Cell disorder for hematology course.pptx

Hematology

1. CHAPTER-ONE FUNCTION AND STRUCTURE OF RED BLOOD CELL 1 3/24/2024 BY:TAMIRAT E

2. Outline 2 Red blood cell membrane M orphology of normal red cells A bnormal red blood cells forms Ansiocytsosis Pokilocytosis 3/24/2024 BY:TAMIRAT E

3. 3/24/2024 BY:TAMIRAT E 3 Introduction The structure of Red blood cell membrane is composed of Lipid membrane Surface or membrane protein Carbohydrates

4. RBC Membrane composition 3/24/2024 BY:TAMIRAT E 4

5. 3/24/2024 BY:TAMIRAT E 5 Carbohydrate on RBC membrane They occur only on the external surface of red blood cells T hey are composed of glycoproteins and glycolipids they are important for: R ecognizing harmful cells (cell-cell recognition ) and providing protection for cells . Red blood cell membrane proteins are classified into two I ntegral proteins : Proteins that cross both layers of the phospholipid bilayer Peripheral proteins : proteins that are only on the top half or bottom half of the phospholipid bilayer

6. 3/24/2024 BY:TAMIRAT E 6 Examples of integral proteins Band 3 protein, glycoporin A, B, C and D Band 3 protein   red blood cells are able to recognize metabolically active tissues and to supply the minimum amount of oxygen to the tissues . Act as anion transport channel Glycophorins. In humans, there are four glycophorins : A, B, C and D.  play an important role in the invasion of red blood cells (RBCs) by malaria parasites, which involves several ligands binding to RBC receptors Act as receptor for blood group antigens

7. 3/24/2024 BY:TAMIRAT E 7 Red cell peripheral proteins interact to from a cytoskeleton cytoskeleton act as a tough supporting a framework for lipid bilayer Examples of red blood cell peripheral proteins :- Spectrin : which is the most abundant one Ankyrin , Protien 4.1, Actin ankyrin-1 The binding of membrane proteins to one another.  maintains the stability and structure of red blood cells but also allows for their flexibility.

8. 3/24/2024 BY:TAMIRAT E 8 Spectrin T he most abundant and consist two of chains , alpha and beta, wound around each other Gives the cell membrane its flexibility and strength Actin protein A ctin proteins forms filaments that provide cells with mechanical support and driving forces for movement . It contributes to biological processes such as S ensing environmental forces , I nternalizing membrane vesicles, M oving over surfaces and dividing the cell in two

9. function of RBC Membrane Role of red cell   membrane : Surface deformability, Flexibility, Adhesion to other cells and Immune recognition. These functions are highly dependent on its composition, which defines its properties .

10. 3/24/2024 BY:TAMIRAT E 10

11. Importance of Red C ell M orphology Studies 11 The studying the morphology/structures of red blood cells is the basis of diagnosis of hematological disorders such as: Anemia Systemic diseases Infections Leukemia Other blood related disorders 3/24/2024 BY:TAMIRAT E

12. Morphology of normal m ature r ed cells (Discocytes ) 12 In health, red cells are said to be normocytic and normochromic In well spread and stained films the great majority of the cells have: Round smooth contours Have diameters within the comparatively narrow range of 6.0-8.0  m A thickness of 2.5  m at the periphery and 1.0  m in the center As a rough guide, normal red cell size appears to be about the same as that of the nucleus of a small lymphocyte 3/24/2024 BY:TAMIRAT E

13. Morphology of Normal Mature Red cells ( Discocytes ) cont’d 13 The hemoglobin stains with the eosin component of Romanowsky dyes and owing to the biconcavity of the cell, stains: More palely at the center, and Quite deeply at the periphery This depth and distribution of staining in normal red cells is described as normochromic 3/24/2024 BY:TAMIRAT E

14. Morphology of normal m ature r ed cells 14 Peripheral blood film of a healthy subject showing normal red cells and platelets. The red cells show little variation in size and shape 3/24/2024 BY:TAMIRAT E

