Hematology-diagnostics

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mrman
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Hematology-diagnostics
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2011-11-28 00:49:25
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Hematology-diagnostics
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  1. Total volume of blood in average adult
    5L

    • 3L = plasma
    • 2L = cells
  2. Blood collection for CBC
    Purple top = anticoagulant EDTA
  3. Distinguishing feature of immature cells
    Big nucleus (-BLAST)

    • -in bone marrow only
    • -should never be in periphery
  4. Hematopoiesis
    process by which immature precursor cells develop into mature blood cells
  5. blood formation before birth
    liver
  6. blood formation mid-fetal life
    spleen & lymph nodes
  7. blood formation after birth
    initially: RBCs from mother

    after 1y/o: bone marrow
  8. cells in peripheral blood
    • -Erythrocytes (RBCs)
    • -Lymphocytes
    • -Monocytes
    • -Platelets
    • -Granulocytes (neutrophils, segmented/banded, eosinophils, basophils)
  9. Erythropoiesis
    RBC formation

    • -Rubriblast
    • -Reticulocyte (used as indicator of RBC production w/anemia)
  10. Regulation of erythropoiesis
    with EPO and renal oxygen tension

    -EPO released from kidney and travels to bone marrow to produce more RBCs

    (renal disorders can lead to anemia)
  11. Hemoglobin
    1/3 of RBC

    -oxygen carrying molecule
  12. Hemoglobin variants
    changes in molecule shape = decreased O2 carried

    Hemoglobin S = Sickle cell

    Carboxyhemoglobin = carbon monoxide poisoning
  13. Red Blood Cells
    • -life span of 120 days
    • -new RBCs released into circulatory system every day

    • -Reusable components = iron & protein
    • (stored in body)
    • -Waste products = converted to bilirubin and eliminated from from body (urine/feces)
  14. Quality control for CBC
    Hct = Hb x 3 (+-2)

    *CBC must be repeated if this does not correlate
  15. MCV
    Mean Cell Volume

    • -volume/size of average RBC
    • -macrocyctic, normocytic, microcytic

    *most important w/MCHC
  16. MCH
    Mean Cell Hemoglobin
  17. MCHC
    Mean Cell Hemoglobin Concentration

    -cell color

    *most important w/MCV
  18. RDW
    Red Cell Distribution Width

    -degree variability
  19. Components of CBC
    • WBC count
    • RBC count
    • Hb
    • Hct
    • Platelets

    • *MCV
    • *MCHC
    • MCH
    • RDW
  20. RBC morphology
    Size = macrocytosis, microcytosis

    Shape = ovalocytes, spherocytes, schistocytes

    Inclusions = Pappenheimer bodies, malaria
  21. Anemia
    Decreased RBC, Hct, Hb

    • -implies a decline in oxygen-carrying capacity
    • -etiology & morphology

    • 1. losing blood (RBC loss)
    • 2. bone marrow not producing
    • 3. body destroing RBCs
  22. Anemia critical levels
    • Transfusion:
    • Hb <6.0 = heart failure, death
    • Hct <20%

    • Clotting:
    • Hb >20.0 = hemoconcentration and capillary clogging
    • Hct >60% = spontaneous clotting
  23. Anemia patient presentation
    • -fatigue
    • -HA
    • -vertigo
    • -dyspnea
    • -pica
    • -chest pain
    • -hematuria
    • -dark stools
  24. Anemia physical findings
    • -Hepatomegaly
    • -Spleenomegaly
    • -heart abnormalities
    • -skin pallor
    • -neurological changes
    • -esophageal webs
  25. Considerations for diagnosing Anemia
    • -Rate of onset
    • -Severity
    • -Age
    • -Sex (males Hb > females)
    • -Geographic location (malaria, high altitude)
  26. Etiologic Classification of Anemia
    Causes of erythrocyte and Hb depletion

    • 1. Impaired RBC production
    • 2. Excessive destruction
    • 3. Blood loss
  27. Morphological Classification of Anemia
    • Characteristic changes in RBC size, shape, color
    • -use RBC indicies (MCV) (size)

    • 1. Macrocytic (increased mean cell volume) large
    • 2. Microcytic (decreased MCV) small
    • 3. Normocytic (normal MCV) medium
  28. Anemia: Impaired RBC Production
    Etiological classification

    • 1. Abnormal bone marrow
    • -aplastic anemia
    • -leukemia, cancer metastasis

    • 2. Essential factors deficiency
    • -deficient in iron, B12, folic acid
    • -anemia w/renal disease: EPO

    • 3. Stimulation factor deficiency
    • -chronic disease (autoimmune)
    • -hypopituitarism
    • -hypothyroidism
  29. Anemia: Excessive destruction of RBCs
    (intracorpuscular)
    Etiological classification

    • 1. Hemolytic anemia: Intracorpuscular defect
    • (inside the cell)
    • -Membrane: hereditary spherocytosis, ovalocytosis, etc
    • -Enzyme: G-6PD deficiency
    • -Hb: thalassemia (wrong Ab); hemoglobinopathies
  30. G-6PD
    Enzyme

