HEMATOLOGY (INTRODUCTION)

 Hematology – study of blood cells

 Red blood cells/RBC = erythrocytes
- For oxygenation or respiration
 White blood cells/WBC = leukocytes
- Immune function: blood cells can produce antibodies which are derived from plasma cells. Plasma cells
are derived from B cells. B cells are small lymphocytes. Large lymphocytes are also called T cells
participate in cellular mediated immunity which means it has the participation of macrophages, T cells
and antigen presenting cells and others. Antibodies are needed for humoral immunity.
 Platelets = thrombocytes
- Hemostasis
- Hemostasis 2 important steps: clotting and bleeding
 Blood – respiratory fluid that circulates all over the body

 Different types of cells:

 Neutrophil
- Acute bacterial infection
- Has proteolytic enzyme needed for killing of bacterial protein
 Lymphocyte
- Viral infection
- Most viral infection elevates lymphocytes because lymphocytes have this CD4 which attracts viruses.
 Monocytes
- Chronic bacterial infection which includes syphilis, tuberculosis, subacute bacterial endocarditis
 Red blood cells
- Contains hemoglobin: respiratory and coloring pigment of RBC needed for respiration or oxygenation
 Platelets
- Hemostasis

 Components of blood
1. Liquid
- Contains glucose, proteins, lipids and others
Two types of the liquid component of blood:
 Serum
- Clotted without fibrinogen which means fibrinogen has been converted to fibrin through the process
known as coagulation.
- Three pathways of coagulation:
1. Intrinsic
2. Extrinsic
3. Common pathway

 Plasma
 - Unclotted without fibrinogen
- Anticoagulant: substance that prevents blood from clotting
- Procoagulant/clotting factors: compounds that enhance clotting

2. Gas
- Consists of oxygen, carbon dioxide and carbon monoxide (present in heavy smokers and persons
exposed in big cities)
3. Solid
- Composed of RBCs, WBCs and platelets

 Functions of blood
1. Secretory
- Hormones and enzymes
2. Excretory
- Wastes products e.g. NPNs are eliminated in the blood
3. Nutritive
- Vitamins and minerals
4. Respiratory
- Hemoglobin, myoglobin (found in the muscles)
5. Immunologic
- Antibodies (humoral immunity), WBCs (cellular-mediated immunity)

Anticoagulants (additives which prevents blood from clotting)

Anticoagulant Color of rubber stopper Action

Heparin Green Acts on antithrombin-III (inhibitor of
(For blood gases) clotting factors V and VIII),
thromboplastin (only clotting factor not
found in plasma or serum since it is
found on endothelial cell or in blood
vessel)
Citrate Light blue Reacts with calcium
(Coagulation studies particularly PT
and APTT)
Ethylenediaminetetraacetic Lavender Chelation and sequestration
acid/EDTA (complete blood count)

Components of CBC using manual

method:
- RBC count, WBC count, diff count,
hemoglobin, hematocrit
 - if maguse ug automated machine,
mainclude na ang RBC indices
Oxalate (erythrocyte sedimentation Black Reacts with calcium
rate)
Fluoride (Glucose determination Gray Reacts with calcium
because it prevents glycolysis)

Order of draw:

If you use a glass ETS tube, follow this order. If ang imong I use kadtong plastic, you can start with the blue. Why? Glass
has borosilicate component which is a clot activator. It activates intrinsic pathway of coagulation. If you start with the red,
then you start the clotting mechanism.

 Yellow top
- Sodium polyanethol sulfonate (SPS)
- For blood culture
 Red with gray tube
- For blood chemistry
- Contains serum separator gel. Red top does not

 Other colors
 Orange/Gray/Yellow
- Contains thrombin (active form of prothrombin; procoagulant)
- Blood chem
 Tan
- Contains heparin/EDTA
 - Lead analysis
 Royal blue
- Contains heparin/EDTA
- Toxicology, trace metals, nutritional analysis

 Methods of blood collection/phlebotomy

1. Venipuncture
- Specimen obtained is venous blood which is dark red since it is deoxygenated
- Hemoglobin found is deoxyhemoglobin (HHb)
2. Arterial puncture
- Arterial blood and has a bright red color since oxygenated sija
- Hemoglobin found is oxyhemoglobin (HbO2)
3. Capillary/arteriolar puncture
- Capillary/arteriolar/peripheral blood which is bright red since it has HbO2
- Palmar surfaces of the middle or ring finger.
*Why? Forefinger is used for pointing and other purposes. Pinky finger is too small. Thumb has more
callouses and is quite big. If you have dengue you can choose any of the fingers.
- Plantar surfaces of the heel or big toe (for infants and newborn)
- Free margin of the earlobe
*most ideal but is intimidating so it is not commonly used.

 Types of blood specimens

- Blood contains 55% fluid, 45% blood cells
1. Whole blood
FOR:
- Hematology: RBC, WBC, platelet counts, hemoglobin, hematocrit
- Blood glucose: glucometer
- Blood gases: O2, CO2, blood pH
2. Plasma
- Liquid portion of unclotted blood with fibrinogen
- Clear, light yellow to slightly hazy because of more proteins

FOR selected blood chem tests e.g. :

- Fluoride (glucose)
- Heparin (coag studies and blood gases)
3. Serum
- Liquid portion of clotted blood without fibrinogen
- Standard fasting hrs for glucose (8-10 hrs) = specimen is clear, pale yellow
- Non-fasting samples: turbid or milky because of chylomicrons (carrier of cholesterol, TAG and other
lipids; made up of 95% TAG)
 - Icteric serum: dark yellow (high bilirubin which may be seen in hemolytic, obstructive and liver
diseases and in patients with high carotene intake)

FOR:

- Routine and special blood chem (hormones, drugs, antigens, antibodies)

 Problem sites in phlebotomy

1. Burns, scars and tattoos
- impaired circulation
2. Damaged veins
- sclerosed (hardened), thrombosed (clotted) = occluded and lack resiliency
3. Edematous and cyanotic areas
- false decrease of cell counts because imong maobtain nga blood kay diluted
*what to do if both arms have IV fluids? Use right or left foot. What if right and left foot are edematous? Last
option is to request the nurse to stop the IV then wait for 5? Mins

4. Mastectomy

- stoppage of lymph flow: swelling

5. Hematoma

- swelling or mass of blood in skin due to wrong puncture

- causes: fragile veins, large needle, hitting through and through, partial insertion of the needle, excessive
blind probing, removing needle with tourniquet, insufficient pressure after collection

HEMATOPOIESIS 1

- formation of blood cellular components (cellular maturation)

- affected by hormones particularly erythropoietin which enhances synthesis of RBCs, interleukins
which enhances synthesis of WBCs, chemotaxis (chemo: chemicals ; taxis: calling thus, calling of
chemicals), blood loss and other factors
- blood cellular components (erythrocytes/RBCs, leukocytes/WBCs and thrombocytes/platelets)
 General rules
- all blast cells don’t have granules
- all cells starting with “PRO” have basophilic granules ; cells ending with “CYTES” have eosinophilic or
neutrophilic granules ; all cells starting with “PRO” and ending with “CYTES” have granules except
thrombocytes, erythrocytes and reticulocytes
- neutrophils, eosinophils and basophil (with granules)
- nucleoli can be only observed in cells starting with pro and ending with blast
- size of the cell decreases during maturation except for megakaryocytes (platelet synthesis)
- increased mitosis due to low iron = smaller RBCs
- decreased mitosis due to low folate or low vitamin B12 = large RBCs
- nuclear size decreases during maturation process
- cytoplasmic size increases during maturation process
- increase in immature cells is called shift to left (e.g. increase in band cells, prolymphocyte,
promonocyte, metarubricyte, rubricyte)
- increase in mature cells is called shift to right (e.g. increase in erythrocyte, basophil, monocyte,
lymphocyte)
- hypoxia (low O2) and blood loss stimulates erythropoiesis
 2 conditions which will facilitate erythropoiesis: low oxygen and blood loss
- Chemotaxis (call of cells by chemicals) stimulates granulopoiesis, lymphopoiesis and monopoiesis
(wa koy sure kay natabunan sa nawng ni sir)
- Hemorrhage stimulate megakaryopoiesis
- Estrogen suppresses erythropoiesis
 Explains why women have lower hgb than men
- Hormones which stimulate erythropoiesis include:
 Erythropoietin (kidneys)
 TSH (pituitary gland)
 ACTH (pituitary)
 GH (pituitary gland)
 Thyroxine/T4 (thyroids)
 Cortisol (adrenals)
 Testosterone (testes)
- hypoxia and blood loss, erythropoietin/EPO, stimulates erythropoiesis
- chemotaxis, interleukins-3,5,11 stimulates leukopoiesis
- blood loss, interleukins-3,6,11 stimulates thrombopoiesis
- stem cell → differentiation, self-renewal, apoptosis (programmed cell death)
- Symmetric hematopoiesis: stem cell divides → 2 daughter cells → differentiation
 When 2 daughter cells differentiate from a stem cell
- Asymmetric hematopoiesis: stem cell divides → 2 daughter cells → differentiation and self-renewal
- Phases of hematopoiesis:
1. Primitive
Mesoblastic: blood islands of the yolk sac (19-20 days of gestation)
2. Definitive
 Hepatic: liver (5th-6th up to 30th week of gestation ; may occur in adults with anemias (extra
medullary) )
* also stimulated by spleen, thymus and lymph node
 Myeloid: bone marrow (5th month of gestation ; pelvis, vertebrae, ribs, sternum, skull and
other bones and the long bones ; occurs mainly in elderly)
* hepatic and myeloid phase will work hand in hand if an individual has a severe type of
anemia

- red marrow: active (sternum, skull, scapulae, vertebrae, ribs, pelvic and long bones)

- yellow marrow: inactive (adipocytes)

 - retrogression: conversion of red to yellow marrow

 Cytokines:

- released by adipocytes, macrophages, fibroblasts and endothelial cells

- cytokines are needed for maturation of blood cells

 Liver
- stores vitamin B12 (6 years)
- stores folate (6 months)
- B12 and folate are essential for RBC production ; deficiency of both produces macrocytic RBCs
 Spleen
- 2 parts:
 White pulp: lymphocytes, macrophages and dendritic cells
 Red pulp: erythrocytes ; removes senescent RBCs (culting) ; sequesters platelets
 Lymph node
- Formation of new lymphocytes (from the bone marrow)
- Processing of immunoglobulins
- Filtration of debris and bacteria
 Thymus
- Lymphocytes → t cells (converted to T helper cytotoxic cells) and b cells (converted to plasma cells)
- Macrophages (phagocytosis)
- Reticular cells
- Mesenchymal cells

How does hematopoiesis occur?

*GEMM: granulocyte, erythrocyte, monocyte and megakaryocyte

Totipotent hematopoietic stem cell/ferrata cell

Colony forming unit-lymphocyte/CFU-L Colony forming unit-spleen/CFU-S or CFU-GEMM

Lymphoblast

Prolymphocyte

Lymphocyte

B-lymph and T-lymph

*How will you differentiate the three?
Nucleoli can be found in lymphoblast and prolymphocyte. Granules cannot be found in lymphoblast? Lymphocyte has
azurophilic or neutrophilic granules. Size of the nucleus is biggest in lymphoblast while it is smallest in lymphocyte.
Cytoplasm is largest in lymphocyte. Cytoplasm in lymphoblast is basophilic while for lymphocyte it is neutrophilic.

- Lymphopoiesis: cellular maturation of lymphocyte from CFU-L

Colony forming unit-spleen/CFU-S or CFU-GEMM

CFU-EO Eosinophil and Basophil

CFU-GM Neutrophil/Granulocytes and Monocytes

BFU-E (Burst-forming unit) CFU-E (Colony-forming unit) Erythrocytes

CFU-MEG Megakaryocytes Thrombocytes

*Granulopoiesis: Eosinophils, Basophils and Neutrophils

*Monopoiesis: Monocytes

*Erythropoiesis: Erythrocytes

*Megakaryopoiesis: Platelets

Granulopoiesis

Myeloblast

Promyelocyte

Myelocyte

Metamyelocyte

Stab/Staff/Band

Eosinophils, Neutrophils, Basophils

Eosinophil

- Eosinophilic or acidophilic granules

- Bilobed to trilobed
- Allergies and parasitic infections
Neutrophil

- Azurophilic or neutrophilic granules

- 3-6 lobes
- More than 6 lobes: hypersegmented neutrophil ; observed in pernicious anemia
- 2 or less lobes: hyposegmented ; observed in acute myeloblastic leukemia
- Acute bacterial infection

Basophil

- Basophilic granules
- Allergic reaction and malignancies

*All granules of eosinophil, neutrophil and basophil are large

How will you differentiate each stage in granulopoiesis?

 Stab/staff/band
- Horse shoe shaped, may have neutrophilic, basophilic and eosinophilic granules
- Most common: neutrophilic stab cell

 Metamyelocyte
- Sausage shaped granules? Huh? Syor ser, azurophilic granules since this is the precursor of neutrophils, if it is
the precursor of basophil expect a darker color of cytoplasm, if it is the precursor of eosinophil expect orange
granules of cytoplasm

 Myelocyte
- Large azurophilic granules, oval or round indented nucleus found in the side of the cytoplasm although not all
myelocyte have this type of nuclei

 Promyelocyte
- Basophilic granules, indented nucleus, has nucleolus

 Myeloblast
- has nucleolus, do not have granules in the cytoplasm, fried egg appearance

Monopoiesis

Monoblast

Promonocyte

Monocyte

Macrophages, microglia (CNS), Kupffer cells

*Monocytes are phagocytic cells like neutrophils. Lymphocytes are nonphagocytic but they participate in killing particularly
the T-cytotoxic cells being helped by T-helper cells.

 Monoblast
- No granules, with nucleoli
  Promonocyte
- With basophilic granules, with nucleoli

 Monocyte
- With azurophilic granules no nucleoli

Erythropoiesis

Rubriblast/erythroblast/normoblast

Prorubricyte/basophilic normoblast

Rubricyte/polychromatophilic normoblast

Metarubricyte/orthochromatophilic normoblast

Reticulocyte

Erythrocyte

 Rubriblast/erythroblast/normoblast
- No granules, with nucleolus

 Prorubricyte/basophilic normoblast
- Basophilic granules

 Rubricyte/polychromatophilic normoblast
- Azurophilic granules, hgb starts to develop in this stage

 Metarubricyte/orthochromatophilic normoblast
- Azurophilic granules,
- *nucleoli can only be seen in blast and pro. So no nucleoli na ani nga stage daw?

 Reticulocyte
- Immediate precursor of erythrocyte
- Contains remnants of RNA, stained with brilliant cresyl blue or methylene blue (both are supravital stains)

 Erythrocytes
Megakaryopoiesis

Megakaryoblast

Promegakaryocyte

Basophilic megakaryocyte

Granular megakaryocyte

Mature megakaryocyte

Thrombocyte/Fragmented megakaryocytes

 Megakaryoblast
- No granules, has nucleoli

 Promegakaryocyte
- basophilic granules

*as platelets mature, their size becomes bigger. Thus, megakaryoblast is the smallest

Endomitosis

- division of nucleus of the cell

- unique feature of platelets
- observed in promegakaryocyte
HEMOCYTOMETRY

- Counting of blood cells

1. AUTOMATED MACHINES

 Coulter Counter (Coulter Electronics)

- Oldest hematology analyzer
 Cell Dyne 3000 (Abbott Diagnostics)
 Cobas Helios (Roche)
 E-5000, K-1000, NE-8000, SE-9000 (Sysmex)

Tests performed:

Complete Blood Count (CBC) Histogram

- RBC
- WBC
2. FLOW CYTOMETRY/ LIGHT SCATTERING
- Platelets
- RBCs, WBCs, Platelets
- Differential count
- a modification of spectrophotometry
- Hemoglobin
- with light source and detector
- Hematocrit
* Light source – the light amplification of by stimulated
- Red Blood Cell Indices
emission of radiation or laser which will strike on
- Reticulocyte count (some machines)
different cells

N – large azurophilic granules

2. MANUAL METHOD E – large acidophilic granules
- Microscope, Centrifuge, Spectrophotometer B – large basophilic granules
L & M – also granulated but the granules are smaller
CBC:

- WBC
- Differential count
- Hemoglobin
- Hematocrit

METHODS & PRINCIPLES OF AUTOMATED CELL

COUNTERS

1. ELECTRICAL IMPEDANCE
- counting of RBCs, WBCs, and Platelets

 The properties such as the granules, lobes, and

sizes, will affect the scattering of the light
 Because of the granularity, lobularity, and the
size of the cell will be scattered forward (called
0⁰ angle)
 The forward scattering of the light will be
detected by the Photodiode detector
  Photodiode – a detector which will convert light
to electricity after a change of electric potential
 Right angle scattering of the light – 90⁰ angle;
measured by Photomultiplier detector
 Photomultiplier detector – converts the light to
energy but there is dianode which will allow the
multiplication of the light
Forward scatter – photodiode detector
Right scatter – photomultiplier detector
* the 2 detectors connected to a computer, which will
record on the count of the cells*
Sysmex – uses the fluorescence flow cytometry, they add
a dye which has better differentiation for the scattering
of the light and also better separation for the better
detection and counting of the cells
Aperture – allows the passage only of certain group of
cells
Flow Cell
- passage of cells which is made up of quartz
- allows the cells to pass through so that the light
or the laser can strike 1 cell at a time
Fluorochromes/ Fluorescent Dyes
- used for better differentiation
Types of Light Scattering:
 Reflection – bending of light due to change of
speed (large angles)
 Diffraction – bending around corners (small
angles)
 Refraction – turning back by the surface
(intermediate angles)
*The scattering of the light will be directed towards the
detector which measures the light intensity and converts
the light into electricity.*
Factors affecting the scattering of the light:
1. Cell Size – Forward angle scatter
Larger cell – more forward angle scatter
Smaller cell – less forward angle scatter
2. Lobularity/Complexity of the Nucleus – Right angle
scatter
Small particle
- Light scattered symmetrically but minimally at
90⁰
- ex. Neutrophil, Eosinophil, Basophil
Very large particles
- Light mostly scattered forward
 - ex. Monocyte
Large particles
RDW (Red Cell Distribution Width)
- Light scattered preferentially forward
- ex. Lymphocyte RDW = _______________SD_______________
MCV of Red Cells in a given population

 Hemoglobin determination
- Spectrophotometric method using: PDW (Platelet Distribution Width)
 Potassium cyanate, Potassium PDW = _______________SD_______________
ferricyate, Sodium bicarbonate (Coulter, MCV of Platelets in a given population
Roche, Abbottt)
 Sodium Lauryl Sulfate (Sysmex)
3. CENTRIFUGAL ANALYSIS

 Hematocrit - do not count cells but just analyze RBC and

- derived from RBC count buffy count in %
- 1% Hct = 42, 000 RBCs - ex. QBC analyzer (Becton Dickinson)
- uses Acridine Orange dye
- layers formed after centrifugation
 plasma
 RBC Indices
- Computed by:  granulocytes
 platelets
MCV (Mean Corpuscular Volume)  expanded rbcs
 measurement of the size of RBC  non-granulocytes
 80 – 100 femtoliters/fL  packed rbcs

MCV = ___Hct x 10__

RBC in millions MANUAL HEMOCYTOMETRY (Hemacytometer, Thoma
Pipets – RBC & WBC, Microscop, Spectrophotometer
(Hb), Centrifuge (Hct))
MCH (Mean Corpuscular Hemoglobin)
Types of Hemocytometer
 measurement of the amount of
 Closed: Thoma-Zeiss
hemoglobin compared to the
 Open: Spencer, Burker, Levy, Levy-Hausser
RBC count
 Addis/Exton (Urinalysis)
 27-32 picograms/pg or
micromicrograms/uug  Petroff (Bacteria)
 Thoma
MCH = ___Hgb x 10__  Tuerk
RBC in millions  Fuchs-Rosenthal
 Bass-Jones
 Neubauer
MCHC (Mean Corpuscular Hemoglobin  Improved Neubauer
Concentration)
 33-36%
MCHC = _Hgb_ x 100%
Hct
Improved Neubauer  Depth correction factor = 10
Thickness of hemocytometer counting chamber:
- .1 mm thick = .1 mm2 x 10 = 1 mm2
- Number of squares in corresponding area:
 9 large squares = 9 mm2 Dilution of factor:
= Volume of bulb (100) = 200
 4 corner large squares (WBC) = 1 mm2 x
Volume of blood (.5)
4 = 4 mm2
 16 intermediate squares = 1/16 mm2 = Area factor: 5/25 (intermediate squares)
.0625 mm2
RBC = Cells counted x 10 x 200 = 10,000 (multiplication factor)
1/5 or .2
 1 central large squares (RBC) = 1 mm2
 25 intermediate squares = 1/25 = .04
mm2 Manual Hemocytometry Errors:
 16 small squares = 1/16 x 25 = .0025 - Random/Human
mm2 - Standard/Systematic (equipment)
- Inherent/Field (random settling of cells: Poisson’s
 5 intermediate squares = .04 x 5 = .2 Law)
mm2
 80 small squares (5 x 16) = .0025 x 80 =
(used in RBC) = .2 mm2 RBC Diluting Fluids:
1. Hayem’s + HgCl
 4 large squares (not used) = 1 mm2 x 4 =
- NaCl, NaSO4, Distilled H2O
= 4 mm2 2. Gower’s + Glycerine
- NaCl, NaSO4, Distilled H2O
WBC Count
3. Toisson’s + Methyl Violet
= Cells counted x Depth correction factor x Dilution factor - NaCl, NaSO4, Distilled H2O
Area Factor 4. Bethel’s + Sodium Thiosulfate
- NaCl, NaSO4, Distilled H2O
5. Formol Citrate/Dacie’s (best)
 Depth correction factor = 10
6. Normal Saline Solution
To get the depth correction factor:
= 1/thickness of the chamber (Neubauer)
= 1/.1 = 10
WBC Diluting Fluids:
Thickness of hemocytometer counting chamber:  2-3% HAc/CH3COOH with Methyl Violet (to
= .1 mm2 x 10 = 1 mm2 differentiate from RBC diluting fluid)
 1% HCl with Methyl Violet (to differentiate from RBC
Dilution of factor: diluting fluid)
= Volume of bulb (10) = 20
Volume of blood (.5)

