen in which age
Upto 3 yrs of age
Pre T cell ALL usually seen in which age
Puberty
Prognosis of Pre B CELL ALL
Better prognosis
Prognosis of T cell ALL
Bad Prognosis
Good prognosis Factors in ALL
Hyperploidy
t(12;21)
Trisomy 4/7/10
White race
1-10 years of age
Female gender
Less blast count (<1 lakh)
Pre B cell ALL
Drug reponse
Remission <14 days
Bad Prognosis Factors in ALL
Hypoploidy
MLL/KMT2A translocation
t(9;22), t(1;19) , t(4;11) , t(5;14)
Black race
<1 year ; >10 year
Male gender - testicular involved
More blast count (>1 lakh)
Pre T cell ALL
no response to drug
Remission >14 days
Treatment of ALL
Anticancer drugs (Childrens tolerate well than adults)
Bone marrow transplantation
CAR-T Therapy
CAR-T Therapy
Infusion of modified antigenic T cells - Targets CD19 (usually present on Tumor cells) - destroys tumor cells
CAR-T Therapy is associated with
Massive release of cytokines
Chronic myeloid lukemia is an example of
Myeloproliferative disorder
CML arises from
Pleuripotent hematopoietic stem cells
Risk factors of CML
Radiation exposure
t(9;22) - Philadelphia chromosome
Gene present on Chromosome 9(CML)
ABL gene - Tyrosine kinase activity present
Gene present on Chromosome 22(CML)
BCR gene
BCR-ABL Fusion gene chromosome also known as
Philodelphia chromosome
Fusion gene BCR-ABL leads to
Increased activity of Tyrosine kinase - needed for cell replication - due to which no. Of cells increases
Philodelphia chromosome can be seen in
CML (MC)
ALL (B Cell)
Chronic neutrophilic leukemia
Age group in risk of CML
25-60years , mostly >50
Clinical features of CML
Non specific Clinical features - Fatigue, fever, weight loss
Extra medullary hematopoiesis - Massive splenomegaly - Abdominal fullness
Abdominal pain can be present in case of Splenic infarct
Blood examination in CML
TLC increased
Hb levels low
Platelet count increases
Peripheral smear in CML
Myeloid precursors increased
Basophils ++
Eosinophils +
Differential diagnosis of Leukemoid reaction with CML
Benign condition
No philodelphia chromosome
TLC(40-50K) i.e; less than 1lakh
Basophilia and Eosinophilia usually not seen
Serum B12 levels in CML
Increases
LAP score in CML
Decreased
BM Examination in CML
Cellularity increases
Reticulin +++
Sea blue histiocytes
Pseudo gaucher cells
Increased no. Of WBC precursors
Blast cells increases
Sea blue histiocytes are seen in
CML
Pseudo gaucher cells can be seen in
Gaucher like cells
Can be seen in - CML, Multiple myeloma, Myelodysplastic Syndrome, Thalessemia
Difference between pseudo gaucher cells and Gaucher cells
PGC - No iron staining
No inclusions in cytoplasm
Stages according to no. Of Blast cells
Chronic stage
Accelerated stage
Blast stage
Chronic stage in CML
Asymptomatic
Blasts <10%
Philodelphia chromosome +
Accelerated stage in CML
10-19% Blasts
Splenomegaly, Basophils increased
Cytogenetic changes
WBC Count increased
Platelet count increases
Response to Tyrosine kinase Inhibitors therapy
Blast stage in CML
Blasts >20%
Lymphadenopathy
Sudden increase in size of lymph nodes in CML patient indicates
Patient reached to Blast stage
CML can progress t0
AML (70%)
ALL (30%)
College girl appearance seen in peripheral smear in which disease
CML
Philodelphia chromosome can be identified by which method
FISH - Fluorescent insitu Hybridization
Fusion gene in Philadelphia chromosome is detected by
FISH
mRNA in Philadelphia chromosome is detected by
PCR
Treatment of CML
Tyrosine kinase Inhibitors - Imatinib
Response to TKI depends on
1)Hematological resistance to 1st TKI
2)Hematological/cytological/molecular resistance for 2 sequential TKIs
3) >2 mutations in BCR-ABL gene if patient on TKI
Treatment of CML In young patients
Allogenic BM transplantation
Prognostic index used for CML
SOKAL Index
Hassford index
SOKAL index includes factors like
Spleen size
% of circulating blasts
Clonal cytogenetic defects
Age
Level of platelets
In Hassford index factors includes
