SEED Haematology. Looking deeper into inflammatory conditions from a laboratory and clinical perspective

Transcription

1 SYSMEX EDUCATIONAL ENHANCEMENT AND DEVELOPMENT JULY 2018 SEED Hemtology Looking deeper into inflmmtory onditions from lortory nd linil perspetive Inflmmtion nd infetion re two different things, lthough they very often our together. Inflmmtion desries exlusively the ody s immunovsulr response, irrespetive of the use. It is our ody s nturl defene ginst dmged ells, physil or hemil gents, llergens or pthogeni orgnisms nd ims to remove these hrmful or foreign invders nd reover. Generlly there re two different types of inflmmtion. One is ute inflmmtion, the other is hroni. Aute inflmmtion strts quikly, presents with redness, swelling, pin, het, nd mye even loss of funtion of the inflmed re, nd generlly disppers in few dys s the tissue hels. Chroni inflmmtion n lst for months or yers s result of permnent filure to eliminte the use nd/or minor, repeted exposure to one or more proinflmmtory gents. A poor diet, stress, minor food llergies, sedentry lifestyle nd more n ontriute to hroni inflmmtion. As mtter of ft, inflmmtion isn t lwys helpful proess. In some ses it hs gret destrutive potentil, whih is demonstrted when the immune system mistkenly trgets the ody s own tissues in utoimmune diseses suh s type 1 dietes, rheumtoid rthritis nd lupus. Inflmmtion is the ody s immunologi response to tissue dmge used y the invsion of foreign odies, miroorgnisms or hrmful hemils. Infetion is the invsion of the ody y pthogeni miroorgnisms, inluding their multiplition nd the ody s response. The term infetion is used when pthogeni orgnisms invde the tissue of host orgnism, multiply, nd the ffeted tissue rets to these orgnisms nd the toxins they produe. Infetions re used y miroorgnisms suh s viruses, teri nd viroids, ut lso lrger orgnisms suh s prsites nd fungi. Also prions tht re entirely omposed of protein mteril re onsidered infetious gents. Hosts n fight infetion using their immune system nd ret with n innte response, often involving inflmmtion, followed y n dptive response. Inflmmtion is therefore not synonym for infetion, not even in ses where inflmmtion is used y infetion.

2 2 Glol helth hllenges pndemis nd epidemis Infetious diseses re used y pthogeni miroorgnisms tht infiltrte the ody s nturl rriers nd multiply to indue illnesses, whih severity n rnge from mild to dedly. They n pose serious thret to puli helth, not lest euse epidemis n e diffiult to predit. For exmple, s the 2009/2010 H1N1 flu pndemi illustrted, muttions in the influenz virus n turn nnul flu outreks into glol helth threts. Or, tking nother exmple, the Eol outrek 2014/2015 reted ommon wreness tht it is no longer regionl prolem. Aording to dt of the World Helth Orgnistion (WHO), more thn 8,000 helthre professionls in over 80 ountries were trined over the durtion of the epidemi [1] sine the virus tht uses this infetion n trvel eyond orders nd ross oens emphsising tht mjor outreks of ommunile diseses re shred puli helth hllenge. Antimiroil resistne on the dvne Another relted topi is the growing prolem of ntimiroil resistne. Antiiotis, ntivirls, nd other ntimiroils hve sved millions of lives worldwide, ut these drugs re losing their effetiveness euse of ntimiroil resistne. Antimiroil resistne refers to miroes nturl ility to evolve genetilly to ounter the drugs. Some of this is inevitle, ut over-presription nd improper use of ntimiroils ply ig role, too. In the EU, out 25,000 ptients die eh yer from n infetion used y these drug-resistnt teri. Consequenes for hospitl ptients inlude delyed dministrtion of pproprite ntiioti therpy, longer length of sty, higher helthre osts nd poor ptient outomes [2]. Differentition is essentil It is useful to differentite inflmmtion nd infetion s there re lso mny pthologil situtions where inflmmtion is not driven y miroil invsion for exmple trum, ishemi or utoimmune diseses. There re lso pthologil situtions where miroil invsion does not result in lssi inflmmtory response, for exmple prsitosis or eosinophili. Fst nd effiient differentition etween vrious inflmmtory onditions is linilly very importnt euse the treting physiin needs to deide on pproprite therpy for the ptient idelly without dely. A orret differentil dignosis of suspeted infetions y linil exmintion, iohemil mrkers nd miroiologil lood ultures is oth ostly nd time-onsuming. However, if the lortory hs fst initil indition, unneessry follow-up tests, suh s smer reviews or flow ytometry nlyses, n e voided. This mens the physiin n strt or, with tretment lredy egun, dpt