HEMATOLOGY 1 (LECTURE)

- Reduction of red cell mass - Small and pale red cells because hemoglobin is
- Decreased concentration of hemoglobin not enough
- There is a decreased ability of RBCs to transport - Any deficiency problem with hemoglobin
out oxygen components may result in decrease production
- Hemoglobin level is the first one to check to of hemoglobin
evaluate anemia - Causes:
o Male: < 12 g/dL o Iron deficiency anemia
o Female: < 11 g/dL o Chronic disease
- Relative anemia: normal RBC mass, low volume o Sideroblastic anemia
o Transient or temporary o Thalassemia
o normal retics
o Example: dehydrated IRON DEFICIENCY ANEMIA (IDA)
- Absolute anemia: low RBC mass, normal volume - Most common cause of anemia
o low RBC delivery to circulation (bone
- Usually smaller in size
marrow is not producing enough RBCs) - Due to dietary inadequacy, malabsorption,
o there is an impaired production of RBCs
increase iron loss, & increased iron requirement
o loss of RBC from circulation
- Do not diagnose IDA by measuring iron alone
▪ destruction of RBCs because of - Low ferritin confirms IDA
antibodies or certain external
factors such as malaria
Lab Findings
▪ bleeding because of accidents,
acute or chronic bleeding, etc. ✓ CBC: decreased hemoglobin
✓ Retics: low to normal
✓ OFT: decreased
Signs and Symptoms
✓ Bone marrow: erythroid hyperplasia
• easy fatigability ✓ Others:
• dyspnea on exertion o Decreased: serum iron, % saturation,
• bounding pulse serum ferritin (stored iron)
• palpitations o Increased: Total Iron Binding Capacity
• systolic murmur (TIBC – ability of the iron to be stored as
• headache, faintness, and vertigo ferritin) and Free Erythrocyte
• pallor Protoporphyrin (FEP)
• low BP
• spoon nails ANEMIA OF CHRONIC DISEASE
- Due to chronic infections, inflammatory process,
Evaluation of Anemia and malignant neoplasms
• red cell count - Blockage in deliver of iron to the developing red
• red cell indices cells
• hemoglobin and hematocrit - Low serum iron and TIBC; high serum ferritin
• red cell distribution width (RDW)
• Peripheral Blood Smear (PBS): to evaluate the SIDEROBLASTIC ANEMIA
morphological features of RBCs - Abnormalities in heme metabolism
• Reticulocyte count: index of normal - Adequate iron stores but unable to incorporate it
erythropoiesis into hemoglobin because there is lack of
o Especially in cases of hemolytic anemia protoporphyrin IX
to determine whether the bone marrow - Presence of nucleated RBC with iron granules
is responding or not - Primary: idiopathic (cause is unknown)
• Osmotic Fragility Test (OFT): evaluates the - Secondary: side effect (other diseases that
relationship of RBCs surface area to its volume results to sideroblastic anemia such as B12
ratio deficiency, porphyria, and leukemia)
o Especially in cases of spherocytosis - RDW increased
• Bone marrow examination - Hypercellular BM
- Normal retics
CLASSIFICATION OF ANEMIA - High serum iron, serum ferritin, and LDH
Physical Characteristics - (+) stain: Prussian blue (Perl’s stain)
- Pappenheimer bodies on Giemsa
• Degree of hemoglobinization: diameter of
central pallor
Evaluation of Anemia
• Size of red cells
Serum Serum
TIBC FEP RDW
Iron Ferritin
Pathogenesis IDA Low High Low High High
• Disorders of red cell formation Chronic
Low Low High High Normal
Disease
• Excessive loss of red cell
Sideroblastic High Normal High Low High
• Abnormal distribution of red cells
 HEMATOLOGY 1 (LECTURE)

