Hema 2 Post quiz

• The presentation focuses on Hematology 1 and was prepared by Genevieve Dizon for MTAP.

Hematology Topics Covered

• Scientific and technical components of laboratory testing
• Blood cell production, structure, metabolism, and function
• Routine laboratory evaluation of blood cells
• Blood disorders
• Coagulation
• Quality assurance and laboratory communication

Pre-Quiz information given

• The Pre-quiz totals 20 POINTS and lasts 20 minutes
• Answers should be shaded on the answer sheet provided on the 2nd page.
• Pens and pencils are allowed for the pre-quiz.

D. Blood Disorders

• The text is allocated 9 points to Blood Disorders as part of the overall marking scheme

D.1. Erythrocyte Disorders

• Includes RBC anomalies like Anisocytosis, Anisochromia, Poikilocytosis, and RBC Inclusion Bodies
• Also includes Anemia

Red Blood Cell Anomaly notes

• Anisocytosis relates to the increased number of RBCs with a variation in SIZE.
• Anisochromia relates to the variation in the normal coloration of RBCs.
• Poikilocytosis relates to the increased number of RBCs with a variation in SHAPE.
• Inclusion Bodies relate to the presence of Abnormal structures inside the RBC.

Anisocytosis

• Macrocytes are large RBCs, greater than 8.0um in size and are seen when Mean Corpuscular Volume (MCV) is greater than 100fL
  • Macrocytes are associated with impaired DNA synthesis.
• Microcytes are small RBCs, less than 6.0um and are seen when MCV is less than 80fL
  • Microcytes are associated with defective Hemoglobin(Hgb) formation.

RBC Histogram

• RBC histograms display cell size and frequency
• The two parameters computed with RBC histogram are Mean Corpuscular Volume (MCV) and Red cell Distribution Width (RDW)
• The count volume of sizes between 36fL and 360fL are counted as RBCs
• The count volume of sizes between 24fL and 36fL are not counted as RBCs

Red Cell Distribution Width (RDW) notes:

• RDW is a calculated index that identifies Anisocytosis
• The reference value for RDW is 11.5% to 14.5%.
• RDW is the Both width of RBC distribution curve and the mean RBC size
• Two methods can be used to measure RDW
  • RDW Coefficient of Variation (CV) are measure of erythrocyte variability: reference value is 39-46fL
    • Width of the curve is measured at the point that is 20% above baseline level and is not influenced by MCV
  • RDW Standard Deviation (SD) is the earliest method.

Normal RBC Histogram

• A normal RBC Histogram displays a Normocytic RBC Population
  • MCV is 89fL
  • RDW Coefficient of Variation RDW (CV) is 13%

Shift to the Left

• A Shift to the Left RBC Histogram displays a Microcytic RBC Population
  • MCV: 75fL
  • RDW: 14.2%

Shift to the Right

• A Shift to the Right RBC Histogram displays a Macrocytic RBC Population
  • MCV: 125fL
  • RDW: 13.8%

Shift to the Left

• A Shift to the Left RBC Histogram displays a Microcytic RBC Population
  • MCV: 64fL
  • RDW: 25.1%
• Lower discriminator includes WBC fragments, Large platelets, microcytic RBCs, and platelet clumps
• Higher discriminator includes RBC agglutination, cold agglutination, nucleated RBCs and small Lymphocytes

Bimodal Curve

• Represents two greater populations of RBC.
• Represents Automatic anisocytosis and recent blood transfusion

Conditions with Mean Corpuscular Volume (MCV) and Red cell Distribution Width (RDW)

• Normal RDW can be associated with:
  • Decreased MCV: Anemia of Chronic Inflammation
  • Normal MCV: Glucose -6-Phosphate Dehydrogenase Deficiency (G6PD)
  • Increased MCV: Liver disease
• Increased (Anisocytosis) RDW can be associated with:
  • Decreased MCV: Iron Deficiency Anemia
  • Normal MCV: Sickle Cell Anemia
  • Increased MCV: Megaloblastic Anemia

Anisochromia notes

• Variation in the normal color (Salmon-pink) of RBC
• Central pallor: approximately 1/3 of diameter

Hypochromic cells

• Usually microcytic, includes Grading of Hypochromia 1+: 1/2 Central pallor
  • 2+: 2/3 central pallor
  • 3+: 3/4 central pallor
  • 4+: Thin Rim of Hgb
• Anulocyte, aka Pessary cell and Ghost cell are types of hypochromic cells and related to Iron Deficiency Anemia (IDA)

Hyperchromic cells

• Lack of central pallor and true hypochromia occurs with high Mean Corpuscular Hemoglobin Concentration (MCHC)
• Hereditary Spherocytosis is only disease with high MCHC
  • Consists of 3 key clinical manifestations: Splenomegaly, Anemia and Jaundice
  • Increase in Autohemolysis test is noted.
  • Osmotic Fragility Test (OFT) is not diagnostic with Hereditary Spherocytosis
  • EMA binding test (eosin 5 maleimide test): decreased fluorescence