or disontinue tretment fster. How lood ell nlysis n ontriute The immune system is mehnism tht protets our odies from hrmful sustnes, foreign miroorgnisms nd even ner. White lood ells (WBC), s prt of the immune system, help to fight infetion nd defend the ody ginst other foreign sustnes. Different types of WBC re involved in reognising intruders, killing hrmful teri, nd synthesizing ntiodies to protet the ody ginst future exposure to these teri nd viruses. The two si types of immunity re innte nd dptive the ltter lso referred to s quired immunity. Some of our white lood ells ply role in innte immunity, others in dptive immunity, while some re involved in oth. Innte immune response is tivted minly t the site of infetion, wheres dptive immune response is tivted in peripherl lymphoid orgns. The two types of responses work together to eliminte invding pthogens. Both types of immunity inlude humorl nd ell-medited immunity omponents. Humorl immunity is medited y mromoleules found in extrellulr fluids suh s sereted ntiodies, omplement proteins nd ertin ntimiroil peptides. The nme humorl derives from the ide tht the involved sustnes re found in the humors, or ody fluids. Cell-medited immunity follows prinipl mehnisms y whih ells help to defend the ody ginst infetion y killing the miroes diretly, killing the ells tht hrour miroes, preventing ess to or expelling the miroes from the ody, nd providing defene ginst lrger prsites suh s worms in the gut. The dptive immune system n rememer previous experienes. This is why we develop lifelong immunity to mny ommon infetious diseses fter our initil exposure to the pthogen.

3 3 Inflmmtion is initited nd ontrolled y phgoyti WBC suh s neutrophils, monoytes nd mrophges. But lso nturl killer ells s innte lymphoid ells re involved. Neutrophils migrte from the lood vessels into tissue during n inflmmtory response nd ttk miroorgnisms suh s teri nd fungi. Bsophils initite n inflmmtory response to environmentl ntigens, wheres eosinophils defend the ody ginst prsites nd/or llergens. Nturl killer ells use potent hemils to kill infeted ells upon ontt. Mrophges t s svenger ells in tissue. One mrophge phgoytoses foreign invder, it presents typil fetures of tht orgnism to T lymphoytes, produes inflmmtory meditors nd initites progression to the dptive immune response. Neutrophil tivtion With norml dults, neutrophils ount for more thn hlf of the irulting white lood ells [3]. Together with monoytes nd mrophges they re ommonly known s professionl phgoyti ells of the innte immune system. However, neutrophils use t lest two different strtegies to fight pthogens: phgoytosis nd seretion. One tivted, they serete vriety of proinflmmtory ytokines nd ntiteril sustnes nd lso t s ntigen-presenting ells, whih re le to tivte the dptive immune response [4]. Fig. 1 Different exmples of neutrophils ) toxi grnultion ) Döhle odies ) intrellulr grm-negtive rods d) vuolistion The ove eing intrellulr tivities, neutrophils lso entrp nd kill teri extrellulrly y forming neutrophil extrellulr trps (NETs) [6], whih re networks of extrellulr fires, primrily omposed of DNA. NETs provide for high lol onentrtion of ntimiroil omponents nd ind, disrm nd kill miroes extrellulrly, independent of phgoyti uptke. d Altertions in neutrophil morphology (size, shpe nd omposition), mehnis (deformility) nd motility (hemo txis nd migrtion) hve een oserved during infetion [5]. Ativted neutrophils n e distinguished morpho logilly from resting neutrophils y different fetures (Fig. 1 d). Toxi grnultion is the term used to desrie n inrese in the stining density nd numer of grnules tht ours regulrly with teril infetion nd often with other uses of inflmmtion. The presene of ytoplsmi vuoles is inditive of n inresed phgoyti tivity of the neutrophils in response to teril infetion. Rrely, in the presene of overwhelming numers of teri or fungi, miroorgnisms re seen within vuoles or freely in the ytoplsm of the neutrophils. Mny neutrophils in the loodstrem ontining Döhle odies re lso sign of tivtion fter inflmmtory stimultion. Lymphoyte tivtion The primry ells tht ontrol the dptive immune re sponse re the lymphoytes, in prtiulr the T nd B ells. Mture T ells eome tivted y reognising proessed foreign ntigens on ntigen-presenting ells nd egin to divide rpidly so tht first memory T ells nd susequently effetor T ells re generted. In the humorl response, B ells re tivted to serete ntiodies, whih ind speifilly to the foreign ntigen tht stimulted their prodution. In ertin ses in the erly phse of infetion lso unspeifi (T ell-independent) ntiodies n e sereted y B ells.