    -causes Hemolytic Intracorpuscular anemia when deficient

    • -etiological classification: Excessive RBC destruction
    • -Normocytic Anemia
  31. Anemia: Excessive destruction of RBCs
    (extracorpuscular)
    Etiological classification

    • 1. Hemolytic anemia: Extracorpuscular defect
    • (outside the cell)
    • -Mechanical: Microangiopathic HA (MAHA)(schistocytes)
    • -Chemical/physical
    • -Infection: clostridium tetani
    • -Antibodies: SLE
    • -Hyperspleenism: enlarged spleen
  32. Anemia: Blood loss
    Etiological classification

    • 1. Acute blood loss
    • -accident, GI bleed (hemocult test)

    • 2. Chronic blood loss
    • -Hypermenorrhea
    • -parasitic infection
  33. Normocytic Anemia
    • MCV 82-92
    • (normal cells, just decreased #s)

    • 1. Acute hemorrhage
    • 2. Increased plasma volume (pregnancy, overhydration)
    • 3. Hypoplastic marrow
    • 4. Infiltrate BM (leukemia, mult. myeloma)
    • 5. Abnormal endocrine (hypothyroid, adrenal insuf)
    • 6. Kidney disease
    • 7. Hemolytic anemia (depends of cause)
  34. Normocytic Anemia additional diagnostic studies
    • -Bone marrow biopsy:
    • 1. normal cells, decreased production (bone marrow infiltration w/leukemia, aplastic anemia)
    • 2. non-competent/functioning marrow (if reticulocyte count is decreased)

    • -Urobiligen: hemolysis (?)
    • -RBC enzymes: G-6-PD deficiency
    • -RBC morphology: abnormal shapes, spherocytes, schistocytes
    • -AHG (Coombs) test
  35. Microcytic Anemia
    • MCV < 80
    • (small cells)

    • 1. Iron deficiency (chronic blood loss, inadequate diet, malabsorption)
    • 2. Chronic disease (autoimmune)
    • 3. Defective heme or globin production
    • -Hemoglobinopathy: sickle cell, Hb C disease
    • -Thalassemia
    • -Lead poisoning: interferes with heme production
  36. Hemoglobinopathy
    • -defective globin production; causes increased RBC destruction and decreased heme production
    • -sickle cell; Hb C disease

    • -Mycrocytic Anemia (MCV <80)
    • -Excessive destruction of RBCs (intracorpuscular hemolytic anemia)
  37. Thalassemia
    -decreased globin production, alpha or beta chains, creates wrong Ab

    • -Intracorpuscular hemolytic anemia (excessive destruction of RBCs)
    • -Microcytic Anemia (MCV <80)
  38. Lead poisoning: Anemia
    Mycrocytic Anemia

    • -lead interferes with heme production
    • -children under 5 y/o high-risk
    • (live in old house, candy from other countries, underserved populations)
  39. Mycrocytic Anemia additional diagnostic tests
    • Iron studies:
    • -TIBC (capacity of plasma to carry more iron)
    • -Transferrin (protein that carries iron)
    • -Ferritin (reflects marrow iron stores)
    • -Lead levels
    • -Hb electrophoresis (for hemoglobinopathies)

    • Microcytic Anemia w/iron deficiency =
    • 1. Iron and ferritin decreased
    • 2. TIBC and transferrin increased
  40. Macrocytic Anemia
    • MCV > 94
    • (large cells, large nucleus)

    • 1. Megalobastic dyspoiesis
    • -Vit B12 deficiency: Pernicious anemia
    • -Folic acid deficieny: Nutritional megaloblastic anemia, sprue, malabsorption
    • -Abnormal DNA synthesis: chemotherapy, anticonvulsant, ETOH, liver disease, cirrhosis
  41. Pernicious Anemia
    • Macrocytic anemia
    • -megaloblastic dyspoiesis

    -cause by Vit. B12 deficiency
  42. Macrocytic Anemia additional diagnostic tests
    • -B12 levels
    • -Folate levels
    • -Intrinsic factor
  43. Polycythemia
    Increased RBC, Hb, Hct

    Relative: decreased plasma volume (can result from dehydration)

    Absolute: total RBC mass increases

    • Primary: independent of erythropoietin stimulation
    • (malignant hematologic d/o: Polycythemia vera)

    • Secondary: lowered oxygen tension
    • (smokers, respiratory d/o)
  44. Erythrocyte Sedimentation Rate
    Rate at which RBCs fall

    • -non-specific test for inflammatory conditions
    • (increased levels bc of fats, proteins, other factors in blood from inflammation)

    -measure to look for presence and severity of pathologic process( RA, lupus, gout, carcinoma)
  45. Granulopoiesis
    Process by which WBCs mature

    • -Myeloblast
    • -Myelocytic cell line produces:
    • 1. Granulocytic -neutrophils, eosiniphils, basophils
    • 2. Monocytic -monocyte, tissue macrophage
  46. Granulocytes
    Neutrophils: highly mobile, eat small particles, defend from infection, inflammatory rxn

