Hematologic Pathology p1-23

7/30/2019 Hematologic Pathology p1-23

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Hematopathology Preview Fri. 10/15/2010

von Willebrand Disease platelet function problem (primary hemostasis).

Bleeding time is elevated (the amount of time it takes for a laceration toclot). PT is normal. vWF serves as a receptor for platelets, and it is also thecarrier protein for Factor VIII if abnormal vWF, may also haveabnormal/deficient Factor VIII would give high PTT. This happensfrequently, but not always (so change chart to high or normal).

Hemophilia A Factor VIII deficiency the PTT will be elevated. DIC consumptive coagulopathy: bleeding clotting bleeding clotting

etc = you use up everything. Bleeding time, PT, and PTT will be high. If youmeasured fibrinogen, it would be high. If you measured D dimer, it would be

high. War/HepIf you are monitoring coumadin or heparin therapy, PT and PTT

will be abnormal. Clinically, following the PT forcoumadin therapy worksbest, and following the PTT forheparin works best.

von Willebrand Disease, Bernard-Soulier Syndrome, and GlanzmannThromasthenia:

- von Willebrand Disease deficiency of vW factor

Glycoprotein I = receptor for vW factorGlycoprotein II = the receptor for fibrinogen

- Bernard-Soulier Syndrome deficiency of Glycoprotein I (vW factor receptor)- Glanzmann Thrombasthenia deficiency of Glycoprotein II (fibrinogen receptor)

Any of these can give rise to abnormal platelet structure. If a person has a low platelet #,will have problems w/primary hemostasis

Thrombosis: many factors that favor it andmany factors that inhibit it.

Remember that in DIC, all the factors areconsumed. Patients are clotting lysingclotting lysing. They use up all the

platelets, the factors, the fibrinogen everything gets consumed and eventually theywill bleed out.

Factors that favor thrombosis:Tissue factor: produced by endothelial cellsin response to cytokines (TNF, IL-1, bacterialendotoxin); major activator of extrinsic clottingcascadePAIs: produced by endothelial cells; inhibitorsof plasminogen activator limit fibrinolysisand favor thrombosis

Factors that inhibit thrombosis:

Prostacyclin (PGI2) + NO: produced by endothelial cells to impede platelet adhesionAdenosine diphosphatase: degrade ADPAntithrombin III: with cofactor, inactivate thrombinThrombomodulin: binds thrombin convert to anticoagulant via ability to activate protein C

- Protein C inhibits clotting by inactivating Va + VIIIaTissue Factor Pathway inhibitor(TFPI): cell surface protein that directly inhibits TF VIIa and Xat-PA: protease cleaves plasminogen to form plasmin plasmin cleaves fibrin to degrade thrombi

Remember that in DIC, all the factors are consumed. Patients are clotting lysing clotting lysing. They use up all the platelets,the factors, the fibrinogen everything gets consumed and eventually they will bleed out.

Test q:A 66F comes to the ER 3 hours after the onset of chest pain that radiates to her neck and left arm. She is diaphoretic and hypotensive; theserum troponin I level is elevated. Thrombolytic therapy is begun. Which of the following drugs is most likely to be administered? Tissue plasminogenactivator. (Other choices: Aspirin, Heparin, NO, Vit K)

or normal


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Fibrinolysis: Plasmin: breaks down fibrin and interferes with its

polymerization FDPs: act as weak anti-coagulant factors Elevated FDPs (fibrin derived D-dimers) can be used in

diagnosing abnormal thrombotic states, including DIC, DVT,pulmonary embolism

Protein C + S: anti-coagulation factors; protein S is a cofactorfor protein C; function to degrade activated factors VIII and V

The Leiden mutation is a structural mutation in Factor V renders Factor V resistant to the action of Protein S and activated Protein C.Factor V still works, but it is no longer subject to the limitations of activated Protein C. Leiden mutation can lead to recurrent DVT.

Test q:A 25F has had multiple episodes of DVT during the past 10yr and one episode of pulmonary thromboembolism during the past year. PT, PTT,platelet count, and platelet function studies are all normal. Which of the following risk factors has most likely contributed to the patients condition?Leiden mutation. (Other choices: Antithrombin III deficiency, Mutation in protein C, Hyperhomocysteinemia, Smoking cigarettes) REPEATED x3

Above (both pictures): Thrombus causing microangiopathic hemolytic anemia. Patients w/DIC have abnormal multimers of fibrin inthe blood vessels shred RBCs as they pass through. Microangiopathic, small blood vessels, hemolytic anemia. Destroy RBCs, andthe fractured RBCs are called schistocytes. Schistocytes = microangiopathic hemolytic anemia. May have abnormal heart valve thatcould shred RBCs can also cause microangiopathic hemolytic anemia. DIC and certain types of leukemia can also cause this.

Test q:A 45M has a 3-day history of f lank pain and fever. On phys exam, his temp is 37.9C. There is right costovertebral angle tenderness. Lab

studies include a urine culture that is positive forEscherichia coli. The WBC count is 13,310/mm

3

. Two days later, he becomes hypotensive, and ablood culture is positive forE. coli. He requires increasing pressor support to maintain blood pressure. He develops a guaiac-positive stool and

ecchymoses of the skin. CBC shows Hgb 9.2 g/dL, hematocrit 28.1%, and platelet count 70,000/mm3. Increased amounts of fibrin split products are

identified in the blood (elevated D dimer). Which of the following conditions is most likely responsible for the low hematocrit? Microangiopathichemolytic anemia. (MAHA). Robbins explanation: This patient has DIC, which can result from gram-negative septicemia. This is a form of MAHA in

which there is deposition of fibrin strands in small vessels. The RBCs are damaged during passage between these strands. Coagulation factors andplatelets are consumed, which does not occur w/other forms of hemolytic anemia.

