Exam 2 Exam 1 Flashcards

Question

Identify cancer ‒second most common NHL ‒ 40% of adult lymphomas in US ‒Architecturally, mimics the normal lymphoid follicles ‒strongly associated with translocations involving BCL2

Answer 1

**Follicular Lymphoma** **Clinical features;** •painless adenopathy, generalized or localized •BM almost always involved – Stage 4 •Rarely PB involvement **Morphology;** * **–LN:** nodular or nodular and diffuse pattern * •2 cell types; •centrocytes - small cleaved cells •centroblasts – larger cells; count for grading •Low grade •High grade * **– BM:** paratrabecular aggregates; seen in 85% * – Spleen/Liver = white pulp; portal tracts **Diagnosis**; Immunophenotyping - CD19/CD20/CD10 - surface light chain restriction * •**BCL2 expression;** •anti-apoptosis protein •normally shut off in germinal center to allow for normal lymphocyte maturation * •**BCL6 expression;** •DNA-binding zinc-finger transcription repressor required for normal germinal center formation and regulation •3q27 * **•Genetics** – t(14;18); •14 – IGH; 18 – BCL2 Prognosis; •incurable, but indolent; high dose chemotherapy not effective •Transformation/progression to higher grade occurs in 20% at 8 years •Grade 1-2 ---- Grade 3 •DLBCL

Answer 2

**Mantle cell Lymphoma** **Clinical features;** ‒painless, generalized lymphadenopathy ‒involvement of PB varies from a few cells to a leukemic picture ‒BM involvement in most ‒Lymphomatoid Polyposis = GI involvement ‒multifocal mucosal involvement of small and large bowel **Diagnosis;** * ‒Morphology; ‒nodular or diffuse pattern ‒homogeneous population of small round to slightly irregular lymphs ‒surround and infiltrate normal germinal center ‒blastoid variant is more aggressive * Immunophenotype; ‒CD19/CD20/**CD5** ‒**bright** surface light chain ‒typically CD23 negative * Cytogenetics; ‒t(11;14) Cyclin D1 (11) with IgH (14) ‒Cyclin D1 not normally expressed in lymphocytes or myeloid cells ‒increased cyclin D1 expression = progression of cell cycle from G1 to S Prognosis; incurable

Answer 3

**Marginal Zone Lymphoma - MZL** –**extranodal** (e – mzl) vs. nodal vs. splenic in origin – 7- 8% of B cell NHL **E-MZL** * •MALT = mucosal associated lymphoid tissue •Permeable mucosal sites are vulnerable to pathogens and antigens; Peyers patches (terminal ileum) and tonsils (nasopharynx) are examples of MALT •MALT exists to protect the mucosa * •MZL = neoplastic proliferation of cells that destructively mimic the normal marginal zone of MALT **Clinical Features** ‒most cases arise in tissue that don’t normally have MALT, but instead are involved by a chronic inflammatory process ‒stomach – H. pylori ‒thyroid – Hashimotos ‒parotid – Sjogren disease **polyclonal to oligoclonal to monoclonal theory** * •reactive polyclonal inflammatory reaction * •mutations are acquired over time with the eventual emergence of an oligoclonal or monoclonal population that is still dependent on reactive T cells for growth and survival * •acquisition of t(11;18) or t(1;14) with upregulation of BCL10 or MALT1 leading to a neoplastic population that no longer responds to antibiotics * •growth now independent of extrinsic stimuli

Answer 4

Diffuse Large B cell lymphoma (DLBCL) **1) Clinical Features;** •rapidly enlarging, symptomatic mass •nodal or extranodal site •“B-type” symptoms present in many patients •BM involvement occurs late in disease **2) Morphology**; •**diffuse effacement of architecture by large lymphocytes** •convoluted nuclear contours, 1-3 nucleoli, pale cytoplasm, indistinct cell borders, mitotically active 3) Diagnosis * Immunophenotype * ‒CD19/CD20 * ‒ +/- CD10, rare CD5 * ‒ surface light chain restriction * GCB vs ABC * ‒Based on expression of CD10, bcl6 and MUM1 antigens * ‒ABC subtype is poor prognostic indicator * cytogenetics * – BCL6 (3q27) mutation – 30% * – required for normal germinal center formation * – mutation represses normal B-cell differentiation, growth arrest and apoptosis * – BCL2 (18) mutation – 20% * •may be associated with t(14;18) and be a transformed follicular lymphoma * •de-novo rearrangement * •usually lack bcl6 * – MYC (8) mutation – 5% 4) prognosis * ‒aggressive and fatal if untreated * ‒Combination chemotherapy (R-CHOP) can result in remission for 60% * ‒limited disease does better than widespread bulky disease

Answer 5

**Burkitt Lymphoma** **Clinical Features:** * •30% of childhood NHL •BM and PB involvement unusual •Usually extranodal a) Sporadic – abdominal mass (ileocecum) b) Endemic – mandibular mass or abdominal viscera * •**Tumor Lysis Syndrome**; -rapid cell turnover -tumor cell death releases uric acid, potassium, calcium -medical emergency requiring hydration, binding agents for electrolytes, and in some cases, hemodialysis * •CNS disease occurs in most patients **Morphology** **Why it grows so fast? (WARBURG EFFECT);** * •translocation involving MYC gene = increased myc protein * •myc increases expression of genes needed for glycolysis; •tumor cells can constantly be using glucose and glutamine to make all building blocks for growth and division (Warburg effect) **Diagnosis** * Immunophenotype * – CD19/CD20/CD10 – surface light chain restriction – bcl6 – myc – No bcl2, CD34, TdT – Ki67 - \>99% * Cytogenetics; translocation involving ; t(8;14) * ‒ translocation involving MYC (8) ‒t(8;14) ‒t(2;8) ‒t(8;22) **Prognosis**; •aggressive, but responds well to intensive systemic chemotherapy with intrathecal CNS chemotherapy

Answer 6

Thrombosis is a clot in the cardiovascular system 1. Endothelial injury 2. Abnormal blood flow 3. Hypercoagulability

Answer 7

**Endothelial Injury** Dysfunction of endothelium * Etiology – htn, turbulent flow, bacterial endotoxins * Increased procoagulant factors, decreased anticoagulant effectors

Answer 8

Abnormal blood flow

Answer 9

**Hypercoagulability - PRIMARY and SECONDARY condition** **Primary (Genetic)** * •Common: Mutations: Factor V, prothrombin gene, MTHFR gene (increases homocysteinemia) * •Rare: Deficiencies: antithrombin III, protein C, protein S. Antithrombin III activated by binding to heparin-like molecules then inactivates thrombin and multiple coagulation factors **Secondary (acquired)** * •High risk; •Prolonged immobilization •Myocardial infarction, a-fib, prosthetic cardiac valves •Tissue damage •Cancer •DIC •Heparin-induced thrombocytopenia (HIT) •Antiphospholipid antibody syndrome * Antiphospholipid antibody syndrome * Lower risk; •cardiomyopathy, nephrotic syndrome, hyperestrogenic states (pregnancy), oral contraceptive use, sickle cell anemia, advancing age (decreases endothelial PGI2 production), cigarette smoking, obesity **Combined States** * •Homozygous mutations •Concurrent inheritance of different mutations (combined heterozygosity) •Mutations plus acquired risk factors •Pts under age of 50 with venous thrombosis should be checked for genetic risk factors even in setting of acquired risk factors

Answer 10

**Inherited hypercoagulable state**; Factor V Leiden - Mutant Factor V is resistant to cleavage by protein C **Factor V Leiden** * •Arg→Glu substitution at a.a. residue 506 •Mutant factor V is resistant to cleavage by protein C •2-15% of Caucasians carry the mutation •Heterozygotes have 5X relative risk of venous thrombosis •Homozygotes have 50X relative risk of venous thrombosis •60% of patients with recurrent DVTs have this mutation **Prothrombin gene**; •1-2% of population carry the mutation •Mutation causes elevated prothrombin levels •3X relative risk of venous thrombosis **MTHFR gene (increases homocystenemia)**; •5 – 15% of white and East Asians carry the mutation •Variant of 5,10-methylenetetrahydrofolate reductase •Causes a modest elevation of homocysteine •Homocysteine may inhibit antithrombin III and endothelial thrombomodulin **Deficiencies (rare)**; antithrombin III, protein C, protein S. Antithrombin III binds to heparin-like molecule, inactivates heparin

Answer 11

**•Secondary (Acquired)** **•High risk;** •Prolonged immobilization •Myocardial infarction, a-fib, prosthetic cardiac valves •Tissue damage •Cancer •DIC •Heparin-induced thrombocytopenia (HIT) **•Antiphospholipid antibody syndrome** * •Antiphospholipid antibody syndrome (formerly lupus anticoagulant syndrome) * •Antibodies bind to protein epitopes exposed by phospholipids * •Mechanism by which hypercoagulability is induced is unknown **•Antiphospholipid antibody syndrome** **•Two categories of patients:** * Pts with autoimmune disease (secondary) * Pts without autoimmune disease (primary) * Clinical: recurrent thrombi and miscarriages, cardiac valve vegetations, thrombocytopenia, prolonged PTT * Treatment: chronic anticoagulation, immunosuppression **•Lower risk:** cardiomyopathy, nephrotic syndrome, hyperestrogenic states, oral contraceptive use, sickle cell anemia, advancing age (decreases endothelial PGI2 production), cigarette smoking, obesity

Answer 12

**Combined states** * Homozygous mutations * Concurrent inheritance of different mutations (combined heterozygosity) * Mutations plus acquired risk factors * Pts under age of 50 with venous thrombosis should be checked for genetic risk factors even in setting of acquired risk factors

Answer 13

* Anywhere in circulatory system * Laminations **(Lines of Zahn)** * •Pale layers are platelets * •Darker layers are fibrin and RBCs * •Indicate thrombus is formed in flowing blood * •More prominent in arterial thrombi * Attach to underlying heart or vessel wall * Types of thrombi * •Arterial system * •Venous system * •Post-mortem

Answer 14

**Coronary artery recent thrombosis - occlusive**. The while strips are cholesterol plaques **Arterial thrombi** * •Usually occlusive * •Coronary, cerebral, femoral * •Usually overlies atherosclerotic plaque * •Gray-white, friable mesh of platelets, fibrin, rbcs, wbcs * •Grows retrograde to blood flow (**toward the heart)**

Answer 15

**Venous Thrombi**

Answer 16

**Post-Mortem clots**

Answer 17

1) Propagation 2) Embolization 3) Dissolution – esp. recent thrombi 4) Organization and recanalizaton +/-incorporation * •Endothelial cells, fibroblasts, smooth muscle cells grow into clot * •Small channels develop through clot * •Clot may incorporate into vessel wall

Answer 18

1) **Venous thrombosis**; Superficial venous thrombosis 2) Deep Venous thrombosis (DVT)

Answer 19

* Coronary artery thrombosis – MI * Cerebral artery thrombosis – stroke, TIA * Femoral artery thrombosis – gangrene * Atrial mural thrombus – secondary to a-fib or mitral valve stenosis, can embolize * Ventricular mural thrombus – secondary to MI, cardiomyopathy, can embolize

Answer 20

**EMBOLISM** * Pulmoary thromboembolism * Systemic thromboembolism * Less common sources of embolism; Fat embolism, Air embolism, Amniotic fluid embolism

Answer 21

**Pulmonary thromboembolism** * •200,000 deaths per year in US * •**Source is DVT in lower extremity** in 90-95% of cases * •Often occurs as multiple emboli, sequentially or shower

Answer 22

**Systemic thromboembolism** * •Go to various sites: Lower extremities (75%), brain (10%), intestines, kidneys, spleen, upper extremities * •Ischemia or infarction of tissue distal to embolism depends on extent of collateral or dual circulation

Answer 23

**FAT EMBOLI** **Fat embolism syndrome** – **1-3 days** post injury * •Pulmonary insufficiency * •**Neurologic effects** * •Anemia and thrombocytopenia (what do you see clinically?); pallor and petechiae * •Etiology – obstruction of pulmonary and cerebral microvasculature, toxic injury from release of free fatty acids

Answer 24

**Air Embolism** •_Decompression sickness_ * •Air breathed at high pressure increases amount of air that dissolves in the blood * •Gas bubbles out of the blood during rapid depressurization forming emboli * •Gas bubbles in muscle and tissue around joints is painful, “the bends” * •Treatment: 100% O2, compression chamber

Answer 25

**Amniotic fluid embolism** •Infusion of amniotic fluid or fetal tissue into maternal circulation at delivery

Answer 26

SHOCK * •Cardiogenic shock * •Hypovolemic shock (loss of blood volume) * •Septic shock * •Anaphylactic shock * •Neurogenic shock (damage to nervous system)

Answer 27

**S**ystemic **I**nflammatory **R**esponse **S**yndrome **(SIRS)** * Diagnosed by **two or more** signs of systemic inflammation (fever, tachycardia, tachypnea, leukocytosis or leukopenia): * Temperature \>100.4°F (38°C) or \<95°F (35°C). * HR \>90 bpm. * RR \>20 breaths per minute. * WBC \>12,000/µl or \<4000/µl (immature - bands) * \>10% immature WBCs is also significant.

