TRANSCRIBER | Mary Kaye

HEMA 311| LECTURE Picar

FINALS - WEEK XIV & WEEK XV
LEUKEMIA, MD’s & MPD’s

INTRODUCTION
 Leukopoiesis has five stages of NON-MALIGNANT LEUKOCYTE
maturation from myeloblast I, II, III DISORDERS
o TYPE I – few to no
 Originate from an underlining changes
cytoplasmic granules in number an morphology of WBCs
o TYPE II – less than 20/30
cytoplasmic granules Qualitative Defects
o TYPE III – many cytoplasmic
granules, more associated MORPHOLOGICAL DEFECT
with leukemic process
 In promyelocyte stage “start of NUCLEAR ABNORMALITIES
differentiation” for eosinophil (Charcot
Leyden crystals) there is a detectable A. Pelger-Huet Anomaly (PHA)
amount of a primary granules and the  Otherwise known as True PHA /
start of secondary granules production. Congenital PHA
Both myeloblast and promyelocyte is  Inheritance pattern is autosomal
dominant
still in mitotic pool or (proliferation)
 Decreased number of nuclear
 The myelocyte stage is called “dawn segmentation (bilobed/unilobed)
of neutrophilia” detectable amount of  Neutrophil has 2 lobulation or no lobule
primary granules production, secondary at all
granules, and start of tertiary granules  Round, dumbbell shape of nucleus
production. It is still capable of mitosis  Mutation in Lamin B-receptor
 The metamyelocyte stage there is a o Plays a major role in
sufficient amount of primary granules, leukocyte nuclear shape
secondary granules, tertiary granules changes that occurs during
and start of secretory granules normal maturation
production. There is also a start of o Hyposegmentation in
indentation ‘kidney bean shape’. It is neutrophil
no longer capable of mitosis  HETEROZYGOUS PHA
 The band cell there is a sufficient o Only 1 gene is inherited
amount of granules and secretory o The nucleus of neutrophils
granules. It has prominent lobulation are round, ovoid, peanut-
“sausage shape or horse- shoe shape shaped
nucleus”. This cell will mature to o Bilobed form
eosinophil, basophil, neutrophil etc. o 55% – 93% of neutrophils are
 Mature WBC cells will be released to affected.
circulation from bone marrow  HOMOZYGOUS PHA
o 50% goes to marginating pool o Nucleus appears to be round
(adheres to blood vessel and no peanut shape nucleus
walls) o 100% neutrophils are affected
o 50% circulates in the body o Could be mistaken as
 Basophils has three notable granule lymphocyte or blast cell
secretions o The neutrophils appear
o Heparin abnormal but normal in
o Eosinophil chemotactic factor function
A (calls for eosinophil that has  PSEUDO PHA
histaminase to neutralize o Morphologically speaking, the
histamine action) neutrophils has
o Histamine (vasodilation and hyposegmentation but has no
bronchoconstriction) causes mutation with Lamin B-
histamine if excessive receptor gene

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o Nucleus of neutrophils circulation keading to

appears to be round neutropenia
o Cytoplasm is hypogranular/ o Neutrophils appear
little granules hypermature
o May be developed in cases of o Mutation: CXCR4 receptor
myelodysplastic disorders:
AML, CML, Preleukemia,
CYTOPLASMIC ABNORMALITIES
Patients with infections or
tumors that metastasized to
the bones, HIV infectiom, A. Alder-Reilly Anomaly
 Autosomal recessive

