Hematology Rotation

• @20x examine marrow to fat ratio
• normal= 1:1
• Hyper= >4:1, hypo = <1:4

• @100x examine myeloid to erythroid ratio
• normal= 4:1 will also see macrophages, osteoblasts and osteoclasts

WBC dont live as long, so you need to be making more to keep up

Neutrophils, erythroblasts, lymphocytes

increase in tissue due to cell proliferation, gross enlargement

• Infection, M:E 5:1 unless a chronic hemolytic process
• Dysplasia, increased number of precursors getting stuck somewhere in development
• Leukemia, >20% blasts
• Lymphoma, increased lymphocytes

abnormality of cell development, increases number of blasts

underdevelopment of tissue

• old age, fewer precursor stem cells left
• improper BM collection
• aplastic anemia, stem cell autoimmunity
• reticular fibrosis, fiber cells replacing BM

cell is more transcriptionally active, less mature cell

More proteins have been made, more mature cell

primary and secondary granules

folding within the nucleus

cytoplasm is more grey, nucleus is folded, cytoplasm doesnt usually bend around RBCs

prolymphocytes

present antigen

bind antigen for specific antibody response

Non reactive lymphs are very round with course clumped chromatin, reactive lymphs spread out to attack cells

Golgi apparatus, making proteins

for llymphocytes (T cells)

+ in hairy cell leukemia

For neutrophils

• differentiates btwn leukemoid reaction (high) and leukemia (low)
• stains certain cytoplasmic components that are not present in abnormal cells

neutrophils and mast cells

Monocytes, megakaryocytes and plasma cells

varies based on maturity of cell, differentiates btwn myelocytes

+ in granulocytes and monocytes, - in lymphocytes

stains iron stores, ringed sideroblasts

• carbohydrate stain
• differentiates btwn Guahcer's and Nieman Pick

it can identify cells by their surface markers which are more specific than staining

• Changes in cell morphology that occur due to issues with DNA replication
• hypersegmentation, discontinuity of development, etc.

infection or activation of neutrophils

• Rough ER remnants
• Associated with stress, infection, exposre to cytotoxic agents, etc.

• look for bilobed neutrophils
• Cells act normally, but can be pre-leukemic

• Lipids in the cytoplasm of cells, looks a lot like toxic granulation
• cell function is normal but can point to Hurler's or Hunter's disease

• Giant fused granules in neuts and lymphs
• Cell can engulf but dont kill bacteria causing pyrogenic

• Autosomal dominant, blue Dohle-like inclusions and giant platelets
• cells function normalls but can have thrombocytopenia due to size of platelets

• Normal wright's stain
• Cells cant kill bacteria, lacking oxidative burst.

• accumulation of glucocerebroside in macrophages (tissue paper cytoplasm)
• Casues enlarged spleen and liver to try to process out the bad macrophages

• Foamy macrophage cytoplasm due to accumulation of sphingomyelinase, complete ensyme knock out
• Fatal before childhood

• sibling disease to HIV, also a retrovirus
• infects T cells diagnosed with antibody assay
• long incubation period

• attacks CD4+ T cells, kills the cells that perform the everyday immune responses
• Diagnosed with nucleic acid based tests
• now treated like a chronic disease, not a death sentence

• infectious mononucleosis, infects B cells
• diagnosed with monospot (heterophile Ab), although not 100% accurate

The overproduction of one or more of the myeloid cells, the brakes are off!

• extreme elevation of myeloid cells in PB and BM
• Chronic phase: way too many cells, normal function
• accelerated phase: non-funtional mature cells
• Blast crisis: so many blasts, starting to make their way into circulation

• CML
• Translocation is stuck in on, errors in cells accumulation due to such high production

Usually incidentally, lab sees high WBCs

• Can present with petechiae
• bone marrow ME ratio 10:1-50:1
• <20% blasts

• Medication for CML based on understanding of molecular basis of the disease
• doesn't work in juvenile CML

• CML: low LAP, blasts present, Ph chromosome,
• Leukemoid: dohle bodies, toxic granulation, vacuoles, high LAP

fibroblast proliferation in BM replaces normal hematopoetic tissue

• Extramedullary hematopoesis due to fibrosis, BM will go wherever it an. 
• Tear drop cells (dacrocytes), elevated LAP

Increased cells, especially RBCs (due to long lifespan).  Stem cells extra sensitive to EPO

• a combination of things that say I have a lot of everything
• Increased RBC, splenomegaly, Thrombocytosis, etc.

