Outline: Objectives RED BLOOD CELL. Pathology of RBC and WBC. Morphology and normal value of red blood cell

Transcription

1 SCBM343: Clinical Pathology Pathology of RBC and WBC RED BLOOD CELL Niwat Kangwanrangsan, Ph.D. Department of Pathobiology, Faculty of Science, Mahidol University 272 Rama VI Road, Rachathevi, Bangkok Objectives Outline: Discuss the morphology and normal value of red blood cell Discuss the pathophysiology changes in the quantity of red blood cell Discuss the abnormal morphology of red blood cell Categorize and discuss about laboratory test procedures used in the diagnosis of red blood cell disorders Morphology and normal value of red blood cell Pathophysiological changes in the quantity of red blood cell Abnormal morphology of red blood cell Diagnosis of red blood cell disorders

2 Red Blood Cell (RBC) Erythropoiesis Factors involved in release of RBC Destruction of RBC Hypoxia Erythropoietin Thyroid hormone Androgen Growth hormone Prostaglandins

3 Red cell disorders A. Anemia - decrease in production - increase in destruction B. Polycythemia (erythrocytosis) A. Anemia a reduction in the oxygen-transporting capacity of blood, which usually stems from a decrease in the red cell mass to subnormal levels Pathology - blood loss (hemorrhage) - increased red cell destruction (hemolysis) - decreased red cell production

4 Anisocytosis aniso = unequal red blood cells present in different size Poikilocytosis red blood cells with abnormal shape normally found in patients with anemia, thalassemia, folic acid or Vit.B 12 deficiency

5 A1: Anemia of blood loss (hemorrhage) acute blood loss may results in normocytic and normochromic (recovery by compensatory rise in erythropoietin) reticulocytosis (acute blood loss >20% of blood volume hypovolemic shock*) chronic blood loss iron deficiency anemia A2: Hemolytic anemia Hereditary spherocytosis Sickle cell anemia Thalassemia Glucose-6-phosphate dehydrogenase (G6PD) deficiency Immunohemolytic anemias Malaria A3: Anemia of diminished erythropoiesis Iron deficiency anemia Anemia of chronic disease Megaloblastic anemia Aplastic anemia Myelophthisic anemia B. Polycytemia increase in red cells per unit volume of peripheral blood, usually associated with an increase in hemoglobin concentration primary polycythemia (autonomous proliferation) secondary polycythemia (elevated level of erythropoietin)

6 Lab tests for red cell disorders Complete blood count (CBC) (blood indicies; Hb, Hct, MCV, MCH, / Platelet / WBC count / Differential WBC) Reticulocyte count Special tests of blood cells Clotting test Measures of proteins and other substances Abnormal morphology of red cells anisocytosis poikilocytosis macrocytosis microcytosis hypochromia polychromasia spherocyte ovalocyte target cells acanthocytes echinocytes stomatocytes tear drop cells cigar cells bite cells red cell rouleaux Howell-Jolly bodies malaria WHITE BLOOD CELL 24

7 Outline: Lineages of Hematopoiesis Normal WBC - blood-forming / hematopoiesis - typical life span - structure and function Alterations of leukocytes - quantitative/qualitative leukocyte disorders - leukocytosis/leukopenia - morphological abnormality - common diagnosis Summary Typical life span of blood cells 27 28

8 White blood cell (WBC) count manual automated Total white cell count number of white cells per cubic millimeter of blood * reference range based on age, sex, and ethnic background Adults: x 10 3 cells/mm 3 Children: x 10 3 cells/mm 3 Newborns: x 10 3 cells/mm 3 [mm 3 = L] Differential white cell count ratio (%) of each cell type in peripheral blood ne % ly % mo - 6.0% eo - 2.5% ba - 0.0% = 100.0% Absolute white cell count total number of each cell type = %cell type counted x total white cell count 31 32

9 Neutrophil PMN M Nucleus 2-5 lobes Cytoplasm : Pale blue to pink Abundant 2 o granules % of total WBC Phagocytosis, chemotaxis Life span: hrs to 3 days Eosinophil M Nucleus: 2-3 lobes Cytoplasm: Pink, irregular borders Granules: Red to orange, round 0-5 % of total WBC count Fight parasitic worm, allergic reactions Life span : days Basophil Lymphocyte M Nucleus: 2 lobes Cytoplasm : Lavender to colorless Granules: Deep purple to black, irregular 0-1% of total WBC count Release histamine Life span: hrs to 3 days 7-18 M Nucleus : Round to oval, indented Cytoplasm : Scant to moderate, sky blue, vacuoles Granules : Few azurophilic 20-40% total WBC count CMI (T cell), HMI (B cell) Life span : days to yrs 35 36