Tumor Markers:PSA Prostate cancer = prostate specific antigen

CEA Colorectal/PancreaticCA 19-9 PancreaticAlpha-fetoprotein Hepatic/Yolk sacBeta-HCG Choriocarcinoma/Molar pregnancy

CA 125 Ovarian cancerS-100 Melanoma/AstrocytomaThyroglobulin Thyroid cancerCalcitonin Medullary carcinoma of ThyroidCatecholamines Pheochromocytoma/NeuroblastomaTRAP stain Hairy cell leukemia = tartrate resistant acid phosphatase

Alkaline phosphatase Mets to bones, Pagets disease of bone

Test q:A 76M has experienced lower back pain for the past year. On phys exam, the physician palpates a firm nodule in the prostate. Lab studiesshow an alkaline phosphatase level of 290 U/L and a serum prostate specific antigen level of 17 ng/mL. A prostate needle biopsy specimen shows a

moderately differentiated adenocarcinoma. Which of the following mechanisms best accounts for these findings? Metastases to vertebrae. (Otherchoices: Tumor extension to rectum; Paraneoplastic syndrome; High tumor grade; and Tumor angiogenesis) REPEATED x3

Translocations:t (9;22) CML (bcr-abl)t (8;14) Burkitts lymphoma (c-myc)t (14;18) Follicular lymphoma (bcl-2)t (15;17) AML M3 (promyelocytic

leukemia)

t (1;14) T-cell Lymphoblastic lymphomat (11; 22) Ewings sarcomat (11; 14) Mantle cell lymphoma (bcl-1)t (11; 18) MALT lymphoma (API-2)t (1; 14) MALT lymphoma (bcl-10)


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Test q:A 71M present to his primary care physician for a check-up accompanied by his wife, who reports that she had to push him out of the door togo to see a doctor as his last physical exam was almost 8yr ago. He states that he has been feeling well other than having some lower back pain. Phys

exam reveals a firm, nodular prostate. On further questioning, the patient states that he has not noticed any change in urination. Lab studies reveal amildly elevated serum prostate-specific antigen level and a serum alkaline phosphatase level almost three times normal. These findings are mostconsistent w/which of the following? Metastatic prostate carcinoma.

Test q:A 77M has experienced increasing malaise and a 6kg weight loss over the past year. He has noted more severe and constant back pain for thepast 3 months. On phys exam, his temp is 38.7C. His prostate is firm and irregular when palpated on digital rectal exam. Lab studies include a urine

culture positive forEscherichia coli, serum glucose of 70 mg/dL, creatinine 1.1 mg/dL, total bilirubin 1.0 mg/dL, alkaline phosphatase 293 U/L, calcium10.3 mg/dL, phosphorus 2.6 mg/dL, and PSA 25 ng/mL. CBC shows Hgb 9.1 g/dL, hematocrit 27.3%, MCV 94m

3, platelet count 55,600/mm

3, and

WBC count 3570/mm3

with 18% segmented neutrophils, 7% bands, 2% metamyelocytes, 1% myelocytes, 61% lymphocytes, 11% monocytes, and 3

nucleated RBCs per 100 WBCs. Which of the following is the most likely diagnosis? Metastatic carcinoma.

Test q: Thyroglobulin is used clinically as: a tumor marker.

Above (left): Schistocytes fragmented RBCs. Seen in DIC, microangiopathic hemolytic anemia, mechanical heart valves.Above (right) : Can do reticulocyte count lab will tell you how many reticulocytes are present per 100. Useful when monitoringpeople with iron deficiency on iron therapy patients should start reticking. Reticking actively making red cells. People w/Fedeficiency do not make enough RBCs.

Figure: Blood smear. Want to find Goldilocks zone not too thick, not too thin, just right. Find area wherered cells are just barely touching each other.

Above: -thalassemia. See RBC abnormalities. Howell-Jollybodies nuclear remnants that remain in RBCs becausepatient does not have a functional spleen. Seen in sickle cellanemia patients because they infarct their spleen by age 6-7.These patients are also highly susceptible to infection by S.pneumoniae, Salmonella, H. influenzae (due to lack of spleen).

Above: Spherocytes RBCs are smaller and perfectlyround. Hereditary spherocytosis abnormality inmembrane of RBC take very small shape. These cellsdo not live 120 days (which classifies hereditaryspherocytosis as a hemolytic anemia). Will see nucleatedRBCs, spherocytes, and reticulocytes (aka polychromasia bi blue cells ver oun er throc tes .


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Above (left): Iron deficiency anemia. See lymphocyte RBCs are smaller than the lymphocyte (= microcytic). RBCs haveexaggerated pale area in the middle (= hypochromic donut-looking, less color). Microcytic, hypochromic anemia fits irondeficiency. Poikilocytosis = abnormal shape. Anisocytosis = abnormal size. Anisopoikilocytosis = abnormal size and shape (describesiron deficiency).Above (right): megaloblastic anemia. Macrocytic anemia RBCs are larger than the lymphocyte. They are often oval-shaped, not

round. Seen in folate/Vitamin B12 deficiency. In addition to large RBCs, will also see multisegmented neutrophils.

Case 1. 70 y.o. female with fatigue. No hemoptosis or vaginal bleeding. Normal

physical exam except for pallor.

