Week 3 Flashcards
What is monocytosis
-absolute count greater than 1.0 x 10^9/L in adults and greater than 3.5 x10^9/L in neonates
-seen after neutropenia or overwhelming infection can be sign of recovery from acute infection
-TB
-malaria
What is monocytopenia
absolute monocyte count of less than 0.2 x 10^9/L
-rare
-aplastic anemia
-chemotherapy induced cytopenia
-Hairy Cell leukemia HCL
Absolute monocytopenia can be found in
-pt with steroid therapy or hemodialysis
-pts with sepsis
-pt with viral infections - EBV
What are qualitative changes in monocytes
-immature monocytes can be seen in PBS as a response to infection or inflammation not as common as a neutrophilic left shift
hematologic neoplasms
What are some reactive changes that you would see in monocytes
reactive changes can be seen during infection, recovery from BM aplasia or post GM-CSF
nuclear contortion
increased cytoplasmic volume
increased cytoplasmic granules
-phagocytic activity (cytoplasmic vacuolation, intracellular debris, and irregular cytoplasmic borders)
-thin band like segmentation
Functional abnormalities in mono and macro
Lysosomal storage diseases
what can they be classified into
mucopolysaccharide storage disease
lipid storage disease
-represent group of inheritied enzyme deficiencies that cause flawed degradation of phagocytized material resulting in buildup of that partially digested material in that phagocyte
-seen in macrophages and monocytes found in the BM and in the spleen
Inherited condition that affects mucopolysaccharide storage that also affects the neutrophils- Alder Riley
lipid storage diseases that affects macrophages
Gaucher disease
-most common lysosomal lipid storage disease
-defect/deficiency of an enzyme responsible for glycolipid metabolism so unmetabolized lipid accumulates in macrophages through out the body
-BM has Gaucher cells which are macrophages that have a fibrillar blue gray cytoplasm with wrinkled appearance
-pts asymp and others have neurological def
-anemia and thrombocytopenia
lipid storage diseases that affects macrophages
neimann pick disease
-mutation to genes controlling enzymes responsible for lipid metabolism and flow of lipids into and out of the cell.
-causes build up of lipids in cellular lysosomes of organs and macrophages = impairs function depending on the organ that is affected
-niemann pick cells found in BM
-macrophages with a foamy cytoplasm packed with lipid filled lysosomes that look like vacuoles after staining
What are the three types of Niemann Pick Disease
Type A - in infancy = failure to thrive death by age 4
Type b - from 1st decade to adulthood no neruocognitive impairment
Type c - heterogenous
What are age related qualitative differences in lymphs
Reverse ratio in childhood
lymphocytosis compared to adults
-need to use age related RI
-in children age related lymphocytosis is an absolute count greater than 10.0 x 10^9/L but in adults it is a count greater than 4.5 x 10^9
When looking at smear from a child what do you have to pay attention to
-dont assume they are all lymphs
-look at morph - can be blasts
-lymphs have a higher N:C ratio than myeloblasts and can be smaller
Acute lymphoblastic leukemia is most common cancer in childern
What is lymphocytopenia
age dependent
in children - absolute lymph count under 2.0 x 10^9/L but in adults it is a count below 1.0 x 10^9/L
Lymphocytosis without morphologic alterations
-bordetella pertussis
-acute infectious lymph - smaller lymph
Lymphocytosis with morphologic alterations
most common cause
infectious mononucleosis - larger lymphs
-infectious hepatitis
cytomegalovirus infection
viral influenza
lymphoid malignancies
Lymphocytopenia most common cause
steroid therapy
strenuous exercise
morphine administration
HIV
genetic abnormalities
inherited vs acquired
What do large granular lymphs look like
