Hematology

1. Hematology Dan Cushman

2. What am I? Neutrophil

3. What am I? Eosinophil

4. What am I? Basophil

5. What am I? Monocyte

6. What am I? Lymphocyte

7. Blood Cells And the Award Goes To… Size: 6-8um Count: 4-6 million/uL Lifespan: 120 days What is the size, count, and lifespan of an erythrocyte? Size: 2-3um Count: 150,000-400,000/uL Lifespan: 8-12 days What is the size, count, and lifespan of a platelet? 5,000-10,000/uL What is the normal cell count for leukocytes? What are the two methods in which blood cells are counted? Manual, electronic (flow cytometry) Nerdiest Phrase of the Module The RBCs are lysed and the Hb is quantified by spectrophotometry How is the Hemoglobin Concentration (Hgb) measured? How is Hematocrit (Hct) calculated? The volume of RBC is divided by the volume of total blood “Flow Cytometry!” Lymphocytes, basophils, eosinophils, monocytes, neutrophils What are the five types of leukocytes? 6 hours – few days What is the lifespan of a neutrophil?

8. Blood Cells Months – years What is the lifespan of a lymphocyte? Lymphocytes, neutrophils What are the two most numerous leukocytes? Young = “band” Old = “Poly” What is a young neutrophil called? An old one? Polys Which is segmented – polys or bands? Decreased platelets What is “thrombocytopenia?” Anemia What is low RBC called? Hematopoietic precursor cells in the medullary tissue of cancellous bone (“red” bone marrow) Where do blood cells come from?

9. Blood Cells Individual cell evaluation, comparison of relative numbers of different cells What are the two main advantages of getting an aspirate of bone marrow? Overall cellularity assessment Infiltrative lesions can be seen What are the two main advantages of getting a bone core biopsy of bone marrow? Megakaryocytes From what type of cell do platelets derive? 1:1 What is the ratio of fat to hematopoietic tissue?? Biopsy Should a smear or a biopsy be used to determine bone marrow cellularity? 14 days How long does it take for granulocyte precursors to completely maturate in the bone marrow? Myeloblast From what type of cell do granulocytes derive? Myeloblasts and hematopoietic stem cells What is CD34 found on?

10. Blood Cells It can be detected by flow cytometry How is CD34 measured? Not normally Are plasma cells found in the bone marrow? A granuloma What type of infectious lesion can be found in bone marrow?

11. Hemoglobin Although they have similar properties, their amino acid sequences are quite different How similar are myoglobin and hemoglobin? Perpendicular Are the distal and proximal histidines in a Hgb molecule oriented perpendicular or parallel to the heme plane? Binding of oxygen will increase the stability of the molecule due to its structure What is the significance of this? Decrease Will a decrease in pH increase or decrease affinity for O2? Increased CO2 or decrease pH results in decreased affinity for O2 What is the Bohr effect? It’s usually about 50/50 Is there generally more hemoglobin or BPG in the blood? Lowers Does BPG raise or lower the oxygen affinity of hemoglobin? Higher Does fetal hemoglobin have a higher or lower affinity for oxygen than adult?

12. Hemoglobin Quarternary Which structure of hemoglobin (secondary, tertiary, etc.) changes due to oxygenation? Oxygenated Is iron in the plane of the porphyrin when the hemoglobin is oxygenated or un-? The terminal amino groups Where does CO2 bind in hemoglobin? A single point mutation in the beta chain of hemoglobin What type of genetic alteration causes sickle cell anemia?

13. Anemia The cords of Bilroth in the spleen Where are RBCs removed from the blood? Decreased lifespan of RBCs Development of anemia Bone marrow compensation What are the 3 general characteristics of hemolytic anemia? A newly-formed RBC (contains residual cytoplasmic organelles) What is a reticulocyte? Around 1 percent What percentage of RBCs are normally reticulocytes? Bone marrow function What is a reticulocyte count a measure of? Membranopathies Enzymopathies Hemoglobinopathies What are the three main types of intrinsic RBC abnormalities? Spherocytosis, elliptocytosis What are the two main membranopathies? G6PD deficiency What is the most common enzymopathy?