Area factor: 4
: total number of large squares used in cell counting MANUAL HEMOCYTOMETRY (>10 NRBC’S/HPF)

WBC = Cells counted x 10 x 20 = 50 (multiplication factor) Corrected WBC/CWBC:

4 If >10 Nucleated RBC’s/NRBC’s (immature)
100 WBC’s in the Differential Count
WBC = Cells counted x 50 = Cells/mm2
Long method:
CWBC = Uncorrected Count x No. of NRBC’s
RBC Count 100 + NRBC’s x Uncorrected Count
= Cells counted x Depth correction factor x Dilution factor
Area Factor Short method:
CWBC = 100/100 + NRBC’s x Uncorrected Count
 Female = .36 - .46 Liter/Liter or 36 – 46 %
DIFFERENTIAL COUNT RBC Indices
- counting various types of WBC’s (in %) in a blood smear MCH = 26 – 34 picograms (pg) or micromicrograms (uug)
- ideal: 200 MCV = 80 – 100 femtoliters/fL
MCHC = 31 – 37 %

Blood smear must:

- Occupy ½ to 2/3 of the slide Platelet Count
- Have feathery edge = 1 x109 to 3 x109 cells/Liter or 100,000 – 300,000 cells/mm3
- Have no holes
- Have no overlapping cells
- Have gradual transition from thick to thin Reticulocyte/Retics Count
- Stained by: Wright’s or Giemsa (MB, Eosin) Adults = .5 – 1.5 %
Infants = 2 – 6 %

Making a Blood Smear for Differential Count

1. 2-Slide method (commonly used) WBC
2. Slide and Coverslip method Male & Female
3. 2-Coverslip method = 4.5 – 11 x109 or 4,500 – 11,000 cells/mm3

Differential Count (Per 200 or 100 cells)

Factors affecting the Quality of the Smear: o Neutrophils/Segmenters = 47 – 79.5 %
o Size of the drop of blood o Lymphocytes = 12.5 – 40 %
o Angle (30 degrees) o Monocytes = 2 – 11%
o Speed of Spreading o Eosinophils = 0 – 7.5 %
o Pressure on the slide o Basophils = 0 – 2 %
o Surface of the slide and spreader o Bands/Stab/Staff = 0 – 5 %

*Platelets must also be estimated (8-10/OIF)

Methods of Counting:
 2 Field Meander Estimated WBC & Differential Count
 4-Field Meander
 3. Exaggerated Battlement WBC/HPF WBC/Liter
 Strip Differential/Crenelation 2–3 4 x103 – 7 x103
4–6 7 x103 – 10 x103
7 – 10 10 x103 – 13 x103
REFERENCE VALUES FOR CBC: 11 – 20 13 x103 – 18 x103

RBC
Male = 4.5 – 5.9 x 1012 cells/Liter
or
4,500,000 – 5,900,000 cells/mm3
Female = 4.0 – 5.2 x 1012 cells/Liter
or
4,000,000 – 5,200,000 cells/mm3
Hemoglobin
Male = 13.5 – 17.5 grams/deciliter
(135 – 175 grams/Liter)
Female = 12 – 16 grams/deciliter
(120 – 160 grams/Liter)
Hematocrit
Male = .41 - .53 Liter/Liter or 41 – 53 %
Common Greek and Latin Prefixes Used:
 A/An = lack, without, absent, decreased
 Aniso = unequal, dissimilar
 Cyt = cell
 Dys = abnormal, difficult, bad
 Erythro = red
 Ferr = iron
 Hemo/hemato = pertaining to blood
 Hypo = beneath, under, deficient
 Hyper = above, beyond, extreme
 Iso = equal, alike, same
 Leuko = white
 Macro = large, long
 Mega = large, giant
 Meta = after, next, change
 Micro = small
 Myelo = from bone marrow, spinal cord
 Pan = all, overall, all-inclusive
 Phleb = vein
 Phago = eat, ingest
 Poikilo = varied, irregular
 Poly = many
 Schis = split
 Scler = hard
 Spleen = spleen
 Thromb = clot
 Xanth = yellow
 Cyto = cell
 Emia = blood
 Itis = inflammation
 Lysis = destruction/dissolving
 Oma = swelling/tumor
 Opathy = disease
 Osis = abnormal increase
 Penia = deficiency, decrease
 Phil = attracted to, affinity for
 Plasia = cell production or repair
 Poiesis = cell production, formation and
development
 Poietin = stimulates production

 Anisocytosis = variation in cells size

 Poikilocytosis = variation in cell shape
 Aplasia = absence of cellular production
 Dysmyelopoiesis = abnormal development of
marrow cells
 Panmyelosis = an abnormal increase in an marrow
cells
ERYTHROCYTE STUDIES
– Hb I
ERYTHROCYTE/ DISCOCYTE/ NORMOCYTE
– Hb G-PHILADELPHIA

● Carrier of hemoglobin for cellular respiration – Hb O-ARAB

● Counted by manual hemocytometer or flow cytometry or
electrical impedance Synthesis Of Hemoglobin
● Derived from BFU-E and CFU-E
● Not nucleated except for the immature forms (NREs)
• Succinyl Co-A + Glycine
HEMOGLOBIN ↓ + Ala Synthase
(1 GRAM Hb = 1.39 ML OXYGEN, 3.47 mg of IRON)
● Respiratory pigment of RBC
• Aminolevulinic Acid/ ALA
↓ + PBG Synthase
● Carrier of oxygen (replaces 2,3 diphosphoglycerate/
2,3 DPG in the heme portion) • Porphobilinogen
↓ + PBG Deaminase
Made up of:
○ HEME (4 PYRROLE RINGS WITH IRON) • Hydroxymethylbilane
○ GLOBIN (WITH 23 DPG) (146 AMIND ACIDS) ↓ + UPBG III Synthase
○ 2 ALPHA, 2 BETA CHAINS= Hb A (94.5 %)
○ 2 ALPHA, 2 DELTA CHAINS= Hb AZ (3.5%) • Uroporphyrinogen III ⟶ Uroporphyrin III
○ ALPHA,2 GAMMA CHAINS= Hb F (2%) ↓ + UPBG II Decarboxylase

● Myoglobin - respiratory pigment in skeletal and

• Coproporphyrinogen III ⟶Corproporphyrin III
cardiac muscle ↓ + CPBG III Oxidase
Protoporphyrinogen
• ↓ + PPBG IX Oxidase

3 types of embryonic Hb
• Protoporphyrin IX + Iron
↓ + Ferrochelatase
1. PORTLAND
2. GOWER I
3. GOWER II
• Heme + Globin

– ↓
Abnormal Hb/ Hemoglobinopathies HEMOGLOBIN
● HbS = Sickle Cell Anemia (Porphyrias = Porphyrin In Urine)
● Hb BARTS = Alpha Thalassemia
● Hb H = Alpha Thalassemia
● Hb F (In Adults) = Beta-Thalassemia
● Hb Lepore = Fusion Of Delta Or Gamma With Beta Chain
● Hb-M = Freiburg, Tubingen, St. Louis,
Methemoglobinemia (Unstable Hb) (Heinz Bodies)

➢
ABNORMAL Hb
● Hb Kansas, Caribbean, Hope, Seattle - Decreased
Oxygen Affinity
● Hb Chesapeake, Koln, Gun Hill - Increased Oxygen
Affinity
● Hb C - Hb Cc Disease (Hb Cc Crystals)
● Hb Constant Spring (Few Microcytic Cells And
Target)
● Hb SC - Hb Sc Disease (With Few Sickle Cells)
● Hb SD - Mild Sickle Cell Anemia (Sickle Cell)
● Hb E - Beta-Thalassemia (Target Cells)

Abnormal hemoglobin with no associated anemias

– Hb C-HARLEM, Hb C-GEORGETOWN

– Hb D-PUNJAB
 ○ Female = 12-16 Grams/dl(120-160 Grams/l)
Types Of Hemoglobin

• Hb + O2 = Oxyhemoglobin/Hbo2 (bright Red)

METHODS FOR HEMATOCRIT/ PACKED CELL VOLUME
DETERMINATION
• Hb + Co2 = Carbaminohemoglobin / Deoxyhemoglobin
1. Adams/ Micromethod
Hbco2/hHb = Dark Red
- Uses Capillary Tube, Centrifuge (10,000-13,000 Rpm,
• Hb + Co = Carboxyhemoglobin/Hbco = Cherry Red 5 Minutes) And Microhematocrit Reader
2. Wintrobe/macro method
• Hb + Sulfur = Sulfhemoglobin/sHb (lavender) - Uses Wintrobe Tube, Centrifuge (3000 Rpm, 15

• Hb + Oxidizing Agent = Methemoglobin/hHb/hemoglobin

Minutes)
- Height Of Packed Cell/RBC X 100% = Hct
(chocolate Brown)
(%)
- Height Of Packed Cell + Height Of Plasma
OXYGEN DISSOCIATION CURVE
- Reference Values
• Shift to the right/str -
-
Male = .41-.53 Liter/liter Or 41-53 %
Female = .36-.46 Liter/liter Or 36-
Decreased affinity of Hb for o2
46 %
• Shift to the right/stl
Increased affinity of Hb for o2 ERYTHROCYTE SEDIMENTATION RATE/ESR

• Factors affecting
A. Time Of The Settling Of RBC’s After Addition Of
Anticoagulant (citrate Or Oxalate)
increased temperature = str B. RBC’s Negatively-Charged → Attraction → Rouleaux
increased ph = stl Formation
increased 2,3 dpg = str C. Anticoagulant → Positively-Charged
increased co2 = str D. Settling In A Westergren Or Wintrobe Tube
increased Hb f = stl

METHODS FOR HEMOGLOBIN DETERMINATION 3 STAGES

1. Direct Visual (tallquist, Dare) 1. Initial Rouleaux Formation = 1st 10 Minutes
2. Acid Hematin (hemometer) 2. Rapid Settling Of RBC’s = Next 40 Minutes
- Blood (Hb) + Acid (hcl) → Acid Hematin 3. Final Settling = Last Ten Minutes
→ STD (BROWN)
➢ Sahli-Hellige •
➢ Sahli-Hayden
➢ Sahli-Adams • REFERENCE VALUES
➢ Hayden-Hausser
➢ Newcomer
• WINTROBE :
➢ Osgood-Haskin – MALE 0-9 MM/HOUR,

3. Alkali Denaturation Test (Hb F) – FEMALE 0-20 MM/HOUR

Blood (Hb F) + Drabkin’s Reagent + Naoh +
-
(nh4)2oh • WESTERGREN:
-
-
Alkaline Hematin → Spectro
Wu, Clegg And King
– MALE = 0-15/HOUR, 0-20/2 HOURS

4. Spectrophotometric – FEMALE = 0-20/HOUR, 0-30/2 HOURS

- K3fe(cn)6 (hi)
- Blood (Hb) + Drabkin’s Reagent = Methemoglobin +
Kcn = Hicn (cyanmethemoglobin) → Spectro
5. Gravimetric (copper Sulfate)
6. Acid Elution Slide Test (kleihauer-Betke Stain) = Hb F
- Whole Blood (Hb F) + Citric Acid-Phosphate Buffer
- Elution Of Other Hb Types
- + Ehrlich’s Hematoxylin And Eosin/erythrosin
● Bright Pink-Red Rebc’s (Hb F)
● Reference Values
○ Male = 13.5-17.5 Grams/dl(135-175 Grams/l)
INTRINSIC FACTORS AFFECTING ESR RESULTS
1. Number Of RBC’s (increased Number =
Overcrowding, Lesser Rouleaux Formation, Slower
Esr)
2. Size Of The RBC’s (bigger RBC, Faster Esr Eg.
Macrocytic Anemia)
3. Viscosity (decreases Esr)
4. All Serum Proteins Except Albumin (increases Esr:
Decreased Negative Charge Of RBC’s)
EXTRINSIC FACTORS AFFECTING ESR RESULTS
1. Length of tube = more space, faster esr
 2. Room temperature = faster esr (37 decrees celsius) (tube Number 21 Or 22)
3. Pipetting = bubbles (lesser RBC’s), faster esr Complete Hemolysis/ch = Red Solution With No Sediments
4. Excess anticoagulant = prevents rouleaux formation, (tube Number 16 Or 17)
slower esr - No Hemolysis /nh= Clear Supernatant With Compact
5. Excess time = faster esr Sediments
Reporting: Tube Number X.02 = %nacl
DISORDERS WITH INCREASED (FASTER) ESR - Initial Hemolysis = .42-.44 % Nacl
1. Blood Loss (menstruation, Pregnancy, Accidents, - Complete Hemolysis = .32-.34 % Nacl
Hemorrhage)
2. Inflammatory Conditions (increased Immunoglobulins/ Disorder With High Osmotic Fragility
Crp, Fibrinogen) - (lesser Space For H2O In RBC’s)
- 2.1 Rheumatoid Arthritis/ Rheumatic Fever 1. Hereditary Spherocytosis:
- 2.2 Acute Myocardial Infarction Ih = .48 % (24) Ch = .40 % (20)
- 2.3 Tuberculosis/tb Disorders With Low Osmotic Fragility
- 2.4 Multiple Myeloma/mm - (more Space For H2O In RBC’s)
2.5 Waldenstrom’s Macroglobulinemia
-
- 2.6 Nephrosis • 1. Sickle Cell Anemia
-
-
2.7 Hepatitis
2.8 Sub-Acute Bacterial Endocarditis/sabe
• 2. Thallasemia

● • 3. Severe Iron Deficiency Anemia

Disorders with normal to decreased (slower) esr – IH = .38 % (19), Ch = .30 % (15
- ( Effect on rouleaux formation)
1. Sickle cell anemia
2. Thallasemia
3. Hereditary spherocytosis
4. Poikilocytosis
5. Iron defeciency anemia

Reticulocyte count (rv =.5-1.5 %)

- Reticulocyte = immature RBC with reticulin strands or
dots which are rna remnants

- Methods of staining
OSMOTIC FRAGILITY TEST
1. Dry: 20 ul of whole blood + 20 ul of bcb
- Measures the rigidity and fragility of the RBC’s when
(slide) mix, stand for 15 minutes smear →
exposed to hypotonic salt solution (.5 % nacl)
dry → count → (oio per 1000 RBC’s)
- Hypotonic solution = water enters RBC’s, swelling, (.5
2. Wet: 1 drop of whole blood + 1 drop of
%) hemolysis
bcb(slide) coverslip ( 5 minutes)
- Hypertonic solution = water goes out from RBC’s ,
crenation (echinocytes)(.9 %)
- Methods of counting
- Isotonic solution = no hemolysis and no crenation (.85
1. Oio per 1000 RBC’s
%)
- Relative reticulocyte count = retics
counted /1000 RBC’s x
Methods (sanford, Giffin And Sanford, Dacies)
100 %
Procedure (sanford)
2. Calibrated miller disc (placed in the ocular)
a. Tube No.
- (20 oil immersion fields required)
25 24 23 22 21 20 19 18 17 16 15 14
- Relative reticulocyte count = retics counted
b. .5 % Nacl (drops)
in square a x 100/ total RBC’s in square b x
25 24 23 22 21 20 19 18 17 16 15 14
9
c. Distilled H2O (drops) 0 - 11
- Absolute reticulocyte count /arc= retics
d. 5 % Blood (EDTA AND NSS) 1 DROP EACH TUBE
count(%)/100 xRBC = 10-110 x 109 /l
reticulocyte
Interpretation (after 2 Hours)
- Corrected reticulocyte count/crc = arc (%) =
Initial Hemolysis / Ih= Pink Supernatant With Few Sediments
 hct (l/l)/.45 l/l h. Drepanocytes/sickle Cells (globin
- Production index/rpi= crc = 2-3 %/day Defect,sickle Cell Anemia, Hb, Sc, Hb Sd)
- Maturation time in peripheral blood (days) i. Schistocytes (hyaline Thrombus In Small
Blood Vessels, Maha, Ttp, Dic, Hus)
Anemias with high retics count and reticulocyte
production index/rpi (>3) j. Keratocytes/ Blister Cells/ Bite Cells / Horn
1. Blood loss (eg. Accidents, hemorrhage, chronic Cells ( Hyaline Thrombus In Small Blood
hepatic or renal disorders) Vessels, Maha, Ttp, Dic, Hus)
2. Hemoglobinopathies k. Dacrocytes/teardrop Cells (myelofibrosis,
3. Thalassemias (alpha and beta) Myelophthisic Anemia)
4. Enzyme deficiency anemias (glucose-6-phosphate l. Microspherocytes/ Pyropoikilocytosis
dehydrogenase and pyruvate kinase deficiencies) (spectrin Defect And Heat Sensitivity, 45
5. Immune Hemolytic Anemias Degrees Celsius , Pyropoikilocytosis)
- Paroxysmal Nocturnal Hemoglobinuria/pnh m. Semilunar Bodies/ Half-Moon (damaged By
- Autoimmune Hemolytic Anemias/aiha (cold And Parasites, Malaria)
Warm Types)
- Alloimmune Hemolytic Anemias 5. Hemoglobin Content
- Drug-Induced Hemolytic Anemias ( Immune ○ Hypochromia
Types) ○ Hyperchromia
6. Non-Immune Hemolytic Anemias ○ Anisochromia Or Polychromasia
-
-
Microangiopathic Hemolytic Anemias/maha
Thrombotic Thrombocytopenic Purpura/ttp •
- Disseminated Intravascular Coagulation/dic 6. RBC Inclusions
- Hemolytic Uremic Syndrome/hus
– Hb CC Crystals
Morphological Evaluation Of Erythrocytes (RBC Anomalies) – Hb Sc Crystals
1. Rouleaux Formation = Short Or Long Stacks Of
RBC’s (stack Of Coins) – Howell-Jolly Bodies
- Hyperproteinemia, Multiple Myeloma (bence-
Jones Proteins), Hyperfibrinogenemia – Cabot’s Rings
- Increased Zeta Potential Of RBC’s
2. Agglutination = Random Aggregation Of Cells Into
– Pappenheimer BodieS

Clusters And Masses – Basophilic Stipplings

Autoantibodies (cold And Warm Ab’s)
–
-
- Alloantibodies (donor’s RBC’s) Heinz-Bodies
3. Anisocytosis
– Hb H Inclusions
➢ Macrocyte = > 9 Micra (liver Disease) •
➢ Megalocyte = > 12 Micra (pernicious
Anemia)