Intrinsic Hemolytic Anemia

- Normal in size and color Hereditary defects
Abnormalities of red cell membranes
- The number of circulating red cells are low
Hereditary Spherocytosis
- Quality/Quantity - Autosomal dominant trait in whites
- Delivery of oxygen is depleted - Causes:
- Causes: o Increased temperature
o Aplastic anemia o Certain antibodies
o Deficiency in spectrin
o Hemolytic anemia
- Loss of red cell membrane resulting in decreased
o Renal disease surface area
o Acute blood loss - Cells are less deformable
- Clinical features: jaundice, splenomegaly, skeletal
abnormalities, chronic leg ulcers, gall stones,
APLASTIC ANEMIA spherocytes, and stomatocytes in PBS
- Absence of hematopoietic cells in the BM - Lab findings:
- Usually associated with pancytopenia (all cell o Increased: OFT, B1, LDH, urobilinogen
▪ Since OFT is also increased in cases of AIHA,
counts are low) perform Direct Antiglobulin Test (DAT) to
- Associated with: detect the presence of antibodies
o Drug exposure, such as chloramphenicol o Decreased: haptoglobin
and sulfonamides Hereditary Elliptocytosis
o Viral infections such as parvo virus B19 - Inherited disorder characterized by deficiencies in
protein band 4.1
(one of the common causes of aplastic - Defective membrane protein skeleton structure,
anemia), measles, cytomegalovirus, and elongated elliptical cells
Epstein-Barr virus - Variant: hereditary pyropoikilocytosis
o Exposure to toxins such as benzene, Inherited RBC enzyme defects
G6PD Deficiency
pesticides, or radiation
- X-linked disorder
o Tuberculosis - Deficiency in G6PD will result to the loss of NADPH
o Chemicals - Inability to neutralize oxidation stress
- Fanconis anemia: congenitally acquired anemia - Hemoglobin molecule is unstable, susceptible to
- Severe if 3 of the 4 criteria are present: hemolysis
- When RBCs are oxidized, hemoglobin is denatured
o Neutrophil count: < 500/uL
- Rapid intravascular destruction
o Platelet count: < 20,000/uL - Resistance to malaria
o Reticulocyte count: < 10,000/uL - Clinical patterns:
o Markedly hypocellular marrow o Neonatal jaundice (increased bilirubin)
o Congenital hemolytic anemia
- Common in people 50 years old and above
o Drug-induced hemolysis (caused by primaquine)
- 50% of people with aplastic anemia has a six o Favism (after consuming fava beans)
months mortality rate - Classes of G6PD deficiency
- Treatment: bone marrow transplantation o Class I: severe deficiency
▪ Hemolysis is chronic
▪ < 10% activity of G6PD
Pure Red Cell Aplasia o Class II: severe deficiency
- Hypoplasia of erythrocyte precursors only ▪ Hemolysis is intermittent
- Other cell precursors are still normal ▪ < 10% activity of G6PD
o Class III: mild deficiency
- Severe anemia with reticulocytopenia ▪ 10-60%
- If the causes of pure red cell aplasia is not ▪ Exposure to stress
addressed, it can progress to aplastic anemia - Lab diagnosis
- Associated with: o Inclusion bodies: Heinz bodies (recovered using
o Hemolytic anemia supravital stain)
o Increased retics, bilirubin, serum LDH
o Parvovirus infection o Hemoglobinuria
o Drugs o Decreased haptoglobin
o Thymoma o Negative Coomb’s test
- Diamond-blackfan syndrome: congenitally - G6PD testing is part of the newborn screening
- Confirmatory: G6PD assay or G6PD fluorescence
acquired testing
- Other tests:
HEMOLYTIC ANEMIA o Ascorbate cyanide test (non-specific)
▪ Red cells are exposed to sodium cyanide
- Shortened red cell survival and sodium ascorbate
- Destruction of RBCs ▪ Normally, RBCs Should remain intact
- Intracorpuscular or extracorpuscular defects ▪ Solution should remain red
- Classification: ▪ If there is G6PD deficiency, red cells are
lysed resulting to brownish color solution
o Intrinsic: red cell itself has a problem
Pyruvate Kinase Deficiency
o Extrinsic: red cells are normal but there - Problem in E-M pathway
are external factors that destroy RBCs - Pyruvate kinase is an enzyme needed in the production
- Intravascular: RBC is lysed within the vessel of energy
o The hemoglobin binds with haptoglobin o Lack of this enzyme will result to lack of energy
o Sodium and calcium can now easily enter the
- Extravascular: RBC is lysed outside the vessel RBC, resulting to lysis
(particularly by macrophages in the spleen) - Failure to generate sufficient ATP results in defective
control ions
- Jaundice and splenomegaly
- Confirmatory test: PK assay
 HEMATOLOGY 1 (LECTURE)

Disorders of Hgb production - Laboratory findings:

Hemoglobinopathy o Elevated reticulocyte count
Thalassemia o Increased concentration of indirect bilirubin
o Hemoglobinuria
o Positive Donath-Landsteiner of Rosenbach or
Acquired defects Ehrlich or Sanford test
Paroxysmal Nocturnal Hemoglobinuria o Positive for methemalbumin
- Red cells are lysed because of complement Alloantibody
- It is manifested by hemosiderin in the urine Transfusion Reactions
- Deficiency in DAF - Blood incompatibility
- Decay Accelerating Factor (DAF) regulates complement - Laboratory findings:
- Increased susceptibility to complement mediated red cell o Direct antiglobulin test (DAT) positive
lysis o High hemoglobin (even in the urine)
o EM: protuberances on the red cell surface
- Chemical abnormalities
o Deficient acetylcholinesterase activity and abnormally Non-Immune Hemolytic Anemia
constituted glycoprotein - Antibodies are not involved
- Lab diagnosis - Transient forceful contact of the body with hard surfaces
o Screening: Sugar of sucrose lysis test o Associate with athletes, boxers, triathletes, marathon
▪ Excessive hemolysis when exposed to low ionic runners, tennis players
strength solution - May be caused by mechanical trauma, microangiopathic
▪ Px’s RBC + serum + sucrose hemolytic anemia, chemical and toxic agents, infections,
▪ Make sure that the serum is compatible to the hypersplenism, and systemic disease
patient - Mechanical trauma: chemicals, drugs, snake venom,
o Confirmatory: Ham’s acid hemolysis test prosthetic heart valves
▪ Excessive hemolysis when exposed to o Defective prosthetic heart valves has been associated
complement containing serum at low pH with Waring Blender Syndrome
▪ Has three different set-up - Thermal burns: red cells are exposed to increased
• Tube 1: Px’s RBC + serum + acid (0.2 N HCl) temperatures
o Lysis is present - Infections: damages red cell membranes
• Tube 2: Px’s RBC + own serum o Microbial infections such as Plasmodium falciparum or
o Lysis is present Clostridium perfringens
• Tube 3: Px’s RBC + inactivated serum (56°C) - Associated with microangiopathic hemolytic anemia (cells
o Lysis is not present because are lysed because of the problem within the blood vessel):
complement is destroyed o Disseminated Intravascular Coagulation (DIC): fibrin is
deposited in small vessels
▪ Unwanted clots is formed
Extrinsic Hemolytic Anemia o Hemolytic Uremic Syndrome: renal damage
Immune Hemolytic Anemia ▪ Kidney problems resulting to bleeding forming a
Autoantibody clot
o Thrombotic Thrombocytopenic Purpura: deficiency of
Cold Autoimmune Hemolytic Anemia (cAIHA)
enzyme ADAMST13
- Due to IgM cold reactive antibody
▪ The body keep on forming unwanted clots
- Occurs in association with infection, malignancies, or
autoimmune disorders
- The cold reacting antibodies binds to the RBCs resulting HEMORRHAGIC ANEMIA (BLEEDING)
to destruction
- Laboratory findings: - Acute bleeding: sudden loss of blood resulting
o Direct antiglobulin test (DAT) is positive from injury or trauma
▪ To check for complement coated RBCs - Chronic bleeding: long-term and gradual
o Cold agglutinins titer is increased o Example: gastrointestinal bleeding
▪ Cold agglutinin syndrome
- Cold agglutinins:
- Red cells are normocytic and normochromic
o Anti-I: infected with mycoplasma pneumoniae - Body adjusts, increased heart rate
o Anti-i: infected with Epstein-Barr virus that cause - Expanding circulatory volume
infectious mononucleosis o Hematologic response to acute blood
- Peripheral smears
loss
o Polychromatophilia
o Spherocytosis - Increase platelet count, circulating granulocytes
o Agglutination of red cells - Increased EPO levels in 6 hours
Warm Autoimmune Hemolytic Anemia (wAIHA) - Reticulocytosis in 24 hours
- RBCs react with IgG and/or complement
- Idiopathic cases or secondary
- Laboratory findings: RENAL DISEASE
o High: OFT, bilirubin, retics - Decreased release and production of
o Direct antiglobulin test (DAT) positive
erythropoietin
▪ To differentiate it between spherocytosis
- Autoimmune hemolysis is positive because of the - Decreased in RBC count
antibody - Red cells are normocytic and normochromic