4 4 T nd B ells eome morphologilly distinguishle from eh other only fter they hve een tivted y ntigens [7]. In oth teril nd virl infetions, trnsformed lymphoytes my e seen in the peripherl lood smer. Usully these ells present with heterogeneous morphologil fetures inluding lrger size, round nuleus often with lrge nuleolus, nd undnt, deeply sophili ytoplsm (Fig. 2 ). In their most mture form, whih is lled plsm ell, effetor B ells re filled with n extensive rough endoplsmi retiulum (Fig. 2d). In ontrst to tht, effetor T ells ontin very little endoplsmi retiulum nd do not serete ntiodies. From morphologil point of view, it is sometimes firly diffiult to distinguish retive lymphoytes from neoplsti ones. etween these ells (from lssil vi intermedite to non-lssil) during the ourse of n infetion or with mrophge olony-stimulting ftor (M-CSF) tretment so tht there is first n inrese of the intermedite ells followed y n inrese of the non-lssil monoytes [8]. Altertions in the distriution of monoyte susets re ssoited with linil outomes, e. g. of rdiovsulr diseses. When tivted (see Fig. 3), monoytes n eliminte pthogens y phgoytosis, relese retive oxygen speies (ROS), produe proinflmmtory ytokines nd modulte the T ell immune response. d Fig. 3 Ativted monoytes s found in infetious mononuleosis Fig. 2 Exmples of tivted lymphoytes s found in infetious mononuleosis Ativted monoytes Monoytes nd mrophges re the key plyers in the innte immune system. Their heterogeneity in size, mor pho logy, phgoyti funtion nd ell dhesion hd een desried, nd susequently three different monoyte susets lssil, intermedite nd non-lssil monoytes were defined sed on differenes in the expression of the surfe mrkers CD14 nd CD16 [8]. Clssil monoytes re the ells tht hd een known to hemtologists for entury s monoytes on the sis of struture, where s the somewht smller, non-lssil monoytes, whih ount for only 10 % of ll monoytes, were desried only 20 yers go. There ppers to e developmentl rel tionship Quntifition nd hrteristion of retive ells eyond lssil 5-prt differentil The XN-Series nlysers, whih use fluoresene flow y tom etry s the mesurement priniple for the WBC differentil, ontriute to the detetion of tivted neutrophils nd lymphoytes s these ells mesured signls differ signifintly from those of resting ells. Using fluoresene flow ytometry llows the mesurement of ell funtionlity within the sope of routine lood test.