➢ Microcyte = < 6 Micra (iron Deficiency

Anemia)
4. Poikilocytosis
a. Spherocytes (spectrin Deficiency, Hereditary
Spherocytosis)
b. Elliptocytes/ovalocytes (protein Band 4.1
Defect)
c. Echinocytes (depletion Of Atp, Excess
Anticoagulant)
d. Burr Cells (renal Diseases)
e. Acanthocytes /spur Cells (lecithin-
Sphingomyelin Ratio, Liver Diseases,
Abetalipoproteinemia)

f. Stomatocytes (defective Na+-K+ Pump,

Liver Diseases)
g. Codocytes/platycytes/planocytes/meniscocyt
es/target Cells (globin Defect, Thalassemia,
Hb Cs, Hb E)
ANEMIA 1
Definition:
A condition characterized by
✓ Decrease in circulating erythrocytes
(destruction or loss exceeds production in the
bone marrow)
✓ Hemoglobin level that is below the reference
range (there are differences in the range of
male and female, upper limit and lower limit of
hemoglobin)
*destruction caused by antibodies, caused by drugs,
blood clots, and others, can also lead to anemia.
SIGN (objective evidences of anemia)
✓ Jaundice (yellowish discoloration of skin due to
high bilirubin level is a sign of hemolytic
anemia) *example of hemolytic anemia are
paroxysmal nocturnal hemoglobinuria (PNH),
cold autoimmune hemolytic anemia.
✓ Leg ulcers (this is caused by sickle cell anemia)
*sickle cell anemia is common in Africa and in
the Middle East
✓ Spooned nails (which is a sign of Iron deficiency
anemia – a most common type of anemia in
children)
✓ Dark lines at the base of teeth (due to lead
toxicity)
✓ Lymph node enlargement (lymphadenopathy –
this is due to anemia secondary to leukemia
and lymphoma
✓ Spleen enlargement (splenomegaly) *this is a
sign of hemolytic anemia or liver disease or
both
✓ Liver enlargement (hepatomegaly) *is a sign of
hemolytic anemia
✓ Frontal bossing (prominent forehead) *caused
by thalassemia or sickle cell anemia, but it is
the thalassemia that demonstrates the frontal
bossing because of the bone deformities syde to
such disorder.
✓ Bone tenderness (due to anemia secondary to
myeloma _malignancy of plasma cells involving
plasma cells
✓ Bluish skin color ( due to the condition of
methemoglobinemia – an anemia caused by
oxidized hemoglobin or unstable hemoglobin)
SYMPTOMS (vary from person to person)
Common symptoms include:
Tachycardia (because of the increase in
circulation?, because of the decrease in oxygen)
Hypotension (decrease blood volume)
Cold clammy skin, insomnia, fatigue, dizziness
(all affects the ??? due to CNS complication)
4 MAJOR CLASSIFICATIONS OF ANEMIA:
I. ETIOLOGIC (CAUSE)
E.g.
o
Iron Deficiency (IDA) - *what is the
cause of IDA? – it’s the iron
deficiency*
o B12 deficiency (Pernicious
Anemia/PA)
o Spectrin Deficiency (Hereditary
Spherocytosis)
o Globin chain defect particularly the
alpha or beta globin chain
(Thalassemia)
o Globin chain defect (Sickle cell
anemia)
II. MORPHOLOGIC (RBC size and hemoglobin
content)
o Normocytic Normochromic (6-8
micra with normal hemoglobin
content – 2/3 of the RBC). Example:
Blood Loss Anemia
*its only the acute blood loss
anemia that will demonstrate
normocytic normochromic.
Hemolytic anemia are classified as
normochromic normocytic BUT the
moment you have kodocytes or
target cells, then it becomes
microcytic hypochromic
o Microcytic Hypochromic (less than
6 micra with low hemoglobin
content – 1/3 of the RBC). Example:
Iron deficiency anemia
*aside from IDA, other example of
microcytic hypochromic are
hemochromatosis or hemosiderosis
caused by iron overload or iron
 excess, then all anemias with target
cells or kodocytes or platicytes
*what are anemias with kodocytes?
– alpha and beta thalassemia,
hemoglobinopathies, hemoglobin c
disease, and many others.
o Microcytic Normochromic (less
than 6 micra with normal
hemoglobin content – 2/3 of the
RBC). Example: Anemia of Chronic
Disease particularly anemia of
chronic kidney disease
o Macrocytic Normochromic (greater
than 9 micra with normal
hemoglobin content – 2/3 of the
RBC). Example: Pernicious anemia
*more than 9 micra – macrocytes
*more than 12 micra – megalocytes
or also known as ovalocytes
III. HEMOLYSIS TREE/ANEMIA
TREE/ALGORITHM (By: Dr. William R.
Best)
*in Dr. Best classification, we have
hemolytic anemias to the right side of the
tree and non-hemolytic anemias to the left
side of the tree. Based on his classification,
there are more hemolytic anemias than
non-hemolytic anemias.
*Based on Padiera’s rule:
All anemias are hemolytic
except:
✓ Iron deficiency anemia,
hemochromatosis/hemosiderosis -
(Mi,H)
✓ Pernicious anemia (B12 def), Refractory
Anemia (associated with leukemia),
Folate deficiency Anemia (anemia of
pregnancy), Diphyllobothriasis - (Ma, N)
✓ Blood loss anemias (acute, chronic) -
*acute – N,N
*chronic – Mi, H due to the chronic loss
of blood and iron
✓ Anemias of chronic diseases (renal,
ulcers, etc) – Mi, N
✓ Aplastic anemia (fanconi’s anemia) – a
type of hypoproliferative anemia,
meaning there is decrease of
proliferation caused of the bone
marrow defect. This anemia is
characterized by pancytopenia
(decrease production or decrease in the
number of circulating platelets, RBCs,
WBCs – N,N
✓ Pure Red Cell Aplasia (Diamond
Blackfan Anemia) – no pancytopenia
IV. PHYSIOLOGIC (ERYTHROPOIESIS,
RETICULOCYTOSIS, RETICULOCYTE
PRODUCTION INDEX/RPI)
* ERYTHROPOIESIS – production of red
blood cells
* RETICULOCYTOSIS – increased number of
reticulocyte or immature RBC’s
* RPI – which ranges from 2 to 3%.
Formula for RPI:
RPI = Corrected reticulocyte / maturation
time in peripheral blood
(2-3%/DAY)
Low RPI = value of less than 2
High RPI = value of more than 3
If the RPI is below 2.0, the anemias
are classified as anemias with
ineffective erythropoiesis. The
anemias include:
1. Hypoproliferative anemias –
decrease proliferation or
decrease production.
- Due to bone marrow failure
which includes: Aplastic
Anemia (Pancytopenia), and
Pure Red Cell Aplasia (PRCA
- Due to decreased bone
marrow stimulation which
includes: anemia of chronic
disease, and Renal Disease
Anemia
- Normocytes are seen (all
are normal except RDA
which is Microcytic
Normochromic)
2. Anemias due to maturation
disorders
- IDA and Sideroblastic
Anemia (High RDW and Low
MCV with microcytes)
- Thalassemia and Anemia of
Chronic Disease (Normal
RDW and MCV with
microcytes)
 - Liver disease (High RDW
and MCV with macrocytes)
- Folate deficiency anemia &
vitamin B12 deficiency (high
RDW and MCV with
macrocytes)
- Endocrine diseases (High
RDW and MCV with
macrocytes)
- *RDW – basically measures
about the variation of sizes
of the rbc, so the more
variation the higher the
RDW
IF THE RPI IS ABOVE 3, the anemias
are classified as Anemia with
Effective Erythropoiesis. The
anemias include:
1. Blood Loss Anemias
- Acute Blood loss (accidents,
hemorrhage, abortions) –
N,N
- Chronic blood loss (gastric
ulcer and gastric cancer) –
Mi, H
2. Hemolytic Anemias
- Anemias with target cells
(beta-thalassemia, alpha-
thalassemia, hemoglobin CC
disease, and other typr of
hemoglobinopathies with
target cells)
- Anemias with RBC
fragments/schistocytes(mic
ro-angiopathic hemolytic
anemia, thrombotic
thrombocytopenic purpura)
- Anemias due to RBC
enzyme deficiencies (G6PD,
pyruvate kinase deficiency
anemia)
- Anemias due to antibodies,
complements and drugs
(cold autoimmune
hemolytic anemia, warm
autoimmune hemolytic
anemia, paroxysmal
nocturnal hemoglobinuria)
- Anemias with
predominance of
morphologic variant
Anemias with Target Cells:
▪ Thalassemia
Alpha type (with hemoglobin H inclusions and
target cells)
Beta type (with preponderance of target cells)
▪ Hemoglobinopathies
Hemoglobin S in sickle cell anemia (sickle cells
and target cells)
Hemoglobin C in Hemoglobin C disease (target
cells)
Hemoglobin SC in Hemoglobin SC disease
Anemia (sickle cells and target cells)
Anemias with RBC fragments/schistocytes:
▪ Microangiopathic hemolytic anemia/MAHA
▪ Hemolytic Uremic syndrome/HUS (with Burr
cells)
▪ Disseminated Intravascular Coagulation/DIC
(low platelet count)
▪ Thrombotic thrombocytopenic purpura/TTP
(low platelet count
▪ Cardio-pulmonary Bypass Surgery/CPBS
▪ RBC anomalies seen include schistocytes,
keratocytes and microspherocytes
Anemias due to enzyme deficiencies:
▪ Deficiency/G6PD anemia (due to take of nuts
with oxidants and others like Ginko Biloba,
Heinz bodies may be seen) *oxidized
hemoglobin will be demonstrated as heinz
bodies stained with Brilliant Cresyl Blue, not
Prussian blue as it is for Papenheimer bodies
seen in hemochromatosis – N,N
▪ Pyruvate kinase deficiency anemia (with
echinocytes – creanated rbcs, may be caused by
excess anticoagulants) – N,N
▪ Lecithin cholesterol acyl transferase
deficiency/LCAT (with target cells) – Mi, H
Anemias due to antibodies, complements and
drugs (with spherocytes):
▪ Cold antibodies/Donath Landsteiner antibodies
(reacts at 4°) – presence of spherocytes, but
 spherocytes are more commonly seen in o PA, FDA (Ma, N)
hereditary spherocytosis o Thalassemia (Mi, H)
▪ Warm antibodies (reacts at 37° o Anemia of Chronic Disease (Mi, N)
-autoantibodies (self destructing antibodies) o Hepatic disease anemia (Ma, N)
-alloantibodies (destructing the RBC of the
donor) – antibodies against the donor’s blood Effective erythropoiesis (RPI = >3)
or mother’s infant’s blood in HDN 1. Blood loss anemias
▪ Complements (which causes hemolysis in o Acute blood loss anemias (N,N)
paroxysmal nocturnal hemoglobinuria/PNH) – o Chronic blood loss (Mi, H)
because the complements will form the 2. Hemolytic anemias
membrane-attack complex Predominance of one morphologic variant:
▪ Antibodies due to drugs like penicillin or L-DOPA o Hereditary spherocytosis
– this can lead to destruction of RBCs leading to o Hereditary elliptocytosis
hemolysis o Hereditary stomatocytosis
o Hereditary acanthosytosis
Anemias with predominance of morphologic (all above are N,N)
variant: o Hereditary pyropoikilocytosis (Mi,H)
Presence of target cells:
▪ Hereditary spherocytosis/HS (Deficiency of
o Hemoglobinopathies
Spectrin and Protein Band 4.2 in the surface of
o Hb S, SC, SD
RBCs) – high osmotic fragility with spherocytes
o Hb E
seen, common in northern Europeans
o Hb F
▪ Hereditary elliptocytosis (deficiency of protein
o Hb H
band 4.1 in the surface of RBCs) – elliptocytes
o Hb BARTS
seen with normal osmotic fragility, common in
o Hb CS
southeast asians
(if there are many target cells seen,
▪ Hereditary stomatocytosis (defective sodium
them Mi, H. but if the target cells are
potassium pump) – somatocytes seen high
just rare and normocytes predominate,
osmotic fragility
then it is classified as N,N)
▪ Hereditary acanthocytosis (APO B deficiency in
Presence of spiculated RBC’S/Spherocytes
the RBC surface and liver disease and
and Antibodies (Mi, H)
Abetalipoproteinemia) – thorn cells with thorny
o Autoimmune Hemolytic
appearance, acanthocytes differ from burr cells
Anemias/AIHA (warm and cold)
as acanthocytes has irregular shape compared
o Paroxysmal Nocturnal
to burr cells which are more likely spherical
Hemoglobinuria/PNH
▪ Hereditary pyropoikilocytosis/HPP – due to
o Paroxysmal Cold
thermal damage of RBCs, pyropoikilocytes of
Hemoglobinuria/PCH
microspherocytes seen
o Isoimmune Hemolytic Anemia
Ineffective erythropoiesis (RPI = <2) (Donor, Mother)
o Drug-induced Hemolytic Anemias
1. Hypoproliferative anemias
o RBC enzyme deficiencies (G6PD, PK)
o Aplastic anemia (N,N)
Presence of RBC Fragments (Schistocytes) –
o Pure red cell aplasia (N,N)
N,N
o Myelophthisic anemia (N,N)
o Microangiopathic Hemolytic
o Refractory anemia (Ma, N)
Anemia
o Anemia of Chronic disease, endocrine
o TTP
disease, renal disease (Mi, N) (Ma, N)
o DIC
2. Maturation disorders
o HUS
o Sideroblastic anemia (Mi, H)
o BURNS
o IDA (Mi, H)
 o PREGNANCY Now, what are the cells that can be seen in peripheral
smear of patient having pernicious anemia? – inclusion
bodies, basophilic stiplings, howly-jelly bodies (??),
cabot rings, which represents the remnants of the
chromatin during the maturation of RBC. Aside from
that, we can also see the hypersegmented neutrophil
also known as macropolycytes, ovalocytes, and others.

o Folate deficiency, Pernicious Anemia of

Pregnancy – megalocytes are seldom seen,
mostly the cells are macrocytes
o Liver disease associated with alcoholism and
others – both megalocytes and ovalocytes can
be seen
o Liver disease can lead to deficiency of B12 or
folate acid or both.

MICROCYTIC HYPOCHROMIC
Classic example: IDA
Anemias can be evaluated based on three
o Iron overload, which is opposite to IDA, which
parameters: has the presence of papeinheimer bodies
✓ Red blood cell count representing the iron deposits stained with
✓ Hemoglobin level Prussian blue. Those pappenheimer bodies are
✓ Hematocrit characteristics of hemochromatosis or
hemosiderosis caused by iron overload or iron
How do we know if the anemia is hemolytic or non- excess. It should be classified as Microcytic
hemolytic? hypochromic non-hemolytic type.
▪ Reticulocytosis – measure the reticulocyte
NORMOCYTIC NORMOCHROMIC
count using the wet or dry method or the
reticulocyte production index. If the RPI is o Renal disease – both should be classified as
greater than 3, the anemia is hemolytic. If it is normocytic normochromic and microcytic.
less than 2, then it is non-hemolytic. o Acute blood loss
o Chronic infection
Three types of non-hemolytic anemia:

✓ Macrocytic
✓ Normocytic HEMOLYTIC ANEMIAS:
✓ Microcytic
Two sub-categories of hemolytic anemia:
MACROCYTIC
✓ Target cells
(usually normochromic & is associated with ✓ Spherocytes
reticulocytosis but nor hemolytic) – cells are larger than
Anemias of target cells:
normal and is spherical in shape
o Beta-Thalassemia
Schilling test – screening test for B12 deficiency anemia,
o Alpha-Thalassemia
which detects the ability of RBC to react when vitamin
o Hemoglobinopathies
B12 is injected to the patient suspected to have B12
o Hb C disease
deficiency anemia or pernicious anemia.
Anemias of spherocytes:

o Cells with high OFT

o Burns and toxins (microspherocytes or
pyropoikilocytes)
o Antibody coated cells
o Hereditary spherocytosis

Sickle cell preparation – patient finger is tied with a

rubber band to decrease oxygen level, then after
disinfection, finger prick is done , then the blood sample
is placed in the slide covered with coverslip and observe
for the sickling of RBC due to decrease O2

Solubility test – the reagent used is diothionite (???)

which will decrease the oxygen level of the blood, and
the positive solubility test indicates sickle cell

If the sickle cell is seen and the patient is symptomatic,

then it is called Sickle Cell Disease. However, if the
patient does not show symptoms of sickle cell, then it is
only a sickle cell trait.

Those patients who are negative of sickle cell test will

undergo autoantibody test. For positive autoantibody
test, the possible disorder will be warm and cold
autoimmune hemolytic anemias.

Enzyme deficiency anemias, this include the pyruvate

kinase deficiency anemias, G6PD, and other types. This
will also demonstrate the presence of spherocytes,
together with Paroxysmal Nocturnal hemoglobinuria
which is not mainly associated with antibodies but
rather with complements which serve as the membrane
attack complex causing hemolysis to RBC. Spherocytes
can be seen in all of these disorders.
Blood Loss Anemia

✓ Ineffective Erythropoiesis
✓ If it is Acute Blood Loss, it is Normocytic Normochromic. Examples include hemorrhage and accidents.

✓ If it is Chronic Blood Loss, it is Microcytic Hypochromic due to frequent use of Iron. Examples are ulcers,
gastritis and other disorders of GIT.

Pathophysiology

Low blood volume → Low blood vessel pressure → Carotid arteries activated → Brain activated → Adrenal glands
activated → Release epinephrine → Vasoconstriction → Increases heart rate → Increases venous return and cardiac
output

Other Regulators of Blood Pressure

1. FLUID SHIFT: Extravascular to Intravascular

2. INCREASED BLOOD OSMOLALITY (Glucose is released from the liver to the blood also known as
glycogenolysis)
3. KIDNEYS → Renin → Angiotensinogen → Angiotensin → Adrenals → Aldosterone → Reabsorption of water and
sodium

Another Mechanism of Blood Loss Anemia

Low oxygen in cells → Anaerobic glycolysis → High Lactic Acid → Acidosis → Increase 2, 3 DPG and Decreased affinity
of O2 to Hb → More O2 to tissues

Hypoproliferative Anemias

(There is decreased production of RBC in the bone marrow due to defect in bone marrow or maturation defect. It is
classified as ineffective erythropoiesis).

Classification:

1. Normal RBC Morphology with Normal RDW

a) Bone marrow failure (Aplastic Anemia/AA and Pure Red Cell Aplasia/PRCA)
Aplastic anemia is also associated with Paroxysmal Nocturnal Hemoglobinuria or PNH and Acute
Myelopthisic Anemia or AML which are classified as Normocytic Normochromic.
Main difference between Aplastic anemia and Pure Red Cell Aplasia is that Aplastic anemia has
pancytopenia and reticulocytopenia.

b) Decreased Marrow Stimulation

Chronic Renal Failure (Microcytic Normochromic)
Endocrine Disease (Macrocytic Normochromic)

2. Abnormal RBC Morphology with Increased RDW

a) Refractory/Sideroblastic Anemia (may develop to Leukemia) Macrocytic Normochromic

 Ring Sideroblast. Pappenheimer bodies surrounds the RBC because
of Iron excess or iron overload

b) Myelophthisic Anemia (secondary to leukemia) Normocytic Normochromic

Tear drop shaped cell in Myelophthisic anemia

Types of Aplastic Anemia

I. Primary
a) Congenital Fanconi Anemia (chromosomal damage and associated with PNH and AML)
b) Acquired Idiopathic
II. Secondary
a) Drugs (chloramphenicol, sulfonamides, chlorothiazide, chloroquine, etc) these damage the bone
marrow
b) Chemicals
c) Radiation
d) Infection to HCV, TB, Brucellosis

*patients with aplastic anemia are prone to bleeding and will have PANCYTOPENIA.

Differentiation of Fanconi Anemia/FA and Diamond BlackFan Anemia/DBA

FANCONI ANEMIA DIAMOND BLACKFAN ANEMIA

Classification Aplastic Anemia Pure Red Cell Aplasia
Peripheral Blood Pancytopenia Anemia
Brown Skin Pigmentation and Common Uncommon
Thum abnormalities

Myelophthisic Anemia

✓ Associated with malignancies (lymphomas, leukemia and leucoerythroblastic reaction)

✓ With nucleated RBCs, myelocytes, metamyelocytes, dacryocytes
Anemia of Chronic Renal Failure

✓ Decreased Erythropoietin/EPO
✓ Due to decrease kidney function, there is accumulation of Urea in Blood (uremia)
✓ Microcytic Normochromic

Anemia of Endocrine Disorders

✓ Macrocytic Normochromic to Normocytic Normochromic

✓ Hypothyroidism (TSH inhibits erythropoietin leading to anemia). Example is Cretinism wherein open mouth is
major characteristic
✓ Hypogonadism (Androgens are needed for RBC production and if low, it causes anemia). Example is Kallman
syndrome in children
✓ Addison’s Disease (low cortisol) common in older person

Special Hematology Tests to Rule Out Hypoproliferative Anemias

Hb K (Kleihauer-Betke Stain)
→ To rule out Thalassemia. It Hb F is increase, it is not hypoproliferative anemia or bone marrow defect
but due to Thalassemia or globin chain defect.

Bright red cells are positive in Hb F

Leukocyte Alkaline Phosphatase Score/LAP Score

✓ Test for Acute Myeloplastic Anemia/AML
Serum Iron – for iron deficiency anemia
Complete Blood Count
Reticulocyte Count
Sucrose Hemolysis Test – to rule out Paroxysmal Nocturnal Hemoglobinuria
Ham’s Acidified Serum Test - to rule out Paroxysmal Nocturnal Hemoglobinuria
 ANEMIAS OF MATURATION DISORDERS

Megaloblastic Anemia

✓ Macrocytic Normochromic classification

✓ Cause is abnormal nuclear development and defective RBC DNA synthesis wherein folic acid and B12 are
deficient.
✓ High MCV, MCH, Normal MCHC
✓ Following can be seen: Oval Macrocytes, Schistocytes, Dacryocytes, Hypersemented Neutrophils or
macropolycytes
✓ Cabot’s ring (remnants of nuclear membrane)
✓ Howell-Jolly Bodies

✓ Basophilic stippling
✓ Folate and B12 deficiency

Role of Folate and B12

• B12 is a cofactor of folate metabolism

• Folate is needed for DNA synthesis of RBC
• B12 is needed to metabolize homocysteine to methionine and methylmalonic acid/MMA during folate
metabolism
• Homocysteine and Methylmalonic Acid are elevated in patients with Pernicious anemia and Folate deficiency
anemias

Pernicious Anemia or B12 Deficiency Anemia

✓ Folate may be normal or decreased depending on severity (if B12 deficiency due to dietary cause, normal
folate levels but if cause is malabsorption, folate levels decrease)
✓ Serum Iron and LDH increased (LDH is derived from RBC)
✓ B12 is markedly decreased, Homocysteine and Methylmalonic Acid/MMA are increased
✓ Intrinsic factor facilitates B12 intestinal absorption
✓ Common in Scandinavian, British, Irish
✓ Type A blood and 60 years old are common
✓ Pernicious Anemia can also be caused by Autoimmune Antibodies
o Blocking Intrinsic Factor Antibodies
o Binding Intrinsic Factor Antibodies
✓ PA can also be caused by Acquired B12 deficiencies
o Dietary strict vegetarians and malabsorption syndrome (pepsin is needed for absorption)
o Gastrectomy and Diphyllobothriasis (parasite in the GIT which competes with the absorption of B12)
can also cause PA
o Intrinsic factor molecular defect
o Imerslund syndrome
o Small bowel bacterial overgrowth
o AIDS
Folate Deficiency Anemia

✓ Vitamin B12 may be normal or decreased

✓ Folate/FA is markedly decreased
✓ Homocysteine is increased
✓ Caused by:
o Dietary
o Alcoholic Cirrhosis affecting Folate Metabolism)
o Pregnancy
o Malnutrition in children
o Drugs such as methotrexate and pyrimethamine
o Common in southeast Asia and Africa

Tropical Sprue

✓ Characterized by Folate and Vitamin B12 Deficiency

✓ Caused by hypersensitivity to wheat protein or glutin. Due to hypersensitivity, there is malabsorption

Differentiation of Megaloblastic Anemias

Pernicious anemia or Folate Deficiency Tropical Sprue

B12 Deficiency Anemia
B12 Markedly Decreased
Folate Normal or Decreased
Methylmalonic Acid Markedly Increased
Homocysteine Markedly Increased
Anemia
Normal or Decreased Decreased
Markedly Decreased Decreased
Normal Markedly Increased
Markedly Increased Markedly Increased

Congenital Dyserythropoietic Anemias (No deficiency of B12 and Folate)

Morphology Acidified Serum Test

Type I Slightly macrocytic with Cabot rings Negative
and Basophilic stipplings
Type II Normocytic, Anisocytosis, Positive
Poikilocytosis (variation in size and
shape)
Type III Slightly macrocytic and Negative
Gigantoblasts

Special Hematology Tests

1) Competitive Protein Binding (radioimmunoassay method) - Confirmatory Test

Serum (B12 and Folate) + Intrinsic Factor + Beta Lactoglobulin → 57Co – Cobalamin and 125 I2 – Folate
→ Scintillation Detector

