Hematology Studies Hematology Studies and Lab Reportsand Lab Reports

22

Normal Blood Cells:Normal Blood Cells:

33

THE THE WBCWBC

Identify the Identify the segmented segmented neutrophil, neutrophil,

band band neutrophil, neutrophil, lymphocyte, lymphocyte, monocyte, monocyte, eosinophil, eosinophil, basophil, and basophil, and platelet in the platelet in the imageimage

44

Neutrophil – targets bacteria/fungi. Fine, faintly pink granules Neutrophil – targets bacteria/fungi. Fine, faintly pink granules when stained. Have many lobes within which can look like one when stained. Have many lobes within which can look like one single lobe (banded) or several (segmented). First responders, single lobe (banded) or several (segmented). First responders, main component in pus. main component in pus.

Eosinophil – targets larger parasites, modulates allergic rsvp. Eosinophil – targets larger parasites, modulates allergic rsvp. Pink orange granules. Have 2 lobes. Pink orange granules. Have 2 lobes.

Basophil – releases histamine for inflamm rsvp. Large and Basophil – releases histamine for inflamm rsvp. Large and blue. Can be bi or tri lobed, but hard to see because of the blue. Can be bi or tri lobed, but hard to see because of the multitude of dark granules. multitude of dark granules.

Lymphocyte – Bcells release antibodies and assist in activating Lymphocyte – Bcells release antibodies and assist in activating T cells. Also are T cells and NK cells. Stain deeply, “eccentric.”T cells. Also are T cells and NK cells. Stain deeply, “eccentric.”

Monocyte – migrate from blood stream to tissues then change Monocyte – migrate from blood stream to tissues then change into macrophages or dendritic cells (which also help activate T into macrophages or dendritic cells (which also help activate T cells). Kidney bean shaped lobes. cells). Kidney bean shaped lobes.

Macrophages – phagocytes that engulf debris and pathogens. Macrophages – phagocytes that engulf debris and pathogens. Stimulate lymphocytes and other cells that rsvp to pathogens.Stimulate lymphocytes and other cells that rsvp to pathogens.

55

band neutrophilband neutrophil, ,

eosinophil,eosinophil,

segmented segmented neutrophilneutrophil

lymphocyte, lymphocyte,

basophil, basophil,

monocyte, monocyte,

66

77

Bone Marrow Cellularity:Bone Marrow Cellularity:

NormalNormal HypercellularHypercellular HypocellularHypocellular

88

Normal RBCNormal RBCThe red blood cells here are The red blood cells here are normal, happy RBC's. They normal, happy RBC's. They have a zone of central pallor have a zone of central pallor about 1/3 the size of the about 1/3 the size of the RBC. The RBC's demonstrate RBC. The RBC's demonstrate minimal- minimal-

variation in size variation in size (anisocytosis) and (anisocytosis) and shape shape (poikilocytosis).(poikilocytosis). A few A few small fuzzy blue platelets small fuzzy blue platelets are seen. In the center of the are seen. In the center of the field are a band neutrophil field are a band neutrophil on the left and a segmented on the left and a segmented neutrophil on the right.neutrophil on the right.

99

Proerythroblast(Pronormoblast)

BasophilicNormoblast

PolychromatophilicNormoblast

OrthochromatophilicNormoblast

ReticulocyteReticulocyte

ErythrocyteErythrocyte

Early Intermediate Late

Steps in ErythropoisisSteps in Erythropoisis

1010

HCT (Hematocrit) (114)HCT (Hematocrit) (114)The packed cell volume (HCT) is the The packed cell volume (HCT) is the percentage of total volume occupied by percentage of total volume occupied by packed red blood cells when a given volume packed red blood cells when a given volume of whole blood is centrifuged at a constant of whole blood is centrifuged at a constant speed for constant period of time. The HCT is speed for constant period of time. The HCT is one of the most precise methods of one of the most precise methods of determining the degree of anemia or determining the degree of anemia or polycythemia. polycythemia.