14. Anemia And the Award Goes To… Sickle Cell Disease What is the most common type of hemoglobinopathy? Microangiopathy (mechanical) Infection Immune-mediated What are three main types of extrinsic causes of hemolytic anemia? Immune-mediated Which type of extrinsic cause of hemolytic anemia is associated with spherocytes? What test is used to help diagnose immune-mediated hemolysis? Coomb’s Scariest diagnosis for a marine biologist with a speech impediment Schistocytes What is present histologically in microangiopathic hemolytic anemia? In the embryo, where are blood cells first created? For how long? Yolk sac – weeks 1-10 “Anemone anemia!” Liver/spleen for weeks 11-20 … where next? … how long? EPO  RBCs; Colony-Stimulating Factor  Granulocytes; Thrombopoietin  platelets What growth factor is responsible for the production of RBCs? …of granulocytes? … of platelets?

15. Anemia 1 week until it’s a “normal” RBC How long does it take for a new, nucleated RBC to enter circulation? Acute Does dyspnea occur more often with acute or chronic anemia? Usually depressed Would serum haptoglobin generally be elevated or depressed in patients with anemia? Decreased ability to reduce glutathione  oxidative damage What is the mechanism for injury in G6PD deficiency? Fresh-water; it creates a hypotonic environment that can lyse RBCs Which will cause more hematologic trouble, near-drowning in fresh or salt water? Dad = Rh+ Mom = Rh- Baby = Rh+ What combination of Rh factors (mom, dad, baby) can result in problems? Decreased EPO production  normocytic anemia How can renal failure lead to anemia? Usually yes (reactively) Is the reticulocyte count elevated during hemolysis?

16. Sickle Cell Disease Normocytic Are sickle cell erythrocytes micro-, normo-, or macrocytic? No, they’re usually episodic Are sickle cell disease symptoms constant? Vasoocclusion infarcts  localized pain What is the main symptom from sickle cell disease? The spleen is usually infarcted by childhood Why are sickle cell patients immunosuppressed? Streptococcus pneumoniae To which type of infection are sickle cell patients especially prone? ↑ bilirubin, ↓ haptoglobin What happens to the bilirubin and haptoglobin levels in sickle cell patients? Marrow infarct  fat emboli  lungs What causes acute chest syndrome? Hydroxyurea What therapy is useful for the prevention of sickle-cell-mediated infarcts?

17. Hemoglobinopathies S, C, and E What are the three main types of abnormal hemoglobin molecules? Decreased production of normal hemoglobin What is the general mechanism for thalassemias? α = 16 β, γ, and δ = 11 On which chromosomes are the different globin chains contained? Month 6 of fetal life When is fetal hemoglobin (HbF) switched off? βS Which type of hemoglobin is present in sickle-cell patients? “Target” cells What is the histologic presentation of Hemoglobin C disorders?

18. Microcytic Anemia 10% How much iron is absorbed from the diet (percentage)? From skin sloughing Where is the majority of iron lost in males? It’s an indirect measure of transferrin levels; it measures the amount to which Fe-binding sites can be saturated What does the Total Iron-Binding Capacity test measure? It prevents Fe from being oxidized during transport in the cell What is the function of ferritin? Children, women of child-bearing age Who commonly has iron deficiency? Rule out colon cancer If an elderly person presents with iron deficiency, what is the next step? A variation in the size of RBCs What is “anisocytosis?” The coolest word ever! Presence of abnormally-shaped RBCs What is poikilocytosis?

19. Microcytic Anemia (Mean Corpuscular Volume) The average size of RBCs What is MCV? (Mean Corpuscular Hemoglobin) The amount of hemoglobin in each RBC What is MCH? MCV = 80-100fL MCH = 25-30pG What are the normal values for MCV and MCH? Micro/hypo: MCV<80, MCH<25 Macro: MCV>100 What are the cutoffs for microcytic/hypochromic and macrocyticanemias? Pale, small, large central pallow What do microcytic, hypochromic RBCs look like? Iron deficiency Thalassemia Chronic disease What are the three main types of microcytichypochromic anemia? Increased RBC production  iron overload What happens with the serum iron levels of a β-thalassemia patient? They are similar to thalassemia patients What do the iron tests of a Hgb E patient resemble?