* High Radioactivity = Low Serum B12 and Folate

* Low Radioactivity = High Serum B12 and Folate

2) Schilling’s Test – Screening test

 57Co-B12: given orally | B12 : given intramuscular → Measured excretion in urine → Scintillation detector

Reference Values:
Condition Excretion without Intrinsic Excretion with Intrinsic Factor
Factor
Normal >8% >8%
Pernicious Anemia <8% <8% (corrected)
Tropical Sprue and <8% <8%
Diphyllobothriasis

3) Food Schilling Test

✓ Uses egg yolk source of B12 (57Co)

4) Methylmalonic Acid/MMA Test (Gas Chromatography /MS)

5) Homocysteine Assay (Chromatography/Fluorometry)

Treatment:

✓ Treated by B12 (Cyanocobalamin)

✓ B9 (Folate/Folic Acid), Liver and Kidneys, Egg yolk
 ANEMIAS OF MATURATION DISORDERS (Microcytic Hypochromic Anemias)

Iron Deficiency Anemia/IDA

✓ Low MCH, MCV and MCHC, High RDW (since there is anisocytosis)
✓ Causes:
o Increased physiologic demand
→ growth, pregnancy and lactation
o Inadequate diet
→ (Vegetables:Ferric) (Meat:Ferrous) ; if meat you need to have Vitamin C since it converts
Fe+++ (ferric) to Fe++ (ferrous). It is the ferrous that is absorbed in the GIT
→ Achlorhydria (absence of gastric acidity) there is defect in absorption
o Blood loss
→ Menstruation, Bleeding

Signs and Symptoms

✓ Spooned nails
✓ Angular stomatitis
✓ Tongue sores
✓ Fatigue
✓ Breathlessness
✓ Dizziness

Anemia of Chronic Diseases/ACD

✓ Decreased iron in the blood in the presence of adequate iron stores

✓ Classification is Normocytic Normochromic to Microcytic Hypochromic depending on the amount of iron
✓ Diseases with anemia of chronic disease
Infectious:
o Tuberculosis
o Subacute bacterial endocarditis/SABE
o Pelvic pulmonary disease/PID caused by Neisseria
o Pulmonary infections
o Osteomyelitis
o Meningitis
o Chronic fungal diseases

Non-infectious:

o Rheumatoid arthritis
o Thermal injury
o Systemic Lupus erythematosus

Malignant Diseases

o Carcinoma
o Lymphomas (starts in the lymph node)
o Leukemia (starts in the bone marrow)
o Multiple myeloma (involves plasma cells)

Pathogenesis of Anemia of Chronic Disease

1. Shortened Erythrocyte Survival

Diseases stimulates production of Macrophage → Releases Interleukin-1 → Stimulates apoferritin synthesis →

Apoferritin iron → Ferritin
(formation of ferritin can lead to decrease supply of iron since iron is now being store in the organs)
 2. Impaired bone marrow response

Macrophage → releases tumor necrosis factor → defective production of RBC

* Treated by iron supplementation, steroids, antibiotics, antifungal drugs, chemotherapy

Sideroblastic Anemias/Refractory Anemias

✓ Microcytic Hypochromic Classification

✓ X-linked, autosomal (5,7,8,20), drugs, lead, alcoholism (inhibit enzymes necessary for synthesis of
hemoglobin)
✓ RBCs with Iron (stained with Prussian Blue called Pappenheimer bodies)
o Siderocytes = Erythrocytes with Iron (mature rbc with iron deposits)
o Sideroblasts = Erythroblasts with Iron (immature rbc with iron deposits)

*If there are immature RBCs or sideroblasts, the classification is macrocytic normochromic. If there are no sideroblast
and only siderocytes, classification is microcytic hypochromic

Type I Sideroblast 4 aggregates of

Pappenheimer bodies
Type II Sideroblast 6 aggregates of
Pappenheimer bodies
Type III Sideroblast Ring

*Treated with Vitamin B6 (PYRIDOXINE). It cannot be treated with iron since you have an increase in iron in the body

✓ Sideroblastic anemia may have anisocytosis (dimorphic:normocytes, macrocytes and microcytes)

✓ Poikilocytosis
✓ Basophilic stipplings
✓ Howell-jolly bodies
✓ NRBC’s

Hereditary Hemochromatosis/Hemosiderosis

✓ HLA-A3 of chromosome 6 (autosomal recessive systemic iron overload)

o Hemosiderin (Iron deposits in RBCs)
o Ferritin (Iron deposits in Organs)
o Iron deposits may cause damage to the heart, liver and other organs
o Treated by blood letting, chelating agents (deferoxamine removes excess iron)

Differentiation of Microcytic Hypochromic Anemias

Lab Test Iron Deficiency Sideroblastic Anemia of Chronic Hemochromatosis

Anemia Anemia Disease
Serum Iron Low High Low High
Serum Ferritin Low High High High
Total Iron Binding High Low to normal Low to normal Normal
Capacity/TIBC
 (indirect
relationship to
iron)
MCV Low Variable Low to normal
RDW High High High to normal

Laboratory Tests for Microcytic Hypochromic anemias

1. Serum Ferritin
o Reference Range: Men: 20 – 250 ug/dl Women: 10 – 120 ug/dl

2. Serum Iron
o Reference Range: Men: 60 – 175 ug/dl Women: 50 – 170 ug/dl
o Serum (Ferric) Iron-Ferritin + HCL → (Ferric) – Iron + Acid Ferrozine → Ferrous → Spectrophotometer

3. Total Iron Binding Capacity (250 – 425 ug/dl)

o Amount of iron that the circulating transferrin can bind (indirect measure of serum transferrin)
o Serum Transferrin = TIBC x .007
o % Transferrin Saturation = Serum Iron / TIBC x 100%
4. Free Erythrocyte Protoporphyrin or Protopophyrin IX (Fluorometric Assay)
o Normal to increased in IDA, SA, ACD and Hemochromatosis
ANEMIA 7
6. Mutations (Change or Loss of N2 base)
Anemias of Abnormal Globin Development ✓ No Beta Gene Production: (Hb F)
(Hemolytic Anemias) o Beta Thalassemia Major/ Cooley’s
Anemia/Mediterranean Anemia- most
severe type of Beta Thalassemia but
compared to hydrops fetalis, HF is still
Molecular Abnormality Classification of more fatal because it is common in
Hemoglobinopathies: newborn babies.
▪ Cooley- first patient
1. Amino Acid Substitution ▪ Mediterranean- commonly
✓ Hb S (Glu to Val)- most pathologic found
✓ Hb C (Glu to Lys) ✓ Decreased Beta Gene Production: (Hb F)
✓ Hb E, Hb O-Arab (Glu to Lys) o Beta Thalassemia Intermedia, Minor,
✓ Hb D-Los Angeles (Glu to Gln) Minima
✓ Hb D-Punjab (Glu to Gln) o Hb H is associated with Alpha
o Glu- Glutamine Thalassemia, Hb F is associated with
o Val- Valine Beta Thalassemia
o Lys- Lysine ✓ Globin Chain Fusion: (Hb Lepore)- not so severe
o Gln- Glutamic acid o 3 Categories of Beta Thalassemia:
2. Amino Acid Deletion ▪ Baltimore
✓ Hb Gun Hill (↑O2) ▪ Boston
- increased O2 affinity, thus, oxygen not ▪ Hollandia
delivered to tissue ✓ Deletion or inactivation of Gene
o Hereditary Persistence of Fetal
3. Amino Acid Elongation Hemoglobin/HPFH- there is high level of
✓ Hb Constant Spring (Alpha Thalassemia) Hb F in patient’s blood

4. Globin Chain Fusion

✓ Hb Lepore (Beta Thalassemia)

5. Gene Deletions
Functional Classification of Hemoglobinopathies:
✓ 4 Alpha Genes of Globin: Hb Barts, Hb Portland,
Hydrops Fetalis (Alpha Thalassemia) 1. Aggregation with Reduced Solubility of Hb:
o Alpha Thalassemia- most severe type of Hb S- associated with Sickle Cell Anemia
Thalassemia
✓ 3 Alpha Genes of Globin: Hb H (Hb H Disease)
(Alpha Thalassemia)
✓ 2 Alpha Genes of Globin with Elongation: Hb H,
Hb CS (Constant Spring Disease)
✓ 2 Alpha Genes Deleted: Hb H (Alpha Thalassemia
minor)
o 4 Types of Alpha Thalassemia:
2. Crystallization of Hb: Hb C- Hb C Disease
a. Hydrops Fetalis- most severe type
b. Hb H disease
c. Constant Spring disease
d. Alpha thalassemia minor- mildest
✓ 1 Alpha Gene Deleted: Silent Carrier: Hb H
o If a person who is a carrier marries
another carrier, this will result to
abnormal hemoglobin and offspring may
develop alpha thalassemia
 3. Unstable Hb: Hb KOLN, Hb GunHill (GK)- ↓ MCV, MCH,
associated with Heinz Bodies stained with NRBCs, Target
Thalassemia
Bromcresol blue ↑ Cells, Stipplings
minor
Rare= 1+ (2-
10/OIF)
↓ MCV, MCH,
NRBCs, Target
Thalassemia
Normal Cells, Stipplings
minima
Rare= 1+ (2-
10/OIF)

4. Methemoglobin: Hb M, Freiburg, Tubingen, St.

Louis (MFST) Other Types of Beta Thalassemia
5. Increased O2 affinity: Hb Cesapeake, Kol, Gun ✓ Hereditary Persistence of Fetal
Hill (CKG) Hemoglobin/HPFH
6. Decreased O2 affinity: Hb Kansas, Carribean, o Pancellular= Uniform Distribution of
Hope, Hammersmith, Seattle (KCHHS) Cells (Hb F)
o Heterocellular= Subpopulation of Cells
(Hb F)
Differentiation of Alpha Thalassemia ✓ Hb S-Beta Thalassemia
o combination od sickle cells and target
(Africa, Middle East, India, China, Southeast Asia (Phil) cells
o Basophilic stipplings
No. of Genes RBC o Low MCH and MCV
Type
Deleted Morphology o No Splenic Infarction
Low MCH, MCV, o Common in Mediterranean, Turkish,
Hydrops Fetalis
4 Low/Normal Indian, Romanian, North African
(Fatal Anemia)
MCHC, NRBCs
Hb H Disease Low MCH, MCV,
(Moderate 3 Hb H Inclusions
Anemia) Pathophysiology of Thalassemias
Thalassemia Mow MCH,
Minor (Mild 2 MCV, Hb H
anemia) inclusions

Differentiation of Beta Thalassemia

(Africa, Middle East, India, China, Southeast Asia (Phil)
RBC
Type RBC
Morphology
↓MCV, MCH,
NRBCs, Target o Abnormal Hb and Ineffective Erythropoiesis
Thalassemia
↑ Cells, Stipplings because of the defect in the production of Globin
Major
Moderaye= 3+ will lead to hemolysis for the Abnormal Hb and
(20-50/OIF) reduced oxygen affinity for ineffective
↓ MCV, MCH, erythropoiesis. Aside from abnormal production
NRBCs, Target of Hb F which is an abnormal Hb, there is also a
Intermedia ↑ Cells, Stipplings low production of Hb A which is the normal Hb.
Few= 2+ (10- Because of the reduced oxygen capacity, there
20/OIF) will be bone deformities seen in the facial
features of the patients which will also lead to
 RBCs in the liver (Extramedullary erythropoiesis) ANEMIA 8
which results to NRBCs. Iron deposits are formed
in the liver, spleen, heart, pancreas which can Laboratory Tests:
lead to multiple organ failure. 1. Solubility: Screening for SCA

Pathophysiology of Sickle Cell Anemia/SCA/ Sickle

Cell Disease
✓ Hb SS (SCA)
✓ Hb AS (Sickle Cell Trait)
o Common in Africa, US
o Resistant to Plasmodium falciparum
o Sickling (Low oxygen)
o Polymerization/Crystallization
Oxygen)
o Affects various organs:
▪ Heart (cardiomegaly)
▪ Kidneys (Hematuria)
▪ Liver (Hepatomegaly)
▪ Spleen (Splenomegaly)
▪ Lungs (Pneumonia)
▪ Skin (Ulcer)
(Low
o RBCs are added with saponin so that Hb
are released then Sodium dithionite is
added to decrease oxygen from Hb and
then precipitation/
polymerization/crystallization which is
indicated by a turbidity of the tube
indicates positive result.
o Sickling test or scriver waugh- another screening
test; patient’s finger is tied with rubber band and
then, prick is made and then, blood is mounted
on slide and checked for sickling of cells

2. Acid Elution Test (Screening for Beta

Thalassemia)- detects presence of Hb F
✓ Kleihauer- Betke Stain (Hematoxylin and
Eosin)
✓ Bright Red/Pink RBCs (+)

3. Alkali Denaturation Test for Hb F (Screening for

Beta Thalassemia)

o Sickle cells impede the flow of the blood vessels

leading to tissue death and organ infarction,
later on to pain. Then, sickle cells will be engulfed
by phagocytes leading to intravascular
hemolysis. Presence of fever means sickle cell
crisis, increase blood viscosity (Vasoocclusive
crisis), infectious crisis (pneumonia), Dactylitis
(Hands and feet), Splenic sequestration
(Splenomegaly), aplastic crisis (decreased RBC,
Hb, Hct)
o Blood is added with ammonium sulfate
& NaOH, then they denature Hb A, A2
and since Hs F is resistance to
ammonium sulfate and NaOH, Hb F is
retained, Drabkin’s rgt is added to form
Cyanmethemoglobin (brownish colored
 complex) measured in
spectrophotomer.

4. Staining of Heinz- Bodies and Hb H (Screening

for Unstable Hb: Hb Koln, Hb Gun Hill, Hb H)
✓ Stain: Bromcresol Blue
✓ Anticoagulant: Sodium citrate

5. Heat Denaturation Test (Screening for Unstable

Hb: Hb Koln, Hb Gun Hill) 8. Globin Chain Electrophoresis

o RBCs are added with water and
phosphate buffer, then heated to 50
degrees celcius for 3 hours, precipitation
means positive, indicating presence of
unstable hemoglobin.
9. Isoelectric Focusing (pH 3-10)
✓ pH is for better separation of abnormal Hb
Treatment: Blood Transfusion, Gene Therapy, Bone
Marrow Transplantation/Graft

6. Cellulose Acetate Hb Electrophoresis (pH 8.4-

8.6)- preliminary identification of Hb
o RBCs are added with KCN to enhance
hemolysis. Cellulose acetate is the
support medium. Anode and cathode
are connected to the electrophotograph
and migration is observed.
o Only ideal to detect Hb F for Beta
Thalassemia

7. Citrate Agar Hb Electrophoresis (pH 6.0-6.2)-

differentiates Hb Variants
✓ Hb S from D & G
✓ Hb C from E & O
ANEMIAS 9 4. Hereditary Stomatocytosis/ Hydrocytosis
✓ Defective Sodium-Potassium Pump which
Hereditary Anemias of Increased Destruction increases cellular sodium and decreases cellular
1. Hereditary Spherocytosis= Deficiency of potassium, causing the entry and exit of water in
Spectrin, Ankyrin, Protein Band 4.2 RBCs causing the swelling of cells (stomatocytes)
✓ High Osmotic Fragility, High MCHC ✓ High MCV, Low MCHC
✓ Decreased Membrane Lipid & Reduced Cell
surface area are the cause of high OF
✓ Impaired permeability of Sodium (transported
with ATP)
✓ Spherical cells can be destroyed in the spleen
(hemolysis)
✓ There is also slight hypoglycemia due to splenic
destruction
✓ In children it can lead to skeletal abnormalities
and pancytopenia

5. Pyruvate Kinase/PK Deficiency Anemia

✓ Deficiency of the enzyme needed for the
glycolytic pathway
✓ Poikilocytosis, Echinocytes, NRBCs, High MCV

2. Hereditary Elliptocytosis= Deficiency of Protein

Band 4.1 with abnormal spectrin structure
✓ RBC destruction in the spleen due to abnormal
shape
✓ Normal Osmotic Fragility
✓ Hemolysis and Jaundice
✓ Southeast Asia

3. Hereditary Pyropoikilocytsosis= Abnormal

Spectrin Structure
✓ Microspherocytosis, Anisocytosis, Schistocytosis
✓ Heat Instability (45 degrees Celcius) &
Hypercalcemia
✓ Hemolysis with High Osmotic fragility
✓ Low MCV
 6. Glucose-6-Phosphate-Dehydrogenase 5 .35 90-97 % (CH)
Deficiency/ G6PD Anemia 7 .45 0-45% (IH)

2. PK Fluorescent Spot Test and Quantitative PK

assay

✓ X-Linked
✓ West Africa, Middle East, Southeast Asia
✓ Heinz Bodies 3. G6PD Fluorescent Spot Test

7. Abetalipoproteinemia
✓ APO B Deficiency in Blood (membrane lipid
component)
✓ Acanthocytes/Acanthrocytes with Low Tag and
Cholesterol (Free and Esterified)

4. Autohemolysis Test
8. Lecithin-Cholesterol Acyltransferase Deficiency ✓ Test for G6PD, PK, Hereditary Spherocytosis
Deficiencies
✓ Target cells with increased Free Cholesterol

Laboratory Tests:
1. Osmotic Fragility Test/ OFT
✓ Methods: (25-14)
o Sanford
o Giffin and Sanford
o Dacies
✓ Reference values of Sanford Method (12 test
tubes)
o Initial Hemolysis= (21-22) .42-.44% NaCl 5. Methemoglobin Reductase Test
o Complete Hemolysis= (16-17)= .32-.34%
NaCl
o Hereditary Spherocytosis: IH= .48%
(24); CH= .40% (20)
o Pyropoikilocytosis, Stomatocytosis,
Severe Iron Deficiency Anemia: IH=
.34% (17); CH= .30% (15)
✓ Reference values of Dacies’ Method
(Spectrophotometric Method, 13 test tubes)

Tube No. % NaCl % Hemolysis

4 .30 97-100% (CH)
 6. Ascorbate Cyanide Test- for G6PD

7. Blood Chemistry Tests (Elevated)

7.1 Lactate Dehydrogenase
7.2 Bilirubin Test (Plasma/Serum)
7.3 Urobilinogen (Urine/Stool)
7.4 Ferritin (Plasma/ Serum or Urine)
7.5 Haptoglobin (Plasma/Serum)
7.6 Hemopexin (Plasma/Serum)

TREATMENT: Bone Marrow Transplant, Transfusion

HEMOSTASIS 1 antifibrinolytic factors which are needed for
hemostasis.
Hemostasis
o Procoagulants/Coagulation factors- facilitates
✓ stoppage of flow after an injury in the Blood clotting
vessel o Anticoagulants- prevents clotting
✓ cellular and biochemical events that helps blood o Fibrinolytic factors- those which lyses clot
in its liquid form in the blood vessel

Divisions of Hemostasis:

1. PRIMARY: platelets and endothelium

o Platelets release serotonin and Thromboxane A-
2 in which these compounds cause the
contraction of the smooth muscle
(vasoconstriction) which occurs in the central
part of the blood vessel (tunica media)
o Endothelium releases vWF which happens when
there is injury to the blood vessel. Aside from
vWF, it also releases prostaglandin, prostacyclin,
adenosine & nitric oxide which facilitate
o Aggregation is enhanced by agonists which
vasodilation (muscle relaxes).
are used for the diagnosis of bleeding
o Since there is now a balance between the
disorders or hemorrhagic disorders. Agonists
substances released by the platelets and
include restocetin (ristocetin), arachidonic
endothelium, primary hemostasis happens.
acid/ARA, ADP, collagen, thrombin and
epinephrine (*CATARE)-mnemonics
▪ Other agonists include CA2+ ,
Adenosine diphosphate/ADP,
PF4, Thrombospondin
o Aggregation can be inhibited by Antagonists
such as:
▪ Penicillin- treatment for
bacterial infection
▪ Aspirin- non-steroidal anti-
inflammatory drug or Treatment
for fever and pain
▪ Cephalothin- antibiotic for
microorganism
o Aside from releasing serotonin and ▪ Ticlodipine, Clopidogril- blood
thromboxane A-2, platelets also adhere to the thinners for heart disease
endothelium other once they are activated. And ▪ Other antagonists: Alcohol,
then, the vWF connects the platelet to the onion, garlic- can prevent
endothelium. As more and more platelet adhere aggregation of platelets
to the endothelium, aggregates form
(aggregation). Then, later on, there is platelet
plug formation wherein the injured site will be
blocked by the plug so that blood will stop form
flowing. Platelet now secretes anticoagulants,
procoagulants, fibrinolytic factors,
 2. SECONDARY: Coagulation and Fibrinolysis 2. INTRINSIC
o Coagulation- formation of blood clot due to o Does not require tissue injury but rather:
clotting factors o Exposed collagen
o Fibrinolysis- lyses of blood clot by the action o Negative surface exposure: glass slides,
of plasmin. capillary tube, test tube
o Fibrinogen (Factor I) converted to fibrin and o Drugs, toxins, chemicals
then platelet plug will be added so that this
platelet plug and fibrin will be lysed by 3. ALTERNATE
plasmin and convert fibrin to FDP/FSP which o Special pathway
includes X, Y, D & E. o Interaction between extrinsic and intrinsic
▪ Plasmin- derived from pathways
plasminogen and synthesized in
the liver
▪ FDP- Fibrin degradation
products
▪ FSP- Fibrin split products
o The conversion of plasminogen to plasmin is
influenced by Tissue Plasminogen
Activator/TPA and Plasminogen Activator
Inhibitor/ PAI

ANTICOAGULANTS

✓ prevents clotting/ facilitate bleeding

✓ inhibitors of coagulation factors (procoagulants)
✓ Produced by the liver:
C’1 Inactivator- CF/Clotting Factor 2, PK
Heparin Cofactor---- CF/ Clotting Factor
2
Alpha 2 Macroglobulin—CF 2, PK
PATHWAYS OF COAGULATION Alpha 1 Antitrypsin--- CF 2 & 11
✓ Produced in the endothelium:
1. EXTRINSIC Antithrombin- III/AT-III (CFs 2, 9, 10, 11,
o Extrinsic since it requires tissue injury in 12)
which the injury enables the tissue factor Thrombomodulin- Protein C-S (CFs 5&8)
(Factor 3) to be released form the - PAI-1 (CF2)
endothelium - TFPI (CFs 3,7 & 5)
▪ Factor 3 is the only procoagulant
that is not found in plasma nor
serum and only in blood vessel.
Tissue factor is released from
the outside to the inside.
 o Factor 4 is common among 3 pathways and
platelet is required for the activation of all the
pathways.
o Then once common pathway is activated, Factor
2 is activated becomes 2A which converts
Fibrinogen to Fibrin.

