Pathology Revision E6.5 PDF

Pathology Revision 1 01 1 PATHOLOGY REVISION 1 ----- Active space ----- Normal Smears 00:00:14...

Pathology Revision 1 01 1 PATHOLOGY REVISION 1 ----- Active space ----- Normal Smears 00:00:14 WBC Granulocytes Agranulocytes Neutrophil Eosinophil Basophil Lymphocyte Monocyte Peripheral smear : 00:00:34 Usually contains only mature cells. 3-5 lobes. Platelet Neutrophil Granules in cytoplasm. RBC Eosinophil Round cell with central 1/3 rd Binucleate pallor. (Spectacle shaped). Monocyte Brick red granules. Largest WBC. Horse shoe shaped Lymphocyte Basophil nucleus. Smallest WBC. Nucleus obscured by Small central blue granules. nucleus. Bone marrow (BM) examination : Bone marrow aspirate : Contains mature and immature cells. Cells Fat globules Pathology Revision v1.0 Marrow 6.5 2023  2 01 Pathology ----- Active space ----- Bone marrow biopsy : Cells RBC Fat Bony trabeculae Bone marrow biopsy Note : % cellularity = (100 - Age of the patient). Bone marrow needles : Bone marrow needles Salah’s needle Klima needle Jamshidis needle Can do aspiration Side screw present and biopsy using the same needle M/C site of bone marrow examination : In adults : ASIS or PSIS or Iliac crest. In children : Anterior surface of the tibia or shin of tibia. ASIS : Anterior Superior Iliac spine PSIS : Posterior Superior iliac spine On aspiration → Dry tap → Then do bone marrow biopsy. Causes of dry tap Aplastic anemia Myelofibrosis Hairy cell leukemia AML-M7 Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 1 01 3 WBC Disorders 00:10:20 ----- Active space ----- A. Non Neoplastic Disorders : Normal TLC : 4,000 - 11,000/mm3. Neutrophils : 40-70 % Lymphocytes : 15-40 % Monocytes : 2-8 % Eosinophils : 1-6% Basophils : 30 % blasts in the peripheral blood or bone marrow. Exception : Diagnosis can be made even if blast count < 20 % if Any one of the 3 present t(15:17) t(8:21) Inv 16 Lymphoblast vs myeloblast : Lymphoblast Myeloblast Cell size Small Large Cytoplasm Scanty Moderate Granules in Absent Present cytoplasm Auer rods Absent May be present Faggot cells Absent May be present Coarse or clumped up Opened up or homogenous Chromatin (dark purple) (Pinkish) Nucleoli Inconspicuous 2-5 prominent nucleoli PAS : Positive Myeloperoxidase +ve. Staining (Dot/Block positivity) Non specific esterase +ve. Sudan Black B +ve. Auer rod (Most important Cytoplasm : morphological feature) Scanty. No granules. Opened up chromatin Prominent nucleoli Coarse chromatin Myeloblast Lymphoblast Myeloblast markers : CD 13, CD 33, CD 117, MPO +ve. Pathology Revision v1.0 Marrow 6.5 2023  6 01 Pathology ----- Active space ----- 1. ALL (Acute Lymphoblastic Leukemia) : 00:30:49 Common in younger age group : 2-9 yrs. C/F : Hb / TLC Platelet Organ involvement Anemia. Increased risk of Bleeding Hepatosplenomegaly. Fatigue. infection. tendency. CNS, testis, lymph node can also be involved. Classification of ALL : FAB classification : Based on the morphology (L1, L2, L3).. Note : Practically difficult to differentiate ALL-L2 from AML. WHO Classification : B- ALL T- ALL more common. Less common. Better prognosis. Poor prognosis. Usually seen in children. Usually seen in adults. Mediastinal involvement : Absent. Mediastinal involvement : Present. Loss of function mutation : Gain of function mutation : PAX 5. NOTCH 1 gene. E2A. RUN X1. EBF gene. t(12;21). Peripheral smear : > 20 % lymphoblast Investigations Special Stain : PAS +ve (Dot and block) B-ALL CD 19, CD 20, CD 22, PAX 5, TdT Markers T-ALL CD 1 , CD 2, CD 3, CD 5, CD 7 IOC : Flow Cytometry. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 1 01 7 Peripheral smear- ALL : ----- Active space ----- Hand mirror cells (Cytoplasmic protrusion) seen in ALL Hand mirror cells Note : AML-M6 is also PAS positive but diffuse PAS +ve as compared to ALL which shows block/dot positivity. Prognostic factors : Feature Good prognosis Bad Prognosis Age 2-9 yrs 10 yrs Sex Female male Race Whites Blacks FAB type L1 (Best prognosis) L2, L3 WHO type B-ALL T-ALL Organ involvement : CNS Not involved Involved Testis Lymph node Hyperdiploidy Hypodiploidy Cytogenetics (M/C cytogenetic abnormality in ALL). Trisomy 4, 7, 10 /t(12;21) t(9;22) Leukocyte count TLC 1,00,000/ml 2. AML (Acute Myeloid Leukemia) : 00:41:33 Average age : 15-39 years. Features similar to ALL. Additional features in AML Gum bleeding/hyperplasia Chloroma DIC Pathology Revision v1.0 Marrow 6.5 2023  8 01 Pathology ----- Active space ----- Chloroma : In myeloblastoma/granulocytic sarcoma. MPO : +ve. M/C site : Orbit. Color : Greenish. Arbiskov cells : Monocytes in chloroma. Chloroma : Soft tissue involvement FAB classification : Based on cell type and degree of differentiation (morphology of the blast). FAB classification M0 Undifferentiated. M1 AML with minimal maturation. M2 AML with maturation. M3 Acute