 Characterized by: presence of

abnormally large, darkly staining
azurophili granules (Alder-Reilly
bodies) compose primarliy of digested
mucopolysaccharides resembling
toxic granulation
 Granules may be seen in monocyte,
neutrophils, and lymphocyte
 Defect is incomplete degradation of
tuberculosis, M. pneumoniae mucopolysaccharides
and severe bacterial
infections and drugs
o Herler sundrome
o Drugs: mycophenolate o Hunter syndrome
mofetil, valproate, o San-filippo syndrome
sulfisoxazole, ganciclovir, o Maroteaux- Lamy
ibuprofen, chemotherapies
polydystrophyc dwarfism
(paclitaxel and docetaxel)
B. Chediak-Higashi Syndrome
B. Neutrophil Hypersegmentation  Autosomal recessive
 Greater than 5 lobulation of neutrophils  Characterized by abnormal fusion of
granules in most of the granulated
 Happens in abnormality of DNA
cells throught the body
metabolism
 Hematologic findings: giant lysosomal
 Associated with Megaloblastic anemia/
granules in granulocytes, monocytes
processes
and lymphocytes
 Autosomal dominant if congenital
 Fused granules result in leukocyte
condition
dysfunction and recurrent pyogenic
C. Hereditary Hypersegmentation
infections (results in ineffective
 Autosomal dominant
respiratory burst)
 The patients are asymptomatic
 Associated with platelet abnormality
 Myelokathexis and Undritz Anomaly (lacks dense granules)
D. Acquired Hypersegmentation
 Also lacks giant granules in
 Associated with Megaloblastic anemia, o Neutrophils
folic acid deficiency, VB12 deficiecny
o Monocytes
and pernicious anemia
o Lymphocytes
 Myelokethaxis
o Rare hereditary condition  S. aureus and other G (+) organism
o Normal granulocyte  Albinism
production: however there is  Accelerated stage
impaired release intro the o Hepatosplenomegaly

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o Liver failure  Ways of evaluation:

o Lymphadenopathy o Chemiluminescene or Flow
o Neuropathy Cytometry
o Death  Uses
 CHS1 LYST gene mutation Dihydrorhodamine
123
C. May-Hegglin Anomaly
 Autosomal dominant o Nitroblue Tetrazolium Test
 Characterized with thrombocytopenia, (NBT Test)
low platelet count, giant platelet, large  Evaluates
dohle-like inclusions in neutrophils, respirqatory burst by
eosinopils, monocytes, and basophil reduction of the
nitroblue tetrazolium
dye inside
phagocytes
 NBT is a product

 MYH9 gene mutation

 Majority of individual are aymptomatic
and sometimes had mild bleeding that can be reduced
tendencies by normal
 Dohle bodies: pale blue, spindle- neutrophils into
shaped inclusions from rough formazan
endoplasmic reticulum
 Principle: reduction
of a yellow water-
FUNCTIONAL DEFECT
soluble nitroblue
tetrazolium dye
FUNCTIONAL ABNORMALITIES
 Reagent: Nitroblue
A. Chronic Granulomatouse Disease (CGD) Tetrazolium Dye
 Rare, inherited disorder caused by (yellow)
dicreased ability of phagocytes to  (+) blue (formazan)
produce superoxide and reactive  (-) yellow
oxygen species
 NADPH Oxidase Deficiency –
important in producing hydrogen
peroxide (used for respiratory burst)
 Characterized by defects in the
respiratory burst oxidase system
 Cells engulf but are unable to kill
microorganisms B. Leukocyte Adhesion Disorder
 Normal morphology, defect in function  Defect in adhesion function
 Mutation: GP91 PHOX or P47 gene
 Clinical Findings:
o Recurrent chronic bacterial
and fungal infections of the
lungs, skin, lymph nodes, and
liver
o Formation of granuloma (can
destruct hollow organs)
o Recurrent pneumonia
 most common cause
of death