THEORIES OF COAGULATION

1. Morawitz- simplest and oldest theory 3. Revised

o Prothrombin (2) is converted to its active form o Different since it has no Factor 12 and no
Thrombin (A2). Then, thrombin converts platelet needed in extrinsic and common
Fibrinogen (1) to Fibrin (blood clot) pathway.

2. Cascade/Waterfall/Traditional
o In the INTRINSIC pathway, Factor 12 is activated
by a negative surface, glass…. Then, Factor 12
activates Factor 11, then 11 activates Factor 9, 9
activates Factor 8, 8 activates Factor 4, and 4
combines with platelet
o For the EXTRINSIC pathway, it starts with Factor
3 which activates 7, then 7 combines with 4
o Both extrinsic and intrinsic pathway activates
Factor 10 &5 which activates 4 + Platelet which
are in COMMON pathway.
4. Alternate OTHER COMPONENTS OF HEMOSTASIS:
o Combination of the extrinsic, common, and
1. EXTRAVASCULAR
intrinsic pathway.
o surrounding tissues (CT muscle), swells and
traps escaped blood from the endothelium If
injured
2. VASCULAR
o 3 layers/ coats of blood vessels
2.1 Tunica Adventitia- Connective Tissues
2.2 Tunica Media- collagen, smooth muscle &
elastic fibers
2.3 Tunica Intima- releases anticoagulants and
anti-fibrinolytic factor, and Vwf
- anticoagulants -PRIMARY
5. Complete Theory (Rodak) - anti-fibrinolytic factor-
SECONDARY
- Vwf- PRIMARY
3. INTRAVASCULAR-
o procoagulants/ clotting factors (secondary),
platelets (primary)

6. Complete Theory (Stein-Martin)

o Most accepted theory
 HEMOSTASIS 2,3,4 COAGULATION FACTORS/PROCOAGULANTS

 FACTOR I/ FIBRINOGEN
PLATELETS Fibrinolysis  FACTOR II/ PROTHROMBIN
Coagulation
 FACTOR III/TISSUE THROMBOPLASTIN
(procoagulan
(Plasmin)  FACTOR IV/ CALCIUM
ts)
 FACTOR V/ LABILE FACTOR/ AC
GLOBULIN/PRO-ACCELERIN?
Blood  FACTOR VII/ STABLE FACTOR/ SERUM
Hypercoa Vessels Hypo PROTHROMBIN CONVERSION
gulation coagulati ACCELERATOR/ SPCA
on  FACTOR VIII/ ANTIHEMOPHILIC
GLOBULIN/AHG/ ANTIHEMOPHILIC
FACTOR A
 FACTOR IX/PLASMA THROMBOPLASTIN
Eg. Thrombosis Eg. Bleeding and COMPONENT/CHRISTMAS
and embolism hemorrhage FACTOR/ANTIHEMOPHILIC FACTOR B
BODY  FACTOR X/ STUART-PROWER FACTOR/
STUART FACTOR
 FACTOR XI/ PLASMA THROMBOPLASTIN
 This is the summary of the role of the ANTECEDENT/PTA/ANTIHEMOPHILIC
platelets and the blood vessels or the FACTOR C
endothelium in the balance between  FACTOR XII/ HAGEMAN FACTOR/ GLASS
coagulation and fibrinolysis OR CONTACT FACTOR
 Coagulation- Facilitated by  FACTOR XIII/ FIBRIN STABILIZING
procoagulants (clotting factor) FACTOR/ FSF
 Fibrinolysis- Facilitated by plasmin  PREKALLIKREIN/PK/FLETCHER FACTOR
which is derived from plasminogen  HIGH MOLECULAR WEIGHT
 Hypercoagulation- Increased in KINNENOGEN/HMWK/FITSGERALD
coagulation FACTOR
 Hypocoagulation- increased in
fibrinolysis (bleeding)
 Platelets- participates in coagulation  III= ABSENT IN PLASMA AND SERUM
 Blood vessels- facilitates in the primary (ENDOTHELIUM)
hemostasis by producing compounds  This tissue factor cannot be
which functions as vasodilators measured by the extrinsic
 Embolism- There is a blood clot running pathway test , intrinsic pathway
through the circulation test and the common pathway
 Thrombosis- The presence of blood test because it is absent in
clots (eg. Thrombotic thrombocytopenic plasma and serum
purpura)  Once the factor III is released,
the pathway is called extrinsic
 I,V,VIII,XIII = ABSENT IN SERUM RV= 75-120 SECONDS
(DESTROYED BY PLASMIN )(LABILE OR
HEPARIN THERAPY= 140-185 SECONDS
FIBRINOGEN GROUP)
 EXTRINSIC GROUP= III ANS VII
 INSTRINSIC GROUP= XII, XI,IX,VIII,
PREKALLIKREIN/PK, HIGH MOLECULAR 3. ACTIVATED PARTIAL THROMBOPLASTIN
WEIGHT KININOGEN/HMWK TIME/APTT
 COMMON GROUP= X,V,IV,II,I and XIII
CITRATED PLASMA+ CLOT ACTIVATOR
 PROTHROMBIN GROUP/ VITAMIN K
(KAOLIN, CELITE, SILICA, ELLAGIC ACID) +
DEPENDENT= II, VII, IX,X
PHOSPHOLIPID (SUBSTITUTE FOR
 FIBRINOGEN GROUP/ LABILE= I, V, VIII, THROMBOPLASTIN) + CACL2 AT 37
XIII (DESTROYED BY PLASMIN)
DEGREES CELCIUS= CLOT (RECORD TIME)
 CONTACT GROUP= XII,XI,PK,HMWK
(ACTIVAYED BY A NEGATIVE SURFACE) RV= 20-45 SECONDS
 COFACTOR GROUP= III, IV, V, VIII (HELP
ENZYMES)
 ZYMOGEN GROUP= II, VII, IX, X, XI, XII, 4. CLOTTING TIME (SLIDE OR TEST TUBE
XIII (ENZYME PRECURSORS) AS THE ACTIVATOR)
 SLIDE METHOD
 CAPILLARY TUBE METHOD
LAB TEST FOR INTRINSIC AND COMMON  LEE AND WHITE CLOTTING TIME
PATHWAYS OR WHOLE BLOOD
 CLOTTING TIME (3 TEST TUBES
DETECT DEFICIENCIES OF FACTORS
AT 37 DEGREES CELSIUS)
1,2,5,10,8,9,11,12

1. PLASMA RECALCIFICATION TIME/PRT

LAB TEST FOR EXTRINSIC AND COMMON
PLATELET-RICH PLASMA+ CACL2 (GLASS
PATHWAYS
TUBE) = CLOT (RECORD TIME), RV= 100-150
SECONDS DETECTS DEFICIENCIES OF FACTORS
1,2,5,7,10
PLATELET-POOR PLASMA+ CACL2 (GLASS
TUBE)= CLOT (RECORD TIME), RV= 130-240 MONITORS ANTICOAGULANT THERAPY
SECONDS

1. PROTHROMBIN TIME/PTT
2. ACTIVATED CLOTTING TIME/ACT CITRATED PLASMA+ CACL2+
THROMBOPLASTIN AT 37 DEGREES
CITRATED PLASMA+ DIATOMITE (CLOT
CELCIUS = CLOT (RECORD TIME)
ACTIVATOR) AT 37 DEGREES CELCIUS= CLOT
RV= 12-14 SECONDS, 10-12 SECONDS
(RECORD TIME)
(PHOTO-OPTICAL)
 INTERNATIONAL NORMALIZED 3. LAUREL ROCKET IMMUNOPHORESIS
RATIO/INR= PT OF THE PATIENT/ PT OF AGAROSE (Ab)+ Ag (FIBRIN) IN A
CONTROL PLASMA = 2-3:1 TO 2.5-3.5:1 GLASS PLATE WITH ELECTRICAL
CURRENT = PRECIPITATION

2. STRYPVEN TIME & PROTHROMBIN-

PROCONVERTIN TIME 4. CROSSED
IMMUNOELECTROPHORESIS= 2D
METHOD
LAB TESTS FOR COMMON PATHWAT
(DETECT FACTOR DEFICIENCIES) 5. RADIOIMMUNOASSAY
Ag(FIBRIN) + Ab + RADIOACTIVE
1. THROMBOPLASTIN GENERATION MATERIAL= RADIOACTIVITY
TIME/TGT (DETECT FACTOR MEASURED IN A SCINTILLATION
DEFICIENCIES) COUNTER

PLASMA + BaSO4 = ADSORB FACTORS

2,7,9,10 6. ENZYME LINKED IMMUNOSORBENT
BLOOD= CLOT + SERUM (NO FACTORS ASSAY/ ELISA
1,5, 8 AND 13) Ag(FIBRIN) + Ab + ENZYME =
EXTRACT SERUM+ ADSORBED PLASMA= PRODUCT MEASURED A
DO PT OR APTT SPECTROPHOTOMETER OF
FLUOROMETER

2. PROTHROMBIN CONSUMPTION LABORATORY DETERMINATION OF

TEST/ PCT FIBRINOGEN (COMMON PATHWAY)
BLOOD IS ALLOWED TO CLOT FOR 60
MINUTES (DETECTS DEFICIENCIES OF
FACTORS 5,8,9,10,11,12 )

LABORATORY DETERMINATION
FIBRIN (COMMON PATHWAY)
1. PRECIPITATION/
DENATURATION (HEAT AND
OF
SALT) = TURBIDIMETER

2. FIBRIN CLOT DENSITY =

1. OUCHTERLONY DOUBLE DIFFUSION
AUTOMATED
Ag(Fibrin) + Ab(AGAR) = (Ag-Ab)
RADIAL DIFFUSION

3. COAGULABLE PROTEIN ASSAY=

2. RADIAL IMMUNODIFFUSION
WEIGHT OF CLOT USING UV
Ag(FIBRIN) + Ab(AGAR) = (Ag-Ab)
ABSORBANCE
HALO FORMATION
 INHIBITOR STUDIES LUPUS ANTICOAGULANT

4. THROMBIN CLOTTING TIME/  PATIENT’S PLASMA + NORMAL PLASMA

TCT/ THROMBIN TIME/ TT = CORRECTED PT AND APTT IF DUE TO
PLASMA + THROMBIN = CLOT FACTOE DEFICIENCY
(RECORD TIME)  PATIENT’S PLASMA + NORMAL PLASMA
RV= 20-25 SECONDS = UNCORRECTED PT AND APTT IF DUE
TO ANTICOAGULANT THERAPY
(HEPARIN, WARFARIN, COUMADIN)
5. HIGH-DOSE THROMBIN TIME  LUPUS ANTICOAGULANT
PLASMA+ THROMBIN +
REPTILASE SNAKE VENOM, 1. TISSUE THROMBOPLASTIN INHIBITION
PROTAMINE, CALCIUM = CLOT TEST (DETECTS FACTORS 2, 5, 10
(RECORD TIME) DEFICIENCIES)
RV= 8-9 SECONDS  PATIENT’S PLASMA +
THROMBOPLASTIN + CaCL2 AT
37 DEGREES CELCIUS = CLOT
(RECORD TIME)
6. REPTILASE TIME
 CONTROL PLASMA +
PLASMA + THROMBIN-LIKE
THROMBOPLASTIN + CaCl AT 37
SUBSTANCE FROM REPTILE
DEGREES CELCIUS= CLOT
(REPTILASE) = CLOT (RECORD
(RECORD TIME)
TIME)
 RV: 1:1 (NORMAL), 1:3
RV= 8-9 SECONDS
(ANTICOAGULANT THERAPY OR
LUPUS ANTICOAGULANT)
PT, APTT & TT RESULTS OF FACTOR
DEFICIENCIES 2. DILUTE RUSSEL’S VIPER VENOM (RVV)
TIME (DETECTS FACTORS 2, 5, 10
FACTOR PT APTT TT DEFICIENCIES)
I ABN ABN ABN  PATIENT’S PLASMA + RVV +
II ABN ABN NOR
Ca++ = CLOT (RECORD TIME)
V ABN ABN NOR
VII ABN NOR NOR  CONTROL PLASMA + RVV +
VIII NOR ABN NOR Ca++ = CLOT (RECORD TIME)
IX NOR ABN NOR  RV: 1:1 (NORMAL), 1:3
X ABN ABN NOR (ANTICOAGULANT THERAPY OR
XI NOR ABN NOR LUPUS ANTICOAGULANT)
XII NOR ABN NOR
3. PLATELET NEUTRALIZATION
PROCEDURE
  PLASMA + PLATELETS (FREEZE-  An immunoglobulin
THAWED) that binds to
phospholipids and
 NEUTRALIZATION OF LUPUS proteins associated
ANTICOAGULANT with the cell membrane
(Wikipedia, 10/6/14)
 DECREASED APTT  “anticoagulant”
accurately describes its
functions in vitro
 In vivo, it functions as a
4. TEXTARIN TO ECARIN RATIO
pro-coagulant
 TEXTARIN
prothrombotic agent
 ACTIVATES FACTOR 2 IN
 Cause an increase in
THE PRESENCE OF 3,4,5
inappropriate blood
 ECARIN
clooting
 ACTIVATES FACTOR 2
 Blood clots in the legs
WITHOUT 3,4,5
or the lungs as well as
 WITH LUPUS ANTICOAGULANT:
stroke or heart attack
 TEXTARIN TIME= PROLONGED
 Recurrent miscarriages
 ECARIN= NORMAL
 Persons with disease
 RV: <1.3:1
such as systemic lupus
erythematosus (SLE)
 Drugs: phenytoin,
5. BETHESDA ASSAY (PROLONGED APTT) hydralazine, quinine,
 PLASMA + FACTOR 8 and amoxicillin
37 DEGREE CELCIUS  Inflammatory bowel
disease (Crohn’s
disease and ulcerative
 RESIDUAL FACTOR 8 colitis, infections and
ELISA, EID, IRMA certain kinds of tumors)
 NORMAL FACTOR 8 LEVEL
(LUPUS ANTICOAGULANT)
 LOW FACTOR 8 LEVEL (FACTOR
8 DEFICIENCY)

LUPUS ANTICOAGULANTS

 Antibodies against
substances in the lining
of cells (Medline Plus,
10/6/14)
DISORDERS WITH POSITIVE RESULTS OF ROLES OF PLATELETS IN FIBRINOLYSIS
FIBRINOLYTIC TESTS:
 (1) the secretion of a number of key
 DISSEMINATED INTRAVASCULAR proteins and molecules during platelet
COAGULATION/DIC, activation that influence the
(THROMBOCYTOPENIA) fibrfinolytic syste,, the most noteworthy
 PULMONARY EMBOLISM of which, platelet pai-1, correlates
(THROMBOCYTOPENIA) directly with the lysability ofnthrombi;
 DEEP VEIN THROMBOSIS  (2) the platelet membrane provides a
(THROMBOCYTOPENIA) surface to support .plasminogen
 AMI (HYPERFIBRINOGENEMIA) activation via binding of plasminogen,
 ABRUPTIO PLACENTAE plasminogen activators, and proteins of
(HYPERFIBRINOGENEMIA) the contact pathway; and
 PREEECLAMPSIA, ECLAMPSIA  (3) platelets modify clot structure clot
(HYPERFIBRINOGENEMIA) structure, with dense areas of fibrin
 FETAL DEATH IN UTERO forming around platelet masses, which
(HYPERFIBRINOGENEMIA) hinders movement of the lysis front
 POST-PARTUM HEMORRHAGE through the clot
(HYFIBRINOGENEMIA)
 MALIGNANT NEOPLASM
(THROMBOCYTOPENIA) LABORATORY EVALUATION OF
 OVARIAN TUMOR FIBRINOLYSIS
(HYPERFIBRINOGENEMIA)
 POLYCYSTIC OVARY DISEASE 1. EUGLOBULIN CLOT LYSIS/ ECLT (FP:
(HYPERFIBRINOGENEMIA) TOURNIQUET, TIME OF COLLECTION
 RENAL FAILURE, NEPHRITIS LOWFIBRINOGEN LEVEL, FN: LOW
(URINARY EXRETION OF FACTORS PLASMINOGEN)
2,7, 9, 10, AND 12 AT- III & PROTEIN  DETECTS: PLASMINOGEN,
C) PLASMIN FIBRINOGEN,
 THROMBOLYTIC SURGERY PLASMINOGEN ACTIVATORS
(THROMBOCYTOPENIA) (EUGLOBULIN)
 MENSTRUATION, PREGNANCY  PLATELET-POOR PLASMA+ H20
(THROMBOCYTOPENIA, + ACID (37 DEGREES CELCIUS)
HYPERFIBRINOGENEMA) (WITH EUGLOBULINS)
 =PRECIPITATED EUGLOBULINS
(ACTIVATORS) + (INHIBITOR:
ANTIPLASMIN) IN
SUPERNATANT DECANTED
 =EUGLOBULIN PRECIPITATE +
THROMBIN= CLOT+ PLASMIN
 = CLOT LYSIS, RECORD TIME
(RV= 1-2 HOURS)
2. TANNED RED CELL
HEMAGGLUTINATION TEST/ TRCHI
 PATIENT’S SERUM (FDP) + ANTI-
HUMAN FIBRINOGEN/ AHF
 = AHF-TYPE O CELLS
AGGLUTINATE
 LESSER AHF-TANNED RBC
AGGLUTINATES= HIGHER FDP
 (RV:< 12 MICROGRAM FDP)
3. STAPHYLOCOCCAL CLUMPING TEST
 WHOLE BLOOD IS CLOTTED
 =SERUM (X & Y, FIBRINOGEN) =
Staphylococcus aureus
 X & Y – Staphylococcus aureus
PRECIPITATE
 (RV, 0-8 MICROGRAM
FIBRINOGEN/ML OF SERUM)
4. PROTAMINE SULFATE DILUTION TEST
 PLASMA (FDP’s : X, Y, D, E) +
PROTAMINE SULFATE
= PARACOAGULATION
(POLYMERIZATION/GEL
FORMATION)
 FP: HIGH FIBRINOGEN
5. ETHANOL GELATION TEST
 PLATELET-POOR-PLASMA (X, Y,
D, E) + 50% ETHANOL
=POLYMERIZATION/GEL
FORMATION
6. HEMAGGLUTINATION TEST
 PLATELET-POOR-PLASMA (X, Y,
D, E) + RBC’S COATED WITH
FIBRIN
7. LATEX FDP ASSAY
 PATIENT’S SERUM (D & E) +
LATEX (ANTI-D AND ANTI-E)
 =AGGLUTINATION (GET TITER:
HIGHEST DILUTION WITH
AGGLUTINATION)
 FP: FIBRINOGEN
 FN: HEPARINTHERAPY
8. D-DIMER
 PLASMA (D-DIMER ) + LATEX
(ANTI D-DIMER=
AGGLUTINATION (GET TITER)
 RV,< 200 NG/ML
 FP : RHEUMATOID FACTOR/Rf
9. PLASMINOGEN ASSAY
 RADIAL IMMUNODIFFUSSION
 PLASMA (PLASMINOGEN) IN
AGROSE MATRIX (ANTI-
PLASMINOGEN) =
PRECIPITATION
 FUNCTIONAL ASSAY
PLASMA (PLASMINOGEN) +
STREPTOKINASE (ACTIVATOR)
= PLASMIN + CHROMOGEN
=COLOR
(SPECTROPHOTOMETER)
10. TISSUE PLASMINOGEN ACTIVATOR/ TPA
ASSAY
 PLASMA (TPA) IN MICROTEST
WELL (ANTI-TPA) + PEROXIDASE
+ SUBSTRATE
 =YELLOW COLOR (SPECTRO)
 RV, 9-10.5 NG/ML

11. PLASMINOGEN – ACTIVATOR

INHIBITOR-1 / PA- 1 ASSAY
 PLASMA (PAI) + TPA-PAI
COMPLEX +RESIDUAL TPA
 RESIDUAL TPA + PLASMINOGEN
+ SUBSTRATE
 =PLASMIN+ COLORED
PRODUCT (SPECTRO)

12. ALPHA 2-ANTIPLASMIN ASSAY

 PLASMA (A2A) + PLASMIN
 PLASMIN-ANTIPLASMIN
COMPLEX +UNBOUND PLASMIN
+ P-NITRANILINE
 =COLORED COMPLEX
(SPECTRO)

