White blood cell disorders Flashcards
benign leukocyte disorders
benign leukocyte disorders are non- neoplastic conditions affecting WBCs
They can be qualitiative or quantitative disorders
Quantitive (numerical) leukocytes disorders:
increased WBC numbers (cytoses)
Decreased WBC numbers (cytopenia)
quantitative leukocyte disorders that dont fit in the cytopenia or cytoses categories
leukemoid reaction
Leukoerythroblastic reaction
leukemoid reaction
a benign, exaggerated response to infection it is NOT leukemia >50,000 uL
Neutrophils, lymphocytes, or eosinphils
Perforating appendicits- neutrophilic leukemoid reaction
Whooping cough (bordetella pertussis) - Lymphocytic leukemoid reaction
Nematode infestation (cutaneous larva migrans)- eosinophilic leukemoid reaction
leukoerythroblastic reaction
- Presence of immature bone marrow cells in the peripheral blood
- bone marrow infiltrative process such as bone marrow fibrosis or metastatic cancer leads to immature WBCs (blasts) or RBCs (nucleated RBCs) in peripheral blood
- Neoplastic conditions that are accompanied by leukoerythroblastic reaction
- Severe bone marrow stress due to benign conditions (sepsis, growth factor admin)
Neutrophilia
Absolute neutrophil >7000 uL
Infection (acute appendicitis)
Sterile inflammation with Necrosis (acute MI)
Drugs (G- CSF, Steroids catecholamines, lithium)
In an infection, Nuetrophils increase in number, but also have prominent blue primary granules (instead of secondary orange granules)– TOXIC CHANGE
Neutropenia
Absolute neutrophil <1500/uL
Apalastic anemia, immune destruction, septic shock, chemotherapy
Eosinophilia
Absolute eosinophil count>700/uL Type 1 HS Invasive helminths Hypocortisolism (addisons) Neoplasms (hodgkins lymphoma) Morphologically the same as normal eosinophils
Basophilia
Absolute basophil>200uL
Allergic and hypersensitivity disorders
Infections
Chronic kidney disease
CHRONIC MYELOID LEUKEMIA
Myeloproliferative neoplasms (MPNs) and Myelodysplastic syndromes (MDSs)
Members of the larger category of Myeloid neoplasms
Acute myeloid leukemia
a set of neoplastic stem cell disorders that involve one or more cell lineages
Myeloproliferative neoplasms (MPNs) (definitions, classification)
Clonal hematopoietic stem cell disorders characterized by proliferation of one or more of the myeloid lineages (granulocytic, erythroid, or megakaryocytic)
Usually all cell lineages are increased but one is the most
CML, PV, PMF, and ET
More common in adults, hypercellular bone marrow with effective hematopoiesis (incresed numbers of cells in the peripheral blood)
Usually splenomegaly and/or hepatomegaly, potential for disease progression to bone marrow fibrosis or acute leukemia
almost all MPNs have have INCREASED TYROSINE KINASE activity
MPN vs MDS
Both MPN and MDS are neoplastic condtions (pre acute leukemia states),
MPNs are hyper cellular bone marrow with INCREASED CELL PROLIFERATION, cytosis
MDS is hypercellular bone marrow with INNEFFECTIVE HEMATOPOIESIS - DECREASED peripheral blood, cytopenias- MDS promotes cell proliferation and cell death, but cell death out ways it
Chronic myeloid leukemia (CML)
BCR- ABL 1 fusion gene positive–> produces tyrosine kinase
neoplastic proliferation of mature myeloid cells GRANULOCYTES and their precursors also characteristically BASOPHILS!!!!!! extremely high leukocytosis (>100k/uL( with neutrophila and immature myeloid cells, rare myeloblasts, BASOPHILIA, thrombocytisis
hypercellular BM and granulocytic hyperplasia
The BCR-ABL1 fusion gene is driven by the PHILIDELPHIA chromosome t (9,22) leads to increased tyrosine kinase (seen via FISH, RT PCR)
1st line therapy is IMATINIB tyrosine kinase inhibitor, Splenomegaly is common, enlarging spleen is indicative of progression to accelerated phase of disease, transformation to acute leukemia usually shortly thereafter (to AML2/3 or ALL 1/3) mutation is in the pluripotent stem cell
CML is different from a leukemoid reaction–negative leukocyte alkaline phosphatase, Increased BASOPHILS, philidelphia chromosome
Chronic phase (3 years), accelerated phase (1 year), blast phase (acute leukemia >20% blasts in PB or BM)
NO cure, eccept allogeneic stem cell transplant
Polycythemia vera (PV)
A MPN of mature myeloid cells, especially RBCs
granulocytes and platelets are also increased
JAK 2 kinase mutation–> increased tyrosine kinase
