rodak-s-hematology-5th-edition.pdf

i. r ss a n is er.p iv p Hematology/Hemostasis Reference Intervals Unless otherwise noted, data for reference interval tables were compiled from multiple sources and may vary slightly from intervals listed withi...

i. r ss a n is er.p iv p Hematology/Hemostasis Reference Intervals Unless otherwise noted, data for reference interval tables were compiled from multiple sources and may vary slightly from intervals listed within chapters. Each laboratory must establish its particular intervals based on its instrumentation, meth- odology and demographics of the population it serves. COMPLETE BLOOD COUNT REFERENCE INTERVALS (ADULT) Assay Units Reference Intervals Assay Units Reference Intervals RBC, male 3 106/µL (3 1012/L) 4.20–6.00 RETIC % 0.5–2.5 RBC, female 3 106/µL (3 1012/L) 3.80–5.20 NRBC /100 WBC 0 HGB, male g/dL (g/L) 13.5–18.0 WBC 3 103/µL (3 109/L) 3.6–10.6 (135–180) NEUT % 50–70 HGB, female g/dL (g/L) 12.0–15.0 NEUT (ANC) 3 103/µL (3 109/L) 1.7–7.5 (120–150) LYMPH % 18–42 i. r HCT, male % (L/L) 40–54 LYMPH 3 103/µL (3 109/L) 1.0–3.2 (0.40–0.54) MONO % 2–11 HCT, female % (L/L) 35–49 MONO 3 103/µL (3 109/L) 0.1–1.3 s (0.35–0.49) EO % 1–3 MCV fL 80–100 EO 3 103/µL (3 109/L) 0–0.3 s MCH pg 26–34 BASO % 0–2 BASO 3 103/µL (3 109/L) 0–0.2 n MCHC g/dL 32–36 RDW % 11.5–14.5 PLT 3 103/µL (3 109/L) 150–450 is a RETIC 3 103/µL (3 109/L) 20–115 MPV fL 7.0–12.0 r REFERENCE INTERVALS FOR OTHER COMMONLY ORDERED TESTS (ADULTS) e Assay Units Reference Intervals Assay Units Reference Intervals ESR, male (Westergren) mm 1 hour 0–15 (0250 y) ESR, female mm 1 hour 0–20 (0250 y) p 0–20 (.50 y) (Westergren) 0–30 (.50 y). Serum iron µg/dL 50–160 Serum vitamin B12 pg/mL 200–900 iv p Total iron-binding µg/dL 250–400 Serum folate ng/mL. 4.0 capacity RBC folate ng/mL. 120 Transferrin saturation % 20–55 Haptoglobin mg/dL 30–200 Serum ferritin, male ng/mL 40–400 Free serum hemoglobin mg/dL 0–10 Serum ferritin, female ng/mL 12–160 HEMOGLOBIN FRACTION REFERENCE INTERVALS Fraction Adult Reference Intervals (%) Newborn Reference Intervals (%) Hb A. 95 10–40 Hb F 0–2.0 60–90 Hb A2 0–3.5  BONE MARROW ASPIRATE REFERENCE INTERVALS (ADULT) WBC Differential Reference Intervals (%) Erythrocyte Series Reference Intervals (%) Blasts 0–3 Promyelocytes 1–5 Pronormoblasts 0–1 N. myelocytes 6–17 Basophilic NB 1–4 N. metamyelocytes 3–20 Polychromatophilic NB 10–20 N. bands 9–32 Orthochromic NB 6–10 N. segmented (polymorphonuclear) 7–30 Eosinophils 0–3 Other Basophils 0–1 M:E ratio 1.5–3.3:1 Lymphocytes 5–18 Megakaryocytes 2–10/lpf Plasma cells 0–1 Monocytes 0–1 Histiocytes (macrophages) 0–1 COMPLETE BLOOD COUNT REFERENCE INTERVALS (PEDIATRIC) i. r s Assay Units 0–1 d 2–4 d 5–7 d 8–14 d 15–30 d 1–2 mo 3–5 mo 6–11 mo 1–3 y 4–7 y 8–13 y s RBC 3 106/µL 4.10–6.10 4.36–5.96 4.20–5.80 4.00–5.60 3.20–5.00 3.40–5.00 3.65–5.05 3.60–5.20 3.40–5.20 4.00–5.20 4.00–5.40 (3 1012/L) n HGB g/dL (g/L) 16.5–21.5 16.4–20.8 15.2–20.4 15.0–19.6 12.2–18.0 10.6–16.4 10.4–16.0 10.4–15.6 9.6–15.6 10.2–15.2 12.0–15.0 is a (165–215) (164–208) (152–204) (150–196) (122–180) (106–164) (104–160) (104–156) (96–156) (102–152) (120–150) HCT % 48–68 48–68 50–64 46–62 38–53 32–50 35–51 35–51 34–48 36–46 35–49 MCV fL 95–125 98–118 100–120 95–115 93–113 83–107 83–107 78–102 76–92 78–94 80–94 MCH pg 30–42 30–42 30–42 30–42 28–40 27–37 25–35 23–31 23–31 23–31 26–32 r MCHC g/dL 30–34 30–34 30–34 30–34 30–34 31–37 32–36 32–36 32–36 32–36 32–36 RDW % * * * * * * * 11.5–14.5 11.5–14.5 11.5–14.5 11.5–14.5 e RETIC % 1.8–5.8 1.3–4.7 0.2–1.4 0–1.0 0.2–1.0 0.8–2.8 0.5–1.5 0.5–1.5 0.5–1.5 0.5–1.5 0.5–1.5 p RETIC 3 103/µL 73.8–353.8 56.7–280.1 8.4–81.2 0.0–56.0 6.4–50.0 27.2–140.0 18.3–75.8 18.0–78.0 17.0–78.8 20–78.0 20–124.2. (3 109/L) NRBC /100 WBC 2–24 5–9 0–1 0 0 0 0 0 0 0 0 iv p WBC 3 103/µL 9.0–37.0 8.0–24.0 5.0–21.0 5.0–21.0 5.0–21.0 6.0–18.0 6.0–18.0 6.0–18.0 5.5–17.5 5.0–17.0 4.5–13.5 (3 109/ L) NEUT 3 103/µL 3.7–30.0 2.6–17.0 1.5–12.6 1.2–11.6 1.0–9.5 1.2–8.1 1.1–7.7 1.2–8.1 1.2–8.9 1.5–11.0 1.6–9.5 (ANC) (3 109/L) LYMPH 3 103/µL 1.6–14.1 1.3–11.0 1.2–11.3 1.5–13.0 2.1–12.8 2.5–13.0 2.7–13.5 2.9–14.0 2.0–12.8 1.5–11.1 1.0–7.2 (3 109/L) MONO 3 103/µL 0.1–4.4 0.2–3.4 0.2–3.6 0.2–3.6 0.1–3.2 0.2–2.5 0.1–2.0 0.1–2.0 0.1–1.9 0.1–1.9 0.1–1.5 (3 109/L) EO 3 103/µL 0.0–1.5 0.0–1.2 0.0–1.3 0.0–1.1 0.0–1.1 0.0–0.7 0.0–0.7 0.0–0.7 0.0–0.7 0.0–0.7 0.0–0.5 (3 109/L) BASO 3 103/µL 0.0–0.7 0.0–0.5 0.0–0.4 0.0–0.4 0.0–0.4 0.0–0.4 0.0–0.4 0.0–0.4 0.0–0.4 0.0–0.3 0.0–0.3 (3 109/L) PLT 3 103/µL 150–450 150–450 150–450 150–450 150–450 150–450 150–450 150–450 150–450 150–450 150–450 (3 109/L) *The RDW is markedly elevated in newborns, with a range of 14.2% to 19.9% in the first few days of life, gradually decreasing until it reaches adult levels by 6 months of age. Pediatric reference intervals are from Riley Hospital for Children, Indiana University Health, Indianapolis, IN. Some reference intervals are listed in common units and in international system of units (SI units) in parenthesis. ANC, absolute neutrophil count (includes segmented neutrophils and bands); BAND, neutrophil bands; BASO, basophils; d, days; EO, eosinophils; ESR, erythrocyte sedimentation rate; Hb, hemoglobin fraction; HCT, hematocrit; HGB, hemoglobin; lpf, low power field; LYMPH, lymphocytes; MCH, mean cell hemoglobin; MCHC, mean cell hemoglobin concentration; MCV, mean cell volume; M:E, myeloid:erythroid; mo, month; MONO, monocytes; MPV, mean platelet volume; N, neutrophilic; NB, normoblast; NEUT, neutrophils; NRBC, nucleated red blood cells; PLT, platelets; RBC, red blood cells; RDW, red blood cell distribution width; RETIC, reticulocytes; WBC, white blood cells; y, year. Please see inside back cover for additional reference interval tables. Hematology RODAK’S CLINICAL PRINCIPLES AND APPLICATIONS i. r ss n is a e r. p iv p YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Evolve Student Resources for Keohane: Rodak’s Hematology: i. r s Clinical Principles and Practice, 5th Edition, include the s following: n Glossary  is a e r. p iv p Activate the complete learning experience that comes with each textbook purchase by registering at http://evolve.elsevier.com/Keohane/ REGISTER TODAY! You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products.  Fifth Edition Hematology RODAK’S CLINICAL PRINCIPLES AND APPLICATIONS i. r ss n is a e r p Jeanine M. Walenga, PhD,. Elaine M. Keohane, PhD, MLS iv p Chair and Professor, Department of Clinical Laboratory Sciences MT(ASCP) School of Health Related Professions Professor, Thoracic-Cardiovascular Surgery, Pathology, Rutgers, The State University of New Jersey and Physiology Newark, New Jersey Co-Director, Hemostasis and Thrombosis Research Unit Stritch School of Medicine Larry J. Smith, PhD, SH(ASCP), Loyola University Chicago Maywood, Illinois HCLD/CC(ABB) Director, Clinical Coagulation Core Laboratory and Special Coagulation Laboratory Assistant Attending Scientist and Director, Coagulation Laboratory Director, Urinalysis and Medical Microscopy Department of Laboratory Medicine Associate Director, Point of Care Testing Memorial Sloan-Kettering Cancer Center Loyola University Hospital New York, New York Maywood, Illinois Adjunct Professor, Department of Health Professions York College, The City University of New York Jamaica, New York Adjunct Associate Professor, Department of Clinical Laboratory Sciences School of Health Related Professions Rutgers, The State University of New Jersey Newark, New Jersey 3251 Riverport Lane St. Louis, Missouri 63043 RODAK’S HEMATOLOGY: CLINICAL PRINCIPLES AND APPLICATIONS, FIFTH EDITION ISBN: 978-0-323-23906-6  Copyright © 2016, 2012, 2007, 2002, 1995 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. i. r This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices ss n Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical is a treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety r of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the e most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration p of administration, and contraindications. It is the responsibility of practitioners, relying on their. own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, iv p assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The Publisher ISBN: 978-0-323-23906-6 Executive Content Strategist: Kellie White Content Development Manager: Laurie Gower Content Development Specialist: Rebecca Corradetti Publishing Services Manager: Julie Eddy Project Manager: Sara Alsup Design Direction: Teresa McBryan Text Designer: Ashley Miner Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1  To my students for being great teachers, and to Camryn, Riley, Harper, Stella, Jackie, Alana, Ken, and Jake for reminding me about the important things in life. EMK To my wonderful mentors and students who have taught me so much about laboratory medicine. i. r LJS ss To my teachers, both formal and informal, for all this n fascinating knowledge in clinical laboratory sciences which made possible my interesting career. is a JMW e r. p iv p  Special Dedication To Bernadette “Bunny” F. Rodak, with great admiration and gratitude for your vision, perseverance, and courage to first publish Hematology: Clinical Principles and Applications in 1995; for your over 20-year commitment to publish the highest quality text through five editions; for your mentorship and guidance of five co-editors and over 50 authors; and for sharing your great enthusiasm for hematology and hemostasis i. r and lifelong learning that has inspired a generation of students and faculty in this country and around the world. Special Acknowledgment ss n is a To George A. Fritsma, with our sincere gratitude for your dedication and reasoned approach that has kept Hematology: Clinical Principles and Applications at the leading edge as r a comprehensive, state-of-the-art, yet practical textbook, guided e by you as co-editor for two editions and through the multiple number of chapters that you have authored. We are indebted p to you for sharing your vast knowledge in hematology. and hemostasis and for your unwavering commitment to iv p the profession of clinical laboratory science. Reviewers Keith Bellinger, PBT(ASCP) Steve Johnson, MS, MT(ASCP) Medical Technologist Program Director, School of Medical Technology The United States Department of Veterans Affairs New Jersey Saint Vincent Health Center Health Care System Erie, Pennsylvania East Orange, New Jersey; Adjunct Assistant Professor, Clinical Laboratory Sciences Haywood B. Joiner, Jr., EdD, MT(ASCP) Rutgers, The State University of New Jersey Chair, Department of Allied Health Newark, New Jersey Louisiana State University at Alexandria Alexandria, Louisiana Susan Conforti, EdD, MLS(ASCP)SBB i. r Associate Professor, Medical Laboratory Technology Amy R. Kapanka, MS, MT(ASCP)SC Farmingdale State College MLT Program Director Farmingdale, New York Hawkeye Community College s Waterloo, Iowa s Shamina Davis, MS, MT(ASCP) Faculty, College of Biomedical Sciences and Health Linda Kappel, MLT(FCP, CAET) n Professions Instructor, Medical Diagnostics University of Texas at Brownsville Saskatchewan Polytechnic, Saskatoon Campus is a Brownsville, Texas Saskatoon, Saskatchewan, Canada Kathleen Doyle, PhD, M(ASCP), MLS(ASCP)CM Linda J. McCown, PhD, MLS(ASCP)CM r Medical Laboratory Scientist, Consultant Chair and Program Director, Clinical Laboratory Science e Professor Emeritus, Clinical Laboratory and Nutritional University of Illinois Springfield Sciences Springfield, Illinois p University of Massachusetts Lowell. Lowell, Massachusetts Christine Nebocat, MS, MT(ASCP)CM iv p Assistant Professor Michele Harms, MS, MLS(ASCP) Farmingdale State College Program Director, School of Medical Technology Farmingdale, New York WCA Hospital Jamestown, New York Tania Puro, CLS, MS, MT(ASCP) Instructor, Clinical Lab Science Program Jeanne Isabel, MS, MT(ASCP), CLSpH(NCA) San Francisco State University Associate Professor and Program Director, San Francisco, California Allied Health and Communicative Disorders Northern Illinois University DeKalb, Illinois vii Contributors Sameer Al Diffalha, MD Pranav Gandhi, MD, MS Pathology Resident PGY3 Hematopathology Fellow Loyola University Medical Center Scripps Clinic Maywood, Illinois La Jolla, California Larry D. Brace, PhD, MT(ASCP)SH Bertil Glader, MD, PhD Clinical Pathology/Laboratory Consultant Professor, Pediatric Hematology/Oncology Emeritus Professor of Pathology Stanford University University of Illinois at Chicago Palo Alto, California Chicago, Illinois; i. r Scientific Director of Laboratories Linda H. Goossen, PhD, MT(ASCP) Laboratory and Pathology Diagnostics at Edward Hospital Professor, Medical Laboratory Science Naperville, Illinois Associate Dean, College of Health Professions s Grand Valley State University s Karen S. Clark, BS, MT(ASCP)SH Grand Valley, Michigan Point of Care Manager n Baptist Memorial Hospital Teresa G. Hippel, BS, MT(ASCP)SH Laboratory Manager is a Memphis, Tennessee Baptist Memorial Hospital Magdalena Czader, MD, PhD Memphis, Tennessee Director, Division of Hematopathology r Director, Clinical Flow Cytometry Laboratory Debra A. Hoppensteadt, BS, MT(ASCP), MS, PhD, DIC e Department of Pathology and Laboratory Medicine Indiana University School of Medicine Professor of Pathology and Pharmacology p Indianapolis, Indiana Loyola University Chicago. Maywood, Illinois iv p Kathryn Doig, PhD, MLS(ASCP)CMSH(ASCP)CM Professor, Biomedical Laboratory Diagnostics Cynthia L. Jackson, PhD College of Natural Science Director of Clinical Molecular Biology Michigan State University Lifespan Academic Medical Center East Lansing, Michigan Associate Professor of Pathology Warren Alpert Medical School at Brown University Sheila A. Finch, CHSP, CHMM, MS, BS, MT(ASCP) Providence, Rhode Island Executive Director, Environment of Care/Emergency Management Ameet R. Kini, MD, PhD Detroit Medical Center Director, Division of Hematopathology Detroit, Michigan Medical Director, Hematology & Flow Cytometry Associate Director, Molecular Diagnostics George A. Fritsma, MS, MLS Associate Professor of Pathology, Manager Stritch School of Medicine The Fritsma Factor, Your Interactive Hemostasis Resource Loyola University Medical Center Birmingham, Alabama Maywood, Illinois Margaret G. Fritsma, MA, MT(ASCP)SBB Clara Lo, MD Associate Professor, Retired Instructor, Pediatric Hematology/Oncology School of Health Professions Stanford University Division of Laboratory Medicine, Palo Alto, California Department of Pathology University of Alabama at Birmingham Birmingham, Alabama viii  Contributors ix Sharral Longanbach, MT, SH(ASCP) Tim R. Randolph, PhD, MT(ASCP) Senior Technical Application Specialist Chair and Associate Professor, Department of Biomedical Siemens Healthcare Diagnostics Laboratory Science Deerfield, Illinois Doisy College of Health Sciences Saint Louis University Lynn B. Maedel, MS, MLS(ASCP)CMSHCM St. Louis, Missouri Executive Director Colorado Association for Continuing Medical Bernadette F. Rodak, MS, CLSpH(NCA), Laboratory Education, Inc. (CACMLE) MT(ASCP)SH Denver, Colorado Professor, Clinical Laboratory Science Program Department of Pathology and Laboratory Medicine Naveen Manchanda, MBBS Indiana University School of Medicine Associate Professor of Clinical Medicine, Division of Indianapolis, Indiana Hematology-Oncology Indiana University School of Medicine Woodlyne Roquiz, DO Indianapolis, Indiana Hematopathology Fellow i. r Loyola University Medical Center Steven Marionneaux, MS, MT(ASCP) Maywood, Illinois Manager, Clinical Hematology Laboratories s Memorial Sloan Kettering Cancer Center Kathleen M. Sakamoto, MD, PhD New York, New York Professor and Chief, Division of Hematology/Oncology s Adjunct Assistant Professor, Clinical Laboratory