When patients come in complaining of tiredness/have no energy, may indicate anemia not enough RBCs, not distributing enough oxygen to tissues. May also indicate apulmonary disease.

Blood smear: see lymphocyte compare RBC size microcytic. Some arehypochromic. Also see abnormal shapes. Anisopoikilocytosis. See platelets so noproblem w/the platelets.

CBC: Normal:Hgb 5.9 ~15 (man), ~14 (woman) Low. Not enough RBCs.MCV 56.2 80-100 MCV = volume of RBCs. Patients low value = microcytic anemia.RDW 20.2 Teens (13-19) Measure of size variation in RBCs. Patients is high.

WBC 5,900 4000-8000 Normal.Plt 383,000 200,000-400,000 Normal.

Normally, hematocrit = 3x hemoglobin, so normal hemotocrit for man = 45; woman = 42.

1a. The RBCs show?A. MacrocytosisB. HyperchromasiaC. SpherocytosisD. SchistocytosisE. Anisopoikilocytosis too small and some are funny-shaped.

1c. Before the patient leaves your office you should?

A. Order TSH and T3B. Order TSH and T4C. Prescribe multivitamins with ironD. Perform stool exam for occult blood ALWAYS check if patient is an older person w/iron deficiency anemia.E. Perform stool exam for hookworms and other parasites

Test q:A 70F complains of fatigue. She cites no history of hemoptosis or vaginal bleeding. Phys exam is normal except for pallor. CBC shows: Hgb

5.9 g/dL, MCV 56.2 m3, RDW 20.2, WBC 5900/mm

3, Plt 383,000/mm

3, anisopoikilocytosis. What lab result would you expect? Low serum iron and

high TIBC. Before the patient leaves your office you should? Perform stool exam for occult blood. BOTH PARTS REPEATED x2

Test q:A 73M has been healthy all his life. He takes no meds and has had no major illnesses or surgeries. However, for the past year, he has becomeincreasingly tired and listless and appears pale. Phys exam shows no hepatosplenomegaly and no deformities. CBC shows Hgb 9.7 g/dL, hematocrit29.9%, MCV 69.7mm

3(one year, MCV was 59.0), RBC count 4.28 million/mm


3, and WBC count 5500/mm

3. Which of the

following is the most likely underlying condition causing this patients findings? GI bleed. REPEATED x2 (One year, answer was occult malignancy)

1b. What lab result would you expect?A. Elevated serum ferritin B. Elevated serum ironC. High serum iron and low TIBCD. Low serum iron and high TIBCE. Low serum iron and low TIBC

D High Total Iron Binding Capacity becausepatient is trying to compensate.


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Case 2. 34 y.o. female with 2-day history of fever, petichiae and hematuria; alsoheadaches and mental confusion.

Symptoms are characteristic ofthrombotic thrombocytopenic pupura (TTP). Itis a consumptive coagulopathy (like DIC) bleeding clotting bleeding clotting. TTP has a pentad of symptoms (5 things): fever, thrombocytopenia(obvious because of petechiae), renal disease (hematuria), headache (CNSdisease), and microangiopathic hemolytic anemia (MAHA).

Blood smear: Platelets missing. See schistocytes, spherocytes, but platelets are

used up. Microangiopathic hemolytic anemia. Fits TTP.

CBC:Hgb 7.0 Low = anemic.MCV 77 Not too lowRDW 23 High consistent w/the spherocytes, schistocytes, size variation.WBC 17,000 HighPlt 14,000 Very low

2a. Describe the RBCs:A. NormochromicB. MicrocyticC. Spherocytes and schistocytesD. Drepanocytes and schistocytes

E. Howell-Jolly bodies

Schistocytes are classic in MAHA, but you also usuallysee some spherocytes.

2b. Diagnosis?A. Sickle cell anemiaB. Hereditary spherocytosisC. Thrombotic thrombocytopenic purpura (TTP)D. Anemia of chronic disease secondary tohypothyroidismE. Folate deficiency

C. TTP unknown cause. Some kind of autoimmunedisease can detect auto-antibodies, but the trigger isnot known. Much more common in females. Treatmentis exchange phoresis (trade plasma). Used to beuniversally fatal now can save 90% of patients. Tendsto recur.

2c. What test result would you expect?A. D dimer elevatedB. Haptoglobin elevatedC. Plasma free hemoglobin decreasedD. BUN normal

E. Urine protein negative

A is correct. If you have a consumptive coagulopathy(clotting lysing clotting lysing), expect to see Ddimer.B: Haptoglobin is a protein in blood that combinesw/any free hemoglobin. If youre destroying RBCs(and releasing hemoglobin) it will complex w/haptoglobin haptoglobin level goes down in hemolytic anemia.C: If you are rupturing RBCs and releasing hemoglobininto the blood, plasma free Hgb will be increased.D: BUN is a measure of renal function patient hasrenal disease, so BUN will be abnormal.

E: Patient will have proteinuria because of renal disease

Test q:A 30F mother of 4 exhibits a dramatic fall in hematocrit after atrip to West Africa. Plasmodium falciparum is identified on a Wright

stain of blood. In this patient: Haptoglobin is decreased; plasmafree Hgb is increased.

Test q:A 54F sees her physician because of sudden onset of headaches and photophobia. This condition has been worsening for the past 2 days. Onphys exam, she has a temperature of 38C and is disoriented. CBC shows Hgb 11.2 g/dL, hematocrit 33.7%, MCV 94m


3,

and WBC count 9900/mm3. The peripheral blood smear shows schistocytes. The serum urea nitrogen level is 38 mg/dL, and the creatinine level is 3.9

mg/dL. Which of the following is the most likely diagnosis? Thrombotic thrombocytopenic purpura.

