Hematology 1 Reviewer PDF

MEDICAL TECHNOLOGY REVIEWER BY REYVEN NIÑA C. DY, RMT HEMATOLOGY 1 REVIEWER RED BLOOD CELLS (ERYTHROPOIESIS) ERYTHROPOIESIS The process by which erythrocytes are produced Red cells exist and develop in BONE MARROW as erythroblastic islands consisting of a macrophage surrounded...

MEDICAL TECHNOLOGY REVIEWER BY REYVEN NIÑA C. DY, RMT HEMATOLOGY 1 REVIEWER RED BLOOD CELLS (ERYTHROPOIESIS) ERYTHROPOIESIS The process by which erythrocytes are produced Red cells exist and develop in BONE MARROW as erythroblastic islands consisting of a macrophage surrounded by maturing normoblasts o These normoblasts found in bone marrow MACROPHAGES supply developing red cells with iron for hemoglobin synthesis During the maturation of the erythroid cell, four mitotic divisions occur between the pronormoblast and polychromatic normoblasts stages. Up to 16 erythrocytes may be produced from each pronormoblast Pronormoblasts to orthochromic normoblast: 3 to 5 days After 1 day, the nucleus is extruded and it will become a reticulocyte RETICULOCYTES o Remain in bone marrow for 2-3 days then released in the circulation o In the circulation, the reticulocytes continue to mature for one more day o Then the reticulocytes become mature red cells and have a life span of 120 days o Reticulocytes are blood cells which retain a reticulum when stained with a vital stain (stain for living cell) such as brilliant cresyl blue. o Reference ranges are 0.5-1.5% for adults and 2.5-6.5% for newborns, with slightly increased ranges at higher altitudes. o A supravital stain is used to enumerate reticulocytes. o Reticulocyte count is one of the best indicators of bone marrow function ERYTHROCYTE Anormalerythrocyteisanon– nucleated, slightlyroundcellwhichoriginatesinthe bone marrow from a nucleated cell called rubriblast. Life Span of Red blood Cells: 120 days Erythrocyte production is CONSTANT PROCESS REGULATORS OF ERYTHROPOIESIS 1. Erythropoietin: Primary regulator produced mainly by kidneys in response to Hypoxia Stimulates proliferation, growth and differentiation of erythroid precursors and may have minor effects on megakaryocytes Target cells: pronormoblasts and CFU-E Hypoxia: stimulus for EPO production o Shift cells: immature reticulocytes prematurely released indicating increased red cellproduction o Stress Reticulocytes: macroreticulocytes found in more severe conditions, are young cells released from bone marrow after older reticulocytes have been released. This is a response to increased need, ✓ Specific Action of EPO: o Induces committed progenitor cells (BFU-E and CFU-E) in the bone marrow to differentiate and proliferation into pronormoblast. o Shortens the generation time of pronormoblast. o Promotes the early release of reticulocytes to the peripheral blood. 2. IL-3 This hormone induces the erythropoiesis Produced by T cells along with EPO Stimulates the formation of BFU-E and CFU-E HEMATOLOGY 1 REVIEWER SUBSTANCES NEEDED FOR RED CELL PRODUCTION 1. IRON: Must be in the ferrous state (Fe2+) to transport oxygen 2. Vitamin b12 and folic acid DNA and celldivision 3. Manganese, Cobalt, Zinc Vitamin C, E and B6, thiamine and pantothenic acid- For normal erythropoiesis SEQUENCE OF ERYTHROPOIESIS 1. Decrease in arterial oxygen content is followed by decrease in tissue oxygen 2. EPO is released from the kidneys and stimulates undifferentiated reticulum cells to form into pronormoblasts 3. The increased red cells mass will increase the amount of hemoglobin available deliver oxygen, thereby increasing the tissue oxygen level. ELEVATED EPO LEVELS OBSERVED IN: 1. Erythroid hyperplasia 2. Aplastic anemia DECREASED EPO LEVELS ARE OBSERVED IN: 1. Polycythemia vera 2. After blood transfusion ERYTHRON o The single functional entity composed of red cells and their precursors. ERYTHROCYTE STAGES OF MATURATION Normoblast Erythroblast Rubriblast Pronormoblast Proerythroblast Rubriblast Basophilic normoblast Basophilic erythroblast Prorubricyte Polychromatic Polychromatic Rubricyte normoblast erythroblast Orthochromic Orthochromic Metarubricyte normoblast erythroblast Reticulocyte Reticulocyte Reticulocyte Erythrocyte Erythrocyte Erythrocyte 1. Polychromatophilic Normoblast/Rubricyte start of hemoglobinsynthesis Last stage of capable of mitosis 2. Orthochromic normoblast/Metarubricyte Youngest cell not anymore capable of mitosis Last nucleated stage 3. Reticulocyte/Diffusely basophilic erythrocyte/ Polychromatophilic erythrocyte End of hemoglobinsynthesis 4. Mature red cell/ Discocyte No mitochondria thus no hemoglobin or protein synthesis ERYTHROCYTE STRUCTURE Morphology Range Average Size 6 -8 um 7 um Thickness 1.5 – 2.5 um 2 um Volume 75 – 95 fL 87 fL Surface Area 130 – 150 135 sq.um sq.um Central 1/3 of itsdiameter Pallor Shape Biconcave disc (discocytes) HEMATOLOGY 1 REVIEWER COMPOSITION OF ERYTHROCYTE 1. 60% water and 40% solid 2. Hemoglobin – iron bearing protein which serves as the most important agent in the erythrocytes. 3. Red Cell enzymes 4. RBC membrane 40% Lipid o External Surface: 52% Protein 8% Carbohydrate ERYTHROCYTE MEMBRANE Protein Responsible for the shape and deformability of the RBC. It includes pumps and channels for movement of ions and other material between the RBC’s interior and the blood plasma. Acts as receptors, RBC antigens and enzymes. Peripheral Membrane Proteins: compose of the membrane skeleton. They are located adjacent to the cytoplasmic surface of the phospholipid bilayer MAJOR PROTEINS OF RBC MEMBRANE They are responsible for the variation of the RBCs 1. Spectin: o comprises 50% - 70% of the skeletal mass that consist of: o framework or cytoskeleton regulating shape and deformability 2. Actin 3. Protein 4.1 4. Ankyrin 5. G6PD Integral or transmembrane protein: span the phospholipid bilayer and are anchored to the peripheral protein meshwork at specific points Protein Band 3 Inorganic anion transport channel Glycophorin A,B,C,D and band 3 These are glycosylated at various points on theexternal membrane surfacewith tetrasaccharides containing high content of sialic acid residues which gives red cells NEGATIVE CHARGE on the red cell membrane Also serve as red cell receptors for certain bacterial and certain parasitic organisms Glycophorin A Bears ABO blood group Antigens Glycophorin C Associated with peripheral protein 4.1 and probably serves a role in the