Hematology

hematology , iron deficiency anemia, thallasemia, microcytosis, macrocyte, hypochromic, sickle cell anemia, lymphocytes, neutrophil, RBC, basophil, eosinophil, ALL, CLL, AML, CML, Aplastic anemia, anemia of chronic disease, Vitamin B12 deficiency, folate deficiency, blasts, auer rods, sickle cell, target cells, howell jolly bodies

1. Step to PG-MD/MS/DNB - Dr.Akif A.B HEMATOLOGY - Dr.Akif A.B

2. Explaining full hematology in pdf is not possible So I will just try to help u with the peripheral smear pictures of Various conditions Rest u can follow in whichever book u r reading………….

3. Step to PG-MD/MS/DNB - Dr.Akif A.B The red blood cells here are normal RBC's . They have a  zone of central pallor  about 1/3 the size of the RBC. The RBC's demonstrate minimal variation in size ( anisocytosis ) and shape ( poikilocytosis ). A few small fuzzy blue  platelets  are seen . Segmented neutrophil Band neutrophil

4. Step to PG-MD/MS/DNB - Dr.Akif A.B A normal mature lymphocyte with a single large nucleus LYMPHOCYTE Segmented neutrophil

5. Step to PG-MD/MS/DNB - Dr.Akif A.B Here is a monocyte . It is slightly larger than a lymphocyte and has a folded nucleus. MONOCYTE

6. Step to PG-MD/MS/DNB - Dr.Akif A.B In the center of the field is an eosinophil with a bilobed nucleus and numerous bright red cytoplasmic granules. Just underneath it is a small lymphocyte. Eosinophil small lymphocyte

7. Step to PG-MD/MS/DNB - Dr.Akif A.B There is a basophil in the center of the field that has a multi-lobed nucleus (like PMN's) and numerous coarse, dark blue granules in the cytoplasm, just like tissue mast cells. A band neutrophil is seen on the left, and a large, activated lymphocyte on the right. basophil band neutrophil

8. Step to PG-MD/MS/DNB - Dr.Akif A.B The RBC's here have stacked together in long chains . This is known as " rouleaux formation " and it happens with increased serum proteins, particularly fibrinogen and globulins . Such long chains of RBC's sediment more readily. This is the mechanism for the sedimentation rate, which increases non-specifically with inflammation and increased "acute phase" serum proteins. Seen in Multiple Myeloma

9. Step to PG-MD/MS/DNB - Dr.Akif A.B The RBC's here appear smaller than normal and have an increased zone of central pallor. This is indicative of a hypochromic (less hemoglobin in each RBC) and microcytic (smaller size of each RBC) anemia. There is also increased anisocytosis (variation in RBC size) and poikilocytosis (variation in RBC shape). Seen in Iron deficiency Anemia

10. Step to PG-MD/MS/DNB - Dr.Akif A.B  larger zones of  central pallor  in these small RBCs, along with poikilocytosis . The most common cause for a hypochromic microcytic anemia is iron deficiency. Central Pallor

11. Step to PG-MD/MS/DNB - Dr.Akif A.B Microcytosis is indicated by the low MCV (mean corpuscular volume). Hypochromia correlates here with the low MCH (mean corpuscular hemoglobin).

12. Step to PG-MD/MS/DNB - Dr.Akif A.B Anemia of Chronic Disease The peripheral blood smear shown here appears normal, because it is . A normal neutrophil and lymphocyte are present. Only a CBC will demonstrate anemia. This is a normochromic , normocytic anemia.

13. Step to PG-MD/MS/DNB - Dr.Akif A.B There is impaired utilization of iron , without either an absolute deficiency or an excess of iron. There is cytokine-mediated blockage in transfer of iron from the storage pool to the erythroid precursors in the bone marrow. The defect is either inability to free the iron from macrophages or to load it onto transferrin . Inflammatory cytokines also depress erythropoiesis Inflammatory conditions release cytokines such as interleukins 1 and 6 (IL1, IL6) that stimulate hepatic production of hepcidin , which reduces iron absorption and decreases release of iron from stores in macrophages . Anemia of chronic disease is addressed by treating the underlying condition. Anemia of Chronic Disease

14. Step to PG-MD/MS/DNB - Dr.Akif A.B

15. Step to PG-MD/MS/DNB - Dr.Akif A.B Here is a hypersegmented neutrophil that is present with megaloblastic anemias . There are 8 lobes instead of the usual 3 or 4. Such anemias can be due to folate or to B12 deficiency. The size of the RBC's is also increased ( macrocytosis , which is hard to appreciate in a blood smear)

16. Step to PG-MD/MS/DNB - Dr.Akif A.B The  macro- ovalocytes  in a case of pernicious anemia are larger than the normal small  lymphocyte . Note that these large RBCs lack a zone of central pallor . There is no polychromasia , and if a reticulocyte count were done, it would be low . The serum homocysteine and methylmalonic acid levels are increased, often before macrocytosis and a decrease in cobalamin (B12) occurs. As the disease progresses cobalamin (vitamin B12) levels will be consistently decreased as well. Only homocysteine will be increased with folate deficiency.

