Leukocyte Disorders Flashcards
Cause of Pelger-Huet
mutation = decreased expression of β-lamin receptor
How to differentiate true vs Pseudo Pelger-Huet
Pelger-Huet = no clinical significance
Pseudo = disorders (MDS, AML, plasma cell myeloma, drugs) will have other affected characteristics
PBS of Pelger-Huet
Hypo-lobed neutrophils
Clinical significance of Pelger-Huet
Normal cell function
Cause of Alder-Reilly
Recessive allele = lacks enzymes to breakdown mucopolysaccharide for storage = mucopolysaccharide accumulation in cytoplasm
Clinical significance of Alder-Reilly
- normal WBC function
BUT = mental retardation, dwarfism, skeletal deformities, lifespan: 10-20 years
PBS of Alder-Reilly Anomaly
- large pink granules in neutrophils
- can be mistaken for toxicity but NO VACUOLES or NO DOHLE BODIES
Cause of Chediak Higashi
LYST gene mutation = abnormal Lysosomal Trafficking (transport of material to lysosomes)
Clinical Significance of Chediak Higashi
- Defective de-granulation
- Diminished delivery of enzymes to phagosomes
- Abnormal chemotaxis
- Short life expectancy
PBS of Chediak Higashi
- “bubbly” granules = aggregation of primary + secondary granules
- NEUTROPENIA, THROMBOCYTOPENIA
Cause of May-Hegglin Anomaly
MYH9 gene mutation (Myosin-heavy chain-9) = abnormal cytoskeletal proteins in PLATELETS
Clinical significance of May-Hegglin Anomaly
- normal WBC function
- possible bleeding tendencies due to thrombocytopenia
PBS of May-Hegglin Anomaly
- Long BLUE inclusions in ALL GRANULOCYTES
- THROMBOCYTOPENIA
- GIANT PLTs
Cause of Chronic Granulomatous Disease
Mutation in gene responsible for producing NADPH oxidase complex = Neutrophils cannot produce super-oxides (anti-microbial)
Clinical significance of Chronic granulomatous disease
- ABNORMAL NEUTROPHIL FUNCTION = cannot produce superoxides
- recurrent INFECTIONS in lungs, tissues, skin, lymph nodes, liver
- infection contained in macrophage-rich GRANULOMAS bc no superoxides for killing
Additional testing for Chronic Granulomatous Disease
- Nitro-blue-tetrazolium reduction test
- Flow cytometry
Cause of Infectious Mononucleosis
Infection of B-lymphocytes by EPSTEIN-BARR VIRUS
PBS of Infectious Mononucleosis
- WBC increased
- Reactive lymphocytes
Additional testing for Infectious Mononucleosis
- Monospot POSITIVE
- Immunological testing = EBV specific antigens
Which non-malignant disorder may develop an anti-i/ cold agglutinin syndrome ?
Infectious mononucleosis
Leukemia is a __ condition involving __ tissue.
Leukemia is a MALIGNANT condition involving HEMATOPOIETIC tissue.
Define oncogenes
- Altered genes responsible for cell cycles/ proliferation/ regulation
- Mutations that lead to cancer = abnormal cell processes + uncontrolled cell growth
Explain the body’s mechanism against oncogenes
- tumor suppressor genes
- promotes apoptosis of irregular cells
Leukemia can occur secondary to which conditions ?
- Previous hematological disease (MPN, MDS, MM)
- Genetic (Fanconi’s AA, Down syndrome)
- Immunodeficiencies
MPN = Myeloproliferative neoplasms
MDS = Myelodysplastic syndrome
MM = Multiple Myeloma
Acute Leukemia characteristics
- rapid onset
>20% blasts - affects all ages
CBCD in Acute Leukemia
- N/N anemia (RBC decreased)
- WBC increased
- THROMBOCYTOPENIA
- NEUTROPENIA
>20% blasts
Testing for Acute leukemia
- PBS and BM morph
- Immunophenotyping (Flow cytometry)
- Special cytochemical stains
- Enzyme markers
- Cytogenetics
- Molecular genetics
Differentiate myeloid vs lymphoid blasts
Myeloid:
- larger (more cytoplasm)
+/- auer rods
- azurophilic granules
- lacier chromatin
Lymphoid:
- smaller than myeloblasts
- scant cytoplasm
- less lacy chromatin
- rare granules
A positive Myeloperoxidase stain indicates __ BUT what does a negative result imply ?