Sciences Department of Pediatrics n Rutgers, The State University of New Jersey Stanford University School of Medicine Newark, New Jersey Lucile Packard Children’s Hospital at Stanford is a Stanford, California Richard C. Meagher, PhD Section Chief, Cell Therapy Laboratory Gail H. Vance, MD r Department of Laboratory Medicine Sutphin Professor of Cancer Genetics Memorial Sloan Kettering Cancer Center Department of Medical and Molecular Genetics e New York, New York Indiana University School of Medicine p Indianapolis, Indiana. Shashi Mehta, PhD Staff Physician Associate Professor, Clinical Laboratory Sciences Indiana University Health Hospitals iv p School of Health Related Professions Carmel, Indiana Rutgers University, The State University of New Jersey Instructor and Student Ancillaries Newark, New Jersey Case Studies, Instructor’s Guide, Test Bank Martha K. Miers, MS, MBA Susan Conforti, EdD, MLS(ASCP)SBB Assistant Professor, Division of Medical Education Associate Professor, Medical Laboratory Technology and Administration Farmingdale State College Vice Chair, Finance and Administration Farmingdale, New York Department of Pathology, Microbiology, and Immunology PowerPoint Slides Vanderbilt University School of Medicine Kathleen Doyle, PhD, M(ASCP), MLS(ASCP)CM Nashville, Tennessee Medical Laboratory Scientist, Consultant Professor Emeritus, Clinical Laboratory and JoAnn Molnar, MT(ASCP) Nutritional Sciences Core Laboratory Technical Specialist University of Massachusetts Lowell Loyola University Medical Center Lowell, Massachusetts Maywood, Illinois PowerPoint Slides Kim A. Przekop, MBA, MLS(ASCP)CM Carolina Vilchez, MS, MLS(ASCP)H Assistant Professor, Clinical Laboratory Sciences Assistant Professor, Clinical Laboratory Sciences School of Health Related Professions School of Health Related Professions Rutgers, The State University of New Jersey Rutgers, The State University of New Jersey Newark, New Jersey Newark, New Jersey PrefacePreface x The science of clinical laboratory hematology provides for the analy- Part I: Introduction to Hematology sis of normal and pathologic peripheral blood cells, hematopoi- Chapters 1 to 5 preview the science of clinical laboratory hema- etic (blood-producing) tissue, and the cells in non-vascular body tology and include laboratory safety, blood specimen collection, cavities such as cerebrospinal and serous fluids. Laboratory he- microscopy, and quality assurance. The quality assurance chap- matology also includes the analysis of the cells and coagulation ter was significantly updated to include enhanced sections on proteins essential to clinical hemostasis. Hematology laboratory statistical significance; assay validation with applications of the assay results are critical for the diagnosis, prognosis, and moni- Student’s t test, ANOVA, linear regression, and Bland-Altman toring treatment for primary and secondary hematologic disor- difference plots; and assessment of diagnostic efficacy. ders. Similarly, hematology results are used to establish safety in the perioperative period, monitor treatments during surgical Part II: Blood Cell Production, Structure, i. r procedures, and monitor transfusion needs in trauma patients. and Function Clinical laboratory hematology has been enhanced by pro- Chapters 6 and 7 use photomicrographs and figures to describe found changes as reflected in the numerous updates in the fifth general cellular structure and function and the morphologic and s edition of Rodak’s Hematology: Clinical Principles and Applications. molecular details of hematopoiesis. Chapters 8, 12, and 13 dis- Automation and digital data management have revolutionized the cuss erythropoiesis, leukopoiesis, and megakaryopoiesis using s way blood specimens are transported and stored, how assays are numerous photomicrographs demonstrating ultrastructure and n ordered, and how results are validated, reported, and interpreted. microscopic morphology. Chapters 9 and 10 examine mature red Molecular diagnosis has augmented and in many instances blood cell metabolism, hemoglobin structure and function, and is a replaced long-indispensable laboratory assays. Hematologic red blood cell senescence and destruction. Iron kinetics and labo- disorders have been reclassified on the basis of phenotypic, ratory assessment in Chapter 11 was substantially updated with cytogenetic, and molecular genetic analyses. Diagnoses that new figures and updated coverage of systemic and cellular regula- r once depended on the analysis of cell morphology and cyto- tion of iron. Chapter 13 includes detailed descriptions of platelet chemical stains now rely on flow cytometry, cytogenetic test- adhesion, aggregation, and activation with updated figures. e ing, fluorescence in situ hybridization (FISH), end-point and Part III: Laboratory Evaluation of Blood Cells p real-time polymerase chain reaction assays, gene sequencing,. and microarrays. Traditional chemotherapeutic monitoring of Chapter 14 describes manual procedures such as microscopy- leukemias and lymphomas at the cellular level has shifted to based cell counts, hemoglobin and hematocrit determinations, iv p the management of biologic response modifiers and detection and point-of-care technology. Chapter 15 has been substan- of minimal residual disease at the molecular level. Hemostasis tially updated to include descriptions and figures of the latest has grown to encompass expanded thrombophilia testing, automated hematology analyzers. Chapter 16 describes pe- methods that more reliably monitor newly available antiplate- ripheral blood film examination and the differential count let and anticoagulant drugs, molecular analysis, and a shift correlation to the complete blood count. New figures correlate from clot-based to functional and chromogenic assays. red blood cell and platelet histograms to their morphology. Rodak’s Hematology: Clinical Principles and Applications sys- Chapter 17 follows up with bone marrow aspirate and biopsy tematically presents basic to advanced concepts to provide a collection, preparation, examination, and reporting. Chapter solid foundation of normal and pathologic states upon which 18 describes methods for analyzing normal and pathologic readers can build their skills in interpreting and correlating cells of cerebrospinal fluid, joint fluid, transudates, and exu- laboratory findings in anemias, leukocyte disorders, and hem- dates, illustrated with many excellent photomicrographs. orrhagic and thrombotic conditions. It provides key features for accurate identification of normal and pathologic cells in Part IV: Erythrocyte Disorders blood, bone marrow, and body fluids. The focus, level, and Chapter 19 provides an overview of anemia and describes cost- detail of hematology and hemostasis testing, along with the effective approaches that integrate patient history, physical ex- related clinical applications, interpretation, and testing algo- amination, and symptoms with the hemoglobin, red blood cell rithms, make this text a valuable resource for all healthcare indices, reticulocyte count, and abnormal red blood cell mor- professionals managing these disorders. phology. Chapters 20 to 22 describe disorders of iron and DNA metabolism and bone marrow failure. New algorithms help the reader to distinguish types of microcytic and macrocytic ane- ORGANIZATION mias. Chapters 23 to 26 discuss hemolytic anemias due to in- Rodak’s Hematology: Clinical Principles and Applications fifth edition trinsic or extrinsic defects. Chapter 23 is fully updated with new is reorganized into 7 parts and 45 chapters for enhanced pedagogy. figures that detail extravascular and intravascular hemolysis and Chapter highlights and new content are described as follows: hemoglobin catabolism. Chapters 27 and 28 provide updates in x  Preface xi pathophysiology, diagnosis, and treatment of hemoglobinopa- technicians, and