10 Monocyte M Cytoplasm : Blue-gray Nucleus : Round, horse-shoe- or kidney-shaped Granules : Fine, ground glass appearance 3-8% of total WBC count Phagocytosis, transform to mø Life span : Month Alterations of WBC range from defects in the quality and quantity (leukopenia) to increase in number of leukocytes (leukocytosis) A. Quantitative leukocyte disorders - result from decreased production / increased destruction of WBC in circulation - response to infections B. Qualitative leukocyte disorders disruption of WBC function - result from congenital or acquired disorders A. Quantitative disorders Leukocytosis - Neutrophilia - Lymphocytosis - Monocytosis - Eosinophilia, Basophilia Leukopenia - Neutropenia - Lymphocytopenia Neutrophilia (leukocytosis, granulocytosis) >7,500 cells/cu.mm (>75%) Most common hematologic abnormalities mechanisms - increased production in bone marrow - accelerated maturation process - increases release from bone marrow - redistribution in circulation ( demarginalization ) - decreases splenic trapping 39 40

11 41 42 Shift to the Left Leukemoid Reaction Persistent neutrophilia of 30,000-50,000 /L Shift to the left WBC immature forms (increased leukocyte alkaline phosphatase) Acute infection metamyelocytes, myelocytes, band cells 43 44

12 Neutropenia < 2,000 cells/cu.mm. < 500 cells/cu.mm severe neutropenia reduced granulopoiesis / marrow injury Infections: hepatitis, typhoid, malaria Marrow aplasia Nutrition: Deficit folic acid, vit B12 Others: SLE, antileukocyte Ab, immunodef Severe granulocytopenia (Agranulocytosis) secondary to arrested hematopoiesis in bone marrow or massive cell destruction in circulation marrow suppression by chemotherapeutic drugs recurrent and persistent life-threatening infection (particularly of the respiratory system) septicemia, fever, tachycardia, ulcers in mouth Acute Infection Neutrophilia : -15,000-25,000 cells/cu.mm. good prognosis - Increased production (colony stimulating factor) Neutropenia poor prognosis - Alcoholic + malnutrition, marrow aplasia and colon, sepsis (death within 3-6 days) 47 48

13 Chronic Infection Neutrophilia > 25,000 cells/cu.mm. good prognosis Shift to the left poor prognosis * increased production of colony stimulating factor Neutropenia Shift to the left poor prognosis * septicemia, fungemia Eosinophilia > 450 cells/cu. mm. Allergic disorders (type I hypersensitivity) asthma, hay fever, exfoliative dermatitis, drug reactions Parasitic diseases (particularly metazoan parasites) Neoplasms : myeloproliferative disorders, Hodgkin disease Basophilia > 50 cells/cu.mm. Rare Response to inflammation and immediate hypersensitivity reactions Myeloproliferative disorders 51 52

14 Eosinopenia Migration of cells into inflammatory site May be seen in Cushing syndrome (steroid), and as a result of stress, shock, trauma, burns Basopenia Found in hyperthyroidism (Graves disease), acute infection, long-term steroid treatment May be seen during ovulation and pregnancy Monocytosis > 800 cells/cu.mm. often transient and not related to a dysfunction of monocyte production commonly occur with neutropenia Infections (chronic): TB, rickettsia, bacterial endocarditis (particularly in the late stage and recovery stage) Myeloproliferative disorders Hodgkin's disease can be seen in normal newborn (physiologic) Lymphocytosis > 5,000 cells/cu.mm. Physiologic: infants & young children (4 mo 4 yr) Acute infections: hepatitis, typhoid, CMV Chronic infection: congenital syphilis Metabolic disorders : thyrotoxicosis Malignancy: lymphocytic leukemia Infectious mononucleosis ("atypical" lymphocytosis) 55 56

