Maryna Krawczuk-Rybak Department of Pediatric Oncology and Hematology

1. Blood morphology in non-haematological diseases of childhood:- interpretation of abnormal blood morphology- infections- gastrointestinal diseases- kidney diseases- connective tissue diseases- cardiovascular diseases- hormonal disorders- the effect of drugs Maryna Krawczuk-Rybak Department of PediatricOncology and Hematology

2. Hematopoietic system • Supply of oxygen to the tissues • Prevention of infections • Maintaining hemostasis The bone marrow produces daily: • 10¹² red blood cells • 10¹¹ whitebloodcells • 10¹¹ platelets

3. The bone marrow is sensitive to diseases, which: • disrupt the anatomical integrity • inhibit the production of hematopoietic growth factors • stimulate the production of proinflammatory cytokines • Reduce the survival time of circulating bloodcells THE ANSWER TO THE QUESTION: • Is it a primary blood disease? • Or isit secondary, resulting from systemic disease? → Interview → Clinicalexamination (jaundice, telangiectasia, lymphadenopathy, hepatosplenomegaly, splenomegaly) → Analysis of bloodmorphology, bloodsmear, reticulocytosis

4. Anemia Normal erythropoiesis is the result of 4 independent processes: • Proliferative abilityof the erythroid line of progenitor cells • Factors stimulating production of red blood cells • Sufficient nutritional requirements (iron, folic acid, vitamins) • Red blood cell survival (shortening due to premature destruction or bleeding)

5. Anemia in the course of systemic diseases Hypoproliferativeanemias: • Vascularinflammation • Infections • Cancers • Diseases of kidney parenchyma • Hypopituitarism • Hypothyroidism • Disorders of absorption (celiacdisease)

6. Aplasia / hypoplasia of the red-bloodcells system: • Hematopoieticmalignancies • Solid tumors, bloodmalignancies • Immunedisorders (collagenosis) • Infections (Parvovirus B19, EBV, Hepatitis A, B, C) • BMT Hemolyticanemias: • Infections (malaria, EBV, Bartonellahenselaeinfection, basesiosis, clostridium, mycoplasmosis) • Solid tumors • Wilson disease, microangiopathies (TTP, HUS, vasculitis, malignanthypertension, DIC)

7. Anemia as a result of chronic diseases • Moderate or severe anemia • Low iron values and lowiron binding capacity • TIBC, transferrin - correct or low • Low transferrin saturation • Low iron storage in bone marrow • Normal or elevated level of ferritin •  low levels of EPO and reticulocytes • Inadequate EPO production due to:   - Increased intracellular iron accumulation -Stimulation of hepcidin production by: •         Proinflammatory cytokines → blocking the absorption of iron in the intestine •         Release of iron from macrophages

8. Leukocytosis / leukopenia • Autoantibodies • Cytotoxic leukocytes (Felty syndrome: rheumatoid arthritis, neutropenia, splenomegaly) • Infections • Myelofibrosis • Hyperthyroidism • Splenic sequestration • Enteropathy with protein loss

9. Blood platelets - thrombocytopenia 1. Disturbedproduction 2. Increasedplateletdestruction Both as a result of: • DIC • TTP (thromboticthrombocytopenic purpura) • Sepsis • Autoantibodies • Vasculitis • Inflammation • Splenicsequestration

10. Excessive platelet production • Livercancer (hepatoblastoma, hepatocarcinoma) • Reactive: - Inflammation (leukocytosis, thrombocytopenia) • Anemia • aftersurgery / injury / burns • gastroesophagealreflux

11. Pancytopenia Secondarybonemarrowaplasia in the course of: • Thymoma • Autoimmunediseases • Bonemarrownecrosis • Splenicsequestration • Hepatitis • Haemophagocyticsyndrome

12. Leukaemoid reaction • Lymphoidormyeloid • Oftenafterinfection • Myeloidreaction (afterbacterialinfections, in proliferativediseases, TBC) → toxicgranularity in granulocytes, lowmyelocyte and myeloblastcount • Lymphoidreaction - in the pertussis - increase in the number of lymphocytes to 100 x 10⁹ / L, -Coxsackie viruses - lymphocytosis <50 x 10⁹ / L