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 Deficient in marginating pool
 Autosomal recessive
 Neutrophils and monocyte are not able
to migrate to endothelial cells and to
migrate from blood to tissues
 LAD 1
o Mutation in genese
responsible for B2 integrin
subunits (needed for
neutrophil adhesion
endothelial cells, recognition
of bacteria, and outside
signaling)
o Clinical Findings:
 Recurrent infections
 Neutrophilia
 Lymphadenopathy
 Splenomegaly
 Skin lesions
 LAD II
o Rarer than LAD 1
o Leukocytes have Normal B2
integrin
o Abnormality in SLC35C1
gene
o Clinical Findings:
 Recurrent infections
 Neutrophilia
 Physical growth
retardation
 Coarse face and/or
other physical
deformities
 Neurological defects
 LAD III
o Very rare
o Abnormality in KINDLIN-3
gene (need for diapedesis
leukocyte rolling)
o Clinical findings:
 Mild LAD I-like
immunodeficiency
 Recurrent bacterial
and fungal infections
 Increased risk of
bleeding
C. Job’s Syndrome
 Also known as
Hyperimmunoglobulinemia E
 Excessive IgE obscures receptors of
neutrophils
 Chemotaxin – signals impairment
 Random movement of phagocytes is
normal but directional motility/
chemoactivity is impaired
 Cells respond slowly to chemotactic
agents
 Clinical Findings
o Persistent boils
TRANSCRIBER | Mary Kaye
o Recurrent “cold”
staphylococcal abscesses
o Skeletal abnormalities
D. Lazy Leukocyte Syndrome
 Both random and directed movement
of the cells are defective
 Bone marrow reserves of
granulocytes are normal, but
to release to the peripheral blood is
poor
 Cells contain defective actin filaments
 Clinical findings:
o Neutropenia
o Low-grade fever
o Recurrent infections involving
the gums, mouth, and ears
E. Congenital C3 Deficiency
 C3
o defective abnormal
complement cascade
o Most abundant
o Most important in the
activation of the complement
pathways
 Autosomal recessive
 Most severe complement deficiency
 Clinical findings:
o Severe recurrent infections
with encapsulated bacteria
(cannot pbe phagositized and
needs opsoneme)
o Glomerulonephritis
F. Myeloperoxidase Deficiency
 Autosomal recessive and dominant
 MPO gene chromosome 17
 Deficient in granules of neutrophils and
lysosomes of monocyte
 MPO
o Important in respiratory burst
o Most common neutrophil
abnormality
o Stimulates production of
oxidant agents that attack
phagocytized microbes
 Acquired myeloperoxidase deficiency
o Hematologic neoplasms
o Lead poisoning
MONOCYTE/ MACROPHAGE
LYSOSOMAL STORAGE DISEASES
A. Mucopolysaccharide/
Glycosaminoglycan Storage
 Also known as
Mucopolysaccharidoses
 Family of inherited disorders of GAG
degradation
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 Autosomal recessive  Common in

 Cells in affected tissues are swollen Ashkenazi Jews
and have apparent balloning and o TYPE II
cleaning cytoplasm  Infantile/ Cerebral
 Partially degraded GAG builds up in  Infancy onset
the lysosomes and results in  Hepatosplenomegaly
o Physical abnormality  Skeletal degeneration
o Mental Retardation (-)
 Alder-reilly bodies/ Reilly bodies  Neurodegeneration
 Purple using toluidine blue (+)
 Death by 2 years
B. Lipid Storage Diseases  Pan-ethnic
 More sever form of
 Also known as Lipidoses
gaucher’s disease
 Macrophage and monocytes has
o TYPE III
lipidoses in cytoplasm
 Subacute/
 Macrophages of one or more tissues
Neuropathic/
become overloaded with lipid
Juvenile
 Lipid catabolism is defective  Childhood onset
 Autosomal recessive  Hepatosplenomegaly
 Lack of b-glucosidase  Skeletal Abnormalities
 Accumulation of glucosides in  Neurodegeneration (-)
monocytes and neutrophils  Death during 2nd to 4th
decade of life
1. Gaucher’s disease  Common in Swedes
 Most common of the lipidoses  In PBS crampled
 Ashkenazi Jews tissue paper
 Hepatosplenomegakly appearance in
 Increased serum
phosphatases
 Gaucher cells in B,
 NORMO/NORMO anemia
 Leukopenia
 Thrombocytopenia
 G. cells – large macrophage with
small eccentric nucleus with
striated appearance
 Chitotriosidase – useful in
determining the level of
glucocerebroside in storage