15. Assessment of red cell structure/ morphology 3/24/2024 BY:TAMIRAT E 15 Red cell morphology is evaluated in terms of Size( Anisoscytosis ) Shape( poikilocytosis ) Colour (hemogilobin content) hypochromasia Normochromasia Polychromasia hyperchromasia Dimorphism/ Anisochromasia Arrangement Normal distribution rouleax formation Agglutination Inclusions bodies. Howell jolly bodies Cabot ring Basophilic stippling Malaria and other parasites

16. Size Variation (Anisocytosis) 16   Macrocytes Due to impaired DNA which results megaloblastic erythropoiesis synthesis leading to decreased number of cellular division and consequently a larger cell Have diameter greater than 8.0  m and the mean cell volume is also increased Because of their increased hemoglobin content they stain darker than discocytes Macrocytosis is seen in stress erythropoiesis in hemolytic anemia during recovery from acute blood loss 3/24/2024 BY:TAMIRAT E

17. Size Variation cont’d 17 The film also shows anisocytosis with both microcytes and macrocytes 3/24/2024 BY:TAMIRAT E

18. Size Variation cont’d 18 Megalocyte Large (greater diameter may measure 12  m), often oval shaped cells with increased hemoglobin content 3/24/2024 BY:TAMIRAT E

19. 3/24/2024 BY:TAMIRAT E 19 Macrocytosis may be oval or round , with specific casual relationships. Oval macrocytes are MCV>120fl S een in Megaloblasti c anaemias (folate/ cobalamin deficiencies), C hemotherapy or drug therapies such as hydroxyurea Myelodysplastic syndrome Neutrophilic hypersegementation Round macrocytes are MCV is b/n 100 and 120fl Non- megaloblastic macrocytosis Due to accelerated erythropoiesis which results release of premature red cell Seen in liver disease and excess alcohol use. Acute Blood loss, hypothyriodism

20. Size Variation cont’d 20 True megalocytes are identified only if megaloblasts have been identified in bone marrow aspirates Megalocytes are seen in vitamin B 12 and/or folic acid deficiency, in association with some leukemias and in refractory anemias 3/24/2024 BY:TAMIRAT E

21. Size Variation cont’d… 3/24/2024 BY:TAMIRAT E 21 Microcytes Defect in impaired hemoglobin synthesis:- which results in microcytic picture. MCHC<32% and increased central pallor area Have diameter less than 6.0  m but may appear to have normal size caused by flattening of the cells during smear preparation The mean cell volume is decreased to less than 80.0fl Area of central pallor usually increases because of the coexistent hypochromia Are seen in iron deficiency anemia and a slight degree of microcytosis is seen in inflammation

22. Size Variation cont’d 22 Microcytosis in a patient with β thalassaemia trait 3/24/2024 BY:TAMIRAT E

23. 2. Variation in Shape ( Poikilocytosis ) 3/24/2024 BY:TAMIRAT E 23 Poikilocytes are categorized as either Spiculated or Non- spiculated . Spiculated red cells have at least one pointed projection from the cell surface. S piculated poikilocytes includes :- Burr cells( E chinocyte ), schistocytes (red cell fragments), S ickled red cells (drepanocytes), A canthocytes and tear drop red cells (dacrocytes). Non- spiculated poikilocytes include :- Target Cells, Ovalocytes Stomatocytes

24. Variation in Shape (Poikilocytosis ) 24 Acanthocytes Spheroidal cells with 3-12 spicules of uneven length irregularly distributed over the cell surface. Acanthocytes are formed caused by:- altered distribution or proportion of membrane lipids By altered distribution of membrane proteins By membrane skeleton abnormalities Seen in: disorders of lipid metabolism alcoholic liver cirrhosis and Hepatitis 3/24/2024 BY:TAMIRAT E