maintenance of the membrane shape andmechanicalproperties HEMATOLOGY 1 REVIEWER Protein 4.5 or glucose transporter The membrane is thin and pliable. It is a dynamic semi-permeable. Retaining potassium in high concentration within cell and excluding sodium The membrane allows hydrogen, chloride and bicarbonate ions to pass freely into or out of the cell in proportion to the ions gradient METABOLISM OF ERYTHROCYTES 3 Energy Molecules Needed by RBC to Maintain Metabolic Activities: ATP (Adenosine Triphosphate) ADP (Adenosine Diphosphate AMP (Adenosine Monophosphate EMBDEN-MEYERHOF PATHWAY 90-95% of glycolysis of rbc requirement Anaerobic pathway Onemolecule of glucose is converted to 2 moles of ATP ATP o Used to controlflowof Na+(sodium) and K+ (potassium) osmotic equilibrium o Maintain biconcave shape of the cell and protect membrane lipids Lactic acid o is formed as a waste or end product HEXOSE MONOPHOSPHATE SHUNT 5-10% of glycolysis of rbc OR PENTOSE PHOSPHATE PATHWAY requirement Aerobic or oxidative pathway Provides REDUCED GLUTATHIONE to prevent oxidative denaturation of hemoglobin Decreased activity of an enzyme (G6PD) in this pathway results oxidized hemoglobin which denatures and precipitates as HEINZ BODIES RAPOPORT-LUEBERING PATHWAY PRODUCTION OF 2,3DPG which regulates the affinity of hemoglobin for oxygen 2,3 DPG combines reversibly with deoxygenated hemoglobin, decreasing affinity o Increase 2,3 DPG = decrease Oxygen affinity (shift to the right ODC) o Decrease 2,3 DPG = increase Oxygen affinity (shift to the left ODC) METHEMOGLOBIN REDUCTASE Maintains iron present in the PATHWAY hemoglobin molecule in a functional REDUCED STATE (FERROUS IRON) for oxygen transport Methemoglobin cytochrome C reductase the enzyme responsible for the reduced state of iron HEMATOLOGY 1 REVIEWER FUNCTIONS OF ERTHROCYTES 1. To mediate the exchange of respiratory gases, oxygen and carbon dioxide between the lungs and tissues. 2. To control the blood pH and to assist in the maintenance of acid – base equilibrium (HOMEOSTASIS) RED CELL DESTRUCTION 1. As the red cell ages, changes occur that make it susceptible to destruction. 2. Alteration in the membrane integrity takes place. 3. Loss of sialic acid and lipids, decreased ATP and increased Calcium has been implicated in the aging process. 4. At 120 days the erythrocytes are recognized as abnormal and are removed by phagocytic cell in the RES. 5. As the cell ages it is depleted of glucose and their surface area decreases. 6. The spleen recognizes abnormalities in the cell and sequesters it for removal. MECHANISM OF RED CELL DESTRUCTION 1. Fragmentation – lossofaportionoftheerythrocytemembrane, accompanied by lossof cellular contents including hemoglobin. 2. Osmotic lysis – passing of water into the red cell as to ultimately burst it. 3. Erythrophagocytosis - ingestion of wholeredcellsbycirculatingmonocytesor neutrophil or by fixed macrophages of the mononuclear phagocyte system. 4. Compliment induced cytolysis – compliment has the ability to attach itself to the cells and induce lysis. 5. Hemoglobin denaturation – when Hb is exposed to oxidant stress and the mechanism to protect the cell from such damage fails to work denatured Hb precipitates forming inclusion bodies known as Heinz bodies. 2 TYPES OF ERYTHROCYTE DESTRUCTION INTRAVASCULAR HEMOLYSIS Lysis of erythrocytes which occurs within the circulation through the classic pathway. It is the usual outcome of sensitization of erythrocytes with compliment. 10% of aged red cell undergoes the destruction. Red blood cells break down in the circulation. Free hemoglobin; binds to haptoglobin, oxidized to methemoglobin. Heme recovered from haptoglobin, albumin or hemopexin (formed from methemoglobin). Bilirubin conjugated by hepatocytes then excreted as urobilinogen and urobilin SUMMARY: 10% Aged red cell destroyed Occurs within bloodvessels Peripheral smear: Schistocyte Decreased serum haptoglobin and hemopexin Hemoglobin present in urine Hemoglobinemia Hemoglobinuria Decreased unconjugated bilirubin ABO hemolysis Activated Complement: IgM CAUSES OF INTRAVASCULAR HEMOLYSIS: ABO mismatched blood transfusion Cold agglutinin disease HEMATOLOGY 1 REVIEWER Paroxysmal cold hemoglobinuria Burns Snake bites Bacterial C. perfringenssepsis Parasitic infections – Plasmodium spp. Mechanical heart valves Paroxysmal nocturnal hemoglobinuria EXTRAVASCULAR HEMOLYSIS Lysis of erythrocytes outside the circulation, in the RES of the cell liver, spleen. This is usually happens throughphagocytosis. About 90% of aged red cells are destroyed. RES phagocytosisof RBCs. RBCmembrane isdisrupted. Lysosomal digestionof Hb. Recovered iron transported to bone marrow. Protoporphyrin metabolized to bilirubin, conjugated and excreted. Occurs when senescent/old RBCs are phagocytized by macrophages in the liver or spleen Summary: 90% aged red cells destroyed Occurs in MPS or RES Peripheral Smear: Spherocyte DAT: Positive Complement System: Not activated (IgG) Increased unconjugated bilirubin Increased urine and fecal urobilinogen Associated with Rhhemolysis CAUSES OF EXTRAVASCULAR HEMOLYSIS Bacterial/Viral infections Drug induced Autoimmune Microangiopathy – Malignacy *DIC, *TTP, Eclampsia Hemoglobinopathies Membrane Defects – spherocytosis, elliptocytosis, Acanthocytosis Metabolic Defects – G6PD deficiency/oxidant drugs Disseminated Intravascular Coagulation Thrombotic Thrombocytopenic Purpura RED BLOOD CELL NORMAL AND ABNORMAL MORPHOLOGY VARIATION IN HEMOGLOBIN CONTENT OR RED CELL COLOR 1. NORMAL/ NORMOCHROMIC CELL Refers to erythrocyte NORMAL AMOUNT OF HEMOGLOBIN Possesses a central pallor which is about 1/3 of its diameter. Central Pallor: 1/3 or rbc diameter MCHC: 32 to 36% Disease Associated: 1. Acute hemorrhage 2. Hemolytic anemia 3. Aplastic anemia HEMATOLOGY 1 REVIEWER 2. HYPOCHROMIC CELL Refers to erythrocytes wherein the CENTRAL LIGHT AREA OF THE CELL IS LARGER AND PALER THAN THE NORMAL. Central Pallor: >1/3 of RBC diameter MCHC: 36% Disease associated: 1. Megaloblastic anemia 2. Hereditary Spherocytosis 4. ANISOCHROMIA A condition wherein BOTH HYPOCHROMIC AND NORMOCHROMIC are present. Cells which have altered normal biconcave shape “bronze” staining since central pallor islacking ✓ Disease Associated: 1. Sideroblastic anemia 2. Iron deficiency anemia after iron therapy VARIATION IN STAINING PROPERTY 