promyelocytic leukemia. M4 Acute myelomonocytic leukemia. M4 eos Acute Myelomonocytic leukemia with eosinophilia. M5 Monocytic leukemia. M6 Acute erythroid leukemia. M7 Acute megakaryocytic leukemia. Salient features : AML type Salient features M/C FAB type. AML M2 Translocation : t(8:21). M/C associated with chloroma. Translocation : t(15:17). Associated with DIC. AML M3 Maximum Auer rods. Rx : All trans retinoic acid or arsenic trioxide. Best prognosis. Associated with gum bleeding. Associated with leukemia cutis. AML M4, M5 Non specific esterase +ve. AML M4 : Inv 16. Also called Di Guglielmo disease. AML M6 Diffuse staining with PAS. Least common. CD 41, CD 61 : +ve. AML M7 Associated with Down’s syndrome. Associated with myelofibrosis (D/t platelet derived growth factors) → Dry tap. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 1 01 9 ----- Active space ----- Auer rod Faggot cell MPO positivity in Myeloblast Criss cross pattern of auer rods Myeloproliferative Disorders 00:50:29 1. Chronic Myeloid Leukemia : Middle age to elderly Massive splenomegaly on clinical examination. Pathogenesis : 95 % cases : t(9;22) Philadelphia chromosome BCR-ABL fusion transcript: 22 kDa Constitutive Activation of tyrosine kinase Myeloproliferation inhibit CML Imatinib mesylate ( Gleevac) Formation of BCR- ABL fusion transcript Pathology Revision v1.0 Marrow 6.5 2023  10 01 Pathology ----- Active space ----- Diagnostic criteria of CML in accelerated phase Persistent spleen size Peripheral Cytogenetic Blast 10-19% in Thrombocytopenia and WBc blood basophil evidence of blood and/or (20%. clonal bone marrow. therapy. to therapy. evolution. (OR) Persistent Thrombocytosis (>1000 x 109) unresponsive to therapy. Note : Investigations : Massive splenomegaly Peripheral smear : causes in India : Malaria. Kala Azar. All stages of myeloid CML. maturation Polycythemia vera. Myelofibrosis. Basophilia Gauchers disease. Hairy cell leukemia Peripheral smear looks more like a bone marrow Bone marrow aspirate : Contain Pseudo gaucher cells + Sea blue histiocytes. Pseudo gaucher cells FISH : Investigation of choice. Normal BCR- ABL fusion (Fusion of red and green) Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 1 01 11 NAP Score : Neutrophil Alkaline Phosphatase. ----- Active space ----- a. Normal score : 40-100. b. Decreased in CML. Decreased NAP score Paroxysmal nocturnal hemoglobinuria Myelodysplastic syndrome Increased NAP Score Stress Infection Leukemoid reaction Pregnancy Myeloproliferative disorders other than CML Rx of choice in CML : Bone marrow transplantation. 2. Polycythemia vera : 00:59:51 Major criteria Minor criteria 1. Hb 1. Subnormal serum > 16.5 g/dl in men. erythropoetin levels. > 16.0 g/dl in women. 2. Bone marrow trilineage myeloproliferation with pleomorphic megakaryocytes. 3. Presence of JAK2 mutation. Diagnostic criteria : All 3 major criteria or first 2 major + 1 minor criteria Note : All other myeloproliferative disorders except CML, the translocation seen is JAK2 V617F translocation. 3. Essential Thrombocytosis : 01:02:05 Diagnostic criteria : All 4 criteria needed for diagnosis. Platelet count ≥ 4,50,000. JAK2 V617F mutation or no evidence of reactive thrombocytosis. Not meeting WHO criteria for other MPN Megakaryocytic proliferation with large and mature morphology; no or little granulocyte or erythroid proliferation. Pathology Revision v1.0 Marrow 6.5 2023  12 01 Pathology ----- Active space ----- 4. Myelofibrosis : 01:02:52 Diagnostic Criteria : Major criteria Minor criteria 1. Atypical megakaryocytic hyperplasia with 1. Leukoerythroblastosis. reticulin/collagen fibrosis (Due to PDGF 2. Elevated LDH. elaboration). 3. Anemia. 2. Exclusion of WHO criteria for other 4. Palpable splenomegaly. myeloproliferative disorders (CML, MDS, MPDS or PV). 3. JAK2V617F or other clonal markers, if not rule out other clonal markers. Investigations : Peripheral smear Reticulin stain : Silver stain Tear drop cells (Dacrocytes) Bony Fibrosed fibres : trabeculae Black Note : Leukoerythroblastic blood picture : Leukoerythroblastic blood picture also seen in : Myelofibrosis. Hairy cell leukemia. AML-M7. Space occupying lesions of BM. Metastatic cancer. Both immature myeloid and erythroid Myelopthisic anemia. cells in blood picture. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 2 02 13 PATHOLOGY REVISION 2 ----- Active space ----- Differences between Hodgkin & Non-Hodgkin lymphoma : Hodgkin Lymphoma Non-Hodgkin Lymphoma Lymph node Single group of axial nodes (Cervical, Multiple peripheral lymph involvement mediastinal, para-aortic). nodes. Spread Contiguous. Non-contiguous. Mesenteric nodes, Rarely involved. Commonly involved. Waldeyer’s ring Extra nodal Uncommon. Common. involvement Reed Sternberg (RS) Present/Characteristic. Not present. cells Hodgkin’s Lymphomas (HL) 00:01:40 Age : Bimodal distribution (15-20 years & elderly). C/F : Cervical lymph node enlargement (M/c). B symptoms : Fever (Pel Ebstein : waxing & waning), night sweats & wt. loss. Mediastinal involvement → Nodular sclerosing HL (Also seen in T-ALL). Itching can be present. Reed-Sternberg (RS) cell : Reed sternberg cells CMV inclusions Normal lymphocyte Popcorn / LH RS cell Lacunar RS cell (Lympho Histiocytic) (Empty space seen) Nodular sclerosis HL NLPHL Pathology Revision v1.0 Marrow 6.5 2023  14 02 Pathology ----- Active space ----- Owl’s eye appearance : Large binucleate cells with prominent eosinophilic macro nucleoli. Note : Owl’s eye appearance is also seen in CMV inclusions Types of HL : Classical HL Non classical HL Nodular Mixed Lymphocyte Lymphocyte Nodular lymphocyte Types sclerosis cellularity rich depleted predominant HL M/C M/C in HIV - - globally. India. associated. M:F M=F M>F Age Young. Biphasic. Elderly. Young. Lacunar LH (Popcorn) variant RS cell variant Present. Present. Present. seen. seen. CD 15, CD 30 : - Markers CD 15, CD 30 : + CD 20, BCL 6, EMA : + EBV Uncommon. Associated. Never associated. Prognosis 2nd best. Very good. Worst. Best. Non- Hodgkin’s Lymphomas (NHL) 00:13:10 A. Chronic Lymphocytic Leukemia (CLL) / Small Lymphocytic Lymphoma (SLL) : When lymph nodes (LN) become involved in CLL → SLL. Pathogenesis : Del 13q/11q/17p; trisomy 12. Normal lymphocytes C/F : Elderly (60-70 years) patient with painless lymphadenopathy & Auto Immune Hemolytic Anemia (AIHA). Investigations : Absolute lymphocytes > 5000/mm3. Peripheral Smear (PS) : Smudge cells/ Smudge parachute cells/basket cells. cells LN biopsy : Proliferation centers (Pathognomic finding). Flow cytometry (IOC) : Markers : CD 5+, CD 23+, CD 200+. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 2 02 15 ALL CLL ----- Active space ----- Seen in young patients. Seen in elderly PS : Blast cells PS : Normal lymphocytes, smudge cells CLL CML Lymphocytes with similar morphology Lymphocytes with different morphologies (College (Convent girl appearance). girl/ Garden party appearnce). B. Burkitt’s Lymphoma : 00:18:20 Disorder of B cells. Usually seen in children. Note : Pathogenesis : n-myc : Neuroblastoma 1. t(8 : 14) or gain of function in c-myc. L-myc : Lung cancer 2. t(2 : 8), t(8 : 22). Markers : CD 19, CD 20, BCL 6 : +. Types African/Endemic Sporadic HIV associated EBV associated. 15-20 % EBV Site : Anywhere Site : Jaw, mandible. associated. Site : GIT, peritoneum. HPE of LN biopsy : Starry sky appearance. Lymphocytes (SKY) Histiocytes → Macrophages (STAR) Starry sky appearance C. Hairy Cell Leukemia : 00:22:00 Disorder of B cells. Pathogenesis : BRAF V600E mutation. C/F : Massive splenomegaly. Investigations : CBC : Pancytopenia (Myelofibrosis d/t ↑ Platelet Derived Growth Factor). PS : Hairy cells (Cells with hair-like projections → Best seen with phase contrast microscope). Bone marrow (BM) aspiration : Dry tap. BM biopsy : Fried egg/honey comb appearance. Special stain : Tartrate resistant acid phosphatase (TRAP) +. Markers : Annexin A1, CD 25, CD 11c, CD 103 : +. Pathology Revision v1.0 Marrow 6.5 2023  16 02 Pathology ----- Active space ----- Note: Conditions with BRAF V600E mutation : 1. Hairy cell leukemia. 2. Langerhans cell histiocytosis. 3. Papillary carcinoma thyroid. 4. Pilocytic astrocytoma. TGF b is the most fibrogenic cytokine. Fried egg appearance also seen in : Fried egg appearance Oligodendroglioma. Annexin 5 is a marker for apoptotic cells. Hairy cells Peripheral smear Electron microscopy of hairy cell leukemia D. Other B cell NHLs : Follicular Mantle cell Burkitt’s Marginal zone Features DLBCL Lymphoma Lymphoma lymphoma Lymphoma M/C indolent M/C NHL in Incidence - - - NHL in the west. India & globally. BCL6 t(14 : 18), t (8 : 14), Pathology t(11 : 14). dysregulation, t(11 : 18). MLL gene. t (2 : 8). t(14 : 18). Follicles, small Small - medium Diffuse Lympho- centrocytes, Histology irregular - patterned big, epithelial larger lymphocytes. pleomorphic cell. lesions. centroblasts. Cyclin D1 +, CD 5+, CD 19 +, CD CD 19 +, CD 20 +, Markers BCL 2 + CD 43+ CD 23-, SOX 11 + 20+, BCL 6 + BCL 6 + Seen in H. pylori Para- EBV infection, trabecular Lymphomatoid Others associated, - Hashimoto’s lymphoid polyposis. jaw/GIT lesion. thyroiditis, aggregates. Sjogren’s syndrome. Note : CLL is CD5+. CD23+. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 2 02 17 E. T cell NHLs : 00:30:33 ----- Active space ----- Mycosis Fungoides /Sezary Adult T cell Anaplastic Large Cell Features syndrome / Cutaneous T cell Leukemia Lymphoma (ALCL) Lymphoma Pathology HTLV 1. - ALK gene on ch 2p. Flower cells/clover Histology Sezary cells (cerebriform nuclei). Hallmark cells. leaf cells. Note : ALK gene mutation is seen in ALCL, Adenocarcinoma of lung, Inflammatory myofibroblastic tumors. Plasma Cell Disorders 00:31:35 Plasma Cell : Oval cell. Eccentric nucleus. Cart wheel/clock face chromatin. Perinuclear hoff/halo. A. Multiple Myeloma (MM) : Tumour of post germinal center B cells. C/F : Middle-aged to elderly. Fever, pallor, fatigue, abdominal pain. Bone pains, pathological fractures. ↑ Risk of infections (M/c cause of death). Diagnostic Criteria of MM : 1. Clonal bone marrow plasma cell ≥ 10 %. OR Biopsy proven bony or extramedullary plasmacytoma. Plus Positive malignancy biomarkers : Clonal BM plasma cells ≥ 60%. Involved : Uninvolved serum free light chain ratio > 100. > 1 focal lesion on MRI. 2. A Myeloma OR defining event Evidence of end organ damage d/t underlying plasma cell disorder : Hypercalcemia Renal insufficiency CRAB features Anaemia Bone lesions Pathology Revision v1.0 Marrow 6.5 2023  18 02 Pathology ----- Active space ----- Investigations : PS : RBC rouleaux formation (Stack of coins) d/t ↑ ESR; no plasma cells seen. BM aspiration : 1. Flame cell (Flame shaped immunoglobulin). 2. Mott / Morula cell (Grape like cluster). 3. Russell body. 4. Dutcher body (Intranuclear Ig inclusion). Rouleaux formation Russel body Dutcher (intracytoplasmic body Immunoglobulin) Mott / Morula cell Russel body Dutcher body Note : Ig increase : IgG (M/c) > IgA > IgM. rody X-ray findings : Lytic/punched out lesions. M/c involved bones : Lumbar vertebra. Biochemical tests : 1. ↑ S. Calcium → Metastatic calcification. 2. Abnormal kidney function test. 3. Reversed S. Albumin/Globulin ratio. Lytic lesions 4. ↑ ESR → Rouleaux formation. 5. ↑ S. b2 microglobulin : Most important prognostic factor in MM. 6. Bence Jones proteinuria : Not very specific; Light chain Igs which precipitate at 40-60°C, disappear on boiling & reappear on cooling. 7. Markers : CD 138 (syndecan 1), CD 56. Protein electrophoresis (IOC) : g-globulin peak seen Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 2 02 19 B. Other Plasma Cell Disorders: 00:41:07 ----- Active space ----- Disorders Features >20% plasma cells in the blood Plasma cell Leukemia (Normally, no plasma cells seen in blood). BM plasma cells >10%. Smoldering / Asymptomatic No CRAB lesions. myeloma S. monoclonal M protein >3gm/dl. M/c plasma cell abnormality. Monoclonal gammopathy of BM plasma cells 20% lymphoblasts myeloblasts smudge cells maturation, basophilia MPO, Stains PAS + Sudan black B, - - oil red O B ALL : CD 19, CD 10, PAX 5 + CD 13, CD 33, CD Markers T ALL : CD 1, CD2, CD CD 5, CD 23 + - 117, MPO + 5, CD 7 + Both : TdT + t(8 : 21), Trisomy 12, Path - t(15 : 17) t(9 : 22) del 13q, 17p inv 16 BM findings in diseases : Disorder BM Aspiration BM biopsy ALL >20% Lymphoblasts >20% Lymphoblasts AML >20% Myeloblasts >20% Myeloblasts CLL ↑ Lymphoid cells ↑ Lymphoid cells Pseudo gaucher cells, CML - Sea blue histiocytes Hairy cell leukemia Dry tap Fried egg appearance LCH - Coffee bean nuclei Myelofibrosis Dry tap ↑ Fibrosis Multiple myeloma ↑ Plasma cells - Aplastic anemia Dry tap ↑ Fat Megaloblasts : Erythroid Megaloblastic Anemia precursors with sieve like - chromatin Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 3 03 21 PATHOLOGY REVISION 3 ----- Active space ----- RBC 00:00:35 Peripheral smear : Peripheral smear Platelet Eosinophil Neutrophil Basophil RBC (Central 1/3rd pallor) Lymphocyte Monocyte Stains for peripheral smear : Romanowsky stains. 1. Geimsa stain. 2. Leishman stain. Ideal shape of peripheral smear on gross examination : Tongue shaped. Anisocytosis : Variation in the size of RBCs. Poikilocytosis : Variation in the shape of RBCs. RBC series : Proerythroblast Cell size Early normoblast (Basophilic) Nuclear size Intermediate normoblast (Polychromatic) Late normoblast (Orthochromic) Reticulocyte No nucleus RBC 1st stage of RBC with no nucleus : Reticulocyte. Hb production starts in : Proerythroblast. Hb is first seen/visualized in : Intermediate normoblast. Pathology Revision v1.0 Marrow 6.5 2023  22 03 Pathology ----- Active space ----- Reticulocytes : Mature RBC Reticulocyte (Bluish meshwork like : Ribosome/RNA) Supra vital stain Staining process : Supra vital staining. Supra vital stains : Brilliant cresyl blue, New methylene blue. Normal reticulocyte count : 0.5% - 1.5%. Conditions : Reticulocytosis Reticulocytopenia 1. Hemolytic anemia. 1. Aplastic anemia. 2. Acute blood loss. 3. Response to Rx in iron/ B12 deficiency anemia. Patient Hb Corrected reticulocyte count = Retic % x Normal Hb for that age RBC abnormalities on peripheral smear 00:13:00 Peripheral smear finding Conditions 1. Microcytic hypochromic RBC’s : S : Sideroblastic anemia, lead poi- soning. I : Iron deficiency anemia. T : Thalassemia. A : Anemia of chronic disease (Nor- mocytic normochromic anemia is Microcyte (MCV < 80 fL) (Central pallor > 1/3rd ) also seen). Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 3 03 23 Peripheral smear finding Conditions ----- Active space ----- 2. Macrocytic RBC’s : L : Liver disease. H : Hypothyroid. M : Megaloblastic (B12/folate defi- ciency anemia). C : Cytotoxic drugs. Macro ovalocyte 3. Pencil cells : Iron deficiency of anemia. 4. Bite cells : G6PD deficiency. Bite cells 5. Spherocytes : Hereditary spherocytosis. Autoimmune hemolytic anemia (M/c cause of spherocytosis). Blood transfusion reaction. Burns. Spherocyte (Absence of central pallor) 6. Burr cell/echinocyte : Chronic renal failure. Uremia. Liver disease. Burr cell (Blunt projections) Pathology Revision v1.0 Marrow 6.5 2023  24 03 Pathology ----- Active space ----- Peripheral smear finding Conditions 7. Spurr cell/acanthocyte : Abetalipoproteinemia. Spur cells (Pointed spicules ) 8. Sickle cell : Sickle cell anemia. Sickle cells 9. Target cell/codocyte : Thalassemia. Liver disease. Iron deficiency anemia. Target cell 10. Schistocytes/helmet/fragmented RBC : Microangiopathic hemolytic ane- mia (MAHA) : 1. HUS 2. TTP 3. DIC Prosthetic cardiac valves. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 3 03 25 Peripheral smear finding Conditions ----- Active space ----- 11. Tear drop cells/dacrocyte : Myelofibrosis. Myelodysplastic syndrome (MDS). Myelophthisic anemia. Tear drop cells 12. Heinz bodies/bite cells : G6PD deficiency. Heinz bodies (Denatured ppt. of Hb) (Seen on supravital stain) 13. Howell jolly bodies : Asplenia. Megaloblastic anemia. Thalassemia. Howell jolly bodies (Remnant of nucleus) 14. Pappenheimer bodies : D/t precipi- Sideroblastic anemia. tation of iron. 15. Rouleaux formation : Multiple myeloma. 16. Cabot ring : Megaloblastic anemia. Thalassemia. Cabot ring (Fig. of 8 formed from microtubules) 17. Polychromasia : Hemolytic anemia. Pathology Revision v1.0 Marrow 6.5 2023  26 03 Pathology ----- Active space ----- Peripheral smear finding Conditions 18. Basophilic stippling : Sideroblastic anemia. Lead poisoning. Thalassemia. Megaloblastic anemia d/t B12 de- ficiency. Basophilic stippling 19. Stomatocytes : Hereditary stomatocytosis. WBC abnormalities on peripheral smear 00:25:20 Peripheral smear finding Conditions 1. Hypersegmented neutrophil : > 5 lobes. Megaloblastic anemia. 2. Bilobed neutrophil : Pseudo Pelger Huet MDS. cell. Myelofibrosis. 3. Toxic granules : Dark blue granules. Sepsis. 4. Dohle bodies : Patches of dilated ER. Parasites on peripheral smear 00:33:34 Ring form of Plasmodium Microfilaria Microfilaria Ring form of Plasmodium Gametocyte of P. falciparum LD bodies (seen in Leishmaniasis) Gametocyte of P. falciparum LD bodies : Bone marrow aspirate of a pt. with massive splenomegaly. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 4 04 27 PATHOLOGY REVISION 4 ----- Active space ----- RBC indices 00:00:12 Index MCV MCH MCHC RDW Mentzer index Definition Average Average mass Average Hb Degree of MCV/ RBC volume (size) of Hb per red concentration anisocytosis count of red cells. cell. in a volume of (variation of packed red red cell size). cells. Normal 82 - 96 fL 27 - 32 pg 33 - 37 gm/dl 11 - 14% 13 Significance Microcytic Hypochromic ↑sed in To diff b/w < 13 : Macrocytic Normochromic Hereditary thalassemia Thalassemia. Normocytic spherocytosis (Normal) & iron deficiency > 13 : Iron anemia (↑sed). deficiency anemia. Causes : Microcytic Normocytic Macrocytic (MCV < 80 fL) (80 - 100 fL) ( > 100 fL) Sideroblastic anemia, Aplastic anemia. Liver disease. lead poisoning. PNH. Hypothyroidism. Iron deficiency anemia. Hemolytic anemia. Megaloblastic anemia Thalassemia. Anemia of chronic disease. d/t B12 deficiency. Anemia of chronic disease. Cytotoxic drugs. Anemia 00:06:07 ↓sed Hb mass/↓sed Hb according to patients age & sex. Classification of anemia : 1. Hypoproliferative anemia : Aplastic anemia. Pure red cell aplasia (PRCA). Myelophthisic anemia. 2. Deficiency anemia : Vit B12 deficiency anemia. Iron deficiency anemia. 3. Hemolytic anemia. Pathology Revision v1.0 Marrow 6.5 2023  28 04 Pathology ----- Active space ----- Hypoproliferative anemia 00:07:28 1. Aplastic anemia : D/t to bone marrow suppression (No cells in bone marrow). H/o of cytotoxic drugs, radiation exposure or viral infection. C/f : Anemia : Pallor, fatigue. Leucopenia : Risk of infections. Thrombocytopenia : Petechiae, purpura, bleeding. No splenomegaly. On investigation : Pancytopenia Bone marrow aspiration : Dry tap. Bone marrow aspirate in Bone marrow Bx (IOC) : ↓sed cellularity & ↑sed fat. Aplastic anemia 2. Pure red cell aplasia : ↓sed erythroid progenitor/RBC, but TLC & platelet count is normal. Associated with : Parvo virus B19 infection. Thymoma. 