Case 3. 34 y.o. male in for routine physical has pallor and icterus;splenomegaly on PE

Pale = not enough RBCs, not enough oxygenation. Icteric breaking downRBCs and releasing Hb.

Blood smear:See lymphocyte, platelets. Lots of spherocytes (small, roundRBCs), polychromasia (reticulocytes). Everything fits hemolytic anemia.

CBC:Hgb 11MCV 84WBC 6,000Plt 350,000 Hgb low. Rest normal.


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3a. Describe the RBCs.A. NormochromicB. SchistocytosisC. MicrocyticD. Spherocytosis perfectly round and dark redE. Hypochromic

3b. What test should you order to confirm your diagnosis?A. Serum ironB. Osmotic fragilityC. Reticulocyte countD. Malaria screenE. D dimer

Osmotic fragility is a test for hereditary spherocytosis (spherocytes die quickly in salt water).

In this case, the spleen is large because the spleen destroys spherocytes. Spleen recognizes that they are not normalshape or size and destroys them they do not live 120 days (definition of a hemolytic anemia). Hemolytic anemia canoccur in the blood vessels or in the spleen (intravascular vs. extravascular).

Case 4. 37 y.o. female treated lifelong for a seizure disorder complains of fatigueand lightheadedness.

A lot of seizures medications predispose to vitamin B12 deficiency. These patientsfrequently develop macrocytic anemia.

Blood smear: See hypersegmented neutrophil. No lymphocytes present for sizecomparison (RBCs), but these are large, oval RBCs = macrocytosis.

CBC: fits w/macrocytic anemia.Hgb 6 LowMCV 130 HighWBC 6,000 NormalPlt 220,000 Normal

4a. All of the following correctly describe the RBCsEXCEPT:A. NormochromicB. MacrocyticC. AnisocytosisD. OvalocytosisE. Spherocytosis not this. Would look small.

A bone marrow aspirate was performed On bone marrow aspirates, tend to see giant band neutrophils. The final stage inneutrophil development is the segmented neutrophil, and the step immediatelybefore that is the band neutrophil. If you have >5 segments in a neutrophil, toomany = macrocytic anemia. The labeled band at the top is huge should be thesame size as a neutrophil, but this is 2-3x bigger. Giant bands, hypersegmentedneutrophils in bone marrow = macrocytic anemia.

4b. What findings on the bone marrow aspirate suggest folate deficiency?A. Hyposegmented neutrophilsB. HypocellularityC. Giant bands and hypersegmented neutrophilsD. Miniature bands and hypersegmented neutrophils

E. Hypersegmented blasts and promyelocytesTest q:A 37F has been treated lifelong for a seizure disorder and now complains of fatigue and lightheadedness. CBC shows: Hgb 6g/dL, MCV 130

mm3, WBC 6000/mm

3, Plt 220,000/mm

3, ovalocytosis, hypersegmented neutrophils. You suspect: Dilantin treatment and folate deficiency.

LEUKEMIA:AcuteALL and AMLHi/Low WBC (unpredictable)Rapidly fatal if untreated (matter of weeks); anemic andthrombocytopenic (almost always. Patient is very sick.)Curable

ChronicCLL and CMLAlways high WBCSlowly progressive- patient lives many yearsDifficult to cure

M = myeloid (granulocytic); L = lymphoid (as in ALL, AML, CLL, CML).


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Acute Leukemias:

5a. In Acute Leukemias you will almost always find:A. Normal hct, normal plateletsB. Normal hct, decreased plateletsC. Decreased hct, increased paltelets

D. Anemia, thrombocytopeniaE. WBC count >100,000

D: Patient is always really sick.

Myeloid PrecursorsSegmented PMN normal, mature cell. Band isstep immediately before. In a normal patient,should not see any blasts. Blast is very earlystage if you see lots of blasts, it is an acuteleukemia.

There are two stem cells types in the bone marrow lymphocytic/plasma cell lineage andRBC/megakaryocyte/granulocyte/monocyte (everythingelse) lineage.

ALL has only one type (lymphocyte). AML has manyvarieties. Promyelocyte M3 version. Produces MAHAand DIC. Unique presentation, unique treatment.

5b. In Chronic Leukemias you will almost alwaysfind:A. Anemia, thrombocytopeniaB. WBC count >50,000

C. Normal hct, increased plateletsD. Anemia, thrombocytosisE. Circulating blasts

Above: lymphoblasts. Not normal lymphocytes very large(compare to RBCs). Have nucleoli all over the place, veryactive-looking chromatin (so they are blasts). Cannot tell bylooking at this whether they are lymphoblasts or myeloblasts can definitely tell they are blasts, however. = Acute leukemia.

Must do more testing to figure out which one.

Above: ALL (PAS stain). ALLs (lymphoid in origin)are PAS + and myeloperoxidase (MPO) negative.Makes sense since MPO is made by granules ingranulocytes so AMLs are MPO positive.


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Test q:A 37F visits her physician because of a cough and fever of one weeks duration. On phys exam, her temp is 38.3 degrees C. She has diffuse

crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. CBC shows Hgb 13.9 g/dL, hematocrit 42%, MCV 89m

3

, plateletcount 210,000/mm

3, and WBC count 56,000/mm

3with 63% segmented neutrophils, 15% bands, 6% metamyelocytes, 3% myelocytes, 1% blasts, 8%

lymphocytes, 2% monocytes, and 2% eosinophils. The peripheral blood leukocyte alkaline phosphatase score is increased. Which of the following isthe most likely diagnosis? Leukemoid reaction. REPEATED x4 (Once, was a 50M instead)

Above: Immature granulocytes (leftshift). See lots of granulocytes ininfections body produces lots ofgranulocytes in response to bacteria(WBC count very high). Will see normalgranulocytes, bands, metamyelocytes, butNO BLASTS. If you have an infection anda high neutrophil count, will get a leftshift lots of immature forms. Benign

condition.