Increased megakaryoctes, normal RBCs but decreased HgB

• AKA BM failure, not enough healthy RBCs, brakes are on!
• decreased or ineffective cell cycling

• signs the DNA replication isnt working right
• oval macrocytes, siderocytes, howell-jolly bodies, etc.
• abnormal precursors

• anemia unresponsive to iron therapy
• reticulocytopenia, oval macrocytes

Refractory anemia with ringed sideroblasts, >15% of BM cells are ringed sideroblasts

• Refractory anemia with excess blasts
• up to 19% blasts, hypogranular neutrophils, pseudo pelger huet cells

Deletion of the q arm of chromosome s

• mostly older women, refractory macrocytic anemia, thrombocytosis, erythroid hypoplasia
• Responds to lenalidomide

• Technically MDS/MPD
• peripheral blood looks like RA with high WBC count
• BM 5-20% blasts

>20% blasts in PB or BM

Acute promyelocytic leukemia

• promyelocytes predominate in PB, folded nucleus, often auer rods
• Can by hyper or hypogranular

• Myeloperoxidase +
• chloroacetate +
• non specific esterase -

• High dose of vitamin A to push along maturation process
• Disease has a vitamin A receptor defect that prevents maturation

• AML, minimally differentiatied, myeloblasts without granules
• Myeloperoxidase -
• chloroacetate -
• Non specific -
• all stains are negative because the cells are very immature, really can't be identified yet

• AML without maturation, <10% myeloid cells show maturation, auer rods often seen
• Myeloperoxidase + (light)
• chloroacetate + (strongt)
• Non specific  -

• AML with maturation, 50% of the time leukocytosis, thrombocytopenia, myeloblasts in PB and BM
• Myeloperoxidase +
• chloroacetate +
• Non specific  -

• Acute myelomonocytic leukemia, myeloid and monocytic cells in PB and BM. >30% blasts in BM, increased serum muramidase (monocytic component)
• Myeloperoxidase +
• chloroacetate +
• Non specific +
• Lysozyme 3x normal

• Acute monoblastic leukemia, most common in young 2 subtypes
• a= less mature cells, b= more mature cells
• Myeloperoxidase -
• chloroacetate -
• Non specific +

• Acute Erythroid leukemia, only seen in adults, erythroblast is predominant BM cell, can evolve into M1 or M2
• 2 subtypes
• erythroleukemia= significant myeloblastic component
• pure erythroid leukemia= no significant myeloblastic component

Acute megakaryoblastic leukemia, dry tap due to fibrosis  from increase in megakaryocytes, ID'd by immunophenotyping and cytochemistry

Reed Sternberg cells

• B-cell neoplasms
• small cell lymphocytic lymphoma- nodes
• chronic lymphocytic leukemia- PB and BM

• <10 (excluding 5)= T cell
• >10 (plus 5)= B cell

CLL

Plasma cells (B cells)

malignant proliferation of plasma cells, lytic bone lesions, elevated serum calcium, bence jones proteins

Monoclonal ab present in the absence of plasma cell dyscrasia, can progress to multiple myeloma

mycosis fungoides, T cell derived tumors of the skin, only bad prognosis if it progresses beyond the skin

Most common in young children, typical findings are neutropenia, thrombocytopenia, anemia

• Immature B cell (most common)
• Pre B cell
• T cell
• B cell

early B cell ALL

balancing of clotting and bleeding

deliver O2 and nutrients, take away waste

transport lymph fluid, water and cells

inert to platelets and coag factors, (i.e. blood vessels)

• formation of the primary platelet plug
• adhere via vWF

• stabilize and strengthen via XIII
• activate the coag cascade via VIIa after exposure to TF

in the BM by megakaryocytes

• in-vitro sampling, anticoag clumps
• remedy by using sodium citrate (blue top) tubes

disk-->spiky-->pancake

adhersion, aggregation, secretion

• platelets roll and cling to non platelet surfaces to seal endothelial gaps
• vWF required
• Reversible

• platelets adhere to each other
• requires fibrinogen
• irreversible

• Platelets secrete granular contents, essential for coagulation
• \irreversible

• Alpha- larger, factor V, factor XI, fibrinogen, vWF, etc.
• Delta- smaller, Ca, Mg, serotonin, etc.

