Clinical Pathology

Hematology
CER, MD

HEMATOLOGY • It produces TISSUE HYPOXIA as a result of

• Hematology includes the study of BLOOD CELLS and decreased O2 transport
COAGULATION. • The chief sources of the gas are:
• It encompasses analyses of: 1. Gasoline Motors
1. The concentration, structure, and function of cells in 2. Illuminating Gas
blood 3. Gas Heaters
2. Their precursors in the Bone Marrow 4. Defective Stoves
3. The chemical constituents of Plasma or Serum 5. Smoking of Tobacco
intimately linked with blood cell structure and function • Exposure to CO → one of the hazards of
I. HEMATOLOGY PRINCIPLES AND PROCEDURES modern civilization.
Hemoglobin o The gas has even been found in the air
• Hemoglobin (Hb), the main of busy streets of large cities in
component of the red blood sufficient concentration to cause mild
cell (RBC), is a CONJUGATED symptoms in persons such as traffic
PROTEIN that serves as the police officers, who are exposed to it
vehicle for the transportation over long periods of time.
of Oxygen (O2) and Carbon • HbCO may be quantitated by DIFFERENTIAL
Dioxide (CO2). SPECTROPHOTOMETRY or by GAS CHROMATOGRAPHY
• The Red Cell Mass of the adult Hematocrit (Packed Cell Volume)
contains approximately 600 g • The Hct of a sample of blood is the ratio of the volume of
of Hb, capable of carrying 800 Erythrocytes to that of the whole blood.
mL of O2 • It may be expressed as a Percentage (Conventional) or as a
• A molecule of Hb consists of 2 pairs of Polypeptide Chains Decimal Fraction (SI units).
(“Globins”) and 4 Prosthetic Heme Groups, each containing • Interpretation of Results:
one atom of Ferrous Iron 1. Reflects the concentration of RED CELLS → not the total
o Located near the surface of the molecule, the Heme red cell mass
reversibly combines with one molecule of O2 or CO2. 2. The Hct is low in hydremia of pregnancy, but the total
• The Main Function of Hb is to transport O2 from the lungs, number of circulating red cells is not reduced.
where O2 tension is high, to the tissues, where it is low 3. The Hct may be normal or even high in shock
Hemoglobin Derivatives accompanied by hemoconcentration, although the total
Hemiglobin (Methemoglobin) red cell mass may be decreased considerably owing to
• Methemoglobin (Hi) is a derivative of Hb in which the Ferrous blood loss
Iron is oxidized to the Ferric State, resulting in the inability of • Unreliable as an estimate of Anemia immediately after loss
Hi to combine reversibly with O2. of blood or immediately following transfusions
• Polypeptide chains are not altered. Erythrocyte Indices
• A normal individual has up to 1.5% Methemoglobin • Have been useful in the Morphologic Characterization of
• Will cause chocolate-brown Anemias.
discoloration of blood, cyanosis, and • They may be calculated from the Red Cell Count, Hb
functional “anemia” if present in Concentration, and Hct.
high enough concentrations Mean Cell Volume (MCV)
o Cyanosis becomes obvious at a • The MCV, the average volume of red cells, is calculated from
concentration of about 1.5 g the Hct and the Red Cell Count.
Methemoglobinemia Hi/dL • MCV = Hct × 1000/RBC (in millions per μL)
• This increased amount of Hi in the • Expressed in FEMTOLITERS or CUBIC MICROMETERS
Erythrocytes may result from Mean Cell Hemoglobin (MCH)
increased production of Hi or • The Mean Cell Hemoglobin (MCH) is the content (weight) of
decreased NADH-Cytochrome-b5 Hb of the average red cell → it is calculated from the Hb
Reductase activity Concentration and the Red Cell Count
• May be Hereditary or Acquired • MCH = Hb (in g/L) / RBC (in millions / μL)
Sufhemoglobin • Value is expressed in PICOGRAM
• SHb is a mixture of oxidized, partially denatured forms of Hb Mean Cell Hemoglobin Concentration (MCHC)
that form during oxidative hemolysis • The Mean Cell (Corpuscular) Hemoglobin Concentration
• SHb cannot transport O2, but it can combine with Carbon (MCHC) is the average concentration of Hb in a given volume
Monoxide (CO) to form CARBOXYSULFHEMOGLOBIN. of Packed Red Cells.
• Unlike Methemoglobin, SHb cannot be reduced back to Hb, • It is calculated from the Hb Concentration and the Hct
and it REMAINS IN THE CELLS until they break down. • MHCH = (Hb / Hct) x 100
• The blood is MAUVE-LAVENDER in Sulfhemoglobinemia • Expressed in g/dL (SI units are g/L)
• SHb has been reported in: • The reference values for the indices will depend on whether
1. Patients receiving treatment with Sulfonamides or they are determined from the centrifuged Hct or the cell
Aromatic Amine Drugs (Phenacetin, Acetanilid) counters.
2. Patients with Severe Constipation • The 95% Reference Intervals for Normal
3. Cases of Bacteremia due to Clostridium perfringens Adults are as follows:
4. Enterogenous Cyanosis Erythrocyte
1. MCV: 80-90 fL
Carboxyhemoglobin Indices
2. MCH: 27-33 pg
• Endogenous CO produced in the degradation of Heme to 3. MCHC: 33-36 g/dL
Bilirubin normally accounts for about 0.5% of • Low MCV: 50 fL
Carboxyhemoglobin (HbCO) in the blood and is increased in Microcytic • Low MHC: 15 pg
Hemolytic Anemia Anemia • Low MCHC: 22 g/dL
o Hb has the capacity to combine with CO with an affinity
• Rarely do any become lower
210 times greater than for O2.
o CO will bind with Hb even if its concentration in the air is • High MCV: 150 fL
extremely low (e.g., 0.02%–0.04%). • High MHC: 50 pg
o HbCO cannot bind and carry O2. Macrocytic • MCH is Normal or Decreased
• Increasing concentrations of HbCO shift the Hb-O2 Anemia • The MCHC typically increases only in
Dissociation Curve increasingly to the LEFT, thus adding to SPHEROCYTOSIS, and rarely is over 38
the Anoxia. g/dL.
• If a patient poisoned with CO receives pure O2, the
conversion of HbCO to HbO2 is greatly enhanced.
• HbCO is light sensitive and has a typical brilliant cherry-red
color.
Acute CO • Acute CO poisoning is well known.
Poisoning

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 Clinical Pathology
Hematology
CER, MD

Reference Values Blood Film Examination

A. Erythrocytes
• In the blood from a healthy
person, the Erythrocytes, when
not crowded together, appear as
CIRCULAR, HOMOGENEOUS DISKS
of NEARLY UNIFORM SIZE, ranging
from 6 to 8 μm in diameter
• However, even in normal blood,
individual cells may be as small as
5.5 μm and as large as 9.5 μm
• The center of each is somewhat
PALER than the periphery.
• In disease, Erythrocytes vary in
their Hb content, size, shape,
staining properties, and
structure.
• Color reflects the Hemoglobin Content
• Hb is 1-2 g/dL higher in MALES • The depth of staining furnishes a rough
o The indices are similar in males and females, but the Hb guide to the amount of Hb in red cells
is 1 to 2 g/dL higher in males, with commensurate • The terms Normochromic, Hypochromic,
increments in Hct and RBCs and Hyperchromic are used to describe this
o This is believed to be mainly the effect of ANDROGEN in feature of red cells
STIMULATING ERYTHROPOIETIN PRODUCTION and its 1. Normochromic - normal intensity of
effect on the marrow staining
o In older men, the Hb tends to fall; in older women, the Hb 2. Hypochromic
tends to fall to a lesser degree or even rise slightly o When the amount of Hb is
o In older individuals, therefore, the sex difference is >1 g diminished, the central pale area
Hb/dL becomes larger and paler
• Posture and Muscular Activity o MCH and MCHC are usually
o Posture and muscular activity change the concentration decreased
of the formed elements. 3. Hyperchromic
o The Hb, Hct, and RBC counts increase by several percent o Megaloblastic Anemia →
in going from RECUMBENCY to STANDING, and strenuous because the red cells are larger
muscular activity causes a further increase, presumably and, hence, thicker, many stain
owing primarily to loss of plasma water. deeply and have less central
• Diurnal Variation pallor (MHC is increased, MCHC is
o Diurnal Variation that is not related to exercise or to normal)
analytic variation also occurs. o Hereditary Spherocytosis →
o The Hb is highest in the morning, falls during the day, MCH is normal but the MCHC is
and is lowest in the evening, with a mean difference of usually increased because of a
8% to 9% reduced surface/volume ratio
Reticulocytes • The presence of hypochromic cells and
normochromic cells in the same film is
Color called ANISOCHROMIA or, sometimes, a
DIMORPHIC ANEMIA
o This is characteristic of Sideroblastic
Anemias but also is found some weeks
after Iron Therapy for Iron Deficiency
Anemia or in a Hypochromic Anemia
after transfusion with normal cells
Polychromatophilia
• A BLUE-GRAY TINT to the Red Cells
• Reticulocytes are immature nonnucleated red cells that (Polychromatophilia or Polychromasia) is a
contain Ribonucleic Acid (RNA) and continue to synthesize combination of the affinity of Hb for ACID
Hb after loss of the nucleus STAINS and the affinity of RNA for BASIC
• When blood is briefly incubated in a solution of new STAIN
Methylene Blue or Brilliant Cresyl Blue, the RNA is • The presence of residual RNA in the red cell
precipitated as a DYE-RIBONUCLEOPROTEIN COMPLEX. indicates that it is a YOUNG RED CELL that
• Microscopically, the complex appears as a dark-blue has been in the blood for 1 to 2 days.
network (Reticulum or Filamentous Strand) or at least 2 dark- • These cells are larger than mature red cells
blue granules that allow reticulocytes to be identified and and may lack central pallor
enumerated
• Young cells with residual RNA are
• Normal Adult: 0.5-1.5% or 24-84 x 109/L POLYCHROMATOPHILIC RED CELLS on air-
Reference • Newborn Infants: 2.5-6.5% dried films stained with Wright’s Stain but
Values o This falls to the adult range by the end are RETICULOCYTES when stained
of the 2nd week of life supravitally with Brilliant Cresyl Blue.
• Because Reticulocytes are immature red o Therefore, increased Polychromasia
cells that lose their RNA a day or so after implies RETICULOCYTOSIS → it is most
reaching the blood from the Marrow, a marked in hemolysis and in acute blood
Reticulocyte Count provides an estimate of loss
the rate of Red Cell Production.
• An Absolute Reticulocyte Count or
Reticulocyte Production Index is more
helpful than the percentage
Interpretation
• Uses:
1. Allows early detection of Increased
Erythropoietic Response Microcytic Hypochromic Red Cells
2. Determining response of Bone Marrow in Iron Deficiency Anemia.
recovering from Chemotherapy Red cells are hypochromic—the
3. Transplant or erythropoietin therapy amount of hemoglobin per cell is
Normochromic decreased, and the central pale
response
• May also be used in classifying Anemias area becomes larger (more than
one-third

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 Clinical Pathology
Hematology
CER, MD

Myeloid Metaplasia, Megaloblastic Anemia,

and Sickle Cell Anemia
Spherocytes

Megaloblastic Anemia. Hereditary Spherocytosis.