Above: CML. Also see spectrum of cellstages, but especially see lots ofBLASTSw/nucleoli. When a patient comes in with ahigh granulocyte count, your differential mustinclude both benign condition and leukemia.If WBC count >50,000, leukemia. If lessthan 50, usually leukemoid reaction (left

shift).

Above: LAP stains. LAP = leukocyte

alkaline phosphatase. Made bynormal granulocytes, not CML cells. Ifleft shift (leukemoid reaction - benignconditions), LAP score will be >20. IfCML, they dont make it at all, so LAPscore will approach 0. Left: alkalinephosphatase stain. Benign cells.Right: LAP, CML.

Above: The real diagnosis of CML is made by cytogeneticsdemonstrating that a small piece of chromosome 22 breaks off

and attaches to chromosome 9 9 22 translocation .

Above: FISH can also diagnose if ABL (green) and BCR(red) genes are on the same chromosome, will see a yellow

color ri ht .

Above: CML and AML. See many blasts. CML amixture of forms (segmented neutrophils, bands,metamyelocytes, blasts but relatively few blasts).AML pretty much all blasts (no spectrum of forms).

Above: Left = AML. Can tell they are blasts because they are 4xthe size of RBCs and have prominent nucleoli. Know it is acuteleukemia, but cannot tell which one. Right: Presence of Auer rod(little red rod) = AML. Auer rods are crystallized myeloperoxidase same thing as on MPO stain. Auer rods are only seen in AML,but you dont have to have Auer rods to call it AML. Most AMLs

do not have Auer rods.


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M0-M7 stages classified based on how the cells look:

M1 Myeloblastic. M2 Myeloid. M3 look like promyelocytes (intermediate stage in granulocyte production), sonamed promyelocytic leukemia. Lots of granules = DIC in patient (cause MAHA). Auer rods common. Very fastprogression dead in a few days w/o treatment. For promyelocytic leukemia treatment, use retinoic acid.M4 myelomonocytic (in between granulocyte and monocyte).

Test q: The myeloperoxidase stain is generally positive in: M2, M3, M4.

Above: M6 erythroid (RBC). M7 megakaryocytic version.

Below: Myeloperoxidase (MPO)AMLs are MPO positive.

Above: Sudan Black stain. AMLsare MPO positive. If moving towardmonocyte side of spectrum, may

also be Sudan black + (fat stain).May be fat stain + or non-specific

esterase +.

Above: Nonspecific esterase. IfSudan black + and nonspecificesterase +, is either amyelomonocytic cell or monocyticcell.

Above: M5 monocytic leukemia. Patientspresent with ULCERS (deposits of these cellsin the mouth). If they have mouth ulcers orhyperplasia of the gums = monocyticleukemia. If patient presents w/MAHA, it ispromyelocytic leukemia.


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Case 6. 25 y.o. male with fever, recurrent URIs and submandibular swelling;also poor wound healing.

Submandibular swelling indicates problems in the mouth.

Blood smear: See fold in cell (top right) monocyte-like. Also see Auer rod incell (bottom right). This is an AML but going toward the monocytic series.

CBC:Hgb 9.9MCV 106.3WBC 7.9 (70% abnormal cells)Plt 50,000

Platelets are low, patient is anemic. WBC w/acute leukemias remember:may or may not be high.

6a. Diagnosis?A. ALLB. AML because Auer rod is present.C. CLLD. CMLE. Hereditary spherocytosis

Test q:A 25M has rever, recurrent URIs and submandibular swelling; also poor wound healing. The peripheral blood smear shows WBCs w/high

nucleus-to-cytoplasm ratio, prominent nucleoli, and red, needle-like cytoplasmic inclusions. Diagnosis? AML (M2). Which test on a bone marrowaspirate confirms your diagnosis? MPO(+).

Case 7. 6 y.o. male with URIs, headache, bone pain and easy bruising;axillary and cervical lymphadenopathy; hepatosplenomegaly.

Easy bruising = low platelets (thrombocytopenia). If a young child, usuallyhave ALL.

Blood smear: Top middle cell prominent fold. Right top boxing glove.

Cells look monocytic. Cleaves in cells butt cells or plumber cells. Bigcells, nucleoli = acute leukemia. Cannot tell which one just by looking.Because the patient is 6 years old = ALL.

CBC:Hgb 9MCV 82WBC 92,000 (86% abnormal)Plt 18,000

7a. Diagnosis?A. ALLB. AML

C. CLLD. CML

7b. What test results are expected on a bone marrow aspirate?A. MPO (+), PAS (+)B. MPO (-), PAS (-)

C. TdT (+), Precursor B cell (+)D. TdT (-), Precursor T cell (+)E. Sudan black B (+); CD 10 (-)

C. TdT positive and precursor B cell positive. Would be Sudan black + if we sawmonocytic cells. CD10 (cluster designation) ALL marker (aka CALLA: common ALLantigen). If patient has ALL, will be CD10+.