17. Step to PG-MD/MS/DNB - Dr.Akif A.B There are numerous fragmented RBC's seen here. Some of the irregular shapes appear as " helmet " cells. Such fragmented RBC's are known as " schistocytes " and they are indicative of a microangiopathic hemolytic anemia (MAHA) or other cause for intravascular hemolysis . This finding is typical for disseminated intravascular coagulopathy ( DIC).

18. Step to PG-MD/MS/DNB - Dr.Akif A.B The CBC of a patient with microangiopathic hemolytic anemia (MAHA) demonstrates a markedly increased RDW (red cell distribution width) due to the marked variation in size and shape of the RBC population.

19. Step to PG-MD/MS/DNB - Dr.Akif A.B The RBC in the center of the field contains several  Howell-Jolly bodies , or inclusions of nuclear chromatin remnants. There is also a  nucleated RBC  just beneath this RBC. Abnormal and aged RBC's are typically removed by the spleen. The appearance of increased  poikilocytosis ,  anisocytosis , and RBC inclusions suggests that a spleen is not present . ( Asplenia ) Nucleated RBC Howell-Jolly bodies

20. Step to PG-MD/MS/DNB - Dr.Akif A.B The size of many of these RBC's is quite small, with lack of the central zone of pallor . These RBC's are spherocytes . In hereditary spherocytosis , there is a lack of spectrin , a key RBC cytoskeletal membrane protein. This produces membrane instability that forces the cell to the smallest volume--a sphere . In the laboratory, this is shown by increased osmotic fragility . The spherocytes do not survive as long as normal RBC's.

21. Step to PG-MD/MS/DNB - Dr.Akif A.B The sinusoids are packed with RBC's in this case of hereditary spherocytosis . The osmotic fragility of spherocytes is increased, because the RBC's have decreased surface area per unit volume. The major clinical features are anemia, splenomegaly , and jaundice. An aplastic crisis may occur with parvovirus infection.

22. Step to PG-MD/MS/DNB - Dr.Akif A.B   increased central pallor , consistent with hypochromic microcytic anemia . The most common cause is iron deficiency. RBC's are large and lack central pallor, consistent with  macro- ovalocytes . The most common cause is megaloblastic anemia , from vitamin B12 or folate deficiency. RBC's are small and lack central pallor, consistent with  spherocytes  lacking central pallor. Hereditary spherocytosis .

23. Step to PG-MD/MS/DNB - Dr.Akif A.B The nucleated RBCs contain  basophilic stippling  of the cytoplasm. This suggests a toxic injury to the bone marrow, such as lead poisoning . Such stippling may also appear with severe anemia, such as a megaloblastic anemia.

24. Step to PG-MD/MS/DNB - Dr.Akif A.B Atypical lymphocytes are shown here .  These WBC's are "atypical" because they are larger (more cytoplasm) and have nucleoli in their nuclei. Such atypical lymphocytes are often associated with infectious mononucleosis from Epstein-Barr virus (EBV) infection.

25. Step to PG-MD/MS/DNB - Dr.Akif A.B Bilobed neutrophils this is indicative of an uncommon condition known as Pelger-Huet anomaly , an inherited condition . associated with abnormal neutrophil function. Just be aware of this condition when you get back a  manual differential count  with mostly "bands", but the WBC count is normal or the patient shows no signs of infection or inflammation.

26. Step to PG-MD/MS/DNB - Dr.Akif A.B This is sickle cell anemia - Autosomal Recessive Disease

27. Step to PG-MD/MS/DNB - Dr.Akif A.B Though in early childhood the spleen may be enlarged with sickle cell anemia, continual stasis and trapping of abnormal RBC's leads to infarctions that eventually reduce the size of the spleen tremendously by adolescence. This is sometimes called " autosplenectomy ". Seen here is the small remnant of spleen in a patient with sickle cell anemia. Autosplenectomy

28. Step to PG-MD/MS/DNB - Dr.Akif A.B Severe, chronic anemias (such as thalassemias and sickle cell anemia ) can increase the bone marrow response to form RBC's . This drive for erythropoiesis may increase the mass of marrow and lead to increase in marrow in places, such as the skull seen here, that is not normally found. Such an increase in marrow in skull may lead to " frontal bossing " or forehead prominence because of the skull shape change.