o TYPE I cytoplasm
 Non-neuropathic/
Adult
 Childhood to o PSUEDO-GAUCHER CELLS
adulthood onset  Result of excessive cell
 Cells in blood and turn-over and
tissues contain overwhelming of
vacuoles glucocerebrosidase
 Hepatosplenomegaly enzyme
 Skeletal Abnormalities  Found in BM of patients
 Neurodegeneration (-) with: Thalassemia, CML,
 Death is variable AML
 Treatment: Enzyme
Replacement Therapy
with Recombinant
Glucocerebrosidase,
Stem cell transplant

2. Niemann-Pick Disease
 Autosomal recessive
 Deficient in sphingomyelinase

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 Abnormal accumulation
sphingomyelin and cholesterol in
mononuclear phagocytic cells and
some parenchymal cells
 More commonly seen in Ashkenazi
jews
 Clinical findings:
o Hepatosplenomegaly
o Poor physical development
o Foam cells/pick cells
 Abnormal
macrophage whose
cytoplasm is filled
with many small
lipid droplets
 Increased numbers
may lead
macrophage
overload
 TYPE A AND B
o SMPD gene mutation
o Deficiency
Sphingomyelinase
o Subsequent build-up
sphingomyhelin in the liver,
kidneys, and lungs (brain is
also affected in type A)
o Niemann-pick cell in BM
o Disease is often fatal in 3
years of age
o Type A: <5% normal
sphingomyelinase activity
o Type B: 10-20% normal
sphingomyelinase activity
 TYPE C
o Milder form than A and B
o Decreased in cholesterol
exffluxinf from the
intracellular
TRANSCRIBER | Mary Kaye
in endosome/lysosome of
cytosol
o With Systemic, Neurologic,
and Psychiatric symptoms
o Most patients die before 25
years old
3. Tay-sachs Disease
 Accumulation of glycolipid and
gangliosides
 Autosomal recessive
 (+) Vacuolated cytoplasm
 Deficiency: Hexoaminadase A
4. Sandhoff’s Disease
 Accumulation of glycolipid and
gangliosides
 Deficiency: Hexoaminadase A and B
5. Sea-blue Histiocytosis
 Autosomal recessive
 Unknown enzyme deficiency
 Syndrome marked by:
o Hepatosplenomegaly
o Thrombocytopenia
o Accumulation in the spleen
and bone marrow of
histiocytes filled with lipid-rich
to granules than stain blue-
green (using Wright’s Giemsa
stain)
GENETIC B AND T LYMPHOCYTE
in ABNORMALITIES
 Genetic disorders that generally result in
the abnormal production of B cells, T cells
or both
 Microdeletion in Chromosome band 22 in
q11.2
T-LYMPHOCYTE ABNORMALITY
A. Digeorge Syndrome
of  Absence or underdevelopment of
thymus
 Markedly decreased number of T
lymphocytes
 Microdeletion in 22q11
 Complete DiGeorge Syndrome: also
known as athymic anomaly
B-LYMPHOCYTE ABNORMALITY
A. Sex- Linked Agammaglobulinemia (XLA)
 B-cell disease most frequently caused
by mutation in the gene encoding for:
o Bruton Tyrosine Kinase
 Recurrent bacterial infection
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COMBINED T-LYMPHOCYTE o Reactive leukocytosis

>50x109/L with neutrophilia
and a marked shift to the left
o Mostly a result of acute and
chronic infection, metabolic
disease, inflammation, or
response to malignancy
o May be confused wit Chronic
Myelogenous Leukemia
(CML) | only the LAP score
differs (low to normal in LAP)