Answer 28

**•Sepsis** is SIRS with a culture-proven infection or obvious infection •**Septic shock** is clinical sepsis severe enough to lead to organ dysfunction and hypotension

Answer 29

**Epidemiology** * •Mortality rate is 20% * •200,000 deaths per year in US * •Number 1 cause of death in ICUs **Triggers** * •Gram-positive bacterial infections – most common * •Gram-negative bacterial and fungal infections **Major pathophysiologic factors** * •Inflammatory mediators * •Endothelial cell activation and injury * •Metabolic abnormalities * •Immune suppression * •Organ dysfunction

Answer 30

Inflammatory mediators

Answer 31

Endothelial cell activation **Thrombosis**; DIC (up to 50% of pts with septic shock) * •Inflammatory mediators stimulate tissue factor and PAI-1 production * •Decreased production of tissue factor pathway inhibitor, thrombomodulin and protein C * •Decreased blood flow producing stasis **Increased vascular permeability**; causes “3rd spacing” and edema which increases interstitial fluid pressure which impedes blood flow into the tissues = tissue hypoperfusion and stasis **Vasodilation** – Increased NO synthesis + vasoactive inflammatory mediators lead to vasodilation, hypotension and tissue hypoperfusion

Answer 32

**Metabolic abnormalities – hyperglycemia and insulin-resistance**

Answer 33

Immune suppression

Answer 34

Organ dysfunction * •Decreased cardiac output, increased vascular permeability and endothelial injury can damage the lungs resulting in **adult respiratory distress syndrome (ARDS)** * •Organs are affected by the changes that take place in septic shock particularly **kidneys, liver, lungs and heart**

Answer 35

* •**Nonprogressive phase** – reflex mechanisms compensate and tissue perfusion is maintained (SIRS) * •**Progressive stage** – tissue hypoperfusion ensues with worsening circulatory and metabolic imbalances including acidosis * **•Irreversible state** – extent of cellular and tissue injury is so great that death is inevitable even with infection control and hemodynamic correction

Answer 36

**•Treatment** * •Control infection * •Fluid resuscitation and vasopressor drugs to maintain systemic pressures * •Insulin therapy for hyperglycemia * •Corticosteroids at physiologic doses * •Anti-inflammatory tx to control inflammation has not been successful * •Activated protein C to reduce coagulation and inflammation is still controversial **Clinical Outcome (depends on the cause)** * •Initial threat of shock is **from the underlying cause**: MI, hemorrhage, infection etc. * •Rapidly the secondary complications of tissue hypoperfusion exacerbate the situation * •Prognosis varies with origin of shock, duration, and **underlying comorbidities** of the patient

Answer 37

1) TISSUE HYPOXIA 2) Amputated all extremities

Answer 38

•Group of diseases caused by a clonal plasma cell proliferation * •M component/protein = monoclonal protein secreted by the plasma cell and identified in the blood * •Bence Jones protein = the monoclonal free light chain found in the urine * •A spectrum of diseases, ranging in severity * •Multiple myeloma * •Plasmacytoma * •MGUS

Answer 39

Multiple myeloma **Pathogenesis** * •**Genetic alterations**; translocations involving IgH and Cyclins, deletions of 17p (TP53) and rearrangements involving MYC * •**tumor cells produce IL6** which is a **growth factor** for the tumor cell; •can monitor serum levels of IL6 in patients * •tumor cells influence: * •activation of osteoclasts * •inhibition of osteoblast Pathophysiology * Marrow infiltration by the plasma cells - pathologic fractures and bone pain (hypercalcemia) * Monoclonal protein production * •IgG \> IgA \> IgM, IgE, IgD * •Most patients have both increased monoclonal Ig in the blood and Bence Jones proteins in the urine * Inadequate normal immunoglobulin production

Answer 40

Multiple Myeloma Abnormal labs * - CBC: anemia, sometimes pancytopenia * - Metabolic Panel: hypercalcemia, increased creatinine * - Quantitative Immunoglobulins * - IgG \> IgA \>\>\> IgM, IgE, IgD * - one class will be elevated (monoclonal protein); the rest will be decreased **•Serum and Urine Protein Electrophoresis and Immunofixation** * •identifies, specifies and quantitates increased proteins in the gamma region * •Bence Jones Proteinuria = excess free light chains in the urine…toxic to renal tubules **•Serum Free Light Chain Immunoassay** * •baseline quantity and ratio important prognostic indicator for every type of plasma cell neoplasm * •free light chain kappa;lambda ratio is powerful determinant of disease activity **Radiology;** skeletal survey identifies bony lytic lesions (vertebral column, ribs, skull, pelvis)

Answer 41

**– disease is patchy - requires adequate BM aspirate and biopsy** * •Plasmacytosis (\>10%), groups and sheets * •inclusions can be seen * •multinucleation * •immature features = worse prognosis **– Flow cytometry: clonal light chain restricted plasma cells** * –Often have aberrant antigen expression (as compared to normal) **–PB \*\*\*_rouleux\*\*\*_ due to increased protein** **– PB plasma cell leukemia = end stage** **Peripheral blood findings in MM;** * -excess immunoglobulins are acidic and take up the basophilic stain * - increase in serum immunoglobulins cause RBC adhesion resulting in **_“rouleaux formation_**

Answer 42

Smoldering Myeloma **Treatment and Prognosis** * •Prognosis related to extent of disease burden, cytogenetics * •Morbidity/mortality related to infections, renal failure * •Chemotherapy, radiation therapy, and stem cell transplant (prolong life, but not yet curative)

Answer 43

MGUS (monoclonal gammopathy of undetermined significance)

Answer 44

Plasmacytoma

Answer 45

**Lymphoplasmacytic Lymphoma (LPL)** **_Waldenstrom’s macroglobulinemia_** * •IgM is the largest of the heavy chains so increased levels increase the blood viscosity * •Visual sx * •Neurologic sx * •Bleeding – interference with coag factors and platelets * •Cryoglobulinemia – IgM precipitates at low temps (fingers/toes) * •autoimmune hemolytic anemia (10%) * •due to cold agglutinins (IgM) that bind to RBC’s at temps \<37C * •Plasmapheresis alleviates sx by removing the large amounts of IgM **•Acquired mutation of _MYD88_**; a gene that when mutated ultimately promotes the growth and survival of tumor cells

Answer 46

**Hairy Cell Leukemia (HCL)** **Clinical Features** * ‒symptoms related to cytopenias and splenomegaly * ‒ infections * ‒fatigue, weakness * ‒early satiety * ‒spleen and BM involvement * ‒PB involvement but due to pancytopenia, sometimes hard to find the cells * ‒monocytopenia

Answer 47

**•Morphology** * •diffuse "fried eggs" in BM * •round to reniform nuclei with moderate amount of pale blue cytoplasm which has “hairs” * •cells incite reticulin fibrosis = dry tap of BM * •splenic red pulp involvement with obliteration of white pulp **Immunophenotype** * •CD19/CD20/surface light chain restriction * •CD11c/CD25/CD103 **Prognosis** * •indolent course * •**treatment differs from other NHL** because the neoplastic cells are very sensitive to a different type of chemo (purine analogs) = long remissions * •BRAF inhibitors used in patients that have failed chemotherapy

Answer 48

**Mature T cell Neoplasms** T cells do not have light chains but you can interrogate the T cell antigens with flow or immunohistochemistry. you will see some aberration

Answer 49

Peripheral T cell Lymphoma, not otherwise specified | (PTCL-NOS)

Answer 50

**ALCL (Anaplastic large cell lymphoma)** \*\*\* 3 cancers in kids; ALL, burkitt and ALCL Diagnosis **•Morphology** * •hallmark cells = large anaplastic appearing cells with horseshoe or wreath shaped nuclei * •Sinusoidal pattern * • neoplastic cells often congregate around venules and in sinuses of node. (DDx = metastatic ca) Prognosis * ‒ kids - lymphoma is ALK (+) * ‒prognosis is good with 75-80% cure rate with chemo * ‒ adults - lymphoma ALK (+) or negative; ALK negative less favorable

Answer 51

**Adult T-cell leukemia/lymphoma** (ATCL)

Answer 52

**Mycosis fungoides/Sezary syndrome (MF/SS)** Clinical Features **–MF – 3 stages:** patch, plaque, and tumor –**SS** * –generalized exfoliative erythroderma plus leukemia * –Disease can spread to involve nodes and BM Morphology - MF * • Skin – infiltration of epidermis and upper dermis * • **Neoplastic cell = cerebriform nuclear contours** Morphology – SS * • - Skin – looks same as MF * •**Sezary cell = neoplastic cell in blood**

Answer 53

Large Granular Lymphocytic Leukemia **•Felty Syndrome** * •Rheumatoid arthritis – autoimmunity provoked by the neoplastic cells * •Neutropenia * •Splenomegaly – infiltrates in the spleen •Treatment is supportive

Answer 54

**•Classical – Reed Sternberg cell** * –Nodular Sclerosing * –Mixed Cellularity * –Lymphocyte Rich * –Lymphocyte Depleted **•Nodular Lymphocyte Predominance (NLPHL)** * – L&H cell (popcorn cell)

Answer 55

Hodgkin Lymphoma 1) arises in a single node or chain of nodes **2) spreads in a contiguous fashion** * •Stage rather than histologic type is most important prognostic factor * •usually curable with radiation and chemotherapy * **•Stage I and II – 90%** * **•Stage III and IV – 70%** **3)** **Reed-Sternberg cell – the malignant cell** * •make up the minority of the cell population * •most cells are reactive cells that have been recruited by cytokines secreted by the RS cell * •cross-talk occurs between the reactive cells and the RS to support growth of RS cells * large, 15-45 um ( RBC is 6-7um) * Large, inclusion-like nucleolus * sometimes “mummify” in classical subtypes

Answer 56

Hodgkin Lymphoma - **Reed Sternberg cell variants** (clasical vs NLPHL) 1) Classical * •**Diagnostic;** •Bilobed to multilobed nucleus * **•Mononuclear;** •Single lobe nucleus * **•Lacunar;** •Above, with pale cytoplasm that has been disrupted by fixation; looks like it’s sitting in a hole * Classic RC cell immunophenotype; * –CD30 + CD15 + * – CD45, B and T cell antigen negative 2) NLPHL * •L&H; Popcorn cell; polypoid nucleus with inconspicuous nucleoli * •NLPHL L&H cell immunophenotype – CD20 + CD45 + – CD15, CD30 negative