25. Variation in Shape cont’d 25 Acanthocytes in a patient with anorexia nervosa 3/24/2024 BY:TAMIRAT E

26. Variation in Shape cont’d 26 Dacrocytes ('Tear drop cells ') These are tear drop or pear shaped red cells Could be considered to be discocytes with a single drawn out spicule . It is thought that stretching of the cell membrane beyond a certain limit results in loss of deformability and ability to revert to normal discoid shape. Seen in : Myelofibrosis : replacement of bone marrow with full of fibers Myeloid metaplasia Tumour metastases to the bone marrow Tuberculosis Drug-induced Heinz body formation 3/24/2024 BY:TAMIRAT E

27. Variation in Shape cont’d 27 Tear drop cells 3/24/2024 BY:TAMIRAT E

28. Variation in Shape cont’d 28 Drepanocytes ('sickle cells ') Substitution of valine for glutamic acid at position 6 of the beta chain in the hemoglobin molecule These are crescent shaped red cells because of the formation of rod-like polymers of Hb S. Have an increased surface area a nd increased mechanical fragility which leads to hemolysi s severe anemia Common finding in sickle cell anemia 3/24/2024 BY:TAMIRAT E

29. Variation in Shape cont’d 29 Sickle cells in a patient with sickle cell anemia 3/24/2024 BY:TAMIRAT E

30. Variation in Shape cont’d 30 Echinocytes ('crenated cells') Red cells showing numerous, short, evenly distributed spicules of equal length These are probably the most common artifacts in a blood film: found in blood samples that have been stored for at room temperature for long duration It cause of diffusion of alkaline substances from the slide into the cells resulting in an increase in pH and thus crenation of the cells In vivo they are seen in U remia pyruvate kinase deficiency neonatal liver diseases 3/24/2024 BY:TAMIRAT E

31. Variation in Shape cont’d 31 Echinocytes Peripheral blood film showing storage Artefact- crenation (echinocytosis), a disintegrated cell and a neutrophil with a rounded pyknotic nucleus 3/24/2024 BY:TAMIRAT E

32. Variation in Shape cont’d 32 Elliptocytes/ovalocytes Normally less than 1% of the red cells are elliptical/oval shaped. Found in almost all anemias where approximately 10% of the red cells may assume elliptical/oval shape In hereditary elliptocytosis where almost all the red cells are elliptical . 3/24/2024 BY:TAMIRAT E

33. Variation in Shape cont’d 33 Peripheral blood film of a patient with hereditary elliptocytosis showing elliptocytes and ovalocytes 3/24/2024 BY:TAMIRAT E

34. Variation in Shape cont’d 34 Schistocytes ('fragmented cells') Two types can be distinguished: Small fragments of cells of varying shape, sometimes with sharp angles or spines ( 'spur cells' ), sometimes round in contour, usually staining deeply but occasionally palely as a result of loss of hemoglobin at the time of fragmentation 3/24/2024 BY:TAMIRAT E

35. Variation in Shape cont’d 35 Schistocytes Peripheral blood film of a patient with compound heterozygosity for haemoglobin S and haemoglobin S-Oman showing the ‘Napoleon hat’ red cells that are characteristic of haemoglobin S-Oman 3/24/2024 BY:TAMIRAT E

36. Variation in Shape cont’d 36 Larger cells mainly with round contour from which fragments have been split off, e.g., 'helmet cells' They are findings in certain genetically determined disorders , e.g., The thalassemias Hereditary elliptocytosis Acquired disorders of red cell formation, megaloblastic and iron deficiency anemias Direct thermal injury as in severe burns   3/24/2024 BY:TAMIRAT E

37. Variation in Shape cont’d 37 Leptocytes ('target cells'/'Mexican hat cells') They are abnormally thin cells with an area of central staining They are common findings in obstructive liver diseases where there is accumulation of cholesterol and lecithin Variable numbers are seen in iron deficiency anemia Common finding in all types of thalassemia There is gross target cell formation after splenectomy Bull´s eye like structure 3/24/2024 BY:TAMIRAT E

38. Variation in Shape cont’d 38 Peripheral blood film of a patient with haemoglobin C disease showing irregularly contracted cells and several target cells 3/24/2024 BY:TAMIRAT E

39. Variation in Shape cont’d 39 Stomatocytes These are cells with a narrow slit like area of central pallor They are common findings in liver diseases associated with chronic alcohol abuse Mouth like structure 3/24/2024 BY:TAMIRAT E