Plasma(55% of whole blood

Buffy coat: leukocyctes and platelets(<1% of whole bloodErythrocytes

(45% of whole blood)

1111

MCH (149)MCH (149)

(Mean Corpuscular Hemoglobin): Indicates (Mean Corpuscular Hemoglobin): Indicates the weight of hemoglobin in a single red blood the weight of hemoglobin in a single red blood cell. cell. MCH increase or decrease along with an MCH increase or decrease along with an increase or decrease in MCV is a significant increase or decrease in MCV is a significant finding if there is a need for folic acid and/or finding if there is a need for folic acid and/or B12 B12 A decrease in MCH with a decrease in MCV A decrease in MCH with a decrease in MCV indicates a need for iron, copper, or B6. indicates a need for iron, copper, or B6.

1212

MCV (150)MCV (150)

(Mean Corpuscular Volume): This (Mean Corpuscular Volume): This measurement indicates the volume in cubic measurement indicates the volume in cubic micron occupied by an average single red micron occupied by an average single red blood cell. MCV increase or decrease along blood cell. MCV increase or decrease along with an increase or decrease in MCH is a with an increase or decrease in MCH is a significant finding for folic acid and/or B12 significant finding for folic acid and/or B12 need (increase) or iron, copper or B6 need need (increase) or iron, copper or B6 need (decrease). MCV and MCH should always be (decrease). MCV and MCH should always be viewed together. viewed together.

1313

Complete Blood Count Complete Blood Count (85)(85)

WBC: Total and differential countsWBC: Total and differential countsRBC: RBC: HGB (Hemoglobin): HGB (Hemoglobin): HCT (Hematocrit):HCT (Hematocrit):MCV (Mean Corpuscular Volume):MCV (Mean Corpuscular Volume):MCH (Mean Corpuscular Hemoglobin): MCH (Mean Corpuscular Hemoglobin): MCHC (Mean corpuscular hemoglobin concentration):MCHC (Mean corpuscular hemoglobin concentration):PLATELETS: Platelets are concerned with the clotting of the PLATELETS: Platelets are concerned with the clotting of the blood and also clot retraction. blood and also clot retraction.

1414

WBC :Differential Count WBC :Differential Count (220)(220)

SEG :SEG : A type of neutrophil, its A type of neutrophil, its primary function is primary function is phagocytosis. phagocytosis.

BANDS:BANDS: Non-segmented neutrophils (metamylocytes) Non-segmented neutrophils (metamylocytes)

the youngest forms that are normally found the youngest forms that are normally found in the in the peripheral blood. peripheral blood.

These forms increase in the presence of acute These forms increase in the presence of acute infections with or infections with or

without an absolute increase in the total WBC. without an absolute increase in the total WBC.

1515

WBC :Differential CountWBC :Differential CountLYMPH LYMPH ::

Lymphocytes help to destroy the toxic products of Lymphocytes help to destroy the toxic products of protein protein metabolism. Lymphocytes originate from metabolism. Lymphocytes originate from lymphoblasts in the lymphoblasts in the spleen, lymph glands, tonsils, spleen, lymph glands, tonsils,

thymus, bone marrow, and thymus, bone marrow, and possibly the possibly the appendix. appendix. NK cellNK cell

1616

WBC :Differential CountWBC :Differential CountMONOMONO : : monospot test (125) EBV antibodies monospot test (125) EBV antibodies (95)(95)

Monocytes phagocytize some bacteria, Monocytes phagocytize some bacteria, particulate matter, and protozoa. particulate matter, and protozoa.

The monocytes remain to phagocytize The monocytes remain to phagocytize fragments of cells, etc; hence, the reason for fragments of cells, etc; hence, the reason for an elevation of the monocytes during the an elevation of the monocytes during the recovery phase of infection. recovery phase of infection.

1717

The WBC's seen here are "atypical" lymphocytes. They are atypical because they are larger (more cytoplasm) and have nucleoli in their nuclei. The cytoplasm tends to be indented by surrounding RBC's. Such atypical lymphocytes are often associated with infectious mononucleosis.