13. VENOUS OCCLUSION TEST

 SAMPLE 1 (NO TOURNIQUET
 SAMPLE 2 (BLOOD PRESSURE
CUFF FOR 10-20 MINUTES)
(VENOUS STATIS= RELEASE TPA)
 PAI + TPA = PAI – TPA +
RESIDUAL TPA
 RESIDUAL TPA +
PLASMINOGEN= PLASMIN
 PLASMIN + CHROMOGENIC
SUBSTRATE = COLOR (SPECTRO)
 HEMOSTASIS 5  PLASMA MEMBRANE
 Outermost layer
PLATELETS
MORPHOLOGIC DESCRIPTION:  SUBMEMBRANE
 Fragments of megakaryocytes (VENOUS SINUSOIDS)  Regulation of the
 1 -4 micrometer in diameter (smaller than RBCs) passage of compounds inside and outside of
the cells
 0.5 – 1 in micrometer in thickness
 5 – 7 femtoliter in volume
 Dense blue to purple particles (Romanowsky Stain)  CYTOSKELETON
 SOL – GEL ZONE
 Produces vasoconstrictors  MATRIX / MUSCLE AND SKELETAL PORTION
 Binds with Von Willebrand Factor so that it can attach in (responsible for its motility)
the endothelium
 Participates in the extrinsic, intrinsic, and common  ORGANELLES
pathway  MITOCHONDRIA
 Appears purplish or pinkish in peripheral smear using – Energy source / powerhouse
Giemsa wright stain  LYSOSOMES
 They are a derivative of larger cell megakaryocytes – Get rids of invading
 PRECURSOR CELL: microorganisms/toxins
MEGAKARYOBLAST  megakaryocytes thrombocytes  DENSE BODIES
 GRANULES
 MEGAKARYOCYTES – Alpha granules (produces either
 Granular megakaryocytes anticoagulants/ procogulants/fibronylitic
 Basophilic megakaryocytes factors/antifibronylic factors)
 Mature megakaryocytes PLASMA MEMBRANE
 GLYCOCALYX
 Are the only cells in the blood which undergoes  Surface Coat
endomytosis (the process of division of the nucleus and
 PORE – LIKE INDENTATION
cytoplasm of the cell)
 After endomytosis, the megakaryocytes are broken down
 Communication Channels
to thrombocytes, which are now called as platelets  GLYCOPROTEINS IN GLYCOCALYX
 Adhesion and aggregation
 PROCESS: adhesion, aggregation, platelet plug
formation, and secretion of the different component  Ia, Ib, Ic, IIa, IIb
 Sometimes, as almost as large as WBC, called giant  III, IV, V, IX
platelets (a syndrome)
– Any deficiency of these glycoproteins can lead
to platelet disorders
– The disorders are classified as
adhesion/aggregation disorders

 SURFACE ADHESION FOR FACTORS

(PROCOAGULANTS):
1, 5, 8, 10, 11, 12 & 13

HEMOSTATIC FUNCTION
PARTS OF A PLATELET  Platelets membrane glycoporoteins
HEMA (MTAP) HEMO 5, 6, & 7 Page 1 of 11
 GP Ib-IX:
 Constitue active receptor for vWF (attached to
clotting factor 8)
 Mediates vWF dependent adhesion of platelets
to subendothelial
 GP IIb/IIIa:
 On activation serve to bind fibrinogen
 Mediates aggregation
 Also receptor for vWF, fibronectin and SUBMEMBRANE
thrombospondi  CIRCUMFERENTIAL MICROFILAMENTS
 GP Ia-IIa:
 Regulates discoid shape
 Constitutively active receptor for collagen
 Responsible for the prevention of contact between
 Mediates platelets adhesion independent of vWf. the organelles and plasma membrane

CYTOSKELETON (SOL – GEL ZONE)

 CONSISTS OF:
 Microtublues
 Microfilaments
MADE UP OF:
Example of one platelet adhering to another platelet; in the Actinin, Actin, Actin-Binding Protein, Myosin
middle is the fibrinogen; attachement is due to Glycoprotein/GB  Responsible for the contraction of
IIB and IIIA; platelet is attached to endothelium, the von
platelets for the motility
willIbrand factor (VWF)

 Communication
 Contractile response to stimulation
 Forms the Pseudopodia (fall split?)
 Responsible for the movement of platelets
during adhesion, aggregation, and platelet
PLASMA MEMBRANE (cont…) plug formation
 Responsible for regulating the entry and exits of OGANELLES
particles in an platelets
CONSISTS OF:
 E.g.
 DENSE GRANULES (MAGCAGS)
– Serotonin
 ADP
– Anticoagulants
 ATP For energy regulation
– Procoagulants
 GDP
– Fibrinolytic factors
 GTP Regulates platelets
– Anti-fibrinolytic factors
 Ca ++ movements
 Na+ / K+ ATPase PUMP  Mg ++
 Attachment for the von WILLIBRAND FACTOR  Serotonin Regulates
vasoconstriction of the
 PHOSPHOLIPIDS (responsible for the permeability blood vessels
 ALPHA GRANULES
of platelets; regulating the entry and exit of
 Coagulation Factors
compounds)
– 5 & 11
 Phosphatidylcholine
 Fibrinolytic Inhibitors
 Phosphatidylserine
– Plasminogen Activator
 Phosphatidyl Inositol
Inhibitor (PAI)
– ALPHA2-PASMIN INHIBITOR
= 2AP
HEMA (MTAP) HEMO 5, 6, & 7 Page 2 of 11
  Platelet Specific Proteins
– Pf4
– Thromboglobulin (produced
by endothelium ; stimulates
the secretion
anticoagulants)
=4T
 Mitogenic Factors (growth factors;
responsible for cellular growth)
– Platelet Derived Growth
Factor (PDGF)
– Transforming Growth Factor
(TGT)
– Epidermal Growth Factor
(EGF)
– Endothelial Cell Growth
Factor (ECGF)
=PETE
 Multimerin
 Membrane – Associated Proteins
– P-Selectin
– Osteonectin
 Adhesive Glycoproteins =FFVVT
– Fibronection
– Fibrinogen (CF 1)
– Vitro-Nectin
– Thrombospondin
– vWF
LABORATORY EVALUATION
OF PLATELETS
1. BLEEDING TIME
 Time for a standard skin wound to stop blood
flow in vivo (inside the body)
 The blood flow is regulated by platelets
because of the ability of the platelets to:
 Adhesion
 Aggregation
 Platelet-Plug Formation
a. DUKE’S METHOD
 Most common BT
 Filter paper in the earlobe (pre-margin)
 3 mm deep
3 mm is sometimes 2 mm deep.
The rationale is that with that
depth you can reach the capillary
beds. If you failed to reach the 2.5
or 3 mm deep, then the possibility
is that you won’t reach the
capillary bed, lesser blood flow,
insufficient sample, incorrect
of
bleeding time
 1 – 7 minutes
 Advantages if done correctly:
– more free flow of blood, no need
to press earlobe for blood to flow
– lesser nerve endings, therefore
less painful than finger puncture
b. COPLEY – LALITCH
 Finger
 NSS
 6 mm deep
 Requires deeper puncture
 A.K.A Immersion technique
 1 – 7 minutes
 Advantages if done correctly:
– more free flow of blood, no need
to press earlobe for blood to flow
– lesser nerve endings, therefore
less painful than finger puncture
c. IVY’S METHOD
 Standard method
 Uses a puncturing device that looks like
a scalpel called Surgicutt
 40 MMHg
 In the antecubital fossa
 5 mm long, 1 mm deep
 7 – 15 minutes
For other methods, the BT is 1 – 3 minutes. For type O some
are 6 minutes. Rationale is that type O individuals have lesser
levels of Von willibrand factor, which serves as link between
platelets and endothelium. Type O will have longer bleeding
time compared other blood types
(DUKES AND COPLEY-LALITCH)
RV (<9 minutes) PROLONGED:
– Decreased platelets count / Thrombocytopenia
<100, 000 cells/CUMM
– Von WILLIBRAND’S DISEASE
– ASPIRIN THERAPY (aspirin prevents aggregation
of platelets)
HEMA (MTAP) HEMO 5, 6, & 7 Page 3 of 11
2. PLATELET COUNT
 Quantitative determination of platelets
a. DIRECT
 HEMOCYTOMETER
 RV: 150 – 400 X 109/L
a.1 TOCANTIN/RESS AND ECKER
– Citrate, Formaldehyde,
Pipet, Light microscope
– DILUTION FACTOR = 20
a. 2 GUY AND LEEKE
– Formaldehyde, RBC Pipet, Light
microscope
– DILUTION FACTOR = 200
a.3 BRECKER AND CRONKITE
– Ammonium Oxalate, WBC Pipet,
Phase-Contrast Microscope
– Also used for check for the
accuracy of machines
– GOLD STANDARD
– DILUTION FACTOR = 20
a.4 UNOPETTE
– Get average count of 2 large
squares X 10 X 100
– Advantage is that it is
disposable
– You just get the sample directly from
the unopette because it has already a
capillary. Then, press, allow the sample
to dilute and then you count.
b. INDIRECT
 SLIDE (CELLS/1000 RBC’S X RBC)
 RV: 250-500 X 109/L
 DROP OF MgSO4 on the site of
puncture
 Examples:
– DAMSHEK
– FONIO
– OLEF
c. PLATELET ESTIMATE IN PERIPHERAL
BLOOD FILMS
 3-10/100 RBC’s in Oil Immersion
Field
 5-20/200 RBC’s in OIF (Adequate)
d. AUTOMATED COUNTS
 Flow Cytometry
 Fluorescence Flow Cytometry
 PRINCIPLE:
LASER  strikes a PLATELET
So that it will form a light scatter
– FORWARD LIGHT
WBC SCATTER (0 DEGREE)
– SIDEWARD LIGHT
SCATTER (90 DEGREES)
 DECTOR (using this, it will now
determine the count, based on
the scattering of the light)
3. PLATELET FACTOR / PF3 ASSAY
Platelet Rich Plasma/PRP (sample) + KAOLIN +
EPINEPHRINE = PF3 ACTIVITY (LIPID SURFACE TO
ENHANCE CLOTTING FACTORS)
4. PLATELET FACTOR 4 / PF4 (HEPARIN –
BINDING PROTEINS IN ALPHA
GRANULES)
 Measured by Radioimmunoassay (RIA)
 Based on radio activity usually
expressed in millicurie
 Bases for detecting the platelet factor
4
 Requires antigen, antibody, and radio nuclei
 INCREASED IN:
 Acute Myocardial Infraction (AMI)
 VENOUS THROMBOSIS
 Diabetes Mellitus (DM)
 INFLAMMATORY STATES
 Platelet factor 4 is an indicator of inflammation
5. HISTORYCAL TESTS
a. GLASS BEAD RETENTION TEST (IN VITRO)
 Blood is allowed to pass in glass beads
 Do platelet count of effluent Blood (before
and after putting in the glass beads)
 RV: 70% of platelet retained in the column
b. PLATELET ADHESIVENES TEST
 Serial Platelet counts from forearm
compared with venous platelet count
(control)
c. CLOT RETRACTION TEST
 BLOOD  CLOT  RETRACTS (Platelets,
Ca++, ADP, Fibrinogen)
 RV: 1 – 24 HOURS
HEMA (MTAP) HEMO 5, 6, & 7 Page 4 of 11
6. PLATELET AGGREGOMETRY
 Uses AGONISTS:
 Collagen
 ADP
 Thrombin
 Arachidonic Acid/ARA
 Restocetin
 Epinephrine

 PRINCIPLE:
PLATELET – RICH PLASMA + AGONIST (TURBID
SUSPENSION) = AGGREGATION (CLEAR
SUSPENSION)
LIGHT TRANSMITTANCE  AGGREGOMETER

INTERPRETATION OF AGGREGOMETRY
POSITIVE
RESPONSES IN ALL = NORMAL / REFERENCE RESULT
AGONISTS
 MINIMAL RESPONSE WITH
ARA,
ASPIRIN THERAPY =
 POSITIVE RESPONSES IN ALL
AGONISTS
von WILLIBRAND’S  POSITIVE RESPONSES IN ALL
=
DISEASE AGONISTS EXCEPT RETOCETIN
 MINIMAL RESPONSE WITH
BERNARD-SOLIER
RESTICETIN,
SYNDROME =
 POSITIVE RESPONSES IN ALL
(adhesion disorder)
AGOINSTS
 NEGATIVE RESPONSES WITH
GLANZMAN’S
= ADP, ARA, EPINEPHRINE,
THROMBASTHENIA
COLLAGEN AND THROMBIN
 POSITIVE RESPONSES IN ALL
STORAGE-POOL AGONISTS,
=
DISEASE  ADP HAS BELL-SHAPED
RESPONSE

HEMA (MTAP) HEMO 5, 6, & 7 Page 5 of 11

 HEMOSTASIS 6 TESTED BY:
 BT
CONGENITAL HEMORRGHAGIC  RISTOCETIN COFACTOR ASSAY / rCo ASSAY
 VWF:Ag ASSAY
DISORDERS  PLATELET COUNT
 APTT
 FACTOR 8 ASSAY
VON WILLEBRAND DISEASE  LOW-DOSE RESTOCETIN-INDUCED PLATLET
 TYPES: AGGREGOMETRY (LD-RIPA), AGAROSE –GEL
 1 ELECTROPHORESIS
 2-A
 2-B TREATED BY:
 2-M  ESTROGEN
 2-N  DDAV (INSCREASES VWF)
 3  E-AMONICAPROICACID/EACA (INHIBITS PLASMIN)
 FACTOR 8 CONCENTRATE
 QUANTITATIVE (there is a deficiency in the
concentration) or STRUCTURAL ABNORMALITY OF VWF
(leading to a disorder) HEMOPHILIAS
 (DECREASED ADHESION OF PLATELET AND  Second in prevalence among congenital bleeding
ENDOTHELIUM) disorders
 Decreased VWF leads to BLEEDING  Occur in 1 in 8000 (1:10,000) individuals, mostly male
 TYPE O = Lowest VWF  TYPES:
 INCREASED IN:
 Pregnancy TYPE A 85% FACTOR 8
 Stress FACTOR 9
 Inflammation TYPE B / CHRISTMAS DISEASE 14%
(HINDUS)
 Exercise TYPE C / ROSENTHAL
1% FACTOR 11 (JEWS)
SYNDROME

 SEX / X-CHROMOSOME ASSOCIATED (FEMALE CARRIER,

MALE OFFSPRINGS)
 DELETIONS, NON-SENSE MUTATIONS, MISSENCE
MUTATIONS
XX CARRIER
XY HEMOPHILIAC

HEMA (MTAP) HEMO 5, 6, & 7 Page 6 of 11

 SYMPTOMS:
 BLEEDING (CNS, PERITONIUM, GIT, KIDNEYS)
ACQUIRED HEMORRHAGIC
 PARALYSIS, STROKE, SIEZURES, COMA
 HEMORRAHGE (JOINTS AND MUSCLES), BRUSING /
DISORDERS
ECCHCHYMOSIS
 MUCOSKELETAL LESIONS AND DEFORMITIES TESTED BY:
 MAY DEVELOP AIDS  APTT, PTT, TT/TCT
 PLATELET COUNT
 Spontaneous bleeding  COMPLETE BLOOD COUNT
 Prolonged bleeding from cuts
 Nosebleeds with no known cause TREATED BY:
 Tightness in your joints  VITAMIN K
 Internal bleeding  FRESH FROZEN PLASMA/FFP (2 UNITS)
 CRYOPRECIPITATE (FIBRINOGEN)
 PLATELET CONCENTRATE
TESTED BY:  PROTHROMBIN
 PT (NORMAL)  ACTIVATD PROTEIN C
 TT (NORMAL)  FACTOR VII ANTITHROMBIN – III / AT – III CONCENTRATE
 APTT (PROLONGED)
 FACTOR ASSAY (8)
 MIXING STUDIES/INHIBITOR STUDY

HEMOPHILIA A SPECIFIC HEMORRHAGIC

CORRECTED =

LUPUS ANNTICOAGULANT DISORDERS

UNCORRECTED =
INHIBITOR/ALLOANTIBODIES 1. LIVER DISEASES
 HEPATITIS, CIRRHOSIS, HEPATOMA, ETC.
 VITAMIN K DEPENDENT  DYSFUNCTIONAL
TREATED BY: ↓
 FACTOR 8 (2x/DAY), 9, 11 LOW PROCOAGULANTS (2, 7, 9 & 10)
 DDAVP (5=SPECIFIC) EXCEPT 1, 3, 4, 8, & 12
 FACTOR 7 (EXTRINSIC)
 STEROIDS  REGULATORY PROTEINS (PROTEINS & C, AT-III)
 DIFFUSED INTRAVASCULAR COAGULATION/DIC
PATIENT’S PLASMA VOLUME X ↓
FACTOR 8 + D-DIMER + FDP, PROLONGED
= TARGET FACTOR 8 LEVEL –
DOSAGE EUGLOBULIN CLOT LYSIS
INITIAL FACTOR 8 LEVEL
PATIENT’S
WEIGHT (KG) X 65 ML / KG X  FIBRINOGEN (1) IS HIGH :
PLASMA =
1 - HCT  ACUTE PAHASE REACTANT.
VOLUME
 MAY HAVE AN ABNORMAL
STRUCTURE : DYSFIBRINOGENEMIA

 PROLONGED REPTILASE TIME (CONFIMARTORY)

 THROMBIN TIME (TT) (COMMON PATHWAY)
 HIGH DOSE THROMBIN TIME (HiTT) (COMMON
PATHWAY)
 LOW PLATELET COUNT AND AGGREGATION
SURVIVAL

HEMA (MTAP) HEMO 5, 6, & 7 Page 7 of 11

2. RENAL FAILURE TESTED BY:
 Associated with platelet dysfunction  MIXING STUDIES
 BLEEDING (GIT)
 SLE, AGN PATIENT’S PLASMA  PT & APTT  PROLONGED
 HEMOLYTIC UREMIC SYNDROME / HUS and
 THROMBOTIC THROMBOCYTOPENIC + NORMAL PLASMA/CONTROL PLASMA  CORRECTED
PURPURA/TTP UNCORRECTED PT & APTT (FACTOR
 HYALINE THROMBI (causes lysis of (INHIBITOR) DEFICINECY)
RBC’s)
 SCHISTOCYTES (ruptured RBC’s) 5. AUTO ANTI – VIII INHIBITOR
 Inhibits 8, 2, 5, 9, 13 & VWF
FINDINGS:  Common in Pregnant patients and Men >60
 Decreased platelet adhesion. Aggregation years
 Platelet coating by Guanidosuccinic acid or  Associated with SLE, RA and
phenolic compounds LYMPHOPROLIFERATIVE DISORDERS
 + D-DIMER, + FDP
 FIBRINOGEN (HIGH) 6. ACQUIRED VON WILLEBRAND’S DISEASE
 PROLONGED BLEEDING TIME  Associated with : (VwF INHIBITOR)
 NORMAL PT and APTT  Autoimmune diseases
 Lymphoproliferative disease
TREATED BY:  Myeloproliferative disease
 DESMOPRESSIN ACETATE/DDAVP (Increases VWF)  Benign monoclonal gammopathy
 Wilm’s tumor
3. NEPHROTIC SYNDROME  Intestinal angiodysplasia
 Increased glomerular permeability  HUS
 Associated with:  Pesticide exposure
 PROTEINURIS
 HEMATURIA 7. ACQUIRED HEMOPHILA
 LIPIDURIA/CHYLURIA  DUE TO ANTIBODIES
 Damage of nephrons in patients not associated
with streptococcal diseases ANTIPROTHROMBIN LUPUS
 URINARY EXCRETION OF: FACTORS 5 & 8
 FACTORS 2, 7, 9, 10 & 12, AT-III & IZONIAZID
INHIBITORS
PROTEIN C FACTORS 5 & 2 BOVINE
 Affected tests: INHIBITORS THROMBIN
 APTT (prolonged)
 PT (prolonged) TESTED BY:
 TT (normal because factor 1 is not  MIXING STUDIES
excreted)
PATIENT’S PLASMA  PT & APTT  PROLONGED
4. VITAMIN K DEFICIENCY
 MAY BE DUE TO: + NORMAL PLASMA/CONTROL PLASMA  CORRECTED
 BILIARY TRACT OBSTRUCTION UNCORRECTED PT & APTT (FACTOR
(ATRESIA) (INHIBITOR) DEFICINECY)
 FAT MALABSORPTION (VITAMIN K =
FAT SOLUBLE), DIARRHEA
 HDN (STERILE GUT)
 PROTEIN IN VITAMIN K
ANTAGINISTS/PIVKA
– E.g WARFARIN (Dysfunctional
Factors 2, 7, 9 & 10)
HEMA (MTAP) HEMO 5, 6, & 7 Page 8 of 11
 HEMOSTASIS 7
QUALITATIVE PLATELET 2. GLANZMANN’S THROMBASTHENIA
DISORDERS  Deficiency of GP Ib/ IIIa which binds to VWF and
FIBRINOGEN
 Disorder is not due to high or low platelet count but, it’s
 Low PF3 (Platelet Factor 3)
due to different abnormal functions of platelets due to
 Associated with chromosome 17
some structural defects in the surface or other types of
 Prolonged CRT (Clot Retraction Time)
defects.