40. Variation in Shape cont’d 40 Spherocytes/ Microspherocytes Dense staining spherical cells with smaller diameter and greater thickness than normal They are formed as a result of loss of membrane due to: Genetic lack of structural proteins in the red cell membrane Chemicals Bacterial toxins ( Clostridium welchii ) Antibody-mediated hemolytic anemias Burn injury 3/24/2024 BY:TAMIRAT E

41. Variation in Shape cont’d 3/24/2024 BY:TAMIRAT E 41 They are commonly seen in hereditary spherocytosis that is associated with: A bnormalities in membrane protein (band 3, band 4.2 and ankyrin L ipid loss E xcessive flux of Na + across the membrane

42. Variation in Shape cont’d 42 Peripheral blood film of a patient with severe burns showing spherocytes, microspherocytes and red cells that appear to be budding off very small spherocytic fragments Peripheral blood film of a patient with clostridial septicaemia showing many spherocytes Peripheral blood film of a patient with hereditary spherocytosis as a result of a band 3 mutation showing pincer or mushroom cells 3/24/2024 BY:TAMIRAT E

43. Arrangement /distribution of red cells 43 Rouleaux formation Red cells are aligned in formations resembling stacks of coins May be seen as artifacts in the thick areas of the blood film They are often associated with: Hyperproteinemia C hronic inflammatory disorders M ultiple myeloma M acroglobulinemia 3/24/2024 BY:TAMIRAT E

44. Variation in Shape cont’d 44 Peripheral blood film in multiple myeloma 3/24/2024 BY:TAMIRAT E

45. Abnormalities in Red cell Hemoglobinization 45 A. NORMOCHROMASIA or Normochromatic The term normochromic indicates normal color . Pallor area does not exceed 3µm when measured linearly. Hemoglobinized cytoplasm with distinct zone of central pallor area . Normal red cell will appear reddish-orange in color . 3/24/2024 BY:TAMIRAT E

46. Abnormalities in Red cell Hemoglobinization contnued … 3/24/2024 BY:TAMIRAT E 46 B. Hypochromia/Hypochromasia Hypochromic red cells: Contain less than the normal amount of hemoglobin The central pale area is increased to more than one-third of the cell diameter In severe hypochromia the hemoglobin appears as a thin rim at the peripher y of the cell NB: any RBC having central area of pallor greater than 3µm is said to be hypochromic

47. Abnormalities in Red cell Hemoglobinization cont’d 47 Hypochromic red cells in a patient with iron-deficiency anemia 3/24/2024 BY:TAMIRAT E

48. Abnormalities in Red cell Hemoglobinization cont’d 48 hypochromaisa is a consistent finding in I ron deficiency anemia, T halassemia and S ideroblastic anemia . 3/24/2024 BY:TAMIRAT E

49. Abnormalities in Red cell Hemoglobinization cont’d 49 C . Hyperchromia / Hyperchromasia Because over-saturation of a red cell can not take place , true hyperchromia does not exist Usually, deep staining of red cells (no central pallor) is seen in: Macrocytosi s when the red cell thickness is increased and the mean cell volume also increased ( MCHC>36%) Spherocytes in which the red cell thickness is greater than normal and the mean cell hemoglobin concentration is slightly increased Decreased or absent of central pallor area Seen patients with hemolytic anemia or severe burn.   3/24/2024 BY:TAMIRAT E

50. spherocytes 3/24/2024 BY:TAMIRAT E 50

51. Abnormalities in Red cell Hemoglobinization cont’d 51 Polychromasia/ Polychromatophilia As reticulocytes contain residual RNA: They will have the affinity for the basic component of the Romanowsky stain, and Assume a degree of blue staining proportional to the amount of RNA An increase in reticulocytes in the peripheral blood will be seen as a polychromatic red cell population which is also macrocytic 3/24/2024 BY:TAMIRAT E