-expanded nucleus with clumped chromatin
-increased cytoplasmic volume but the color is still pale blue
-azurophilic cytoplasmic granules
normal cytotoxic T cells or NK cells
How is the change in morphology related to function in lymphs
- small lymphs are not end cells = resting lymphs
-reactions to AG can be enlargement or blastogenesis
What happens when an lymphocyte interacts with the correct ag
-turns into active cell = blastogenesis (converting from resting to active cell - BLAST)
-cell enlarges, chromatin changes - homogenous and nucleoli are more distinct
-increase in cytoplasm and it becomes more blue because of increased RNA and protein production
-divides by mitosis making more memory and effector cells
Depending on the stage of blastogensis what variations would you see in
nuclear shape
Small, round, central
Oval, extended
Enlarged, irregular, clings to inner membrane
Clefting
Depending on the stage of blastogensis what variations would you see in chromatin
cell shape
color
Dark, clumped
Delicate, homogenous
Nucleoli
Depending on the stage of blastogensis what variations would you see in
cell shape
Round or oval
Enlarged, ‘squarish’
Very enlarged, spreading around RBCs
Increased cytoplasm
Depending on the stage of blastogensis what variations would you see in
color
Pale blue
Darker blue
Extremely basophilic
Azurophilic granules
What are reactive lymphocytes
-activated lymph
-<10% of total lymph count
-have many shapes and sizes
variation in
N:C ratio
nuclear shape
chromatin pattern
visible nucleoli
increased cytoplasm being blue to dark blue
-spreading cytoplasm and peripheral basophilia (Edges of cytoplasm darker blue where it touches red cells)
dont confuse with monocytes because reactive lymphs have regular shaped nuclear membrane (round or oval) and blue cytoplasm (hugging the RBC)
infectious monoculeosis caused by
EBV
-affects mostly young children
-infection occurs in childhood and goes unnoticed because youre asymp
-it becomes symp when teens and adults get it
What are the symptoms of IM
-3-7 week incubation
Sore throat- dysphagia
Lymphadenopathy
Fever/chills
Excessive fatigue
Headache
splenomegaly
hepatomegaly
Etiology of IM
and how is the infection control through a cellular response
-virus infects B lymphs during incubation by attaching to the CD21 receptors
-EBV infects epithelial cells of pharynx, cervical lymph nodes and THEN B lymphs
activation of natural killer (NK) lymphocytes, CD4+T cells, and CD8+memory cytotoxic T cells in response to B cell infection
What is the IM immune response
Th cells secrete cytokines to activate normal, un-infected B-cells
circulating reactive lymphs are activated T cells
non infected Host plasma cell produce anti EBV AB
What can PT IM caused by EBV produce
-EBV stimulates infected host plasma cells to produce non EBV AB
A non specific heterophil antibody
-AB that reacts with an AG from a species that is different than the AG that stimulated its production
Patients with I.M. caused by the EBV produce an antibody (IgM) to the virus but ALSO produce Heterophile antibodies that react with sheep or horse RBCs
What are the two types of antibodies that are being produced within a patient with mono
One, it’s the anti Epstein Barr IgG antibody made by the healthy plasma cells. Two is the heterophile antibody made by the infected plasma cells.
not everyone makes this heterophile AB - young kids dont
What do reactive lymphs in IM look like
- pleomorphic , large, blue
-each cell looks different
-lots of blue cytoplasm
-Round, oval or irregular nucleus - may have nucleoli
-Irregular margins – cytoplasmic projections ‘hug’ red cells
Peripheral basophilia
lesser found clinical manifestation of IM
Mild Cold Autoimmune HA
-caused by auto Anti i which react best at 4 degrees but can start to bind at 30 C.