Red cells are larger and thicker, Spherocytes are nearly perfectly
stain deeply, and lack central round, smaller than normal red
pallor cells, and lack central pallor
(Hyperchromic) • Spherocytes are nearly spherical
erythrocytes, in contradistinction to normal
biconcave disks.
o Their diameter is smaller than normal.
• They lack the central pale area or have a
smaller, often eccentric, pale area →
because the cell is thicker and can come to
rest somewhat tilted instead of perfectly
flattened on the slide
• They are found in:
Anisochromia. Polychromatophilia. 1. Hereditary Spherocytosis (HS)
Anisocytosis and Anisochromia Polychromatophilic red cells are
characterized by the presence of young red cells, larger than mature
2. Some Cases of Autoimmune Hemolytic
microcytic hypochromic cells, red cells; they lack central pallor Anemia (AHA)
normocytic cells, and few and appear slightly basophilic on 3. In some conditions in which a Direct
macrocytes Wright’s stain. They are called Physical or Chemical Injury has
Reticulocytes when stained occurred to the cells, such as from
supravitally with Brilliant Cresyl Heat
Blue
Leptocytes
• Microcytes – abnormally small
• Macrocytes – abnormally large
• Anisocytosis – abnormal variation in size
o Anisocytosis is a feature of most
anemias → when it is marked in degree,
both Macrocytes and Microcytes are
usually present
• In analyzing causes of Anemia, the terms
Microcytic and Macrocytic have greatest
meaning when considered as CELL
VOLUME rather than Cell Diameter • Target Cells are erythrocytes that are
Size o We perceive the diameter directly from thinner than normal (Leptocytes) and when
the blood film and infer volume (and the stained show a peripheral rim of Hb with a
Hb content) from it dark, central, Hb-containing area.
• Thus, the Red Cells in IDA are MICROCYTIC; • They are found in:
because they are HYPOCHROMIC, they are 1. OBSTRUCTIVE JAUNDICE → there
thinner than normal and the diameter is not appears to be an augmentation of the
decreased proportionately to the volume cell surface membrane
• Also, the Mean Cell Volume in the blood of 2. Postsplenectomy State → there is a
the patient with Spherocytosis is in the lack of normal reduction of surface
normal range membrane as the cell ages
o Although many of the cells have a small 3. Hypochromic Anemia, especially
diameter, their volume is not decreased Thalassemia
because they are thicker than normal. 4. Hb C Disease
• Poikilocytosis – variation in shape Schistocytes
• Any abnormally shaped cell is a
POIKILOCYTE.
• Oval, pear-shaped, teardrop-shaped,
saddle-shaped, helmet-shaped, and
irregularly shaped cells may be seen in a
single case of Anemia, such as
Megaloblastic Anemia
Elliptocytes

• Schistocytes (Cell Fragments) indicate the

presence of HEMOLYSIS, whether in
Megaloblastic Anemia, Severe Burns, or
Microangiopathic Hemolytic Anemia
Shape
Acanthocytes

• Elliptocytes are most abundant in

Hereditary Elliptocytosis, in which most
cells are elliptical → this is a dominant
condition that is only occasionally
associated with Hemolytic Anemia
• Elliptocytes are seen in normal persons’ • Acanthocytes are irregularly spiculated red
blood but account for < 10% of the cells. cells in which the ends of the spicules are
• They are more common, however, in Iron bulbous and rounded
Deficiency Anemia, Myelofibrosis with