Example: Paroxysmal Cold Hemoglobinuria

- Associated with biphasic IgG antibodies
o When red cells are exposed to cold environment, MEGALOBLASTIC ANEMIA
complement binds to the RBCs but there is no
lysis - Deficiency in:
▪ IgG antibody allows complement to bind o Vitamin B12 (Cobalamin)
on red cells o Folic acid (folate)
o When red cells are exposed to warm
- Defective DNA production
environment (37°C), RBCs are destroyed
- This is a rare state in which hemolysis occurs when - Earliest signs: hypersegmented PMNs, oval
blood is warmed after previous exposure to chilling macrocytes
- Associated with Donath-Landsteiner antibody or Anti-
P antibody
 HEMATOLOGY 1 (LECTURE)

- Megaloblastic state affecting the RBCs

- Megaloblastic: it does not only affect RBCs. It
- Excess production of cells
also affects other cells such as WBCs and
- Primary erythrocytosis: uncontrolled growth of
platelets
cells for no apparent purpose
o All cells contain nucleus which need the
- Associated with Polycythemia vera
same set of nutrients for their
maturation such as B12 and folic acid
- Lab diagnosis: Differentials of erythrocytosis
o Pancytopenia (all cells are low) - Primary polycythemia: PV
o Macroovalocytes - Secondary polycythemia: high altitude, CPD,
o WBCs and platelets are low cyanotic congenital heart disease, low cardiac
o Hypersegmented PMNs output, hypoventilation syndrome, high affinity
o Low retics Hgb variants, neoplasms-renal artery stenosis,
o BM: marked erythroid hyperplasia renal transplant
o Blood chem: increased B1, serum iron
and LDH
o Inclusions: Howell-Jowell bodies, as well
- Abnormal cell production, unresponsive to
as pappenheimer bodies, cabot rings, treatment
and basophilic stipplings - Hallmark is ineffective erythropoiesis, with
markedly hypercellular marrow and abundant
Vitamin B12 (Cobalmine) Deficiency abnormal erythroid precursors
- Intrinsic factor: needed to absorb Vit. B12 in - Precursors are megaloblastic
terminal ileum - It will later on lead to leukemia if it is not
o intrinsic factor is synthesized by parietal managed immediately
cells - A person has anemia (there is insufficient
- Pernicious anemia: most common cause, amount of RBCs) because the bone marrow
characterized by a deficiency in intrinsic factor produces and releases immature cells
(presence of antibody that acts against the
intrinsic factor or parietal cells)
o Gastrectomy, atophic gastrisis
o Veganism - Usually a genetically acquired inborn error of
o Diphyllobothrium latum infection metabolism
- Features: weakness, jaundice, sore tongue, - Deficiencies of enzymes involved in porphyrin-
numbness, and other CNS disease heme biosynthesis pathway
- Laboratory findings: - Diagnosis: spectroscopy and biochemical
o Low vitamin B12 analysis of blood, urine, and stool
o Folic acid may be decreased - Urine porphobilinogen is mostly elevated
o Elevated metabolites because it is not - Associated with sideroblast cells (accumulation
absorbed of iron in RBCs)
- Schilling test: for megaloblastic state - Patients are photosensitive
o Abnormal in cases of vit. B12 deficiency
Genetic Porphyrias
Vitamin B9 (Folate or Folic Acid) Deficiency - Manifestation may be neurologic (excruciating
- It does not affect the CNS pain and other neurologic symptoms),
- Due to: cutaneous
o Dietary (most common) - Acute intermittent porphyria (AIP)
o Intestinal malabsorption
o Increased demand Acquired Porphyrias
o Excess loss - Associated with lead poisoning
o Defective synthesis - Lead will block the protoporphyrin pathway,
which will affect the heme synthesis
NON-MEGALOBLASTIC ANEMIA o D-ALA will not be converted into
porphyrins
- Anemia of liver disease
- Adults (occupational) and children (PICA)
- Membrane abnormalities of RBCs
- Enzymes depressed:
- Liver provides vital components for the
o Delta amino levulinic dehydratase
maturation of RBCs
o Heme synthetase
o Problems with liver will result to
- Features: abdominal pain, weakness
incomplete development of RBCs at well
- Lab diagnosis:
as its membrane
o Anemia (micro/normo)
o Increased reticulocytes
Liver Disease
o Decreased OFT
- Non-megaloblastic anemia o Inclusions: basophilic stipplings
- Decreased cholesterol synthesis
- Spur cells, acanthocytes
 HEMATOLOGY 1 (LECTURE)