SUBTYPES:
PROLONGED BLEEDING TIME A. TYPE 1

WITH NORMAL PLATELET B. TYPE 2
ABSENT GP IIb / IIIa

COUNT  SUBNORMAL

TREATED BY:
I. ADHESION DEFECTS  NORETHINDRONEACETATE (HORMONE)
 ANTIFIBRINOLYTIC (AMINOCAPRDIC/TRANEXANIC
ACID)
1. BERNARD – SOULIER / GIANT PLATELET  FACTOR 7
(LARGE PLATELETS) SYNDROME

II. SECRETION DISORDERS /

RELEASE REACTIONS
 Deficiency of GP Ib/ IX /V which binds to VWF
 Hereditary
1. STORAGE POOL DISEASES
 Associated with chromosomes 3, 17 & 22
 In ALBINO (Absence) or NON-ALBINO (Small
 Treated by:
Amount)
 DESMOPRESSIN ACETATE
– Elevates VWF  Accumulation of SEROTONIN (derived from
– Essential for binding of platelets platelets)
to endothelium

 FACTOR 7
– May help in the adhesion
function of platelet EXAMPLES:
 HERMANSKY PUDLACK SYNDROME
– Swiss cheese platelet appearance
– Associated with chromosome 19
– Dilation of the tubular system

HEMA (MTAP) HEMO 5, 6, & 7 Page 9 of 11

 DECREASED AGGREGATION
4. DEFICIENCY OF PLATELET RECEPTORS FOR
ADP
P2x, P2y1, P2y2
 PARIS – TROSEAU SYNDROME 5. DEFICIENCY OF ALPHA – ADRENERGIC
– GIANT ALPHA GRANULES RECEPTOR DEFECTS
– CHROMOSOME 11 EPINEPHRINE

 CHEDIAK - HIGASHI SYNDROME
– DEFICINECY OF DENSE GRANULES of
platelets
– Associated with CHROMOSOME 13
(PANCYTOPENIA)
– GIANT LYSOSOMALGRANULES IN WBC’S
6. SCOTT SYNDROME
 Deficient transport of PHOSPHATIDYL
CHOLONE and PHOSPHATIDYLETHANOLAMINE
 PHOSPHOLIPID FLIP IN PLATELET ACTIVATION
7. STORMDKEN SYNDROME
 Defective AMINOPHOPHOLIPID TRANSLOCASE
 Platelets are always in the activated state
 Platelets easily aggregates, adhere, and forms a
plug

III. PLATELET FUNCTION DEFECTS

DUE TO DRUGS
 WISCOTT – ALDRICH SYNDROME
– X-LINKED (MALE)
1. CYCLOOXEGENASE INHIBITORS
– LOW ALPHA AND DENSE GRANULES
– THROMBOCYTOPENIA  INHIBITS PLATELET AGGREGATION
 ASPIRIN/ACETYLSALICYLIC ACID,
 IBUPROFEN,
 GRAY PLATELET SYNDROME
 KETOPROFEN,
– DEFICIENCY IN ALPHA GRANULES
 FENPROFEN
– THROMBOCYTOPENIA
 SULFINPYRAZONE

 QUEBEC PLATELET DISORDER

– DEFICIENCY OF MULTIMER PROTEIN IN
2. MEMBRANE FUNCTION INHIBOTORS:
ALPHA GRANULES  INHIBITS PLATELET AGGREGATION AND
BINDING OF GP IIb/IIIa and FIBRINOGEN
 CLOPIDOGREL,
 TICLOPIDINE

 INHIBITS PHOSPHODIESTERASE WHICH

CONVERTS cAMP to AMP (DECRESING
PLATELET FUNCTION)
 ABCIXIMAB (drug for inflammation)
 DIPYRIDAMOLE

2. THROMBOXANE PATHWAY DISORDER

 INHIBITS CALCIUM AND THROMBIN AND
ASPIRIN,
INHIBITS PLATELET FUNCTION
IBUPROFEN (INHIBITS CYCLOOXEGENASE)
 ANTIBIOTICS:
3. DEFICIENCY OF GP VI  PENICILLIN
HEMA (MTAP) HEMO 5, 6, & 7 Page 10 of 11
  CEPHALOSPHORIN
 MONOBACTAM
 CARBAPENEM
 NITROFURANTOIN
3. PLASMA EXPANDERS:
 INHIBITS PLATELET AGGREGATION
 HYDROETHYL STARCH
 DEXTRAN (substitute if blood is not
available)
4. OTHERS:
 INHIBITS PLATELET AGGREGATION AND
SECRETION
 NITROGLYCERIN
 ISOSORBIDE DINITRATE
 NITROPRUSSIDE
 PHENOTHIAZINE
 PROPANOLOL (for patients with CHF)
 TRICYCLIC ANTIDEPRESSANTS (for
patients with psychiatric disorders)

HEMA (MTAP) HEMO 5, 6, & 7 Page 11 of 11

Hematology 4.3 Cardiopulmonary Bypass
Surgery (CPB) – is a procedure
HEMOSTASIS
where:

4. DISORDERS AFFECTING Platelet Activation

PLATELET FUNCTION

4.1 Myeloproliferative
Disorders: Polycythemia Vera Fragmentation and
(PV), Myelofibrosis (MF) Degranulation

 Abnormal shape of
platelets (because of the Thrombocytopenia
normal shape, it affects the
(Accumulation in the Bypass
clotting mechanism so it has,)
 Decreased procoagulant Materials) – caused by excessive
production of platelets due to the
activity (platelets are essential surgical procedure
for coagulation, particularly
intrinsic, extrinsic, and common
pathway)
 Decreased secretory Bleeding
granules and survival CPB- a procedure that affects the platelet
(leading to excessive bleeding) number because of the materials used in
Bypass
4.2 Multiple Myeloma and
4.4 Liver Diseases- can affect a lot
Waldenstrom’s
of factors or compounds, particularly:
Macroglobiulinemia – are disorders
affecting your plasma cells, in which:  Decreased Procoagulants
(2, 7, 9, 10)- Vitamin K
Paraprotein
dependent
(a certain kind of protein produced by  And Regulatory Proteins,
Multiple Myeloma and Waldenstrom’s
Macroglobiulinemia) (S, C & AT- III), PF3 – all
produced by the liver
 Dysfibronogenemia-
abnormal fibrinogen, may be
Coats Platelet Membrane produced if you have liver disease
 Increased Fibrinolysis
 Hypersplenism
Interferes Fibrin  Thrombocytopenia
Polymerization of your blood clot  Decreased Platelet
Adhesion, Aggregation

Bleeding Bleeding

Hyperviscosity
4.5 Uremia- disease of the kidney  Thrombosis
caused by:  Hyperlipidemia
Inhibition of Urea Cycle  Peripheral Arterial
Occlusive Disease
 Acute Arterial Occlusion
Increased Guanidosuccinic
Acid (GSA), Nitric Oxide
 Increased Platelet
Activity Increased
Guanylate Cyclase Activation Aggregation and Clotting
 Increased Fibrinogen

Inhibition of Platelet Adhesion

QUANTITATIVE PLATELET
and Aggregation
DISORDERS: HIGH PLATELET
COUNT

Bleeding 2. Thrombocytosis (450,000/µl-

1,000,000µl)
4.6 Hereditary
Afibrinogenemia- absence of  May be reactive/
fibrinogen in the blood (Prolonged secondary to other
BT, PT, APTT, TT, CRT) disease like:
o Iron Deficiency
Abnormal Fibrinogen- may be
Anemia (IDA) (Blood
produced in the liver
Loss)
o Stress (Release of
Decreased Platelet platelets from

Aggregation, Adhesion Spleen)

o Polycythemia Vera
(PV)
Bleeding o Myeloid Metaplasia
(Hematopoiesis)
4.7 Hypercoagulable Platelets  May be due to Physiologic
- Platelets can be easily activated due to Responses like:
inflammatory conditions and these o Exercise (Transfer of
platelets are called Hypercoagulable
Platelets
water to Extra
Vascular Fluid)
 Mycordial Iinfraction
o Blood Loss
 Diabetes Mellitus
o Surgery
 Stroke
 o Rebound (Marrow EG. Fanconi Anemia=
Suppressants Classic Aplastic Anemia
Withdrawal) due to chemicals like
 May be due to Infections benzene (characterized by

like: pancytopenia)

o Kawasaki Disease
o Ulcerative Colitis Pancytopenia (low RBC,
WBC, and platelets)
 Treated By:
o Interefron 1.11 Neonatal Hypoplasia
o Myelosuppressive = viruses and bacteria
Drugs (Melphalan, attack Megakaryocytes
Busulfan, and Thrombocytes
Hydroxyurea, This viruses are due to:
Anagrelide)
Varicella(chickenpox),
QUNATITATIVE PLATELET Rubeola(measles),
DISORDERS: PROLONGED Rubella(german measles)
BLEEDING TIME WITH LOW
Cytomegalo virus/CMV,
PLATELET COUNT
Epstein Bar Virus/ EBV
1. Thrombocytopenia=
Neisseria meningitides
Decreased Count
(<100,000 cells/µl) Toxin
Common signs of
Thrombocytopenia: Damage endothelium
 Petechiae= <3 mm
the damage endothelium requires
& pinpoint platelets. The platelets becomes
(characteristic of dengue activated because of the
fever) endothelium
 Purpura= >3 mm
1.12 Acquired
(skin) (darker in color
compared to petechiae)
Hypoplasia= Radiation,
 Epitaxis (bleeding of the Drugs: Cytotoxicity to
Nose) Megakaryocytes
 Ecchymosis/bruise=  Chlorothiazide
>3 mm & irregular (diuretic)
found in extremities and  Toltbutamide (for
other parts of the body
diabetes)
 Gingival Bleeding  Chloramphenicol
1.1 HYPOPLASIA= lack of (antibiotic)
bone marrow  Anagrelide
megakaryocytes  Diethylstilbestrol
 1.12 Acquired Hypoplasia 1.4 IMMUNE PLATELET
Chemotherapeutic Drugs: DESTRUCTION
Nuclear Destruction of (Immune- associated with
antibodies)
Megakaryocyte
1.41 Idiopathic
 Methotrexate, Thrombocytopenic
 Busulfan Purpura/ ITP
 Cytosine Arabinoside Prolonged BT and CRT
 Cisplastin  Caused by viral
 Cyclophosphamide infections in
 Zidovudine children
 Destruction by
1.2 INEFFECTIVE antibodies (reason
THROMBOPOIESIS why it is called an
immune platelet
 Pernicious
destruction) and T-
Anemia
cytotoxic cells in
 Fanconi Anemia
adults
 Viruses
 Treated by
 Multiple Myeloma
Intravenous
 Lymphoma
Immunoglobulins
 Other
(IVIG), Steroids ,
malignancies
Splenectomy

1.3 NON-IMMUNE PLATELET 1.42 Immunologic

DESTRUCTION (not Drug- Induced
antibody related) Thrombocytopenia
1.31 Idiopathic (due to the destruction of
the drug through a protein
Thrombocytpenic
and antibody which
Purpura/ITP- the cause is destroys the platelet)
unknown and there is what
you call low platelet count Drug – Fab OF Ab – GP lb/X, GP II-b/III-
and there is the presence of A Platelet (Innocent Bystander)
the red spots >3 mm
Drug (Hapten) – Protein – Ab – Platelet
 Petechiae (Eg. Penicilin)
 Ecchymosis
Drug – Autoantibodies – Platelets (Eg.
 Epistaxis Gold Procainamide, Levodopa)
 Purpura
Other drugs which can
 Hematuria
destroy platelets are:

Analgesis/ NSAID’s (PAS)

 Phenylbutazone,  Carbamazepin
 Acetaminophen, e
 Salicylate)  Meprobamate
 Phenobarbital
Sulfa Drugs: CF
Others: QICQAC-
 Chlorthalidone
chemicals used for
 Furosemide) agriculture

Antibiotics: SPRANC  Quinine

 Insecticides
 Streptomycin
 Chloroquine
 Penicillin
 Quinidine
 Refampin
 Alkaloids
 Aminosalicylic
 Carbamazepine
acid
 Novobicin 1.43 Neonatal Alloimmune
 Cephalothin Thrombocytopenia/ NAIT

Heavy Metals: GAMB Platelet specific antigens:

GPIII-a (Caucasians), GP II-b
 Gold
(Asians)
 Arsenic
 Mercury
 Bismuth
Father HP 1a Ag+
Oral Hypoglycemics:
CT
Antibodies Baby
 Chlorpropamid
e HP 1a Ag+
 Tolbutamide
Mother HP 1A Ag-
Sedative/
Platelet destruction
Anticonvulsants:
CDMP For example, the father is positive
for the antigen (Human Platelet 1a
 Chlorpromazine Ag), and the mother is negative, and
 Diphenylhydant the baby got the platelet type from
the father. So that, the mother
oin
develop antibodies, and these
 Methion antibodies are capable of platelet
 Troxidone destruction because of the exchange
of blood between the baby and the
CMP mother. Just like the incompatible
blood type (Rh incompatibility), we 1.46 Secondary
also have the incompatibility of the
Thrombocytopenia Presumed
platelet type between the mother and
To Be Immune Mediated
the baby and this condition is known
as the NAIT Interferons

1.44 Neonatal Autoimmune In CLL, SLE & Malaria Interleukin-2

Thrombocytopenia (Mother with
Colony Stimulating Factors
ITP or SLE)
Thrombocytopenia
Increased removal of platelet
 Associated with conditions
antibodies by Reticulo
known as Chronic
Endothelial System (RES)
Lymphocytic Leukemia,
Decreased maturation of RES Systemic Lupus
of infants Erythematosus, and
Malaria.
1.45 Post- Transfusion
 The said diseases are
Purpura: W>M
capable of producing:
1 week after FFP, PC o Interferons –antiviral
Transfusion agents
o Interleukin-2 – a type
 Alloantibodies of patient of cytozyme produced by
of the patient will develop WBC
 This Alloantibodies of tje o Colony Stimulating
patient may include the: Factors/ CSF
o HPA- Ia Ag DR (PI-  These Interferons,
A1, PI-A2) Interleukin, and CSF has
o HPA- 3a Ag (BAK) the ability to facilitate
o HPA-4 (PENN) the destruction of
o HPA- 5b (Br) platelets in which the
 These antibodies usually mechanism is unknown
destroys the platelets of  These compound
the donor produced by the person
 The antigen of the having such diseases, has
donor’s platelets will be the ability to develop
attacked by the Thrombocytopenia
antibodies of the patient
1.47 Pregnancy- Associated  In HDN, this is caused by
Gestational Thrombocytopenia/ the incompatibility (Rh or
Incidental Thrombocytopenia of ABO) between the baby
Pregnancy and the mother
 Usually the Mother is Rh-
The pregnant patient develop
or the mother has the
these: HELLP
ability to develop
 Hemolysis, antibodies against the
 Elevated Liver Enzymes, baby’s antigen, and the
 Low Platelet Count baby’s antigen is derived
from the father’s blood
Disseminated Intravascular
type
Coagulation (DIC) may be the
 After the lysis of the RBC
cause of Thrombocytopenia
caused by the reaction
Unknown cause/s but between the antibodies of
associated with: the mother and the
baby’s RBCs, there will be
 Pre-eclampsia and other
products produced after
Hypertensive Disorders of
the RBC hemolysis
Pregnancies
 These products can also
Other Symptoms: destroys platelets causing
platelet destruction.
 Proteinuria
 Abdominal Pain 1.49 HIV, SLE, TTP,
 Blurred Vision Antiphospholipid Syndrome
 Headache
Associated with
 Mental Function
Thrombocytopenia immune by
Disturbance
that destruction
 Seizure

1.48 HDN= RBC Lysis Products 1.5 NONIMMUNE PLATELET

DESTRUCTION
Platelet Destruction
(EXPOSURE OF
Thrombocytopenia PLATELETS TO
NONENDOTHELIAL
 Thrombocytopenia may be
SURFACES)
also associated with
Hemolytic Disease of the
Newborn (HDN)
 1.51 Thrombotic blocking of the
Thrombocytopenic Purpura/ Hyaline Thrombi. The
TTP/ Moschcowitz Syndrome decrease of blood
supply is called
Triad of Symptoms:
Ischemia.
 Microangiopathic
Hemolytic Anemia/
Moschcowitz Syndrome is also
MAHA –means there is
hemolysis caused by the
associated with the
destruction of RBCs accumulation of usually large
 Thrombocytopenia vWF/U:vWF with endothelial
 Neurologic cells and megakaryocytes (all of
Abnormalities these will block the small blood vessels
leading to destruction of RBCs and
Pentad of Symptoms: platelets)

 +Fever Stored in Weibel-Palade Bodies

 Renal Dysfunction (Granules)

What causes the destruction of A disintegrin-like

the platelets and the RBCs as metalloprotease domain with
well? Thrombospondin Type 1 Motiff/
Adamts 13 (enzyme)
 The presence of Hyaline
Thrombi (VWF & Platelets)  Which will cleave the
in Arterioles & Capillaries large VWF/ULVWF into
o This causes the smaller VWF
fragmentation of Other Symptoms:
RBCs and platelets
so that there will be  Hemoglobinuria –because of
the hemolysis, presence of
three types of RBC haemoglobin in urine
fragmentations:  Hemosiderinuria –for those
a. Schistocytes with excess iron which are
demonstrated in the urine
b. Keratocytes (Bite
 Hyperbilirubinuria
Cells)
 Albuminuria
c. Microsperocytes –
small microcytic  High LDH (Due to
hypochromic cells Hemolysis)
o Which will lead to  Anorexia
later on, a decrease  Diarrhea
in blood supply  Nausea
because of the  Weakness
 Has 4 types  Entero Hemorrhagic E.coli
(EHEC) which produces
1. Single = with Adamts 13
Shigella-like toxin
2. Recurrent = with Adamts
12 This toxin can damage the
3. Drug Induced (Ticlopidine, kidneys leading to the
Clopidogrel) = with formation of Hyaline
Adamts 13 Thrombi which can cause
4. Chronic Relapsing = Thrombocytopenia
deficiency of Adamts 13
Drugs (Methotrexate) is also
Treated By: associated with HUS, and
can cause Damage to Renal
 Plasmapheresis
Endothelium leading to the
 Steroids
formation of ULVWF leading
 FFP –rich with other Factors
except Factor A
to Platelet Aggregation and
 Cryoprecipitate-Poor then later on,
Plasma –rich in Factor A Thrombocytopenia
 Immunosuppressive
Agents (Vinchristine,
Azathioprine) 1.53 Disseminated
Intravascular Coagulation/ DIC
All are given to inhibit the immune
system because the possibility is,
= A Thrombotic Disorders
all these nonimmune type of Which Shows Thrombocytopenia
platelet destruction, the
complications will lead to the Caused by:
formation of antibodies which can
cause further damage to the  Trauma
organs of the patients
 MI
1.52 Hemolytic Uremic  Embolism
Syndrome (HUS) = Milder  Aneurysm
Symptoms Of TTP With Renal What’s unique about the DIC is that
Failure (High Creatinine & there is both coagulation and bleeding
at the same time so there is an
BUN), Anuria, Cylindruria, With
imbalance in the Hemostasis
No Neurologic Symptoms
Can also be caused by:
Caused by:
 CA
 Shigella dysenteriae which
 Endotoxins (Bacteria,
produces Shiga Toxin Protozoan, Fungal,
Viral)
  Snake and Spider
Venom
 Headstroke
 Transfusion Reactions
 Eclampsia
 Leukemia
 Pancreatitis
 TTP
 HUS
 DM
 Thrombotic Diseases

1.54 Others:

 Gaucher’s Disease
(Gaucher Cell/ Cell With
Mucopolysaccharide
Deposits)
 Hodgkin’s Disease (Reed-
Sternberg Cell/ Plasma
Cell) – having a nose and eyes
appearance
 Sarcdidosis
 Lymphoma
 Cirrhosis
 Splenomegaly which
increases Sequestration in
the Spleen leading to
Thrombocytopenia
 Thrombocytopenia can
also be cause by Whole
Blood Transfusion causing
Damage Platelets because
of antibodies
NON-MALIGNANT QUALITATIVE LEUKOCYTE 3. PELGUER-HUET ANOMALY
DISORDERS
• HYPOSEGMENTATION OF NEUTROPHILS (3-5
- Not cancerous; cells are abnormal but will normal) WITH INCREASE CHROMATIN
not affect other organs
• PEANUT OR DUMBELL –SHAPED NUCLEUS
• ASSOCIATED WITH AML (acute myelocytic
*“BELOW ARE THE QUALITATIVE”
leukemia) (PSEUDO-PELGUER)
1. REACTIVE LYMPHOCYTE/VIROCYTE/VARIANT
• SHIFT TO THE LEFT (STL)
LYMPHOCYTE /ATYPICAL LYMPHOCYTE
• TYPE 1: DENSE CHROMATIN WITH VACUOLES
• TYPE 2: FRIED EGG CYTOPLASM WITH
VACOULES (other name is Downy Cell
associated with infectious mononucleosis-
caused by hepatitis virus)
• TYPE 3: FINE CHROMATIN, WITHOUT
VACUOLES WITH NUCLEOLI
• ASSOCIATED WITH VIRAL INFECTIONS,
TOXOPLASMOSIS (parasitic disease caused by 4. HYPERSEGMENTED
toxoplasma gondii; cat is definitive host; man NEUTROPHIL/MACROPOLYCYTE
is accidental host), PERTUSSIS (caused by
• ASSOCIATED WITH PERNICIOUS ANEMIA
Bordetella pertussis)
(STR - Shift to the Right)
• INFECTIOUS MONONUCLEOSIS, HEPATITIS,
ETC.