Clinical symtoms due to hyperviscosity of blood (blurry vision and headache, increased risk of venous thrombosis, flushed face due to congestion, itching after bathing), splenomegaly, goutm histamine release
Treatment is phlebotomy, and hydroxyurea
Death in one year
How PV is different from reactive polycythemia (in PV EPO is decreased and SaO2 is normal, reactive due to high altitude or lung disease SaO2 is low and EPO is increased., Reactive polycytemia is due to ectopic EPO is made peripherally and is hifh, and SaO2 is normal
To say someone has PV they need to have JAK2 mutation and hypercellular BM with erythroid hyperplasia
PV usually have a long clinical course (>10 year) most pts die of thrombosis or hemorrhage, 15-20% pts have a spent phase (Primary myelofibrosis), 2-3 % of patients may develop a MDS or AML
Primary myelofibrosis (PMF)
an MPN of mature myeloid cells especially megakaryocytes, produces excessive PDGF, causing bone marrow fibrosis and extramedullary hematopoiesis(EMH) in the spleen, liver and lymph nodes. Pts get splenomegaly, causing portal HTN
Early prefibrotic PMF show peripheral blood leukocytosis, typical fibrotic PMF shows normal anemia, TEAR DROP RBCs (theyre struggling to get out of the fibrotic material)
JAK 2 mutation is found in 50% of cases (3-7 year survival for fibrotic and >10 for prefibrotic), pts may devleop AML
Usually EPO binds JAK and then JAK tells the cell to start proliferating, in fibrosis, JAK is always phosphorylated–> excessive proliferation
Essential Thrombocythemia (ET)
An MPN characterized by a proliferation of megakaryocytes– elevated platelet count in peripheral blood, with an atypical morphology, RBC
Associated with JAK2 mutations, increased risk of bleeding or thrombosis, rarely progresses to marrow fibrosis or Acute leukemia, no real risk for gout/hyperuricemia
BM is hypercellular w/abnormal megakaryocytes
survival is relatively long, treatment is alkylating agents to lower the platelet count
Myelodysplastic syndromes (MDS)
MDSs are clonal hematopoietic stem cell disorders with cytopenia, dysplasia in one or more myeloid cell lineages. Ineffective hematopoiesis and increased risk of developing AML
Enhanced degree of apoptosis–> cytopenia
MYELOBLASTS ARE ALWAYS <20% in PB and BM cut off for AML
AML (20 % or more in PB and BM), MDS (less than 20% myeloblasts)
MDS: cytopenias, dysplastic features, a hypercellular BM, ring sideroblasts, chromosomal abnormalities
hypogranular and/or hypolobulated PMNs, large, hypogranular platelets, multinucleated red cell precursors, small hypolobulated megakaryocytes in BM aspirate, ring sideroblasts (occur due to abnormal iron accumulatin in impaired mitochondria)
MDS clinical and treatment
MDS is more frequent in elderly individuals, weakness, infection or hemorrhage
Survival 1-3 years, progression to AML (30%)
hard to cure, managed supportively with blood products, Antibiotics, growth factors, hypomethylating agents (decitabine azacytidine), these drugs reduce bone marrow cellularity, the precentage of blasts, and improve cytopenias
Allogenic stem cell transplant only cure
Acute myeloid leukemia general
acute leukemias are neoplastic proliferations of immature cells blasts, recapitulating progenitor cells of the hematopoietic system
2 different types of acute leukemias:
Myeloblastic/myeloid vs lymphoblastic
From a clinical standpoint, acute leukemias are proliferations of immature cells for weeks to months. Chronic leukemias are proliferations of mature cells and have a history of months to years
Acute myeloid leukemia (AML) vs Acute lymphoblastic leukemia
ALL is more common in children, seen in adults too
AML is more in adults (Mature= aMl)
AML and ALL therapy is very different and prognosis is different
Cytochemistry differences between AML vs ALL
can tell appart the presence of intra cellular enzymes, different colors)
AML has myeloperoxidase (MPO generates a black intracellular product) and NSE (non specific esterase, a brick red intracellular product)
immunophenotyping of AML vs ALL
can also identify subtypes of AML
immunohistochemistry uses antibodies,flow cytometry uses tagged Ab that recognize Ag expressed by cells in cell suspension
for AML, markers of immaturity CD34 and CD117
Acute myeloid leukemia (AML)
Generally a poor outcome (survival of 25%)
AUER RODS, AUER RODS, AUER RODS, AUER RODS!!!