13. Infections Hematological response to infections depends on: • Type of invasion • State of health prior to infection Acutebacterialinfections → neutrophilia (exception: severeinfections / sepsis, prematureinfants - oftenparadoxicalneutropenia) • Growth of immatureneutrophils (BAND) • Subacute, chronicinfections (Salmonella, Brucella, TBC) → increase in monocytecount Viralinfections → transitionalneutrophilia (acutephaseresponse) → lymphocytecount and morphologyabnormalities Parasiticinfections → eosinophilia

14. Anemia in the course of inflammation • Infections (bacterial, viral, fungal, parasitic) • Autoimmunediseases (LE, RA, sarcoidosis, vasculitis, inflammatoryboweldiseases) • Malignancies (lymphomas, solid tumors) • Chronicdiseases (cardiovascular, renal) ↓ • Disturbed iron homeostasis (stimulation of hepcidin by proinflammatory cytokines → reduced absorption of iron in the gastrointestinal tract) • Impaired erythropoiesis (as above+ sequestration of iron in macrophages → limiting of ironavailability for erythropoiesis) • Inhibitory effect of cytokines on progenitor cells of the red blood cell system • Accompanying vitamin B12deficiency and folic aciddeficiency

15. Haemolytic anemia Haemolytic anemia with the presence of cold antibodies * Mycoplasma, * EBV Agglutination → increase in MCV, MCH, MCHC Paroxysmalnocturnalhaemoglobinuria (PNH): • Occursrarely • Acuteintravascularhemolysis • Afterviralinfections (mumps) • Parasitic and bacterialinfections (Clostridium welchii / perfringens, Bartonella, Plasmodium falciparum, Babesia)

16. Selected infections: Tuberculosis: • anemia, • monocytosis, myeloidreactions, • thrombocytopenia, sometimes pancytopenia Epstein-Barr virus (infecting B lymphocytes): - leukocytosis, lymphocytosis, atypicalmononuclearcells - sometimesneutropenia (evensevere) - thrombocytopenia (in 1/3 of patients) - the presence of coldagglutinins → agglutination of red bloodcells -> hemolysis - spherocytosis, polychromasia

17. HIV • Importance of the presence of the virus, malnutrition, presence of autoantibodies • Cytopenia: • Anemia, reticulocytopenia • Thrombocytopenia • Sometimesneutropenia (eg. afteranti-viraldrugs) Parvowirus B19 • Facial erythema, arthritis • Prolonged pancytopenia • Aplasia of the red-bloodcell system TORCH • Anemia, thrombocytopenia Kawasaki disease - neutrophilia - thrombocythemia

18. Hemolytic uremic syndrome (HUS) • Microangiopathic hemolytic anemia + thrombocytopenia + acute renal failure • Anemia, reticulocytosis • thrombocytopenia • In the blood smear - the presence of schizocytes

19. Thrombotic thrombocytopenic purpura - TTP • Usually during puberty • Symptoms like HUS + neurological disorders +/- fever, headache, muscle aches +/- hepatosplenomegaly, jaundice • ADAMTS-13 proteinase deficiency (decomposes large multimers of von Willebrand factor binding to surface antigens of thrombocytes causing aggregation); presence of anti-ADAMTS-13 antibodies

20. Chronic renal diseases • EPO deficiency → abnormal erythropoiesis, • Increase in urea of 10 mmol / L → decrease in hemoglobin of 2 g / dL • Basically leucopoiesis and megakaryocytopoiesis are normal • Normochromatic normocytic anemia; + keratocytes, echinocytes • Hypersegmentation of neutrophils • Shortened red blood cell survival time (hemodialysis) • Efficient recombinant EPO treatment

21. Chronic kidney disease (CKD) • At stage 1, anemia was found in 31% of children; atstage 4 and 5 in 93.3% • Anemia is more severe in infants and young children than in older children and adults. • Hypochromic, normocytic anemia due to iron and EPOdeficiency, in addition: - Reduced iron bindingcapacity - Deficiency in vitamins: folicacid, vit. B12 - Blood loss, includinguremicbleeding, caused by (for example) impairedfunction of the platelets - Inflammation - hyperparathyroidism - The use of immunosuppressivedrugs, angiotensinconvertingenzymeinhibitors (ACE-I)

22. Chronic kidney disease (CKD) • Recommended diagnostic tests to explain the cause of anemia in chronic kidney disease (according to KDIGO 2012) • Patients with CKD and anemia should perform the following tests within the preliminary diagnosis: - Blood cell morphology and bloodsmear (automatic) - mean cell volume (MCV) and mean hemoglobin content in bloodcell (MCH) - total number of reticulocytes - serum ferritinconcentration • serum iron concentration and total iron bindingcapacity (TIBC) for calculating iron transferrinsaturation (TSAT); TSAT iscalculated as follows: serum iron concentration x 100 / TIBC • concentration of vitamin B12 in serum • concentration of folic acid in serum