AKA delta granules

alpha granule deficiency

vWF receptor, facilitates adhesion to exposed collagen

Fibrinogen receptor, allows platelets to bind to each other.

Liver

• most common bleeding disorder in the US
• quantitative or qualitative vWF defect

• 1: you just don't have as much (most common)
• 2A: chopped up faster
• 2B: cleared out quicker
• 2M: less GP Ib, no primary plug
• 2N: factor VIII deficiency
• 3: absence of all multimers

platelet type, mutation in GP Ib gene instead of vWF gene

• deficiency/dysfunction of GP Ib (vWF receptor)
• Qualitative PLT disorder--> giant platelets

• deficiency/dysfunction of GP IIB/IIIA
• aggregation cannot occur unless treated with ristocetin

assessment of PLTs for adequate function via exposure to collagen and ADP or epi

• induces full aggregation and secretion of granular components
• conversion of fibrinogen to fibrin

binds PLT membrane to stimulate dense granule release and shape change

• Immune Thrombocytopenia Purpura
• PLT destruction due to autoantibodies
• labeled PLTs are removed quickly from the system leaving the patient with thrombocytopenia

• Thrombic Thrombocytopenia Purpura
• single acute episode in which clots form in the small vessels of the body
• leaves body with fewer clotting resources, PLT and vWF thrombi w/o fibrin
• clotting cannot occur without ristocetin

• Hemolytic Uremic Syndrome
• resembles TTP but in children

• False
• coag factors precipitate in the cold

be suspicious of a clot!

XII-->XI-->IX(+VIII)-->X(+V)-->II-->I

III(TF)-->VII-->X(+V)-->II-->I

type of coag analyzer, if iron ball stops moving signifies a clot

scattered light detection to look for clots

• prothrombotic agent
• causes clotting in vivo, prolongs clotting in vitro
• anti-phospholipid protein complexes

• Thrombin Time
• Time to clot with thrombin added
• qualitative measurement of fibrinogen
• heparin interference

Like thrombin time but with reptilase

• prothrombin time
• evaluate extrinsic pathway using thromboplastin
• can be used to measure warfarin

used to normalize PT results regardless of strength of reagent

• Partial thromboplastin time
• measures the intrinsic pathway

accelerates inactivation of thrombin, AKA antithrombin

• vitamin K antagonist
• effects II, VII, IX, X, C+S

• heparin induced thrombocytopenia
• IgG antibody binds to heparin/platelet compound activating the platelet and starting the clotting cascade. Patient must be pulled off of heparin to remedy

• Direct thrombin inhibitor
• Can be used to avoid HIT
• binds thrombin active site on platelets without activation

• Factor XIII defiiency
• x-linked recessive disorder, "classic" hemophilia

• Factor IX disorder
• x linked recessive
• Christmas disease

• Factor XI deficiency
• autosomal dominant

greater protein C resistance

• cuts fibrin
• forms split products like D dimers

• fibrin degradation product
• can be used to disagnose thrombosis

• disseminated intravascular coagulation
• Over-active coag factors can cause random small clots throughout the body and uses up factors and platelets, leaving the body low on them when they may be needede to stop bleeding. Can cause diffuse bleeding throughout the body

formation of blood cellular components

multipotent stem cell --> pronormoblast --> basophilic normoblast --> polychromatophilic --> nRBC --> reticulocyte --> erythrocyte

nRBC

polychromatophilic

• hormone to regulat RBC production in bone marrow
• produced by kidneys, acts in BM
• normal levels replace 1% of RBCs per day

• high RBC count, hematocrit and hemoglobin
• associated with renal disease

ratio of rbc volume to total blood volume

• storage- 1/3 of wbcs and plts
• filtration- inspects cells for abnormalities
• piting- removes abnormalities with macrophages
• culling- phagocytose cells
• immunologic- produces IgM

different sized RBCs

different shaped rbcs

build up of porphyrina, Fe2+ can't incorporate into heme

• RBC glucose metabolism, 90-95%
• anaerobic pathway, nets 2 ATP

It competes with O2 for binding to Hgb and promotes the release of any remaining O2.