Polychromatophilic Erythrocytes

• Also know as diffusely basophilic erythrocytes (Reticulocytes in Wright stain)
• A Bluish tinge is caused by residual RNA
• Grading Polychromasia measures Slight: 1%, 1+: 3%, 2+: 5%, 3+: 10%, and 4+: >11%

Poikilocytosis cell types

• Stomatocyte is a Mouth cell: Elongated RBC with slit-like central pallor
  • Related to Rh Deficiency Syndrome, alcoholism, Electrolyte imbalance, Severe liver disease, and Overhydrated HS
• Dehydrated HS: also know as Hereditary Xerocytosis, a dehydrated form of stomatocyte, half dark and half light
• Acanthocyte, also know as Thorn cell or Spur cell
  • Related to Abetalipoproteinemia, also know as Hereditary Acanthocytosis in Bassen Kornzweig Syndrome
  • Results in absent Lipoproteins (VLDL, LDL and chylomicron)
  • Related to McLeod Syndrome (associated with Kell blood group system), Pyruvate Kinase Deficiency
• Ovalocyte is Oval shaped RBC and Hereditary Ovalocytosis
  • South East Asian ovalocytosis
• Elliptocyte is Elliptical (Cigar shaped RBC)
  • Related to Hereditary Elliptocytosis or Thalassemia also know as Mediterranean Anemia
• Schistocyte is a Fragmented RBCs also known as Schizocyte
  • Related to MicroAngiopathic Hemolytic Anemia (MAHA) or MAHA: includes Helmet cells (schistocyte)
  • Related to Thrombotic thrombocytopenic purpura (TTP) or Hemolysis, Elevated Liver enzymes, low platelet count (HELLP)
  • Related to Hemolytic Uremic Syndrome (HUS) associated with E.coli serotype 0157:H7 withDisseminated Intravascular Coagulation (DIC)
• Drepanocyte , also know as meniscocyte (sickle or crescent shaped RBCs)
  • Related to Sickle cell anemia and Hemoglobin SC disease
  • 2 forms of Drepanocytes 1. Irreversible Sickle cells (ISC), crescent shaped and fragment when reoxygenated
  • 2. Oat shaped sickle cells has less pronounced projections and return to original when reoxygenated

Inclusion Bodies

• Basophilic Stippling are punctuated Aggregated RNA, irregularly distributed in Stain: Wright stain and Supravital stain.
  • Related to lead Poisoning such as Plumbism/ Saturnism and Megaloblastic Anemia
• Siderotic Granules also know as Siderocytic Granules or Pappenheimer bodies
  • Multiple dark blue irregular granules (Prussian blue iron stain)
  • Pale blue clusters (Wright stain), an Intra-erythrocytic collections of Iron.
  • The Stain used are Iron Stains (Perl's reagent through Prussian blue reaction). and NMB and Wright Stain: Pappenheimer bodies
  • Related to Sideroblastic anemia in Dimorphic blood where it contains normochromic and hypochromic RBCs
• Heinz bodies are large and round, blue to purple material eccentrically located along the inner membrane.
  • Consists of denatured and precipitated Hemoglobin (Hgb)
  • Stains: Supravital stains (BCB, NMB, Crystal violet, Methyl violet) but dissolves in Wright stain
  • Related to deficiency in G6PD, Drug Induced Hemolytic anemia (DIHA) and Unstable Hgb (Hb Casper, Hb Genova Hb Bristol, Hb Torino, etc)
• Howell-Jolly bodies are Usually round, blue to purple and frequently appears singly
• Howell-Jolly bodies can be mistaken as Heinz bodies
• Consists of denatured and precipitated Hemoglobin (hgb)
• Stains with Wright stain, NMB, or Feulgen reaction (+): Histochem, reaction for DNA.
• Related to Megaloblastic Anemia, Refractory anemia and Lead poisoning

Anemia

• A decrease of one or more of one or more (Red blood cell count, Hemoglobin, Hematocrit)
• Classified by Morphologic or Pathophysiologic

Anemia by Morphologic

• Normocytic, Normochromic Anemia
• Microcytic, Hypochromic Anemia
• Macrocytic, Normochromic Anemia