20. Microcytic Anemia It’s normal What does the electrophoresis result of a thalassemia patient show? α2β2 What is the most common type of hemoglobin in the adult? Decreased Is the TIBC elevated or decreased in patients with chronic disease? Elevated Is the TIBC elevated or decreased in patients with iron deficiency?

21. Iron tests

22. Macrocytic Anemia B12 and folate deficiencies What are the two main causes of macrocytic anemia? Erythroid hyperplasia, megaloblasticdyserythropoiesis What happens to the bone marrow in B12 deficiency? Erythroid hyperplasia, megaloblasticdyserythropoiesis What happens to the bone marrow in folate deficiency? Every cell in the body (including granulocytes and megakaryocytes) What type of cell is affected by B12 deficiency? Hypersegmentedneutrophils What is another WBC-related feature of B12/folate deficiency? 24 hours How quickly does the bone marrow recover from a B12 deficiency? Folate = jejunum B12 = terminal ileum Where are folate and B12 absorbed in the GI tract? Lack of IF (auto-antibody against IF-producing parietal cells)  decreased B12  anemia What’s pernicious anemia?

23. Macrocytic Anemia Serum levels, B12 deficiency also can have neurologic symptoms How can B12 deficiency be differentiated from folate deficiency? About 7 days How long does it take for the reticulocytosis to be seen after B12 infusion? 3-10 years How long does it take for B12 to become depleted in the body? A problem with DNA synthesis What is biochemically common to all macrocyticanemias?

24. Anemias

25. Anemia Reticulocyte count Which test(s) differentiate these conditions? Which test(s) differentiate these conditions? MCV, MCH Inappropriately low reticulocyte count Appropriately elevated reticulocyte count Which test(s) differentiate these conditions? Serum LDH, bilirubin TBIC, Serum ferritin, marrow Fe Which test(s) differentiate these conditions? Which test(s) differentiate these conditions? Serum B12, folate levels Hypochromic / microcytic Macrocytic Hemolysis Bleeding Coomb’s test Which test(s) differentiate these conditions? Normocytic Immune Non-immune

26. Leukocytes Granulocytosis Lymphocytosis What are the two classes of leukocytosis? Neutrophilia What is another name for granulocytosis? Infection, trauma, inflammatory conditions, parturition When is a granulocytosis appropriate? 0% (though, a small amount can be present in reactive states) Normally, what percentage of granulocytes in the blood are immature? Leukemoid reaction What is the name for the condition where immature granulocytes are reactively present? Granulocytes = CML Erythroids = polycythemia vera Megakaryocytes = Essential thrombocythemia What are the three classes of myeloproliferative disorders? Yes – infections Is it ever “normal” to have lymphoid proliferations?

27. Leukocytes It’s been activated What does a large lymphocyte suggest? It can just be reactive, or it can be a neoplastic lymphoid cell What about an atypical lymphocyte? Mature Are the lymphoid cells in lymphoproliferative disorders immature or mature? B = CD20, Ig T = CD3, CD4, CD8 Precursor = CD34, TdT What are the main antigens on B cells? T cells? Precursor (B & T) cells? Immature granulocytes Blasts Nucleated red cells What cells in the peripheral blood are indicative of a myeloproliferative or lymphoproliferative disorder? Newborns Hemolytic anemias When is it normal to see nucleated RBCs peripherally?

28. Where does this occur? Isolated IgADefic. X-linked Agammag. Wiskott-Aldrich IPEX Di George SCID Common Variable Immuno-deficiency Mature T cell Effector T cell Thymus T lineage progenitor cell CD8 Tc Tc CD4 Th Antigen Presenting Cell Lymphoid progenitor cell M CD4 T reg B B Y Y Mature B cell B lineage progenitor cell Antibody secreting cell Pre-B cell

29. Immune Deficiencies And the Award Goes To… Viruses, fungi, intracellular pathogens What type of infections are common in patients with T cell deficiencies? Bacteria, enteric viruses What type of infections are common in patients with B cell deficiencies? Antibody deficiency What is the most common general type of immunodeficiency? What are the main presenting features of SCID patients? Severe infections, failure to thrive, GVHD Worst lecture ever markedly reduced T cells; reduced, normal, or elevated B cells Are SCID patients deficient in T cells or B cells? Are there any radiologic findings of SCID? Absent thymus The lecture entitled, “Look at What I Know About Test-taking,” a.k.a. this lecture BMT or cord blood What is the treatment for SCID? Neutrophil deficiency What immune deficiency is most commonly related to gingivitis?