5 5 1. Assessment of neutrophil tivtion For eh WBC tht psses the lser em, the forwrd sttered light (FSC), side sttered light () nd fluoresene intensity () signls re reorded nd grphilly displyed in sttergrm. The positioning of the neutrophil popultion in the WDF sttergrm (generted in the ourse of n XN-DIFF nlysis) llows n ssessment of the neutrophils tivtion (Fig. 4 ). When running n XN-DIFF nlysis, unique omintion of regents (lysis nd lelling) together with the inution time permits to seprte the different white lood ell popultions. First, the lysis regent perfortes ell memrnes, wherey the extent of memrne dmge depends on the lipid omposition, whih in turn depends on the ell type (mturity level) nd the stte of the ell (tivtion sttus). Ativted ells do not only hve different memrne lipid omposition ut lso show greter tivity in the ytoplsm s they tively produe e.g. ytokines. Consequently, the intensity of the fluoresene signl of tivted ells is greter thn tht of resting ells. The prmeter NEUT-RI reflets this neutrophil retivity intensity, expressed in the unit FI (Fluoresene Intensity). The 90-degree side sttered light of the WBC differentil hnnel provides informtion out ell density or omplexity, whih represents the grnulrity of the ells. Therefore, if the omplexity of neutrophils inreses upon hnge in funtionlity, e. g. y toxi grnultion or vuolistion, the position of the neutrophil luster in the sttergrm will lso e ffeted. The prmeter NEUT-GI, expressed in the unit SI (Stter Intensity), hnges ordingly. The NEUT-RI nd NEUT-GI prmeters do not reflet speifi ell ount ut the intensity of the fluoresene nd side stter signls, respetively, mesured t the entroid position of the NEUT popultion. The following prgrphs explin wht this tully signifies. Fig. 4 The WDF sttergrm plots intrellulr struture () on the x-xis nd the ontent of RNA/DNA () on the y-xis. Eh dot represents one nlysed ell. ) helthy person ) ptient with sepsis ) ptient with tuerulosis. The dotted lines were dded for illustrtion purposes. Fig. 5 WDF sttergrms showing the position of retive lymphoyte lusters ( ). ) helthy person ) lotion of AS-LYMP s n independent popultion t the top of the sttergrm ) RE-LYMP with n inresed fluoresene signl

6 6 2. Counting tivted lymphoytes The XN-Series lso supports the detetion of retive lymphoytes s their tivtion goes long with n in resed ellulr tivity in the ytoplsm. Retive lymphoytes re deteted y n inresed fluoresene signl ompred to non-tivted lymphoytes (Fig. 5 ). Ativted B lymphoytes re quntified y the prmeter AS-LYMP (ntiody-synthesizing lymphoytes) wheres ll of the tivted lymphoytes (inluding ntiody-synthesizing lymphoytes) re quntified y the prmeter RE-LYMP (retive lymphoytes). Extended Inflmmtion Prmeters The Sysmex XN-Series nlysers re le to urtely determine ounts of retive mture lymphoytes (RE-LYMP nd AS-LYMP) nd quntify the tivtion sttus of neutrophils (NEUT-GI nd NEUT-RI). These new dignosti prmeters re ville s Extended Inflmmtion Prmeters (EIP) from XN IPU softwre version onwrds. With the EIP the lortory is le to desrie inflmmtory onditions in quntittive mnner, nd therefore relily nd fster. The Extended Inflmmtion Prmeters re hemtologil prmeters derived from routine lortory test nd n e used to hrterise retive smples. The ide is to use these prmeters with retive smples, mening mlignnt ondition hs to e ruled out first, sine the tivted lymphoytes nd neutrophils n only e onfidently quntified if they re truly retive nd not mlignnt. In order to exlude potentil mlignny of smple, nlysis in the white preursor nd pthologil ell (WPC) hnnel is needed. By running XN-DIFF nd WPC nlysis nd so omining these two flow ytometry hnnels, mlignnt nd retive ells n e onfidently differentited due to their differenes in ell funtionlity. An overview of the Extended Inflmmtion Prmeters desriing ell popultion, immunologil interprettion nd referene intervl is listed in Tle 1. Clinil interprettion of the Extended Inflmmtion Prmeters The new prmeters support the differentition etween inflmmtion nd infetion, different pthogeni uses of infetion nd the different types of immune response: erly innte, ellulr or humorl immune response [9, 11 14]. Using the Extended Inflmmtion Prmeters n help liniins with the dignosis, tretment nd monitoring of ptients with inflmmtory disorders y supporting the differentition etween inflmmtion nd infetion. supporting the differentition etween different pthogeni uses of infetion (e. g. teril, virl). supporting the differentition etween different types of immune response: erly innte, ellulr or humorl immune response. This informtion my help to identify the stge of infetion. permitting detiled monitoring of inflmmtory onditions. Tle 1 Overview of the Extended Inflmmtion Prmeters Prmeter Cell popultion Detiled desription Immunologil interprettion Referene intervl 1 RE-LYMP AS-LYMP i Totl retive lymphoytes Antiody-synthesizing lymphoytes n RE-LYMP# Innte nd dptive ell-medited x 10 9 / L immune response n RE-LYMP% ii 0 5 % n AS-LYMP# Innte nd dptive humorl 0 ells/ L immune response n AS-LYMP% ii 0 % NEUT-GI Cytoplsmi grnultion of neutrophils Neutrophil Grnulrity Intensity Erly innte immune response SI [9] NEUT-RI Retivity of neutrophils (metoli tivity) Neutrophil Retivity Intensity Erly innte immune response FI [9] 1 Referene rnges should e lwys exmined for suitility in given ptient popultion ording to the method reommended y the Interntionl Federtion of Clinil Chemistry nd Lortory Mediine [10]. i When ntiody-synthesizing lymphoytes (AS-LYMP) re present, they re lso inluded in the totl retive lymphoytes (RE-LYMP). ii As perentge of ll WBC.