Answer 57

* •Bimodal (classical) – young; \>55 * •painless localized or generalized adenopathy * •+/- B sx * •mediastinal adenopathy with enlarged mediastinum is common presentation * •long term survivors have increased risk of secondary malignancies (alkylating chemotherapy)

Answer 58

1. NSHL (nodular sclerosing HL) 2. MCHL (mixed cellularity HL)

Answer 59

**•Normal hematopoiesis** is fine tuned by various cytokines and growth factors * •this is deranged in marrows involved by myeloid neoplastic cells which have escaped the control factors **•Abnormal hematopoiesis** - the characteristics of the neoplasm depend on: * –the stage at which the cell escapes from control * –the effect this stage has on differentiation * •may be blocked * •may be shunted toward one lineage at the expense of the others

Answer 60

Myeloid Neoplasms - MPN (myeloproliferative Neoplasms); e.g CML - MDS - AML

Answer 61

MPN (Myeloproliferative Neoplasm) * •CML-BCR-ABL1 positive (**chronic myeloid leukemia**) * •PV polycythemia vera) * •ET (essential thrombocytosis) * •PM (primary myelofibrosis)

Answer 62

•**effective hematopoiesis**, just too much of it * •marrow hypercellularity with associated increased peripheral counts; **no dysplasia** •**Multipotent stem cell is neoplastic cell,** thus capable of giving rise to all myeloid lines * **•exception is CML** in which the neoplastic cell is a pluripotent stem cell, so it can give rise to myeloid and lymphoid lines – neoplastic stem cell can circulate and home to secondary hematopoietic organs (spleen and liver) to give rise to EMH – there is a considerable degree of overlap between the subcategories – **Genetic abnormalities have tyrosine kinase activity (cell growth)** * •t(9;22) = BCR – ABL1 = philadelphia chromosome = CML * •JAK-2 * •MPL * •CALR

Answer 63

CML (Chronic Myeloid Leukemia) Morphology (peripheral blood, bone marrow, spleen/liver) * •Peripheral Blood * –marked **leukocytosis with left shift** * **–eosinophilia and basophilia** * –thrombocytosis in 50% * •Bone Marrow * –packed marrow with prominent granulocytic hyperplasia; no dysplasia * –sea- blue histiocytes – due to increased cell turnover; not specific * •Spleen/Liver * –Splenomegaly and/or hepatomegaly due to extramedullary hematopoiesis

Answer 64

Clinical features * –middle age * – often incidental finding * – EMH – LUQ pain/fullness * – Slow progression without treatment * – chronic phase to accelerated phase to blast phase (defined criteria) Treatment; **Tyrosine kinase inhibitors** * •Gleevac (Imantinib) * • inhibits bcr-abl kinase activity, thus suppressing the clone * •does not eliminate the clone, thus patient may eventually accelerate * •resistance can occur * •subclones with mutations that alter the efficacy with which the TKI binds to the BCR-ABL1 protein * •new generation of TKI’s now available

Answer 65

**PV (polycythemia Vera)** **Secondary polycythemia;** increased epo/epo-like substance * –**Physiologically Appropriate** * •High altitude * •Chronic hypoxic disorders * •Hemoglobinopathies * **–Physiologically Inappropriate** * •Dysregulated epo production (renal transplant, cystic disease, or hydronephrosis) * •Abnormal production of epo-like substance by neoplasm * –Uterine leiomyoma –Renal cell carcinoma –Cerebellar hemangioblastoma –Ovarian carcinoma –Hepatoma –Pheochromocytoma

Answer 66

PV (Polycythermia Vera) **•JAK2 mutation** – hematopoietic cell lines not responsive to growth factor regulation * •Increased RBC mass * •Abnormally functioning platelets * • in up to 15% of patients, symptoms can occur before abnormal blood parameters; may have JAK2 mutation. * •hyperuricemia with gout due to high cell turnover

Answer 67

PV - **increased RBC mass** •**Bleeding and thrombosis 25%, initial presentation** * – Thrombi involving major arteries or veins * –DVT MI * –Hepatic, Portal, Splenic and Mesenteric vein thrombosis * –CNS venous sinus thrombosis leading to stroke * – Acquired von Willebrand syndrome * – abnormal platelet function * Bleeding can lead to iron deficiency which can mask diagnostic polycythemia Hgb/Hct levels

Answer 68

Morphology of PV * **Peripheral Blood** * –erythrocytosis, leukocytosis, thrombocytosis * –basophilia * **Bone Marrow** * –hypercellular with trilineage hyperplasia * –no dysplasia * –minimal reticulin fibrosis, EMH * **Disease progression** * •Marrow failure with fibrosis and EMH – most common * •Transformation to AML Treatment of PV * –Phlebotomy and aspirin to keep Hct below 45% * –JAK2 inhibitors

Answer 69

ET (Essential thrombocytosis) * •diagnosis of exclusion – R/O: * – reactive thrombocytosis * – iron deficiency anemia * – inflammatory processes * – asplenism * – other MPN, especially CML **Clinical findings** * •asx in 50%; discovered by abnormal CBC * •Thrombosis * •Like PV: DVT, MI, Stroke, Portal or Splenic vein thrombosis * •Microcirculatory sx: headaches, dizziness, blurred vision, erythromelagia (burning and reddness due to ischemia of distal digits) * •Bleeding – less common; due to acquired von Willebrand’s syndrome * •Treatment with myelosuppressive agent like Hydroxyurea to lower platelet count

Answer 70

**Blood** * –Thrombocytosis ( \> 450K/ul) * •giant forms to small forms * •Circulating micromegs and megakaryocyte fragments * –WBC normal to mildly elevated (30K/ul) * •Basophilia or eosinophilia not typically seen * –Normal RBC’s **Bone Marrow** * • mildly hypercellular * • Megakaryocyte clustering * •Large hyperlobated megs * •Minimal Reticulin fibrosis * •if present think of other MPN * • Mild erythroid and granulocytic proliferation; no increase in blasts

Answer 71

PM (Primary myelofibrosis) **Clinical features** * •Older patient (\> 60 yrs) * •Two Disease phases * •Pre –fibrotic; •Marked thrombocytosis (differential dx is reactive vs ET) * •Fibrotic; •Anemia, leukoerythroblastosis and splenomegaly •Fatigue, early satiety Morphology •**Early: Pre-Fibrotic stage** * – Hypercellular marrow with prominent neutrophil proliferation * – Markedly atypical megakaryocytes, both architecturally and cytologically * – Minimal fibrosis •Progression: Fibrotic stage * –hypocellular marrow with replacement by fibrosis * –still see atypical clusters of megs * –intra-sinusoidal hematopoiesis * –osteosclerosis * –EMH * –Peripheral Blood * **•leukoerythroblastosis with marked erythrocyte anisopoikilocytosis**

Answer 72

**RBC** (on electron microscopy) / **erythrocyte** (peripheral smear) \*\*come from myeloid progenitor stem cell

Answer 73

**Anemia** * •**Acute anemia** = 3x increase in RBC production within 7 – 10 days * •**Chronic hemolytic anemia** = up to 6x – 8x RBC production \*\*•**Bone marrow = factory**. When bone marrow erythropoiesis cannot compensate for blood loss (through various mechanisms) --\> **anemia results** * •Anemia is about **tissue hypoxia;** •Inadequate perfusion of vital organs * •Manifests as: (**when Hgb \< 7 – 8 g/dl in younger, 10 – 12 g/dl in older persons**) * •_Easy fatigue_ * _•Dyspnea_ * •Pallor\* (sign not a symptom) * •Syncope * •Postural hypotension * •Angina

Answer 74

**CBC (Complete blood count)** * •Frequently ordered; very good screening test (any abnormalities warrant microscopic exam) * •Measures: (with \*electronic blood counter) * •Hemoglobin concentration, **Hb** * •Hematocrit (plasma cell volume) * •RBC indices (see later) * •WBC (sometimes a differential white count also ordered) * •**Average adult blood volume** = **5 liters:** 3 liters of plasma + 2 liters of blood cells

Answer 75

* **•Hb^\*** = Hemoglobin concentration (g/L) * **•Hematocrit\*** (Hct, “crit”, packed red cell volume,%) * **•RBC count** (millions of RBCs per picoliter [10-12 of a liter] * **•MCV\*** (mean corpuscular volume, fl) = average size of a RBC * •Normal = 80 - 100 fl * •Low MCV = microcytic * •High MCV = macrocytic * •Normal MCV = normal sized RBCs * **MCH\*** (mean corpuscular hemoglobin, pg) = _average amount/mass of Hb in a RBC_ = Hb/RBC count Normal = 27 - 31 pg/ml * **MCHC** (mean corpuscular hemoglobin concentration, %) = _proportion of each red cell taken up by Hb_ = [Hb/Hct] x 100 Normal = 32 - 36 g/dL * **RDW\*** (red cell distribution width) = coefficient of variation of RBC volume; variation in cell size High RDW = anisocytosis

Answer 76

**Reticulocyte count** * **_•Helps classify anemia._** (It is very important to classify anemia type and underlying cause e.g bleeding, vit deficiency, genetic disease). \*\*Remember though anemia is a diagnosis, it is most often a sign * •Reticulocyte = young RBC with residual rRNA, stainable; also polychromasia on smear * **•Normal = 1 % (0.6 – 2.0 %).** RBC lifespan is 120 days * •Increases in patients w/ normal renal (epo) and bone marrow functions * •**Reticulocyte count can be falsely elevated in anemia**. * •Corrected Retic= Retic (Hct/45) * •\>3% indicates good compensatory response.

Answer 77

1) According to **pathophysiologic mechanism** * Depletion of RBCs (hemorrhage) * Excessive destruction of RBCs - hemolysis * Production of abnormal RBCs; Due to factor deficiency (vitamin B12, folate, iron) * Underproduction of RBCs; Due to marrow disease (neoplasia, fibrosis, aplasia, infection etc 2) Accrding to **morphology** - most common **(low MCV)** * **•Microcytic, hypochromic** anemia * **_•Iron deficiency_**, thalassemias, * •Decreased MCV, MCH, MCHC * **Normocytic, normochromic** anemia * Acute blood loss, and associated with chronic disease * Normal MCV, MCH, MCHC * **Macrocytic** anemia * Vitamin B12 and folate deficiencies * Increased MCV, variable MCH and MCHC **Anemia due to factor deficiency** * **_Iron deficiency anemia_** * Vitamin B12, folate deficiencies

Answer 78

**IRON DEFICIENCY ANEMIA** (peripheral film) - **Hypochromic, microcytic, anisopoikilocytic** RBCs

Answer 79

Mechanism * Production defect in hemoglobin due to deficient iron * nIron needed for formation of **heme** and other enzymes * Iron cycle * Iron mostly in Hb (80%), then hemosiderin, ferritin * **1 mg/day lost thru exfoliated skin, mucosal cells but no natural mechanism for excretion** **Iron cycle: Tight control by 3 proteins:** * •transferrin = delivers iron to cells; duodenum * •transferrin receptor = binds, absorbs iron-laden transferrin at cell surface * •ferritin = binds iron for storage in cells and circulation * •Total body iron: 2 – 4 g: * •50 mg/kg, men * •35 mg/kg, women * •70-90% iron in hemoglobin in RBCs (200 – 400 mg in myoglobin, nonheme enzymes **\*\*\*POOR ABSORPTION**