1. Polychromatophilia/Polychromasia/Diffuse Basophilia This condition wherein the red cell is stained with various shades of blue with tinges of pink. This is due combinationof the affinity of Hb to acid stain andthe affinity of RNA to the basic dye. Characteristic of the immature red cell with residual of RNA. Cells are larger than the normal and correspond to reticulocytes. Associated Disease: Reticulocytosis Hemolysis Acute blood loss Pernicious anemia Other anemias 2. Punctuate Basophilia or Basophilic Stippling Special form of polychromasia in which basophilic granules usually isolated either fine orsometimes coarse appear inthe cytoplasmoferythrocytes. Stippling probably represents aggregated RNA. Associated Disease: Toxic anemia Hemolytic anemia Leukemia Lead poisoning HEMATOLOGY 1 REVIEWER Thalassemia and congenital forms of anemia 3. Hypochromasia Condition where in the red cells appears pale. 2 possible causes: o Decrease in Hb o Abnormal thinness of the cells Seen in: o Iron Deficiency Anemia(IDA) o Sideroblastic Anemia (SA) o Thalassemia 4. Hyperchromasia Conditionwherein the red cells are deeply stained to abnormal thickness of cells. Seen in: o Macrocytosis o Spherocytosis o Megaloblastic Anemia (MA) ANISOCYTOSIS: VARIATION IN SIZE 1. Normocyte/Normocytic (Normal Size) ✓ Normal Size: 6-8 um ✓ MCV: 80-100 fl ✓ Disease Associated: o Acute hemorrhage o Hemolytic anemias o Aplastic anemia 2. Microcyte/microcytic Cellwhichislessthan 100 fl ✓ Associated disease: o Megaloblastic anemia o Myelodysplastic syndrome o Chronic liver disease o Bone marrow failure o Reticulocytosis o High glucose levels (>600 mg/dl) o Hypothyroidism o Alcoholism HEMATOLOGY 1 REVIEWER 4. Megalocyte large oval shaped red cell which is 9 -12 um. Cell with impaired DNA synthesis Defect: abnormal nuclear maturation but normal cytoplasmic maturation ✓ Size: 9-12 um ✓ Associated Disease: o Megaloblastic anemia like pernicious anemia o Vitamin B12 deficiency anemia o D. latum infection POIKILOCYTOSIS: VARIATION IN SHAPE 1. Discocyte Normal cell with a biconcave disc shape with increased surface are normal erythrocytes that are approximately the same size as the nucleus of a small lymphocyte. Associated Disease: o Normal condition o Acute Post Hemorrhagic Anemia o Aplastic Anemia 2. Target Cells/ Mexican Hat/ Bull’s eye/ Codocytes Cell with central area of Hemoglobin surrounded by colorless area and a peripheral ring. cells have an increased surface-to-volume ratio Defect: o Deficiency in cholesterol, Phospholipid in the membrane. o Deficiency in LCAT o Caused by excessive cholesterol in the membrane or a hemoglobin distribution imbalance Associated Disease: o Thalassemia o Liver Disease o Hemolytic Disease o Hb SS Disease o Hb CC Disease o LCAT deficiency 3. Spherocyte Small round dense cell which lacks the central pallor area usually microcytic and sphere shaped. Disk-shaped cell with a smaller volume than a normal erythrocyte; cells have a decreased surface-to-volume ratio Cells become smaller and denser with increase Hb content and become less deformable with age. Increased staining intensity (bronze-staining red cell) Increased osmotic fragility due to decreased surface: volume ratio Defect: o Primary: Spectrin deficiency o Secondary: Defective interaction of Spectrin with other skeletal proteins. o Shortened survival time because they can be sequested in the spleen and destroyed. o Cells not easily deformed and lose their membrane by fragmentation o Banked blood stored for a long time developed spherocytes. Associated Disease: o Hereditary Spherocytosis ✓ Increase osmotic fragility and MHC and + DAT o Chronic Lymphatic Leukemia, Immune Hemolytic Anemia due to ABO incompatibility and Extensive Burns HEMATOLOGY 1 REVIEWER 4. Acanthocyte/Spur Cell/Thorny Cell Abnormal RBC with spines, spicules or thorny projection that is equal in length and distribution. Have unevenly spaced pointed projections; lack a central pallor area Red blood cells with spiny projection of various lengths and irregular spacing have 5 – 10 spicules. Defect: o Abnormal membrane defect caused by an increase sphingomyelin and decrease in cholesterol and phospholipid. o Due to increased ratio of cholesterol/lecithin on RBC membrane. o Decreased lecithin cholesterol acyltransferase (LCAT) Associated Disease: o Liver Disease o Abetalipoproteinemia o Alcoholism o Hereditary Acanthocytosis o MAHA o Pyruvate Kinase deficiency o McLeod Syndrome o Hemolytic Anemia o Post Splenectomy 5. Biscuit Cell/Folded RBC Cell assumes a “Pocket book roll” appearance or biscuit shape. Defect: Cell membrane is folded. Disease associated: o Hb SC disease o Hb CC disease 6. Burr Cell Cell with irregularly spaced blunt processes, resembles crenated RBC. Defect: Abnormal lipid content of the membrane. Associated Disease: o Uremia o MAHA o Liver Disease o DIC o TTP o PK deficiency 7. Blister Cell/Bite Cell Cell with eccentric vacuoles due to the plucked-out Heinz bodies Defect: G6PD deficiency resulting to accumulation of Heinz bodies Associated Disease: o G6PD deficiency o HUS o MAHA 8. Echinocyte/Crenated Cell/Sea Urchin Cell RBC with blunt or pointed, short projections that are usually evenly spaced over the surface of cell. Have evenly spaced round projections; central pallor area present Smallcellsor cell fragmentsbearing spinesorspiculesevenlydistributedofthe cells Defect: o ATP deficiency due to prolong storage of anticoagulated blood. o Due to abnormal lipid content of the membrane. Associated Disease: o Uremia o Bleeding Ulcers HEMATOLOGY 1 REVIEWER o Gastric carcinoma o Hepatitis o Cirrhosis 9. Teardrop Cell/Dacryocyte Cells appear in the shape of a teardrop or pear with a single short or long protrusion. Pear-shaped cell with one blunt projection Defect: Abnormal maturation, squeezing and fragmentation during splenic passage. Associated Disease: o Hemolytic Anemia o Megaloblastic Anemia o Myelofibrosis w/ Myeloid Metaplasia (MMM) 10. Elliptocyte/Ovalocyte Sausage - shaped, oval, pencil form, egg shape, cigar – shaped. Hemoglobin appears to be concentrated at the two ends of the cell leaving a normal central area of pallor. Defect: o Abnormal membrane due to defective spectrin and deficiency in band protein 4.1. o Life span isshortened Associated Disease: o Healthy Person o Megaloblastic Anemia o Hypochromic Anemia o Hereditary Ovalocytosis o