15 Lymphocytopenia Immunodeficiency: AIDS, agammaglobulinemia (Bcell), DiGeorge syndrome (T-cell) Lymphocyte destruction: steroid, radiation, chemotherapy, Hodgkin lymphoma, renal failure, Atypical lymphocytes - Larger, more cytoplasm & nucleoli - Cytoplasm tends to be indented by surrounding RBC's - Associated with infectious mononucleosis 57 heart failure (elevated cortisol), TB, SLE, aplastic anemia 58 Pancytopenia reduction in all cellular components of blood granulocyte/monocyte/lymphocyte/erythrocyte/megakaryocyte found in leukemias (progenitor cell undergoes malignant transformation) Abnormal neutrophils Nucleus : 0-2 lobes - Pelger Huet anomaly - Pseudo Pelger Huet anomaly > 5 lobes - Hypersegmented neutrophils - Polycyte Cytoplasm : Inclusion bodies - May-Hegglin anomaly - Dohle bodies Abnormal azurophilic granules - Alder Reilly anomaly - Chediak-Steinberg Higashi syndrome - Toxic granulation Vacuole 59 60

16 Hypersegmentation PMN >5 lobe, large PMN Maturation abnormality Abnormal DNA synthesis Deficiencies of folic acid & vit B 12 Megaloblastic anemias Myeloproliferative disorders Chemotherapy Polycyte : - PMN >5 lobes, normal size - Recovery phase of infection Pelger-Huet anomaly Hereditary, autosomal dominant, neutrophils : - Mostly bilobed in heterozygote (normal function) - Unilobate in homozygote (fatal) - Excessively coarse clumping of chromatin WBC count is normal Mostly bands Infections, leukemia Metastatic cancer May-Hegglin anomaly Inherited : rare autosomal dominant, large, prominent Dohle-like bodies Leukopenia Thrombocytopenia Giant platelets Cyst-like cytoplasmic inclusions Dohle Inclusion Body Blue, small, irregularly shaped in cytoplasm (free ribosomes or RER) of N, E Acquired : - Infections - Trauma, burns - Cancer - Pregnancy - Cytoloxic drugs (poisoning) - Chemotherapy 63 64

17 Activated Neutrophil - Dohle Body Chediak (Steinberg) Higashi Syndrome 65 Giant azurophilic granules in neutrophil (rare) Abnormal lysosomes & leukocyte function Autosomal recessive: Chediak-Higashi syndrome - infections - albinism, photophobia, hepatosplenomegaly - pancytopenia - lymphadenopathy - neurologic defects 66 Toxic Granulations Increased azurophilic (1 o ) granules Bacterial infections Cytoplasmic vacuolization B. Qualitative disorders B1. Defects in cell maturation Severe infection, burn, drug 67 68

18 B2. Defects in cell activation Common Diagnosis Neutrophilia - Infection, inflammation, stress Eosinophilia - Allergies Basophilia - Polycythemias, allergic reactions Monocytosis - Lymphoproliferative disorders Leukemia Lymphocytosis - Infection, immunodeficiencies Lymphoproliferative disorders Leukemia References: 1. Pathophysiology : The Biologic Basis for Disease in Adults and Children (2010) 6 th Edition, Kathryn McCance, Sue Huether, Valentina Brasher, Neal Rote. Mosby, Elsevier 2. Pathophysiology (2009 ) Ivan Damjanov. Saunders, Elsevier 3. Blood Cells: An Atlas of Morphology (2007) Gene Gulati, Jaime Caro. American society for Clinical Pathology Press 4. Clinical Hematology Atlas (2013) 4 th Edition, Rodak BF and Carr JH. Elsevier LABORATORY 71 72

19 Blood smear 1. blood collection 2. blood film preparation 3. fixation 4. staining 5. observation

20 normocytic normochromic red cells Lab.2: RBC Morphology Sample slides Slide #2 Slide #7 Slide #8 Slide #9 Slide #10 Slide #11 Slide #xx Thalassemia Homozygous Hb CS Iron deficiency Hereditary ovalosis Hereditary spherocyte Hereditary acanthocyte Malaria Lab.2: WBC Morphology Sample slides Slide #16 Slide #19 Slide #20 Slide #21 Slide #22 Slide #24 Megaloblastic anemia (Macro-, hypersegmented) Neutrophilia (Drum stick, hypersegmented) Eosinophilia Lymphocytosis (Atypical lymphocyte) Monocytosis (monocyte vacuolization) Acute myeloblastic leukemia (Auer rods)