2. Beta Thalassemia
➢ Hemochromatosis - Production of B chain will occur only at 3-6
o Increased GIT absorption and systemic months after birth
iron overload - Homozygous beta thalassemia: (major, cooley’s
o iron deposits in liver anemia, Mediterranean anemia) severe lifelong
➢ Hemosiderosis anemia
o secondary iron accumulation. - Heterozygous beta thalassemia: one normal and
o Iron deposits in parenchymal cells and one abnormal beta chain (minor)
Kupffer cells in the portal tract Other Names Description
Minor • Heterozygous - results when one of the 2
• Cooley’s trait genes that produce beta
• Rietti-Greppi- globin is defective
Micheli disease - usually presents a mild,
- characterized by decreased rate of production or asymptomatic anemia
total absence of globin chains Intermediate • Thalassemia - more severe but do not
Intermedia require regular transfusion
- less globin = less hemoglobin produced = less - occasional transfusions
delivery of oxygen to tissues Major • Homozygous - decrease or complete lack
- 2 important chromosomes for the production of • Cooley’s Anemia of beta chains
• Mediterranean - most severe form
globins: Anemia - TRANSFUSION dependent
o Chromosome 16: responsible for the • Target Cell Anemia anemia
synthesis or generation of alpha and
zeta globins 3. Hereditary Persistence of Hb F (HPHF)
o Chromosome 11: responsible for the - thalassemia with increased levels of fetal
synthesis or generation of beta, delta, hemoglobin
epsilon, and gamma globins - partial or total suppression of beta and delta
- gene for synthesis is located in chromosome 16 chains and Hb F increased to compensate
and chromosome 11 - less delivery of oxygen to tissues
o Alpha Thalassemia – decreased - test for Hb F:
production of alpha chains o alkali denaturation test
o Beta Thalassemia – decreased ▪ Singer test
production of beta chains ▪ Betke test
- demographics: o Acid elution test: citric acid phosphate
o Southeast Asia and Mediterranean buffer is used (high amount of Hb F
region yields to pinkish to reddish solution)
- Clinical presentation:
o Minor: mild anemia (confused with IDA)
4. Hemoglobin Lepore
o Intermedia: moderate anemia
- a rare class of thalassemia caused by crossing
o Major: severe anemia (Hydrops Fetalis)
over of beta and delta genes

TYPES OF THALASSEMIA 5. Hemoglobinopathy + Thalassemia

1. Alpha Thalassemia ➢ Hemoglobin S-Thalassemia
- Each individual has 4 genes for hemoglobin o is a double heterozygous abnormality
- Severity of disease depends on the number of o the abnormal genes for Hb S and
genes/globin chains defective or missing thalassemia are coinherited
o If 2 = alpha trait (minor) o Types:
o If 3 = H hemoglobin (intermedia) ▪ Hb S-α-thalassemia
▪ Can be observed using ▪ Hb SS-α-thalassemia
supravital stain ▪ Hb S-β-thalassemia
o If 4 = Barts hemoglobin (major) ➢ Hemoglobin C-Thalassemia
Hemoglobin o β thalassemia with inherited Hb C
Description
Present ➢ Hemoglobin E-Thalassemia
Silent Carrier (- α / α α) deletion of one α birth: 1%-2% Hb
globin gene, leaving 3 Bart’s
o co-inherited of Hemoglobin E and β
functional α globin adult: normal Hb A, thalassemia that results to a marked
genes Hb Bart reduction of β chain production.
α Thalassemia Trait deletion of two α birth: 2%-10% Hb
Homozygous (- α / - α) globin gene Bart’s
Heterozygous (- - / α α) adult: normal Hb A LABORATORY FINDINGS OF THALASSEMIA
Hemoglobin H Disease caused by the birth: 10%-40% Hb
(- - / - α) presence of only one Bart’s replaced by • CBC
gene producing α Hb H 30-50% o ↓Hb and Hct
chains. remainder: Hb F,
HbA₂, Hb Bart’s o ↑RBC count
and Hb A o ↓RBC indices (MCV and MCHC)
adult: 70% Hb A
o ↑RDW
Hydrops Fetalis (- - / - -) results in the absence birth: 80%-90% Hb
of all α chains Bart’s 5%-20% Hb • Peripheral Smear
synthesis and Portland, trace of o microcytic hypochromic
incompatible with life Hb H
o exhibits anisocytosis and poikilocytosis
(target cells and elliptocytes)
o presence of NRBC
o polychromasia and basophilic stippling
 HEMATOLOGY 1 (LECTURE)

