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- Plasma - 54%
- WBC - 1%
- Redcells - 45%
- White Blood Cells 4.5 - 11.0 K/uL Low = Leukopenia
- High = Leukocytosis
Neutrophils - Segs - bacteria eater
Neutrophils - Bands
- if band is high means that body is being attacked hugely = shift to the left. - SEPTIC!
Lymphocytes - Lymphs
- Go up in viral infection
Monocytes - Monos
- goes up in chronic infection, TB, mono.
Eosinophils - Eos
- allergies, worms, parasites
Basophils - Basos
- go up in allergies
, and anything weird --> refer to hematologist, they will do bone marrow biopsy if you cannot figure what's going on out.
Atypical Lymphs - common in mono
Types of hemoglobin in the RBC (3) and where do they come from? Test for which hemoglobin you have?
- Hem A - alpha beta
- Hem F -alpha and gamma - transforms at 6 mo. to when you get the hg that you will have for the rest of your life.
- ( In sickle cell this switch might stay on, and it is a good thing bc they don't sickle as much - hydroxyurea keeps switch on)
- Hem A2 - alpha delta chains. -
body compensate for when alpha or beta isn't enough. - make more Feta or more A2 to compensate ( Thalassemia alpha, beta)
They come from chromosomes 11 and 16
- all nb get screened for which hemoglobin they have.
What are reticulocytes?
When do we need and why do we need retics?
- how is it responding to anemia.- when anemia ocurs, BM needs to be making more RBC.
- Reticulocytes, or Retics are young red cells just released from the bone marrow. The Retic
- count is the best indicator about how
- the marrow factory is doing.
If anemic and retic is high = bleeding - possibly GI tract.
- or = Hemolytic anemia
Usually retic count is low when people are anemic
- Reticulocyte Count 0.5 -1.5 %
- Low in anemia = low marrow output
- High = RBC loss
Signs that someone is hemolysing
- high indirect bili
- high LDH
- high rectic count
What is hepcidin?
- hormone made in the liver to regulate iron
- goes up when body is inflmmaed ( autoimmune disease, HIV, SLE, etc ...) --> and it increases levels of and block absorption of iron and cell release --> cause of anemia, all iron stored in bone marrow and cannot come out.
What is Erythroprotein?
- made in the kidner and tell BM to make more red cells. - when kidney are without O.
- People can get anemic from kidney disease
- Epo can be replaced
What is Gilbert's disease?
- people always hemolyzing bc bilirubin is not properly processed in the liver
- harmless and does not require treatment
hb, hct, rbc, cell count normal numbers?
- Male= 15.5 +/- 2 mg/dl Low = Anemia
- Female = 13.5 +/- 2 High = polycythemia
- Male= 46.0 +/- 6% "
- Female= 41.0 +/- 6% "
- RBC - Red Blood
- Male = 4.3 - 5.9 Million/uL "
- Cell Count
- Female = 4.0 - 5.2 “ High in Thalassemia
Low hg and high red count = thalessemia
MCH and MCHC
- Mean Corpuscular Hg
- 27 -32 pg
- Low = Hypochromic
- High = Hyperchromic
- Mean Corpuscular Hg concentration 30 - 36 gm/dl
- Low = R/O Fe def.
- High = Spherocytosis
MCV and RDW - How big are my red cells? - next big clue to know what's going on?
Red Cell Distribution Width
- Mean Corpuscular Volume 80 - 94 fl Low = Microcytosis
- High = Macrocytosis
11.5 - 14.5 Variation in RBC size (High in Iron deficiency)
Platelets - how low can you go?
- normal: 150 - 400 K cell/uL
- Low = Thrombocytopenia - 20k
- High = Thrombocytosis - 1 million
Most lab do corect the retic, but if it is not corrected how do you correct it?
reticulocyte (%) = absolute number of reticulocytes ÷ number of RBC × 100
reticulocyte index = % reticulocytes × actual hematocrit ÷ normal hematocrit
- corrected reticulocyte index (corrects for appropriate bone marrow release of
- reticulocytes) = reticulocyte index ÷ maturation factor
maturation factor = 3.25 – (actual hematocrit ÷ 20)
- - if hematocrit 45, maturation factor = 1
- - if hematocrit 35, maturation factor = 1.5
- - if hematocrit 25, maturation factor = 2
- - if hematocrit 15, maturation factor = 2.5
Corrected retic index < 2 indicates bone marrow production problem
Corrected retic index >2 indicates acute red cell loss (hemolysis or bleed)
- T-Thalassemias ( genetics)
- I-Iron Deficiency
- C-Chronic Inflammation
- S-Sideroblastic - lead, drug, or hereditary
What are some mycrocytic tests to order?
- Serum Iron
- TIBC = Total Iron Binding Capacity = Transferrin binding sites for transporting iron
- % Saturation = Transferrin saturation with Iron
- Ferritin = Storage Iron – best way to tell if iron is low. --> best peripheral blood test to see if you are iron deficient. ( after liver biopsy which is more invasive)
- HBELP = Hemoglobin Electrophoresis --> best to check for Thalassemia
- Lead level if exposed
- Hereditary – Alpha or Beta chain production - from electropherosis - iron is usually normal.