Answer 80

**Iron Regulation** * •Iron absorption is regulated by hepcidin. * •**Hepcidin** is a small circulating peptidethat is synthesized in the liver. * •Released from the liver in response to increases in intrahepatic iron levels. **Hepcidin** * •Hepcidin inhibits iron transfer from the enterocyte to plasma by binding to feroportin and causing it to be endocytosed and degraded * •As hepcidin levels rise iron becomes trapped in duodenal cells in the form of mucosal ferritin lost through cells sloughing. * •When body is replete with iron, high hepcidin levels inhibit iron absorbtion into blood. * When body stores of iron are low , hepcidin synthesis falls and iron absorbtion is facilitated. * Hepcidin inhibits feroportin.(duodenum)

Answer 81

**Rare non-iron responsive microcytic anemia**

Answer 82

* •Nutritional/deficient diet * •Excessive milk-fed infant * •Malabsorption * •Gastrointestinal surgery, enteritis, celiac sprue * •Blood loss * •Menstrual loss = in women of reproductive age * **•Occult gastrointestinal bleeding** = tumors, ulcers in men, postmenopausal women * •Hookworm infection •Aspririn •Chronic hemolysis (PNH, etc.) •Traumatic hemolysis (cardiac prosthesis) •States requiring increased iron intake •Infancy •Adolescence •Pregnancy (esp. repeated) •Lactation

Answer 83

Iron deficiency Anemia * **•Serum iron studies:** * •Serum iron [Fe] * •TIBC (total iron-binding capacity) * •Serum ferritin * •Serum transferrin saturation * •(If do bone marrow exam, marrow stores are decreased/depleted.) * **•[ Normal values** * •serum iron = 120 mg/dl (men); 100 mg/dl (women) * •total iron-binding capacity (TIBC) = 300 to 350 mg/dl * •serum ferritin = 100 mg/L * •serum transferrin saturation = 33% ] * •Serum iron [Fe], ferritin, TIBC and transferrin saturation * •Low serum iron [Fe] (measured) * **•High TIBC** (total iron-binding capacity; measured ) * •Low serum ferritin (measured) \< 12 mcg/L * •Thus, low serum **transferrin saturation (TRF)** (calculated) * **[Fe] / TIBC = TRF (**transferrin saturation)

Answer 84

Casues of IDA Males and postmenopausal females- **GI occult bleeding** Females - **menstrual loss** * Note: Iron deficiency anemia in **all males and all postmenopausal females** requires investigation into etiology * Due to **occult bleeding,** such as gastrointestinal lesions (ulcers, tumors), gynecologic lesions (tumors), etc. * May also be due to chronic hemolytic states (see later lectures) * Treatment: giving iron supplements will correct anemia, but need to find out source of bleeding

Answer 85

Anemia of Chronic Disease Bone marrow unable to compensate for anemia * •Suppression of bone marrow response to erythropoietin by inflammatory cytokines (TNF, IL-1) * •**Defective reutilization of iron** salvaged from old RBCs * •Iron sequestered in **phagocytes** * •Inflammatory cytokines increase phagocytic uptake of iron * •Iron stores * •low serum iron * •normal to low transferrin * •low transferrin saturation * •high serum ferritin (tissue stores) * •Increased hepcidin production. * •Increased bone marrow iron stores * •Mostly in macrophages (hepcidin) * •Surpressed EPO (hepcidin)

Answer 86

* •**Chronic renal failure** * •Chronic bleeding, hemolysis, decreased erythropoietin, hematosuppression * **•Chronic disease** * •Diabetes mellitus (poor absorption, renal insufficiency, chronic blood loss) * •Inflammation (endocarditis, autoimmune dz) * •Cancer * •Liver disease * **•Alcoholism - complex effects** * •Alcohol directly toxic * •Nutritional deficiencies * •Bleeding (gastritis) * •Congestive splenomegaly, portal hypertension * •Lipoprotein abnormalities: acanthocytes •

Answer 87

Megaloblastic anemias * •Two most common causes: * **_•Vitamin B12 deficiency_** * **_•Folate deficiency_** * •CBC: **pancytopenia** * •Decreased RBC counts, WBC counts, platelet counts * Peripheral blood smear * **Macrocytic anemia** * Macro-ovalocytes (MCV usually \> 115 fl) * Anisopoikilocytosis * Hypersegmented neutrophils * Bone marrow (in megaloblastic anemias) * **Giant bands, nuclear-cytoplasmic asynchrony**

Answer 88

**Megaloblastic anemia** •Clinical signs and symptoms in **B12, folate deficiencies** * •Anemia * •Atrophic glossitis (smooth tongue with no contour) * •Gastric gland atrophy * •**Neurologic deficits ( only in vitamin B12 deficiency**, not in folate deficiency) * •Due to demyelination; •degeneration of white matter (brain) and of dorsolateral columns (spinal cord)

Answer 89

**Vitamin B12 deficiency;** **•Pernicious anemia** most common cause = **malabsorption** * •Starvation amidst plenty” * •Due to **absent intrinsic factor (IF) or IF antibodies which binds vitamin B12** * •Genetic predisposition, rarely manifests before age 35y \*\*\*Need to give IV injection of vit B12 because they cannot absorb oral vit B12

Answer 90

**Pernicious anemia** * •Associated with **autoimmune diseases** * •Hashimoto’s thyroiditis * •Adrenalitis (Addison’s disease) * •Grave’s disease * •Chronic atrophic gastritis * •Parietal cells lost * •Schilling test – radiolabeled B12

Answer 91

Folate deficiency •Clinical picture as in vitamin B12 deficiency, but **without neurologic deficits**

Answer 92

**Serum levels** * Low vitamin B12 (cobalamin) * \<170 pg/mL, symptoms when \<100 (normal \>240 pg/mL) * Low serum and RBC folate * \<150 ng/mL RBC folate * High methylmalonic acid (B12 def.) and homocysteine (both in folic acid def.) * Autoantibodies (PA) * Antiparietal cell * Anti-IF, anti-cobalamin/IF complex * Clinical trial – give B12 IM - reticulocytosis * **Schilling test**: for absorption of B12; •Rarely used today, difficult to do

Answer 93

* •Vitamin B12 = intramuscular injections * •Corrects anemia, reverses neurologic deficits (if less than 6 months’ duration) * •Folate supplements * •Passively absorbed even with SI malabsorption * •Folate treatment **partially corrects vitamin B12 deficiency, but does not affect neurologic deficits**

Answer 94

* •Chemotherapy/Drugs (AZT) * •Alcoholism * •Hypothyroidism * •Liver disease * •Myelodysplastic syndromes (cancer of bone marrow with poor prognosis)

Answer 95

**Production Defect Anemias** * •The “factory” = bone marrow = is underproducing * **•Aplastic anemia** * •Acquired * •Hereditary * •Pure red cell aplasia * •Diamond-Blackfan syndrome \*\*\*No abnormal cells (just underporducing)

Answer 96

**Aplastic Anemia** (from damage to stem cell so bone marrow is underproducing) * Clinically: * Anemic (weakness, pallor, dyspnea etc.) * Prone to infections (neutropenia) * Prone to bleeding - petechiae, ecchymosis (thrombocytopenia) * No splenomegaly (no hemolysis) or lymphadenopathy

Answer 97

**1. Acquired** * Chemicals, toxins, drugs * Benzene, alcohol, myelotoxic drugs, chloramphenicol, nonsteroidal anti-inflammatory drugs (NSAIDs) * Radiotherapy/irradiation * •Viral infections * •Hepatitis, Epstein-Barr virus, HIV, parvovirus * •Systemic lupus erythematosus, rarely * •Most common cause: *autoimmune suppression by a T cell-mediated cell mechanism* * •Half are **idiopathic** **2. Genetics (fanconi's anemia)** * •Autosomal recessive * •Defects in **DNA repair mechanism** = chromosomal instability * •Congenital anomalies (hypoplastic radii, thumbs, organs) * •May be pre-malignant: evolve into myelodysplasia, acute and chronic myeloid leukemias

Answer 98

**Aplastic anemia treatment** * •Supportive – **transfusions, antibiotics** * •Severe (\<500 neutros/microL, platelets \<20K, retics \<1%, \<20% BM cellularity) - need to raise blood cell count - **•Immunosuppression** * •ATG, Steroids, Rituxan, IVIG * •High-dose with cyclophosphamide in refractory cases * •If no suitable BM donors * •Bone marrow transplantation (\< 50 y.o.)

Answer 99

**Pure Red Cell Aplasia** (2 forms) * •**Primary** form * •**Diamond-Blackfan syndrome; • Severe anemia** first year of life, with congenital anomalies * **•Secondary** forms; * •Infections: **parvovirus B19** * •Solid tumors * •Rheumatic diseases; •Sjogren’s syndrome, lupus erythematosus * •Medication; •Phenytoin, azathioprine, isoniazid * •Idiopathic Treatment of pure red cell aplasia * •Stop offending drugs * •Thymoma resection sometimes ameliorates anemia * •High-dose IV immunoglobulin (parvo) * •Immunosuppression – ATG + cyclosporine

Answer 100

**GI TRACT**

Answer 101

**Sideroblatsic anemia**; Ringed sideroblasts in bone marrow: Cells with iron granules around nucleus (Prussian blue stain).

Answer 102

Sideroblastic anemias * n**Hereditary form** is X-linked recessive; Due to defects in **amino-levulonic acid synthase (ALA synthase),** rate-limiting enzyme in heme synthesis * nInsufficient hemoglobin produced * nIron in mitochondria •**Acquired forms: etiologies** * •Myelodysplasia * •Drugs * •Alcohol, isoniazid/INH, chloramphenicol) * •Toxins; **•Lead,** zinc) * •Nutritional deficiency; •Pyridoxine, copper **•Treatment:** * **•Pyridoxine** (vitamin B6) treatment seems to help * Treat underlying condition, remove exposure to toxins, etc

Answer 103

1) Anemia due to blood loss (**Acute blood loss**) 2) Anemia due to blood loss (**Chronic blood loss**)

Answer 104

**Hemolytic Anemias** * •Due to increased rate of RBC destruction, or premature RBC destruction * **•Acute** * •**Fatigue,** fever, pallor, jaundice, **low back pain**, splenomegaly, congestive heart failure * **•Chronic** * •In addition to above: gallstones, abnormal bone growth, fractures * **•Lab findings** * •Increased **unconjugated bilirubin** * •Decreased serum **haptoglobin conc.** (which take up free Hb) * •Increased serum **LDH** / lactate dehydrogenase (RBC enzyme released) * •Reticulocytosis * •**Peripheral smear** = spherocytes, schistocytes (RBC fragments that look like helmets), reticulocytosis, polychromasia (like reticulocytosis)

Answer 105

**Extravascular Hemolysis** •Lab * •Increased unconjugated serum bilirubin * •Normal or slightly decreased haptoglobins (due to some leakage of Hb into plasma) - *because it's not occuring in the circulatory system* * **•Spherocytes** in peripheral blood (cells getting smaller - helmet like - RBC fragments)

Answer 106

**Intravascular Hemolysis**

Answer 107

**Intrinsic (Inherited, Hereditary)** Hemolytic Anemias * •Predominantly **extravascular hemolysis** * •Defects in hemoglobin * •Quantitative defect = **Thalassemias** * •Qualitative defect = **Hemoglobinopathies** * •Defects in RBC membrane * •Hereditary spherocytosis etc. * •Defects in RBC enzymes * •Glucose-6-phosphate dehydrogenase deficiency etc.