30. Immune Deficiencies Aberrant development of the 3rd and 4thbranchial arches What is the embryological cause of DiGeorge Syndrome? Cardiac problems, facial deformities, absence of thymus, absence of parathyroid glands What are the main characteristic clinical findings of DiGeorge Syndrome? No Are the B cells affected by DiGeorge Syndrome? X-linked recessive (mutation of WASP protein) What is the genetics of Wiskott-Aldrich Syndrome (WAS)? Eczema, infections (polysaccharide antigens), thrombocytopenia What are the main clinical findings of WAS? H. influenzae, Strep pneumoniae, Pseudomonas What pathogens are commonly implicated in diseases associated with Antibody Deficiency Syndromes? Pyogenic infections (S. pneumoniae) What pathogen commonly takes advantage of C3 deficiencies? Neisseria What pathogen commonly takes advantage of C5-C9 deficiencies?

31. Myeloproliferative Disorders Altitude LR shunt Chronic lung disorders What are three reasons for appropriate erythrocytosis? Yes Do the proliferating cells mature? Pan-myeloid hyperplasia, hypercellular What is the histology of the bone marrow in myeloproliferative disorders? No obvious cause What is the cause of polycythemia vera (PV)? A non-receptor tyrosine kinase that activates transcription factors What is JAK? PV, essential thrombocythemia, chronic idiopathic myelofibrosis With what diseases is JAK associated with? Immature granulocytes What abnormal blood cells are seen peripherally in CML? BCR-ABL What abnormal protein is implicated in CML?

32. Myeloproliferative Disorders And the Award Goes To… t(9;22) What is the chromosomal abnormality associated with CML? Fibrous tissue within the medullary tissue What can be seen in the bone marrow of a patient with myelofibrosis? Anisocytosis What is abnormal about the erythrocytes in myelofibrosis? Extreme splenomegaly What is the main clinical presentation in a patient with myelofibrosis? Best student’s name in a hematologic-associated condition To what can myeloproliferative disorders progress? Acute leukemia They’re not; the large amount of them can cause viscosity problems, however How are the erythrocytes produced in PV abnormal? 2nd Place: SplenoMEGHAly Honorable mention: GraNEILocytosis Honorable mention: JAK Honorable mention: HemoPHILia Honorable mention: Wiscott-AldRICH Syndrome 3rd Place: Sickle CELL Anemia 1st Place: HARRY cell leukemia What cell causes the fibrosis in myelofibrosis? Megakaryoctes fibroblasts

33. Myeloproliferative Diseases

34. Lymphoproliferative Disorders Mature In lymphoproliferative disorders, are the proliferating cells immature or mature? Genotypic – Ig heavy chain gene or T-cell receptor gene; Phenotypic – Ig light chain restriction What tests show whether a lymphoproliferative disorder is clonal? B cells that express CD5 and exhibit surface Ig Light chain restriction What type of cells are in CLL? High-grade and low-grade How can Non-Hodgkin lymphomas be split (2 general groups)? Follicular, large B-cell lymphomas What are the 2 most common types of Non-Hodgkin lymphoma? B cells What type of cell is found in follicular lymphomas? Low Are follicular lymphomas high- or low-grade? T(14;18)  BCL-2 deregulation What is the cause of follicular lymphomas?

35. Lymphoproliferative Disorders They can be either, but most are B cell Are diffuse lymphomas made of B or T cells? High-grade Are diffuse large-cell lymphomas high- or low-grade? Usually low-grade Are diffuse small-cell lymphomas high- or low-grade? A translocation on chromosome 8  mycderegulation What is the cause of Burkitt lymphoma? B cells What are the neoplastic cells in Hodgkin lymphoma? Hodgkin have Reed-Sternberg cells (abnormal B cells) What differentiates Hodgkin from Non-Hodgkin lymphoma histologically? Unknown, but EBV is suspected What is the cause of Hodgkin lymphoma? Lymph nodes, GI tract, bone marrow Where are malignant lymphomas most commonly found?