• Increased Reticulocyte count ▪ protected from Plasmodium

• Bone marrow examination falciparum infection
o shows hypercellular with extreme ▪ normal PBS
erythroid hyperplasia ▪ positive sickle cell solubility test
• Decreased OFT
• Supravital stain Laboratory Diagnosis
o shows Hb H inclusions • Peripheral Blood Smear:
• Electrophoresis (migration pattern) o marked poikilocytosis, inclusion bodies,
o differentiates hemoglobin variants sickle cells (6-18%)
• Mass Spectrophotometry o increased WBCs, platelets, retics
o assess the difference in mass of the • Bone Marrow:
globin chains o marked erythroid hyperplasia
o detects single amino acid substitutions o high iron storage
in the globin chains • Blood Chemistry:
• DNA analysis o increased B1, serum iron
o identify globin gene mutations
▪ PCR HEMOGLOBIN SC (Hgb SC) DISEASE
▪ Signal Amplification System
- Hgb SC disease is a double heterozygous
• Increased Indirect Bilirubin condition where an abnormal sickle gene from
one parent and an abnormal C gene from the
other parent inherited.
- The problem is more on the amino acids of o One beta is replaces by valine and the
globins other beta is replaced with lysine
- These are a group of inherited disorders causing - Laboratory:
structurally abnormal globin chain synthesis due o Moderate to severe normocytic/
to amino acid substitutions (qualitative defect) normochromic anemia with target cells
- changes in RBC deformability and o characterized by SC crystals
electrophoretic mobility can occur. o may see rare sickle cells or C crystals
- Homozygous/ disease conditions (both globin o positive haemoglobin solubility
chains affected) are more serious than screening test.
heterozygous/trait conditions (only one globin
chain affected). HEMOGLOBIN C (Hgb C) DISEASE
- resembles Hgb S but instead of valine, lysine is
SICKLE CELL DISEASE seen on the 6th position of B chain
- Hgb S – most common abnormal hemoglobin - mild hemolytic anemia
- normal glutamic acid at 6th position in the B chain - Hgb C crystals and clam shaped cells
is replaced by valine - Laboratory:
- Results in: altered solubility, altered ability to o Normochromic/ normocytic anemia
withstand oxidation, instability, increased with target cells
propensity for methemoglobin production, o characterized by intracellular rodlike C
increased or decreased oxygen affinity crystals
- Hgb A is lacking, Hgb S is present - Hgb C migrates with hemoglobins A2, E, and O on
- Sickling is increased alkaline hemoglobin electrophoresis; can
o low oxygen tension differentiate hemoglobins using acid
o low pH electrophoresis.
o increased body temp
- confers protection against falciparum malaria HEMOGLOBIN E DISEASE
- laboratory tests: - Caused when lysine replaces glutamic acid at
o Sodium metabisulfite test position 26 on the beta chain.
▪ Positive: sickling - Homozygous condition results in mild anemia
o Solubility test with microcytes and target cells; heterozygotes
▪ Reagent: sodium dithionate are asymptomatic.
▪ Positive: turbidity - Hgb E migrates with hemoglobin A2, C, and O an
- Clinical considerations: alkaline hemoglobin electrophoresis.
o Homozygous S (SS) – lifelong, severe,
hemolytic anemia
HEMOGLOBIN D (PUNJAB) DISEASE
▪ hemolytic crisis, vaso-occlusive
episodes, prone to infection - Caused when glycine replaces glutamic acid at
(pneumococcus), gallstone is position 121 on the beta chain.
common, bone pain and - Hgb D migrates with Hgb S and Hgb G on alkaline
tenderness hemoglobin electrophoresis.
o Heterozygotes – one Hgb S gene, one
Hgb A
▪ Sickle cell trait (Hgb AS)
▪ usually with no apparent disease
HEMATOLOGY 1 (LECTURE)
 HEMATOLOGY 1 (LECTURE)

