hematology (1) the blood and bone marrow, abnormal blood count, anemias: an overview

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2. Hematology Course: an overview of Clinical Hematology Dr. Ahmed Elshebiny , MD Lecturer of Internal Medicine Faculty of Medicine, Menoufyia University Former Clinical Research Fellow, Joslin Diabetes Center, Harvard University 3. Course includes

  • Hematology an Overview : The blood and bone marrow
  • Clinical Hematology : The full blood count
  • Anemia : a Clinical approach
  • Deficiency anemias
  • Hemolytic anemia : Acquired
  • Hemolytic anemia : inherited
  • Bone marrow failure syndromes ( aplastic, myeloysplastic, PNH)
  • Hypoproliferative anemias (of chronic disease)
  • Myeloproliferative disorders
  • Leukemias
  • Lymphomas & Myelomas
  • Porphyria & Hemochromatosis
  • Leukocyte disorders
  • Interpretation of standard hematologic tests

4. Structure and Function The blood and bone marrow 5. Blood as a circulatory fluid

  • A protein rich fluid called plasma in which cellular elements are suspended
  • Carrier of O 2and CO 2
  • Carries nutrients
  • Carries waste
  • Hormones
  • Immunity
  • Hemostasis

6. 7. Blood is continuously renewed 8. The Bone Marrow is the blood Factory May be exposed to damage or failure 9. Spleen?

  • Blood filter
  • Immunity

10. Red blood cells

  • A nucleated
  • Diameter and thickness
  • Membrane
  • Metabolism

11. Red cell membrane

  • Phospholipid bilayer
  • Intracellular protein network
  • 50%cholestrol
  • Membrane proteins
    • (glycophorin c and band 3)
  • Reticuloproteins
    • ( spectrin , actin, ankyrin)

12. Hemoglobin

  • Tetramer of 4 globin chains (proteins)
  • Each with a heme group containing iron
  • Can be distinguished by electrophoresis
  • Chain types
    • Alpha
    • Beta
    • Gamma
    • Delta
    • Zeta and epsilon are embryonic

13. 14. Fetal and neonatal hemoglobins 15. HB and MCVvalues with age & sex 16. Haemopooiesis

  • Yolk sac ( 3 rd week)
  • Liver and spleen ( 6 wk to 7 months)
  • Bone marrow
  • Red marrow & yellow marrow
  • Extramedullary ---- When?

17. 18. Aplastic Anemia 19. Bone marrow aspiration and biopsy 20. Bone marrow aspiration 21. P.N.H 22. Hematology Course (2): Clinical Hematology Abnormal Blood count 23. Manifestations of blood diseases

  • Anemia
  • High hemoglobin
  • Bleeding
  • Thrombosis
  • Infections
  • Lymphadenopathy
  • Splenomegaly

24. Full blood count

  • Common investigation
  • Can point to hematological disorders
  • Cornerstone of hematological diagnosis
  • Manual or automated
  • Automated counting and sizing by different methods e.g.( Aperture impedance)
  • They also measure the hemoglobin byspectrophotometry
  • Some other parameters are calculated ( MCH, MCHC)
  • The automated analyzers can diffrentiate leukocyte

25. N.B.

  • 5% of the normal population lie outside the normal range
  • Race may affect the CBC
  • Be careful of artifacts

26. Anemia

  • Definition
  • Morphological approach
  • Etiological( kinetic ) approach
  • RBCs in the blood film

27. Polycythemia

  • True Polycythemia( Primary and secondary)
  • Relative ( decreased plasma volume)

28. Leucocytosis

  • Examine the differential count
  • Examine a blood film
  • Commonest is neutrophilia

29. WBCs

  • 5 WBCs line ( diffrential)
    • Neutrophils
    • Lymphocytes
    • Monocytes
    • Eosinophils
    • Basophils

30. Neutropenia

  • Clinically evident when ANC < 500
  • Congenital and acquired
    • Congenital ( e.g Kostman;s syndrome and cyclic neutropenias)
    • Most cause of acquired neutropenia is drugs

31. Drugs associated with neutropenia

  • Anticonvulsants---- phenytoin
  • Antithyropid------- carbimazole
  • Phenothiazines ------ carbamazepine
  • Antibacterial -------- phenylbutazone
  • Anti-inflammatory ------ co trimoxazole
  • Cytotoxic
  • Others ----- gold, penicillamine, imipramine

32. Neutrophil disorders

  • Infections( viral, salmonella, protozoal, malaria)
  • Drugs
  • Autoimmune
  • Alcohol
  • Congenital
  • Infections ( bact, fungal)
  • Surgery, Burns
  • Infarctions
  • Inflammation ( gout,RA, IBD)
  • Malignancy (CML)
  • Physiological

Neutroppenia Netrophilia 33. Lymphocytic count disorders

  • Infections( recent viral)
  • (immunosuppressive, cortisone)
  • Autoimmune & CT diseases
  • Sarcoidosis
  • Chronic renal failure
  • Congenital : severe combined immunodifficiency
  • Infections ( viral, pertussis,glandular fever)
  • Lymphoproliferative ( CLL, lymphoma )
  • Post splenectomy

Lymphopenia Lymphocytosis 34. Eosinophils

  • Acute inflammation
  • Steroids
  • Catecholamines
  • Allergy ( asthma, eczema)
  • Infections ( Helminths, viral)
  • Skin disease
  • C.T disease e.g PAN
  • Malignancy ( solid tumors and lymphomas)
  • Gold therapy

Eosinopenia Eosinophilia 35. Basophils

  • Hyperthyroidism
  • Inflammation ( Acute hypersensitivity, IBD)
  • Iron difficiency
  • Myeloproliferative disorders ( Polythycemia, CML)

basopenia Basophilia ( rare) 36. Monocytosis

  • Viral and fungal infections
  • T.B infection
  • C.T diseases
  • Inflammatory bowl disease
  • Myeloproliferative
  • Chronic Myelomonocytic leukemia ( one of MDS)
  • Malignancy e.g solid tumors

37. Platelets (thrombocytopenia)

  • Spurious
  • Increased consumption
  • Decreased production

38. Platelets (thrombocytosis)

  • Reactive
  • Primary

39. Blood film

  • Abnormal shape ( poikilocytosis)
  • Spherocytes
  • Target cells
  • Polychromasia
  • Dimorphic film
  • Lobulation and toxic granulation
  • A typical cells
  • Blast cells
  • Malaria
  • others

40. Hematology Course (3): Clinical Hematology Anemia :a clinical approach! 41. Anemia is operationally defined as a reduction in one or more of the major RBC measurements:hemoglobin concentration, hematocrit, or RBC countKeep in mind these are all concentration measures most accurately measured by obtaining a RBC mass via isotopic dilution methods.Definition: 42. Kinetic approach to anemias

  • Decreased erythrocyte production
    • Decreased erythropoietin production
    • Inadequate marrow response to erythropoietin
  • Erythrocyte loss
    • Hemorrhage
    • Hemolysis

43. Normal blood film 44. Morphological approach 45. Reticulocytes

  • Increased reticulocytes (greater than 2-3% or 100,000/mm3 total) are seen in blood loss and hemolytic processes, although up to 25% of hemolytic anemias will present with a normal reticulocyte count due to immune destruction of red cell precursors.
  • Retic counts are most helpful if extremely low (

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