36. Lymphoproliferative Disorders Hodgkin = contiguous Non-Hodgkin = hematogenous How are Hodgkin lymphomas spread? Non-Hodgkin? Hodgkin = staging Non-Hodgkin = histology What is the main prognostic factor for Hodgkin lymphomas? Non-Hodgkin? CLL What is the most common lymphoproliferative disorder? There is none, but it has a slow progression What is the cure for CLL? Blast crisis To which condition can CML progress? Functional Are the granulocytes in CML functional or non-functional?

37. Acute Leukemia They can be from either Are leukemias from myeloid or lymphoid cells? Immature Are the cells found in acute leukemias mature or immature? Blasts What cells do the leukemia cells most closely resemble? All normal blood cells are decreased (pancytopenia) What happens to granulocyte precursors in acute leukemia? Thrombocytopenia, neutropenia What causes most of the clinical problems of acute leukemias? Immunophenotyping How can the cell type be found in acute leukemia? Myeloid cells Where are Auer rods seen? Acute progranulocytic leukemia; it responds to retinoic acid therapy What is AML-M3? What’s special about it?

38. Immunophenotyping B cells CD20 Blasts CD34 Myeloid cells CD33 T cells CD3

39. Acute Leukemia Genetic – T(15;17) What is the cause of AML-M3? It is a transmembrane protein that is commonly implicated in AML What is important about FLT3? ALL What is the most common leukemia in children? Yes – 90% cure rate Is ALL treatable in children? Yes, but with much less success than with children Is ALL treatable in adults? T(9;22) can be found – it lends a poor prognosis Is there a genetic component of ALL? Methotrexate – directly into the spinal fluid What treatment is used for CNS involvement of ALL? IFN or adenosine deaminase inhibitors What is the treatment for hairy cell leukemia?

40. Plasma Cell Disorders CLL What is the most common type of leukemia? Lymphocytosis What is the main lab finding in CLL? Slow Is CLL’s progression slow or fast? Clonal B cells What type of cells are present in CLL? Clonal B (plasma) cells What type of cells are present in multiple myeloma? In the bone marrow Where do the plasma cells accumulate in MM? Mostly the immunoglobulin What causes the clinical effects of MM? Electrophoresis, revealing an M spike in the gamma region What test helps diagnose MM?

41. Plasma Cell Disorders And the Award Goes To… Rouleau sign Amyloidosis Bence-Jones casts What three histologic signs are found in MM? Osteopenia Renal failure Pathologic fractures What are the three main clinical presentations of MM? Hypercalcemia Pancytopenia Hyperglobulinemia What are the main lab findings of MM? What radiologic evidence is characteristic of MM? Punched-out lytic lesions of bone Laziest attempt at naming a syndrome IgG – more light-chain than heavy-chain What type of Ig is usually present in MM? What medications should be avoided in MM patients? Nephrotoxic ones (IV contrast, gentamicin) Monoclonal Gammopathy of Unknown Significance (MGUS) Lymphoplasmacytoid proliferation (lymphocytes + plasma cells) What is Waldenstrom’s syndrome? No, it could be MGUS (which is relatively common) Is clonalhyperglobulinemia always MM?

42. Malaria Plasmodium falciparum Which species of malaria avoids the spleen? Plasmodium vivax Which species have the hypnozoites? Primaquine What is the treatment for P. vivax? Glycophorin A & B Duffy Blood Group Antigens Reticulocyte Binding Protein What are the main RBC receptors needed for invasion by merozoites? The result of ingested hemoglobin; it’s a black pigment What is hemozoite? Hemolytic Which type of anemia is caused by malaria? Infection  cytokine-mediated neural damage What is the pathophysiology of cerebral malaria? Ag:Ab complexes What causes the renal failure that can accompany malaria?

