Hematology ReviewDemak L. TobingEmail : dlt@centrin.net.id atau lumbantobingdemak@yahoo.com

IntroductionHematology: the study of blood and blood forming tissues.Blood consists of 55% plasma and 45% formed elements.Formed elements include erythrocytes, leukocytes, and thrombocytes.

ErythrocytesNormal range 4.2-5.5 million per mm3 in adults.Biconcave shape.Diameter 7 microns.Cells for transport of O2 and CO2.Life span 120 days.

LeukocytesNormal range 4 - 11 thousand per mm3 in adults.Five types.Size 8-20 microns.Involved in fighting infection, combatting allergic reactions, and immune responses.

Thrombocytes

Smallest cells in the blood.Normal range 130,000-400,000.Active role in coagulation and hemostasis.

Routine HematologyAnticoagulant of choice: EDTAComplete Blood Counts (CBCs)Manual WBC DifferentialsErythrocyte Sedimentation Rates (ESRs)Sickle ScreensReticulocyte Counts

Automated CountingCoulter PrincipleElectrical impedance: resistance or change in current when cell passes between two electrodes in NaCl solution.

Automated CountingFlow CytometryUses lasers to measure both forward and side scatter.Forward scatter measures size.Side scatter measures granularity.

Sources of ErrorInadequate mixing of specimen.Hemolyzed specimens.Lipemic specimens.Cold agglutinins.Clotted specimens.Platelet clumps or platelet satellitosis.Diluted specimens.

Know Normal Ranges!!!WBCRBCHGBHCTMCVMCHMCHCPLTMPVSEGSLYMPHSMONOCYTESEOSINOPHILSBASOPHILS

Erythrocytic Maturation SeriesRubriblastProrubricyteRubricyteMetarubricyteReticulocyteErythrocyte

RBC Morphology

Elliptocytes Target Cells

Tear Drops Stomatocytes

Sickle Cells Schistocytes

RBC Inclusions

Howell-Jolly BodiesRound, purple inclusions in RBCs.Composed of DNA.Commonly seen in in patients with hypofunctioning spleens. Splenectomy.

Basophilic StipplingNumerous, small purple inclusions in RBCs.Aggregates of ribosomal RNA.Most commonly seen in lead poisoning.

Pappenheimer BodiesClusters of dark blue granules, irregular in size and shape.Composed of iron and ribosomal RNA.Seen in sideroblastic and hemolytic anemias.

ANAEMIA : Is defined as a condition in which the haemoglobin concentration is below reference range for the age, sex, method & altitude Deficient in O2 carrying capacityhypoxia

CUT OFF POINT ANAEMIA IN INDONESIAPre school age11 g/dLSchool age12 g/dLPregnant women11 g/dL3 month post partum12 g/dLFemale12 g/dLMale13 g/dL

CLASSIFICATION OF ANAEMIAMorphologic classification :Macrocytic anaemiaMicrocytic hypochromic anaemiaNormocytic anaemia.

Classifications of AnemiasMicrocytic, HypochromicIron deficiencySideroblasticChronic disease, InflammationLead poisoningThalassemia trait

LABORATORY TESTINTERPRETATIONHypochromic & microcytic anaemiaAbsentIncreasedRinged sideroblastsNormalAbnormalNormalPeripheral smearIron(Bone marrow)Haemoglobin electrophoresisDiagnosis Iron deficiency anaemiaThalassaemia haemoglobino-pathiesLABORATORY DIAGNOSIS OF HYPOCHROMIC MICROCYTIC ANAEMIASideroblastic anaemia

Microcytic, HypochromicMany RBCs smaller thannucleus of normallymphocytes, increased central pallor.Iron deficiency, thalassemias, anemia of chronic disease.

Classifications of AnemiasNormochromicHereditary SpherocytosisHereditary ElliptocytosisPNHG6PD deficiencyAplastic anemiaAcute blood loss

LABORATORY DIAGNOSIS OF NORMOCYTIC ANAEMIAOTHER HAEMOLYTIC ANAEMIASParasitesHypersplenismMicroangiopathic haemolysisHereditary spherocytosisParoxysmal noctural haemoglobinuriaEnzyme deficienciesDrug or toxinHaemoglobinopathiesAUTO IMMUNO HAEMOLYTIC ANAEMIAErythroblastosis foetalisTransfusion reactionCollagen vascular disease OTHERRenal diseaseInfectionMalnutritionAplastic anaemiaRadiationMYELOPHTHISICTumorMyelofibrosisInfectionLeukaemiaBLOOD LOSS ANAEMIAREPLACEMENT OF NORMAL MARROW ELEMENTSDECREASED CELLULARITY

HYPERCELLULAR ERYTHROID HYPERPLASIAHYPERCELLULAR ERYTHROID HYPERPLASIAPOSITIVEPOSITIVENEGATIVENEGATIVENEGATIVEINCREASEDREDUCEDNORMOCYTIC ANAEMIAINTERPRETATIONLABORATORY TESTPERIPHERAL SMEARRETICULOCYTE COUNTBLOOD IN STOOL OR OTHER SOURCE OF BLEEDING IDENTIFIEDANTIHUMAN GLOBULIN (COOMBSTEST)BONE MARROW AND BONE MARROW BIOPSYDIAGNOSIS