23. Chronic liver diseases Anemia: • Moderately macrocytotic(butmicrocyticis common in patients with hepatic failure and esophageal varices – due to bleeding from varices) • Hemolytic anemia - including other evidence of liver damage may suggest a suspicion of Wilson's disease Thrombocytopenia, leukopenia - due to hypersplenism, may be the first sign of chronic liver failure.

24. Viral hepatitis • From minor anemia to aplastic anemia (immunization mechanism) • Reduction in reticulocytosis • Reduced survival time of erythrocytes • Macrocytosis • Leukopenia / lymphocytosis before jaundice • Thrombocytopenia

25. Anemia in liver diseases Wilson's disease (disorder of copper metabolism) • liver, CNS, kidney, corneadamage → hemolytic anemia without morphological abnormalities or with the presence of Heinz's bodies (sudden release of copper from the liver) - sudden hemolytic episodes Reye's syndrome- appears a few days after the viral infection; associated with the use of aspirin -acute encephalopathy + degenerative changes in the liver - coagulation, thrombocytopenia

26. Bowel diseases Crohn'sdisease, ulcerative colitis → • Inadequate absorption (iron, B12 vitamin, folates) • Bleeding • Sulfasalazine → folic acid deficiency, hemolysis • Treatment with folic acid → initially improvement in Hb value, but followed by microcytic anemia • Leucocytosis in the active phase of the disease • Eosinophilia, thrombocytosis – in inflammation of the intestines

27. Celiac disease • Impaired absorption of iron, vitamin B6, vitamin B12, folic acid, riboflavin • Blood loss • Intestinal inflammation → cytotoxic effects of cytokines (INF-gamma, IL-6) → increase in hepcidin synthesis

28. Hypochromic, microcytic anemia in 45-50% of children with subclinical celiac disease • Often the only symptom of celiac disease! • Low iron and ferritin concentration • an increase in UIBC • Treatment: gluten free diet + ironsupplementation + folic acid supplementation • Rarely: leukopenia (folic acid and copper deficiency) • Rare: thrombocytopenia (autoimmune)

29. Iron deficiency and H. pylori infection • The only sign of infection, correction of iron deficiency after eradication of infection • hypochlorchydria → iron absorption disorders • Increased demand for iron - the use of alimentary iron by bacteria for its growth • Gastritis – place of iron sequestration • Bleeding from gastrointestinal tract • Possibility of bacterial production of a matriptase inhibitor - interference with the normal response of the intestinal mucosa - iron depletion

30. Cardiac diseases Cyanotic heart diseases → tissue hypoxia → stimulation of EPO synthesis → polycythemia • Sometimes thrombocytopenia +/- platelet dysfunction • Sometimes symptoms of thrombosis (activation of the coagulation system) DiGeorge syndrome (chromosome 22 microdeletions) • Congenital heart defects • Facial anomalies • Immune disorders, lymphopenia, ↓ T lymphocytes

31. Lung diseases • Hypoxia → polycythemia, increase in blood viscosity → decreased blood flow through tissues • Lung hemosiderosis - intravitreal microvascular bleeding, abnormal iron accumulation in the lungs (hemosiderin) → lung dysfunction, haemoptysis, dyspnea • Often the cyclical course of the disease • Iron deficiency anemia (microcytic) • ↓ iron level, ↑ iron binding capacity, sometimes eosinophilia • Loeffler's syndrome • Eosinophilic pneumonia with peripheral blood eosinophilia in the course of parasitic diseases

32. Diseases of the endocrine glands Thyroid diseases Hypothyroidism: • Moderate normochromatic, macrocytic anemia, possible basophilia Hyperthyroidism : • The increase in MCH, Hb correct,possible lymphocytosis, neutropenia Adrenal insufficiency and hypopituitarism: • Moderate normochromatic anemia, lymphocytosis, eosinophilia, neutropenia Cushing's syndrome • ↑ in erythrocytes, hemoglobin, leucocytes, platelets (stimulation of bone marrow) • ↓ in circulating lymphocytes, monocytes, eosinophils (migration to extracellular space)