Page 3 of 15
 Clinical Pathology
Hematology
CER, MD
• They are seen in ABETALIPOPROTEINEMIA,
hereditary or acquired, and in certain cases
of LIVER DISEASE
Echinocytes
• Burr Cells, or Echinocytes, are regularly
contracted cells that may commonly occur
as an artifact during preparation of film
• They may also be present due to
HYPEROSMOLARITY or to the DISCOCYTE-
ECHINOCYTE TRANSFORMATION.
Basophilic Stippling (Punctate Basophilia)
• This is characterized by the presence,
within the Erythrocyte, of IRREGULAR
BASOPHILIC GRANULES, which vary from
fine to coarse
A. Fine Stippling → commonly seen when
there is increased Polychromatophilia
and, therefore, with increased
production of red cells.
B. Coarse Stippling → may be seen in
Lead Poisoning or other diseases with
impaired Hb synthesis, in
Megaloblastic Anemia, and in other
forms of severe Anemia
• It is attributed to an abnormal instability of
the RNA in the young cell
• Red Cells with inorganic iron-containing
granules (as demonstrated by stains for
iron) are called SIDEROCYTES.
o Sometimes, these granules stain with
Wright’s Stain → if so, they are called
PAPPENHEIMER BODIES
Structure o In contrast to Basophilic Stippling,
Pappenheimer Bodies are few in
number in a given red cell and are rarely
seen in the peripheral blood except
after Splenectomy
Howell-Jolly Bodies
• These particles are smooth, round
remnants of nuclear chromatin.
• Single Howell-Jolly Bodies → may be seen
in Megaloblastic Anemia, in Hemolytic
Anemia, and after Splenectomy
• Multiple Howell-Jolly bodies in a Single
Cell → usually indicate Megaloblastic
Anemia or some other form of abnormal
erythropoiesis
Cabot Ring
• These are ring-shaped, figure-of-eight, or
loop-shaped structures.
• Occasionally, they are formed by double or
several concentric lines.
• They are observed rarely in erythrocytes in
Pernicious Anemia, Lead Poisoning, and
certain other Disorders of Erythropoiesis.
• They stain red or reddish purple with
Wright’s Stain and have no internal
structure.
• The rings are probably microtubules
remaining from a mitotic spindle
• They are interpreted as evidence of
Abnormal Erythropoiesis.
Malarial Stippling
• Fine granules may appear in erythrocytes
that harbor Plasmodium vivax.
• With Wright’s Stain, the minute granules,
“Schüffner’s Granules,” stain purplish red.
• They are sometimes so numerous that they
almost hide the parasites.
• These red cells are, as a rule, larger than
normal.
Rouleaux Formation
• This is the ALIGNMENT OF RED CELLS one
upon another so that they resemble STACKS
OF COINS
• Elevated Plasma Fibrinogen or Globulins
cause Rouleaux to form and also promote
an increase in the Erythrocyte
Sedimentation Rate.
• Rouleaux Formation is especially marked in
Paraproteinemia (Monoclonal
Gammopathy).
• In contrast to Erythrocytes of lower
vertebrates and to most mammalian cells,
the mammalian erythrocyte LACKS A
NUCLEUS.
• NRBCs (Normoblasts) are precursors of
Nonnucleated Mature Red Cells in the
blood.
• In the human, normoblasts are normally
present only in the Bone Marrow
• In general, NRBCs that might appear in the
blood in disease are Polychromatic
Normoblasts.
• In some, however, the cytoplasm is so
Basophilic that it is difficult to recognize
the cell as Erythroid except by:
1. The character of the Nucleus
Nucleated 2. Intensely staining Chromatin
RBCs (NRBC) 3. Sharp separation of Chromatin from
Parachromatin.
• Such Erythroid Cells are often mistaken for
Lymphocytes → an error that usually can be
prevented by careful observation of the
nucleus.
• Significance of NRBCs:
o Normoblasts are present normally only
in the blood of the FETUS and of VERY
YOUNG INFANTS.
o In the Healthy Adult, they are confined
to the Bone Marrow and appear in the
circulating blood only in disease → their
presence usually denotes an EXTREME
DEMAND made on the Marrow,
Extramedullary Hematopoiesis, or
Marrow Replacement.
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 Clinical Pathology
Hematology
CER, MD
o Large numbers of circulating NRBCs are
found particularly in Hemolytic Disease
of the Newborn (Erythroblastosis
Fetalis) and Thalassemia Major.
B. Platelets
• Platelets are round or oval, 2 to 4 μm in diameter, and
separated from one another
• The Platelet Count may be estimated from such films.
o On average, if the platelet count is normal, about one
platelet is found per 10 to 30 red cells
• Platelets contain FINE PURPLE GRANULES that usually fill the
cytoplasm.
• Activated Platelets:
1. Granulomere → granules concentrated in the center
2. Hyalomere → pale cytoplasm
o Occasionally, Granules are concentrated in the center
(the “Granulomere”) and surrounded by a pale
cytoplasm (the “Hyalomere”).
o These are probably ACTIVATED PLATELETS, the
appearance resulting from contraction of the
microtubular band
• Increased Giant Platelets:
1. Immune Thrombocytopenia
2. Bernard-Soulier Syndrome
3. Myelophthisis / Myeloproliferative Syndrome → the
platelets are frequently hypogranular or have a distinct
granulomere and hyalomere
• In blood films made from skin puncture wounds, Platelets
assume IRREGULAR SHAPES with SHARP PROJECTIONS and
tend to clump together.
C. Leukocytes
• Laboratory Examination of Leukocytes occur as part of the
automated CBC for almost every patient
• The total leukocyte count, as well as the relative and absolute
concentration of Neutrophils, Eosinophils, Basophils,
Monocytes, and Lymphocytes is determined and compared
with the normal values for the patient’s age and gender
• The Reference Value differs with age
o Normal value of the Leukocyte decreases as the person
ages
• Leukocytes normally present in the blood:
1. Neutrophils
2. Eosinophils
3. Basophil
4. Monocyte
5. Lymphocyte
Neutrophils
Band Form Neutrophilic Granules
• Also called Polymorphonuclear Neutrophilic Leukocytes /
Segmented Neutrophilic Granulocyte
• Average Diameter: 12 μm
• Smaller than Monocytes and Eosinophils and slightly larger
than Basophils
• The NUCLEUS stains deeply → it is irregular and often
assumes shapes comparable to such letters as E, Z, and S
• What appear to be separate nuclei normally are SEGMENTS of
nuclear material connected by delicate filaments.
• Segmented Neutrophil → has at least two of its lobes
separated by a filament.
• Band Neutrophil → has either a strand of nuclear material
thicker than a filament connecting the lobes or a U-shaped
nucleus of uniform thickness
• The Nucleus in both types of Neutrophils has COARSE
BLOCKS OF CHROMATIN and rather SHARPLY DEFINED
PARACHROMATIN SPACES
• The number of LOBES in normal Neutrophils ranges from 2 to
5, with a median of 3.
• The CYTOPLASM itself is colorless and has tiny granules
(0.2–0.3 μm) that stain tan to pink with Wright’s Stain.
o About 2/3 of these are Specific Granules and 1/3
Azurophil Granules.
• Segmented Neutrophils average 56% of leukocytes
• Band Neutrophils average 3% of leukocytes
• “SHIFT TO THE LEFT” occurs when increased bands and less
mature neutrophils are present in the blood, along with a
lower average number of lobes in segmented cells
• Neutrophilia, or Neutrophilic Leukocytosis, is an increase in
the Absolute Count, and Neutropenia is a decrease.
Eosinophils
• Average Diameter: 13 μm
• The structure of these cells is similar to
that of Polymorphonuclear
Neutrophils, with the striking
difference that, instead of Neutrophilic
Granules, their cytoplasm contains
LARGER ROUND OR OVAL GRANULES
that have a STRONG AFFINITY FOR
ACID STAINS
• They are easily recognized by the size and color of the
granules, which stain BRIGHT RED with Eosin.
• Cytoplasm is Colorless.
• Nucleus stains somewhat less deeply than that of the
Neutrophils and usually has 2 connected segments (lobes),
rarely >3.
Basophils
• In general, Basophils resemble
Neutrophils, except that the nucleus
is LESS SEGMENTED (usually merely
indented or partially lobulated), and
GRANULES ARE LARGER and have a
STRONG AFFINITY FOR BASIC
STAINS
• In a well-stained film, the Granules are deep purple and the
nucleus is somewhat paler and often nearly hidden by the
granules so that its form is difficult to distinguish.
• Basophils are the least numerous of the Leukocytes in
normal blood and average 0.5%.
Monocytes
• The Monocyte is the LARGEST CELL of normal blood
o It generally has about two to three times the diameter of
an Erythrocyte (14–20 μm), although smaller Monocytes
sometimes are encountered
• It contains a SINGLE NUCLEUS, which is partially lobulated,
deeply indented, or horseshoe shaped.
• Cytoplasm is abundant
o Cytoplasm is blue-gray and has a ground-glass
appearance.
o It often contains fine red to purple granules that are less
distinct and smaller than the granules of Neutrophils.
• When the Monocyte transforms into a MACROPHAGE, it
becomes larger (20–40 μm)
• A Perinuclear Clear Zone (Golgi) may be evident.
• The more abundant cytoplasm tends to be irregular at the
cell margins and to contain VACUOLES.
o These are PHAGOCYTIC VACUOLES, which may contain
ingested red cells, debris, pigment, or bacteria
• Evidence of Phagocytosis in Monocytes or the presence of
Macrophages in directly made blood films is PATHOLOGIC
and often indicates the presence of ACTIVE INFECTION.
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 Clinical Pathology
Hematology
CER, MD
Lymphocytes
• Lymphocytes are Mononuclear Cells without specific
Cytoplasmic Granules.
• Small Lymphocytes are about the size of an erythrocyte or
slightly larger (6–10 μm
• The typical Lymphocyte has a single, sharply defined nucleus
containing heavy blocks of Chromatin.
o The Chromatin stains dark blue with Wright’s Stain
• Nucleus is generally round but is sometimes indented at one
side.
• Cytoplasm stains pale blue except for a Clear Perinuclear
Zone.
• Larger Lymphocytes, 12 to 15 μm in diameter, with less
densely staining nuclei and more abundant cytoplasm, are
frequently found, especially in the blood of children, and may
be difficult to distinguish from monocytes.
• The presence of significant proportions of ATYPICAL
LYMPHOCYTES must be noted → these indicate
TRANSFORMATION OF LYMPHOID CELLS as a response to
ANTIGENIC STIMULATION
• Develop from B Lymphocytes
• Plasma Cells have abundant blue
cytoplasm, often with light streaks or
vacuoles, an eccentric round nucleus, and a
well-defined clear (Golgi) zone adjacent to
the nucleus
Plasma Cells • The Nucleus of the Plasma Cell has heavily
clumped chromatin, which is sharply
defined from the parachromatin and is
often arranged in a radial or wheel-like
pattern.
• Plasma Cells are NOT PRESENT NORMALLY
in blood.
• The Lymphocytes and their Derivatives, the Plasma Cells,
OPERATE IN THE IMMUNE DEFENSES of the body
Complete Blood Count
• Measures the CELLULAR COMPONENTS of blood reflecting
the FUNCTIONAL STATUS of the Bone Marrow
• Performed by Manual Methods or Automated Blood Cell
Counts
• Components:
1. RBC Count
2. RBC Indices
3. Hgb Concentration
4. Hematocrit
5. WBC Count
6. WBC Differential Count
7. Platelet Count (and examination of a Wright’s-stained
film)
• RBC, WBC, and Platelet Count → same for males and
females
• Hgb → 1-2 g/dL higher in males
Example of CBC Result
Erythrocyte Sedimentation Rate
• One of the oldest laboratory tests that is still in use →
although its usefulness has decreased as more specific
methods of evaluating diseases, like C-Reactive Protein,
have been developed
• Erythrocyte Sedimentation Rate (ESR) is a useful but
NONSPECIFIC MARKER of underlying inflammation.
• When well-mixed venous blood is placed in a vertical tube,
Erythrocytes will tend to fall toward the bottom.
• The length of fall of the top of the column of Erythrocytes
over a given interval of time is called the ESR.
• Several factors are involved:
1. Plasma Factors
2. Red Cell Factors
• An accelerated ESR is favored by elevated
levels of Fibrinogen and, to a lesser extent,
α2-, β-, and γ-globulins
• These asymmetric protein molecules have
a greater effect than other proteins in
decreasing the negative charge of
Erythrocytes (Zeta Potential) that tends to
keep them apart
Plasma • The decreased Zeta Potential promotes the
Factors formation of Rouleaux, which sediment
more rapidly than single cells.
• Removal of Fibrinogen by DEFIBRINATION
lowers the ESR.
• No absolute correlation has been noted
between the ESR and any of the Plasma
Protein Fractions
• Albumin and Lecithin retard sedimentation,
and cholesterol accelerates the ESR
• Anemia increases the ESR because the
change in the Erythrocyte/Plasma Ratio
favors Rouleaux Formation independently
of changes in the concentrations of plasma
proteins.
• By any method of measurement, ESR is
most sensitive to altered plasma proteins in
the Hct range of 0.30 to 0.40
• The Sedimentation Rate is directly
proportional to the weight of the cell
Red Cell
aggregate and inversely proportional to the
Factor
surface area
• Microcytes SEDIMENT SLOWER than
Macrocytes, which have decreased Surface
Area/Volume Ratios.
• Rouleaux also have a decreased Surface
Area/Volume Ratio and accelerate the ESR.
• Red Cells with an abnormal or irregular
shape, such as Sickle Cells or Spherocytes,
hinder Rouleaux Formation and lower the
ESR.
• Emergency physicians continue to use the ESR in evaluating
Temporal Arteritis, Septic Arthritis, PID, and Appendicitis
• Clinical Significance:
1. Sickle Cell Disease → low in absence of painful crisis,
moderate increase 1 week into the crisis
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 Clinical Pathology
Hematology
CER, MD