1818

WBC :Differential CountWBC :Differential Count

EOS : Eosinophils have an important

role in detoxification, disintegration and removal of protein. Eosinophils are commonly elevated in allergy sensitivity and parasites.

1919

WBC :Differential CountWBC :Differential CountBASOBASO : : With inflammation, basophils deliver heparin to the With inflammation, basophils deliver heparin to the effected tissue to prevent clotting.effected tissue to prevent clotting.

2020

The nucleated RBC in the center contains basophilic stippling of the cytoplasm. This suggests a toxic injury to the bone marrow, such as with lead poisoning.

Differential diagnosis Differential diagnosis of Anemia (397)of Anemia (397)

2222

Sickle Cell Disease:Sickle Cell Disease:

2323

This is sickle cell anemia in sickle cell crisis. The abnormal hemoglobin SS is prone to crystallization when oxygen tension is low, and the RBC's change shape to long, thin sickle forms that sludge in capillaries, further decreasing blood flow and oxygen tension. Persons with sickle cell trait (Hemoglobin AS) are much less likely to have this happen.

2424

Hereditary Hereditary Spherocytosis:Spherocytosis:

2525

Hypochromic Microcytic Hypochromic Microcytic RBCRBC

2626

Microcytic Anemia (IDA)Microcytic Anemia (IDA)

2727

VITAMIN B-12: (216)VITAMIN B-12: (216)FOLIC ACID: (105)FOLIC ACID: (105)

Pernicious anemia is the megaloblastic anemia caused Pernicious anemia is the megaloblastic anemia caused by malabsorption of Vitamin B12. This is usually caused by malabsorption of Vitamin B12. This is usually caused by decreased production of intrinsic factor, a substance by decreased production of intrinsic factor, a substance essential to Vitamin B12 absorption, in the stomach. essential to Vitamin B12 absorption, in the stomach. This test may also be performed as part of the testing This test may also be performed as part of the testing to determine the cause of nervous system disorders.to determine the cause of nervous system disorders.Folic acid (folate) is one of the "B" vitamins needed to Folic acid (folate) is one of the "B" vitamins needed to metabolize homocysteine. Vitamin B12, another B metabolize homocysteine. Vitamin B12, another B vitamin, helps keep folate in its active form, allowing it vitamin, helps keep folate in its active form, allowing it to keep homocysteine levels low.to keep homocysteine levels low.

2828

Megaloblastic anemia:Megaloblastic anemia:Vitamin B12/Folic acid deficiencyVitamin B12/Folic acid deficiencySecond most common type of anemia.Second most common type of anemia.Multi System disease – All organs with Multi System disease – All organs with increased cell division.increased cell division.Macrocytic anemia, pancytopenia.Macrocytic anemia, pancytopenia.Pernicious anaemia – Pernicious anaemia – autoimmune, Gastric atrophy, VitB12 def.autoimmune, Gastric atrophy, VitB12 def.

2929

Macrocytic Anemia Macrocytic Anemia (Megaloblastic):(Megaloblastic):

3030

Vitamin BVitamin B1212 Absorption Absorption

Parietal cells - produce Intrinsic Factor

IF

B12

B12

B12

IF

Stomach

IF

Ileum -IF receptorsB12

B12 absorption

3131

SCHILLING TESTSCHILLING TESTAssesses ability of terminal ileum to absorb vitamin B12Assesses ability of terminal ileum to absorb vitamin B12Oral preparation of vitamin B12 tagged with Co-57Oral preparation of vitamin B12 tagged with Co-57Prior to this ‘normal vitamin B12 injection is given to facilitate Prior to this ‘normal vitamin B12 injection is given to facilitate excretion of oral B12 administeredexcretion of oral B12 administeredTest measures how much of this radioactive isotope is Test measures how much of this radioactive isotope is excreted in urineexcreted in urineMay be given with Inrinsic factor as well to see if excretion in May be given with Inrinsic factor as well to see if excretion in urine increases. urine increases. In pernicious anemia patients In pernicious anemia patients Without Intrinsic factor the excretion is less than7%Without Intrinsic factor the excretion is less than7%When given intrinsic factor tagged B12 is given the excretion When given intrinsic factor tagged B12 is given the excretion rate is greater then 7-20%rate is greater then 7-20%If both are low then it may suggest other cause for If both are low then it may suggest other cause for malabsorptionmalabsorption