• Plots sO2 vs. pO2
• Hemoglobin affinity to oxygen
• Left: wont let go
• Right: wont hold tight

• increased pH
• decreased, 2,3-DPG, pCO2, or temp

• decreased pH
• increased 2,3-DPG, pCO2, or temp

• test for fetal maternal hemorrahge
• stains fetal Hgb to compare to expected <1%

Infection

Viral

Allergies or parasites

Dohle body like inclusions, giant platelets

Bi-lobed neutrophils

Large, irregular, even granules

giant fused granules, peroxidase +

Mostly housekeeping via phagocytosis

exact purpose is poorly understood, some allergic response

Hgbx3=Hct +/- 3%

graph of frequency of distribution, line graph of cell volumes

paired observations, often size vs. complexity

(cells counted)(dilution factor)/(square counted)(depth factor)

depth=.1

• Forward light scatter shows cell size
• Side ligth scatter shows compexity

• RBC distribution width
• closely associated with anisocytosis
• really only concerned with increases

• Its all about the iron, aka IDA
• Decreased HgB, Hct, RBC, MCV, MCHC, Ferritin, transferrin sat.
• Increased RDW, TIBC

iron acquisition exceeding rate of loss

• defect in iron utilization
• impaired heme insertion, iron accumulates in mitochondira
• Look for pappenheimer bodies and ringed sideroblasts

disturbance of heme synthesis

When in DELTA, POR UR cop PROnto a cup of HEME

• acquired porphyria and sideroblastic anemia
• blocks protoporphyrin incorporation into heme and block ALA for heme synthesis

• hepcidin causes macrophages to hold onto iron
• increased ferritin, decreased serum iron

• quantitative defects in Hgb production
• decreased globin chains

• --/-- = death, hydrop barts fetalis
• a-/--= MCV <60, Hgb H disease
• aa/-- or a-/a- = microcytin, hypochromic
• aa/a- = silent carrier

• B+/B = B thal minor, targets and eliptocytes, increased HgBH2
• Gamma to beta switch= B thal major, hypochomia with extreme inclusions

• B12 or folate deficiency  causes ineffective erythrpoesis due to inability to incorporate thymidine into DNA
• effects all cell types
• Increased LDH, indirect bili
• decreased haptoglobin

antibodies against parietal cells, no IF secretion so no B12 absorption

• intravascular hemolysis: RBCs lyse in circulation, Hgb released into plasma, shistocytes
• Extravascular hemolysis: RBCs phagocytized by macrophages

• causes heinz bodies, causes bite cells
• unable to detoxify oxidative compounds to protect Hgb
• avoid fava beans

• B/Bs
• abnormal Hbg forms strands that misshape RBCs, cells lose flexibility and cause painful crises
• shortens RBC lifespan to 10-20 days

• Cold agglutinin syndrome= IgM active @ RT, need to heat up to avoid
• Warm autoimmune= 95% DAT +, extravascular hemolysis, associated with CLL
• paroxysmal cold hemoglobinuria= intravascular hemolysis

• Microangiopathic Hemolytic anemia
• TTP (decreased ADAMS 13)
• HUS (TTP in children)
• DIC (pathologic hyperactiation of coag)

• Plasmodium, mosquito vector
• P. falciparum= multiple per RBC, rings <1/3 of RBC
• P. vivax= 1 per RBC, ring >1/3 of RBC

• Look for tetrads, otherwise very similar to
• malaria
• Deer tick vector

• Borrelia recurrentis
• deer tick vector

• Loa Loa vector
• very large worm

Tse Tse fly or reduviid (cruz=america) bug vectors