2. Osteomyelitis → elevated, helpful in following therapy Examination of Marrow

3. Stroke → ESR ≥28 mm/hr has a poorer prognosis Peripheral Blood
4. Prostate Cancer → ESR ≥37 mm/hr has higher incidence • The Complete Blood Cell Count, including Platelet Count and
of disease progression and death Reticulocyte Count, should be performed on the day of the
5. Coronary Artery Disease → ESR >22 mm/hr in white men marrow study and the results incorporated in the report.
had a higher risk for CAD • The pathologist or hematologist who examines the marrow
6. Cancer Patients → when ESR >100 mm/hr, metastases should also carefully examine the blood film as previously
are usually present described and should incorporate the observations in the
II. BONE MARROW EXAMINATION marrow report
• The Bone Marrow Examination provides a Cellularity of the Marrow
SEMIQUANTITATIVE and QUALITATIVE assessment of the • Marrow Cellularity is expressed as the ratio of the volume of
state of Hematopoiesis and aids in the diagnosis of several hematopoietic cells to the total volume of the marrow space
Hereditary and Acquired Benign and Malignant Diseases. (cells plus fat and other stromal elements).
• Marrow Aspiration and Biopsy can be carried out as an office • Cellularity varies with the AGE of the subject and the SITE.
procedure on ambulatory patients with minimal risk A. If the percentage is increased for the patient’s age, the
o It compares favorably with ordinary venipuncture and is marrow is HYPERCELLULAR, or HYPERPLASTIC
less traumatizing than a lumbar puncture. B. If decreased, the marrow is HYPOCELLULAR, or
o As for any other special procedure, however, the clinical HYPOPLASTIC.
indications for marrow examination should be clear. Marrow Biopsy Evaluation
o In each instance, the physician should have in mind • Histologic sections allow better estimates of marrow
some reasonable prediction of its result and consequent cellularity and of the number of Megakaryocytes than do
benefit to the patient. marrow films
• Without exception, the Peripheral Blood should be examined • In good histologic preparations, cell distribution and
carefully first. maturation abnormalities can be quite reliably determined.
• It is a relatively uncommon circumstance to find • In addition to more reliable detection of the presence of
Hematologic Disease in the Bone Marrow without evidence Lymphomas or Metastatic Tumor, the histologic pattern can
of it in the Peripheral Blood. often be diagnostic of the type of neoplasm.
Indications for Marrow Study • In some conditions, such as Myelofibrosis and Hairy Cell
• Bone Marrow Biopsy and Aspiration should be performed Leukemia, the Bone Marrow cannot be aspirated and biopsy
only when there is a CLEAR CLINICAL INDICATION is necessary to establish a diagnosis
o While widely accepted criteria for assessing adequacy of • Trabeculae should always be examined to detect bone
bone marrow samples for establishing a diagnosis do not abnormalities.
exist at this time, there are some DISEASE-SPECIFIC
GUIDELINE
• Both Bone Marrow Aspiration and Biopsy are performed
routinely together
o If the marrow cannot be aspirated (“dry tap” in
Myelofibrosis and Hair Cell Leukemia), Biopsy is essential
• Besides increasing the yield of diagnostic tissue, each
specimen also provides unique information
• Biopsy provides information about the Bone Marrow
Architecture, whereas cellular details are much better
appreciated on the Aspirate Smears.
• Indications:
1. Neutropenia, Thrombocytopenia, or Pancytopenia →
marrow study is helpful in assessing the presence and
normality of the precursor cells in each series
o This enables one to assess the probability of
decreased production, impaired maturation, or
increased destruction as the mechanism of the
disorder
o In cytopenias, marrow examination sometimes will
reveal the presence of leukemia or another
hematologic neoplasia
2. Marrow examination is essential for the diagnosis and
classification of Acute Leukemia
o It is frequently performed to assist in the diagnosis
and staging of other neoplasms, including
lymphomas and metastatic tumors, and to assess
response to therapy for hematologic disorders
3. Marrow Biopsy should also be performed if blood
changes suggest Myelofibrosis with Myeloid
Metaplasia or if Granulomatous Disease or Metastatic
Tumor is suspected.
Special Studies
• It is recommended that, for evaluation of most hematologic
diseases, an additional Bone Marrow Aspirate Specimen
should be collected for ANCILLARY TESTING, including:
1. Flow Cytometry Analysis
o Best performed on a Heparin- or EDTA-
Anticoagulated Aspirate Specimen, which is stable
for at least 24 hours at room temperature
o For cytogenetic or cell culture analysis,
anticoagulated marrow should be added to tissue
culture medium and analyzed as soon as possible to
maintain optimal cell viability
2. Karyotype
3. Fluorescent In Situ Hybridization (FISH) Assays
4. Molecular Studies
o Best performed on an EDTA-anticoagulated bone
marrow specimen, as heparin can interfere with
some PCR-based assays

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 Clinical Pathology
Hematology
CER, MD

ERYTHROCYTIC DISORDERS • The majority of the daily iron needs (80%–90%) is provided
I. ANEMIA by RECYCLING OF IRON from Senescent Red Cells and the
1. Impaired Production remainder through daily intake of iron
A. Iron Deficiency Anemia • Very little iron is lost from the body
B. Anemia of Inflammation o About 1 mg is lost each day, except in menstruating
C. Megaloblastic Anemia females, whose iron loss averages about 2 mg/day
2. Blood Loss Anemia • Iron Balance is maintained by CONTROL OF ABSORPTION
3. Hemolysis o Absorption takes place largely in the Small Intestine,
A. Membrane Disorders most efficiently in the DUODENUM and UPPER
B. Hemoglobin Disorders JEJUNUM, with Heme Iron absorbed more efficiently
*Thalassemia than Inorganic Iron
C. Metabolic Disorders o Iron absorption is facilitated by ascorbate and citrate
D. Acquired and is inhibited by phytates and tannin
II. POLYCYTHEMIA • Acid production by the stomach lowers the pH in the
1. Relative Polycythemia duodenum, thus enhancing the solubility and uptake of
2. Absolute Polycythemia nonheme ferric iron.
III. PORPHYRIAS • 25-amino-acid antimicrobial peptide
I. ANEMIA • Has been shown to play a major role in Iron
• Anemia is considered to be present if the Hemoglobin (Hb) Homeostasis through a hormonal effect
Concentration or the Hematocrit (Hct) is BELOW THE LOWER • Hepcidin is produced by the liver, is filtered
LIMIT of the 95% Reference Interval for the individual’s age, by the kidney, and accumulates in urine.
sex, and geographic location Hepcidin
• Hepcidin negatively controls the release of
• ABSOLUTE ANEMIA: iron from cells, such as intestinal
o Anemia may be absolute when Red Blood Cell (RBC) mass epithelium and macrophages, to the plasma
is decreased or relative when associated with a higher → it limits the release of intracellular iron
plasma volume into the plasma
o 2 Major Pathophysiologic Categories:
• In the plasma, Total Iron averages 110 μg/dL (19.7 μ mol/L)
1. Impaired Red Cell Destruction
• The great majority of this is bound to the transferrin, which
2. Increased Erythrocyte Destruction (or loss in excess
of the ability of the marrow to replace those losses has a capacity to bind 330 μg of iron per deciliter (or 59.1
o The presence of Anemia may be a sign of an underlying μmol/L) and, therefore, is about one-third saturated
disorder of which the cause should be identified because • A very small amount of iron in plasma is in ferritin. Plasma
correction may be very important to the health of the (or serum) ferritin averages about 100 μg/L in men (less in
individual. women— about 50 μg/L).
• RELATIVE ANEMIA Iron Deficiency Anemia (IDA)
o May occur with: • When iron loss exceeds iron intake for a time long enough to
1. Pregnancy deplete the body’s iron stores, insufficient iron is available
2. Macroglobulinemia for normal Hb production
3. Postflight Astronauts • When well developed, Iron Deficiency is characterized by a
• Classified by Red Cell Morphology → approach that is useful HYPOCHROMIC MICROCYTIC ANEMIA.
in differential diagnosis • Iron Deficiency typically results when:
1. Normocytic 1. The need for iron is INCREASED (e.g., during rapid
2. Macrocytic / Microcytic growth in infancy and childhood, during pregnancy)
• Both pathophysiologic and morphologic classifications 2. When excessive loss of blood has reduced the body’s
should be understood. reserves of iron (e.g., following repeated hemorrhages,
• Some anemias (e.g., blood loss anemia) have more than one excessive menstruation, or multiple pregnancies).
pathogenetic mechanism and go through more than one • Iron Deficiency is probably the MOST COMMON CAUSE OF
morphologic stage. ANEMIA, affecting at least 1.2 billion individuals worldwide
Clinical Signs and Symptoms • If an ADULT MALE had absolutely no iron intake or
• Clinical signs and symptoms result from diminished delivery absorption (which would be extremely unlikely), his body
of oxygen (O2) to the tissues → related to the lowered Hb iron stores of 1000 mg would last for 3 to 4 years before he
concentration and blood volume and are dependent on the would even begin to become Iron Deficient.
rate of these changes. o Therefore, almost all cases of IDA in adult males are due
• In general, the anemic patient complains of: to CHRONIC BLOOD LOSS
1. Easy Fatigability o Common causes of Iron Deficiency in Males and Post-
2. Dyspnea on Exertion Menopausal Females → Hemorrhagic Lesions, such as:
3. Faintness 1. Benign and Malignant Tumors
4. Vertigo 2. Chronic Ingestion of some Medications
5. Palpitations 3. Helminthic Infections
6. Headache Pathophysiology
• More common physical findings are: • Sequence of events in developing IDA is usually as follows:
1. Pallor 1. Stage 1: Iron Depletion
2. Rapid Bounding Pulse When blood loss exceeds absorption, a negative iron
3. Low BP balance exists → Iron is mobilized from stores:
4. Slight Fever a. Storage Iron Decreases
5. Some Dependent Edema b. Plasma Ferritin Decreases
6. Systolic Murmurs c. Iron Absorption Increases
• In addition to these general signs and symptoms, certain d. Plasma Iron-Binding Capacity (Transferrin)
clinical findings are characteristic of the specific type of Increases
anemia. o This stage is known as IRON DEPLETION
1. IMPAIRED PRODUCTION 2. Stage 2: Iron Deficient Erythropoiesis
A. Iron Deficiency Anemia After iron stores are depleted, the plasma iron
• Iron → essential component of Hb, of Myoglobin (in muscle concentration falls, saturation of Transferrin falls below
cells), and of certain enzymes (in most body cells). 15%, and the percentage of Sideroblasts decreases in
the marrow
• 2/3 or more of the body’s total iron is in the ERYTHRON
o Anemia may not be present
(Normoblasts and Erythrocytes)
3. Stage 3: IDA
o Each mL of Red Cells contains about 1 mg of Iron
o Anemia is already detectable
• Storage Iron is present in Macrophages of the
o The Anemia at first is Normochromic and
Reticuloendothelial System in 2 Forms:
Normocytic, gradually becomes Microcytic, and
1. Ferritin -->
finally becomes Microcytic and Hypochromic
2. Hemosiderin