3232

Anemia with high Anemia with high Reticulocyte counts (186)Reticulocyte counts (186)

Differential diagnosis:Differential diagnosis:Bleeding – blood loss internal/externalBleeding – blood loss internal/externalHemolysis – immune, mechanical, toxic, Hemolysis – immune, mechanical, toxic, inf.inf.

Laboratory evaluation Laboratory evaluation Blood film, nRBC, spherocytes, Parasites, Blood film, nRBC, spherocytes, Parasites, Retics.Retics.Hemolysis – indirect Bilirubin, Haptoglobin, Hemolysis – indirect Bilirubin, Haptoglobin, Direct and indirect Coombs test Direct and indirect Coombs test Hemoglobin electrophoresis, G6PD screen etc.Hemoglobin electrophoresis, G6PD screen etc.

3333

Anemia with Low MCV and Anemia with Low MCV and Low ReticsLow Retics

Differential diagnosisDifferential diagnosis Iron deficiency Iron deficiency Anemia of chronic disease Anemia of chronic disease Laboratory evaluationLaboratory evaluation Serum Iron levels, iron-binding capacity, Serum Iron levels, iron-binding capacity, and ferritin and ferritin Blood smear – Micro/hypo, Pencil cells.Blood smear – Micro/hypo, Pencil cells.

3434

C.B.CC.B.CHaemoglobinHaemoglobin - 15±2.5, 14 ±2.5 - - 15±2.5, 14 ±2.5 - g/dLg/dL PCVPCV - 0.47 ±0.07, 0.42 ±0.05 - - 0.47 ±0.07, 0.42 ±0.05 - l/dL (%)l/dL (%) Haematocrit, effective RBC volume - betterHaematocrit, effective RBC volume - better

RBCRBC count - 5.5 ±1, 4.8 ± 1 count - 5.5 ±1, 4.8 ± 1 x10x101212/L/LMCHCMCHC - Hb/PCV - 30-36 - - Hb/PCV - 30-36 - g/dLg/dLHb synthesis within RBCHb synthesis within RBC

MCHMCH - Hb/RBC - 29.5 ± 2.5 - Hb/RBC - 29.5 ± 2.5 pg/Lpg/LAverage Hb in RBC Average Hb in RBC

MCVMCV - PCV/RBC 85 ± 8 - - PCV/RBC 85 ± 8 - fLfL

3535

automated instrument automated instrument datadata

3636

Microcytic Hypochromic Microcytic Hypochromic Report (398, 400)Report (398, 400)

3737

The CBC here shows a markedly increased MCV, typical for megaloblastic anemia. The MCV can be mildly increased in persons recovering from blood loss or hemolytic anemia, because the newly released RBC's, the reticulocytes, are increased in size over normal RBC's, (399)

3838

Anemia Screen (398-Anemia Screen (398-400)400)IRON:IRON:IRON BINDING CAPACITY:IRON BINDING CAPACITY:PERCENT OF IRON SATURATION: Measurement of iron PERCENT OF IRON SATURATION: Measurement of iron in serum. in serum. FERRITIN:FERRITIN:TRANSFERRIN: TRANSFERRIN: VITAMIN B-12:VITAMIN B-12:FOLIC ACID: FOLIC ACID:

Management of Oral Management of Oral Anticoagulant TherapyAnticoagulant Therapy

Principles & Practice (98-99,488)Principles & Practice (98-99,488)