Classifications of Anemias

MacrocyticVitamin B12 deficiencyFolate deficiencyLiver disease

LABORATORY DIAGNOSIS OF MACROCYTIC ANAEMIALABORATORY TESTINTERPRETATIONMacrocytic anaemiaMegaloblastic changesNo megaloblastic changesLowLowHighPossible liver disease (evaluate liver function tests)Probable haemolytic anaemia (continue workup)Responds to folic acidResponds to vit B12Peripheral smearBone marrow examinationReticulocyte countTherapeutic responseDiagnosisVit B12 deficiency (determine if dietary or abnormal absorptionFolic acid deficiency

Macrocytic RBCsMost RBCs larger than nucleus of normallymphocytes, increased MCV.Folate or Vitamin B12 deficiencies, alcoholism, and liver disease.

ReticulocytesImmature RBCs.Contain residualribosomal RNA.Reticulum stains blue using a supravital stain (new methylene blue).Counted and expressed as % of total red cells.

Reticulocyte CountUses supravital stain which stains cells in the living state.

Retic % = # retics per 1000 RBCs 10Corrected retic= % retics x pt. HCT 45

HemoglobinopathiesBeta Chain Substitutions

Hgb S:Valine for glutamic acid(6th position, beta chain)Hgb C:Lysine for glutamic acid(6th position, beta chain)

WBCEvaluation

MyelocyticMaturation SeriesMyeloblastPromyelocyteMyelocyteMetamyelocyteBand NeutrophilSegmented Neutrophil

White Blood Cell CountWBC differential - % of each cell type in peripheral bloodAbsolute count - more important% cell x total WBC countReference ranges - based on age, sex and ethnic background

White Blood Cell CountWBC: 4.3 - 10.3 K/mm3

%

Absolute Counts

Reference Range

Neutrophils

65

4550

1,500-7,500

Lymphocyte

30

2100

1,000-4,000

Monocytes

3

210

0 800

Eosinophils

1

70

0 400

Basophils

1

70

0 - 50

Quantitative Disorders of WBCsLeukocytosis - WBC countGranulocytosis LymphocytosisMonocytosisEosinophilia, BasophiliaLeukopenia - WBC countNeutropenia, Lymphopenia

Leukocytosis (High WBC)Granulocytosis (neutrophilia)Acute inflammationbacterial infectionstissue necrosisLeukemoid reaction - WBC immature formsActivation - toxic granulation,dohle bodies

Leukemoid reaction (toxic granulation)

Activated neutrophil - Dohle body

Leukocytosis (High WBC)LymphocytosisMost often viral infectionChronic inflammationActivated forms - largeMarked lymphocytosis with activated lymphocytes - infectious mononucleosis (EBV)

Lymphocytes - Normal

Reactive Lymphocyte - Viral Infection

Leukocytosis (High WBC)MonocytosisChronic infections -bacterial endocarditismalaria, tuberculosisChronic inflammationcollagen vascular diseases

Monocytes with vacuoles

Toxic GranulationIncreased basophilic granulesin neutrophils.Seen in severe infections, burns, malignancies, and pregnancy.Distinguish from basophils.

Dohle BodiesSky blue inclusions in cytoplasm of neutrophils.Seen in infections, burns, myleproliferative disorders, and pregnancy.Composed of RER and glycogen granules.

Pelger-Huet Anomaly

Special StainsPAS: ALL, ErytrholeukemiaLAP: CML v. Leukomoid ReactionMyeloperoxidase: AML, AMMoL (weak+)Sudan Black: AML, AMMoL (weak+)Specific Esterase: AML, AMMoLNon-specific Esterase: AMML, AMoLTRAP: Hairy Cell LeukemiaTDT: ALLPrussian Blue: Sideroblastic Anemia

CML versusLeukomoid Reaction

Characteristic CML LeukomoidLAP score Decreased IncreasedToxic gran. Decreased IncreasedDohle bodies Absent PresentPhiladelphia May be present Absent chromosome

WBC DisordersAlder-Reilly: Large azurophilic granules, increased mucopolysaccharidesChediak-Higashi: Membrane defect of lysosomes, large primary granules in segsMay-Hegglin: Familial disorder with large platelets and Dohle bodiesPelger-Huet: Hyposegmented neutrophils

FAB ClassificationsM1: Myeloblastic without maturationM2: Myeloblastic with maturation M3: PromyelocyticM4: MyelomonocyticM5a: Monocytic, poorly differentiatedM5b: Monocytic, well differentiatedM6: Erythroleukemia, DiGuglielmosM7: Megakaryoblastic

Acute Myeblastic Leukemia (M1)

Chronic MyelogenousLeukemia

FAB ClassificationsL1: Small, uniform lymphoblasts

L2: Large, pleomorhphic lymphoblasts

L3: Burkitts type (vacuolated and deeply basophilic cytoplasm)

Acute Lymphoblastic Leukemia

Chronic Lymphocytic Leukemia