Page 8 of 15
 Clinical Pathology
Hematology
CER, MD
Laboratory Features
• Early IDA → stained blood film often shows NORMOCHROMIC
NORMOCYTIC ERYTHROCYTES
• Later Stages:
o Microcytosis, Anisocytosis, Poikilocytosis (including
elliptical and elongated cells), and varying degrees of
Hypochromia
o The thin red cells (Leptocytes) have faint red color
compared to normal.
• The Plasma Membranes of iron-deficient cells are
ABNORMALLY STIFF → this abnormality contributes to the
development of Poikilocytes, particularly elongated
Hypochromic Elliptocytes (Pencil Cells).
• Anisocytosis may be identified by Automated Blood
Counters as increased Red Cell Distribution Width (RDW)
o This finding, however, is not specific for IDA
• Reticulocytes are usually decreased in
absolute numbers, except following Iron
Therapy
o Reticulocyte Hemoglobin Content →
Decreased
o MCV → Decreased
o Hb and Hct are relatively lower than the
Erythrocyte Count
• Osmotic Fragility may be decreased
because the Red Cells are thinner than
normal
• Leukocyte Count is normal or slightly
lowered.
Decreased
• Granulocytopenia and a small number of
Hypersegmented Neutrophils may be
present.
• Megaloblastic changes in severe Iron
Deficiency may be related to decreased
activity of the enzyme RIBONUCLEOTIDE
REDUCTASE, which contains an essential
nonheme iron atom
• However, the detection of
HYPERSEGMENTED NEUTROPHILS should
raise suspicion for a MILD FOLATE
DEFICIENCY, which may become more
overt after iron therapy
• Platelets may be increased whether the lack
of iron is due to blood loss or dietary
Increased
deficiency, but tend to be decreased in
severe anemia
• Serum Iron → Low
o The level is lower in iron deficiency and in infection and
anemia of chronic disease
• Serum Ferritin → Low
o In adults, the Reference Values are 12 to 300 μg/L, with
higher values in men than in women
o Serum Ferritin appears to be in equilibrium with Tissue
Ferritin and is a good reflection of storage iron in normal
subjects and in most disorders.
• Serum (Total) Iron-Binding Capacity
o The Reference Interval for adults is 250 to 400 μg/dL (45–
72 μmol/L)
o In IDA, the Serum TIBC is increased.
o It is normal or decreased in the Anemia of Chronic
Disease.
o If chronic infection coexists with chronic blood loss, the
TIBC may not be increased even though the patient is iron
deficient → some laboratories measure TRANSFERRIN
level as an alternative
B. Anemia of Inflammation (ACD)
• Anemia Syndrome typically found in patients with Chronic
Infections or Inflammatory or Neoplastic Disorders
• Characterized by REDUCED RETICULOCYTE RESPONSE
• Also called Anemia of Chronic Disease (ACD) or Cytokine
Response, although Anemia of Inflammation is now a more
common term
• Estimates suggest that up to 40% of Anemias worldwide can
be considered Anemia of Inflammation or Combined Anemia
with a significant Anemia of Inflammation component
• Has also been observed in ACUTE TRAUMA and CRITICAL
CARE PATIENTS
• Higher in the OLDER ADULT population
• Mechanism of Anemia:
1. High levels of cytokines → direct inhibition of
Erythropoiesis
o The most important pathogenic mechanism of
Anemia of Inflammation is the presence of HIGH
LEVELS OF CYTOKINES → may result in: decreased
red cell survival, altered metabolism, direct
inhibition of hematopoiesis, and decreased
erythropoietin secretion
2. Hepcidin → interferes with the release of Intracellular
Iron
o Hepcidin has been shown to be elevated in Anemia
of Inflammation through induction of IL-6
o Considered an Acute Phase Reactant
o Hepcidin may exert an inhibitory effect on Erythroid
Colony Formation at certain levels of EPO and, thus,
may provide a Bone Marrow Inhibitory Effect
3. Cytokine inhibition of EPO production
o Inhibitory effects of cytokines on EPO synthesis
sites such as renal and liver cells have been
suggested
o In addition, Macrophage Activation by inflammatory
cytokines may play an additional role in Shortened
Red Cell Survival
4. Shortened Erythrocyte Survival
• The relative deficiency of EPO induces NEOCYTOLYSIS →
selective hemolysis of the youngest RBCs
• A mild hemolytic event usually accompanies AI
• Anemia usually fails to respond to Iron Therapy
o However, patients treated with EPO have shown
improvement.
• The Anemia is mild to moderate, with Hb
level rarely below 8 g/dL.
• Usually Normocytic and Normochromic
Blood Film
o Although in 20% to 50% of patients, the
Anemia is Microcytic and Hypochromic
• Mild Anisocytosis and Poikilocytosis
• Normocellular or minimally hypocellular or
Marrow hypercellular, and the cell distribution is
not greatly disturbed.
• Reticulocyte, Leukocytes and Platelets,
Normal
Storage of Iron (increased in some case)
• Sideroblast
• Serum Iron Concentration
Decreased
• TIBC (or normal)
• Percent Saturation
C. Macrocytic Anemia
Non-Megaloblastic
• Macrocytic Anemias that are not megaloblastic may be due
to early release of erythrocytes from the marrow, so-called
SHIFT RETICULOCYTE
• Shift Reticulocytes may occur in response to:
1. Acute Blood Loss
2. Hemolysis
3. Bone Marrow Infiltration
4. High Levels of EPO associated with Bone Marrow Failure
Diseases (Aplastic Anemia, Refractory Anemia, and
Diamond-Blackfan Anemia)
• Nonmegaloblastic Macrocytosis is also found in
HYPOTHYROIDISM, in individuals with excessive alcohol
intake, and in liver disease
Megaloblastic Anemia
• Macrocytic Anemias associated with Megaloblastosis differ
from Nonmegaloblastic Macrocytic Anemia in that Macro-
Ovalocytes and Giant Hypersegmented Neutrophils are
present in the blood
• PANCYTOPENIA is the rule.
o Pancytopenia → deficiency of all 3 cellular components
of blood
• Leukopenia is present.
• Granulocytes have increased numbers of lobes
(Hypersegmentation), presumably as a result of abnormal
nuclear maturation.
o Hypersegmentation → Five lobes in more than 5% of the
Neutrophils or any Neutrophil with 6 or more lobes
• Thrombocytopenia is usually encountered and on rare
occasions is sufficiently severe to be responsible for
bleeding
• It is worth noting that significant morphologic changes may
occur in the blood in the absence of anemia and that
neurologic symptoms may be present in the absence of
anemia
• Anisocytosis and Poikilocytosis → extreme
degrees
Blood Film • Red Blood Cell Fragments
• Microcytes and Dacrocytes
• Basophilic Stippling
Page 9 of 15
 Clinical Pathology
Hematology
CER, MD
• Howell Jolly Bodies
• Nucleated Red Cells with Karyorrhexis
• Megaloblasts
Pernicious Anemia
• Pernicious Anemia (PA) is a “conditioned” nutritional
deficiency of COBALAMIN that is caused by failure of the
Gastric Mucosa to secrete Intrinsic Factor.
• This abnormality is genetically determined but usually is not
manifested until late in life
o Less than 10% of cases occur in persons younger than
age 40 years.
• Prevalence is higher in WOMEN
• Positive family history is obtained in approximately 30% of
patients
• Defective production of INTRINSIC
FACTOR → most common cause of
Cobalamin Deficiency
• A DIETARY DEFICIENCY is an extremely
rare cause of Megaloblastic Anemia in the
Etiology
United States and is seen only in persons
who completely abstain from animal food,
including milk and eggs.
• Only strict VEGETARIANS are known to
develop this form of Cobalamin Deficiency.
• Recognition of Megaloblastic Anemia
indicates the likelihood of Cobalamin
Deficiency or Folic Acid Deficiency
• In addition, evidence of neurologic
involvement favors Cobalamin Deficiency
→ this diagnosis can be established by 1 of
4 methods:
1. Therapeutic Trial
o With the patient on a diet low in
cobalamin and folate, a parenteral
physiologic dose of cobalamin (10
Diagnostic
μg/day) is given.
Tests o Optimal hematologic response
indicates deficiency and consists
of reticulocytosis beginning on the
third or fourth day, reaching a peak
on the seventh day.
2. Serum Cobalamin Assay
o This is the usual method of
detecting a cobalamin-deficient
state
3. Methylmalonic Acid and
Homocysteine Assay
4. Deoxyuridine Suppression Test
Folate-Deficient Megaloblastic Anemia
• Megaloblastic Anemia due to lack of Folate is most
commonly associated with INSUFFICIENT DIETARY INTAKE.
o The usual diet does not contain much above the minimal
requirements, and body stores in the adult are sufficient
for only about 3 months’ needs.
• Dietary Folate Deficiency is especially common in the tropics
and in India and, even in those locations, it is usually
associated with increased demand for Folate in pregnancy,
rapid growth in infancy, infection, or Hemolytic Anemia
• Liver Disease
o Liver disease associated with alcoholism may be
associated with Folate-Deficient Megaloblastic Anemia
because of the grossly inadequate diet of the alcoholic
and because the liver is the major site for Folate storage
and metabolism
o Alcohol may exert a direct effect in suppressing
Hematopoiesis by blocking the metabolism of folate.
o In addition, alcohol can interfere with Folate Absorption
and Folate Enterohepatic Circulation, usually resulting in
increased loss of folate in urine.
o With adequate dietary Folic Acid intake, however, the
anemia that is found with liver disease is Macrocytic and
Normoblastic—not megaloblastic.
• Malabsorption Syndromes
o Defective absorption of Folic Acid occurs in association
with Malabsorption Syndromes and in the Blind Loop
Syndrome, in which bacteria preferentially utilize folate
• Increased Requirement for Folate
o The increased need for Folate in pregnancy and in infants
has been mentioned
o Increased cell turnover that occurs in neoplasia and in
the markedly stimulated hematopoiesis of Hemolytic
Anemias may result in Megaloblastic Erythropoiesis.
o The basis for this is the increase in need for a marginal
supply of folate.
• Inadequate Utilization of Folate
o Inadequate utilization of Folic Acid is relatively rare.
o Folic Acid antagonists such as Methotrexate block Folic
Acid Metabolism → because of this, they are used in
therapy of some malignant neoplasms.
o In addition to inhibiting growth of the tumor, they induce
Megaloblastic Hematopoiesis
• Includes:
1. Serum and Red Cell Folate
o A microbiological assay for folic
Diagnostic acid activity employing
Tests Lactobacillus casei is a reliable
method for definitive diagnosis
2. Deoxyuridine Suppression Test
3. Plasma Homocysteine Assay
• As with Cobalamin Deficiency, Total Plasma Homocysteine
is INCREASED in approximately 75% of patients with Folate
Deficiency
Aplastic Anemia (AA)
• AA usually refers to PANCYTOPENIA associated with a
severe reduction in the amount of hematopoietic tissue that
results in deficient production of blood cells in the absence
of a bone marrow infiltrative process or increased Reticulin
• The marrow, although Hypocellular, may have patchy areas
of Normocellularity, or even Hypercellularity.
• The clinical course may be ACUTE and FULMINATING, with
PROFOUND PANCYTOPENIA and a rapid progression to death,
or the disorder may have an INSIDIOUS ONSET and a
CHRONIC COURSE
• The symptoms and signs depend on the degree of the
deficiencies:
1. Bleeding from Thrombocytopenia
2. Infection from Neutropenia
3. Signs and symptoms of Anemia
• As a rule, SPLENOMEGALY and LYMPHADENOPATHY are
ABSENT.
• Bleeding is the most common presentation of acquired AA,
occurring in approximately 40% of patients
o Bleeding usually manifests as Easy Bruisability, Gum
Bleeds, and Episodic Nosebleeds.
• Less than 5% of patients present with infection.
• 2 of the 3 Blood Parameters to diagnose
AA:
1. Hgb <100 g/L
2. Granulocyte Count <1.5x109/L
3. Platelet Count <50x109/L
• Severe AA: Bone Marrow <25% Cellular + at
Diagnosis least 2 of these 3 Peripheral Blood Values is
present
1. Granulocyte: <0.5x109/L
2. Platelet: <20x109/L
3. Reticulocyte: <20x109/L
• Very Severe AA:
1. Granulocyte: <0.2x109/L
2. BLOOD LOSS ANEMIA
Acute Posthemorrhagic Anemia
• Blood may be lost from the circulation externally or
internally into a tissue space or body cavity.
• Blood is lost over a SHORT TIME in amounts sufficient to
cause Anemia → Acute Posthemorrhagic Anemia
• Normal healthy individuals are able to compensate for rapid
blood loss of up to 20% of circulating blood volume with few
symptoms
• After a single episode of excessive bleeding, the major
manifestations are those due to DEPLETION OF BLOOD
VOLUME (HYPOVOLEMIA)
After a day or so, blood volume is returned to previous levels
by movement of fluid into the circulation, and anemia
becomes evident.
Interval Changes
• 1 hr: transient fall in the Platelet Count
• 2-5 hours:
Earliest
Hematologic o Moderate Neutrophilic Leukocytosis
with a shift to the left
Change
o Maximum Leukocyte Count of 10-
35x109/L
• Fall in Hb and Hct → may not reveal the full
2-3 days after
extent of red cell loss until 2 or 3 days after
Hemorrhage
the hemorrhage.
Page 10 of 15
 Clinical Pathology
Hematology
CER, MD
o Hb and Hct do not fall immediately;
rather, they fall slowly as tissue fluids
move into the circulation to
compensate for lost blood volume.
• The anemia that develops at first is
Normochromic and Normocytic, with a
normal MCV and Mean Cell Hemoglobin
Concentration (MCHC) and only minimal
Anisocytosis and Poikilocytosis
3-5 days after
• Increased EPO secretion stimulates
Hemorrhage
Erythroid Proliferation in the Marrow
• Reticulocytes begin to reach the
circulation → maximum of 10 days or so
• Transient Macrocytosis (Increased MCV,
increased Polychromasia and Normoblast)
2-4 days after • Leukocyte Count returns to normal
Hemorrhage
• Morphologic changes will disappear
2 weeks after
Hemorrhage
• Return of red cell values is slower
Chronic Posthemorrhagic Anemia
• If blood is lost in small amounts over an extended period,
both clinical and hematologic features that characterize
Acute Posthemorrhagic Anemia are lacking
• Significant anemia does not usually develop UNTIL AFTER
STORAGE IRON IS DEPLETED → Anemia is one of Iron
Deficiency
• Anemia
o Initial: Normochromic and Normocytic
o Gradually become Microcytic, and then Hypochromic
• Reticulocyte: normal or slightly increased
• Leukocyte: normal or slightly decreased (Neutropenia)
• Platelets: increased but decreased in Severe Iron Deficiency
• The cause of blood loss must be identified because a hidden
malignancy, particularly of the GI tract, may be the cause of
the Anemia
3. HEMOLYSIS
Thalassemia
• 2 Main Groups of Inherited Disorders of Hb:
1. Structure Variants → with defects in the structure
2. Thalassemia → with defects in the synthesis of a globin
chain
o There is an overlap between these groups
• Most Thalassemias involve the α- or β-globin chain.
o δ (Delta)- and γ (Gamma)-Thalassemias are known, but
are clinically less significant.
• In Thalassemia, Globin Chains are produced at a
DECREASED RATE
o Beta-Thalassemia refers to decreased production of β-
chains
o Alpha-Thalassemia, Delta-Beta-, Delta-, and Delta-
Gamma-Beta-Thalassemias refer to reduced synthesis
of the respective polypeptide chains.
• As a result, there is an overall deficit of Hb tetramers in the
red cells, and MCV and MCH are reduced.
• However, it is not the lack of the affected globin chain but
rather the ACCUMULATION OF THE UNAFFECTED ONE that
causes hemolysis and, primarily in β-Thalassemia,
ineffective hematopoiesis in severe forms of the disease.
• Several classifications are used:
1. Thalassemia Major → a severe and transfusion-
dependent form
2. Thalassemia Intermedia → with less severe and
transfusion-dependent form
3. Thalassemia Minor (Carrier State or Trait) → without
clinical symptoms but with hematologic abnormalities
Microcytic and Hypochromic Anemias (↓ MCV and MCH)
• Table above summarizes some laboratory features in
Microcytic Anemia
• MCV has assumed the leading role in the detection of
Microcytic Hypochromic Anemias
• These anemias reflect a quantitative defect in Hemoglobin
Synthesis
• Major causes of Microcytic Anemia include the following:
1. Iron Deficiency Anemia → due to increased
requirement or blood loss not balanced by intake
2. Anemia of Inflammation (AI; Anemia of Chronic
Disease) → associated with infection, neoplasia, or
collagen disease.
o This anemia may be Normochromic and Normocytic,
but in LONG-STANDING DISEASE is often
Hypochromic and Microcytic
3. Thalassemia → genetically determined impairment in
the rate of globin synthesis
4. Sideroblastic Anemia
o Group of refractory anemias with erythroid
hyperplasia of the marrow in which a defect in Hb
synthesis creates a population of hypochromic
microcytic cells.
o The blood film is DIMORPHIC and MACROCYTES may
prevail, making the MCV normal or high, particularly
in acquired forms of Sideroblastic Anemia.
o Microcytic Anemia is common in the INHERITED
FORM.
• Because Iron Deficiency is the most common anemia, the
first step is to determine whether the body lacks iron.
• When blood loss cannot be documented, Serum Ferritin,
Serum Iron and Iron-Binding Capacity, or Bone Marrow
Study for Iron should be performed.
o These will usually discriminate between the two most
common anemias in this category:
1. Iron Deficiency
2. Simple Chronic Anemia (AI) associated with some
other disease → frequently, chronic infection or
cancer
o In both, the Serum Iron Concentration Is Low
o However, in Iron Deficiency, the TIBC is elevated whereas
in Simple AI it is normal or decreased.
o Storage Iron in the marrow is depleted in Iron Deficiency
but is normal or elevated in Anemia of Chronic Disease.
• IDA in an adult male almost always means CHRONIC BLOOD
LOSS → the source must be found and corrected, if
necessary
o If no obvious source for iron loss is identified,
Paroxysmal Nocturnal Hemoglobinuria (PNH) should be
considered, particularly when there is associated
Neutropenia or Thrombocytopenia.
• Hypochromic Anemias (or Hypochromic Erythrocytoses)
with Basophilic Stippling and normal or increased serum iron
are most likely THALASSEMIAS, in which case the next
examinations to perform are Hb electrophoresis and
determination of HbA2 and HbF.
o Family studies are often necessary
• Sideroblastic Anemias include Myelodysplastic Syndrome
with Ring Sideroblasts and anemias that occur after therapy
with certain drugs (e.g., Isoniazid) or in chronic Lead
Poisoning.
o Coarse Basophilic Stippling is common in this group of
anemias.
II. POLYCTHEMIA (ERYTHROCYTOSIS)
• Classically defined as an elevated Hct level above the
normal range.
• In the clinical setting, Polycythemia exists when Hb And Red
Cell Count are INCREASED, reflecting an elevation of the
Total Red Cell Volume
• The recent World Health Organization (WHO) classification of
hematologic malignancies has defined polycythemia as Hgb
>16.5 g/dL for men and >16.0 g/dL for women, as one of the
3 Major Criteria for the diagnosis of Polycythemia Vera
• Absolute Polycythemia
o Refers to an INCREASE in the Total Red Cell Mass in the
body
• Relative Polycythemia
o The Total Red Cell Mass is NORMAL, but the Hct is
elevated because the Plasma Volume is decreased
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Hematology
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• Some classifications are based on EPO response and others