A positive Myeloperoxidase stain indicates MYELOblasts BUT a negative result cannot exclude myeloid lineage (too young to produce MPO)
Which cells produce Myeloperoxidase ?
Granulocytes and Monocytes (primary granules)
Sudan black stains which cells positive ?
Myeloid
Alpha-napthyl esterate stains which cells ? What is an interference ?
- NSE pos = Monocytes > megakaryocytes
- Sodium fluoride is an interference
PAS stains which cells ?
Lymphoblasts = BLOCK POSITIVE
Acute erythroleukemia (AEL), acute megakaryocytic leukemia (AMegL), acute lymphocytic leukemia (CLL) = POS
TdT (enzyme marker) is detected via __ in leukemic __ cells, but rarely in __.
TdT (enzyme marker) is detected via FLOW CYTOMETRY in leukemic LYMPHOID cells, but rarely in AML
Describe cytogenetics studies/ karyotpying
- analysis of chromosomes in metaphase
- detects NUMERIC and STRUCTURAL abnormalities
- chemical stops mitosis and KCl separates chromosomes
- fixative = methanol + acetic acid
Define lymphoma
Tumor mass (involving lymphocytes and lymph nodes) +/- hematopoietic involvement
ALL can be further classified based on the origin of the cell. What are they?
B cell or T cell
How to differentiate B cell vs T cell ALL ?
B cell: CD34, 10, 19, 20, 22, TdT+
T cell: CD1, 2, 3, 4, 5, 7, 8, TdT+
AML involves which cells ?
Granulocytes, monocytes, erythrocytes, and megakaryocytes
PBS/BM of APL
Acute promyelocytic leukemia:
- increased promyelocytes
- bundles of auer rods
- thrombocytopenia (associated with DIC)
APL stain results (MPO, SBB)
MPO pos
SBB pos
APL: Immunophenotyping
CD13, 33, 64, 117
PBS/ BM of AMML
Acute MyeloMonocytic Leukemia:
- normo/normo anemia (RBC decreased)
- increased monocytes in PBS
- NEUTROPENIA, THROMBOCYTOPENIA
- WBC increased (myeloblasts, monoblasts, precursors)
AMML stain results (MPO, SBB, NSE)
MPO pos
SBB pos
NSE pos
PBS/ BM of AMMonoL
Acute Monoblastic/ Monocytic Leukemia:
- 2 subtypes = predominant monoBLASTS OR monoCYTES
- auer rods in monocytic leukemia
AMMonoL stain results (NSE, MPO, SBB)
NSE pos
MPO/ SBB variable
PBS/ BM of Acute AEL
Acute Eryhthroid Leukemia:
- predominant nRBC in PBS/ BM
- 20% blasts
- dysplastic precursors
AEL stain results (PAS, NSE)
PAS pos
NSE pos
AEL: immunophenotyping
CD235
PBS/ BM for AMegL
- increased megakaryocytes, monocytes
- megakaryoblastic fragments
- large PLTs
PBS/ BM of CML (chronic phase)
- normo/normo anemia (decreased RBC)
- increased WBCs, left shift (myeloid)
- increased PLTs
- nRBC
- increased EOS and BASOS
- blasts <2%
PBS/ BM of CML as it progresses from chronic>accelerated>blast phase
Accelerated:
- anemia worsens (decreased RBC)
- WBC and PLTs increase
- BASOS increase
- blasts = 10-19%
Chronic:
- BLASTS >20%
3 stages of CML
chronic > accelerated > blast
LAP result for CML
negative; LAP enzyme is only detected in active neutrophils (leukemoid reaction)
Chronic Leukemia is classified based on __ and __
Chronic Leukemia is classified based on AFFECTED CELL LINE and GENETIC ABNORMALITIES
3 categories of Chronic Leukemia
- Mature B-cell Neoplasms (CLL, hairy cell, MM, Hodgkins)
- Myeloproliferative neoplasms (CML, PV, primary myelofibrosis, ET)
- Myelodysplastic syndromes (MDS)
T or F: CLL does not terminate into an acute leukemia
TRUE; CLL does NOT terminate into an acute leukemia.