5. CHEDIAK-HIGASHI SYNDROME
• GIANT CYTOPLASMIC BIZZARE GRANULES IN
(Monocyte) GRANULOCYTES, PHAGOCYTES AND
LYMPHOCYTES
(Type 1 – 3)
• ASSOCIATED IN ALBINISM (lacks melanin),
HEMORRHAGE AND INFECTIONS
2. LEUKEMOID REACTIONS (>50 X 109/L)
• Marked increase in neutrophils >50,000 x 109
• Shift to left = immature forms
• Severe infection, trauma, bone marrow
infiltration
• Looks like leukemia (no blasts)
Differentiation between the Two

LEUKEMOID CML (Chronic

REACTIONS myelocytic leukemia)
Opposite sa LR
LAP SCORE POSITIVE LAP SCORE NEGATIVE
BAND CELLS (STL) IMMATURE MYELOID
CELLS
ASSOCIATED WITH (tuberculosis) TB, TUMORS,
PERTUSSIS
6. MAY-HEGGLIN ANOMALY
• GRAY-BLUE STAINING INCLUSIONS IN THE
CYTOPLASM OF GRANULOCYTES AND
MONOCYTES
• (low platelet count) THROMBOCYTOPENIA
AND GIANT PLATELETS
• ASSOCIATED WITH HEMORRHAGIC
DISORDERS
7. DOHLE BODIES
• PALE BLUE OR GRAY CYTOPLASMIC
INCLUSION BODIES (rRNA –ribosomal RNA)
IN PARALLEL ROWS SEEN IN NEUTROPHILS
• ASSOCIATED WITH PREGNANCY, SURGERY
AND INFECTIONS
8. ALDER-REILLY ANOMALY
• LARGE AZUROPHILIC GRANULES IN
NEUTROPHILS DUE TO DEPOSITION OF
MUCOPOLYSACHARRIDES
• MUCOPOLYSACHARRIDOSIS
9. GAUCHER CELL
• MONOCYTE WITH GLUCOCEREBROSIDES
AND ECCENTRIC NUCLEUS (CRUMPLED
TISSUE PAPER)
• ASSOCIATED WITH GAUCHER’S DISEASE
(DEFICIENCY OF BETA-GLUCOSIDASE)
3 TYPES
• I (ADULTS: LIVER AND SPLEEN)
• II (INFANTILE: CEREBRUM)
• III (JUVENILE: SPLEEN, LIVER, and
CEREBRUM)
10. NEIMANN-PICK CELL
• MACROPHAGE WITH LIPID DROPLETS
(SPHINGOMYELIN AND CHOLESTEROL)
• ALSO CALLED FOAM CELLS
• NEIMAN-PICK DISEASE
• TYPE A = INFANTS
• TYPE B = ADULTS
NON-MALIGNANT QUANTITATIVE LEUKOCYTE
DISORDERS
“QUANTITATIVE”
NEUTROPHILIA (INCREASED)
• INFECTIONS
o PYOGENIC (PUS-FORMING)
BACTERIA (*staphylococcus,
streptococcus)
o RICKETSSIA EG. Ricketssia prowazeki
(*causes typhus fever)
• INFLAMMATORY RESPONSES TO TISSUE
RESTRUCTION
o CHEMICALS, DRUGS, VENOM
o THERMAL INJURY, SURGERY
o ACCIDENTS, HEMORRAHGE
o NEOPLASIA (*Cancer)
• DRUGS
o LITHIUM (FOR BIPOLAR DISORDER)
o CORTICOSTEROIDS (FOR
AUTOIMMUNE DISORDERS_
• STRESS (PHYSICAL OR EMOTIONAL)
NEUTROPENIA (DECREASED)
• STEM CELL DISORDER
o INHERITED (CFU-GM) (*Granulocyte
& Monocyte)
o ACQUIRED
 BENZENE
 DRUGS (AMIDOPYRINE)
 VITMIN B12 DEFICIENCY
• INCREASED DESTRUCTION
o INFECTIONS
 BACTERIAL: TYPHOID FEVER,
PARATYPOID FEVER,
BRUCELLOSIS
 VIRAL: MEASLES, GERMAN
MEASLES,
 YELLOW FEVER, INFECTIOUS
HEPATITIS
o IMMUNE REACTIONS
 BLOOD TRANSFUSION
 SYSTEMIC LUPUS
ERYTHEMATOSUS/SLE
 DRUGS (AMIDOPYRINE)
• SPLENIC SEQUESTRATION
• PSEUDONEUTROPENIA (DECREASED
NEUTROPHILS WITH NORMAL
GRANULOCYTES, EG. HYPERSENSITIVITY)
EOSINOPHILA (INCREASED)
• TISSUE INVADING PARASITES
• BACTERIAL INFECTIONS (SCARLET FEVER
caused by Streptococcus pyogenes)
• ALLERGIC REACTIONS
o ASTHMA
o PSORIASIS
• NEOPLASIA
• POST-IRRADIATION
EOSINOPENIA (DECREASED)
• ACUTE BACTERIAL INFECTION
o SEQUESTRATION, MARGINATION,
CHEMOTAXIS
• ACTH
o DECREASED BONE MARROW
RELEASE
o INCREASED MARGINATION
BASOPHILA (INCREASED)
• HYPERSENSITIVITY REACTION (ALLERGIES)
• ESTROGEN THERAPY
• HYPOTHYROIDISM
• MYELOPROLIFERATIVE DISORDERS
(INVOLVING CFU-GEMM)
BASOPENIA (DECREASED)
• ACUTE INFECTIONS
• STRESS
• HYPERTHYROIDISM
• GLUCOCORTICOIDS
LYMPHOCYTOSIS (INCREASED)
• NORMAL LYMPHOCYTES
o PERTUSSIS (*Whooping cough)
• REACTIVE/VARIANT LYMPHOCYTES
o ABSOLUTE
 INFECTIOUS
MONONUCLEOSIS (EPSTEIN-
BARR VIRUS/EBV)
 VIRAL HEPATITIS/HAV
(Hepatitis A – Virus)
 KAPOSI’S
SARCOMA/CYTOMEGALOVIR
US/ CMV
o RELATIVE
 TOXOPLASMOSIS (Caused by
Toxoplasma gondii)
 VIRUSES
 - MEASLES o GASTROINTESTINAL DISEASES
- GERMAN MEASLES • CHRONIC MYELOPROLIFERATIVE
- MUMPS DISORDERS/CMPD
- CHICKENPOX o EG, CMML, CML = Chronic
 NON-VIRAL Myelomonocytic Leukemia (CMML),
- TB (tuberculosis) Chronic myelogenous leukemia
(Mycobacterium (CML),
tuberculosis)
- SY (syphilis)
MONOCYTOPENIA (DECREASED)
(Treponema pallidum)
- MALARIA • Due to GLUCOCORTICOID THERAPY
(Plasmodium
falciparum)
- BRUCELLOSIS
(Brucella abortus)
- DIPTHERIA
(Corynebacterium
diptheriae)
- RICKETTSIAL
INFECTIONS
 EG. Ricketssia
prowazeki
 (TYPHUS
FEVER)
 IMMUNE DISORDERS
- AUTOIMMUNE
HEMOLYTIC ANEMIAS
- IDOPATHIC
THROMBOCYTOPENIA
- THYROTOXICOSIS
(TOXIC GOITER)

LYMPHOCYTOPENIA (DECREASED)
o STEROID THERAPY
o EPINEPHRINE RELEASE (FIGHT OR
FLIGHT)
o APPENDICITIS
o AIDS
o SLE (Systemic Lupus Erythematosus)
o CHEMOTHERAPY

MONOCYTOSIS (INCREASED)
• BACTERIAL INFECTIONS
o TUBERCULOSIS/TB
o SABE/SBE/ Subacute Bacterial
Endocarditis caused by
Streptococcus pyogenes
o SYPHYLLIS/SY
• INFLAMMATORY RESPONSES
o SURGERY
o TUMORS
o SLE (Systemic Lupus Erythematosus)
LEUKEMIAS o Common in blast cells or cells
starting with “pro”
 EXCESSIVE PROLIFERATION OF IMMATURE  INCREASED MITOTIC FIGURES
AND/OR MATURE LEUKOCYTES
o If the cells are the immature type =
acute type CYTOPLASMIC
o If cells are mature type = chronic type
 Cells starts in the bone marrow then cells  AUER RODS (seen only in MYELOBLASTS)
will proliferate and goes to peripheral blood o Common finding in acute
then may go to other organs myeloblastic leukemia particularly
MO-M3)
 MIXED GRANULATION (BASOPHIL AND
RISK FACTORS EOSINOPHILS)
 DECREASED GRANULATION
1. CHEMICALS: BENZENE (*can cause aplastic
 CYPLASMIC FRAGMENTATION
anemia), CARBON TETRACHLORIDE, INSECTICIDES,
PESTICIDES, ETC.
2. VIRUSES: HTLV (human T-cell lymphotropic virus), OVERALL
ETC
 ABNORMAL SIZE (GIGANTISM OR
 HTLV-3 is a risk factor for chronic DWARFISM)
lymphocytic anemia  CLUSTERING OF CELLS
 CLONAL MORPHOLOGY (SIMILARITY OF
3. RADIATION
CELLS)

COMMON SYMPTOMS
1. HEPATOSPLENOMEGALY (*enlargement of spleen
and liver)
2. LYMPHADENOPATHY (enlargement of lymph
node)
3. SWOLLEN GUMS
4. PETECHIAE (due to decreased platelet count)

5. BONE PAIN

MORPHOLOGIC EVIDENCE OF LEUKOCYTE

MALIGNANCIES
NUCLEAR

 SHAPE ABNORALITIES (CLEFTING,

CONTORSIONS)
 MULTINUCLEARITY (NEUTROPHILS)
o Common in pernicious anemia to
have macropolycyte hypersegmented
neutrophils
 MEGABLASTOID (ENLARGEMENT)
 HYPOSEGMENTATION OR
HYPERSEGMENTATION
o Bilobed neutrophils could be a sign
of acute myelocytic leukemia
 PROMINENT OR GIANT NUCLEOLI
CLASSIFICATION - Associated with (CHROMOSOME
8, 21, 15, 17, 16, 11)
BASED ON STEM CELL ASSOCIATED
2. CHRONIC (< 30 % BLASTS, LONG
1. LYMPHOPRILIFERATIVE (CFU-L) (*Colony
DURATION) (*15 YEARS life expectancy;
forming unit-lymph)
complications may not be as severe as the
2. MYELOPFOLIFERATIVE (CFU-S/CFU- acute type)
GEMM)
2.1 CHRONIC
 This includes monoblast, LYMPHOPROLIFERATIVE LEUKEMIC
erythroblast, (HTLV-ASSOCIATED) DISORDERS
megakaryoblast, and (*associated with CLL)
myeloblast
- Subtypes: (PROLYMPHOCYTIC
LEUKEMIA/PRL, HAIRY CELL
LEUKEMIA/HCL, CHRONIC
LYMPHOCYTIC LEUKEMIA/CLL)
2.2 DYSMYELOPOIETIC
SYNDROME/DMPS/RA
SIDEROBLASTIC
ANEMIA/SA/MYODYSPLASTIC
SYNDROME/MDS
Subtypes:

BASED ON THE PRESENCE OF IMMATURE CELLS - 2.21 REFRACTORY ANEMIA/RA

1. ALEUKEMIC = NO BLASTS
- Example: Chronic Lymphocytic Leukemia (only
see prolymphocyte and mature lymphocyte)
2. SUB-LEUKEMIC = < 30 % BLASTS
3. LEUKEMIC = > 30 % BLASTS
According to: (FRENCH, AMERICAN BRITISH
GROUP/FAB)
BASED ON DURATION
1. ACUTE (>30 % BLASTS, SHORT DURATION)
(*6 months to 2 years life expectancy)
1.1 ACUTE LYMPHOBLASTIC
LEUKEMIA/ALL
- Subtypes: (L1, L2, L3) associated
with (CHROMOSOME 1, 14, 19, 4,
11)
1.2 ACUTE NON-LYMPHOCYTIC
LEUKEMIA/ANLL OR ACUTE
MYELOCYTIC/MYELOBLASTIC
LEUKEMIA/AML
- Subtypes: (M0, M1, M2, M3, M4,
M5-A, M5-B, M6, M7)
/REFRACTORY CYTOPENIA/RC
- 2.22 REFRACTORY ANEMIA WITH
RINGED SIDEROBLASTS/RARS
- 2.23 REFRACTORY ANEMIA WITH
EXCESS BLASTS/RAEB
- 2.24 REFRACTORY ANEMIA WITH
EXCESS BLASTS IN
TRANSFORMATION/RAEBIT
- 2.25 CHRONIC
MYELOMONOCYTIC LEUKEMIA
(*involves myeloblast,
monoblast)
2.3 CHRONIC MYELOPROLIFERATIVE
DISORDERS/CMPD
Includes the ff:
- 2.31 ESSENTIAL
THROMBOCYTHEMIA/ET
- 2.32 AGNOGENIC MYELOID
METAPLASIA/AMM (FIBROBLASTS)
 - 2.33 CHRONIC MYELOGENOUS CLASSIFICATION
LEUKEMIA/CML (CHROM 9, 22,
(ANEMIA: BONE MARROW DESTRUCTION,
PHILADELPHIA CHROMOSOME)
PANCYTOPENIA low pltlt, wbc, rbc), HYPOSEGMENTED
(*myeloblast and up to the mature
NEUTROPHILS/PSEUDOPELGUER-HUET – common in
cells)
AML)
- 2.34 CHRONIC NEUTROPHILIC
LEUKEMIA/CNL (*Neutrophils) DIFFERENTIAL DIAGNOSIS OF ANLL OR AML
- 2.35 POLYCYTHEMIA VERA/PV
 M0 = ACUTE MYELOBLASTIC LEUKEMIA
(*involves RBC)
WITH MINIMAL
DIFFERENTIATION
 M1 = = ACUTE MYELOBLASTIC LEUKEMIA
CLASSIFICATION
WITHOUT MATURATION (*all myeloblast
PAS +, SBB -, (ANEMIA: BONE MARROW differentiate using cytochemical stains)
DESTRUCTION)  M2 = ACUTE MYELOBLASTIC LEUKEMIA
WITH MATURATION (all stages of cells)
DIFFERENTIAL DIAGNOSIS OF ALL (CLUSTER  M3 = ACUTE PROMYELOCYTIC LEUKEMIA
DESIGNATION/CD 10, 20)  M4 = ACUTE MYELOMONOCYTIC
LEUKEMIA/NAEGELI SYNDROME
- *CD10, 20 is just used to differentiate if  M5 A= ACUTE MONOCYTIC LEUKEMIA WITH
leukemia is ALL or AML but not to PREPONDERANCE OF
differentiate L1 from L2 or L3 MONOBLASTS/SCHILLING’S LEUKEMIA
 M5 B = ACUTE MONOCYTIC LEUKEMIA WITH
Common laboratory findings for ALL PREPONDERANCE OF
PROMONOCYTES/SCHILLING’S LEUKEMIA
o Lymphocytes will have positive result  M6 = ACUTE ERYTHROLEUKEMIA/ DI-
for Periodic Acid-Shiff test (PAS +) GUGLIELMO SYNDROME ACUTE
and negative for Sudan Black B stain ERYTHOCYTIC LEUKEMIA (a lot of nucleated
(SBB-) RBCs in blood smear)
 M7 = ACUTE MEGAKARYOCYTIC LEUKEMIA
L1 L2 L3 (preponderance of megakaryoblast)
Commo CHILDREN ADULTS BURKITT
n in TYPE
TdT + TdT + TdT –
B&T B & T CELLS B CELLS
CELLS
Morphol SMALL & LARGE & LARGE &
ogy HOMOGE HETEROGE HOMOGE
(basis for
differentiation
NOUS NOUS NOUS
)

- *B cells – usually becomes antibody; T cells – Seen in AML; condensed secondary lysosome in
usually becomes T helper, T cytotoxic, T myeloblast; Auer rods seen in M 0,1,2,3,4 usually in
regulator cells promyelocyte and myeloblast)
- *T cells are usually larger than B cells; both
are lymphocytes
- TdT = TERMINAL DEOXYNUCLEOTIDYL
TRANSFERASE STAIN
- (TERMINAL DEOXYNUCLEOTIDYL
TRANSFERASE ENZYME - positive for L1 and
L2)
- (TDT is negative)
- PAS = PERIODIC ACID SCHIFF, SBB = SUDAN
BLACK B STAIN
CLASSIFICATION DIFFERENTIAL DIAGNOSIS OF CLLD
(ANEMIA: BONE MARROW DESTRUCTION, (PAS +, DAT +, B-CELLS AND T-CELLS, ANEMIA,
PANCYTOPENIA (low pltlt, wbc, rbc), HYPOSEGMENTED THROMBOCYTOPENIA)
NEUTROPHILS/PSEUDOPELGUER-HUET – common in
(CHROMOSOMES 1,3,6,7,8,11,12,13,14,17,18)
AML)
CLLD CLL PRL HCL
(CD 13, 14, 15, 33, 41) Types
*ALL CD 10,20 : AML CD 13,14,15,33,41 CELLS LYMPHO PROLYMPH LYMPHOCY
(prepondera CYTES OYCYTES TE (HAIRY
DIFFERENTIAL DIAGNOSIS OF ANLL OR AML nce)
CELL)
AML TYPE PAS AUER RODS SURVIVA 10-15 1 YEAR 5-27 YEARS
(FUSION OF L YEARS
PRIMARY CD 5, 19, 5,103 5,11,19,20,2
LYSOSOMES IN (cluster 21, 22, 2,25,103
MYELOBLASTS) of 23, 24
M 5, 6, 7 + - Different
M 0,1, 2, 3, 4 NA + iation)
 CLLD – Chronic Lympho-proliferated Leukocyte
Disorders

DIFFERENTIAL DIAGNOSIS OF DYSMYELOPOIETIC

SYNDROME/ DMPS/REFRACTORY ANEMIAS/RA/
SIDEROBLASTIC ANEMIAS /SA/MYELODYSPLASTIC
SYNDROME/ MDS
 Monocytes have carbohydrate content in
(CHROMOSOMES 5 AND 7)
cytoplasm thus PAS pos
RC or RARS RAEB RAEBIT CMML
RA
WBC N TO ↓ N TO ↓ N TO ↓ N TO ↓ ↑
CLASSIFICATION PLATELET N TO ↓ N TO ↓ N TO ↓ N TO ↓ N TO ↓
COUNT
% <1 <1 <5 >5 < 5 With
(ANEMIA: BONE MARROW DESTRUCTION, MYELOBLASTS 20%
PANCYTOPENIA, HYPOSEGMENTED IN BLOOD Monoblasts
SIDEROCYTES 1 > 15 1 1 0
NEUTROPHILS/PSEUDOPELGUER-HUET) & RINGED
SIDEROBLASTS
DIFFERENTIAL DIAGNOSIS OF ANLL OR AML %

AML NSE
SBB SE
TYPE ANA ANB
M0 - - - - OTHER TYPES OF LEUKEMIAS NOT INCLUDED IN FAB
M1,2,3 + + - -
CLASSIFICATION
M4 + + + +
M5 +/- - + + 1. ACUTE BASOPHILIC LEUKEMIAS (basophil)
M6,7 NA NA + -
 SBB = SUDAN BLACK B STAIN 2. HYPOPLASTIC ACUTE MYELOID LEUKEMIAS
 SE = SPECIFIC ESTERASE STAIN (myeloblast and other blast cells)
 NSE = NON-SPECIFIC ESTERASE STAIN 3. MIXED LEUKEMIAS (LYMPHOD AND MYELOID)
 ANA = ALPHA NAPHTYL ACETATE
 ANB = ALPHA NAPHTYL BUTYRATE 4. SECONDARY LEUKEMIAS (MYELODYSPLASTIC
SYNDROME)
*Differentiate M1,2,3 through its morphology: M1 = all
monoblast; M2 = all stages can be seen: M3 = 5. LEUKEMOID REACTIONS (REACTIVE
myeloblast and monoblast LEUKOCYTOSIS THAT RESEMBLES LEUKEMIA (> 50 X
109/L LEUKOCYTES IN BLOOD)

 Associated with Bordetella pertussis INFECTION

ERYTHROCYTOSIS LABORATORY DIAGNOSIS For LEUKEMIAS

- Opposite of anemias LEUKOCYTE ALKALINE PHOSPHATASE SCORE/LAP

- Increase RBC count SCORE
- Also known as erythemia (LEUKEMOID REACTIONS, PV)
WBC (LAP) + N, N-DIMETHYL FORMAMIDE + FAST
CLASSIFICATION (2 kinds) BLUE/FAST
 RELATIVE (LOW PLASMA VOLUME) (*so (NEUTROPHILS)
there is false positive increase of RBC) RED
o (NORMAL RED CELL MASS/RCM) + NEUTRAL RED (COUNTERSTAIN) OR
o EG. DEHYDRATION, STRESS, HEMATOXYLIN
SMOKING (CO poisoning)
BLUE-BLACK
 ABSOLUTE (NORMAL PLASMA VOLUME) OR RED PPT (pos result)
o (HIGH RED CELL MASS/RCM)
o PRIMARY (LOW
ERYTHROPOIETIN/EPO) CRITERIA FOR SCORING (100 NEUTROPHILS,
 EG, POLYCYTHEMIA VERA, Reference Value = 13-160) = *normal
ERYTHREMIA (RBC’s 0 = NO GRANULES IN CYTOPLASM
ONLY)
o SECONDAY (NORMAL TO HIGH 1 = SMALL GRANULES (< 50 %)
EPO) 2 = MODERATE STAINED GRANULES (50-80 %)
 EG, HIGH ALTITUDE
(*there is a demand of 3 = STRONGLY STAINED GRANULES (80-100 %)
more RBCs to have more 4 = STRONGLY STAINED GRANULES PACKED
oxygen), SMOKING (CO)
usually has carbon
monoxide thus SUPPORTIVE THERAPIES FOR LEUKEMIAS
competing with oxygen
so will need more RBCs) DRUG CLASS ACTION
VINCRISTINE PLANT ALKALOID INHIBITS RNA
 CARDIAC, PULMONATY SYNTHESIS
DISEASES, Hb PREDNISONE CORTICOSTEROID LYSIS OF
CHESAPEAKE LYMPHOBLAST
S
 RENAL TUMORS,
METHOTREXATE FOLIC ACID INHIBITS DNA
ESSENTIAL OR ANTAGONIST SYNTHESIS
IDIOPATHIC 6-MERCAPTURINE PURINE INTERFERES
ANTAGONIST PURINE
SYNTHESIS
CYCLOPHOSPHAMIDE SYNTHETIC INHIBITS DNA
PATHOPHYSIOLOGY OF POLYCYTHEMIA VERA ALKYLATING AGENT SYNTHESIS
DAUNORUBICIN ANTIBIOTIC INHIBITS DNA
ERYTHROCYTOSIS & RNA
SYNTHESIS
HYPERVISCOSITY OF L-ASPARAGINASE ENZYME (E. coli) LYSIS OF
BLOOD LYMPHOBLAST
S
CYTARABINE PYRIMIDINE INHIBITS DNA
ANTIMETABOLITE SYNTHESIS
DECREASED BLOOD FLOW (*drugs for leukemia are cancer causing;
& TISSUEOXYGENATION DAUNORUBICIN & CYCLOPHOSPHAMIDE causes
cancer)
CARDIAC STRESS &
OVERLOAD (*cardiac diseases/ congestive failure)
TREATMENT; THERAPEUTIC PHLEBOTOMY (usually
done every month to prevent cardiac stress &
overload)