Thalassemia Major o IDA o Myelophthisic Anemia 11. Sickle Cell/Depranocyte/Menisocyte Sicklecellsare thinandelongatedwithpointedendsandarewellfilledwith Hb. Shapes vary but show thin, elongated, pointed ends and will appear crescent shaped; usually lack a central pallor area They may be curved or straight or have S, V and L shaped. Defect: o Crescent shape cell due to abnormal aggregation of Hb S which gives a tendency for the cell to assume a sickle shape. o Polymerization of Hb S o Hb 9 – 10 o Cell shape is caused by cell membrane alterations due to an amino acid substitution Associated Disease: o Sickle cell Anemia o Sickle cell traits 12. Schistocyte/Helmet Cell Triangular shape Defragmented form Irregularly, contracted cell; fragmented cell Defect: Cell fragmentation due to trauma caused by physical and mechanical agents. Disease Associated: o MAHA o TTP o DIC o HUS o Uremia o Extensive Burns o G6PD deficiency HEMATOLOGY 1 REVIEWER 13. Stomatocyte/Hydrocyte/Mouth cells Red cell in which the central biconcave area appears slit like as seen in dried films. Characterized by an elongated or slit-like area of central pallor Particularly present in bloodsmearsof Australians of Mediterranean origin. Defect: o There is a metabolic disturbance which causes a red cell membrane defect which causes the red cell to have a linear unstained area in the center instead of a round, lightly stained center. o Abnormal Potassium ratio on the cell membrane. o Caused by osmotic changes due to cation imbalance Associated Diseases: o Alcoholic Cirrhosis o Hereditary Stomatocytosis o Hepatobiliary Disease o Rh Null Syndrome o Artifact RED CELL INCLUSION 1. Basophilic Stippling of RBC Punctuate Basophilia is due to deficiency in pyrimidine 5’ – nucleotidase enzyme and may be found in nucleatedred cells or diffusely red cells Remnants of RNA "blueberry bagel" appearance Wright Stain: o Blue granules o Red cells have fine to coarse punctate granular inclusion bodies. o Randomly distributed throughout the cell. o The particles are precipitated ribosomal protein. Content: o Precipitated RNA/Remnants of RNA Associated Disease: o Lead Poisoning ▪ Coarse basophilic stippling ✓ PICA in children – associated in lead poisoning ✓ PICA in adult – associated with IDA o Increased red production/polychromatophilia ▪ Fine basophilic Stippling o Thalassemia o Hemoglobinuria o Megaloblastic anemia o Myelodysplastic syndrome o Pyrimidine 5 nucleotidasedeficiency o Hemolytic Anemia o Severe bacterial infection o Drug Exposure o Alcoholism o Anemias with impaired Hb synthesis o Megaloblastic Anemia o Refractory Anemia HEMATOLOGY 1 REVIEWER 2. Howell – Jolly Bodies These inclusions are round, seen singularly or in grouped. Not seen in normal erythrocytes; normally pitted by splenic macrophages Indicative or rapid blood degeneration Generally, eccentrically located. Composed of Chromatin Material (DNA) Wright Stain: o dense round bluish red single or double dotted bodies. o Dark blue-purple dense, round and granule, eccentrically located o Usually one per cell; occasionally multiple Supravital Stain: o Dense round blue single or double dotted bodies. Content: DNA and Feulgen reaction Disease: o Sickle Cell Anemia o Hyposplenism o Hemolytic Anemia o Megaloblastic Anemia o Thalassemia (Thalassemia major) o Myelodysplastic syndrome 3. Pappenheimer Bodies/Siderotic Granules Indicative of faulty iron utilization in the synthesis of hemoglobin Non-heme iron Small, irregular, dark-staining iron granules usually clumped together at periphery of the cell These inclusion bodies are composed of Ferric Iron. Granules usually found along the periphery of the red cells often in clusters. Wright’s stain: o faint blue inclusion, irregular cluster of small light to dark blue granules o Found in the near periphery of the cell. Perl’s Prussian Blue: Confirm with iron stain ✓ Siderotic Granules: ▪ Erythrocyte with few small blue dots give a positive reaction ✓ Sideroblasts ▪ Nucleated red cells containing siderotic granules ▪ Normoblasts with dots around the nucleus in mitochondria ✓ Ringed Sideroblasts ▪ When the granules arranged around the nucleus in the form of ring Diseases: o Sideroblastic Anemia o Megaloblastic anemia o Alcoholism o Following Splenectomy o Some Hemoglobinopathies o Hyposplenism o Thalassemia HEMATOLOGY 1 REVIEWER 4. Heinz Bodies Irregular refractile granules Indicative of disturbed hemoglobin synthesis and breakdown Round dark-blue granule attached to inner RBC membrane Often found at the periphery of the cell. There are from one to six inclusions per cell. Stained with vital stain as NMB, BCB or MV. Heinz bodies are more prominent with the use of a vital stain NMB. NOT VISIBLE TO WRIGHT STAIN Content: o Denatured Hemoglobin Disease: o G6PD deficiency o Hereditary Hemolytic Anemia o Thalassemia o Favism o Unstable hemoglobins o Oxidant drugs andchemicals 5. Cabot Rings Looped or figure of eight shape or ring with red-purple color arranged in linear pattern Indicative of defective regenerative activity Wright stain: o Blue rings or figure of eight in erythrocytes which are destroyed before being released to marrow Content: o Remnant of Mitotic Spindles or Microtubules Disease: o Megaloblastic Anemia o Pernicious Anemia o Lead Poisoning o Myelodysplastic Syndrome 6. Hemoglobin H inclusion Caused instability of Hb H Supravital Stain: Methylene Blue Fine and evenly dispersed, dark-blue granules, imparts “GOLF BALL” appearance to RBC membrane Content: Precipitated of Beta globin chains of hemoglobin Disease: Hb H disease 7. Hemoglobin C crystals Condensed, intracellular, rod-shaped crystal Seen in hemoglobin C or SC disease, but not in trait 8. Hemoglobin SC crystals (Washington monument) 1-2 blunt, fingerlike projections extending from the cell membrane Seen in hemoglobin SC disease HEMATOLOGY 1 REVIEWER SUMMARY: Fuelgen Stain: HOWELL-JOLLY BODIES Supravital Stain (Cresyl Violet, Methylene blue, BMB): o RETICULOCYTES, HEINZ BODIES, HB H, PAPPENHEIMER, BASOPHILIC STIPPLING, HOWELL JOLLY BODIES, CABOT RING Wright Stain: o BASOPHILIC STIPPLING, CABOT RING, HOWELL JOLLY BODIES, PAPPENHEIMER BODIES, POLYCHROMATIC RBCS NOT VISIBLE IN WRIGHT STAIN: o HEINZ BODIES o HB H PRUSSIAN BLUE: o PAPPENHEIMER BODIES (SIDEROTIC GRANULES) HEMOGLOBIN An iron bearing protein contained within the erythrocytes It