Usually has cytopemia (weakness fatigue and petechiae, infections)
Organomegaly, lymphadenopathy and infiltration
Coagulopathy
MAIN diagnostic factor >20% of myeloid basts! in the blood or marrow
bone marrow is hypercellular
peripheral blood can be severe leukopenia to marked leukocytosis, anemia and thrombocytopenia
AML with recurrent cytogenetic abnormalities(favorable prgnosis), AML with myelodysplasia (poor prognosis), therapy myeloid neoplasms, Myeloid with down syndrome
AML with recurrent cytogenetic abnormalities
t(8,21)- RUNX1 inv (16)- CBF t(15, 17)-PML t(9,11)- KMT2A t (6,9)- DEK
t(8,21), inv 16, t(15,17)- good prognosis
t 9/11- intermediate
t 69 - poor prognosis
AML with t(15,17)
AML with t(15,17) or acute promyelocytic leukemia (APL) Atypical promyelocytes (hypergranular),reniform/ bilobed nuclei and occasional cells show multiple prominent AUER RODS
typical hypergranular cases of APL usually show leukopenia, although microgranular variant often manifests leukocytosis
AML is important because it frequently manifests disseminated intravascular coagulation
responds to ALL TRANS RETINOIC ACID (ATRA) which effectively makes it a favorable AML
t(15,17) PML RARA- retinoic acid, important for retinoic acid is myeloiod maturation. RAR disruption blocks maturation and promyelocytes accumulate, ATRA overcomes it and matures the cells, and corrects coagulopathy
Langerhans cell histiocytosis
Proliferation of dendritic cells or macrophages
Langerhans cells are immature Dendritic cells in the skin
Found in many organs, capture Ags and display rhm to T cells
Proliferating langerhans cells express MHC II, CD1 a and langerin (a transmembrane birbeck granules) – give a tennis racket appearance
Abundant vacuolated cytoplasm and vesicular nuclei- histiocytes
Multisystem Langerhans cell histiocytosis (Letterr Siwe disease), kids under 2, multifocal cutaneous lesions, hepatosplenomegaly, lymphadenopathy, pulmonary lesions and destructive bone lesions, pancytopenia
Unisystem langerhans cell histiocytosis (eosinophilic granuloma)- benign proliferations of langerhans in bone
Hand shuller christian triad- BRAF
Hemophagocytic lymphohistiocytosis/ hemophagocytic syndrome
HLH is a potentially fatal hyperinflammatory condition
causes perforin and granzymes, primary HLH– familial HLH
Infectious, rheumatologic, malignant, metabolic conditions
Immune sysntem kills organs
A secondary disorder
AML epidemiology
Rarely inherited, 30% of adult leukemias, etiology 10% therapy related
Favorable: Inv 16, t (16,16), t(8,21), t(16,17) (multiples of 8 or 7)
Intermediate (normal, 9,11)
Poor risk (11q23, non 9 11, 3 ,3 6,9 , 9 22)
AML therapy
Induction (7+3 with Ara- C and daunorubicin Midostaurin and Gemtuzumab)
Consolidation (Chemotherapy, stem c3ell transplant)
Target Threapy : IDH 1 mutation: Ivosidenb,
IDH2: Enasidenib,
FLT3:Giltretinib
CML
Clonal myeloproliferative disorder of puripotent stem cells, Increased proliferation, decreased apoptosis
Philidelphia chromosome, BCR?ABL
7% to 15% of adult leukemias
Incidence 1.5/10x5 , prevalence 5/20^5
Irradiation ais a cause
USE A TYROSINE KINASE INHIBTOR (imatinib, dastinib, bosutinib, ponatinib)
MDS epidemiology
Risk increases with age, M>F, Whites> colored, 3 yr survival 35%
MDS Therapy
Stem cell transplant, Supportive care, hypomethylating agents, lenalidomide
Hypermethylation causes gene silencing, So then a hypomethylating agent would allow for the apoptotic gene to be upregulated