are based on the underlying mechanism (i.e., primary or
secondary and congenital or acquired)
Polycythemia Vera
• Classification: Absolute Polycythemia
o Subclassified as Primary Marrow Disorder
• Polycythemia Vera is a myeloproliferative neoplasm
characterized by PANMYELOSIS
o Panmyelosis → a condition in which excessive
proliferation occurs in Megakaryocytes and
Granulocytes, as well as in Erythrocytes.
• It is manifested by ERYTHROCYTOSIS, LEUKOCYTOSIS, and
THROMBOCYTOSIS of varying degrees
• Serum and Urine Erythropoietin are DECREASED
• Mutation in the JAK2 gene is now described as a constant
finding.
• The production of Erythrocytes is autonomous with
Endogenous Erythroid Colonies (EECs) growing in vitro
without erythropoietin
• There is initially a PROLIFERATIVE PHASE and eventually a
SPENT PHASE, with Iron Depletion and associated Anemia,
Marrow Fibrosis, Increased Splenomegaly, and
Extramedullary Hematopoiesis
III. PORPHYRIA
• Group of inherited and acquire disorders of Heme
Biosynthesis caused by a deficiency or loss of function
mutation of a specific enzyme in the Biosynthetic Pathway
1. Excess production and increased excretion of
precursors formed in the steps before the enzyme
defect
2. Overproduction of Porphyrins and their precursors is
mainly hepatic or erythropoietic in origin
• In the Acute Porphyrias and Porphyria Cutanea Tarda, the
liver is the main source of overproduction
• In Congenital Erythropoietic Porphyria, the marrow is the
main source while in Erythropoietic Protoporphyria,
porphyrins are produced by both the liver and marrow
• Consulting pathologists may take a three-step
approach to this diverse group of uncommon
diseases.
1. Classifying Porphyrias by their clinical
presentation
o Classifying Porphyrias by their
clinical presentation is a helpful
starting point, as clinicians will call
with information about their
patients’ signs and symptoms and
Approach then will ask for help with ordering
to the laboratory studies
Porphyrias 2. Biochemical Studies → a rapid diagnostic
test for Urine Porphobilinogen as a first
step
3. Genetic Testing as guided by biochemical
test results
o Great strides have been made in
identifying the genes and many
mutations causing the Porphyrias →
patients will likely wish to know this
information as they discuss their
diagnosis with family members