the faculty of undergraduate and graduate edu- thies (such as sickle cell disease) and the thalassemias. cational programs in the clinical laboratory sciences. This text is also a helpful study guide for pathology and hematology- Part V: Leukocyte Disorders oncology residents and fellows and a valuable shelf reference Chapter 29 is significantly updated with many excellent photo- for hematologists, pathologists, and hematology and hemosta- micrographs and summary boxes of nonmalignant systemic sis laboratory managers. disorders manifested by the abnormal distribution or morphol- ogy of leukocytes. These include bacterial and viral infections, TEXTBOOK FEATURES various systemic disorders, and benign lymphoproliferative dis- orders. Chapter 30 provides details on traditional cytogenetic Elaine M. Keohane, PhD, MLS, Professor, Rutgers University, procedures for detection of quantitative and qualitative chromo- School of Health Related Professions, Department of Clinical some abnormalities and more sensitive methods such as FISH Laboratory Sciences, co-editor in the fourth edition, and lead and genomic hybridization arrays. Chapter 31 covers molecular editor in the fifth edition, is joined by Larry J. Smith, PhD, diagnostics and was fully updated with new and enhanced fig- Coagulation and Satellite Laboratory Director, Memorial Sloan ures on basic molecular biology, end-point and real-time poly- Kettering Cancer Center, Adjunct Professor at Rutgers Univer- merase chain reaction, microarrays, and DNA sequencing, in- sity, School of Health Related Professions and York College, i. r cluding next generation sequencing. Chapter 32 describes flow CUNY, Department of Health Professions, and Jeanine M. cytometry and its diagnostic applications. It includes numerous Walenga, PhD, MT(ASCP), Professor, Loyola University Chi- scatterplots of normal and leukemic conditions. Chapters 33 to cago, Stritch School of Medicine, Clinical Coagulation Labora- s 36, with significant updating, provide the latest classifications tories Director, Loyola University Health System. and pathophysiologic models for myeloproliferative neoplasms, The outstanding value and quality of Rodak’s Hematology: s myelodysplastic syndromes, acute lymphoblastic and myeloid Clinical Principles and Applications reflect the educational and n leukemias, chronic lymphocytic leukemia, and solid tumor lym- clinical expertise of its current and previous authors and editors. phoid neoplasms, such as lymphoma and myeloma, with nu- The text is enhanced by nearly 700 full-color digital photomicro- is a merous full-color photomicrographs and illustrations. graphs, figures, and line art. Detailed text boxes and tables clearly summarize important information. Reference intervals are pro- Part VI: Hemostasis and Thrombosis vided on the inside front and back covers for quick lookup. r Chapter 37 provides the plasma-based and cell-based coagula- Each chapter contains the following pedagogical features: tion models and the interactions between primary and second- Learning objectives at all taxonomy levels in the cogni- e ary hemostasis and fibrinolysis with updated illustrations. tive domain. p Chapter 38 details hemorrhagic disorders, including the man- One or two case studies with open-ended discussion. agement of the acute coagulopathy of trauma and shock. questions at the beginning of the chapter that stimulate Chapter 39 updates the currently recognized risk factors of interest and provide opportunities for application of iv p thrombosis and describes laboratory tests that identify venous chapter content in real-life scenarios. and arterial thrombotic diseases, particularly for lupus antico- A bulleted summary at the end of each chapter that pro- agulant and heparin-induced thrombocytopenia (HIT) testing. vides a comprehensive review of essential material. Chapters 40 and 41 detail the quantitative and qualitative Review questions at the end of each chapter that corre- platelet disorders using additional tables and figures, and late to chapter objectives and are in the multiple-choice Chapter 42 details laboratory assays of platelets and the coagu- format used by certification examinations. lation mechanisms with helpful new figures and diagrams. Answers to case studies and review questions that are Chapter 43 covers the mechanisms and monitoring methods provided in the Appendix. of the traditional warfarin and heparin-derived antithrombotic The Evolve website has multiple features for the instructor: drugs, as well as all thrombin and factor Xa inhibitor drugs. It An ExamView test bank contains multiple-choice ques- also includes methods for monitoring the different classes of tions with rationales and cognitive levels. antiplatelet drugs, including aspirin. Chapter 44 reviews the Instructor’s manuals for every chapter contain key latest coagulation analyzers and point of care instrumentation. terms, objectives, outlines, and study questions. Learning Objectives with taxonomy levels are provided Part VII: Hematology and Hemostasis to supplement lesson plans. in Selected Populations Case studies have been updated and feature discussion Chapter 45 provides valuable information on the hematology questions and photomicrographs when applicable. and hemostasis laboratory findings in the pediatric and geriatric PowerPoint presentations for every chapter can be used populations correlated with information from previous chapters. “as is” or as a template to prepare lectures. The Image Collection provides electronic files of all the chapter figures that can be downloaded into PowerPoint READERS presentations. Rodak’s Hematology: Clinical Principles and Applications is de- For the student, a Glossary is available as a quick reference signed for medical laboratory scientists, medical laboratory to look up unfamiliar terms electronically. Acknowledgments xii Preface The editors express their immense gratitude to Bernadette F. shared their time and expertise to make Rodak’s Hematology: (Bunny) Rodak, who laid the foundation for this textbook with Clinical Principles and Applications into a worldwide educational her expert writing, editing, detailed figures, and especially her resource and premier reference textbook for medical laboratory contribution of over 200 outstanding digital photomicrographs scientists and technicians, as well as pathology and hematology over the past 2 decades. Now in its fifth edition, she has practitioners, residents, and fellows. authored three chapters, provided invaluable contributions and We also express our appreciation to Elsevier, especially Ellen assistance with additional photomicrographs and figures, and Wurm-Cutter, Laurie Gower, Kellie White, Sara Alsup, Megan provided the opportunity for us to continue her work on this Knight, and Rebecca Corradetti, whose professional support outstanding textbook. We sincerely thank George A. Fritsma for and reminders kept the project on track, and to Debbie Prato his significant contribution to this text as a previous coeditor for her editorial assistance. i. r and author, for sharing his immense expertise in hemostasis, Finally, and with the utmost gratitude, we acknowledge our for updating and authoring ten chapters in the fifth edition, and families, friends, and professional colleagues who have sup- for his constant support and encouragement. We thank Kathryn ported and encouraged us through this project. s Doig for her contributions as coeditor for the third edition; author in previous editions; and for her tenaciousness, creativ- s ity, and care in updating the five chapters authored in the fifth Elaine M. Keohane, PhD, MLS n edition. The editors also thank the many authors who have made and continue to make significant contributions to this Larry J. Smith, PhD, SH(ASCP), HCLD/CC(ABB) is a work. All of these outstanding professionals have generously Jeanine