Non-Neoplastic White Blood Cell Disorders PDF

NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS MORPHOLOGIC CHANGES enlarged, oval-shaped erythrocytes Often the body's response to various diseases and toxic challenges o ACQUIRED HYPE...

NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS MORPHOLOGIC CHANGES enlarged, oval-shaped erythrocytes Often the body's response to various diseases and toxic challenges o ACQUIRED HYPERSEGEMENTATION: associated w/ Vit. B12 deficiency o If there are infection/malignancies → there are changes in cell morphology § Visible abnormalities in RBC to attack foreign materials going inside the body The type of cell affected depends on its function Automated hematology analyzers do not detect specific abnormalities o The medical technologist will be the one to countercheck MORPHOLOGIC ABNORMALITIES OF LEUKOCYTE Toxic Granulation Neutrophil Hypersegmentation Dohle Bodies May-Hegglin Anomaly Undritz Anomaly Hereditary Neutrophil Lysosomal Storage Diseases Hypersegmentation Alder-Reilly Anomaly HYPERsegmentation of Neutrophils (>5 lobes) non megaloblastic anemia Pelger-Huët Anomaly if Acquired hypersegmentation: most often no clinical problems; non- associated with MegaloblasFc Anemia (Vit B9 or B12 pathologic TOXIC GRANULATION deficiency) Prominent dark granulation, either fine or heavy, can be observed in the band and segmented neutrophils or monocytes PELGER HUËT ANOMALY (PHA) / NUCLEAR o represent the precipitation of ribosomal protein (RNA) caused by metabolic HYPOSEGMENTATION toxicity within the cells Benign, Autosomal dominant disorder Present granules: Azurophilic (primary) granules that are peroxidase-positive. decreased nuclear segmentation (Hyposegementation) Associated with infectious states, in conditions such as burns and malignant o distinctive coarse chromatin clumping disorders, or as the result of drug therapy mutation in the lamin β-receptor gene o plays a major role in leukocyte nuclear shape changes Neutrophils in PHA appear to function normally In heterozygous PHS, individuals are clinically normal, while in homozygous PHS, cognitive impairment, heart defects, and skeletal abnormalities may occur Pelger-Huët peanut-shaped (PH) nuclear may appear round, oval, or peanut- shaped. Represent precipitation of ribosomal protein (RNA) due to metabolic toxicity within the cells Found in burns, severe infections, cancer (malignancy), hematoma, tissue undergoing necrosis, or as a result of drug therapy Extent of toxic granulation is usually graded on a scale of 1+ to 4+ being the most severe. Grading depends on the coarseness and amount of granulation within cytoplasm Number of affected neutrophils also correlates w/ C-Reactive Protein which is a HYPOlobulation / HYPOsegmentation (2 lobes) of neutrophils: failure of marker if there is inflammation. segmentation of granulocytic nuclei o Pince-nez (Spectacle-like) DOHLE BODIES o Peanut seen near the periphery of the cytoplasm of neutrophils, although they may be o Dumbbell seen in monocytes or lymphocytes. o cells have normal function represent aggregates of rough endoplasmic reticulum (RNA) Remnants are arranged in a parallel manner. Pelger-Huët Anomaly Myelocyte/Metamyelocyte Cell size is smaller Relatively bigger N:C ratio is lower N:C ratio is higher Chromatin is darker, more coarse, more densely clumped Coloreless cytoplasm Cytoplasmic basophilia (+) neutrophilic left shift [increase of These are the intracytoplasmic pale blue, round inclusions, seen near the periphery immature cells in smear] of the cytoplasm of neutrophils but may also be seen in monocytes or lymphocytes o Delay in preparation of smears make the inclusion more grey than blue or may not be visible at all aggregates of RER (remnants of rRNA) may be seen in conjunction with toxic granulation may also be seen normally but in small amounts associated with burns, infectious disease, scarlet fever, aplastic anemia, but nonspecific because it can also be seen in pregnancy. Nonspecific Conditions where Döhle bodies are seen: o Bacterial infections, Sepsis, Pregnancy, Viral infections, Burns, Intake of certain drugs. HYPERSEGMENTATION Autosomal dominant (Steininger) → asymptomatic More than five lobes or nuclear segments most frequently seen in segmented neutrophils with more than five lobes or Mutation in LMNB1 (Lamin B1 gene receptor) in PHA nuclear segments Differentiation of cell is