33. Skin diseases Eczema • Moderate eosinophilia • Severe eczema / psoriasis: moderate anemia Wiskott-Aldrich syndrome: • Severe eczema, thrombocytopenia, small platelets • Immune disorders

34. Choroby tkanki łącznej Juvenile chronic arthritis • Gastrointestinal bleeding (salicylates, steroids) → Iron deficiency → anemia • Secondary thrombocytopenia • Small leucocytosis • Splenomegaly → neutropenia Lupus erythematosus (LE) • The presence of autoantibodies against platelets (most commonly), erythrocytes, neutrophils → cytopenias → precursors growing in bone marrow • Anemia, leukopenia, lymphopenia, thrombocytopenia

35. Polyarteritis nodosa • Microangiopathic hemolytic anemia • eosinophilia Wegener's granulomatosis • Cough, fever, hemoptysis, infiltration in the lungs, kidneys → • Normochromatic, normocytic anemia • Microangiopathic hemolytic anemia • Fragmentation of erythrocytes • Leukocytosis with neutrophilia and eosinophilia • Secondary thrombocytopenia

36. Anorexia nervosa • severe malnutrition • moderate anemia, macrocytosis • neutropenia • thrombocytopenia

37. Drugs • Myelosuppression • Bone marrow aplasia (chloramphenicol) • Cell survival time reduction • Immunological reactions

38. Thrombocytopenia: • Creation of drug-binding antibody complexes • A drug (hapten) that binds to the surface of the plates • Stimulation of the production of antibodies reacting with antigens on the surface of the plates • Sodium valproate • Phenytoin • Carbamazepine • Rifampicin • Co-trimoxazole • Acetosolamide • Cimetidine • Aspirin • Heparin

39. Classification of drugs due to association with aplastic anemia. Advances in Medical Sciences 4/2000, pp. 17-28 • Drugs that cause toxic bone marrow damage • Cytostatics used in cancer. • Alkylating agents (busulfan, melphalan, cyclophosphamide) • Antimetabolites (nucleotide analogs, folic acid antagonists) and antimitotic agents (vincristine, vinblastine, colchicine) • Antibiotics (daunorubicin, doxorubicin) 2. Drugs that are less likely to cause aplastic anemia. • Chloramphenicol • Non-steroidal anti-inflammatory drugs (phenylbutazone, indomethacin, ibuprofen, diclofenac, naproxen, piroxicam,fenoprofen, fenbufen, acetylsalicylic acid) • Anticonvulsants (hydontoin derivatives, carbamazepine, ethosuximide, fenacemide)Gold, arsenic, bismuth, mercurysalts • Sulfonamides • Antithyroid drugs (methimazole, metylotiuracyl, propylthiouracil) • Antidiabetic drugs (tolbutamide, carbutamide, chlorpropamide) • Inhibitors of carbonic anhydrase (acetazolamide, metazolamide, mesalazine) • D-penicillamine 3. Medications rarely causing aplastic anemia • Antibiotics (streptomycin, tetracyclines, ampicillin, methicillin, mebendazole, albendazole, flucytosine, dapsone, mefloquine) • Antihistamines (cimetidine, ranitidine, chlorpheniramine) • Calming agents (chlorpromazine, prochlorperazine, chlordiazepoxide, meprobamate, methyprone, remoksiprid) • Antiarrhythmics (amiodarone, tokainid) • Allopurinol (may increase the toxic effect of cytostatics on the bone marrow) • Other: ticlopidine, methyldopa, quinidine, lithium, guanidine, deferoxamine, carbimozole, amphetamine, furosemide, mepacrine.

40. Drugs that cause immunohemolytic anemia

41. Drugs and chemicals that can cause megaloblastosis

42. Drugs that can cause sideroblastic anemia .

43. Drugs that may induce selective aplasia of the red blood cell system

44. Drugs that can cause granulocytopenia

46. Drugs that can cause increased leukocytosis histamineCorticosteroidsnorepinephrinelithiumserotoninTetrakosaktydtetracycline

47. Drugs that can cause eosinophilia Interleukin - 2GM - CSFchlorpromazinechlorpropamidephenytoinflucytosineKotrymoksazol PenicillinpentazocineprobucolGold saltsnitrofurantointetracyclinetetracycline .

48. Drugs that can cause thrombocytopenia .

49. Drugs that can cause immunotrombocytopenia

50. Drugs that impair the function of the platelets (aggregation).