M. Walenga, PhD, MT(ASCP) e r. p iv p xii Contents Contributors xiii PART I Introduction to Hematology PART III Laboratory Evaluation of Blood Cells CHAPTER 1 An Overview of Clinical Laboratory Hematology, 1 CHAPTER 14 Manual, Semiautomated, and Point-of-Care Testing George A. Fritsma in Hematology, 187 Karen S. Clark and Teresa G. Hippel CHAPTER 2 Safety in the Hematology Laboratory, 8 Sheila A. Finch CHAPTER 15 Automated Blood Cell Analysis, 208 Sharral Longanbach and Martha K. Miers CHAPTER 3 Blood Specimen Collection, 19 CHAPTER 16 Examination of the Peripheral Blood Film and i. r Elaine M. Keohane Correlation with the Complete Blood Count, 235 CHAPTER 4 Care and Use of the Microscope, 34 Lynn B. Maedel and Kathryn Doig s Bernadette F. Rodak CHAPTER 17 Bone Marrow Examination, 253 s CHAPTER 5 Quality Assurance in Hematology and Hemostasis George A. Fritsma n Testing, 42 George A. Fritsma CHAPTER 18 Body Fluid Analysis in the Hematology is a Laboratory, 269 Bernadette F. Rodak PART II Blood Cell Production, Structure, r  and Function PART IV Erythrocyte Disorders e CHAPTER 6 Cellular Structure and Function, 65 CHAPTER 19 Anemias: Red Blood Cell Morphology and Approach p Elaine M. Keohane. to Diagnosis, 284 CHAPTER 7 Hematopoiesis, 76 Naveen Manchanda iv p Richard C. Meagher CHAPTER 20 Disorders of Iron Kinetics and Heme CHAPTER 8 Erythrocyte Production and Destruction, 95 Metabolism, 297 Kathryn Doig Kathryn Doig CHAPTER 9 Erythrocyte Metabolism and Membrane Structure CHAPTER 21 Anemias Caused by Defects of DNA and Function, 112 Metabolism, 314 George A. Fritsma Linda H. Goossen CHAPTER 10 Hemoglobin Metabolism, 124 CHAPTER 22 Bone Marrow Failure, 331 Elaine M. Keohane Clara Lo, Bertil Glader, and Kathleen M. Sakamoto CHAPTER 11 Iron Kinetics and Laboratory Assessment, 137 CHAPTER 23 Introduction to Increased Destruction of Kathryn Doig Erythrocytes, 348 Kathryn Doig CHAPTER 12 Leukocyte Development, Kinetics, and Functions, 149 Woodlyne Roquiz, Sameer Al Diffalha, and Ameet R. Kini CHAPTER 24 Intrinsic Defects Leading to Increased Erythrocyte Destruction, 367 CHAPTER 13 Platelet Production, Structure, and Function, 167 Elaine M. Keohane George A. Fritsma xiii xiv Contents CHAPTER 25 Extrinsic Defects Leading to Increased Erythrocyte PART VI Hemostasis and Thrombosis Destruction—Nonimmune Causes, 394 Elaine M. Keohane CHAPTER 37 Normal Hemostasis and Coagulation, 642 Margaret G. Fritsma and George A. Fritsma CHAPTER 26 Extrinsic Defects Leading to Increased Erythrocyte Destruction—Immune Causes, 411 CHAPTER 38 Hemorrhagic Disorders and Laboratory Kim A. Przekop Assessment, 667 George A. Fritsma CHAPTER 27 Hemoglobinopathies (Structural Defects in Hemoglobin), 426 CHAPTER 39 Thrombotic Disorders and Laboratory Tim R. Randolph Assessment, 689 George A. Fritsma CHAPTER 28 Thalassemias, 454 Elaine M. Keohane CHAPTER 40 Thrombocytopenia and Thrombocytosis, 713 Larry D. Brace i. r PART V Leukocyte Disorders CHAPTER 41 Qualitative Disorders of Platelets and Vasculature, 739 CHAPTER 29 Nonmalignant Leukocyte Disorders, 475 Larry D. Brace s Steven Marionneaux Laboratory Evaluation of Hemostasis, 760 s CHAPTER 42 CHAPTER 30 Cytogenetics, 498 George A. Fritsma n Gail H. Vance CHAPTER 43 Antithrombotic Therapies and Their Laboratory is a CHAPTER 31 Molecular Diagnostics in Hematopathology, 513 Assessment, 790 Cynthia L. Jackson and Shashi Mehta George A. Fritsma r CHAPTER 32 Flow Cytometric Analysis in Hematologic CHAPTER 44 Hemostasis and Coagulation Instrumentation, 810 Disorders, 543 e Debra A. Hoppensteadt and JoAnn Molnar Magdalena Czader. p CHAPTER 33 Myeloproliferative Neoplasms, 561 PART VII Hematology and Hemostasis  Tim R. Randolph in Selected Populations iv p CHAPTER 34 Myelodysplastic Syndromes, 591 CHAPTER 45 Pediatric and Geriatric Hematology Bernadette F. Rodak and Hemostasis, 829 Linda H. Goossen CHAPTER 35 Acute Leukemias, 604 Woodlyne Roquiz, Pranav Gandhi, and Ameet R. Kini APPENDIX CHAPTER 36 Mature Lymphoid Neoplasms, 619 Magdalena Czader Answers, 847 Glossary, 857 Index, 877  PART I Introduction to Hematology An Overview of Clinical 1 Laboratory Hematology George A. Fritsma T he average human possesses 5 liters of blood. Blood transports oxygen from lungs to tissues; OUTLINE i. r clears tissues of carbon dioxide; transports glucose, proteins, and fats; and moves wastes to the History liver and kidneys. The liquid portion is plasma, which, among many components, provides Red Blood Cells coagulation enzymes that protect vessels from trauma and maintain the circulation. s Hemoglobin, Hematocrit, Plasma transports and nourishes blood cells. There are three categories of blood cells: red blood cells and Red Blood Cell (RBCs), or erythrocytes; white blood cells (WBCs), or leukocytes; and platelets (PLTs), or thrombocytes.1 s Indices Hematology is the study of these blood cells. By expertly staining, counting, analyzing, and recording Reticulocytes n the appearance, phenotype, and genotype of all three types of cells, the medical laboratory professional White Blood Cells Platelets (technician or scientist) is able to predict, detect, and diagnose blood diseases and many systemic dis- is a Complete Blood Count eases that affect blood cells. Physicians rely on hematology laboratory test results to select and monitor Blood Film Examination therapy for these disorders; consequently, a complete blood count (CBC) is ordered on nearly everyone Endothelial Cells who visits a physician or is admitted to a hospital. r Coagulation Advanced Hematology e Procedures HISTORY Additional Hematology p The first scientists such as Athanasius Kircher in 1657 described “worms” in the blood, and Anton van Procedures. Leeuwenhoek in 1674 gave an account of RBCs,2 but it was not until the late 1800s that Giulio Hematology Quality Bizzozero described platelets as “petites plaques.”3 The development of Wright stain by James iv p Assurance and Quality Homer Wright in 1902 opened a new world of visual blood film examination through the micro- Control scope. Although automated instruments now differentiate and enumerate blood cells, Wright’s Romanowsky-type stain (polychromatic, a mixture of acidic and basic dyes), and refinements thereof, remains the foundation of blood cell identification.4 In the present-day hematology laboratory, RBC, WBC, and platelet appearance is analyzed through automation or visually using 5003 to 10003 light microscopy examination of cells fixed to a glass microscope slide and stained with Wright or Wright-Giemsa stain (Chapters 15 and 16). The scientific term for cell appearance is morphology, which encompasses cell color, size, shape, cytoplasmic inclu- sions, and nuclear condensation. RED BLOOD CELLS RBCs are anucleate, biconcave, discoid cells filled with a reddish protein, hemoglobin (HGB), which transports oxygen and carbon dioxide (Chapter 10). RBCs appear pink to red and measure 6 to 8 mm in diameter with a zone of pallor that occupies one third of their center (Figure 1-1, A), reflecting their biconcavity (Chapters 8 and 9). Since before 1900, physicians and medical laboratory professionals counted RBCs in measured volumes to detect anemia or polycythemia. Anemia means loss of oxygen-carrying capacity and is often reflected in a reduced RBC count or decreased RBC hemoglobin concentration (Chapter 19). Polycythemia means an increased RBC count reflecting increased circulating RBC mass, a condition that leads to hyperviscosity (Chapter 33). Historically, microscopists counted RBCs by carefully pipetting a tiny aliquot of whole blood and mixing it with 0.85% (normal) saline. Normal saline matches the osmolality of blood; consequently, the suspended RBCs retained their intrinsic morphology, neither swelling nor shrinking. A 1:200 dilution was typical for RBC counts, and a glass 1 2 PART I Introduction to Hematology with that of a known standard and is mathematically con- verted