o People with the disease are always at

risk in acquiring infections with catalase
➢ Quantitative disorders – abnormalities affecting
positive organisms
the number of WBCs
o Laboratory test: Nitroblue tetrazolium
o Proliferative: Increase in WBCs
test (NBT test)
▪ reactive leukocytes
▪ The buffy coat is mixed with the
▪ neoplasms (cancer)
bacterial suspension
o Leukopenias: Decrease in WBCs
▪ Formation of blue precipitate
➢ Qualitative disorders – abnormalities affecting
the phagocytic activities of WBCs ABNORMAL IN MACROPHAGES/MONOCYTES
Lipid storage diseases – abnormalities affecting the
function of monocyte/macrophages caused by enzyme
LEUKOPENIA deficiency
➢ Decreased production: irradiation, drugs, viral ➢ Gaucher’s disease
infection, congenital o accumulation of glucocerebroside
o The bone marrow is not synthesizing because of the deficiency in enzyme
glucocerebrosidase
enough WBCs
o Associated with aplastic anemia o Wrinkled/crumpled cytoplasm
➢ Niemann-Pick disease
➢ Ineffective production: megaloblastic anemia,
myelodysplastic syndromes o Accumulation of sphingomyelin because
o The bone marrow produces abnormal of the deficiency in enzyme
cells, making it ineffective sphingomyelinase
o Foamy cytoplasm
o If one cell production is ineffective, the
other cell production will also be ➢ Tay-Sach’s disease
ineffective o Accumulation of glycolipids and
➢ Increased destruction: isoimmune neonatal, ganglioside because of the deficiency in
enzyme hexosaminidase A
autoimmune, complement-activation-induced
hemolysis o Vacuolated cytoplasm
o The bone marrow can produce cells but ➢ Sandhoff’s disease
the WBC count is low o Accumulation of glycolipids and
o There may be certain chemicals or ganglioside because of the deficiency in
substances that destroys WBCs enzyme hexosaminidase A and B
o Vacuolated cytoplasm
o Can be immune or non-immune
➢ Splenic sequestration: makes the WBC count ➢ Sea Blue Histiocytes
o Accumulation of lipids
low
o Spleen is enlarged because more WBCs o Specific enzyme deficiency is unknown
are sequestered o Blue-green cytoplasm
➢ Increased margination: has a lot white cell Disease Defect
precursor than red cell precursor Leukocyte Adhesion Def. 1 B chain of CD11/CD18 integrins
Sialylated oligosaccharide
o Low WBC count because more white Leukocyte Adhesion Def. 1
selectin
cells leave the circulation PMN Specific Granulocyte Defective chemotaxis
CGD Decrease oxidative burst
Acquired X linked membrane component
Acquired cytoplasmic component
Has leukopenia; decreased WBC count
MPO Deficiency Absent MPO-H2O2 system
• Thermal injury Chediak Higashi Multiple defects
• Diabetes mellitus
• Malignancy
• Sepsis - It affects all of the formed elements
• Malnutrition - Abnormal, uncontrolled proliferation,
unregulated, and accumulation of one or more
of the hematopoietic cells
➢ Job’s syndrome - Symptoms: fever, weight loss, increased
o normal random activity sweating
o Abnormal chemotactic activity o There could be bone pain from a very
➢ Lazy leukocyte syndrome large leukemic mass especially in cases
o Abnormal random activity of acute leukemia
o Abnormal chemotactic activity - Classifying leukemia based on the origin of the
➢ Chronic Granulomatous Disease (CGD) cell
o Inability to phagocytized
microorganisms Incidence
o Impaired NADPH oxidase - Dominant cause of cancer death in children
o Problem in respiratory burst under 15 years old
o Cannot fully kill or phagocytized the - ALL: most common in children
microorganism - AML: adults under 60
- CLL: adults over 60
 HEMATOLOGY 1 (LECTURE)

Classification - Features: bone pain and tenderness, organ

• Duration infiltration, symptoms related to depressions of
o Acute: lasts for days up to 6 months normal marrow function
o Subacute: 2 to 6 months - Usually encountered with organ failure or
o Chronic: variable (minimum of 1-2 years) organomegaly
• Number of WBC in the peripheral blood - Laboratory Findings:
o Leukemic: > 15k/uL o WBC count: varying blast
o Subleukemic: < 15k/uL o Platelets: usually decreased
▪ White cell count is low o Anemia: present
▪ Abnormal and immature cells
are present in the peripheral Acute Lymphoblastic Leukemia (ALL)
blood - immature form of the lymphoid lineage
o Aleukemic: < 15k/uL predominates
▪ No abnormal and immature cells - Primarily a disease of the children and young
in the peripheral blood adults
▪ Abnormal cells are in the bone - According to morphology of lymphoblasts
marrow o Pre-B cell ALL: t(9;22)
• Types of WBC involved o B cell ALL: t(4;11)
o Acute: last only for days to 6 months o T cell ALL: t(7;11)
▪ Accumulation of immature cells - Prognosis
▪ Immature cells go to the o More than 90% of children with all can
peripheral blood be cured
▪ Immature cells starts to o All in children between 2-10 years old
infiltrate other organs once the with early pre-B phenotype and
spleen does not longer filter hypodiploidy in the range of 51-60
white cells chromosomes: most favorable
▪ Associated with organ failure
▪ Hepatosplenomegaly Types of Acute Lymphoblastic Anemia
o Chronic: minimum of 1 to 2 years ➢ L1
▪ Abundant mature cells o Childhood ALL
▪ Can turn into acute once the o Lymphoblasts: small and homogenous
bone marrow is saturated

Agencies that classify the disease

➢ FAB Classification
o It divides acute leukemias into
lymphoblastic and myeloblastic
o Subdivided according to cellular
morphology, cytochemical staining ➢ L2
results, cytogenetic studies, and T and B o Adult ALL
lymphocytes markers o Lymphoblasts: large and heterogenous
o Acute leukemia: ≥ 30% blasts in the bone o They vary in size
marrow
➢ WHO Classification
o Based on cell morphology, cytochemical
stains, immunologic probes of cell
markers, cytogenetics, molecular
aspects, and clinical manifestations
o Standard in classifying acute leukemia
o More strict and has wholistic approach
o Acute leukemia: ≥ 20% blasts in the bone ➢ L3 (Burkitt type)
marrow o Rare
o Lymphoblasts: large and homogenous
Treatment o t(8;14) with a rearrangement on MYC
• Bone Marrow Transplantation oncogene
• Radiation o it appears to be vacuolated
• Chemotherapy o it has a leukemic manifestation of
• Supportive treatment (Blood transfusion) Burkitt’s disease

ACUTE LEUKEMIA
- Accumulation of blasts due to:
o clonal expansion of transformed stem
cells
o failure of maturation
- there is a prolonged generation time
- depression of the hematopoietic cycle
 HEMATOLOGY 1 (LECTURE)