Answer 108

Thalassemias * **•Beta** thalassemia = beta-globin chains deficient * •Common in people of Mediterranean origin * •**Alpha** thalassemia = alpha-globin chains deficient * •Common in people from Southeast Asia, China

Answer 109

**Beta thalasemia Major** * •Normal allele = b (beta) * •Both alleles abnormal in beta thalassemia major * •Two possible abnormal beta globin alleles, **beta 0 and beta+** : * •**beta 0** produces NO beta-globin at all (abnormal messenger RNA degraded) * •**beta+** produces reduced beta-globin 2 forms * **•Homozygous –** * =beta 0 / beta 0 = **no** normal beta globin synthesis * =beta + / beta + = reduced beta globin * **•Or compound heterozygous** * =beta + / beta 0 = reduced beta globin

Answer 110

Beta Thalassemia Major ; **distorted faces, hepatosplenomegaly and growth retardation, X-ray show crew cut skull, smear show HOWELL-JOLLY BODY** * •Transfusion-dependent for survival * •Clinical findings in survivors * •Growth retardation, distorted facies * •Hepatosplenomegaly * •Death from anemia, complications of iron overload * •Peripheral blood (see pic) * •Microcytosis, hypochromia, anisopoikilocytosis, target cells, teardrop cells, nucleated RBCs * **•Hb electrophoresis or HPLC** * **•Compensatory increase** in Hb A2 and Hb F, variable Hb A

Answer 111

Beta Thalassemia Minor * •Important to differentiate beta-thalassemia minor from iron deficiency anemia * •Iron therapy improves iron deficiency anemia, worsens beta-thalassemia * •Increased or normal serum iron and bone marrow iron in thalassemia

Answer 112

Alpha thalassemia Severity of disease related to # genes lost: * •Loss of all 4 a genes * •Fetal death-in-utero, no HbA, HbF or HbA2 at all * •**Hemoglobin Bart = g4** = excess, unpaired tetrameric **gamma** chains (of fetal hemoglobin, HbF); very high O2 affinity, does not release O2 * •Loss of 3 a genes * **•Hemoglobin H, HbH = b4 = excess,** unpaired tetrameric beta chains * •Unstable, can precipitate, has high affinity for oxygen * •Precipitated HbH results in inclusions in RBC, which are “bitten off” by splenic macrophages * •After splenectomy, can see precipitated HbH as Heinz bodies on staining with crystal violet/cresyl blue * Loss of 2 a genes = Alpha Thalassemia Trait * Two types: * •**Alpha-thal-1:** --/aa (deletion of both genes on same chromosome) * •Hb Bart g4 (from HbF, fetal Hgb) present at birth * •**HbH inclusions** (from HbA-related excess beta chain tetramers b4) in peripheral blood **during life** * •**Alpha-thal-2:** -a/-a (deletion of one gene on each chromosome) * •Hb Bart g4 (from HbF, fetal Hgb) present at birth * •**No HbH inclusions detected afterwards**, cannot screen with staining, need gene mapping to confirm condition

Answer 113

**Intrinsic (Inherited, Hereditary) Hemolytic Anemias** * •Predominantly extravascular hemolysis * •Defects in hemoglobin * •Quantitative defect = **Thalassemias** * •Qualitative defect = **Sickle cell disease**, other hemoglobinopathies like Hb C disease * •Defects in RBC membrane * **•Hereditary spherocytosis** etc. * •Defects in RBC enzymes * **Glucose-6-phosphate dehydrogenase deficiency etc**

Answer 114

**•Sickle cell disease** **Sickled cells** = dense, dehydrated, crescent-shaped, not easily deformable * •Viscosity of blood increased * •Obstruction in microcirculation * •Infarction (tissue death) results •Initially reversible, later irreversible with repeated, rapid sickling/unsickling * •Cytoskeletal damage: **spectrin** now **dimers** instead of normal tetramers * •Up to 30 - 40% RBCs can be irreversibly sickled * •Life span of 20 days only (instead of 120 days)

Answer 115

**Sicle Cell Anemia** * •Expanded bone marrow due to increased hematopoiesis * •Extramedullary hematopoiesis * **•Autosplenectomy** * •Congestion, then infarction, fibrosis * •**Salmonella** osteomyelitis * •Influenza can cause death * **•Chronic leg ulcers** **Vaso-occlusive crises** * •Musculoskeletal “painful” crises (like “the bends”) * •Hand and foot syndrome (**dactylitis** = swollen fingers) in infants * **•Avascular necrosis** of femoral head can cripple (surface of right is flattened) •**Acute Chest syndrome** * •Dangerous microvascular occlusive crisis in lung. * •Fever cough chest pain pulmonary infiltrates. * •CVA * •Infection/sepsis with encapsulated organisms incusing Streptococcus & Haemophilus * •Prophylactic ABX **Aplastic crises (parvovirus bone marrow suppression)** **Splenic sequestration crises** * Rapid splenomegaly and hypovolemia **Priapism in males** **Organ infarction** * Renal papillary necrosis * Pulmonary infarction, cor pulmonale * Cerebral infarction * Abdominal, hepatic, splenic infarction **General growth/development impaired** •**Gallstone formation** * •(from chronic extravascular hemolysis) **•Severe anemia (Hb of 8 g/dl, Hct of 18 - 30%)** **•Peripheral blood** * •Crescent-shaped sickle cells (up to 5 - 15% of cells), anisocytosis, basophilic stippling, Howell-Jolly bodies

Answer 116

* •Peripheral blood film - **sickle cells** * •Sickling test * •Reducing agents like metabisulfate added to blood to induce sickling * **•Hemoglobin electrophoresis** (separates the various hemoglobins according to rate of migration in gel) or **HPLC** (high-performance liquid chromatography) * •Molecular analysis for gene defect * •Prenatal diagnosis possible

Answer 117

1) Factors affecting tendency to sickling * •**Interaction with other hemoglobins** * •HbA = weak interaction, need severe hypoxia to sickle * •HbF = inhibits polymerization, can moderate severity * •HbD = intermediate affinity between HbA and HbC 2) **Hemoglobin C**; SC disease is less severe than SS * •Variant Hemoglobin in which lysine is substituted forglutamic acid in position 6 of the beta globin chain. * •Hemoglobin SC disease is a sickling disorder but clinically less severe than SS 3) Factors affecting tendency to sickling * •Hemoglobin concentration * •**Dehydration** increases MCHC, promoting sickling * •Thalassemia * •Low pH, increase in temperature promote sickling 4) Sickle cell therapy * •Hydroxyurea increases HbF * •Transfusions * •Pain management * •Social support * •90% survive to age 20 * •50% survive beyond 5th decade * •Prophylactic ABX * •Folate

Answer 118

Hereditary spherocytosis * **Mutation in RBC membrane skeleton protein gene, ankyrin** * Weakened anchor for lipid bilayer; Deficiency of **spectrin** (membrane protein) * Due to mutations in **ankyrin gene** (codes for the anchor) * Causes a decreased interaction between membrane cytoskeleton and the overlying lipid bilayer * **Results in spherical shape, which is less deformable**

Answer 119

**Clinical picture** * Usually chronically compensated, mild-moderate hemolytic anemia * Jaundice, splenomegaly (extravascular hemolysis) * Gallstones * Anemic crises (parvovirus infection, hematosuppression, folate deficiency) * Fever- and infection-induced crises **Diagnosis** * Ppossible iron overload from multiple transfusions * Diagnosis * **Osmotic fragility test (**see next slide) * Only notable disease with **microcytosis and increased MCHC** (36 g/dL) * Reticulocytosis * Negative DAT (Coombs test), + family history **Treatment** * Folic acid supplements * Splenectomy – treatment of choice * Does not correct membrane defect or spherocytosis, but - * Eliminates the site of hemolysis (spleen)

Answer 120

**Predominantly extravascular hemolysis** * Defects in hemoglobin * Quantitative defect = Thalassemias * Qualitative defect = Sickle cell disease, other hemoglobinopathies like Hb C disease * Defects in RBC membrane (discussed earlier) * Hereditary spherocytosis etc. * Defects in RBC enzymes * **Glucose-6-phosphate dehydrogenase deficiency**

Answer 121

Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency * In oxygen-carrying RBC, G6PD gives red cell antioxidant protection * Hemoglobin becomes **denatured** during times of oxidant stress without G6PD * Due to inadequate production of NADPH * NADPH needed to maintain GSH levels * **Heinz bodies** formed – denatured hemoglobin * Induced by drugs, infections, certain food substances in absence of G6PD **Variants** * Mediterranean variant = **severe decrease**; in Middle Eastern populations; less than 10% activity * G6PD- (**10% American Blacks, Moderately reduced G6PD Activity**)

Answer 122

G6PD - Glucose 6 phosphate deficiency **Clinical findings**: hemolysis of stressed RBCs * Intravascular hemolysis due to Heinz bodies * Chills, fever, hemoglobinemia, hemoglobinuria * Extravascular hemolysis * **Destruction of affected RBCs in spleen** **Precipitating factors** * **Infections** * Viral hepatitis, typhoid fever, pneumonia * **Oxidant drugs** * Antimalarials paraquine, chloroquine, sulfonamides, nitrofurantoin, chloramphenicol etc.) * **Fresh fava beans (“favism”)** * Occurs 5 - 24 hrs after ingestion * Can also occur with canned, cooked, frozen beans, however! Self-limited acute attacks * Only older RBCs affected; reticulocytes have normal activity * **Stability of enzyme** is the functional defect Between attacks, **peripheral blood smear is normal**

Answer 123

* **Immune** hemolytic anemias * Autoimmune hemolytic anemias (autoantibodies) * Alloimmune (transfusion) hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn) * **Non-immune** hemolytic anemias * Microangiopathy, infections, drugs, acquired membrane defects, mechanical/physical factors

Answer 124

1) Immune hemolytic anemias * Based on the antigen that stimulates antibody or complement-mediated RBC destruction * Autoimmune hemolytic anemias * Alloimmune hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn) 2) Autoimmune Hemolytic Anemias (AHA); Antiglobulin used to detect antibody-coated red cells via agglutination of these cells. * Classification according to thermal reactivity of antibody: **“warm” and “cold”** AIHA * Warm antibody hemolytic anemia (WAHA) * Cold aggutinin hemolytic anemia (CAHA)

Answer 125

1) **Warm Antibody Hemolytic Anemia** * **Drug-induced** WAHA models well-studied * Methyldopa (L-dopa) = antibody against Rh blood group antigen * Penicillin-hapten = antibody against drug, which is bound to the red cell * Tetracyclines, cephalosporins, tolbutamide * **Disorders** associated with WAHA * nLymphatic malignancies (CLL, etc.) * nAutoimmune disorders * nsystemic lupus erythematosus, * nrheumatoid arthritis, * nulcerative colitis * Treatment * nTreat underlying condition * nCorticosteroids * nBlood transfusion, gammaglobulins, plasmapheresis * nSplenectomy \*\*WAHA may antedate the onset of disease by months or years!