52. Abnormalities in Red cell Hemoglobinization cont’d 52 Fragments including microspherocytes in the peripheral blood film of a patient with the haemolytic uraemic syndrome. The film also shows polychromasia and a nucleated red blood cell (NRBC) A polychromatic cell which is also larger then a normal cell; it may be designated a polychromatic macrocyte 3/24/2024 BY:TAMIRAT E

53. Abnormalities in Red cell Hemoglobinization cont’d 53   Dimorphism/ Anisochromasia   This is the presence of two populations of red cells , namely hypochromic and normochromic, in the same film in approximately equal proportions It is a finding in: Treated iron deficiency anemia where there is the new normochromic red cell population a nd the original hypochromic population , and Patients with hypochromic anemia who have been transfused 3/24/2024 BY:TAMIRAT E

54. Abnormalities in Red cell Hemoglobinization cont’d 54 A dimorphic peripheral blood film from a patient with sideroblastic anaemia as a consequence of a myelodysplastic syndrome. One population of cells is normocytic and normochromic while the other is microcytic and hypochromic 3/24/2024 BY:TAMIRAT E

55. Red cell inclusions 55 Basophilic stippling/ Punctate basophilia The red cells contain small irregularly shaped granules which stain blue in Wright stain and which are found distributed throughout the cell surface. It is a common finding in: lead poisoning anemias associated with disorders of hemoglobin synthesis 3/24/2024 BY:TAMIRAT E

56. Red cell inclusions cont’d 56 Prominent basophilic stippling in the peripheral blood film of a patient who has inherited both β thalassaemia trait and hereditary elliptocytosis 3/24/2024 BY:TAMIRAT E

57. Red cell inclusions cont’d 57 Howell-Jolly bodies Small , round inclusions that contain DNA and are usually eccentrically located in the cell They stain deep purple Found: In megaloblastic anemia In some hemolytic anemias, and After splenectomy 3/24/2024 BY:TAMIRAT E

58. Red cell inclusions cont’d 58 The blood film of a splenectomized post-renal transplant patient with megaloblastic anaemia caused by azathioprine therapy showing macrocytosis, acanthocytes and prominent Howell–Jolly bodies 3/24/2024 BY:TAMIRAT E

59. Red cell inclusions cont’d 59 Cabot's rings These are incomplete or complete rings, even figures of '8’ They appear as reddish - violet fine filamentous configuration sin Wright- stained films They are remnants of the microtubules of the mitotic spindle Blood Parasites Malaria Babesia 3/24/2024 BY:TAMIRAT E

60. Red cell inclusions cont’d 60 Ring forms and an early gametocyte of P. falciparum Blood film from a hyposplenic patient with babesiosis caused by Babesia divergens showing numerous parasites including a Maltese cross formation and paired pyriform parasites 3/24/2024 BY:TAMIRAT E

61. Summary for RBC Morphology RBC Morphology: Size, including alterations caused by a heterogeneous or dimorphic RBC population Haemoglobin content RNA concentration (polychromasia/ reticulocytes ) Shape alterations RBC inclusion bodies Variations in red cell pattern Rouleax formation RBC agglutination Normal RBC distribution Artifact synonyms for abnormal RBC morphology composition of RBC inclusion bodies, including stains used to identify abnormal RBC morphology with associated conditions 3/24/2024 61 BY:TAMIRAT E

62. Review Questions 62 What parameters of the red cell morphology are appraised in red cell morphology study? Supplement your answers with examples . 3/24/2024 BY:TAMIRAT E

63. Reference Clinical Hematology Book by Gamal Abdul Hamid , MD,PhD 2013 MA Lichtman , E Beutler , U Seligsohn , K Kaushansky , TO Kipps (Editors). William’s Hematology. 7 th Ed. McGraw-Hill Co. Inc. 2008. Dacie , John V and Lewis, S.M. Practical Hematology 10 th Edition Churchill-Livingstone 2014. Tronto hematology 2018 Post graduate hematology six edition 2011 Clinical laboratory hematology Oxford hand book of hematology Hematology lecture note zewdinehs hematology 2 nd Edition 63 3/24/2024 BY:TAMIRAT E