Acute Myeloblastic Leukemia (AML)

- immature form of the myeloid lineage
predominates
- primarily in adults between 15-39 years old
- Morphology: more abundant cytoplasm, Auer
rods, MPO granules, delicate nuclear chromatin
➢ M5a – Acute monoblastic leukemia without
Chromosomal abnormalities maturation
• 90% of AML o 20 to >80% monocytic cells
• t(9;22)(9q34;q11) Ph’ 10-15% of M1 Poor Prog o Monoblasts: > 80%
• t(8;21)(q22;q22) 20-25% of M2 favorable prog
• t(15;17)(q22;q21) 70-80% M3 RAR-PML fusion
gene
• Absence of Ch.16 20-25% M4 favorable prog
• Absence of Ch.11 30-40% M5 poor prog
• Absence or deletions of Ch.5 or 7 poor prog

Types of Acute Myeloblastic Leukemia

➢ M0 – Accumulation of undifferentiated blasts ➢ M5b – Acute monoblastic leukemia with
➢ M1 – Acute myeloblastic leukemia without maturation
maturation o 20 to >80% monocytic cells
o > 30% blast in the bone marrow o Monoblasts: < 80%
o < 10% granulocytic cells

➢ M6
o Also known as Erythroleukemia or Di
➢ M2 – Acute myeloblastic leukemia with
Guglielmo syndrome
maturation
o 30 % blasts
o > 30% blast in the bone marrow
o > 50% erythroblastic precursors
o > 10% granulocytic cells
o It affects the RBC precursors

➢ M7 – Acute megakaryocytic leukemia

➢ M3 – Acute promyelocytic leukemia o 30% blasts
o > 30% blast in the bone marrow o > 30% megakaryocytes
o > 10% granulocytic cells
o > 50% promyelocytes
o Associated with disseminated
intravascular coagulopathy (DIC)
o Associated with translocations in
chromosomes 15 and 17
o Fusion of primary granules (Auer rods)
▪ Faggot cells: cells that have
bundles of Auer rods

CHRONIC LEUKEMIA
- Predominance of mature cells in the peripheral
blood
- Two types:
o Lymphoproliferative
➢ M4 – Acute myelomonocytic leukemia o Myeloproliferative
o 30% blasts in the bone marrow - Laboratory Findings:
o 20 to < 80% monocytic cells o WBC count: high
o Also known as Naegeli o Platelet count: normal to increase
o M4e: M4 accompanied by eosinophilia o Anemia: normal to mild
 HEMATOLOGY 1 (LECTURE)

Chronic Myelogenous Leukemia (CML) o Common thrombosis, infarction gastric

- mature form of the myeloid lineage ulcer, high BP, stroke, heart attack
predominates o Also associated with JAK genes
- Stem cell disorder affecting the granulocytic, o There will be pancytosis (all cell counts
erythrocytic, and megakaryocytic cell lines in the blood are elevated) and
- It is associated with Philadelphia chromosome panmyelosis (increase number of cell in
o One arm of chromosome 22 is the bone marrow)
translocated to chromosome 9 Absolute
o Negative: poor prognosis (they do not - True polycythemia (the problem is in the
respond well to therapy) production of cells)
o Positive: good prognosis (they respond - Increase hematocrit = increase BM
well to therapy) production
- Associated with Chronic Myeloproliferative - Primary: panmyelosis
Disorders o Increase bone marrow production of
o Clonal neoplasia of multipotent stem cell RBC, WBC, and platelets
o With differentiation and maturation o EPO: low
o Bone marrow fibrosis: reactive process - Secondary with appropriate EPO production:
response to hypoxia
Clinical features o Patients with pulmonary or cardiac
➢ Chronic phase (3 years) diseases
o Expansion of the granulocytic mass o Increase BM production of RBC, WBC,
o Marked increase cellularity and platelets
o Basophilia o EPO: high
o Predominantly myeloid hyperplasia - Secondary with inappropriate EPO
o Splenomegaly production:
o Total absence of LAP o No hypoxia
➢ Accelerated phase (50%) o Tumor of kidneys, liver, brain, arenals
o Gradual failure of response to treatment o Increase RBC, normal WBC, and
(poor prognosis) platelets
o Increasing anemia and o EPO: high
thrombocytopenia Relative
o Additional cytogenetic abnormalities - temporary and transient
➢ Blastic crisis - Increase hematocrit, decrease plasma
o AML (70%), ALL (30%) volume
o Usually ineffective to treatment - Seen when the patient is dehydrated,
stressed, and anxious
Examples of Chronic Myelogenous Leukemia - Spurious polycythemia
➢ Essential thrombocythemia
o Dominant proliferation of Additional information:
megakaryocytic cell line Myelodysplastic syndromes
o No Philadelphia chromosome - Pre-leukemic state
o Platelet count > 1000 x 109/L - Only abnormal or immature cells are produced
o With spontaneous aggregation of - Clonal stem cell disorders characterized by:
abnormal platelets o Maturation defects
o Increase susceptibility of forming o Ineffective erythropoiesis
unwanted and unnecessary clots o Peripheral pancytopenia in spite of
o Formation of clots in the cardiovascular marrow cellularity
and central nervous system - This may result to anemia
o It is still not clear what causes Blasts in Blasts in
Ringed
thrombocythemia, but some literature MDS peripheral Bone
sideroblasts
blood (%) Marrow (%)
said that it is associated with genetic Refractory Anemia/
abnormalities, particularly in Janus Refractory Cytopenia <1% <5% +/-
Kinase (JAK) genes (RA/RC)
Refractory Anemia with
➢ Myelofibrosis with Myeloid Metaplasia ringed sideroblasts <1% <5% >15%
o Fibrosis and granulocytic hyperplasia of (RARS)
the bone marrow with granulocytic and Refractory Anemia with
<5% 5-20% +/-
excess blasts (RAEB)
megakaryocytic proliferation in the liver Refractory Anemia with
and spleen excess blasts in >5% 20-30% +/-
transformation (RAEBIT)
o The patient may suffer from bleeding
Chronic myelomonocytic
o Giant platelets and occasional circulating leukemia (CMML)
<5% 5-20% -