B. Leukoerythroblastic Reaction
 Presence of neutrophils, nucleated red
blood cells, and teardrop cells in the
blood sample
 Possible presence of space occupying
AND B- LYMPHOCYTE ABNORMALITY lesions in the bone marrow
 Strongly associated with Primary
A. Severe Combined Immunodeficiency Myelofibrosis
(SCID)
 Neutropenia
 More common type of combined B and o Decrease in the absolute
T lymphocyte abnormality
neutrophil count below
 May be alike with HIV 2.0x109/L (white adults) and
 Mutation: SCID IL-2 gamma chain below 1.3x109/L (black adults)
receptor o The risk of infection increases
 Results in depletion of T cells, B cells as the ANC lowers, especially
and NK cells below 1.0x109L
o Agranulocytosis – refers to
B. Wiskott-Aldrich Syndorme neutrophil count of less than
 Mutation in gene WASp 0.5x109/L
 Clinical Findings:
o Low levels or absence of 1. Alloimmune Neonatal
Wiskott-Aldrich protein Neutropenia
o Immunodeficiency  Maternal IgG crosses the
o Eczema placenta and binds to
o Thrombocytopenia neutrophil-specific
antigens inherited from
Quantitative Defects the father

NEUTROPHILS 2. Autoimmune Neutropenia in

Children
 Moderate to severe
 Neutrophilia is suspected when the
neutropenia developing
neutrophil count of the patient is above
as a result of antibodies
7.0x109/L in adults and above 8.5 x10-
to HNA-1
9
/L
 Self-limiting and resolves
 Normal relative neutrophil count is
after 7 to 24 months
between
3. Secondary Autoimmine
 Low – neutropenia
Neutropenia
 High – neutrophilia
 Associated with
 50-70% normal (DIFF COUNT) autoimmune disorders:
 1.7 to 7.5x109/L (ABSOLUTE rheumatoid arthritis, Felty
NEUTROPHIL COUNT) syndrome, SLE and
Sjogren’s syndrome
A. Leukomoid Reaction
o Physiologic response to sever 4. Congenital Severe Neutropenia
overwhelming bacterial  Consist of Kostmann
infection syndrome (infantile
agranulocytosis): severe
neutropenia that presents

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shortly after birth and o Chronic inflammatory

bone marrow granulocyte conditions
hypoplasia o Radiation therapy
o Bee stings
5. Chronic Idiopathic
Neutropenia MONOCYTES
 Predominantly affects  > 1.0x109/L (adults)
women of 18 to 35  >3.5x109/L (neonates)
years of age
 Normal monocyte: 2-11
 Bone marrow
 Normal absolute: 0.1-1.3
produces more
 Monocytosis is frequently the first sign
immature neutrophils
of recovery from acute overwhelming
 Treatment: G-CSF
infection or severe neutropenia
 Monocytopenia:
 6. Fanconi Anemia o Absolute monocyte count of
>0.2x100/L
7. Dyskeratosis Congenita o Associated in patients with:
 Aplastic anemia
8. Shwachmann-Bodian-  Chemotherapy-
Diamond Syndrome induced cytopenia
 Patients receicing
EOSINOPHILS steroid therapy
 Major function: Degranulation  Hemodialysis
 Eosinopilia is suspected when the patients
absolute eosinophil count of the patient  Sepsis
is above 0.4x109/L  Epstein-Barr Virus
 Normal relative count: 1%-3% (EBV)
 Normal AEC: 0-0.3% x 109/L LYMPHOCYTES
 2 BROAD CATEGORIES:
 Lymphocytosis is suspected in patients
o Underdeveloped areas: with absolute lymphocyte count
parasite infestation >10.0x109/L and >4.5x109/L (adults)
(Helminthes and protozoa)  Normal relative: 18-42
o Developed countries: allergic  Normal absolute: 1-3.2x109
reactions
 Hypereosinophilic Syndrome
 Lymphocytopena can be defined as an
absolute lymphocyte count <2.0x109/L
o Eosinophilia (>1.5x109/L)
(children) and
lasting for more than 6
months without an identifiable 
cause Morphologic Changes in Leukocytes
 Eosinopenia
o Absolute Eosinophil count of NEUTROPHILS
less than 0.09 x109/L
o Most often associated with 1. Toxic Granulation
conditions that result in  Appears as dark, blue-black
marrow hypoplasia granules in the cytoplasm of
neutrophils
BASOPHIL  PEROXIDASE: (+)
 Basophilia is defined as an absolute  Positively correlated with
basophil count greater than 0.15x109/L levels of CRP (C- reactive
 Normal relative: 0-2 protein)
 Normal absolute: .2 - .02  The intensity of toxic
 Most common cause of basophilia: is granulation is a general
CML measure of inflammation
 Non-malignant causes of Basophilia  Figure
o Allergic rhinitis
o Hypersensitivity to drugs or
food
o Chronic infections
o Hypothyroidism