6b. Which test on a bone marrow aspirateconfirms your diagnosis?A. MPO (-)B. MPO (+)C. PAS (+)D. Iron stain (Prussian blue)

E. Leukocyte alkaline phosphatase = 20


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Case 8. 15 y.o. male with flulike symptoms; axillary and cervicallymphadenopathy; gums are thick and bleeding.

Blood smear: Boxing-glove nuclei. Look like monocytes.

CBC:Hgb 9MCV 90WBC 42,000 (88% abnormal)Plt 22,000 Patient is anemic; platelets are low.

BM Bx results:MPO (-)PAS (-)Sudan Black B (-)Non-specific esterase (++) marker formonocytic series.Serum lysozyme 162 (4-15 normal)

8. Diagnosis:A. AML (FAB M1)B. AML (FAB M3)C. AML (FAB M5)D. ALL (L1)E. Infectious mononucleosis

Test q:A 15M present w/flu-like symptoms; axillary and cervical lymphadenopathy; gums are thick and bleeding. CBC shows: Hgb 9g/dL, MCV 90mm3,

WBC 42,000/mm3

(88% abnormal), Plt 22,000/mm3, blasts present. Bone marrow biopsy results: MPO (-), PAS (-), Sudan Black B (-), non-specific

esterase (++), serum lysozyme 162 (4-15 normal). Diagnosis? AML (FAB M5).

Test q:A 25F visits her physician because she has had bleeding gums for the past 3 weeks. Phys exam shows that her gingivae are thickened and

friable. She has hepatosplenomegaly and generalized nontender lymphadenopathy. CBC shows Hgb 11.2 g/dL, hematocrit 33.9%, platelet count95,000/mm

3, and WBC count 4500/mm

3with 25% segmented neutrophils, 10% bands, 2% metamyelocytes, 55% lymphocytes, 8% monocytes, and 1

nucleated RBC per 100 WBCs. A bone marrow biopsy specimen shows 100% cellularity, with many large blasts that are myeloperoxidase negative andnonspecific esterase positive. Which of the following is the most likely diagnosis? Acute monocytic leukemia.

Test q:A 22y/o university student reports easy fatigability of two months duration. On phys exam, she has no hepatosplenomegaly orlymphadenopathy. Mucosal gingival hemorrhages are noted. CBC shows Hgb 9.5 g/dL, hematocrit 28.2%, MCV 94m


3, and

WBC count 107,000/mm3. A bone marrow biopsy specimen shows that the marrow is 100% cellular with few residual normal hematopoietic cells. Most

of the cells in the marrow are large, w/nuclei having delicate chromatin and several nucleoli. The cytoplasm of these cells has azurophilic, peroxidase-positive granules. Which of the following is the most likely diagnosis? Acute myelogenous leukemia.

THIS IS WHERE WE STOPPED IN CLASS. BELOW ARE THE REMAINING 26 SLIDES:

Case 9. 39-year-old female has routine workup for fibrocystic disease of

breast; splenomegaly present.

CBC:Hgb 13MCV 96WBC 133,000 (seg 56, band 15, meta 13, myelo 4, pro 3); baso 1, eo 1Plt 130,000

9. What test should you order on a bone marrow aspirate?A. MPOB. PASC. Sudan black BD. LAPE. TRAP

10. 30-y/o. female; anemia, thrombocytopenia; CBC- blasts w. Auer rods, schistocytes. Diagnosis?A. ALLB. AML, M1C. AML, M3D. AML, M5E. TTP


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Quick Look at Lymphomas:

Hodgkin Non-HodgkinRS Cells Low grade- slowly progressive, rare cureOften curable High grade- rapidly progressive; a minority are curableStage important Grade importantFew malignant cells Mostly lymphoma< cell-mediated < humoralLocalized radiation Systemic chemotherapy

Follicular hyperplasia, lymph node. See benign Follicular hyperplasia, lymph node. Seefollicles, mantle zone. benign follicles, mantle zone.

Follicular hyperplasia, lymph node. See mantle Follicular hyperplasia, lymph node. Seezone, dark zone, and light zone. See tingible tingible body macrophages, mantle zone, andbody macrophages. lymphoycytes.

Follicular lymphoma, lymph node. See follicles. Follicular lymphoma, lymph node. See follicles.


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Follicular lymphoma, lymph node. See lymphocytes. SLL/SLL, lymph node. See lymphocyte infiltration.

SLL/CLL, spleen see lymphocyte infiltration. SLL/CLL, lymph node. See lymphocytes.

Burkitt Lymphoma, soft tissue. See tingible body Burkitt Lymphoma, soft tissue. See stars and sky.macrophages (stars) and lymphocytes (sky).


14/23

Nodular Sclerosis Hodgkin Lymphoma, Lymph Node. Hodgkin Lymphoma. See eosinophils, lymphocytes,See fibrous bands, nodules. and Hodgkin cells.

Hodgkin Lymphoma, Spleen. See lymphocytes and Radiograph of Plasma Cell (Multiple) Myeloma.Reed-Sternberg cells. See punched out lesions.

Plasma cells and bone spicule. Plasma Cell (Multiple) Myeloma, Bone. See plasma cells.


15/23

Laboratory Session: Abnormalities of Hemostasis Wed. 10/13 or Thurs. 10/14/10

This is the lab talk from the first lab week of this block I usually dont post lab material, but there are some lecture testqs from this material.

Primary Hemostasis:

1. Platelets bind via glycoprotein Ib (GpIb) receptors to von Willebrandfactor (vWF) on exposed ECM and are activated, undergoing shapechange and granular release

2. Released ADP and TxA2 induce additional platelet aggregationthrough platelet GpIIb-IIIa receptor binding to fibrinogen primaryhemostatic plug

vWF helps platelets stick to the endothelium. Plavix blocks the ADPreceptor blocks adherence/aggregation of platelets.