29. Step to PG-MD/MS/DNB - Dr.Akif A.B This patient has hemoglobin SC disease , with hemoglobin S and hemoglobin C both present. With SC disease, the RBC's may sickle, but not as commonly as with Hemoglobin SS disease. The hemoglobin C leads to the formation of  " target" cells- -RBC's that have a central reddish dot. In the center of the field is a rectangular RBC that is indicative of a  hemoglobin C crystal , which is also characteristic for Hemoglobin C Disease. Hemoglobin C Crystal

30. Step to PG-MD/MS/DNB - Dr.Akif A.B Hematopoietic elements in this bone marrow biopsy are markedly reduced. This is a case of aplastic anemia. Aplastic Anemia

31. Step to PG-MD/MS/DNB - Dr.Akif A.B In contrast to aplastic anemia, leukemia results in a highly cellular marrow . The marrow between the pink bone trabeculae seen here is nearly 100% cellular, and it consists of leukemic cells of acute lymphocytic leukemia (ALL) that have virtually replaced or suppressed normal hematopoiesis . Thus , though the marrow is quite cellular, there can be peripheral cytopenias .

32. The WBC's seen here are lymphocytes, but they are blast s--very immature cells with scant cytoplasm and large nuclei that contain nucleoli. Such abnormal lymphocytes are indicative of acute lymphoblastic leukemia (ALL). ALL is more common in children than adults. Blast Cells Step to PG-MD/MS/DNB - Dr.Akif A.B

33. These mature lymphocytes are increased markedly in number. They are indicative of chronic lymphocytic leukemia most often seen in older adults . This disease responds poorly to treatment CLL is defined by more than 5000/ microliter B lymphocytes in peripheral blood marking with CD23 and CD5. Though CLL is a B cell proliferation, marking with CD19 and CD20, it is characterized by the presence of a T cell marker, CD5, as shown by flow cytometry here. This is a systemic disease, and organ involement outside of marrow, such as spleen and liver, is known as small lymphocytic lymphoma (SLL). Step to PG-MD/MS/DNB - Dr.Akif A.B

34. very large, immature myeloblasts with many nucleoli. " Auer rod " composed of crystallized granules. These findings are typical for acute myelogenous leukemia (AML) most prevalent in young adults. Acute Myelogenous Leukemia ( AML) Auer rod Step to PG-MD/MS/DNB - Dr.Akif A.B

35. There are numerous granulocytic forms seen here, including immature myeloid cells and bands. This condition is one of the myeloproliferative states and is known as chronic myelogenous leukemia (CML) that is most prevalent in middle-aged adults. A useful test to help distinguish this disease is the leukocyte alkaline phosphatase (LAP) score , which should be low with CML and high with a leukemoid reaction. Chronic Myelogenous Leukemia ( CML) Step to PG-MD/MS/DNB - Dr.Akif A.B

36. Myeloid cells of CML are also characterized by the Philadelphia chromosome (Ph1) on karyotyping . This is a translocation of a portion of the q arm of chromosome 22 to the q arm of chromosome 9, designated t(9:22). Step to PG-MD/MS/DNB - Dr.Akif A.B

37. Here is another view of a peripheral blood smear in a patient with CML. Often , the numbers of basophils and eosinophils , as well as bands and more immature myeloid cells ( metamyelocytes and myelocytes ) are increased. Unlike AML, there are not many blasts with CML. Step to PG-MD/MS/DNB - Dr.Akif A.B

38. The structure of a lymph node is diagrammed above : A - Afferent lymphatic channels B - Subcapsular sinus C - Follicle D - Sinuses E - Paracortical region F - Medullary cords G - Efferent lymphatic channel Step to PG-MD/MS/DNB - Dr.Akif A.B

39. Here is the normal appearance of a benign reactive lymph node . Lymphatics that drain tissues peripheral to the node enter the subcapsular sinus and lymph percolates around and into lymphoid follicles of variable size and having a surrounding  mantle zone  that is surrounding a  pale germinal center  in which the immune responses are often generated with a predominance of B cells .. Mantle Zone Germinal Center Step to PG-MD/MS/DNB - Dr.Akif A.B

40. Mantle Zone Germinal Center Step to PG-MD/MS/DNB - Dr.Akif A.B