Answer 126

**Cold Agglutinin** Immune Hemolytic Anemia (Cold Agglutinin Disease) * nIgMs * n target blood group antigens (like A, B, O) : I (big I), and i (little i) * nFix complement C3 * nC3-coated red cells are eliminated by the spleen (extravascular hemolysis), but no splenomegaly * nCan also present with acrocyanosis **Acute type:** * An acute, self-limited hemolysis * Atypical pneumonia (Mycoplasma pneumoniae); Cold agglutinins against I (“big I”). * _Infectious mononucleosis_; Cold agglutinins against i (“little I”) **Chronic type :** * Due to lymphoid malignancy or idiopathic * May be unremitting Treatment * Warm environment * Treat underlying condition (atypical pneumonia, lymphoma, infxs mono…)

Answer 127

**Paroxysmal Cold Hemoglobinuria** * Associated with recovery from viral infections (similar to CAD) * Mycoplasma pneumonia * Infectious mononucleosis * (Historically, syphilis) * No jaundice or splenomegaly * Difference = biphasic intravascular hemolysis, hemoglobinuria **Diagnosis** * Test for Donath-Landsteiner antibody = differentiates PCH from CAIHA/cold agglutinin hemolytic anemia * Mix patient’s serum (with antibodies) with test RBCs * First **chill, then warm** to 38oC * **Lysis** of RBCs indicates PCH Treatment: keep patient warm

Answer 128

* Immune hemolytic anemias * Autoimmune hemolytic anemias (autoantibodies) * Alloimmune (transfusion) hemolytic anemias (hemolytic transfusion reactions, hemolytic disease of newborn) * Non-immune hemolytic anemias * Microangiopathy, infections, drugs, acquired membrane defects, mechanical/physical factors

Answer 129

**Hemolytic transfusion reactions** * Administration of ABO-incompatible red blood cells (usually **clerical error**) e.g., giving A RBCs to an O recipient * **Acute reaction** * Brisk, severe **_intravascular_** hemolysis of donor red cells in recipient via complement fixation * Fever, chills, dyspnea, hypotension, low back pain, hemoglobinuria, jaundice, oliguria (even renal shutdown), shock * nTest for hemolysis n**Coombs test**/direct antiglobulin test/DAT nSerum haptoglobin, LDH, serum bilirubin, serum and urine hemoglobin nStop transfusion immediately nBlood bank to repeat blood group typing, antibody screen, cross-match to investigate source of error **Hemolytic disease of the newborn (HDN) - picture below** * a.k.a **erythroblastosis fetalis** = hemolysis of **newborn’s RBCs** * Due to transplacental transmission of maternal antibodies **(anti-Rh or -D) directed against Rh-positive fetal RBCs** * Can happen when mom is Rh-, baby Rh+ * nMaternal immunization (produces anti-Rh antibodies) can result from: * nPrevious blood transfusion * nPrevious pregnancy, delivery (due to fetal-maternal hemorrhage)

Answer 130

**Non-immune hemolytic anemias**

Answer 131

**Microangiopathic** Hemolytic Anemias

Answer 132

Alcoholic liver disease (acquired membrane disorders) * Acanthocytes or “spur” cells, target cells * Due to abnormal lipid in red cell membrane

Answer 133

**Paroxysmal Nocturnal Hemoglobinuria** * Abnormal sensitivity of RBCs to lysis by complement * Complement-regulating proteins CD59 and CD55 absent **Paroxysmal and nocturnal hemolysis** in 25% (chronic form more common) * Blood smear non-diagnostic (micro- or macrocytic) * Intravascular hemolysis, hemosiderinuria, pancytopenia * Iron deficiency anemia may result later * Recurrent thrombosis (hepatic, portal, cerebral) **Clonal disorder, may later evolve into:** * Aplastic anemia * Myelodysplasia * Acute myeloblastic leukemia (AML) **Treatment** * Iron supplements * Prednisone/Immune supression * Eculizamab (Soliris) monoclonal antibody – complement inhibitor. * Bone marrow transplant

Answer 134

Mechanical and Physical Factors (Non-immune hemolytic anemia) **Prosthetic heart valves** * **Artificial** more than porcine valves * Mild compensated anemia to severe, hemolytic anemia; Iron deficiency later * Peripheral blood smear: Hemolysis (schistocytes, burr cells, polychromasia) * Lab findings of hemolysis **March hemoglobinuria** * Marching, marathon running, drum-beating * Hemoglobinuria after exercise * Normal peripheral blood smear, anemia rare **Burn injury** * microsperocytes, barbell shapes, rod shape

Answer 135

**(b) Coombs test** The answer is (b), Coombs test, or the antiglobulin test. * Immune hemolytic anemia would be Coombs positive, and HS would be negative.

Answer 136

Lab diagnosis of anemia 1. **Peripheral blood tests;** (CBC, peripheral blood smears) usually suffice to determine a cause of isolated anemia (meaning, only RBCs are decreased). * However, if **thrombocytopenia and/or granulocytopenia** are also present, marrow is likely to be affected-\> **bone marrow examination** is warranted. 2. **Reticulocyte counts**; to differentiate between **hemolysis** (RBC destruction) and **marrow failure** (decreased RBC production as in aplastic anemia) as cause of anemia. 3. **Iron indices**; to differentiate hypochromic, microcytic anemias due to iron deficiency, anemia of chronic disease, thalassemia minor. 4. **Serum and red cell folate, vit. B12 concentrations** * to determine cause of megaloblastic anemia. 5. **Plasma unconjugated bilirubin and haptoglobin concentrations** * to support diagnosis of hemolytic anemia. 6. **Gel electrophoresis, HPLC** * to detect abnormal hemoglobins (HbS, etc.). 7. **Coombs test** * to detect autoimmune hemolytic anemias.

Answer 137

1) Causes of excessive bleeding (3) * Increased vessel fragility * Platelet deficiency or dysfunction * Derangement of coagulation 2) bleeding due to * Vascular defect (localized or generalized) * Platelet defect * Coagulation defect

Answer 138

Primary hemostasis * Platelet count * •Normal range: 150,000 – 400,000/uL * •False lows: platelet clumps/fibrin strands (traumatic draw) * Bleeding time (BT) ; Not standardized * Platelet function analysis (PFA) * •Simulates in vivo conditions – high shear stress * •Utilizes platelet agonists (collagen/ADP and collagen/EPI) to interrogate platelet function * •Interpretation **(picture)** Secondary hemostatis * **PTT** (partial thromboplastin time in seconds); test is **heparin** is adequate for agglutination * Kaolin + cephalin + Ca2+ + pt plasma → clot * **Tests intrinsic (**XII, XI, IX, VIII) **and common pathway (**X, V, II, Fibrinogen, XIII) * **PT** (prothrombin time in seconds); test **warfarin** effectiveness * Tissue thromboplastin + Ca2+ + pt plasma → clot * **Tests extrinsic (VII) and common pathway (**X, V, II, Fibrinogen, XIII) * **Mixing study**; Pt serum + pooled sera – check PTT (or PT) * •If PTT normal (corrects) then factor deficiency * •If PTT abnormal (no correction) then inhibitor present in patient’s serum * **Clotting factors** * •Known specific factor-poor plasma + pt plasma * •Run either PT or PTT depending on which factor being evaluated

Answer 139

Abnormalities of vessel wall **Clinical picture; petechae and purpura** **Coag test** resuts are **normal** **Causes** * Drugs * •Drug-induced immune complexes deposit in the vascular wall leading to **leukocytoclastic vasculitis** * Impaired collagen support * •Scurvy – vitamin C deficiency – required for hydroxylation of procollagens * •Ehlers-Danlos syndrome – inherited collagen abnormality * •Elderly * •Cushing syndrome: Excessive steroid → protein wasting → loss of vascular support * Henoch-Schönlein Purpura (covered in renal section) * •Systemic hypersensitivity disease in which circulating immune complexes deposit in the vessels * •Unknown etiology * •Colicky abdominal pain, polyarthralgias, acute glomerulonephritis * Hereditary Hemorrhagic Telangiectasia * •AD * •Dilated tortuous vessels with thin walls * Amyloid infiltration; weakens vessel wall. * Amyloid deposits in vessel wall (alzheimer disease) * DIC

Answer 140

_Clinical Findings:_ * - Normal platelet count: 150,000 – 400,000 * - Typically not a problem unless counts \<50,000 * - Post-traumatic bleeding – 20,000 – 50,000 * - Spontaneous bleeding of small vessels at \<20,000 * - Skin, mucus membranes, GI, GU, intracranial _Coag Test Results:_ * - Platelet count decreased; BT and PFA prolonged if Platelet \<75K * - Normal PT and PTT Etiologies * Decreased Production (bone marrow) * Neoplastic; •_Non-hematopoietic neoplasms_ infiltrating marrow (prostate, breast, neuroblastoma, etc) •_Hematopoietic neoplasms_ (AML, ALL, MDS, lymphoma, etc) * non-neoplastic; Infections, drugs, EtOH/toxins, B12/folate deficiency * •Increased Peripheral destruction/decreased survival * Non-immune * All-immune condition (transfusion-related) * Auto immune conditions; ITP, HIT, HIV, TTP/HUS * Non-immune; •Sequestration – splenomegaly (hypersplenism) •Mechanical damage – prosthetic heart valves, malignant hypertension * •Sequestration; * •Dilutional Effect secondary to Massive Transfusions

Answer 141

Immune Thrombocytopenic Purpura (ITP) * **Chronic ITP** * •**Adults, generally** * **•Insidious** onset of symptoms * •Secondary etiologies include SLE, HIV, drugs, other viruses * •Peripheral blood shows thrombocytopenia with giant platelets reflected by increased MPV * **Acute ITP** * **•Kids** * **•Abrupt onset** of thrombocytopenia * •Preceded by viral illness (2 wks) * •Self-limited, resolves in 6 mos. * •20% of kids will persist beyond 6 mo (chronic ITP similar to adults)

Answer 142

**Chronic ITP** * •IgG autoAb against platelet antigens (Gp IIb-IIIa or Gp Ib-IX) * •Ab bind to plts, plts are then opsonized and removed by reticuloendothelial system (spleen) * **•Spleen – normal size**; congestion of sinusoids, macrophages prominent, splenic follicular hyperplasia, occasional megakaryocytes **•BM examination** * •done only if pt not responsive to therapy, to exclude other etiologies of thrombocytopenia * •shows **increased #’s of megakaryocytes** with left shifted maturation **•Treatment** * •Immunosuppression with steroids * •Splenectomy * •IVIg, Rituximab (CD20 antibody)

Answer 143

**Heparin Induced Thrombocytopenia (HIT);** never give any form of Heparin to patient with HIT. For bed ridden patient without HIT, you can use lovenox - not heparin (levonix) will decrease the risk HIT)\*\*\*\*\*\*\*\* KNOW FOR EXAM **1)** HIT Type I 2) HIT Type II 3) HIT Type III * •**Paradoxical thrombosis** due to systemic platelet activation * •Life threatening – must d/c heparin and use alternative anticoagulation * •If pt has history of HIT, Lovenox/enoxaparin (low molecular weight heparin) is also contraindicated * •BUT risk of developing HIT is less with LMW heparin

Answer 144

Auto-immune thrombocytopenia - HIV associated

Answer 145

**TTP - Thrombotic Microangiopathies** **_•ADAMTS 13 deficiency_** * •A metalloprotease that degrades HMW multimers of vWF * •Deficiency results in accumulation of HMW multimers which can promote platelet microaggregation * •Acquired – autoAb against **ADAMTS 13** * •Inherited – inactivating mutation in gene * Endothelial cell injury due to secondary cause can exacerbate * Treatment of TTP is total plasma exchange to remove auto-Ab and replenish normal levels of ADAMTS 13 **•Platelet transfusions are contraindicated** – worsen the thrombi

Answer 146

**HUS (Hemolytic Uremic Syndrome)** \*\*\* Pathogenesis is related to E coli strain not ADAMTS 13. ADAMTS 13 is normal.

Answer 147

**Thrombotic microangiopathies** - TTP (thrombotic throbocytopenic purpura) vs HUS (hemolytic uremic syndrome) **_TTP_** - **ADAMTS 13 deficiency** **_HUS_** - **Ecoli O157**

Answer 148

MDS - Myelodysplastic syndromes * •MDS single lineage dysplasia * •MDS with ringed sideroblasts * •MDS with multilineage dysplasia * •MDS with excess blasts

Answer 149

MDS morphology * •Peripheral Blood * –cytopenic with anemia, usually macrocytic * –dysplastic neutrophils, platelets * •BM * –Hypercellular marrow, usually * –trilineage hyperplasia with dysplasia in at least one line * –increased storage iron * –blasts \< 20% ( greater than 20% is acute leukemia) * Cytogenetics; gains or loss of chromosomes * – **Monosomy 5, 7\*\*\*\*\*\*** * – **del5q del7q** * – tri 8, del20q – no longer MDS defining; can be seen with aging, non-MDS causes of cytopenias (aplastic anemia, ITP) * – \> 50% of cases are normal at the cytogenetic level