balanced → normal, multi-lobed nuclear structure frequently associated with deficiencies of vitamin B12 or folic acid and exists along with abnormally NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS Since the female contains two x chromosomes – the other chromosome is inactivated – sometimes it forms like a barr body In males, barr bodies are not that visible since they only have one X chromosome – it is always active Some disorders, where there is an excess X chromosome in males – barr bodies will be present, because the other X will be deactivate For three X chromosomes, the other two will be inactivated Lack of LMNB1 —> myeloid bias —> Pelger-Huët anomaly (peanut shaped) AUER RODS Pink or red stained needle like crystals in the cytoplasm of myeloid cells Agglomeration of primary granules Positive for: Myeloperoxidase, esterase, acid phosphatase Diagnostic of a myeloid neoplasm (Acute myeloid leukemia) o One of the important characteristics we have to observe for in the Pelger- Huët Anomaly is the “Pince-nez” morphology (Spectacle like) TRUE PHA PSEUDO - PHA FAGGOT CELLS # of Affected 63 - 93% segments disappear —> dark-staining spheres Large, hypogranular platelets. Thrombocytopenia (approx 40- 80 x 10^9/L) Apoptotic nucleus Prolonged Bleeding time Dying neutrophils Pyknotic Nucleus - X or Sex Chromatin Darkly stained structure in the nucleus most often found in the periphery of the nucleus, sometimes in other parts AKA: X or Sex Chromatin Deactivated or inactive X chromosome → also known as Barr bodies o Usually involved in normal female cells The inclusion in the red arrow is thought to be made up of mRNA, but it is actually the precipitation/accumulation of Myosin in the heavy chain that is present. Usually larger and rounder in shape (vs. Dohle bodies in yellow) NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS How to differentiate Döhle bodies from the May-Hegglin Anomalies? Döhle-body like inclusion in MHA is usually larger, and rounder in shape vs. Döhle NIEMANN-PICK DISEASE (FOAM CELLS) accumulation of fat in cellular lysosomes of vital organs LYSOSOMAL STORAGE DISEASE recessive mutations in the SMPD1 gene — a deficiency of acid sphingomyelinase group of more than 50 inherited enzyme deficiencies resulting from mutations in (ASM) and a subsequent buildup of the sphingomyelin in the liver, spleen, and genes that code for the production of lysosomal enzymes. lungs flawed degradation of phagocytized material and buildup of undigested substrates FOAM CELL - macrophage with lipid-filled lysosomes that appear as small within lysosomes vacuoles; nucleus is eccentric All cells containing lysosomes can be affected LSD include o sphingolipidoses, oligosaccharidoses, mucolipidoses, mucopolysaccharidoses (MPS), lipoprotein storage disorders, and lysosomal transport defects STAIN POSITIVE WITH 1. Sudan Black B MUCOPOLYSACCHARIDOSES 2. Oil red O caused by deficient activity of an enzyme necessary for the degradation of dermatan sulfate, heparan sulfate, keratan sulfate, and/or chondroitin sulfate Function is not affected autosomal recessive Results in serious physical and cognitive problems and shortened survival deficiency of the enzyme sphingomyelinase recessive mutations in the SMPD1 gene o A deficiency of acid Sphingomyelinase (ASM) and a subsequent buildup of the sphingomyelin in the liver, spleen, lungs Defective NPC1 and NPC2 genes Regulate intracellular processing and g. transport of LDL-derived cholesterol Large cells filled with lipid droplets Accumulation of sphingomyelin in lysosomes Foam cells: macrophages whose cytoplasm is swollen by numerous lipid droplets in the bone marrow SEA BLUE HISTIOCYTOSIS adult form of Niemann pick disease and chronic granulocytic leukemia histiocytes filled with lipid rich granules that stain blue-green with polychrome stain such as giemsa or wright Accumulation of phosphosphingolipids in cytoplasm SPHINGOLIPIDOSES Gaucher’s disease Niemann pick’s disease GAUCHER’S DISEASE Defect or deficiency in the catabolic enzyme b-glucocerebrosidase (gene located at 1q21-q22). o Enzyme is necessary for glycolipid metabolism accumulation of unmetabolized substrate sphingolipid glucocerebroside in macrophages throughout the body, including osteoclasts in bone and microglia in the brain. (lungs, liver, spleen brain) b-glucosidase (glucocerebrosidase) is available to confirm diagnosis Treatment of Gaucher disease