to hemoglobin concentration. Modifications of the B cyanmethemoglobin method are used in most automated applications, although some automated hematology profil- C ing instruments replace it with a formulation of the ionic D surfactant (detergent) sodium lauryl sulfate to reduce environ- mental cyanide. Hematocrit is the ratio of the volume of packed RBCs to A the volume of whole blood and is manually determined by F transferring blood to a graduated plastic tube with a uniform bore, centrifuging, measuring the column of RBCs, and divid- ing by the total length of the column of RBCs plus plasma.7 The normal ratio approaches 50% (refer to inside front cover E G for reference intervals). Hematocrit is also called packed cell volume (PCV), the packed cells referring to RBCs. Often one H can see a light-colored layer between the RBCs and plasma. i. r This is the buffy coat and contains WBCs and platelets, and it Figure 1-1 ​Normal cells in peripheral blood: A, Erythrocyte (red blood is excluded from the hematocrit determination. The medical cell, RBC); B, Neutrophil (segmented neutrophil, NEUT, SEG, polymorpho- laboratory professional may use the three numerical results— nuclear neutrophil, PMN); C, Band (band neutrophil, BAND); D, Eosinophil s (EO); E, Basophil (BASO); F, Lymphocyte (LYMPH); G, Monocyte (MONO); RBC count, HGB, and HCT—to compute the RBC indices mean cell volume (MCV), mean cell hemoglobin (MCH), and s H, Platelet (PLT). mean cell hemoglobin concentration (MCHC) (Chapter 14). The n MCV, although a volume measurement recorded in femtoli- pipette designed to provide this dilution, the Thoma pipette, ters (fL), reflects RBC diameter on a Wright-stained blood is a was used routinely until the advent of automation. film. The MCHC, expressed in g/dL, reflects RBC staining in- The diluted blood was transferred to a glass counting cham- tensity and amount of central pallor. The MCH in picograms ber called a hemacytometer (Figure 14-1). The microscopist (pg) expresses the mass of hemoglobin and parallels the r observed and counted RBCs in selected areas of the hemacytom- MCHC. A fourth RBC index, RBC distribution width (RDW), eter, applied a mathematical formula based on the dilution and expresses the degree of variation in RBC volume. Extreme RBC e on the area of the hemacytometer counted (Chapter 14), and volume variability is visible on the Wright-stained blood film p reported the RBC count in cells per microliter (mL, mcL, also as variation in diameter and is called anisocytosis. The RDW is. called cubic millimeter, mm3), milliliter (mL, also called cubic based on the standard deviation of RBC volume and is centimeter, or cc), or liter (L). routinely reported by automated cell counters. In addition iv p Visual RBC counting was developed before 1900 and, to aiding in diagnosis of anemia, the RBC indices provide although inaccurate, was the only way to count RBCs until stable measurements for internal quality control of counting 1958, when automated particle counters became available in instruments (Chapter 5). the clinical laboratory. The first electronic counter, patented in Medical laboratory professionals routinely use light micros- 1953 by Joseph and Wallace Coulter of Chicago, Illinois, was copy at 5003 or 10003 magnification (Chapters 4 and 16) to used so widely that today automated cell counters are often visually review RBC morphology, commenting on RBC diameter, called Coulter counters, although many high-quality competi- color or hemoglobinization, shape, and the presence of cytoplas- tors exist (Chapter 15).5 The Coulter principle of direct current mic inclusions (Chapters 16 and 19). All these parameters—RBC electrical impedance is still used to count RBCs in many auto- count, HGB, HCT, indices, and RBC morphology—are employed mated hematology profiling instruments. Fortunately, the to detect, diagnose, assess the severity of, and monitor the treat- widespread availability of automated cell counters has replaced ment of anemia, polycythemia, and the numerous systemic visual RBC counting, although visual counting skills remain conditions that affect RBCs. Automated hematology profiling useful where automated counters are unavailable. instruments are used in nearly all laboratories to generate these data, although visual examination of the Wright-stained blood Hemoglobin, Hematocrit, and Red Blood film is still essential to verify abnormal results.8 Cell Indices RBCs also are assayed for hemoglobin concentration (HGB) Reticulocytes and hematocrit (HCT) (Chapter 14). Hemoglobin measure- In the Wright-stained blood film, 0.5% to 2% of RBCs exceed ment relies on a weak solution of potassium cyanide and the 6- to 8-mm average diameter and stain slightly blue-gray. potassium ferricyanide, called Drabkin reagent. An aliquot of These are polychromatic (polychromatophilic) erythrocytes, newly whole blood is mixed with a measured volume of Drabkin released from the RBC production site: the bone marrow reagent, hemoglobin is converted to stable cyanmethemoglo- (Chapters 8 and 17). Polychromatic erythrocytes are closely bin (hemiglobincyanide), and the absorbance or color in- observed because they indicate the ability of the bone marrow tensity of the solution is measured in a spectrophotometer to increase RBC production in anemia due to blood loss or at 540 nm wavelength.6 The color intensity is compared excessive RBC destruction (Chapters 23 to 26).  CHAPTER 1 An Overview of Clinical Laboratory Hematology 3 Methylene blue dyes, called nucleic acid stains or vital stains, contains submicroscopic, pink- or lavender-staining gran- are used to differentiate and count these young RBCs. Vital (or ules filled with bactericidal secretions. “supravital”) stains are dyes absorbed by live cells.9 Young Eosinophils (EOs; Figure 1-1, D). Eosinophils are cells with RBCs contain ribonucleic acid (RNA) and are called reticulo- bright orange-red, regular cytoplasmic granules filled with cytes when the RNA is visualized using vital stains. Counting proteins involved in immune system regulation. An ele- reticulocytes visually by microscopy was (and remains) a vated eosinophil count is called eosinophilia and often sig- tedious and imprecise procedure until the development of nals a response to allergy or parasitic infection. automated reticulocyte counting by the TOA Corporation Basophils (BASOs; Figure 1-1, E). Basophils are cells with (presently Sysmex Corporation, Kobe, Japan) in 1990. Now all dark purple, irregular cytoplasmic granules that obscure the fully automated profiling instruments provide an absolute re- nucleus. The basophil granules contain histamines and ticulocyte count and, in addition, an especially sensitive measure various other proteins. An elevated basophil count is called of RBC production, the immature reticulocyte count or immature basophilia. Basophilia is rare and often signals a hematologic reticulocyte fraction (Chapter 15). However, it is still necessary disease. to confirm instrument counts visually from time to time, so The distribution of basophils and eosinophils in blood is medical laboratory professionals must retain this skill. so small compared with that of neutrophils that the terms eosinopenia and basopenia are theoretical and not i. r used. Neutrophils, bands, eosinophils, and basophils are WHITE BLOOD CELLS collectively called granulocytes because of their prominent WBCs, or leukocytes, are a loosely related category of cell types cytoplasmic granules, although their functions differ. s dedicated to protecting their host from infection and injury Leukemia is an uncontrolled proliferation of WBCs. Leuke- (Chapter 12). WBCs are transported in the blood from their mia may be chronic—for example, chronic myelogenous (gran- s source, usually bone marrow or lymphoid tissue, to their tissue ulocytic) leukemia—or acute—for example, acute myeloid n or body