Answer 150

MDS - clinical course * •Prognosis dependent on the Revised International Prognosis Scoring System (IPSS-R): * – % blasts * – Cytogenetics * – Hemoglobin * – ANC * – Platelets MDS - Treatment * Dependent on patient and severity of MDS * - supportive care with transfusions, antibiotics, etc * - Vidaza (pyrimadine analog) * -Allo-stem cell transplant

Answer 151

**Acute Myeloid Leukemia (AML)** - pathophysiology \*\*\*\***• \>20% blasts in PB (peripheral blasts) or BM (bone marrow)** •Some patients present pancytopenic because marrow is packed, but blasts are not yet spilling into PB * • acquired genetic alteration causes impaired maturation * §RUNX1, RARA, NPM1 * • mutation in genes involved in signal transduction allow for survival/proliferation advantage * §FLT3, JAK2, KIT * • neoplastic cells repress normal hematopoiesis by physical replacement as well as other unknown mechanisms

Answer 152

AML * •WHO Classification 2016 * –With recurrent genetic abnormalities (8) * –With gene mutations (3) * –With myelodysplasia related changes * –Therapy related Myeloid Neoplasms * –Not otherwise specified (NOS); •Based on morphology/cell lineage

Answer 153

**AML** - with recurrent cytogenetic abnormalities

Answer 154

AML - with recurrent cytogenetic abnormalities ## Footnote **Acute Promyelocytic Leukemia**

Answer 155

AML with gene mutations * •With NPM1 mutation * •50% of adult AML’s with normal karyotype * •Often female patient; often monocytic morphology * **•Favorable prognosis**; Unless there is also a mutation in FLT3 – ITD; seen in 40% of cases * •With biallelic mutations of CEBPA * •With mutated RUNX1

Answer 156

**1) AML** with myelodysplasia related change **2)** Therapy Related Myeloid Neoplasms 3) AML, NOS

Answer 157

1. Splenomegaly 1. Nonspecific acute splenitis 2. HLH (Hemophagocytic Lymphohistiocytosis) 3. Congestive splenomegaly 2. Splenic infarcts 3. Neoplasms; rare except of the hematopoietic system. Can see hemangiomas or fibromas * HCL * HL * NHL * MPN 4. Congenital anomalies * complete absence * hypoplaia * accessory spleen 5. Splenic rupture

Answer 158

Splenomegaly Seen in; nonspecific acute splenitis, HLH, congestuve splenomegaly

Answer 159

Nonspecific Acute Splenitis

Answer 160

**Splenomegaly – Hemophagocytic Lymphohistiocytosis aka HLH;** For HLH diagnosis, you need to have **5 of the 8 signs** in bold * •Activated macrophages * •**HEMOPHAGOCYTOSIS** - phagocytize blood cells in the periphery (spleen, liver, nodes,etc) and in the bone marrow * **•CYTOPENIAS** * **•HEPATOSPLENOMEGALY** and lymphadenopathy * •Cytokine release * •Cytokine storm----Severe inflammation * **•FEVER** * **•HIGH FERRITIN** * **•HIGH SOLUBLE INTERLEUKON-2 RECEPTOR (IL2 aka CD25)** * **•DECREASED NK CELL FUNCTION** * **•HYPERTRIGLYCERIDEMIA or HYPOFIBRINOGENEMIA**

Answer 161

* •High index of suspicion with prompt treatment required * •Immunosuppressives and gentle chemotherapy * •Stem cell transplant if familial, persistent or recurrent * •Approximately 50% survival * •Without treatment – grim prognosis with \<2 month survival

Answer 162

Congestive splenomegaly Pathologc findings * •You will see different things grossly and microscopically, depending on duration of the congestion * • Firmness (due to progressive fibrosis of the sinusoids) will increase over time * • means less efficient passage of the blood with more time for macrophages to destroy cells * •increased pressure = intraparenchymal hemorrhage

Answer 163

Splenic infarcts

Answer 164

* •Complete absence – rare * •Hypoplasia * •Accessory spleen * – Gastrosplenic ligament, tail of pancreas, omentum, large/small bowel mesenteries * – Of no clinical significance; •unless patient is having a therapeutic splenectomy for condition such as idiopathic thrombocytopenia pupura or hereditary spherocytosis – then the overlooked accessory will begin to function as the dominant spleen

Answer 165

Splenic Rupture

Answer 166

1. **Thymic hyperplasia** * •refers to the appearance of secondary follicles (B cells) * •associated with Myasthenia gravis * •also associated with Graves disease, SLE, RA, and other autoimmune disorders 2. **Thymomas** * •tumors of thymic epithelial cells with a background of immature T cells * •anterior superior mediastinum of adults; ‒also a good location for NSHL * •firm gray-white mass up to 20 cm in size * ‒ may have areas of cystic necrosis and calcification * ‒ mixture of epithelial cells and non-neoplastic lymphocytes

Answer 167

* •Benign, encapsulated * –50% * –Medullary or mixed medullary and cortical epithelial cells * Malignant – 2 types * •Cytologically benign, but invasive – 20-25% * –Epithelial cells are usually of the cortical type * •Cytologically malignant - \<5% * –Squamous cell carcinoma * –Lymphoepithelioma-like carcinoma – EBV associated in 50%

Answer 168

**LCH - LANGERHANS CELL HISTIOCYTOSIS** 3 types * Multifocal multisystem - **letter siwe disease** * •Usually \< 2 yrs of age * •Seborrheic appearing cutaneous lesions of trunk and scalp * •Hepatosplenomegaly, lymphadenopathy, pulmonary lesions * •Extensive marrow infiltration = cytopenias * •Untreated = fatal * •Intensive chemotherapy = 50% ofpatients will survive 5 years * Unifocal and Multifocal Unisystem = **Eosinophilic Granuloma** * •Langerhans cells plus chronic inflammatory cells, most notably, eosinophils * •Usually affects bones * •**Unifocal** – indolent with spontaneous healing or treatment by local excision or radiation * •**Multifocal** – young children with multiple erosive bony masses * **•Hand – Schuller – Christian triad = calvarial bone defects, diabetes insipidus, and exophthalmos (due to erosion into the posterior pituitary)** * Pulmonary LCH * Adult smokers * Lesions may regress with smoking cessation

Answer 169

**ABO Blood groups (4)**; the difference between O,A and B is one sugar - carbohydrate chain). **Most common are type O and A**. **least common is type AB.** •If patient has antigen, there will be no antibody •If patient lacks antigen, there will be an antibody against the antigen * Type A * RBC antigens; A * Plasma antibodies; Anti-B * Type B * RBC antigen; B * Plasma antibodies; Anti-A * Type AB * RBC antigen; A and B * Plasma antibodies; NONE * Type O * RBC antigen; None * Plasma antibodies; Anti A and Anti B Rh blood groups * Rh positive (D positive) ; 85% * Rh negative (D negative) * •Can give Rh-negative blood to Rh positive patient * •Can safely give Rh+ blood to Rh neg patients if compatible (patient has no Anti-D) * •Only do in selected situations * •Rh neg recipients of Rh+ blood may make anti-Rh (Anti-D) * •O neg female: Pregnancy exposure to D+ fetus: * •Mother may make Anti-D * •Anti-D can cause * –Hemolytic Disease of the Newborn * –Acute hemolytic transfusion reactions

Answer 170

* **•UNIVERSAL DONOR: Group O** * •If recipient has Anti-A or anti-B, the O RBC lacks these antigens * •Can give group O RBCs to any recipient * **•UNIVERSAL RECIPIENT: Group AB** * •Can receive RBCs from any ABO group * •Lacks any Anti-A or Anti-B * •AB plasma can be used on any blood group because lacks anti-A and anti-B

Answer 171

•DIRECT ANTIGLOBULIN TEST (DAT) * **•Test patient RBC for attached IgG or compliment** * •Not done as part of TS or TC •Positive * 1.Autoantibodies against patient RBC * •Autoimmune anemia is DAT positive * 2.Transfused incompatible RBC; patient has antibody against donor RBC * •Hemolytic transfusion reaction * •Patient antibody on transfused RBC * 3.Passive transfusion of antibodies attach to RBC, eg IVIG; FFP * •Negative * –Rules out majority of autoimmune anemias and acute hemolytic transfusion reactions **•INDIRECT ANTIGLOBULIN TEST (IAT OR ANTIBODY SCREEN)** * •**Test patient serum for antibodies** * •Test is done for TS and TC •Positive: * 1.Alloantibody against foreign RBC antigens * •Main indication for test; done in all type and screens * •Acquired eg Anti-D in an Rh-negative patient * •Passive eg IVIG * 2.Autoantibody can sometimes be detected * •eg autoimmune anemia •Negative: * •No alloantibodies

Answer 172

•TYPE AND SCREEN (TS): * –Check for historical prior blood type * –Patient blood type completed * –Patient antibody screen completed (See IAT below) * •If negative: no further action taken; No dedicated units set aside for patient * •If positive, blood is cross matched * •NO units of blood set aside and dedicated for patient * •Can convert to crossmatch rapidly •TYPE AND CROSS (CROSSMATCH or TC): * –Type and screen (see above) * –Test donor cells against patient plasma * –Compatible dedicated units set aside for patient •Both good for 72 hours, must be repeated after that

Answer 173

* 1.PRBC * 2.Frozen RBC * 3.Washed RBC * 4.Platelets * 5.Frozen plasma: FFP or FP24 * 6.Cryoprecipitate * 7.Four factor prothrombin complex (4-PCC) * 8.Factor VIII * 9.Albumen * 10.Rh immunoglobulin

Answer 174

* Patient does not increase platelets after transfusion (expect ↑ 30K for 6 random) * Causes: * •Splenomegaly (sequestration) * •Accelerated consumption eg DIC, sepsis, bleeding * •Alloimmunization: eg Anti-HLA antibodies destroy platelets

Answer 175

* Processing greatly reduces WBC content * Many blood banks use only leukocyte-reduced PRBC and platelets * •Decreased incidence of alloimmunization against WBC antigens (eg HLA) * •Decreased risk of CMV transmission * •Decreased risk of febrile nonhemolytic transfusion reaction (see below)

Answer 176

* **•ALWAYS FOLLOW THE PROCEDURE TO THE LETTER; most common cause of fatal acute hemolytic reaction is failure to follow procedure!!!!** * •PATIENT IDENTIFICATION WHEN DRAW BLOOD * •PATIENT IDENTIFICATION WHEN ADMINISTER BLOOD * •INFORMED CONSENT * •Only use Normal Saline to mix with blood * •Only used approved blood warmers * •Use blood filter * •Observe patient carefully when first beginning and periodically during transfusion for transfusion reactions

Answer 177

•HEMOLYTIC * –Acute hemolytic transfusion reaction (AHTR) * –Delayed hemolytic transfusion reaction •NON-HEMOLYTIC * –Transfusion related acute lung injury (TRALI) * –Transfusion associated circulatory overload (TACO) * –Febrile non-hemolytic transfusion reaction * –Graft vs Host Disease * –Urticaria * –Anaphylaxis * –Hypotension * –Iron overload * –Infection •FEBRILE * –Acute: * •Acute hemolytic transfusion reaction * •Febrile non-hemolytic transfusion reaction * •Infection: sepsis from bacterial contaminated unit * •Transfusion-related acute lung injury (TRALI) * –Delayed * •Delayed hemolytic transfusion reaction * •Graft vs Host Disease (GVHD) * •Infection •NON-FEBRILE * –Acute: * •Anaphylaxis * •Urticaria * •TACO * •Hypotension * –Delayed: * •Iron overload * •Infection