- Decrease Hemoglobin A
- Hemoglobin ELP and normal Iron are diagnostic
- Supportive therapy or BMT
- Target Cells
- Hemolysis signs
- Increased Red cell count
Iron deficiency causes/ syndromes - what do you treat them with?
- Low Serum iron, Low Ferritin, High TIBC
- Find out why –GI bleed, menses, diet
- Treat FeSO4 300mg tid
F/U in 2- 3 weeks for Retic and Ferritin – should be going up – and then discontinue
Chronic Inflammation - Signs and treatment?
- Block of normal iron stores transport to bone
- marrow factory
- Normal Ferritin, serum iron and TIBC are low with a low saturation
- 30% Microcytic, 70% Normocytic
- High Sed rate or c-reactive protein
- Treat inflammation – RA, SLE, HIV….
- Ring sideroblasts in bone marrow
- Serum iron is increased and TIBC normal resulting in a high saturation. Serum ferritin is increased
- Basophillic stippling - get the lead out! with killetic agents
- Lead toxicity is suspect
NORMOCYTIC = "NORMAL SIZE“
- N-Normal Pregnancy
- O-Over hydration
- R-Renal Disease
- A-Acute Blood Loss
- L-Liver Disease
- S - Systemic Infection
- I- Inflammatory Block
- Z-Zero Production- Aplastic anemia
- E-Endocrine:Hypothyroid, hypoadrenal, hypoandrogen
Normocytic anemia tests?
- Blood Urea Nitrogen (BUN), Creatinine, SGOT, Alkaline Phosphatase, Bilirubin, Erythrocyte Sedimentation Rate (ESR), Urinalysis, and Thyroid profile
- Renal Function tests
- Pregnancy Test
- Bone Marrow Biopsy
If anemia caused by renal failure ( normocytic) - what to do?
- Anemia caused by decrease erythropoetin
- production causing decreased bone marrow production
Can monitor erythropoetin levels
Treat with epoetin alfa injections weekly or darbepoetin alpha every other week or monthly
Aplastic anemia, causes and treatment?
- idiopathic (78% cases)
- hepatitis (5% cases) testing for known hepatitis viruses usually negative
- Parvo virus B19 (Fifths disease)
- Check WBC and Platelet count
- May need Bone Marrow Bx and supportive therapy
- B-B12 Malabsorbtion
- G-Gastrointestinal disease or surgery
- F-Folic Acid Deficiency
- T-Thiamine responsive
- R-Reticulocytes miscounted as large RBCs
- E- Endocrine - hypothyroid
- C-Chemotherapeutic Drugs
- E-Erythro Leukemia
- L- Liver Disease
- L- Lesch-Nyhan Syndrome
- The peripheral blood changes include:
- -Anemia with decreased reticulocyte count, -Increased MCV-
- - Neutropenia with hypersegmented Neutrophils-- Thrombocytopenia with large platelets.
LABS to order:B12, Serum Folate, RBC Folate if all normal, consider TSH, and a Bone Marrow Bx
- Physical signs:
- edema, pallor, jaundice, smooth tongue, decreased vibratory and position sensation
- Hypersegmented polys
- Low serum B12 level
- Metformin, Gastric bypass, or PPI as cause?
- Methylmalonic acid and homocysteine levels
- Pernicious anemia - anti- intrinsic factor antibodies Schilling's test
- •Rx - cobalamin 1000 mg I.M., oral, or Nasal Spray - shots are monthly
- Meds for life - bring them back to see if it is absorbing
- Causes : - liver disease, diet vitamin B12 deficiency, and drugs such as methotrexate,
- ethanol, and dilantin.
- Lab – low serum and RBC Folate - always check
- B12 (needed for conversion)
Elevated homocysteine (Heart disease?)
Rx – Folate 1mg po qD
Hemolytic = HEMATOLOGYST
- H-Hemoglobinopathy: sickle cell disease
- - Hemoglobinuria: Paroxysmal Nocturnal Hemoglobinuria
- E-Enzyme Deficiency
- M-Medication - drug induced: aldomet, INH
- A-Antibodies - Immune attack
- T-Trauma to the red cells: D.I.C , artificial heart valves
- L-Liver disease
- O-Osmotic fragility in Hereditary spherocytosis and in Hereditary Eliptocytosis
- G-G6PD Glucose-6-Phosphate Dehydrogenase Deficiency
- I-Infection: malaria, babesiosis
- S-Splenic destruction in hypersplenism
- - Thalassemias
Hemolysis ( HIT)
- •Hereditary (HEM)
- –Hemoglobin (sickle cell, thalassemia)
- –Enzyme (G6PD deficiency)
- –Membrane (Spherocytosis, Eliptocytosis)
- •Immune attack – Coombs positive (transfusion, IgM – cold antibody-infections, IgG warm
- antibody – Drug induced, Paroxysmal Nocturnal Hemoglobinuria – complement induced)
•Trauma– Microangiopathic (TTP, ITP, HUS, DIC, HIT, HELLP- Eclampsia, Malaria, Splenomegaly)
- 1. Elevated reticulocyte count, with stable
- or falling hemoglobin.