cavity destination. WBCs are so named because they leukemia. There are several forms of granulocytic leukemias are nearly colorless in an unstained cell suspension. that involve any one of or all three cell lines, categorized by is a WBCs may be counted visually using a microscope and their respective genetic aberrations (Chapters 30, 33 to 35). hemacytometer. The technique is the same as RBC counting, Medical laboratory scientists are responsible for their identi- but the typical dilution is 1:20, and the diluent is a dilute acid fication using Wright-stained bone marrow smears, cytoge- r solution. The acid causes RBCs to lyse or rupture; without it, netics, flow cytometric immunophenotyping, molecular RBCs, which are 500 to 1000 times more numerous than diagnostic technology, and occasionally, cytochemical stain- e WBCs, would obscure the WBCs. The WBC count ranges from ing (Chapter 17 and Chapters 30 to 32). p 4500 to 11,500/mL. Visual WBC counting has been largely re- Lymphocytes (LYMPHs; Figure 1-1, F). Lymphocytes com-. placed by automated hematology profiling instruments, but it prise a complex system of cells that provide for host immu- is accurate and useful in situations in which no automation is nity. Lymphocytes recognize foreign antigens and mount iv p available. Medical laboratory professionals who analyze body humoral (antibodies) and cell-mediated antagonistic re- fluids such as cerebrospinal fluid or pleural fluid may employ sponses. On a Wright-stained blood film, most lymphocytes visual WBC counting. are nearly round, are slightly larger than RBCs, and have A decreased WBC count (fewer than 4500/mL) is called leu- round featureless nuclei and a thin rim of nongranular kopenia, and an increased WBC count (more than 11,500/mL) cytoplasm. An increase in the lymphocyte count is called is called leukocytosis, but the WBC count alone has modest lymphocytosis and often is associated with viral infections. clinical value. The microscopist must differentiate the catego- Accompanying lymphocytosis are often variant or reactive ries of WBCs in the blood by using a Wright-stained blood film lymphocytes with characteristic morphology (Chapter 29). and light microscopy (Chapter 16). The types of WBCs are as An abnormally low lymphocyte count is called lymphopenia follows: or lymphocytopenia and is often associated with drug therapy Neutrophils (NEUTs, segmented neutrophils, SEGs, poly- or immunodeficiency. Lymphocytes are also implicated in morphonuclear neutrophils, PMNs; Figure 1-1, B). Neu- leukemia; chronic lymphocytic leukemia is more prevalent in trophils are phagocytic cells whose major purpose is to people older than 65 years, whereas acute lymphoblastic engulf and destroy microorganisms and foreign material, leukemia is the most common form of childhood leukemia either directly or after they have been labeled for destruc- (Chapters 35 and 36). Medical laboratory scientists and tion by the immune system. The term segmented refers to hematopathologists classify lymphocytic leukemias largely their multilobed nuclei. An increase in neutrophils based on Wright-stained blood films, flow cytometric is called neutrophilia and often signals bacterial infection. immunophenotyping, and molecular diagnostic techniques A decrease is called neutropenia and has many causes, (Chapters 31 to 32). but it is often caused by certain medications or viral Monocytes (MONOs; Figure 1-1, G). The monocyte is an infections. immature macrophage passing through the blood from its Bands (band neutrophils, BANDs; Figure 1-1, C). Bands are point of origin, usually the bone marrow, to a targeted tissue less differentiated or less mature neutrophils. An increase in location. Macrophages are the most abundant cell type in bands also signals bacterial infection and is customarily the body, more abundant than RBCs or skin cells, although called a left shift. The cytoplasm of neutrophils and bands monocytes comprise a minor component of peripheral 4 PART I Introduction to Hematology blood WBCs. Macrophages occupy every body cavity; some A low platelet count, called thrombocytopenia, is a common are motile and some are immobilized. Their tasks are to consequence of drug treatment and may be life-threatening. Be- identify and phagocytose (engulf and consume) foreign par- cause the platelet is responsible for normal blood vessel mainte- ticles and assist the lymphocytes in mounting an immune nance and repair, thrombocytopenia is usually accompanied by response through the assembly and presentation of immu- easy bruising and uncontrolled hemorrhage (Chapter 40). nogenic epitopes. On a Wright-stained blood film, monocytes Thrombocytopenia accounts for many hemorrhage-related emer- have a slightly larger diameter than other WBCs, blue-gray gency department visits. Accurate platelet counting contributes cytoplasm with fine azure granules, and a nucleus that is to patient safety because it provides for the diagnosis of throm- usually indented or folded. An increase in the number of bocytopenia in many disorders or therapeutic regimens. monocytes is called monocytosis. Monocytosis may be found in certain infections, collagen-vascular diseases, or in acute COMPLETE BLOOD COUNT and chronic leukemias (Chapters 29, 33, and 35). Medical laboratory professionals seldom document a decreased A complete blood count (CBC) is performed on automated monocyte count, so the theoretical term monocytopenia is hematology profiling instruments and includes the RBC, WBC, seldom used. and platelet measurements indicated in Box 1-1. The medical laboratory professional may collect a blood specimen for the CBC, but often a phlebotomist, nurse, physician assistant, phy- PLATELETS sician, or patient care technician may also collect the specimen Platelets, or thrombocytes, are true blood cells that main- (Chapters 3 and 42). No matter who collects, the medical tain blood vessel integrity by initiating vessel wall repairs laboratory professional is responsible for the integrity of the (Chapter 13). Platelets rapidly adhere to the surfaces of dam- specimen and ensures that it is submitted in the appropriate aged blood vessels, form aggregates with neighboring platelets anticoagulant and tube and is free of clots and hemolysis (red- to plug the vessels, and secrete proteins and small molecules tinted plasma indicating RBC damage). The specimen must that trigger thrombosis, or clot formation. Platelets are the major be of sufficient volume, as “short draws” result in incorrect cells that control hemostasis, a series of cellular and plasma- anticoagulant-to-specimen ratios. The specimen must be tested based mechanisms that seal wounds, repair vessel walls, and or prepared for storage within the appropriate time frame to maintain vascular patency (unimpeded blood flow). Platelets ensure accurate analysis (Chapter 5) and must be accurately are only 2 to 4 mm in diameter, round or oval, anucleate registered in the work list, a process known as specimen acces- (for this reason some hematologists prefer to call platelets sion. Accession may be automated, relying on bar code or radio- “cell fragments”), and slightly granular (Figure 1-1, H). Their frequency identification technology, thus reducing instances small size makes them appear insignificant, but they are of identification error. essential to life and are extensively studied for their complex Although all laboratory scientists and technicians are physiology. Uncontrolled platelet and hemostatic activation is equipped to perform visual RBC, WBC, and platelet counts responsible for deep vein thrombosis, pulmonary emboli, acute myocardial infarctions (heart attacks), cerebrovascular accidents (strokes), peripheral artery disease, and repeated spontaneous abortions (miscarriages). BOX 1-1 Complete Blood Count Measurements The microscopist counts platelets using the same technique Generated