    Eosinophils: immediate hypersensitivity and allergic response, destruction of opsonized tissue

    Basophils: immediate hypersensitivity rxns, inflammation, histamine release
  47. Monocytes
    • Promonocyte
    • Monocyte (similar to lymphocytes but with vacuoles)
    • Macrophage: phagocytic cells; destroy larger tissue than compared to neutrophils
  48. Lymphopoiesis
    Produces mature cells in the lymphocytic line

    • T lymphocytes
    • B lymphocytes
  49. Lymphocytes
    • -Normally found in peripheral blood
    • -Participate in Ab production; particularly viral infections
    • T lymphocytes: thymus; cell mediated immunity
    • B lymphocytes: bone marrow; humoral immunity and Ab production
  50. Neutrophils vs. Lymphocytes
    Neutrophils = bacterial (granulocytes)

    Lymphocytes = viral
  51. Leukocytosis
    increased WBC count

    • -Non-malignant, quantitative
    • Neutrophilia, eosinophilia, basophilia, monocytosis, lymphocytosis
  52. Neutrophilia
    non-malignant, quantitative leukocytosis

    • -Bacterial infection
    • -Toxic response
    • -Tissue destruction/injury
  53. Eosinophilia
    non-malignant, quantitative leukocytosis

    • -Allergic rxns
    • -Parasite tissue infiltration
    • -Chronic skin disorders
  54. Basophilia
    non-malignant, quantitative leukocytosis

    -Active allergic responses
  55. Monocytosis
    non-malignant, quantitative leukocytosis

    -Recovery phase of infections
  56. Lymphocytosis
    non-malignant, quantitative leukocytosis

    • -Viral infection
    • -Infectious mononucleosis (monspot, heterophile Ab)
    • -CMV
    • -Pertussis (culture)
    • -Toxoplasmosis (immunologic testing)
  57. Non-malignant Qualitative WBC d/o
    Can have normal to low WBCs in conjunction with abnormal appearance

    -nuclear abnormalities: Pelger-Huet Anomaly (benign)
  58. Leukopenia
    Decreased WBC count

    • -Neutropenia
    • -Lymphopenia
  59. Neutropenia
    • 1. Decreased WBC production:
    • -compromised bone marrow
    • -toxicity
    • -malignancy

    • 2. Decreased survival/increased destruction:
    • -overwhelming chronic infection
  60. Lymphopenia
    Decreased WBC count

    • -briefly after onset of viral infections
    • (measles, mumps, VZV, hepatitis, roseola)
    • -bone marrow suppresion; primary bone marrow d/os
    • -distribution: steroid therapy, morphine
  61. Malignant WBC disorders
    • Clonal disorders
    • -primary defect occurs in stem cell or precursor cell
    • -leukemias: acute or chronic
  62. Acute leukemia
    Blast cells

    • -increased, decreased, normal WBC count
    • -Anemia
    • -Thrombocytopenia
    • -Erythroleukemia: Red cell line involved
    • -Megakaryoblastic leukemia: platelets involved
    • -Myelogenous leukemia: AML
    • -Lymphocytic leukemia: ALL

    Presentation: fever, lethargy, infection
  63. AML
    Acute myelogenous leukemia

    • -common in all ages
    • -M1-4
  64. ALL
    Acute lymphocytic leukemia

    • -common in Peds
    • -L1 & L2

    special tests: Bone marrow, CD markers, cytogenetics
  65. Chronic leukemia
    Mature cells

    • -Increased WBC (most typical)
    • -Anemia
    • -Thrombocytopenia
    • -few or no blast seen in periphery
    • -Myeloproliferative leukemia: CML
    • -Lymphocytic leukemia: CLL
    • -Hairy cell leukemia: HCL

    Presentation: fever, lethargy, infection
  66. Malignant WBC d/o additional diagnostics
    • -Bone marrow
    • -Cytochemical stain (on bone marrow cells)
    • -Cytogenetics
    • -Flow cytometry
  67. CML
    Chronic myeloproliferative leukemia

    • -common in middle-age
    • -Philadelphia chromosome (gold standard, cytogenetics)
  68. CLL
    Chronic lymphocytic leukemia

    -common in geriatrics
  69. HCL
    Hairy cell leukemia

    • -Chronic
    • -TRAP (+)
    • (tartrate resistant acid phosphatase; cytochemical stain)
  70. Plasma cell dyscracias
    Multiple Myeloma

    • -increased plama cells in peripheral blood (B cell line)
    • -relative lymphocytosis (decreased plasma volume, non-malignant quantitative)
    • -Anemia
    • -Increased sed rate
    • -presence of Bence Jones protein in urine
    • (gold standard)
  71. Lymphoma
    • Solid tumor of lymphoid cells
    • -B/T cells

    • -Hodgkin's lymphoma = REED-stenberg cells
    • -Non-Hodgkin's lymphoma

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