isarespiratoryproteinwhichservesasthemaincomponentofredbloodcells since it accounts for about 85-90% of the total red cell content It isaconjugatedproteinthatserveasvehicleforthetransportationofoxygen from the lungs to tissue and carbon dioxide from the tissue to the lungs It is synthesized by the young erythroblast from the polychromatophilic normoblast stage up to reticulocytes stage 1 gram of hemoglobin can carry 1.34 of oxygen Erythrocyte intracellular protein An oxygen-transporting protein contained within erythrocytes. The heme portion of hemoglobin gives erythrocytes their characteristic red color. FUNCTIONS OF HEMOGLOBIN Transport oxygen(O2) from the lungs to the tissue and carbon dioxide (CO2) from the tissue Acid–base balance regulation – assisting in maintaining hemoglobin o Buffer blood to prevent changes in pH HEMOGLOBIN SYNTHESIS It begins at the polychromatophilic normoblast stage and ends at the reticulocyte stage 65% hemoglobin synthesis occurs in immature nRBCs. 35% hemoglobin synthesis occurs in reticulocytes. ✓ Mature Erythrocyte: no nucleus, ribosome or mitochondria thus unable to synthesize new protein ✓ 6.25 g/day: Amount of hemoglobin lost and synthesized each day ✓ 2x1011 / L : daily production of new red blood cells PHYSIOLOGIC FORMS OF HEMOGLOBIN 1. Oxyhemoglobin Hemoglobin which is in combination with oxygen. This gives pinkness to the skin andmucous membrane 2. Non-Oxygenated hemoglobin or reduced hemoglobin Hemoglobin unassociated with oxygen, this gives blueness of the skin and mucous membrane HEMATOLOGY 1 REVIEWER STRUCTURE OF HEMOGLOBINS Tetrameric: 4 subunits molecule with molecular weight of 66700 Dalton Each subunit contains 1 heme and 1 globin Composed of: o 4 globin chains – proteinous part o 4 protoporphyrin IX – nitrogenous part o ferrous from of iron o 1 (2,3DPG) – 2,3 diphosphoglycerate COMPOSITION OF HEME Heme Iron chelated porphyrin ring which functions as a prosthetic group 1. Protoporphyrin IX Tetrapeptide ring with ferrous iron inserted in to the center and consist of: o Carbon o Hydrogen o Nitrogen 2. Ferrous Iron (Fe 2+) is needed for oxygen binding 3. Ferric iron lost an electron and cannot serve as an oxygen carrier ✓ 1 hemoglobin = 4 molecules of oxygen ✓ Ratio of iron to porphyrin in heme – 1:2 Globin 2 types of chains Zeta: Primitive of ALPHA Epsilon: Primitive of BETA 141 Amino Acids: Alpha and Zeta Chains 146 Amino Acids: Beta, Delta, Epsilon, Gamma OXYGEN DISSOCIATION CURVE Is a graph that shows the percent saturation of hemoglobin at various partial pressures of oxygen Show the equilibrium of oxyhemoglobin and non-bonded hemoglobin at various partial pressure Variables: a. pO2 (partial pressure of oxygen) - The amount of oxygen needed to saturate 50% of haemoglobin - Normal value: 27 mm Hg b. P 50 value - Indicates the oxygen tension at which 50% of hemoglobin are saturated ✓ P50 is normally about 26 torr ✓ Higher P50 is lower binding affinity of hemoglobin inversly prop ✓ Lower P50 is higher binding affinity of hemoglobin c. % O2 saturation - Oxygen content ofhemoglobin FACTORS: Shift to the Shift to the Left Right Temperature Decrease Increase Organic Decrease Increase Phosphates (2,3 DPG) p(CO2) Decrease Increase p(CO) Increase Decrease pH Increase Decrease HEMATOLOGY 1 REVIEWER NOTE: SHIFT TO THE RIGHT Increased P50 Decrease oxygen affinity More oxygen release to tissues SHIFT TO THE LEFT Decreased P50 Increased oxygen affinity Less oxygen release to tissues OXYHEMOGLOBIN DISSOCIATION CURVE Hemoglobin has the ability to bind large quantities of oxygen (O2) Hemoglobin release O2 Hb-oxygen dissociation curve: o The normal position of curve depends on: o Concentration of 2,3-DPG o H+ ion concentration (pH) o CO2 in red blood cells o Structure of hemoglobin(Hb) SHIFT TO THE LEFT Increase affinity of oxygen thus decrease delivery to tissues o Increase in blood pH o Decrease in bodytemperature o Decrease 2,3 DPG o Decrease carbon dioxideconcentration SHIFT TO THE RIGHT Decreased affinity of oxygen thus increase delivery of oxygen to tissues o Decreased blood pH o Increased body temperature o Increased 2,3 DPG o Increased carbondioxide concentration HYPOXIA Inadequate amount of oxygen at the tissue level Hypoxemia Inadequate amount of oxygen in the blood Arterial pO2 < 80 torr Cyanosis Bluish color of the skin due to the presence of more that 5g/dl of deoxyhemoglobin in blood HEMATOLOGY 1 REVIEWER SYNTHESIS OF HEME AND GLOBIN HEME Portion Begins in the mitochondria Condensation of glycine and succinyl coenzyme A (CoA) to form 5-Aminoluvulinic acid (ALA) in the presence of cofactor pyridoxal phosphate and enzyme 5-Aminoluvulunic synthase (ALAS) Heme leaves the mitochondria to combine with globin chain in the Cytoplasm GLOBIN SYNTHESIS GLOBIN Portion Occurs in the cytoplasm/ribosomes of normoblast and reticulocytes Polypeptide chains are manufactured in the ribosomes Globin protein are made via transcription of m genetic code to mRNA and translation of mRNA Directed by geneticloci: o Alpha and Zeta gene: Chromosome 16 o Beta, delta, epsilon and gamma: Chromosome 11 NORMAL HEMOGLOBINS A. Embryonic hemoglobin Found in normal human embryos and fetuses with gestational age of less than three months Absent at birth 1. Hb Gower 1 Globin Chains: 2 Zeta and 2 Epsilon 2. Hb Gower 2 2 Alpha and 2 Epsilon 3. Portland 2 Zeta and 2 Gamma B. Fetal Hemoglobin (Hb F) Major or predominant hemoglobin in fetus and new born Produced four months after conception Increase O2 affinity to hemoglobin 1. Hb F o Globin Chains: 2 alpha and 2 gamma o a compensatory hemoglobin and can be increased in homozygous hemoglobinopathies and beta-thalassemia major. 