by Automated Hematology Profiling Instruments used in counting WBCs on a hemacytometer, although a differ- ent counting area and dilution is usually used (Chapter 14). RBC Parameters WBC Parameters Owing to their small volume, platelets are hard to distinguish RBC count WBC count visually in a hemacytometer, and phase microscopy provides HGB NEUT count: % and absolute for easier identification (Chapter 4). Automated profiling in- HCT LYMPH count: % and absolute struments have largely replaced visual platelet counting and MCV MONO count: % and absolute provide greater accuracy (see Chapter 15). MCH EO and BASO counts: % and One advantage of automated profiling instruments is their MCHC absolute ability to generate a mean platelet volume (MPV), which is RDW unavailable through visual methods. The presence of predomi- RETIC nantly larger platelets generates an elevated MPV value, which sometimes signals a regenerative bone marrow response to Platelet Parameters platelet consumption (Chapters 13 and 40). PLT count Elevated platelet counts, called thrombocytosis, signal in- MPV flammation or trauma but convey modest intrinsic signifi- cance. Essential thrombocythemia is a rare malignant condition BASO, Basophil; EO, eosinophil; HGB, hemoglobin; HCT, hematocrit; LYMPH, lymphocyte; MCH, mean cell hemoglobin; MCHC, mean cell hemoglobin concen- characterized by extremely high platelet counts and uncon- tration; MCV, mean cell volume; MONO, monocyte; MPV, mean platelet volume; trolled platelet production. Essential thrombocythemia is a NEUT, segmented neutrophil; PLT, platelet; RBC, red blood cell; RDW, RBC distri- life-threatening hematologic disorder (Chapter 33). bution width; RETIC, reticulocyte; WBC, white blood cell.  CHAPTER 1 An Overview of Clinical Laboratory Hematology 5 using dilution pipettes, hemacytometers, and microscopes, most COAGULATION laboratories employ automated profiling instruments to gener- ate the CBC. Many profiling instruments also provide comments Most hematology laboratories include a blood coagulation– on RBC, WBC, and platelet morphology (Chapter 15). When testing department (Chapters 42 and 44). Platelets are a key one of the results from the profiling instrument is abnormal, the component of hemostasis, as previously described; plasma instrument provides an indication of this, sometimes called a coagulation is the second component. The coagulation system flag. In this case, a “reflex” blood film examination is performed employs a complex sequence of plasma proteins, some (Chapter 16). enzymes, and some enzyme cofactors to produce clot forma- The blood film examination (described next) is a special- tion after blood vessel injury. Another 6 to 8 enzymes exert ized, demanding, and fundamental CBC activity. Nevertheless, control over the coagulation mechanism, and a third system of if all profiling instrument results are normal, the blood film enzymes and cofactors digests clots to restore vessel patency, a examination is usually omitted from the CBC. However, physi- process called fibrinolysis. Bleeding and clotting disorders are cians may request a blood film examination on the basis of numerous and complex, and the coagulation section of the clinical suspicion even when the profiling instrument results hematology laboratory provides a series of plasma-based labo- fall within their respective reference intervals. ratory assays that assess the interactions of hematologic cells with plasma proteins (Chapters 42 and 44). The medical laboratory professional focuses especially BLOOD FILM EXAMINATION on blood specimen integrity for the coagulation laboratory, To accomplish a blood film examination, the microscopist because minor blood specimen defects, including clots, he­ prepares a “wedge-prep” blood film on a glass microscope molysis, lipemia, plasma bilirubin, and short draws, render the slide, allows it to dry, and fixes and stains it using Wright or specimen useless (Chapters 3 and 42). High-volume coagula- Wright-Giemsa stain (Chapter 16). The microscopist examines tion tests suited to the acute care facility include the platelet the RBCs and platelets by light microscopy for abnormalities of count and MPV as described earlier, prothrombin time and partial shape, diameter, color, or inclusions using the 503 or 1003 oil thromboplastin time (or activated partial thromboplastin time), immersion lens to generate 5003 or 10003 magnification thrombin time (or thrombin clotting time), fibrinogen assay, and (Chapter 4). The microscopist then visually estimates the WBC D-dimer assay (Chapter 42). The prothrombin time and partial count and platelet count for comparison with their respective thromboplastin time are particularly high-volume assays used instrument counts and investigates discrepancies. Next, the in screening profiles. These tests assess each portion of the microscopist systematically reviews, identifies, and tabulates coagulation pathway for deficiencies and are used to monitor 100 (or more) WBCs to determine their percent distribution. anticoagulant therapy. Another 30 to 40 moderate-volume This process is referred to as determining the WBC differential assays, mostly clot-based, are available in specialized or tertiary (“diff”). The WBC differential relies on the microscopist’s skill, care facilities. The specialized or tertiary care coagulation visual acuity, and integrity, and it provides extensive diagnostic laboratory with its interpretive complexities attracts advanced information. Medical laboratory professionals pride them- medical laboratory scientists with specialized knowledge and selves on their technical and analytical skills in performing the communication skills. blood film examination and differential count. Visual recogni- tion systems such as the Cellavision® DM96 or the Bloodhound ADVANCED HEMATOLOGY PROCEDURES automate the RBC and platelet morphology and WBC differen- tial processes, but the medical laboratory professional or the Besides performing the CBC, the hematology laboratory pro- hematopathologist is the final arbiter for all cell identification. vides bone marrow examinations, flow cytometry immunophenotyp- The results of the CBC, including all profiling and blood ing, cytogenetic analysis, and molecular diagnosis assays. Perform- film examination parameters and interpretive comments, are ing these tests may require advanced preparation or particular provided in paper or digital formats for physician review with dedication by medical laboratory scientists with a desire to abnormal results highlighted. specialize. Medical laboratory scientists assist physicians with bed- side bone marrow collection, then prepare, stain, and micro- ENDOTHELIAL CELLS scopically review bone marrow smears (Chapter 17). Bone Because they are structural and do not flow in the bloodstream, marrow aspirates and biopsy specimens are collected and stained endothelial cells—the endodermal cells that form the inner to analyze nucleated cells that are the immature precursors to surface of the blood vessel—are seldom studied in the hema- blood cells. Cells of the erythroid series are precursors to tology laboratory. Nevertheless, endothelial cells are important RBCs (Chapter 8); myeloid series cells mature to form bands in maintaining normal blood flow, in tethering (decelerating) and neutrophils, eosinophils, and basophils (Chapter 12); platelets during times of injury, and in enabling WBCs to and megakaryocytes produce platelets (Chapter 13). Medical escape from the vessel to the surrounding tissue when needed. laboratory scientists, clinical pathologists, and hematologists Increasingly refined laboratory methods are becoming avail- review Wright-stained aspirate smears for morphologic abnor- able to assay and characterize the secretions (cytokines) of malities, high or low bone marrow cell concentration, and these important cells. inappropriate c