- patients often die due to other complications/ infections
Which cells do CLL affect ?
B-cells/ plasma cells
Pathophysiology of CLL
- B-lymphs cannot progress into plasma cells = hypogammaglobulinemia = more susceptible to infections
- abnormal immunoglobulins lead to autoimmunity (AIHA or Thrombocytopenic Purpura)
Hairy cell leukemia is a subtype of __.
Hairy cell leukemia is a subtype of CLL
Additional testing for Hairy cell leukemia
TRAP pos
Immunophenotyping = CD20, increased side scatter; co-expression of CD103 & CD22
TRAP = tartrate resistant acid phosphatase stain
Immunophenotyping results for Hairy cell leukemia
- Increased C20
- Co-expression of CD103 AND CD11c
Plasma cell neoplasms are a subtype of __.
Plasma cell neoplasms are a subtype of MATURE B-CELL NEOPLASMS
What is secreted by plasma cell neoplasms ?
- Immunoglobulins/ paraproteins
- aka M-proteins
List 3 conditions under Plasma cell neoplasms
- Monoclonal gammopathy of undetermined significance
- Plasma cell myeloma (Multiple myeloma)
- Waldenström macroglobulinemia
% of plasma cells in Monoclonal gammopathy of undetermined significance
<10%
How to differentiate Waldenstrom’s macroglobulinemia vs Plasma cell myeloma
Waldenstrom’s mactoglobulinemia:
- serum electrophoresis = IgM
- asymptomatic
Plasma cell myeloma:
- serum electrophoresis = IgG or IgA
- CRAB symptoms (increased Ca2+)
CRAB = calcium elevations, renal damage, anemia, bone lesions
2 classifications of lymphomas
- Hodgkin’s lymphomas
- Non-hodgkin’s lymphoma
Testing for Hodgkin’s lymphomas
Reed-sternberg cells in lymph node biopsies (rarely in PBS)
What do Reed-sternberg cells resemble ?
“Owl-eyes”
Differentiate Hodgkin’s vs Non-Hodgkin’s lymphomas
Hodgkin’s:
- commonly in YOUNGER adults
- affects UPPER lymph nodes (neck, chest, armpit)
- Reed-sternberg cells (“owl-eyes”)
Non-Hodgkin’s:
- in all ages
- any lymph node
- no RS cells
What are Myeloproliferative neoplasms ?
- clonal disorders affecting MYELOID lineage
- commonly in older adults
- genetic stem-cell mutation = uncontrolled cell proliferation
Cell differentiation and metabolism is influenced by the activity of __.
Cell differentiation and metabolism is influenced by the activity of TYROSINE ACTIVITY.
What does uncontrolled tyrosine kinase activity lead to ?
- increased CELL PROLIFERATION/ CELL CYCLES
- inability to perform apoptosis when they should
Cause of CML
- mutation between chromosome 9 and 22 = BCR-ABL fusion gene
- forms Philadelphia chromosome
- BCR-ABL protein increases tyrosine kinase activity in granulocytes
Treatment for CML
- tyrosine kinase inhibitors
- interferon-alpha = suppresses Philadelphia chromosome
- transplants (BM/ stem cell)
- immunotherapy to destroy abnormal cells
Cause of PV
Polycythemia Vera:
- radiation/ toxin exposure = point mutation in JAK2 gene
- valine amino acid replaced by PHENYLALANINE = JAK2 V617F mutation
Pathophysiology of PV
- JAK2 V617F mutation = JAK2 kinase continuously triggers EPO receptors WITHOUT EPO
- increased proliferation of RBCs INDEPENDENT OF EPO
- patients develop anemia, BM fibrosis, and splenomegaly
PBS/ BM of PV
PBS:
- INCREASED RBCs
- normo/ normo
- increased PLTs and WBCS
BM:
- normal M:E
- fibrotic over time
- decreased EPO and iron stores
Testing for PV
Molecular genetics: JAK2 V617F mutation
How to differentiate PV, secondary PV, and relative PV
PV: increased RBCs, WBCs and PLTs with decreased EPO
Secondary PV: increased RBCs AND EPO, but normal WBC and PLTs
Relative: increased RELATIVE RBCs (less plasma volume = more concentrated), BUT normal EPO, WBCs and PLTs
NOTE: all will have HIGH HEMATOCRIT and HEMOGLOBIN
Cause of Primary Myelofibrosis
- Various genetic mutations including JAK2 V617F
- overproduction of HSC = increased proliferation of myeloid lines
Which cell lines are affected in Primary Myelofibrosis ?