2. Hb A or A1 o Predominant hemoglobin after 1 year of age o Normal adult hemoglobin o 95% to 97% of hemoglobin innormaladultsproducedafter oneyearonwards o Globin Chains: 2 Alpha and 2 Beta 3. Hb A2 o Constitutes less than 1.5%-3% of the total hemoglobin o Globin Chains: 2 Alpha and 2 Delta 4. Hemoglobin A3 o Degradation product of Hb A2 o Globin Chains: 2 Alpha and 2 Delta Chains C. Adult hemoglobin Hb F – 1% Hb A – 97% - PREDOMINANT ADULT HEMOGLOBIN Hb A2 -2% HEMATOLOGY 1 REVIEWER ABNORMAL HEMOGLOBINS Caused by Beta Chain Substitution 1. Hemoglobin S Causes the red blood cell to deform and assume a sickle shape when exposed to decreased amounts of oxygen Sickle cell disease Homozygous state: Sickle Cell Anemia Heterozygous state: Sickle Cell trait Globin Chains: 2 Abnormal Beta Chains and 2 Normal Alpha Chains 6TH POSITION of the Beta Chain VALINE substituted GLUTAMIC ACID 2. Hemoglobin C About 2-3% of people of West Africa descent heterozygous Hemoglobin C disease Heterozygote state: One Beta chain Homozygous state: 2 Beta Chain Target cells are often seen and rarely, precipitated Hb C crystals often seen in combination with Hb S. It usually causes a minor amount of hemolytic anemia and a mild to moderate enlargement of the spleen 6th POSITION of the Beta Chain LYSINE substituted GLUTAMIC ACID 3. Hemoglobin E Hb E is one of the most common beta chain hemoglobin variants in the world Hb E disease People who are homozygous for Hb E (have two copies of E) generally have mild hemolytic anemia, microcytic red blood cells, and a mild enlargement of the spleen A single copy of the hemoglobin E gene does not cause symptoms unless it is combined with another mutation, such as the one for beta thalassemia trait Most common hemoglobinopathy in Philippines 26th POSITION of the beta chain LYSINE substituted GLUTAMIC ACID 4. Hemoglobin H A single copy of the hemoglobin E gene does not cause symptoms unless it is combined with another mutation, such as the one for beta thalassemia trait Globin Chains: 4 beta chains produced in response to a severe shortage of alpha chains Tetramer of BETA chains 5. Hemoglobin Barts 4 gamma chains Hb Barts develops in fetuses with alpha thalassemia It isformedoffourgammaproteinchainswhenthereisashortageofalphachains in a manner similar to the formation of Hb H Hb Bart’s disappears shortly after birth due to dwindling gamma chain production Abnormal variant of Hb F Tetramer of GAMMA chains HEMATOLOGY 1 REVIEWER CHEMICALLY MODIFIED HEMOGLOBIN/ABNORMAL HEMOGLOBIN PIGMENTS 1. CARBOXYHEMOGLOBIN Combination of hemoglobin with carbon dioxide which is not capable of binding with or transporting oxygen Hemoglobin with Fe2+ and carbon monoxide (CO); hemoglobin has 200 X more affinity for CO than O2 so CO is earned instead of O2; can result in death, but is reversible if given pure O2 Results from the binding of carbon monoxide to heme iron Hb can combine with carbon monoxide with affinity 200 times greater than that of oxygen Carbon monoxide is termed as silent killer for its colorlessgas, odor and patient becomes easilyhypoxic. Cause of death: hypoxia Formation is REVERSIBLE, revertedtooxyhemoglobinthruoxygen inhalation and administration of strong reducing substance Causes shift to left of the oxygen dissociation curve Impart a CHERRY RED COLOR of blood and skin Disease: Acute Carboxyhemoglobinemia: irreversible tissue damageand death from anoxia Chronic Carboxyhemoglobinemia: increased oxygen affinity and polycythemia Laboratory Test: o Shaking ✓ Whole blood (in EDTA tube) is shaken for 15 minutes ✓ Result: Cherry Red o Katayamas Test ✓ Blood and ammonium sulfide as a reagent ✓ Result: (+) Rose-red color; (-) greenish-brown o Spectrophotometric Method ✓ Absorption band at 541 nm 2. METHEMOGLOBIN Hemoglobin with IRON in the Ferric State Incapable of combining with or transporting oxygen molecule which is replaced by a hydroxyl radical Hemoglobin with Fe3+; cannot transport O2; increased levels cause cyanosis and anemia Inherited Methemoglobinemia: o May be a result of structural abnormality of the globin chains or it may occur of a red blood cell enzyme defect in which methemoglobin formed cannot be converted to the reduced formed of hemoglobin Acquired Methemoglobinemia: o Exposure to certain drugs and chemicals such as Nitrates, Nitrites, quinones and chlorates Laboratory Test: o Shaking: Whole blood (in EDTA tube) is shaken for 15 minutes Result: Chocolate Brown o Spectrophotometric Method Absorption band at 630 nm 3. SULFEHEMOGLOBIN Hemoglobin with S; cannot transport O2; seldom reaches fatal levels; caused by drugs and chemicals; irreversible, not measured by the cyanmethemoglobin method Forms when sulfur atom combines with heme group of hemoglobin Formation is IRREVERSIBLE oxidation of Hb of certain drugs and chemicals HEMATOLOGY 1 REVIEWER Examples: sulfonomides, phenacetin, acetanilide Formed by the addition of hydrogen sulfide to Hb has a greenish pigment Can combine with carbon monoxide to form carboxysulfehemoglobin Shift to the right oxygen dissociation curve Laboratory Test: o Shaking: Whole blood (in EDTA tube) is shaken for 15 minutes Result: bright green or mauve lavender o Spectrophotometric Method Absorption band at 620 nm HAPTOGLOBIN Plasma protein that binds free Hb Normal binding capacity: 70 – 140 mg Hb/dl Circulating haptoglobin can combine with approximately 3g Hb In hemolytic anemia haptoglobin – Hb complexes are rapidly removed – decrease serum haptoglobin Haptoglobin (as an acute phase reactant) increases – inflammation Plasma Hb breaks B1 increases: Heme fraction bound to albumin and methemalbumin appears in plasma Spectroscopic detection ( Schumms Test) Hemochromogen : plasma with methemalbumin and yellow ammonium sulfide When hemoglobin breaks down in kidney tubules, HEMOSIDERIN appears in the urine Yellow brown granules free or within tubular epithelial cells or casts Blue granules which are positive prussian blue reactins (Perls stain) are also observed LABORATORY EXAMINATION HEMOGLOBIN DETERMINATION 1. Copper Sulfate or Specific Gravity Method 2. Gasometric Method (Oxygen Capacity Method) 3. Chemical Method (Iron Content Method) 4. Colorimetric Methods 5. Cyanmethemoglobin method GASOMETRIC METHOD Principle: Hemoglobin will combine and liberate a fixed quantity of Oxygen. The blood is hemolyzed with saponin and the gas is collected and measured in a Van Slyke Apparatus With greatest accuracy Measures functional hemoglobin only 2-12% ofadult hemoglobin may be inactive Uses VAN SLYKE apparatus or NATELSON MICROGASOMETER Estimates oxygen-combining power of blood: 1g of Hb = 1.34 mL oxygen CHEMICAL METHOD (IRON CONTENT METHOD) Total iron content of blood regarded as bound to hemoglobin Hb iron content: 1 g of Hb = 3.47 mg iron COLORIMETRIC METHODS a. Visual Direct Matching Acid Hematin Alkali Hematin HEMATOLOGY 1 REVIEWER b. Photoelectric Oxyhemoglobin Method – measures plasmahemoglobin Cyanmethemoglobin or HiCN Method o Standard and reference method used to measure hemoglobin. o Sulfhemoglobin is not converted to cyanmethemoglobin