4040

Coagulation and Coagulation and FibrinolysisFibrinolysis

FibrinolysisFibrinolysis

Plasmin

Coagulation Factors

Fibrin

FibrinogenPlasminogen

Homocysteine

Cysteine

Glutathione

Lp(a)

t-PA, Urokinase

PAI-1

4141

Prothrombin Time (PT) Prothrombin Time (PT) (182)(182)

Historically, a most reliable and “relied upon” clinical testHistorically, a most reliable and “relied upon” clinical test

However:However:Proliferation of thromboplastin reagents with widely varying Proliferation of thromboplastin reagents with widely varying sensitivities to reduced levels of sensitivities to reduced levels of vitamin K-dependent clotting vitamin K-dependent clotting factorsfactors has occurred has occurredConcept of correct “intensity” of anticoagulant therapy has Concept of correct “intensity” of anticoagulant therapy has changed significantly (low intensity)changed significantly (low intensity)Problem addressed by use of INR (International Normalized Problem addressed by use of INR (International Normalized Ratio)Ratio)

4242J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687 J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687

983.983.

INR: International INR: International Normalized RatioNormalized Ratio

A mathematical “correction” (of the PT ratio) for differences in the A mathematical “correction” (of the PT ratio) for differences in the sensitivity of thromboplastin reagentssensitivity of thromboplastin reagentsRelies upon “reference” thromboplastins with known sensitivity to Relies upon “reference” thromboplastins with known sensitivity to antithrombotic effects of oral anticoagulantsantithrombotic effects of oral anticoagulantsINR is the PT ratio one would have obtained if the “reference” INR is the PT ratio one would have obtained if the “reference” thromboplastin had been usedthromboplastin had been usedAllows for comparison of results between labs and standardizes reporting Allows for comparison of results between labs and standardizes reporting of the prothrombin timeof the prothrombin time

4343

(( ))Patient’s PT in SecondsPatient’s PT in Seconds Mean Normal PT in SecondsMean Normal PT in Seconds

INR =INR =ISIISI

INR = International Normalized Ratio ISI = International Sensitivity Index

INR EquationINR Equation

4444

MeanMeanNormalNormal(Seconds)(Seconds)

PTRPTR ISIISI INRINR

1212

1212

1313

1111

14.514.5

1.31.3

1.51.5

1.61.6

2.22.2

2.62.6

AA

BB

CC

DD

EE

Blood from Blood from a single a single patientpatient

Patient’sPatient’sPTPT

(Seconds)(Seconds)

1616

1818

2121

2424

3838

ThromboplastinThromboplastinReagentReagent

How Different Thromboplastins How Different Thromboplastins Influence the PT Ratio and INRInfluence the PT Ratio and INR

4545

MeanMeanNormalNormal(Seconds)(Seconds)

PTRPTR ISIISI INRINR

1212

1212

1313

1111

14.514.5

1.31.3

1.51.5

1.61.6

2.22.2

2.62.6

3.23.2

2.42.4

2.02.0

1.21.2

1.01.0

2.62.6

2.62.6

2.62.6

2.62.6

2.62.6

AA

BB

CC

DD

EE

Blood from Blood from a single a single patientpatient Patient’sPatient’s

PTPT(Seconds)(Seconds)

1616

1818

2121

2424

3838

ThromboplastinThromboplastinreagentreagent

How Different Thromboplastins How Different Thromboplastins Influence the PT Ratio and INRInfluence the PT Ratio and INR

4646

Bone Marrow MaturationBone Marrow Maturation

4747

4848

Blood Blood GroupGroup AntigensAntigens

AntibodieAntibodiess

Can give Can give blood toblood to

Can receive Can receive blood fromblood from

AB AB A and B A and B None None AB AB AB, A, B, 0AB, A, B, 0

A A A A B B A and AB A and AB A and 0 A and 0

B B B B A A B and AB B and AB B and 0 B and 0

0 0 None None A and B A and B AB, A, B, 0AB, A, B, 0 0 0

Bleeding Disorders Bleeding Disorders (408-409)(408-409)