includes enzyme replacement Enzyme replacement therapy with recombinant glucocerebrosidase GAUCHER CELLS – abundant fibrillar blue-gray cytoplasm with a striated or wrinkled appearance (sometimes described as onion skin-like) STAINS POSITIVE WITH o Trichome, Aldehyde function, Periodic Acid Schiff, Acid phosphatase autosomal recessive most common lysosomal lipid storage disease abundant fibrillary blue-gray cytoplasm with striated or wrinkled appearance 1. Gaucher’s Disease – if there is a lack of enzyme, it cannot be converted into (“onion skin-like”) CERAMIDE B-glucosidase (glucocerebrosidase) is available to confirm diagnosis 2. Accumulation happens - forming Gaucher cell treatment: Enzyme replacement recombinant glucocerebrosidase NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS 1. Gaucher’s disease - if there’s lack of enzyme, it can’t be converted into CERAMIDE 2. Accumulation happens - forming Gaucher cell 3. If there is no sphingomyelinase, Sphingomyelin accumulates forming foam cell rare condition (Niemann-Pick Disease) both random and direct movement are impaired release of cells from the bone marrow - POOR ALDER REILLY ANOMALY o neutropenia is a consistent finding Autosomal recessive (Steininger) o cells fail to respond to inflammatory stimuli but otherwise appear to have Characterized by granulocytes (monocytes and lymphocytes less often) with large, normal phagocytic and bactericidal activity. darkly staining metachromatic cytoplasmic granules § Problems in releasing of neutrophil to the peripheral blood The characteristic granulation, called Reilly bodies, is also found in the o clinical features: low-grade fever and recurrent infections (involving the mucopolysaccharidoses (MPSs). gums, mouth, and ears) o However, Reilly bodies can also be seen in o it also contains defective actin filaments Neutrophils/Monocytes/lymphocytes aka: Schwachman syndrome defective locomotion/mobility actin filaments in the neutrophil is defective o Chemotaxis response defective o Defective mobility (random and directed) o Neutropenia altered structure and function of microfilament leads to altered deformability normal phagocytic and bactericidal activities granules: Mucopolysaccharides resemble toxic granulation DEFECTS IN MICROBICIDAL ACTIVITY o Toxic granulation occurs only on Neutrophils. Chronic Granulomatous Disease seen in Gargoylism mucopolysaccharidosis Myeloperoxidase Activity Chediak Higashi Syndrome TOXIC GRANULATION VS ALDER REILLY ANOMALY WBC Affected Neutrophilia Dohle Bodies CHRONIC GRANULOMATOUS DISEASE With Left Shift group of disorders involving inheritance or either X-linked or autosomal recessive Toxic granulation Neutrophil only +/- +/- gene that affects neutrophil microbicidal function. inheritance Alder Reilly Neutrophil, X-linked - accounts 70% and more severe anomaly monocyte, Symptoms: lymphocyte o recurrent suppurative infection, Pneumonia, Osteomyelitis, draining adenopathy, Liver abscesses, Dermatitis, Hypergammaglobulinemia FUNCTIONAL LEUKOCYTE ALTERATIONS INHERITED ABNORMALITIES IN GRANULOCYTE FUNCTION Job’s syndrome Lazy leukocyte syndrome JOB’S SYNDROME MAIN PROBLEM: decreased ability of phagocytes to produce superoxide and AKA: autosomal dominant hyperimmunoglobulin E syndrome (abnormally reactive oxygen species. increased) PATHOPHYSIOLOGY: one or more mutations in genes responsible for proteins familial disorder; mutation in the STAT 3 gene that make up complex known as NADPH oxidase o STAT3 gene is involved in the intracellular signaling cascade intracellular o A genetic defect in any of the several components of the NADPH oxidase signaling cascade system can result in the CGD phenotype by making the neutrophil o Helpful in the TH17 cell differentiation incapable of generating an oxidative burst. random movement of phagocytes are normal, but directional motility is impaired In a normal setting - cells response to chemotactic factors is slow o If a microbe is engulfed by the phagocytic cell, NADPH oxidase o resulting to more time for bacteria to multiply before attacked o If there is oxygen, it forms Hydrogen peroxide w/ addition of water – and deficits in phagocyte function NADPH will be reduced to NADP with the help of NADPH oxidase enzyme o Ineffective killing o No NADPH oxidase enzyme= cannot form reactive oxygen species o Decrease activation (hydrogen peroxide) o Lack of IL-12 production o random movement