Same as SOKAL Index Except % of Eosinophils and basophils in place of clonal defects
Commonest blood cancer in Adults
Chronic lymphocytic leukemia (CLL)
CLL Arises from
Peripheral B cell
B cell mutations seen in CLL
11q deletion
12q Trisomy
13q deletion
17p deletion
NOTCH-1 +++
Somatic hypermutation
ZAP-70 levels in CLL
Increased - tumor cell rate of replication increases
If there is mutations in B cell it leads to
Formation of abnormal plasma cells - Abnormal antibodies formation
Due to presence of abnormal antibodies in CLL
Decreased Immunoglobulins (Hypogammaglobunemia)
Infection frequency increases
Autoantibodies - RBC destruction
Which protein is defected in case of CLL
Vimentin
Vimentin is responsible for
For maintaining Lymphocytes structure
Defect of vimentin leads to
Fragile tumor cells
Clinical features of CLL
Non specific - Fever/weight loss/night sweats
>60 yr
Fatigue
Lymph node enlargement
Clinical features of CLL
Non specific - Fever/weight loss/night sweats
>60 yr
Fatigue
Lymph node enlargement
Blood examination in CLL
Anemia
Platelet count decreases
TLC Increases
DLC - Lymphocytes increases
Absolute lymphocyte count (ALC) levels in CLL
> 5000/microliter
Hypogammaglobunemia is seen in case of
CLL
Peripheral smear in CLL
Smudge cells or parachute cells due to vimentin defect
Convent girl appearance seen in peripheral smear of
CLL
BM Examination in CLL
Hypercellular BM
Lymphoid precursors +++
Lymph node biopsy or exam in CLL
Disturbed Lymph node appearance - due to infiltration of tumor cells
Investigation of choice in CLL
Flow Cytometry
Investigation of choice in CLL
Flow Cytometry
CD molecules seen in CLL
CD19/20/21/23 +
CD5 +
CD molecules seen in CLL
CD19/20/21/23 +
CD5 +
Good prognostic factors in CLL
13q deletion
Somatic hypermutation - slow growing tumor
Good prognostic factors in CLL
13q deletion
Somatic hypermutation - slow growing tumor
Bad prognostic factors in CLL
11q deletion, 17p deletion, 12q Trisomy
NOTCH ++
ZAP-70 ++
Poorest prognosis in CLL
17p deletion
Poorest prognosis in CLL
17p deletion
Treatment of CLL
Fludarabine - best
Rituximab - against CD22
B cell Tyrosine kinase Inhibitors - IBUTINIB
If there is additional mutations in CLL Patients that leads to syndrome named as
Richter syndrome
Mutations in myeloid stem cells leads to
Dysrerythropoiesis or abnormal erythropoiesis
Myelodysplastic Syndrome is classified into
Primary - usually elderly patients (70yr)
Secondary - therapy related
In case of therapy related myelodysplastic syndrome there is history of
Radiation exposure or Cytotoxic drugs
Epigenetic factors responsible for Myelodysplastic Syndrome
DNA methylation
Histone modification
Genetic factors responsible for MDS
Epigenetic factors
Nuclear transcription factors
RNA Splicing defects
Commonest mutation in adults in MDS
5q deletion
Commonest genetic defect in childrens resulting to MDS
Monosomy 7
Most common genetic mutation responsible for MDS in India
Complex karyotype
Effect on RBCs due to defective myeloid stem cells
Abnormal nuclear budding
Megaloblastic changes
Ring Sideroblast - Prussian blue stain
Effect on WBCs due to defective myeloid stem cells
Neutrophils - 2 lobule - Pseudo-pelger huet Anomaly
Effect of defective myeloid stem cells on Platelets in MDS
Divided multiple nuclear lobes - PAWN BALL Megakaryocytes
Due to additional mutations CLL Or SLL can progress to
Diffuse large B cell Lymphoma(DLBCL)
Clinical features of MDS
Pancytopenia
Weakness/ Fatigue
Increased risk of infection
Bleeding tendency increases
BM Examination in MDS
Hypercellular BM
Blasts <20%
Peripheral smear in MDS
Cell count relatively decreases
Nuclear lobe budding
Ringed sideroblast
Pseudo-pelger huet cells - WBC
PAWN BALL Megakaryocyte - Platelets
Management in MDS
Young - Allogenic BM Transplantation
Symptomatic treatment
Decitabine - inhibits DNA methylation
LENALIDOMIDE - 5q deletion
Further mutations in myeloid cells can progress to
AML