43. Malaria Hypoglycemic (the parasites eat up the glucose) Are malaria patients generally hypo- or hyperglycemic? Spleen-less patients Which patients should be watched very closely in malaria-endemic regions? Increased reticulocytes and WBCs What causes malaria-associated splenomegaly? Blood rosetting By what mechanism are the parasites able to safely pass from one RBC to another? Low-grade infections confer immunity; it lasts as long as they persist in the blood How is immunity gained for malaria? How long does it last? Antibodies are passed via the mother’s milk but PABA (necessary for the parasites) is not passed How do babies that are breast-fed remain malaria-free?

44. Coagulation cascade 4 3 2 1

45. Hemostasis And the Award Goes To… Thrombin (IIa) What converts fibrinogen to fibrin? Factor Xa What converts prothrombin to thrombin? The intrinsic and extrinsic pathways What activates factor X? Which factor(s) in the intrinsic pathway activates X? VIIIa, IXa Most confusing numbering system in a physiological cascade Factor VIIa + tissue factor Which factor(s) in the extrinsic pathway activates X? Which factors are responsible for the intrinsic pathway (up to factor X)? VIII, IX, XI, XII The Coagulation Cascade! It chelates Ca2+, which is responsible for the intrinsic pathway activation of thrombin How does citrate anticoagulate blood? II, VII, IX, X Which are the vitamin-K-dependent factors?

46. Coagulation Tests TT (Thrombin Time) Specific or non-specific? Specific Reagent? Thrombin PT (Prothrombin Time) Specific or non-specific? APTT (Activated Partial Thromboplastin Time) Non-specific Tests for which factor(s)? Fibrinogen Specific or non-specific? Non-specific Reagent? Platelet substitute + thromboplastin Reagent? Platelet substitute + activator Tests for which factor(s)? Extrinsic factors (VII, X, V, II, I) Tests for which factor(s)? Intrinsic factors (all except VII)

47. Hemostasis Factor deficiencies, Factor inhibitor(s) are present How are clotting time tests prolonged? The act together to degrade bound factors V & VIII What do Protein C and Protein S do? It will result in excessive coagulation Will a deficiency in Protein S result in an increase or decrease in coagulation? Antithrombin III What is the other main internal anti-coagulant? PT (INR is calculated from this) Which test monitors Warfarin? Vitamin-K dependent factors (II, VII, IX, X) Which factors does Warfarin decrease? Primary hemostasis Which phase of the hemostatic process does bleeding time assess? Decreased or abnormal vWF What is the general mechanism for vWD?

48. Hemostasis VIII To which factor does vWF bind? Primary hemostasis Coagulation Fibrinolysis What are the three stages of hemostasis? Vascular phase Platelet phase What are the two parts of primary hemostasis? ~5 minutes How long does it take for the platelet phase of primary hemostasis to occur? Coagulation; primary hemostasis only lasts a few hours Which is more durable, coagulation or primary hemostasis? Weeks to months How long does it take for fibrinolysis to fully occur? Yes, it decreases factor VIII Does a decrease in vWF affect any of the clotting factors? On the surface of endothelium, Floating in the blood Where is vWF found?

49. Hemostasis No, it’s a protein that just binds to other proteins Is vWF an enzyme? TTP Which is generally more serious of a condition – ITP or TTP? Corticosteroids Splenectomy IVIG What are the three main treatments for ITP? Auto-antibodies against platelet antigens What is the pathophysiology for ITP? Macrophages become saturated, allowing more platelets to pass through How can IVIG help with ITP? Less platelet destruction How can a splenectomy help with ITP? Adults; children’s usually disappears within a few months Which is generally worse – ITP in children or adults? Renal failure, thrombocytopenia, fever, altered mental status, microangiopathic anemia What are the main symptoms associated with TTP?

50. Hemostasis An auto-antibody against a metalloprotease (ADAMTS13) that cleaves vWF What causes TTP? Increase (the longer vWF polymers are more prone to coagulation) Does the decreased enzyme concentration cause an increase or decrease in coagulation? Platelet Do petecchiae suggest a coagulation or platelet disorder? Primary Does vWD affect primary or secondary hemostasis?