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o Storage of blood in
EDTA for > 2 hours
o Autoantibodies,
acute alcoholism
and exposure to
high doses of
radation

2.  Phagocytic Vacuoles
o Larger (6um) and

Dohle Bodies
 Cytoplasmic inclusions
consisting of remnants of
ribosomal RNA arranged in
parallel rows

are frequently
accompanied by
toxic granulation
o When seen, a
careful examination
 Typically found in band and of the film should be
segmentedneutrophils and made for the
often in cells containing toxic presence of bacteria
granulation or yeat (Ehrlichia
and Anaplasma)
 Intracytoplasmic pale blue
round or elongated bodies
4. Pyknotic Nuclei
between 1um-5um in
 Generally indicate Imminent
diameter
Cell death
 Relatively non-specific
 Nuclear water has been lost
 Maybe present in: bacterial
and the chromatic becomes
infection, sepsis and in
very dense and dark, but
normal pregnancies
filaments can still be seen
3. Cytoplasmic Vacuolation
between segments
 Vacuoles generally reflect
phagocytosis

 Autophagocytic Vacuoles
o Small (2um) and
distributed
throughout
cytoplasm
o
o Can be induced by 5. Necrobiotic Nuclei/ Cell
 Found in dead cell/ old blood

samples
 Rounded fragments of
nucleus with no filaments and
drugs such as
no chromatin pattern
sulfonamides and
chloropin
6. Degranulation

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 Common finding in activated hematologic neoplasms

neutrophils and eosinophils involving in monocytic
 Granules are released into series
the extracellular space
 Current allergic reaction
 In vitro degranulation often
occurs when the cell
membranes of the cells are
disrupted during the process
of making blood films
7. Cytoplasmic Swelling
 Hypotonic environment
 Caused by actual osmotic
swelling of the cytoplasm or
by increased adhesion to the LYMPHOCYTES
glass slide by stimulated
neutrophils 
 Results in variatio in
Reactice
neutrophil size or neutrophil
anisocytosis

changes in lymphocytes are

referred to as: variant
lymphocutes, reactice
lymphocytes, effector lymphocytes,
transformed lymphocytes, Turk
MONOCYTES cells, Downey cells, immunoblasts,
and atypical lymphocytes
1.  Result of complex morphologic and
biochemical events that occur as
lymphocytes are stimulated when
interacting with antigens in
peripheral lymphoid organs
 Plasmacytoid lymphocyte
o Type of reactice
Immature/ Reactive Monocytes lymphocyte that has some
 Irregular nucleus of the morphologic
 Vacuolation features of plamacytes
 Infections or recovery from  Infectious mononucleosis
bone marrow aplasia or o Causative agent Eipsten
GMCSF bar virus
 Nucleus can o CD21 of B lymphocyte
become thin
and band-
like and
may appear
to be
segmenting
 Large
numbers are seen in

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