Test q: The 3 factors involved in primary hemostasis are: Platelets, endothelium, and von Willebrand factor.

Secondary Hemostasis:Local activation of the coagulation cascade (involving tissue factor andplatelet phospholipids) results in fibrin polymerization, cementing theplatelets into a definitive secondary hemostatic plug.

Tissue factor (Factor III, thromboplastin): membrane-boundprocoagulant glycoprotein synthesized by endothelial cells. Acts inconjunction with factor VII as major in vivo initiator of coagulationcascade eventually thrombin generation

Coagulation Cascade: Thrombin is the most important coagulation factor At end of proteolytic cascade, thrombin converts fibrinogen into fibrin monomers that polymerize into an insoluble gel.

Fibrin gel encases platelets Fibrin polymers are cross-linked and stabilized by factor XIIIa

Binding of coagulation factors II, XII, IX, X to calcium depends on addition of y-carboxyl groups to certain glutamic acidresidues. Reaction uses Vitamin K as a cofactor and is antagonized by drugs such as coumadin.

There is a balance of factors thatfavor thrombosis and factors thatinhibit thrombosis. If the balance isthrown off, may have bleeding ormay have thrombosis. (See page 1of this study guide for complete infoon the pro- and anti-thromboticfactors)


16/23

Test of Primary Hemostasis:

PFA-100: Objective test (vs Bleeding Time) Collagen + Epi prolonged = ASPIRIN Collagen + Epi and collagen + ADP prolonged = VON WILLEBRAND

Test q:A 51y/o obese woman w/a history diabetes mellitus had a myocardial infarction three months ago. She is now taking a low dose of aspirin toreduce the risk of arterial thrombosis. On which of the following steps in hemostasis does aspirin have its greatest effect? Aggregation of platelets.(Other choices: Adhesion of platelets to collagen, Production of tissue factor, Synthesis of vWF, and Synthesis of antithrombin III) REPEATED x3

review question from Exam 1 but showed up on 3 different years of Exam 2, too.

Intrinsic pathway: Expose Hageman factor (XII) tothrombogenic surfaces.

Extrinsic pathway: Most physiologically relevantpathway for coagulation to occur following vasculardamage. Activated by tissue factor, expressed at sites ofinjury. Ischemia and tissue damage activate Factor VII complexes w/tissue factor.

Vitamin K Dependent Factors: II VII IX X Protein C Protein S Fetal Bone Protein

Vitamin K deficiencies- liver disease, malabsorptivedisorder

Test q: Vitamin K dependent factors and proteins include all of thefollowing EXCEPT: VIII. (Other choices: II, VII, X, Protein S)

aspirin affectsplatelet aggregation


17/23

Tests for Secondary Hemostasis:

Fibrinolysis: Plasmin: breaks down fibrin and interferes with its

polymerization FDPs: act as weak anti-coagulant factors Elevated FDPs (fibrin derived D-dimers) can be

used in diagnosing abnormal thrombotic states,including DIC, DVT, pulmonary embolism

Protein C + S: anti-coagulation factors; protein Sis a cofactor for protein C; function to degradeactivated factors VIII and V

INR (wantbetween 2-3)

used to measureCoumadin therapy

used to measureHeparin therapy

Abnormal PTT in hemophilia and VonWillebrands Disease.

Lupusanticoagulant

Leiden mutation resistantto contol by Prot C & S(anticoagulant factors)

Lupus- anti-coagulant factor (in vitro) b/cincrease PTT

Leiden mutation: single-nucleotidemutation in factor V Recurrent DVT Factor V resistant to cleavage by

Protein C (anti-coagulant factor)


18/23

Case 1:

Bleeding into joint after minor fall + no family history of bleeding disorderHemophilia A: most commonly familial but also sporadic

The high APTT is consistent w/hemophilia. Normal PT.

Factor VIII mutation is most common.Factor IX is #2.

Below: Hemophilia shows bleeding into joints and/or large muscles.

Test q:A 6yo child has a long history of a hereditary bleeding disorder characterized by spontaneous nontraumatic hemorrhages into joint spaces,skeletal muscle, and mucous membranes. Lab studies reveal a normal PT, elevated PTT, very low factor VIII, normal factor X, normal factor CI, andnormal platelet aggregation studies w/ristocetin. Which of the following is the most likely diagnosis? Hemophilia A.

Test q:A common complication in patients w/hemophilia is: Hemarthrosis.

Test q:A 5y/o boy has had a history of easy bruising and blood in his urine since infancy. Phys exam shows no organomegaly. He has severalecchymoses of the skin on the lower extremities. Lab studies show Hgb 13.1 g/dL, hematocrit 39.3%, platelet count 287,600/mm

3, WBC count

6830/mm3, PT 13s, PTT 54s, and less than 1% factor VIII activity measured in plasma. If he does not receive transfusions of recombinant factor VIII

concentrate, which of the following manifestations of this illness is most likely to ensue? Hemarthroses. REPEATED x2

Above: symptoms of hemophilia. Includes easy

bruising, hepatitis, muscular hematomas, CNShemorrhages, Pneumocystis pneumonia (in AIDS),operative/post-operative bleeding, and spontaneoushemarthoses (bleeding into joints).


19/23

Hemophilia: Usually X-linked but not always clear.

Case 2:

However, note that there is no bleeding into joints, muscles, CNS.