megakaryocytic fragments
➢ Polycythemia Vera Leukemoid reaction
o Exact opposite of aplastic anemia - Not related to leukemia
o All cell counts are high - Not a disease (only a description)
o Characterized by an absolute increase in - Excessive leukocytic response in the blood
red blood cells, white blood cells, and - WBC count > 50x109/L
platelets - Exaggerated response to infection
 HEMATOLOGY 1 (LECTURE)

- Blood picture resembles leukemia

- Increase WBC count with shift to the left
- Sometimes mistaken as CML
o Leukocyte Alkaline Phosphatase (LAP) –
special stain to differentiate CML from
Leukemoid reaction ➢ Mycosis fungoides
o Leukemoid reaction: high LAP score o Positive: PAS
o CML: low LAP score o Incidence: elderly men
o Cutaneous T cell lymphoma + circulating
Chronic Lymphocytic Leukemia (CLL) lymphoma cells
- Most indolent form of all leukemias ▪ Starts with skin itching
- Silent type of leukemia o Splenomegaly and LAD
- 25% of all cases of leukemia in Western countries o Associated with Sezary cells
- Median age: 60 years o Types: pre-mycotic and mycotic
➢ Lymphoma – proliferation of malignant cells in
Chromosomal abnormalities solid lymphatic tissues
- 50% abnormal karyotype o malignancy of lymphoid tissues
- Most common among adults o it can later on spread into the bone
- Associated with deletions in chromosomes 11, marrow and blood
13, and 17, also in Trisomy 12 in some studies o Non-Hodgkin’s
- Require early treatment and have significantly ▪ Classification: Rappaport
shorter survival ▪ Proliferation of neoplastic
lymphocytes (cancer cells)
Clinical features ▪ Associated with Burkitt’s
- Often asymptomatic lymphoma
- Non-specific symptoms o Hodgkin’s
- There could be lymphadenopathy (LAD) with ▪ Reed-Sternberg cell is present
hepatosplenomegaly (50-60%) because of the • Has an owl’s eye
increased accumulation of lymphocytes appearance
• Can be associated with
Laboratory features Epstein-Barr virus
- Absolute lymphocytosis ▪ Proliferation of cells reacting to
- Often hypogammaglobulinemia increase cancer cells
bacterial infection o Diagnosis: definitive-lymph node
- Abnormal antibodies may be present, biopsy
particularly autoantibodies (10-15%) that act ▪ Rye: appearance on histologic
against platelets and RBCs lymph node biopsy
- Present of smudge cells in blood smear ▪ Ann Arbor: staging based on
- 5% monoclonal serum IgG tissue involvement
- CD5+ cells

Prognosis Myeloperoxidase (MPO) (+) AML

- Median survival: 4-6 years - Specimen should be fresh (–) ALL
- Not altered by therapy Sudan Black B (+) AML
- Depend primarily on stage - Staining of fats (–) ALL
- Transformation to acute leukemia with blast Terminal Deoxyribonucleotidyl (+) ALL
Transferase (TdT) (–) AML
crisis is rare Periodic Acid Schiff (PAS) (+) M6 or erythroleukemia
- Superimposed large cell lymphoma Napthol AS-D Chloroacetate (+) granulocytic cells
- Transformation to prolymphocytic leukemia Esterase (Specific Esterase) (–) monocytic cells
α-Naphthyl Acetate Esterase (Non- (+) monocytic cells
specific Esterase) (–) granulocytic cells
Examples of Chronic Lymphocytic Leukemia
α-Naphthyl Butyrate Esterase (+) monocytic cells
➢ Prolymphocytic leukemia (Non-specific Esterase) (–) granulocytic cells
o Problem affecting B cells and T cells Acid Phosphatase – Cannot be (+) Hairy cell leukemia
o Rare, common among aged men stored but it can be treated by
o Massive hepatosplenomegaly with tartrate to become TRAP
Leukocyte Alkaline Phosphatase 0: no red/brown
minimal LAD
(LAP) precipitate
o Poor prognosis - Count 100 neutrophils 1+: slightly diffused red
o Absolute lymphocytosis - Presence of red or brown precipitate
➢ Hairy cell leukemia precipitate 2+: moderately diffused
o “leukemic reticuloendotheliosis” - Normal LAP score: 30-185 3+: heavily diffused
- Increase in: Leukemoid 4+: very heavily diffused
o Positive: Tartrate resistant acid reaction, PV, 3rd trimester in
phosphatase (TRAP) pregnancy
o B cell (CD19 or CD20) with fine hair-like - Decrease in: CML, PNH
cytoplasmic membrane projections Toluidine Blue – binds with acid (+) mast cells and
mucopolysaccharides in blood cells basophils
o Prominent splenomegaly
o Treatment: splenectomy