-Low Titer, IgM , narrow thermal range
so extravascular hemolysis is mild
wide thermal range = intravascular hemolysis through full complement activation
what would we see in the lab when you think we have mono
-elevated WBC count 10-30 x 10^9/L
-absolute lymphocytosis
-variation in lymph morphology
-increased reactive lymphs - HALLMARK OF IM - diagnostic if age and symps match
-reactive lymphs are activated cytotoxic CD8+ T cells ( can be T or B)
-cells seen in blastogenesis
-variation in cells
if >10% of reactive lymphs = increased
some, many in WBC morph
What are some testing strategies used for testing of IM
PT may have primary EBV = Monospot test
-Monospot repeated incase it was too early to detect AB
Monospot negative but EBV is still suspected = EBV specific serology performed by PHOL
How can heterophile AB be used for screening tests
-tests with IgM AB
Monospot - IM latex agglutination test
-latex particles coated with AG from bovine red cells
-pt AB agglutinates latex particles = positive
Screening test
-can have false positives
-negative in IM patients that dont make AB
if you have a confirmed IM diagnosis what do you have
WBC 10-30 x 10^9/L because of absolute lymphocytosis
-reactive lymph morphology
-positive heterophile AB
-positive EBV specific AG and AB test
What are examples of leukocyte artifacts
-Necrotic cells- dead cell
-“Denuded nucleus”- when cytoplasm has disappeared so the nucleus is the only thin that remains - falsely high N:C ratio
-Smudge cells aka basket cell
Broken down cells:
degenerated cells
crushed cell
Anti-coagulant changes
What happens when Granulocytes (neutrophils) sit in EDTA for too long
-necrotic -looking
-increase in artifact smudge cells
-nuclear swelling
-chromatin changes
-loss of structure of lobes
-cytoplasmic rim looks ragged
-increased vacuolization
-loss of granules
-necrotic changes
What happens when mononuclear cells sit in EDTA for too long
cytoplasmic vacuolization
-irregular nuclear lobulation/nuclear budding
-homogenously staining chromatin
-partial nuclear disintegration
how can anticoagulant changes be avoided
-make smears on fresh samples
-put sample in the fridge right after assessment
new sample can be requested if morphological info is required by the physician
What are smudge cells
No nucleus or membranes
-pathological if seen in large numbers
Associated with chronic lymphocytic leukemia (CLL) where lymphocytes are ‘delicate’
-Artifact
Ignore unless suspect CLL – then count separately
What are immunodeficiency states
-conditions were parts of the immune system is defective
Hereditary lymphocyte disorders
T cell like AIDS
B cell
Combined B & T cell
How do you diagnose immunodeficiency disorders
Flow cytometry – quantitative & qualitative:
T – cells
B – cells
SPE and IFE – immunoglobulin
CBC & Smear:
Often a Lymphopenia is seen
Response to infection
What is DiGeorges Syndrome
Defect in T cells
-low t cells
-underdeveloped Thymus, thyroid and parathyroid resulting reduced production of t cells and impaired response to stimulus (cytokines)
-Cardiac and neurological disorders
-thymus is were t cells develop
Susceptible to infections with opportunistic pathogens
Fungi
Pneumocystis carinii
Viruses
What is AIDS
Human immunodeficiency Virus (HIV)
-CD4 T-cells (Helper T) destroyed
causing Host to be immunocompromised
-Chronic infection, chronic inflammation, chronic anemia
last phase of HIV is AIDS
CBC PBS of someone with HIV:
-Pancytopenia with dysplastic marrow
-Normochromic/Normocytic Anemia
-AZT (drug used to treat HIV) can cause Macrocytosis, Megaloblastic changes and marrow Erythroid hypoplasia.
What is Bruton’s Agammaglobulinemia
B cell disorder
-X-linked caused by a mutation in BTK
-This Defect is in B cell lineage (pre-B cells) causes a block in B cell development
-No mature B cells therefore no plasma cells
-No antibody formed
-Major consequence is infections (bacterial)
Treatment:
Intravenous Immunoglobulin (TSML)
IV Ig replaces missing immunoglobulins
IgA Deficiency
hypogammaglobulimia where the pt does not produce or decreased IgA
-Thought to arise after a maturation defect of B cells
-Frequently asymptomatic or
Increased ear, throat, lung infections (since iga is found in mucosal secretions)
upper respiratory
gastrointestinal
-Lab Diagnosis – IFE
-DECREASE in IgA band
-Treat as needed with antibiotics and with IgA deficient blood products
why are blood products IgA deficient
30 - 40% develop anti-IgA AB so if you give them something with IgA then they can have an allergic reaction
Severe Combined Immunodeficiency (SCID)
Severe dysfunction of both T & B cells
Two types :
X-linked is most common
Autosomal recessive
-Both types leads to T cell lymphopenia, B cell dysfunction and a lack of NK cells
Severe infections and death by 2 yrs.
Symptoms show by 2 months
Flow-cytometry essential in Dx
gene therapy - causes risk of leukemic transformation with this procedure.