HemophiliaHemophilia

Von Willebrand Disease (vWD)Von Willebrand Disease (vWD)

5050

Coagulation ProcessCoagulation Process

Stage 1: Release of platelet factors to initiate Stage 1: Release of platelet factors to initiate clottingclottingStage 2: Generation of Thromboplastin by Stage 2: Generation of Thromboplastin by other factorsother factorsStage 3: Conversion of prothrombin to Stage 3: Conversion of prothrombin to thrombinthrombinStage 4: Formation of fibrin from fibrinogenStage 4: Formation of fibrin from fibrinogen

5151

HemophiliaHemophilia Von Von Willebrand Disease Willebrand Disease

(vWD)(vWD)Hemophilia :Affects 18,000 Hemophilia :Affects 18,000 in USin UScaused by deficiencies of caused by deficiencies of either clotting factor either clotting factor VIII or IXVIII or IX Hemophilia Hemophilia AA (factor (factor VIII VIII deficiency), which affects deficiency), which affects about 80% of hemophilic about 80% of hemophilic patients, and hemophilia patients, and hemophilia BB (factor (factor IX IX deficiency) > 30% deficiency) > 30% normal valuenormal valueElevated PTTElevated PTT and and Normal PTNormal PT and and Normal platelet count; Normal platelet count; it is confirmed by specific it is confirmed by specific factor assaysfactor assays

Most common bleeding Most common bleeding disorder affects 1-2% (more disorder affects 1-2% (more common in women)common in women)causes platelet dysfunction causes platelet dysfunction Screening coagulation tests Screening coagulation tests reveal :reveal :normal platelet count; normal platelet count; normal INR; normal INR; prolonged bleeding timeprolonged bleeding time; and, ; and, normal PTT normal PTT Diagnosis is based on low Diagnosis is based on low levels of VWF antigen and levels of VWF antigen and abnormal ristocetin cofactor abnormal ristocetin cofactor activity.activity.. .

5252

PTT (168)PTT (168)

Partial thromboplastin time (PTT) screens plasma for Partial thromboplastin time (PTT) screens plasma for abnormalities in factors of the intrinsic and common abnormalities in factors of the intrinsic and common pathways pathways A normal range of 28 to 34 sec is typical. A normal range of 28 to 34 sec is typical. A normal result indicates that at least 30% of all A normal result indicates that at least 30% of all coagulation factors in the pathway are present in the coagulation factors in the pathway are present in the plasma plasma prolongs the PTT, and the PTT is often used to monitor prolongs the PTT, and the PTT is often used to monitor heparinheparin

5353

PT/INRPT/INR

The PT screens for abnormalities in the extrinsic and The PT screens for abnormalities in the extrinsic and common pathways of coagulation common pathways of coagulation The PT screens for abnormalities in the extrinsic and The PT screens for abnormalities in the extrinsic and common pathways of coagulation common pathways of coagulation A typical normal range for the PT is between 10 and 13 A typical normal range for the PT is between 10 and 13 sec. An INR > 1.5 or a PT ≥ 3 sec longer than a sec. An INR > 1.5 or a PT ≥ 3 sec longer than a laboratory's normal control value is usually abnormal and laboratory's normal control value is usually abnormal and requires further evaluation. requires further evaluation.

5454

A patient with a A patient with a prolonged aPTTprolonged aPTT and a normal PT is considered to have and a normal PT is considered to have a defect in the a defect in the "intrinsic""intrinsic" coagulation pathway. coagulation pathway. A patient with a A patient with a prolonged PTprolonged PT and a normal aPTT has a defect in the and a normal aPTT has a defect in the "extrinsic""extrinsic" coagulation pathway (tissue factor is "extrinsic" to the coagulation pathway (tissue factor is "extrinsic" to the plasma). plasma). Prolongation of Prolongation of bothboth the aPTT and the PT suggests that the defect lies the aPTT and the PT suggests that the defect lies in a in a commoncommon pathway. pathway.