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Hematology
CER, MD

LEUKOCYTIC DISORDERS Mechanism

I. Non-Neoplastic Disorders
A. Granulocytic and Monocytic Disorders
B. Lymphocytic and Plasmacytic Disorders
C. Leukemoid Reactions
II. Neoplastic Disorders
A. Myeloproliferative Neoplasms
B. Precursor Lymphoid Neoplasms
C. Mature B-Cell Neoplasms
D. Mature T-Cell and Natural Killer Cell Neoplasms
E. Hodgkin Lymphoma
F. Immunodeficiency-Associated Lymphoproliferative
Disorders
G. Histiocytic and Dendritic Cell Neoplasms
A. GRANULOCYTIC AND MONOCYTIC DISORDERS
1. NEUTROPHILIA
• Also called Neutrophilic Leukocytosis
• Refers to an absolute concentration of neutrophils in the
blood above normal for age.
• Normal Reference Interval:
o Adult: 1.8 to 7.0 × 103/μL
o Young Children: (.0–8.5 × 103/μL
• Primary Factors Influencing Neutrophil Count:
1. rate of inflow of cells from the bone marrow
2. proportion of neutrophils in the marginal granulocyte
pool (MGP; cells adhering to vessel walls) and the
circulating granulocyte pool (CGP) of the blood
3. rate of outflow of neutrophils from the blood.
Mechanism
1. Acute Inflammatory → collagen vascular,
vasculitis
2. Acute Infectious → bacterial, some viral,
fungal, parasitic
3. Drugs, Toxins, Metabolic → PROCESSES and PARASITIC INFECTIONS.
Key Causes corticosteroids, growth factors, uremia,
of ketoacidosis
Neutrophilia 4. Tissue Necrosis → burns, trauma, MI, RBC
hemolysis
5. Physiologic → stress, exercise, smoking,
pregnancy
6. Neoplastic → carcinomas, sarcomas,
myeloproliferative disorders
• PATHOLOGIC LEUKOCYTOSIS is an increased WBC count
that occurs as a result of disease → usually in response to
infection or tissue damage, and is most often Neutrophilia
• When attracted to a focus of inflammation, Neutrophils leave
the blood and migrate in response to chemotactic molecules
and gradients
• There is COMPENSATORY FLOW OF NEUTROPHILS from the
marrow storage compartment into the blood → the result is
Neutrophilia.
• An increase in immature
peripheral blood
granulocytes is often
termed a “SHIFT TO THE
LEFT”
• Increased WBCs with left
shift and toxic features
may resemble leukemia
and is often termed a
“Leukemoid” Reaction
• If the demand for Neutrophils is extremely great, as in severe
infection, there may be depletion of the marrow storage pool
with decreased CGP (Neutropenia) and MGP because the
supply of cells is insufficient for the demand.
o In these instances, the marrow will show increased Early
Neutrophil Precursors through the Myelocyte Stage, but
decreased Metamyelocytes, Bands, and Neutrophils.
2. NEUTROPENIA
• Neutropenia is a reduction of the Absolute Neutrophil Count
(ANC)
o The ANC is the product of the WBC count and the
percentage of mature as well as Immature Neutrophils in
the WBC differential count
• “Agranulocytosis” → refers to severe neutropenia, usually
<0.5 × 109/L, and is often associated with depletion of
Eosinophils and Basophils
• Severe Chronic Neutropenia (SCN) refers to patients with
ANC <0.5× 109/L for months or years, due to inherited or
acquired rare disorders
• If the Neutrophil Count is <1× 109/L, the risk of infection is
INCREASED, and greater if <0.5× 109/L.
1. Drugs → cancer chemotherapy,
chloramphenicol, sulfas/other antibiotics,
phenothiazines, benzodiazepines,
antithyroids, anticonvulsants, quinine,
quinidine, indomethacin, procainamide,
thiazides
2. Radiation
Key Causes 3. Toxins → alcohol, benzene compounds
of 4. Intrinsic Defects → Fanconi, Kostmann,
Neutropenia cyclic neutropenia, ChédiakHigashi
5. Immune Mediated → collagen vascular
disorders, RA, AIDS
6. Hematologic → megaloblastic anemia,
myelodysplasia, marrow failure, marrow
replacement
7. Infectious → any overwhelming infection
8. Others → starvation, hypersplenism
• Mechanisms by which Neutropenia occurs include:
1. Decreased or ineffective production (Proliferation or
Maturation Defect)
2. Increased removal from the blood (Survival Defect)
3. Altered distribution between CGP and MGP
4. Combinations of these mechanisms
• Neutropenias may be Inherited, Autoimmune, Toxic, or Drug
Associated.
• Drug-Induced Neutropenia occurs through several
mechanisms and is always an important consideration in the
differential diagnosis of Leukopenia.
3. EOSINOPHILIA
• Eosinophilia exists if blood eosinophils exceed ~0.35 to 0.5 ×
109/L
• Reactive Eosinophilia is typically associated with ALLERGIC
• Classically, the major function of eosinophils appeared to be
the release of granule contents or Reactive Oxygen Species
to damage the target organism or offending cell
• Immunoregulatory and Proinflammatory Signaling Roles also
exist → thus, Eosinophils are both EFFECTOR and
REGULATORY CELLS
• Eosinophil production is stimulated by INTERLEUKIN-5 (IL-
5), migration is influenced by the CHEMOKINE EOTAXIN, and
the two factors interact in producing Eosinophilia.
1. Allergic → urticaria, hay fever, asthma
2. Inflammatory → eosinophilic fasciitis,
Churg-Strauss syndrome
3. Parasitic → trichinosis, filariasis,
schistosomiasis
4. Nonparasitic Infections → systemic
fungal, scarlet fever, chlamydial
pneumonia of infancy
5. Respiratory → pulmonary eosinophilic
syndromes (Loeffler, tropical pulmonary
Key Causes
eosinophilia), Churg-Strauss syndrome
of
6. Neoplastic → MPN with translocation of
Eosinophilia
PDGFRA/B or FGFR1, CML, mastocytosis,
Hodgkin lymphoma, T-cell lymphomas,
lymphocytic HES
7. Idiopathic Hypereosinophilic Syndromes
→ affecting heart, liver, spleen, CNS, other
organs
8. Others → certain drugs, hematologic and
visceral malignancies, GI inflammatory
diseases, sarcoidosis, Wiskott-Aldrich
syndrome
4. BASOPHILIA
• Basophilia is an increase in the Absolute Basophil Count
above 0.2 × 109/L.
• Basophilia is seen most frequently in HYPERSENSITIVITY
and ALLERGIC REACTIONS, Chronic Myeloid Leukemia,
Myeloid Metaplasia (Extramedullary Myelopoiesis), and
Polycythemia Vera
• Relative Basophilia may be transient following irradiation.
• Basophilia may be present in HYPOTHYROIDISM, in
CHRONIC HEMOLYTIC ANEMIA, and following
SPLENECTOMY
• Reactive Basophilia is an uncommon finding overall,
sometimes seen in patients combating Helminth Infections
1. Myeloproliferative Disease
2. Allergic → food, drugs, foreign proteins
Key Causes
3. Infectious → variola, varicella
of Basophilia
4. Chronic Hemolytic Anemia → especially
postsplenectomy

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Hematology
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5. Inflammatory → collagen vascular disease, 1. Infectious → many viral, pertussis,