and cannot be measured by this method. CYANMETHEMOGLOBIN OR HICN METHOD Principle: Blood is diluted in a solution of Potassium ferricyanide and Potassium cyanide. The hemoglobin is oxidized to methemoglobin by the Potasssium ferricyanide. The Potassium cyanidethen converts the methemoglobin to cyanmethemoglobin. The absorbance is measured spectrophotometrically at 540nm. Reagent: Modified Drabkin’s Reagent Reagent used in hemoglobin determination. Pale and yellow with a pH of 7.2 ± 0.2 Composition: o Sodium Bicarbonate 1g o Potassium cyanide 52mg o Potassium ferricyanide 198mg o Distilled water 1000mL Specimen Whole blood (EDTA) Reference Range/ Normal Hemoglobin Values - Male: 14 – 18 g/dL - Female: 12 – 15 g/dL Factors That Affects Hemoglobin Results 1. Age 2. Sex 3. Altitude of locality Hyperchromia – increased hemoglobin level found in: a. Polycythemia b. Dehydration c. Changing from high to low altitudes Oligochromia – decreased hemoglobin level found in anemias. FUNCTION OF THE HEMOGLOBIN DETERMINATION TEST IS USED IN: 1. Screening for disease associated with anemia 2. Determine the severity of anemia 3. Follow the response to treatment for anemia 4. ̵Evaluate polycythemia DECREASED HEMOGLOBIN LEVELS o Anemia o Iron Deficiency, Thalassemia, Pernicious anemia o Liver disease o Hypothyroidism o Hemorrhage o Hemolytic anemia causedby: o Transfusion of incompatible Blood o Reaction to chemical or drugs o Reaction to infectiousreagent o Various Systemic Disease o Hodgkins disease o Leukemia o Lymphoma o SLE HEMATOLOGY 1 REVIEWER INCREASED HEMOGLOBIN LEVELS Polycythemia Congestive Heart Failure Chronic Obstructive Pulmonary Disease HEMATOCRIT DETERMINATION/ PACKED RED CELL VOLUME It isthevolumeofpacked RBCsthatoccupiesagivenvolumeofwholeblood. Sampleofblood is theratioofthevolumeoferythrocytes tothatof thewholeblood. Principle: Anticoagulatedwholebloodiscentrifuged,andthetotalvolumeofthered cell mass is expressed as apercentage oradecimal fraction. Reported either as percentage or a decimal fraction IMPORTANCE OF HEMATOCRIT DETERMINATION Gives a rough estimate of the size orerythrocytes and the concentration of erythrocytes but not the whole red cell mass It is used in the calculation of the blood indices Thebuffy coat obtained fromthe hematocrit tube has numerous uses Hematocrit is a good simple screening test for anemia HEMATOCRIT METHODS MACROMETHOD Wintrobe Method Anticoagulant: Double Oxalate Haden’s modification Anticoagulant: 1.1% Sodium Citrate/ Sodium oxalate Van Allen’s Anticoagulant: 1.6% sodium citrate Sanford-Magath Anticoagulant: 1.3 % Sodiumcitrate Bray’s Anticoagulant: Heparin MICROMETHOD Capillary puncture / Adam’s Method Specimen: whole blood or capillary blood Anticoagulant: EDTA layers: plasma, buffy coat and packed RBCs’ Height of the capillary tube: 75mm or 7.5 cm Filled: at least 5 cm Bore: 1.155mm Pricking: 2 – 3mm Clay: 4 – 6 mm long NORMAL VALUE: Male: 42% - 54% Female: 35% - 49% DECREASED HEMATOCRIT Anemia Leukemia Lymphomas Adrenal Insufficiency Chronic disease Acute and Chronic blood loss HEMATOLOGY 1 REVIEWER INCREASED HEMATOCRIT Erythrocytosis Polycythemia vera Shock, when hemoconcentration rise considerably. INTERFERING FACTORS IN HEMACTORIT High altitude Normal value varies with age and gender Lower value in men and women older than 60 y/o. Severe dehydration from cause falsely raises the Hct. SOURCES OF ERROR IN HEMATOCRIT DETERMINATION 1. Speed and duration of centrifugation Decrease incentrifugal force will result in more trapped plasma in between red cells. 2. Type and amount of anticoagulant Excess anticoagulant causes shrinkage of cells. 3. Integrity in the length and diameter of the tube. 4. Errors in the sample, improper techniques in the collection of venous and capillary blood. 5. Failure to mix the blood properly before sampling. 6.Leakage of blood in the case of microhematocrit. 7.Errors in taking the reading and calculating the result. RED BLOOD CELL INDICES Indices define the size and Hgb content of the RBC and consist of the: o Mean Corpuscular Volume (MCV) o Mean Corpuscular Hgb Concentration (MCHC) o Mean Corpuscular Hemoglobin (MCH) Help to determine specific types of anemias. MEAN CORPUSCULAR VOLUME (MCV) Indicates the mean or average volume of a red cell. Individual cell size is the best index for classifying anemias. Index expresses the volume occupied by a single erythrocyte and measures in cubic micrometers (femtoliters) of the mean volume. Indicates whether the RBC size appears normal, smaller than normal or larger than normal ✓ Normocytic cells: 80-100 fl (normal values) ✓ Macrocytic cells: >100 fl ✓ Microcytic cells: 100 fl o Cobalamin (B12) Deficiency (Megaloblastic anemia – hypersegmented) o Decreased ingestion o Competitive Parasite o Fish Tapeworm infestation o Folate deficiency o Lack of vegetable o Alcoholism MEAN CORPUSCULAR HEMOGLOBIN DETERMINATION (MCHC) The average concentration of hemoglobin in each individual erythrocyte. Measures the average concentration of hemoglobin Most valuable in monitoring therapy for anemia. CLINICAL IMPLICATION Decreased MCHC values signify that a unit volume ofpacked RBCs contains less Hgb than normal. Hypochromic Anemia (MCHC 80% Hgb F: 1 – 20% Hgb A2: 2 – 5% Hemoglobin Variants of Sickle Cell Disease SS SC S/D-Los Angeles S/O-Arab S/ βThal S/HPFH SE LABORATORY FINDINGS: 1. Peripheral Smear Normocytic normochromic RBCs Hallmark: Presence of numerous sickle cells and target cells Howell – Jolly Bodies inclusions, Basophilic Stippling, Pappenheimer bodies 2. Decreased OSMOTIC FRAGILITY TEST 3. Increased Mechanical Fragility Test 4. Positive for Hb Solubility Screening Test Hemoglobin Migration Patterns based in the order of increasing mobility of hemoglobin in electrophoretic field Alkaline Electrophoresis (pH = 8.4) A2, E=O=C, G=D=S=Lepore, F, A, K, J, Bart's, N, I, and H Acid Electrophoresis (pH = 6.0-6.2) HEMATOLOGY 1 REVIEWER Sickle Cell Trait heterozygous hemoglobin ASstate a benign condition that generally does not affect mortality and morbidity. generally asymptomatic and present with no significant clinical or hematologic manifestations Hb distribution: ▪ Hb S = 40% HbA₂ = slightly inc. ▪ HbA = >60% Hb F = normal Laboratory Findings: Peripheral smear normal RBC morphology with few target cells/Codocytes Positive for Hb Solubility Screening Test Hb Electrophoresis 