3. Myelophthisic anemia : Any space occupying lesion of bone marrow (Like metastasis, TB granuloma). Clinical picture : Tear drop cells on peripheral smear. Dry tap on bone marrow aspirate. Hemolytic anemia 00:13:58 Caused d/t excessive destruction of RBC. Difference b/w intravascular & extravascular hemolysis : Feature Intravascular Extravascular Hepatosplenomegaly +/- ++ Hemoglobinuria + - Hemosiderinuria + - S. Haptoglobin Decreased Decreased or normal Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 4 04 29 General C/f & investigation in intravascular & extravascular hemolysis : ----- Active space ----- General clinical features Investigations Pallor ↓sed Hb Jaundice Reticulocyte count ↑sed Splenomegaly (M/c in extravascular hemolysis) Unconjugated bilirubin ↑sed Gall stones (Pigmented type) LDH ↑sed Causes of intravascular & extravascular hemolysis : Intravascular hemolysis Extravascular hemolysis Paroxysmal nocturnal hemoglobinuria (PNH). Hereditary spherocytosis. Paroxysmal cold hemoglobinuria (PCH). Sickle cell anemia. Microangiopathic hemolytic anemia (MAHA). Thalassemia. G6PD deficiency. Autoimmune hemolytic Infections. anemia (AIHA). Prosthetic cardiac valves. Extravascular hemolysis : Features of extravascular hemolysis : Feature Hereditary spherocytosis G6PD deficiency Sickle cell anemia Inheritance AD XLR AR M=F M>>F M=F Patho- M/c protein Defect of G6PD : Affects Missense point mutation : genesis defect : Ankyrin. HMP shunt → ↑H2O2 → Glutamic acid is replaced Free radical injury → by Valine at 6th position Most severe Hemolysis of β chain deficiency : Spectrin. (HbS production). Clinical Splenomegaly Episodic haemolysis Crisis (Microvascular features Pigment gall stones No splenomegaly occlusion) like No gall stones bone pain, fracture, Haemoglobinuria chest pain H/o chronic infection, drugs/fava beans intake Hemolysis Extravascular Both Extravascular P/S Spherocytes Bite cells, Heinz bodies Sickle cells Special Osmotic fragility Methaemoglobin Sickling test, test reduction test Hb electrophoresis, HPLC Best test Flow cytometric analysis HPLC Rx Splenectomy Avoid oxidative stress Hydroxyurea (↑sed HbF : Reduce sickling). Stem cell transplant. AD : Autosomal dominant ; AR : Autosomal recessive ; XLR : X linked recessive. Pathology Revision v1.0 Marrow 6.5 2023  30 04 Pathology ----- Active space ----- Note : Heinz bodies can only be visualized on supravital stains. Images Description 1. X ray skull Crew cut appearance Due to extramedullary hematopoisis. Seen in thalassemia > Sickle cell anemia. 2. Hb electrophoresis : Adults : Hb A : α2 β2 (95% - 97%) Hb F : α2 γ2 (< 1%) Hb A2 : α2 δ2 (2% - 3.5%) 3. HPLC High performance liquid chromatography : Best investigation for hemoglobinopathies. It tells about the % of various Hb. Thalassemia : Autosomal recessive. Male = Females. Thalassemia, sickle cell anemia, G6PD deficiency provide protection against P. falciparum. Types of thalassemia : Beta thalassemia Alpha thalassemia Cause Reduced β chain synthesis Reduced α chain synthesis Gene Ch 11 Ch 16 Defect Mostly mutations Mostly gene deletions Incidence M/c Less common Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 4 04 31 Beta thalassemia : ----- Active space ----- Types of beta thalassemia : β thalassemia β thalassemia Feature β thalassemia major intermedia minor Synthesis of Markedly reduced Moderately reduced Mildly reduced beta chain Severe pallor Jaundice Mild pallor Pallor Hepatosplenomegaly Asymptomatic C/F Jaundice H/o repeated blood No response to Hepatosplenomegaly transfusion iron therapy Chipmunk facies Hb 3 - 5 gm% 5 - 8 gm% 8 - 10 gm% Microcytic hypochromic RBC’s Many target cells P/S Few target cells No target cells Basophilic stippling Cabot ring MCV, MCH, MCV, MCH, All most Normal/ RBC indices MCHC :↓ MCHC : ↓ slightly ↓sed RDW : Normal RDW : Normal Iron profile Iron ↑sed (D/t to transfusion) Normal Normal Hb ↑sed HbF Both ↑sed HbA2 3.5 – 9% electrophoresis HPLC ↑sed HbF Both ↑sed ↑sed HbA2 Thalassemic/Chipmunk facies : Frontal bossing D/t extramedullary hematopoiesis Flat nasal bridge in skull & facial bones. Patterns of hemoglobin electrophoresis Origin HbA2 HbF HbA Chipmunk facies Normal Beta thalassemia trait Beta thalassemia major HbS Sickle cell trait Sickle cell anemia Pathology Revision v1.0 Marrow 6.5 2023  32 04 Pathology ----- Active space ----- Alpha thalassemia : Types of alpha thalassemia : Major Disorder Silent carrier Minor Hb H disease (Fetal hydrops ) α α/-- Genotype α α/ α - α -/- - - -/- - OR α -/ α - MCV Normal Low Low Low Anemia None Mild Moderate Fatal 5% - 30% HbH Hb Barts & HbH Hb < 3% Hb Barts 3% - 8% Hb in adults. present. electrophoresis at birth Barts at birth 20% - 40% Hb HbA, HbF & HbA2 Barts at birth are absent. Golf ball inclusions : Seen in Hb H disease. Note : Structures seen on supra vital staining : Reticulocyte. Heinz bodies. Golf ball inclusions Golf ball inclusions. Investigations in Hb disorders : Screening : Hb electrophorosis. IOC : HPLC. Definitive Dx : Globin gene sequencing. Intravascular hemolysis : Paroxysmal nocturnal hemoglobinuria (PNH) : Only acquired intra corpuscular defect. Pathogenesis : Mutation in PIGA gene (Phosphatidyl inositol glycan A) Reduced synthesis of complement regulatory proteins CD 55 : Decay accelerating factor (DAF) CD 59 : Membrane inhibitor of reactive lysis (MIRL) ↑sed complement activation → Intravascular hemolysis Features : Pancytopenia with hypercellular bone marrow. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 4 04 33 Intravascular hemolysis (Nocturnal hemoglobinuria in 30% cases). ----- Active space ----- Thrombosis (i.e hepatic vein thrombosis). M/c cause of death : Thrombosis. Screening test : HAM’s test (Acidified serum lysis test). Best test : Flow cytometry. Rx : Eculizumab. Microangiopathic hemolytic anemia (MAHA) : Includes : Hemolytic uremic syndrome (HUS) : H/o of E.coli O 157 : H7 infection. Thrombotic thrombocytopenic purpura (TTP) : Mutation of ADAMTS 13. Disseminated intravascular coagulopathy (DIC). C/f : Fever. MAHA. Thrombocytopenia. Renal abnormality (M/c in HUS). Neurological abnormality (M/c in TTP). Peripheral smear shows schistocytes/helmet cells (Fragmented RBCs). Deficiency anemia 00:58:08 Iron deficiency anemia (IDA) : M/c worm causing IDA : Hookworm/Ancylostoma duodenale. Maximum iron absorption : Duodenum. Factors influencing absorprtion : Increased by : Ascorbic acid, citric acid. Decreased by : Calcium, milk, phytates, oxalates, tannates. Storage form of iron : Hemosiderin. Transport form of iron : Transferrin. Master regulator of iron metabolism : Hepcidin (Negative regulator). H/o GI malignancy in elderly, H/o pica in child. Plummer Vinson syndrome : 1. Atrophic glossitis. 2. Esophageal webs. Koilonychia : Spoon 3. IDA. shaped nails in IDA Pathology Revision v1.0 Marrow 6.5 2023  34 04 Pathology ----- Active space ----- Iron metabolism : Investigations in IDA : P/S : Microcytic hypochromic RBC’s, Pencil cells. Iron profile : S.iron ↓sed. S.ferritin ↓sed. TIBC ↑sed. Stains for Iron/hemosiderin : Perl’s stain/Persian blue. Sideroblastic anemia : D/t to ↑sed iron overload. Causes : Genetic. Anti tubercular drugs like isoniazid. Lead poisoning. On P/S : Ringed sideroblasts Microcytic hypochromic RBC’s. (Blue colour) Basophilic stippling (In lead poisoning). On bone marrow Bx : Ringed sideroblast (Iron granules arranges in ring like manner around erythroid precursor) Anemia of chronic disease : Causes : Chronic infections : TB. Neoplasms : Multiple myeloma. Autoimmune disorders. Idiopathic. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 4 04 35 Pathogenesis : In chronic infection/neoplasm → ↑sed IL-1, ↑sed IL-6 → ----- Active space ----- ↑sed hepcidin → ↓sed iron → Anemia. On P/S : Normocytic normochromic RBCs > Microcytic hypochromic RBCs. Differential diagnosis of microcytic hypochromic anemia : S. Iron S. Ferritin S. TIBC P/S Extra points RDW ↑ IDA ↓ ↓ ↑ Pencil cells Mentzer index > 13 Sideroblastic Coarse basophilic Ringed sideroblasts ↑ ↑ ↓ anemia stippling (Bone marrow) Anemia of ↓ ↑/Normal ↓ - ESR ↑ chronic disease HbA2 ↑ : 4% - 9% Thalassemia Normal Target cells Mentzer index < 13 trait RDW : Normal Megaloblastic anemia : D/t to B12 deficiency. Site of maximum absorption of B12 : Ileum. M/c worm causing B12 deficiency anemia : Fish tapeworm/Diphyllobothrium latum. Causes : Veg diet. Gastrectomized patients. Ileal resection. C/f : Anemia. Knuckle pigmentation Beefy tongue. Pigmentation of knuckles. Neurological complications. Pancytopenia with hypercellular marrow. ↑sed risk of thrombosis. Biochemical reactions involving vit B12 : Reaction involving B12 In B12 deficiency Pathology ↓sed dTMP : Pancytopenia d/t nuclear 1. d UMP d TMP Thymidine cytoplasm asynchrony. 2. Homocystine Methionine ↑sed Homocystine ↑sed risk of thrombosis. 3. Methyl malonyl coA Succinyl coA Subacute combined ↓sed Succinyl coA (Used in myelination) degeneration of spinal cord Pathology Revision v1.0 Marrow 6.5 2023  36 04 Pathology ----- Active space ----- P/S : Macro ovalocytes. Hypersegmented neutrophil (>5 lobes). Howell Jolly bodies. Cabot rings. On bone marrow aspiration : Megaloblast (Erythroid precursors with sieve like chromatin). Bone marrow aspirate : Megaloblasts Note : Folic acid deficiency anemia : Same as B12 deficiency anemia with no neurological complication. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 5 05 37 PATHOLOGY REVISION 5 ----- Active space ----- Haemostasis 00:00:38 It is interplay of 3 components : 1. Platelets : 1.5-4 lakhs/mL (Normal count). 2. Vascular endothelium. 