ulcerative colitis tuberculosis, toxoplasmosis, rickettsial
5. MONOCYTOSIS 2. Chronic Inflammatory → ulcerative
• Monocytosis is an increase in Monocytes above the upper colitis, Crohn
Key Causes of
reference value, especially when >1.0 × 109/L. 3. Immune Mediated → drug sensitivity,
Lymphocytosis
• Most common causes are: vasculitis, graft rejection, Graves,
1. Recovery from Neutropenia Sjögren
2. Indolent Infections 4. Hematologic → ALL, CLL, lymphoma
• Monocytosis is present during the RECOVERY STAGE from 5. Stress → acute, transient
Acute Infection and from Agranulocytosis, in which it is Pertussis (Whooping Cough)
considered a FAVORABLE SIGN. • Whooping Cough (Pertussis), although reduced by routine
• Monocytosis may be present in SUBACUTE BACTERIAL immunization, still occurs in unimmunized children and is
ENDOCARDITIS. most severe in infants in whom most disease-associated
o In this condition, Monocytes may show phagocytosis of deaths occur.
other blood cells, red blood cells, and leukocytes. • Patients frequently develop SIGNIFICANT
• It may be present in Mycotic, Rickettsial, Protozoal, and LYMPHOCYTOSIS, with counts higher than 30 × 109/L
Viral Infections. recorded.
o Infectious Disease, however, is an uncommon cause of • The Lymphocytes are small, Mature T cells with a normal
Monocytosis. CD4/CD8 ratio
• In a classic study of 160 successive cases of Absolute • The Lymphocytosis is at least partially due to the release of
Monocytosis, more than half (85) were associated with Lymphocytosis-Promoting Factor (LPF) or Pertussis Toxin
HEMATOLOGIC NEOPLASMS. (PT) from the organism
o These included Acute Monocytic and Granulocytic • Lymphocytosis is due to REDISTRIBUTION of lymphocytes
Leukemias, Lymphoma (Hodgkin Lymphoma, most into the peripheral circulation without increased
frequently), Multiple Myeloma, and Myeloproliferative Lymphopoiesis.
Disorders. 2. LYMPHOCYTOPENIA
1. Infectious → tuberculosis, subacute • Lymphocytopenia is present when the Absolute Lymphocyte
bacterial endocarditis, syphilis, protozoan, Count is below ≈1.8 × 109/L in adults and below ≈2.0 × 109/L in
rickettsial children.
2. Recovery from Neutropenia • Normally, about 80% of circulating peripheral blood
3. Hematologic → leukemias, Lymphocytes are CD3+ T Cells, and a majority (≈65%) of
Key Causes
myeloproliferative disorders, lymphomas, these cells are CD4+ helper T Cells
of
multiple myeloma • A number of Immunologic Deficiency Disorders that are
Monocytosis
4. Inflammatory → collagen vascular disease, genetically determined have Lymphocytopenia, along with
chronic ulcerative colitis, sprue, myositis, various other immunologic defects of Humoral or Cell-
polyarteritis, temporal arteritis Mediated Immunity.
5. Others → solid tumor, immune o Lymphocytopenia in these disorders is due to IMPAIRED
thrombocytopenic purpura, sarcoidosis LYMPHOPOIESIS.
6. MONOCYTOPENIA • Increased levels of Adrenocortical Hormones, Administration
• Monocytopenia is a decrease in circulating monocytes below of Chemotherapeutic Drugs, or Irradiation will result in
the lower reference value of 0.2 × 109/L. Lymphocytopenia
1. During therapy with Prednisone, • Impaired drainage of the Intestinal Lymphatics with loss of
Monocytes fall during the first few hours Lymphocytes into the intestines due to a number of causes
after the first dose but return to above has been implicated as a mechanism for Lymphocytopenia.
original levels by 12 hours • In advanced cases of Non-Hodgkin Lymphoma (NHL) and HL,
2. Hairy Cell Leukemia (HCL) as well as in terminal cases of Carcinoma, Lymphocytopenia
Key Causes of 3. Congenital Complex Immunodeficiency is often observed.
Monocytopenia involving Monocytopenia and 1. Destructive → radiation,
susceptibility to Mycobacterial Infection chemotherapy, corticosteroids
(MonoMac syndrome) due to GATA2 2. Debilitative → starvation, aplastic
mutation, anemia, terminal cancer, collagen
4. B-Lymphoblastic Leukemia vascular disease, renal failure
5. Other Rare Immunodeficiencies 3. Infectious → viral hepatitis, influenza,
B. LYMPHOCYTIC AND PLASMACYTIC DISORDERS typhoid fever, TB
1. LYMPHOCYTOSIS Key Causes of 4. AIDS Associated → HIV cytopathic
• Lymphocytosis is an increase in the number of lymphocytes Lymphocytopenia effect, nutritional imbalance, drug
in the peripheral blood effect
• Reference Intervals: 5. Congenital Immunodeficiency →
o Adult: ≈1.5 to 4.0 × 109/L Wiskott-Aldrich syndrome
o Children: ≈1.5 to 8.8 × 109/L 6. Abnormal Lymphatic Circulation →
• Relative Lymphocytosis (an increase in the percentage of intestinal lymphangiectasia,
lymphocytes) is present in various conditions and is obstruction, thoracic duct
especially prominent in disorders with Neutropenia drainage/rupture, CHF
• Lymphocytosis is unusual in acute bacterial infections but is Lymphocytopenia: AIDS
commonly associated with VIRAL INFECTION (Epstein-Barr • Acquired Immunodeficiency Syndrome (AIDS), once a
Virus [EBV], Hepatitis) progressively fatal infectious disorder with characteristic
Lymphocytosis Associated with Viral Infection clinical, hematologic, and serologic abnormalities, can now
• Lymphocytosis is a frequent finding in children with viral be controlled in most patients with Antiretroviral Therapy
infection and may be marked (ART).
• Lymphocytic Leukemoid Reactions were previously referred • AIDS is a disorder secondary to infection with HIV-1 and HIV-
to as Acute Infectious Lymphocytosis (AIL), often lasting 3 to 2—RNA Retroviruses that are CYTOTROPIC for CD4+ T Cells
5 weeks but without other blood changes in most patients. and for other cells, including Macrophages, Monocytes,
• Lymph Node Enlargement is rare and minimal when present Megakaryocytes, and CNS Microglial Cells.
• Spleen and Liver are rarely, if ever, enlarged. o Viral Entry into a cell result from interaction with the CD4
• Lymph Node Biopsy may show REACTIVE FOLLICULAR Receptor and with Chemokine Coreceptors that
HYPERPLASIA but no characteristic changes determine Target Cell Tropism
• In some cases, there has been an increase in White Cells in o HIV is responsible for both direct killing of infected cells
the Cerebrospinal Fluid (CSF), with about 40% Lymphocytes. and indirect killing of neighboring cells, utilizing both
• A Chronic Form of Infectious Lymphocytosis also occurs in Apoptotic-Dependent and Apoptotic-Independent
children. Mechanisms of cell destruction
• The Leukocyte Count is 10 to 25 × 109/L, with 60% to 80%
lymphocytes of normal appearance

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Hematology
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• Because of the Cytotropic Effect of the AIDS viruses for CD4+ 5. Myelofibrosis
cells, there is a MARKED DECREASE in the number of T- 6. Infection (especially Tuberculosis)
Helper Cells and an IMBALANCE in T-Suppressor/Cytotoxic 7. Severe Burns
Cells in the blood and lymphoid tissues of the body 8. Eclampsia
• As a result, a PROFOUND CELLULAR IMMUNE DEPRESSION 9. Certain Toxins
occurs, characterized by infection with a variety of • Examination of the blood is usually more
opportunistic organisms. helpful than marrow examination.
• Initially, B Cells are not involved and immunoglobulin levels • Cells as immature as Eosinophilic
are normal or increased. Myelocytes rarely appear in the blood in
o However, as the disease progresses, the frequency of Eosinophilic reactive Eosinophilia
malignancy in these patients is increased. Leukemoid • Eosinophilic Leukemoid Reactions
• AIDS-Associated Cancers include: Reactions usually occur in children and are
1. Kaposi Sarcoma frequently caused by PARASITIC
2. NHL INFECTION.
3. Cervical Cancer (all AIDS-Defining Cancers) • In patients with or without Anemia,
4. HL circulating normoblasts frequently are
5. Anogenital Cancers accompanied by a Neutrophilic
• The most common hematologic Leukemoid Reaction
abnormality in patients with AIDS is • A Moderate Anemia with normoblasts in
ANEMIA OF CHRONIC DISEASE and Leukoerythro- the peripheral blood is fairly common in
LYMPHOPENIA (80%–85% of cases), blastosis Metastatic Carcinoma involving BM.
Hematologic particularly of the T-Helper/Inducer (CD4) • Leukoerythroblastosis may also be
Abnormality subset. associated with MARROW INFECTION
• Thrombocytopenia occurs in approximately and/ or FIBROSIS, and may be seen in
30% of cases and Neutropenia in 40%, often benign conditions such as GI BLEEDING
with a left shift → the former is often and HEMOLYTIC ANEMIA
Immune Mediated • Extremely high counts of normal-
• Usually displays Atypical Lymphocytes that appearing lymphocytes may occur in
have a PLASMACYTOID APPEARANCE INFECTIOUS LYMPHOCYTOSIS and in
Peripheral
• Monocytes are often large, with a fine PERTUSSIS
Blood Film
nuclear chromatin and cytoplasmic • When Atypical Lymphocytes are
vacuoles. strikingly increased or immature (which
3. PLASMOCYTOSIS may occur in conditions such as IM), the
• Plasma Cells are not normally present in circulating blood distinction from Leukemia may be
o In the Marrow, an average of 1% to 2% of plasma cells are difficult
Lymphocytic
present in adults o Examination of the Marrow may be
Leukemoid
• An increase beyond 4% is significant → Lower values are useful because Lymphocytes are
Reaction
found in children. minimally increased, if at all, in most
• They are increased in a variety of Chronic Infections, in leukemoid reactions in contrast to
Allergic States, in the presence of Neoplasms, and in other leukemia
conditions in which the Serum γ-Globulin Concentration is • Flow Cytometric studies of peripheral
elevated. blood and/or BM would reveal a
• Plasma Cells have also been recorded in the blood of patients NONCLONAL POPULATION of
with Viral Disorders, including Rubella, Measles, Chickenpox, Lymphocytes with a normal combination
and Mumps of cell surface markers in benign
1. Viral → infectious mononucleosis, proliferations.
measles, rubella, HIV
2. Bacterial → tuberculosis, syphilis,
streptococcus, staphylococcus
3. Parasitic → malaria, trichinosis
4. Inflammatory → SLE, RA, inflammatory
Key Causes of
bowel disease, alcoholic liver disease
Plasmacytosis
5. Neoplastic → plasma cell leukemia,
myeloma
6. Immune Stimulation → immune complex
disease (serum sickness), drug
sensitivity, transfusion
7. Trauma
• Increases of up to 20% of Plasma Cells may be found in a
variety of conditions other than Multiple Myeloma, including:
1. Metastatic Carcinoma
2. Chronic Granulomatous Infection
3. Conditions Linked with Hypersensitivity
4. Following administration of Cytotoxic Drugs
• They are often increased in APLASTIC ANEMIA, but this is
probably just a relative increase
C. LEUKOMOID REACTIONS
• A Leukemoid Reaction is an EXCESSIVE LEUKOCYTIC
RESPONSE in the peripheral blood.
• It includes Leukocytosis of 50 × 109/L or higher with a shift to
the left
• Lower counts, even below normal, with considerable
numbers of immature granulocytes
• Depending on the predominant cell, Leukemoid Reactions
may be Neutrophilic, Eosinophilic, Lymphocytic, or
Monocytic.
• Excessive Neutrophilia may occur in
many situations, including:
Neutrophilic
1. Hemolysis
Leukemoid
2. Hemorrhage
Reactions
3. Malignancy with Bone Involvement
4. HL

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