40% Hb S and 60% other normal Hb Hemoglobin C Disease ✓ homozygous Hb C disease of West Africans ✓ Second Most Common ✓ the abnormality is due to substitution ofglutamic acid to lysine in the sixth position of the beta chain. Hgb Distribution: ▪ HgbA: 0% ▪ Hgb C: >90% ▪ Hgb F: < 7% ▪ HgbA₂: 2% Laboratory Findings: Peripheral smear ▪ normocytic normochromic RBCs ▪ presence of target cells and reticulocytes ▪ presence of tetragonal crystals of Hb C in RBC Negative for Hb Solubility Screening Test Hb Electrophoresis: B>90% Hb C and 10% other normal Hb Hemoglobin E Disease: Third Most Common ✓ the abnormality is due to substitution of glutamic acid to lysine in the 26th position of the beta chain ✓ incidence occurs in Southeast Asia Hgb Distribution: ▪ HgbA: 0% ▪ Hgb E: 95% ▪ HgbA₂: 2-4% Laboratory Findings: Peripheral smear ▪ microcytic RBCs and presence of target cells Normal Reticulocyte count DECREASE MCV Negative in Hb Solubility Screening Test Electrophoresis: 95% Hb E HEMATOLOGY 1 REVIEWER Hemoglobin SC o the most common double heterozygous syndrome o results in a structural defect wherein different amino acid o substitutions are found on each of two beta globin chain in the 6th position o glutamic acid to valine (1ST beta chain) o glutamic acid to lysine (2nd beta chain) Hgb Distribution: ▪ Hgb S: 45% ▪ Hgb C: 45% ▪ HgbA₂: 2-4% ▪ Hgb F: 1% Laboratory Findings: Peripheral smear ▪ mild normocytic normochromic RBCs ▪ few sickle cells, target cells and crystalline structures Increased Reticulocyte Count Positive Hgb Solubility Screening Test Electrophoresis: Hgb S: 45%, Hgb C: 45% Hgb F and HgbA₂ = NormalF, A=D=G=E=O=Lepore, S, and C ANEMIA DUE TO CHRONIC RENAL FAILURE Caused by inadequate production of erythropoietin by the kidneys. ANEMIA DUE TO ENDOCRINE DISORDER This is the type of anemia associated with diseases of the endocrine glands like hypothyroidism, pituitary deficiency and adrenal gland deficiency. ANEMIA DUE TO MARROW INFILTRATION (MYELOPTHISIC ANEMIA) Infiltration of abnormal cells into the bone marrow and subsequent destruction and replacement of the normal hematopoietic cells. Aplastic anemia isa rare but potentiallyfatalbonemarrow failure thatcan be acquiredor inherited adults = acquired infants and children ▪ 30% = inherited ▪ 70% = acquired Characteristic Feature of Aplastic Anemia 1. Pancytopenia: Decrease wbc, rbc, platelets 2. Reticulocytopenia: Decrease retics 3. Bone Marrow Hypocellularity 4. Depletion of Hematopoietic Stem Cells 5. LYMPHOCYTE: MAJOR LEUKOCYTE SEEN 2 Types of Aplastic Anemia ✓ Acquired Aplastic Anemia 1) Idiopathic Aplastic Anemia ▪ cause is unknown; no known cause ▪ 70% to 80% of aplastic anemia cases 2) Secondary Aplastic Anemia ▪ cause can be identified ▪ associated with exposure to certain drugs, chemicals, radiation or HEMATOLOGY 1 REVIEWER infectious agents ✓ Inherited Aplastic Anemia ▪ usually present at an early age and may have associated congenital malformations 2 Types of Inherited Aplastic Anemia ✓ Fanconi Anemia ▪ is an autosomal recessive chromosome instability disorder ▪ characterized by aplastic anemia, congenital abnormalities, and cancer susceptibility ▪ Features: Dwarfism, renal disease, mental retardation,Malformations, Skin pigmentation, Short Stature, Congenital abnormalities, Low birth weight, Late growth dev’t, High risk of having cancer ✓ Dyskeratosis Congenita ▪ is a rare, inherited bone marrow failure syndrome ▪ characterized by mucocutaneus abnormalities, bone marrow failure (hypoplasia) and pancytopenia Polycythemia ▪ isanincreasedconcentrationoferythrocytesinthebloodthat isabovethenormalfor age and sex 2 Classifications of Polycythemia A. Relative Polycythemia/ Pseudopolycythemia refers to increase in hematocrit or RBC count due to decreased plasma volume total red cell mass is not increased Causes of Relative Polycythemia a. Acute dehydration severe diarrhea, burns and patients with diuretic therapy b. Stress B. Absolute Polycythemia refers to increase in the total red cell mass in the body 2 Types of Absolute Polycythemia a. Secondary Polycythemia it can be caused by: Appropriate erythropoietin production due to hypoxia arterial oxygen unsaturation due to high altitude, pulmonary disease, methemoglobinemia,and smoker’spolycythemia Inappropriate erythropoietin production as observed in: neoplasms renal disorders familial polycythemia b. Polycythemia Vera one of myeloproliferative disorders characterized by panmyelosis. other names:  True Polycythemia  Erythremia  Vaquez-Osler’s disease  Polycythemia rubra vera Erythrocytosis ▪ is the special name given to the polycythemia found in association with: o Congenital Heart Disease (blue babies) o Chronic Lung Disease (emphysema) leading to considerable reduction in the gas exchange areaormechanismsinthelungsandinthose livingathigh altitudes HEMATOLOGY 1 REVIEWER Hemochromatosis ▪ iron overload and accumulates in the parenchymal cells and injures the tissues Causes of Iron Overload ✓ Increased number of blood transfusion where the iron is usually stored in the macrophages and not in the parenchymal cells of liver ✓ Association with chronic anemias such as thalassemia major and sideroblastic anemia ✓ An increase dietary intake of iron exceeding 100 mg per day Alcohol abuse and liver disease SUMMARY: TYPE OF ANEMIA KEY LABORATORY FINDINGS Microcytic Hypochromic 1. Iron Deficiency Anemia  Fe,  % Saturation,  TIBC 2. Sideroblastic Anemia  Fe,  % Saturation,  TIBC, Ringed Sideroblast ,Pappenheimer Bodies 3. Anemia due to Chronic Inflammation  Fe,  TIBC 4. Thalassemia N Fe, N TIBC, Electrophoresis 5. Lead Poisoning  Blood Lead, Basophilic Stippling Macrocytic Normochromic 1. Vitamin B12 Deficiency  Vit. B12, Schilling Test,  Retics, Oval Macrocytes, Hypersegmented Neutrophil 2. Folic Acid Deficiency  FolicAcid,  Retics, Oval Macrocytes, Hypersegmented Neutrophil 3. Liver Disease  Liver Enzymes Normocytic Normochromic 1. Antibody-Mediated  Biluribin,  Haptoglobin, (+) DAT 2. Membrane Defect A. Hereditary spherocytosis  OFT, Spherocytes B. Hereditary elliptocytosis Elliptocytes C. PNH (+) Ham’s Test, (+) Sucrose Hemolysis Test 3. Enzyme Deficiency A. G6PD Deficiency  G6PD, Heinz Bodies B. PK Deficiency  PK, No Heinz Bodies 4.  Production  Need A. Aplastic Anemia Hypocellular BM,  Retics 5. Hemoglobin Defects Definitive poikilocytosis on smear, Electrophoresis