Lab screen tests: Bleeding time is elevated. Could indicate the absence ofvon Willebrand factor(defect in primary hemostasis).

Test q: Which of the following is responsible for a defect in primary hemostasis? vonWillebrand factor. (Other choices: Factor V; Factors II, VII, IX, and X; Factors VIII and IX;

Fibrinogen)

Symptoms include mucous membrane bleeding, ecchymoses, and bleeding from venupuncture sites.

There is no bleeding into joints or muscles.

Platelet activation by ADP triggers conformational change in theplatelet GpIIb-IIIa receptors that induces binding to fibrinogen, a largeprotein that forms bridging interactions between platelets promote

platelet aggregation.

Platelet adhesion to ECM is mediated largely via interactions withvWF, which acts as a bridge between platelet surface receptors(glycoprotein Ib) and exposed collagen.

vWF associations are needed to overcome the high shear forces offlowing blood.

Bernard-Soulier syndrome: deficiency in vWF receptor (or GpIb)von Willebrand disease: deficiency in vWFGlanzmann thrombasthenia: absence of GPIIb-IIIa complex


20/23

Case 3:

Chronic diarrhea = Malabsorbing fat = malabsorbing Vitamin KSteatorrhea = fat in stool (abnormal). Sudan black (fat) stain will be positive.

Intrinsic (II, IX, X) and extrinsic (VII) coagulation cascadeabnormalities are present. Vitamin K deficiency.

Vitamin K Dependent Factors: II VII

IX X Protein C Protein S Fetal Bone Protein

Test q:A Caucasian infant presents w/failure to thrive and chronic diarrhea. There isoozing from a recent skin laceration. Stoll sample testing reveals steatorrhea.

Diagnosis: Vitamin K deficiency.

Test q:An infant born at term has Apgar scores of 8 and 9 at one and five minutes. The infant appears healthy, but three days after birth, there is

bleeding from the umbilical cord stump, and ecchymoses are observed over the buttocks. Seizures soon develop. A deficiency of which of the followingnutrients best accounts for these findings? Vitamin K (Other choices: Iron, Vit E, Folic acid, Iodine)

Case 4:

Preeclampsia: hi BP, proteinuria, edema, predisposed to develop DIC (constantly clotting and lysing using upcoagulation factors, fibrinogen). Cause: tissue anoxia or ischemia trigger event. Preeclampsia can also lead toeclampsia (life-threatening for mother and baby).

Normal: PT, PTT because not full blown eclampsia

D-dimers increased: b/c constant clot and lyse; allfactors used up eventually in DIC


21/23

Schistocytes = chopped up RBCs.

Above (middle): Schistocyte in microangiopathic hemolytic anemia, most commonly seen with DIC. Microvascularlesion that results in luminal narrowing, often due to deposition of fibrin and platelets. Vascular changes produce shearstresses that mechanically injure passing red cells. Regardless of cause, traumatic damage leads to appearance of redcell fragments (schistocytes) in blood smear.Above (right): Child w/DIC secondary to H. influenzae sepsis. DIC also in infectious disease. DIC may becomplication of anything that goes wrong with placenta.

Test q:A 60M has developed widespread ecchymoses over the skin in the past month. His medical history includes a diagnosis or mucinous

adenocarcinoma of the rectum. On phys exam, he appears cachectic and pale. An abdominal CT scan shows multiple hepatic masses. Lab studiesshow PT 30s, PTT 55s, platelet count of 15,200/mm

3, fibrinogen level of 75 mg/dL, and fibrin split product levels (D dimer) that are very elevated.

Which of the following morphologic findings is most likely to be present on exam of his peripheral blood smear? Schistocytes. REPEATED x2

Robbins: The patient has DICschistocytes.

Test q:A 23F in her 25th

week of pregnancy has felt no fetal movement for the past 3 days. Three weeks later, she still has not given birth and suddenl

develops dyspnea w/cyanosis. On phys exam, her temp is 36.9C, pulse 102/min, respirations 21/min, and blood pressure is 80/40 mm Hg. She haslarge ecchymoses over the skin of her entire body. A stool sample is positive for occult blood. Lab studies show an elevated PT and PTT. The plateletcount is decreased, plasma fibrinogen is markedly decreased, and fibrin split products are detected. A blood culture is negative. Which of the following

is the most likely cause of the bleeding diathesis? Increased consumption of clotting factors and platelets. (Other choices: Increased vascularfragility, Toxic injury to the endothelium, Reduced production of platelets, Defects in platelet adhesion and aggregation.) Robbins: The presence ofthrombocytopenia, increased PT/PTT/fibrin split products, and low fibrinogen concentration all suggest DIC, which was most likely caused by a retained

dead fetus, an obstetric complication that can lead to DIC through release of thromboplastins from the fetus. This release causes widespreadmicrovascular thrombosis and consumes clotting factors and platelets.

Case 5:

PFA-100 is somewhat decreased. Likely to thrombose.


22/23

Counter-regulatory mechanisms, mediated by tissue plasminogenactivator (t-PA, fibrinolytic product) and thrombomodulin, confinehemostatic process to site of injury.

Thrombomodulin: bind to thrombin and converts it fromprocoagulant into anticoagulant via its ability to activate Protein C,which inhibits clotting by inactivating factors Va and VIIIa.

DVT can break off to cause pulmonary embolus.

Above: Can do perfusion scan to check for pulmonary embolus.


23/23

Lab preview for next week:

Goldilocks spot; not too thick and not too thin:

Iron deficiency anemia.

Sickle cell anemia is an example of a hemolytic anemia.

Documents

Hematologic Pathology p1-23