over-production of hematopoietic cells and stimulation of fibroblasts
PBS/ BM of Initial phase in Primary Myelofibrosis
PBS:
- increased WBCs and PLTs
- normo/ normo anemia (decreased RBCs)
BM:
- hypercellular; increased M:E
Which Myeloproliferative neoplasm may progress into hypo/ micro over time ?
Polycythemia Vera
PBS/ BM of Fibrotic phase in Primary Myelofibrosis
PBS:
- normo/ normo anemia (decreased RBCs)
- DECREASED WBCs and PLTs (large/ giant)
- LEUKO ERYTHRO BLASTIC = myeloprecursors + nRBC + blasts
- poikilocytosis (ELLIPTO + TEARS)
BM:
- dry tap
- DECREASED WBCs and PLTs
Additional testing for Primary Myelofibrosis
- Trephine biopsy due to dry tap
- Molecular genetics = multiple mutations
Which cells are affected in Essential Thrombocythemia ?
MEGAKARYOCYTES and PLATELETS
Cause of ET
Essential Thrombocythemia:
- multiple mutations including JAK2, MPL, CALR = abnormal platelets (function + morph)
PBS/ BM of Essential thrombocythemia
PBS:
- INCREASED and ABNORMAL PLATELETS (>600)
- normo/ normo anemia (decreased RBCs)
- megakaryocyte fragments
BM:
- INCREASED and ABNORMAL MEGAKARYOCYTES
- decreased iron stores
Additional testing for ET
Essential Thrombocythemia:
- Molecular genetics = multiple mutations including JAK2, MPL, CAR
MDS can progress into __.
MDS can progress into AML.
Abnormal findings of granulocytes in MDS
PBS:
- decreased WBCs (being destroyed in BM)
- hypogranulated neuts
- hypo/hypergranulated neuts
BM:
- karryohexis (mitotic figures)
- <20% blasts
Abnormal findings of erythoids in MDS
PBS:
- normo/normo OR dimorphic anemia (decreased RBCs)
- POIKILOCYTOSIS (BASOPHILIC STIPPLING, OVAL MACROCYTES, tears, schistocytes, howell jolly bodies, acanthocytes, spherocytes, elliptocytes)
- nRBCs
Abnormal findings of megakaryocytes in MDS
PBS:
- GIANT PLTs
- PLT clumps
- hypogranular PLTs
- megakaryocytic fragments
BM: <20% blasts
- hypercellular; increased M:E
PBS/ BM in Mature B-cell neoplasm (CLL)
PBS:
- increased SMALL LYMPHS/ smudge cells; neutropenia
- normo/ normo anemia (decreased RBCs)
BM:
- increased small lymphs; >30%
- decreased granulocytes, erythrocytes
PBS/ BM of Hairy cell leukemia
PBS:
- increased hairy cells (SMALL LYMPHS)
- normo/ normo anemia (decreased RBCs)
- decreased PLTs (due to fibrosis)
BM:
- dry tap due to fibrosis
- decreased PLTs
PBS/ BM of Plasma cell myeloma/ multiple myeloma
PBS:
- normo/ normo anemia (decreased RBCs)
- DECREASED WBCs (neutropenia), PLTs, retics
- plasma cells
- rouleaux
BM:
- plasma/ flame/ mott cells
- ostolytic lesions
- hypercellular
PBS/ BM of Waldenstrom’s macroglobinemia
PBS:
- normo/ normo anemia (decreased RBCs)
- DECREASED WBCs (neutropenia), PLTs, retics
- rouleaux
BM:
- plasma cytoid lymphs (resemble plasma cells WITHOUT halos)
Common test results for Plasma cell neoplasms (Plasma cell myeloma and Waldenstrom’s macroglobulinemia)
ESR increased
PT and PTT prolonged
Bence jones proteins in urine
Additional testing for CML
LAP stain = neg
Cytogenetics = Philadelphia chromosome (chromosome 9 to 22 translation)
Molecular genetics = BCR-ABL fusion gene
What causes the spherocytes seen in CLL ?