Anemia by Pathophysiologic

• Caused by decreased production
• Caused by increased destruction
• Blood loss

Normocytic, Normochromic Anemia

• Characterized by Normal MCV and MCHC
  • Can categorized via 01 Normal or Decreased Reticulocyte Count
    • Aplastic Anemia, Kidney Disease, and Acute Blood Loss
    • Aplastic Anemia is a rare but potentially deadly bone marrow failure syndrome of Pancytopenia, Reticulocytopenia, BM hypocellularity and depletion of HSC
    • Aplastic Anemia can occur idiopathically or Secondary to chemicals, viruses, drugs where most frequently implicated (Chloramphenicol, Fanconi Anemia).
    • Aplastic Anemia can be Inherited, in Dyskeratosis congenita, Shwachman-Bodian Diamond Syndrome
  • 02 Increased Reticulocyte Count is due to Paroxysmal Nocturnal Hemoglobinuria [PNH] or PCH (Donath Landsteiner Hemolytic Anemia). Other reasons include Sickle Cell Disease, Porphyria, Enzyme deficiency, and Other Hemolytic Anemia.
    • Paroxysmal Nocturnal Hemoglobinuria (PNH) is also known as Marchiafava Micheli Syndrome
    • Deficiency of Complement Regulator Proteins is noted. DAF (Decay-accelerating factor/ CD55) and MIRL (Membrane inhibitor of reactive lysis/ CD59). Flow Cytometry (using FLAER- Fluorescein labeled proaerolysin) confirms diagnoses.

Microcytic, Hypochromic Anemia

• Characterized by low MCV and MCHC. Lack of Iron levels insufficient to maintain normal erythropoiesis
• Includes conditions such as : Chrome blood loss, Thalassemia, Anemia of Chronic Infection, Iron Deficiency Anemia, Lead Poisoning and Sideroblastic Anemia
• Includes Anemia of Chronic inflammation (ACI) formerly Anemia of Chronic Disease (ACD)
  • A common anemia seen with chronic infections such as Tuberculosis (TB), Rheumatoid Arthritis (RA) and Tumors
  • Characterized by sideropenia (decreased serum iron) despite abundant stores
  • Can present as Normocytic and Normochromic in the Early stage, or Microcytic and hypochromic in the Advanced stage
  • Acute phase reactants (APRs) to contribute in ACI
    • Inactivating Hepcidin (master regularoty hormone for systemic iron metabolism, inactivates Ferroportin,) and increases Ferritin or Lactoferrin
• Sideroblastic Anemia is defective in ites iron incorporation into protoporphyrin causing Iron trapped in the mitochondria which then becomes a Sideroblast that is a nucleated RBC precursor with cytoplasmic iron granules and Siderocyte which are anucleate RBC with iron granules
  • The Rings that attach to mitochondria make for the *Ring Sideroblast and Hallmark of Sideroblastic anemias
  • Sideroblastic Anemia is Dimorphic where blood shows normochromic and hypochromic levels.
• Iron Deficiency Anemia (IDA) is the most common Anemia characterized by symptoms of *Koilonychia (spooning of fingernails), *Glossitis (inflammation of tongue) or Angular cheilosis and craving for non-food items (Pica)
  • Possible causes are blood loss, nutritional deficiency, and increased iron demand
  • When diagnosed through serum tests: Stage 1 includes N and N, Stage 2 includes N and decrease and Stage 3 include decrease decrease

Macrocytic, Normochromic Anemia

• MCV is the High and MCHC is rated Normal
• A type can be determined via Megaloblastic Anemia vs NonMegaloblastic Anemia
• Characteristis of Megaloblastic Anemia include: Oval Macrocytes, Present Hypersegmented Neutrophils, andPresent Megaloblasts in Bone Marrow [BM] where is is related to a Vit B12 Deficiency.
• Features of NonMegaloblastic Anemia include: Round Macrocytes, Absent Hypersegmented Neutrophils and absent Megaloblasts in BM which relates to Liver Disease, Alcoholism and BM failure.
  • Pernicious Anemia is present when there isAntibodies against Parietal cells. -Vit B12 Deficiency is due an inadequate intake.
• Presence of:Antibodies against IF Increased need (pregnancy,lactation, growth)

Anemias Caused by Increased destruction vs Decreased production

• Decreased Anemia Aplastic Anemia, Iron Deficiency Anemia, Thalassemia, Anemia, Aplastic Anemia,

Anemia caused by destroyed erythrocytes. - Extracorpuscular abnormality - Infection: Drugs, toxins, burnsAntibody mediated WAIHA, Intracorpuscular abnormality Membrane defect: HS, HE, Enzyme deficiency: Globin abnormality: PNH

Heme Synthesis

• Abnormal hemoglobin, is linked with Porphyria, Hemoglobinopathies and Thalassemia

Porphyria

• Disorders characterized by impaired Heme Synthesis

Hemoglobinopathies

Differences in the arrangement of amino acids in the polypeptide chain Alpha hemoglobinopathies: Alpha thalassemia Beta Thalassemia Molecular

###Alpha Thalassemia Alpha thalassemia is decreased Silent

###WBC Anomalies and Leukemia leukocyte Disorders, WBC Myeloproliferative

###WBC Anomalies - Pick's cell/foam disease Rare autosomal genetic sphingomyelinase Ashkenazi

###WBC Anomalies - Wiskott Aldrich Thrombodystrophy Immune

###Thrombocyte Disorders Microvasculature, infections Thrombomodulin, Recessive ###Test

####Lab Assessment for Thrombotic Disorders Fibrinogen in DIC, PTTPositive for Factor C hyperacidity

###Diagnostic Efficacy Efficacy