is okay but no directional movement HOW TO CHECK IF WBC IS NORMAL OR HAS CGD T helper cells cannot differentiate into Th1 cells (so high Th2 cells) NITROBLUE TETRAZOLIUM REDUCTION TEST o High serum IgE levels o Eosinophilia Deficits in delayed T helper responses Autosomal Dominant Hyperimmunoglobulin E (IgE) syndrome (ADHIES) Clinical Triad o Atopic dermatitis, Recurrent skin staphylococcal infections, Recurrent pulmonary infections Other Manifestations: o Failure to lose primary teeth, Connective tissue abnormalities, skeletal abnormalities LAZY LEUKOCYTE SYNDROME NON-NEOPLASTIC WHITE BLOOD CELL DISORDERS INHERITED, AUTOSOMAL RECESSIVE TRAIT mutation in the CHS1 LYST gene on chromosome 1q42.1-2 o CHS1 LYST gene is responsible for encoding protein that regulates the morphology and function of lysosome related organelles § There is now an abnormal functioning of the lysosomal trafficking regulator protein which affects the size and the function of lysosomes abnormally large lysosomes, which contain fused dysfunctional granules o Can now engulf the microorganism, but DOES NOT have the capacity to digest the microorganism inside § Why? → Dysfunctional granules fuse (primary, secondary, and even specific Normal PMN - Reduce the Yellow Water-Soluble Nitroblue Tetrazolium to a Dark § Impairing its original function Blue Insoluble Formazan – NORMAL RESULT But since it is abnormal - it will not- reduce the Yellow Substance and will retain CLINICAL MANIFESTATIONS OF CHS: All because of the large granules in a variety of cells: HYPOPIGMENTATION OR as Yellow – ABNORMAL RESULT PARTIAL ALBINISM o Impaired packaging of melanin into giant melanosome granules disturb FLOW CYTOMETRIC ASSAY melanin traffic labelled with dihydrorhodamine (DHR) o Fair skin, pale retina, and light blond frosted or silverly hair DHR will fluoresce - reduced (Oculocutaneous Albinism) Defective locomotion/mobility Severed Impaired release of lytic secretory granules by NK cells, rare, majority X-linked but some AR or point mutations Immunodeficiency neutrophil defects Mutations in any of 4 genes for NADPH OXIDASE cytoplasmic inclusions, resembling large lysosomes were Neurologic most serious disorder related to a defect in microbicidal activity → recurrent life- Abnormalities present in all types of neurons; peripheral and cranial threatening disorder neuropathy. composed of a group of genetic disorders in which neutrophils and monocytes Absent or reduced number and irregular morphology of Mild Bleeding CAN INGEST but CANNOT KILL catalase-positive microorganisms platelet- -dense bodies w/c are required for the second wave Techniques Main problem: decrease ability of phagocytes to produce superoxide and reactive of platelet aggregation oxygen species Pathophysiology: o Mutation in genes responsible for proteins that make NADPH Oxidase o This results to neutrophil incapable of generating an oxidative burst o NADPH oxidase: produce ROS (H2O2) that kill engulf microorganisms Catalase-positive orgs: o S. aureus, Burkholderia cepacian, Chromobacterium violaceum, Gram + enteric bacteria, various fungi (Aspergillus, Nocardia) Stimulated phagocytes → X Respiratory burst → X free radicals Associated with: o recurrent suppurative infection, Pneumonia, Osteomyelitis, draining adenopathy, liver abscesses, Dermatitis, hypergammaglobulinemia Negative Nitroblue Tetrazolium (NBT) screening: due to abnormal oxidase activity o indirect test for respiratory burst power o normal PMN: reduce the yellow water soluble nitroblue tetrazolium to a dark blue insoluble formazan LAZY LEUKOCYTE SYNDROME MYELOPEROXIDASE DEFICIENCY AKA Alius-Grignaschi anomaly benign inherited disorder that is usually transmitted by autosomal recessive genes. MAIN PROBLEM: absence of MPO enzyme from neutrophils and monocytes, but not eosinophils o Bacterial killing is slowed but complete. o COMPENSATION: Respiratory burst activity increased. Seen in patients with acute and chronic leukemias, myelodysplastic syndromes, Hodgkin disease, and carcinoma. TAY SACH SYNDROME MPO deficiency / Alius-Grignaschi Anomaly not part of Morphologic and functional Abnormalities benign inherited disorder deficiency of hexosaminidase A occurs when harmful quantities of a fatty acid derivative called a ganglioside LIPIDOSES accumulate in the nerve cells of the brain Chediak Higashi Syndrome Niemann Pick Syndrome Tay Sach Syndrome CHEDIAK-HIGASHI SYNDROME