3. Coagulation cascade. Primary hemostasis Step 1 : Platelet adhesion to endothelium. vWF (Present on endothelium) + GpIb-IX (On platelet). vwf (On endothelium) Gp1b-IX (On platelet) Platelet adhesion Gpllb-IIIa (On platelet) Step 2 : Platelets aggregate to each other by factor GpIIb-IIIa present on their surface & form unstable clot. Blood clot : Aggregation of platelets. Fibrin + Unstable clot/thrombus : Stable clot/Thrombus. Platelet aggregation disorders : Deficiency of factor Disease GpIb-IX Bernard Soulier syndrome GpIIb-IIIa Glanzmann thrombasthenia von Willebrand factor Von Willebrand disease Pathology Revision v1.0 Marrow 6.5 2023  38 05 Pathology ----- Active space ----- Secondary hemostasis The coagulation pathway : XII : Hageman factor, a serine protease. Intrinsic pathway XI : Plasma thromboplastin, antecedent serine protease. Surface factor IX : Christmas factor, serine protease. VII : Stable factor, serine protease. XIII : Fibrin stabilizing factor, a transglutaminase. PL : Platelet membrane phospholipid. XII XIIa XI XIa Extrinsic pathway IX IXa VIIa Tissue damage (VIII, PL, Ca ) 2+ X Xa X XIII Common (V, PL, Ca2+) pathway Prothrombin Thrombin (Serine protease) XIII a Fibrinogen Fibrin Stable fibrin clot Note : vWF also stabilises factor VIII ( T1/2). Tests : a. Extrinsic pathway : Prothrombin time ( in factor VII deficiency). b. Intrinsic pathway : aPTT/Activated partial prothrombin time ( in intrinsic factor deficiency). c. Common pathway factors deficiency : Both PT & aPTT. Disorders of haemostasis Bleeding disorder Coagulation disorder Autosomal mostly. X linked. Inheritance Males = Females. M >> F. Petechiae. Purpura. Mucosal bleeds. Clinically Mucosal bleeds. Ecchymoses. Prolonged bleeding after injury. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 5 05 39 Lab tests Bleeding disorder Coagulation disorder ----- Active space ----- Platelet count Can be affected. Normal. Bleeding time PT Normal. Can be affected. aPTT Immune thrombocytopenic Example Hemophilia. purpura (ITP). Pro- Plate- Bleed- Disorder Pathogenesis throm- aPTT Extra points lets ing time bin time Defect of Platelet Gp1b-IX aggregation (Platelet with ristocetin Bernard Soulier Normal Normal Normal adhesion is abnormal. disorder) Giant platelets. Platelet Defect of aggregation GpIIb-IIIA with ADP is Glanzmann’s (Platelet Normal Normal Normal abnormal. Thrombasthenia aggregation) Bleeding from umbilical stump. Type 2 hy- Bone marrow persenstivity. aspirate : Antiplatelet ITP Normal Normal Megakaryo- antibodies cytes. against GpIb- IX/GpIIb-IIIa. Schistocytes HUS E. Coli O157:H7, Normal Normal reticulocyte (Type of MAHA) Shigella count. Schistocytes TTP Mutation of Normal Normal reticulocyte (Type of MAHA) ADAMTS13 count. Hemophilia A Deficiency of (X-linked factor VIII Normal Normal Normal Factor VIII recessive) M>F Pathology Revision v1.0 Marrow 6.5 2023  40 05 Pathology ----- Active space ----- Pro- Bleeding Disorder Pathogenesis Platelets thrombin aPTT Extra points time time Hemophilia B Factor IX Factor IX (Christmas Normal Normal Normal deficiency disease) Factor VIII. RIPA abnormality. von Willebrand VwF deficiency Normal Normal RiCof assay Disease (Ristocetin cofactor) : Abnormal. Endothelial DIC injury → (Disseminated FDP Activation of intravascular D-dimers coagulation coagulopathy) : & fibrinolytic Type of MAHA. pathways. Vitamin K Deficiency of deficiency factor factor Normal Normal 2, 7, 9, 10. Vascular Normal Normal Normal Normal disorders RIPA : Ristocetin induced platelet aggregation. MAHA : Microangiopathic hemolytic anemia. FDP : Fibrin Degradation Products. Note : M/C cause for Umbilical stump bleeding : Factor x111 deficiency. M/C cause of DIC : Obstetric complications like abruptio placenta/septic abortions. Types of ITP : Acute ITP Chronic ITP Duration 6 months. Common in Children. Adults. Preceding h/o Viral infection. No such history. Steroids & Treatment Self limiting. immunosuppressive drugs. Pathology Revision v1.0 Marrow 6.5 2023  Pathology Revision 5 05 41 Blood banking 00:16:55 ----- Active space ----- Anticoagulants used : Anticoagulant Shelf life CPD (Citrate PO43- dextrose) 21 days CPD-A (Citrate PO43 dextrose adenine) 35 days SAG-M (Sodium adenine glucose mannitol) 42 days Blood components & their storage : Storage Blood product Volume Shelf life Use temp. Based on Whole blood 350 mL 2-6 C o anticoagulant Acute blood loss. used. Fresh frozen Multiple coagulation 200 mL plasma (FFP) factor deficiency. Cryoprecipitate ≤ -18o C 1 year Hemophilia A. (Rich in factor 10-20 von Willibrand d/s. VIII, fibrinogen, mL Factor XIII deficiency. vWf) Hypofibrinogenemia. Random donor 50-70 20-24oC platelets mL with 5 days Thrombocytopenia. Single donor 200-300 agitator platelets mL Note : I unit of blood : Hb by 1 g%. 1 unit of random donor platelets : platelets by 10,00o/MM3. 1 unit of single donor platelets : platelets by 30,00o/MM3. Blood is screened for : HIV/Hepatitis B/Hepatitis C/malaria/syphilis. Infection transmitted by all blood products : Malaria. Component most prone to bacterial contamination : Platelets. Life span of transfused RBCs : 50–60 days. Pathology Revision v1.0 Marrow 6.5 2023  42 05 Pathology ----- Active space ----- Transfusion Transfu