AIHA secondary to CLL; autoAb coat RBCs and are spliced by macrophages in the spleen
Why may a leukomoid reaction be mistaken with CML ?
Leukomoid reaction:
- increased NEUTROPHILS due to infections, hemorrhage, hemolysis
CML:
- ALL MYELOIDS INCREASED
How to differentiate Leukemoid reaction from CML
Leukomoid reaction:
- LAP stain POS
- NEUTROPHILS increased
CML:
- LAP stain neg
- ALL MYELOIDS INCREASED
- Molecular genetics = BCR-ABL fusion gene
- Cytogenetics = Philadelphia chromosome (9 to 22 translation)
Immunophenotyping for AML
CD13, 33, 64, 17
Why may platelet satellite be observed in blood samples of healthy individuals ?
- EDTA chelates calcium
- this exposes Ag on RBCs
- autoAb binds to GP2 B3A Fc receptors
- platelets satellite around RBCs
Which statement is correct with respect to toxic granulation?
a.
It appears in lymphocytes in response to inflammation
b.
It is associated with chronic myelogenous leukemia
c.
It is usually seen along with a ‘left shift’
d.
It is similar to inclusions seen in Chediak-Higashi
c.
It is usually seen along with a ‘left shift’
Which of the following statements about left shift is FALSE?
a.
Bands and myeloids are present in the peripheral blood.
b.
It can be caused by a malignant or non-malignant process
c.
It often accompanies a high WBC count
d.
It affects the lymphocytic cell line
d.
It affects the lymphocytic cell line
An absolute lymphocytosis with reactive lymphocytes suggests which of the following conditions?
a.
Bacterial infection
b.
Viral infection
c.
Parasitic infection
d.
Acute leukemia
b.
Viral infection
Which of the following is NOT a cause of eosinophilia?
a.
Myeloproliferative neoplasms
b.
Helminth infection
c.
Malarial infection
d.
Bacterial infections
d.
Bacterial infections
The following peripheral blood abnormalities are diagnostic clues in MDS EXCEPT:
a.
Oval macrocytes
b.
Target cells
c.
Agranular neutrophils
d.
Elliptocytes
b.
Target cells
What are the abnormal inclusions in Chédiak-Higashi anomaly composed of?
a.
Ribosomal material that looks like dohle-like bodies
b.
Excess lipids that cannot be broken down
c.
fused granules that inhibit bactericidal functions
d.
Excess mucopolysaccharides that disrupt cell function
c.
fused granules that inhibit bactericidal functions
The heterophile antibody can be found in
a.
Infectious mononucleosis
b.
Acute lymphocytic leukemia
c.
Leukemoid reaction
d.
Bacterial pneumonia
a.
Infectious mononucleosis
Which of the following statements is true regarding infectious mono?
a.
Patient will have relative and absolute lymphocytosis
b.
The bone marrow will show a decreased M:E ratio
c.
The WBC differential will show a left shift
d.
B-lymphocytes will demonstrate characteristic reactive morphology
a.
Patient will have relative and absolute lymphocytosis
Which of the following is a feature of secondary polycythemia?
a.
Increased oxygen saturation
b.
Decreased plasma volume
c.
Increased erythropoietin
d.
Normal hematocrit
c.
Increased erythropoietin
Which of the following cytoplasmic inclusion is composed of RNA?
a.
May-Hegglin inclusions
b.
Alder-Reilly inclusions
c.
Heinz bodies
d.
Dohle bodies
d.
Dohle bodies