Answer 178

* •Viruses * •HIV\* * •HTLV\* * •HBV\* * •HCV\* * •West Nile Virus\* * •Herpesvirus [eg Cytomegalovirus (CMV)\*, Human Herpes Virus (HHV), Ebstein-Barr Virus (EBV)] * •Parvo B19 * \* Currently tested for by blood donor centers * •Bacteria * •Acute infections\*: See above * •Others: * •Syphilis\*\* * \* Units are checked for evidence of bacterial conatimination * \*\* Currently tested for by blood donor centers * •Parasites * •Any blood born parasite * •Chagas’ Disease: Trypanosoma cruzi\*\* * •Malaria * •Babesiosis * •Leshmaniasis * •Toxoplasmosis * •Microfilaria * \*\* Depending on donor center location, some donor centers test for this * •Prion disease * •Variant CJD (“Mad cow disease”)

Answer 179

* •Allogeneic blood: * •Volunteer donor: Almost all blood is volunteer * •Paid donor * •Directed donor: Unit donated for specific person * •Autologous blood: Donated for self * •Therapeutic donor: A treatment (“blood letting”); not used for transfusion * •Hemochromatosis (to reduce iron stores) * •Polycythemia (HCT to high; reduces viscosity) * •Two safety processes * –Protect the recipient: eg infectious disease questions and testing, temperature * –Protect the donor: eg Hgb, history * •Donor reactions: * –Vasovagal reaction (“pass out”) * –Hematoma/thrombosis/infection * –Arterial puncture * –Nerve injury

Answer 180

* •Increased fluid in interstitial tissue spaces, body cavities, sometimes cells * •Inflammatory edema: ↑ vascular permeability, results in protein-rich **exudate** (sp.gr. \>1.020) * •Non-inflammatory edema: protein-poor **transudate** (sp.gr. \< 1.012) causes of noninflammatory edema * 1. Increased hydrostatic pressure * 2. Reduced plasma osmotic/oncotic * pressure (hypoproteinemia) * 3. Lymphatic obstruction * 4. Sodium and water retention

Answer 181

•Subcutaneous edema may be diffuse or dependent * •Diffuse – affects all parts of body * Example: Periorbital edema seen in renal failure * •Dependent edema – legs of mobile pts, sacrum of bed-ridden pt * •Pitting edema: Finger pressure leaves depression •Pulmonary edema * •Seen in left-sided heart failure, renal failure etc. * •Lungs 2-3x normal wt and sectioning shows frothy, blood-tinged fluid •Cerebral edema * •May be local or general * •Some causes: * Infection * Neoplasm * Hypertensive crisis * Venous obstruction

Answer 182

•Seen in a variety of patterns * •Petechiae: pinpoint hemorrhage, 1 – 2 mm * •Purpura: hemorrhage measuring \> 3mm * •Ecchymoses: subcutaneous hematomas (bruises) larger than 1 – 2 cm * •Progress of healing of ecchymosis: * •RBCs are phagocytosed by macrophages * •Hemoglobin (red-blue) is converted to bilirubin (blue-green) then to hemosiderin (gold-brown)

Answer 183

* •The extravasation of blood due to vessel rupture most often from trauma, atherosclerosis, or erosion from inflammation or neoplasm * •May be external or internal * •Within a tissue then known as hematoma * •Large accumulations of blood in body cavities are called hemothorax, hemopericardium, hemoperitoneum, hemarthrosis * •Adults may tolerate rapid loss of up to 20% of blood volume * •\>20% loss may result in hemorrhagic (hypovolemic) shock

Answer 184

Platelet function abnormalities (acquired vs congenital) A. Acquired * 1. drugs – ASA, NSAIDS, many others * 2. uremia – unknown pathogenesis B. Congenital * 1. Platelet **adhesion defect** * a. **_Bernard-Soulier - AR_** * - Deficient platelet **Gp Ib-IX** complex where **vWF** needs to bind * - vWF links platelets and endothelium * - Giant platelets * - **Platelet Aggregation Test: everything works but _ristocetin_ (doesn't work)** * 2. Platelet **aggregation defect** * a. **Glanzmann’s thrombasthenia – AR** * - Deficient **Gp IIb-IIIa** which is the place where **fibrinogen** crosslinks between platelets * - **Platelet Aggregation Test: nothing works but _ristocetin_ (works)**

Answer 185

1. Platelet adhesion defect **a. Bernard-Soulier - AR** - Deficient platelet Gp Ib-IX complex where vWF needs to bind - vWF links platelets and endothelium - Giant platelets - Platelet Aggregation Test: everything works but ristocetin (doesn't work) 2. Platelet aggregation defect **a. Glanzmann’s thrombasthenia – AR** - Deficient Gp IIb-IIIa which is the place where fibrinogen crosslinks between platelets - Platelet Aggregation Test: nothing works but ristocetin (works)

Answer 186

**Clotting factor abnormalities** * Von Willebrand disease * Factor VIII deficiency (Hemophilia A) * Factor IX deficiency (Hemophilia B, Christmas disease) * Acquired deficiencies; Vit K deficiency, Liver disease, DIC

Answer 187

Von Willebrand disease 1. Type 1 - AD (70%) * a. **quantitative** decrease in vWF - \<50% activity * b. mutation type is not well defined and varies * c. reduced penetrance and variable expression thus symptoms vary among type 1 patients * d. patients generally do not require treatment, but DDAVP can be given during procedures/surgery, if needed 2. Type 2 – AD (25%) * a. **qualitative** vWF abnormality * b. several subtypes – 2A is the most common * c. abnormal vWF results in defective multimer assembly with **absence of intermediate and large multimers** 3. Type 3 – AR (rare) * a. **quantitative** decrease in vWF - \< 5-10% activity * b. gene deletions and frameshift mutations * c. symptoms are severe and because vWF carries VIII, the symptoms often reflect VIII deficiency as well * d. patients require replacement therapy (Humate P)

Answer 188

Factor VIII deficiency (Hemophilia A) A. VIII is the cofactor for IX D. Clinical symptoms correlated with VIII level * \<1% activity = severe * 2. 2-5% activity = moderate * 3. 6-50% activity = mild E. different mutation types explain the variability of VIII levels * 1. rarely, mutations result in abnormal function of normal levels F. Symptoms; * 1. easy bruising, massive hemorrhage after surgery/trauma * 2. spontaneous hemorrhage into large joints = hemarthroses * 3. no mucous membrane bleeding or petechiae

Answer 189

G. Diagnosis: * 1. Prolonged PTT * 2. Normal PFA, platelet count, PT * 3. Factor VIII assay (functional) H. Treatment = Humate P (purified plasma derived) or recombinant (Kogenate) * 1. purified and recombinant VIII virtually eliminates infectious risk * 2. inhibitor development is still a risk of replacement therapy **Why do symptoms occur if only one arm of cascade is knocked out?** * 1. tests may not reflect true in-vivo reality * 2. fibrin formation/deposition is inadequate to maintain clot * a. extrinsic role is the burst to get the cascade moving; intrinsic pathway maintains it 3. inappropriate fibrinolysis * a. high levels of thrombin needed to activate TAFI (inhibits fibrinolysis); this does not occur with only one pathway working

Answer 190

**Factor IX Deficiency (Hemophilia B, Christmas Disease)** A. clinically identical to VIII deficiency (remember, VIII and IX work together to activate X) \*\*\*Treatment: recombinant factor IX

Answer 191

A. **Vitamin K deficiency** (II, VII, IX, X, Protein C) * - this is how Coumadin works B. **Liver Disease** * - majority of coagulation cascade proteins are made in liver **C. DIC**

Answer 192

DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC) Etiologies **A. Obstetric complications** * 1. Placental abruption * 2. retained products * 3. septic abortion **B. Infections** * 1. gram negative sepsis * 2. meningococcemia **C. Neoplasms** * 1. APL (AML-M3) * 2. Adenocarcinoma **D. Massive Tissue Injury**

Answer 193

**Mechanisms** A. Tissue Factor release into the blood * 1. obstetric complications * 2. substance released by blasts of APL * 3. mucin of adenocarcinoma released into blood directly activating X * 4. gram negative sepsis with bacterial endotoxins result in release of IL1 and TNF which increase the TF on endothelial cells, and B. Wide spread endothelial cell injury * 1. infectious etiologies via TNF production * a. increases leukocyte adhesion and free radical formation which damages endothelium * 2. antigen/antibody complex deposition (SLE) * 3. heat stoke, burns **Consequences** A. **Widespread fibrin deposition in microvasculature** 1. ischemia of associated organs * a. ischemic bowel * b. renal failure * c. hepatic necrosis * d. skin/digit necrosis 2. hemolytic anemia * a. microangiopathic; schistocytes on smear * *B. Hemorrhagic diathesis** 1. factor and platelet consumption faster than production 2. plasminogen activation - fibrinolysis results in increased d-dimer/FDP’s which inhibit platelet aggregation and have antithrombin activity

Answer 194

DIC * A. Acute, fulminent – typically presents with bleeding * 1. endotoxic shock, trauma * 2. obstetric complications * 3. APL * B. Chronic, insidious – typically presents with thrombosis * 1. carcinomatosis * C. Presentation * 1. microangiopathic hemolytic anemia * 2. dyspnea, cyanosis, respiratory failure * 3. convulsions, coma * 4. oliguria, acute renal failure * 5. circulatory shock * D. Coag findings * 1. decreased platelets * 2. prolonged PT and PTT * 3. decreasing fibrinogen * E. Peripheral smear: * 1. **schistocytes** with compensatory increase in retics/nRBCs if marrow stores available * 2. leukocytosis and neutrophilia, sometimes with left shift; toxic changes * 3. decreased numbers of plts; giant platelets * E. Treatment * 1. treat underlying problem/illness * 2. supportive care

Answer 195

Normal PT and PTT – shows it is not a coagulation factor problem 1. **HUS** (hemolytic uremic syndrome) – **Ecoli 0517.** **Fever and neurologic** symptoms – **TTP** (both kids and adults) Factor VIII deficiency – prolonged PTT Bernard-Soulier; ristocetin doesn’t work due to deficient glycoprotein Ib-IX complex where vWF needs to bind 1. **thrombasthenia**; **ristocetin works** but everything else doesn’t 2. **Schistocytes, thrombocytopenia, adult, fever, high BUN, PT/PTT is normal; ADAMTS 13 deficiency (TTP)** 3. **Pregnanct woman –** petechiae, intravascular clotting (fibrin degradation products), increased PT and PTT; **DIC (disseminated intravascular coagulopathy)**

Answer 196

* Diagnosis; **Type II HIT** (heparin induced thrombocytopenia) * Treatment; Anticoagulant – **direct thrombin inhibitor (Argatroban)** started and then patient was discharged on Coumadin (prevent factors II, VII, IX, X). THESE WILL **PREVENT BLOOD CLOTTING**

Answer 197

* What lyse the clot? **tPA (ALTEPLASE)** – cause fibrinolysis * What cause **arterial thrombosis; artthleroscolrosis** * Number 1 cause of **Venous thrombosis**? **STASIS** * What causes SOB in patient**; pulmonary edema** – from heart attack in left ventricle **(left ventricle failure**) – increased hydrostatic pressure. * How does this edema differ from acute type edema; TRANSUDATE SEEN * Most common source of clinically significant **pulmonary emboli**? CLOT FROM THE LEG **(DVT)** * Most common symptom associated with venous thrombi? **ASYMPTOMATIC** (until they have pulmonary embolism) * Most common symptom of **PE; ASYMPTOMATIC**. Others are; SOB, chest pain

Answer 198

Case 3 * Increased PTT differential; von willebrand disease, Factor VIII and IX (hemophilia A and B) * Tests; vWF structural gel analysis; vWF absent (Type III), **vWF reduced (Type I)**, qualitative defect (Type II) Case 4; Factor VIII deficiency * Hemarthrosis (joint swelling); secondary hemostasis * Factor VIII deficiency at risk for **INTRAMUSCULAR HEMORRHAGE**

Exam 2 Exam 1 Flashcards

Hematology (236 cards)