2. Elevated indirect bilirubin -
3. Elevated serum lactate dehydrogenase (LDH)-
- 4. Decreased Haptoglobin levels - Haptoglobin
- binds hemoglobin released in the plasma
- from red cell breakdown.
5. Hemoglobinemia and hemoglobinuria
6. Erythroid hyperplasia in bone marrow
7. Abnormal Hemoglobin Electrophoresis
- 1.The direct antiglobulin (Coombs') test
- Direct Coombs test looks for antibody on the red cells. The Indirect Coombs looks for antibody in the serum.
- 2. Hemoglobin electrophoresis - dx sickle cell and thalassemia
3. Heinz body stain - for G6PD deficiency (test)
4. Osmotic fragility
5. Blood smear
6. Platelet count in the CBC - thrombocytopenia
anti-CD59 and flow cytometry for Paroxysmal nocturnal hemoglobinuria
Sickle Cell Disease – SS, SC, SD, SE, SOarab, S beta Thal - type picked up at Newborn Screening or HbELP
Rx: Daily Penicillin –birth -6yo
TCD screen prevents strokes
Hydroxyurea prolongs life, prevents complications. - is given as soon as 1 yo
Hydration, Oxygen, Temperature, and Folate
X linked genetic
Precipitated by oxidant drugs
Heinz body stain shows denatured Hb
Avoid medications such as antimalarials, aspirin, sulfa drugs, and avoid eating fava beans.
: IgG and Compliment +/-
: immediate or delayed
- IgM – (IgG Neg Comp +) cold antibody infections like, EBV (Mono), HIV, Mycoplasma pneumoniae,
- influenza B, Cytomegalovirus (CMV), rubella virus, varicella-zoster virus (VZV), parvovirus B19, and Chlamydia psittaci
- •IgG warm antibody – Drug induced
- – Antibiotics, Ibuprofen, Autoimmune diseases
- •PNH Paroxysmal Nocturnal Hemoglobinuria –
- Red cells attacked by complement. Lack of CD55 or CD59 on RBC surface
- L-Lymphoma, Leukemia
- Y-Yersinia Pestis (Plague)
- M-Mononucleosis or CMV
- P-Parasite - Toxoplasmosis
- H-Hodgkins Disease or HIV infection - syphilis
- N-Neoplasm or metastisis
- O-Obvious local infection or inflamation
- -Other systemic infections: Hep B, Rubella, Tularemia, Cat scratch
- D-Drug- Procainamide (Pronestyl), Phenytoin (Dilantin)
- E-Endocrine- Addisons, Hypothyroid
- S- Syphilis
- -SLE/Rheumatoid arthritis
- -Serum sickness
- Symptoms and Signs - Itching, Bone pain, weakness, anemia, lytic bone lesions, increased
- protein, M - Spike, Bence Jones protein in urine, Renal failure
- Pop: older, more men than women
Primary - Polycythemia
: Pruritis HA, Dizziness, vertigo, visual disturbance, tinnitus
: Rubor, BP increased, splenomegaly or hepatomegally
: HCT >55 lncreased platelets and WBC count
: Phlebotomy, Hydroxyurea
- Blood is hyperviscosity.
- Testosterone - nico epo filler.
- Increase erythropoietin due to hypoxia (COPD, smokers, high altitude), tumors of kidney,
- ovary, liver, brain, drugs: steroids, androgen, dehydration, burns
PE: No hepatospenomegaly unless tumor
Leukemia and Lymphoma
ALL: Acute Lymphocytic Leukemia (Usually in Children)
AML: Acute Myelogenous Leukemia
CLL: Chronic Lymphocytic Leukemia
CML: Chronic Myelogenous Leukemia
:Fatigue, anorexia, wt loss, fever, bone pain, headaches, lymphadenopathy, non healing infections, thrush, bleeding
- PE: Pallor, gingival hyperplasia, Candida infections, lymphadenopathy, hepatosplenomegaly,
- lung infiltrates, bleeding, bruising
- CBC: elevated WBC/ low platelets, low Hct, WBC
- Differential, Chem 18,
- Bone Marrow Biopsy
- Philadelphia Chromosome seen in CML
- Auer bodies or rods in AML
- Lymph node BX: Reed -Sternberg cells in Hodgkins Disease
- CT - MRI chest and abdomen
- CXR - Chest infiltation, pneumonias
- RX: Chemotherapy, Bone Marrow Transplant
Difference between Mono and Strept when it comes to lymphadenopathy
- Mono ( runs with HIV and syphillis): posterior lymphadenopathy and axillary lymph nodes
- Strep: anterior cervical chain, NEVER posterior chain