7 7 For supplementry informtion on the linil interprettion of the Extended Inflmmtion Prmeters you n downlod our freely ville white pper: Novel hemtologil prmeters for rpidly monitoring the immune system response. Conlusion The Extended Inflmmtion Prmeters re ville from routine lood lortory test, together with the omplete lood ount. They llow quntifition of the tivtion sttus of neutrophils (NEUT-GI, NEUT-RI) nd tivted lymphoytes (RE-LYMP, AS-LYMP). The Extended Inflmmtion Prmeters provide extr informtion out the tivtion of the immune response. One should er in mind, however, tht ll this informtion n only e relily pplied if mlignnt ondition hs een onfidently ruled out nd the smple is onfirmed s retive. Referenes [1] (ess dte: 01/2018) [2] (ess dte: 01/2018) [3] Pekelhring JM et l. (2010): Hemtology referene intervls for estlished nd novel prmeters in helthy dults. Sysmex Journl Interntionl. 20(1): Free online fter registrtion. [4] Wright HL et l. (2010): Neutrophil funtion in inflmmtion nd inflmmtory diseses. Rheumtology. 49 : [5] Zonneveld R et l. (2016): Anlyzing Neutrophil Morphology, Mehnis nd Motility in Sepsis: Options nd Chllenges for Novel Bedside Tehnologies. Crit Cre Med. 44 : [6] Brinkmnn V et l. (2004): Neutrophil extrellulr trps kill teri. Siene. 303 : [7] Alerts B, Johnson A, Lewis J et l. (2002): Lymphoytes nd the Cellulr Bsis of Adptive Immunity. In: Moleulr Biology of the Cell; 4th edition. New York: Grlnd Siene. Aville from: [9] Cornet E et l. (2015): Contriution of the new XN-1000 prmeters NEUT-RI nd NEUT-WY for mnging ptients with immture grnuloytes. Int J L Hemtol. 37(5) : e [10] Solerg HE et l. (2004): The IFCC reommendtion on the estimtion of referene intervls. The RefVl progrm. Clin Chem L Med. 42 : [11] Vn der Ven A et l.: Mnusript in preprtion. [12] Prk SH et l. (2015): Sepsis ffets most routine nd ell popultion dt (CPD) otined using the Sysmex XN-2000 lood ell nlyzer: neutrophil-relted CPD NE- nd NE-WY provide useful informtion for deteting sepsis. Int J L Hemtol. 37(2) : [13] Luo Y et l. (2013): Utility of neut-x, neut-y nd neut-z prmeters for rpidly ssessing sepsis in tumor ptients. Clin Chim At. 422 : 5 9. [14] Henriot I et l. (2016): New prmeters on the hemtology nlyzer XN-10 (Sysmex ) llow to distinguish hildhood teril nd virl infetions. Int J L Hemtol. 39(1) : [8] Ziegler-Heitrok L et l. (2010): Nomenlture of monoytes nd dendriti ells in lood. Blood. 116 : e74 e80. Sysmex Europe GmH Bornrh 1, Norderstedt, Germny Phone Fx info@sysmex-europe.om You will find your lol Sysmex representtive s ddress under EN.N.07/18