Hematopathology

Dr. Awaz Ahmed Kamal

Lecturer /College of Medicine UOS
 Learning outcomes:

After this session you should be able to describe:

1.Basics of hemopoiesis and blood formation.

2.General hematological investigations for anaemia.
3. Definition, classification, and clinical presentations of
anemias.
4. Pancytopenia
5. Aplastic Anemia
 lympholytes includecells that are respfor

Two main types of leukocytes is it a Eisi

granulocytes part of innate ggifrggg
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forhemostasis
against bacteria fungi
Virus Parasites1

mainfunction ofbonemarrow hematopoiesis

The mesenchymal stem cells secrete growth factors requiredfor

stimulating hematopoiesis

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 Blood formation
Blood is a suspension of non-dividing end stage cells in plasma.

Haemopoiesis: is process of proliferation, differentiation and mature blood

cell release. It includes erythropoiesis, leucopoiesis and thrombopoiesis
processes.

Sites of hemopoiesis:
Fetus 0-2 m (yolk sac) young
2-7 m (liver, spleen) Liver
saves
5-9 m (Bone marrow) Blood
Infant Bone marrow (all bones)
Adult Bone marrow (axial skeleton and proximal end of long bones).
 Structure of BM:
• Bone marrow consist of hemopoietic and stromal cells. Hempoietic
tissue including stem, progenitor, precursor and mature cells.

• Stem cells can give rise all cell lines, able to self-renewal (proliferation) and
differentiation, present in few and constant number and require certain growth
factors and suitable microenvironment to work.

• Progenitor cells present in early and late types, and consider intermediate
stage of multi-lineage or uni-lineage cells with increase differentiation over
the proliferation.

Precurserto
• Precursor cells specific for single line and morphologically recognizable in
the bone marrow.
Stem cells

Progenitor
cells

Precursors cells

Mature cells
 Structure of BM:
Red marrow is the active marrow and considered as the site of hemopoiesis,
while yellow marrow is the inactive marrow consist mainly of fat cells. Fat
marrow (yellow marrow) is able to reverse into red marrow (active marrow) in
many diseases when function of active marrow is required.
andheavybleeding
Percentage of active hemopoiesis will differ according to the age and gradually
reduce with progression of the age in compare with percent of fat tissue:

• In adult (fat: haemopoietic tissues) 50%:50%

• In child (fat: haemopoietic tissues) 25%:75%
• In elderly (fat: haemopoietic tissues) 75%:25%
Extramedullary hemopoiesis means process of hemopoiesis occuring outside
the BM (mainly in liver and spleen) , it occurs in certain conditions as in sever
chronic hemolytic anemia and BM fibrosis.
 Erythropoiesis

It mean formation of RBC and require 7 days for complete new RBC
formation. This process requires stem, progenitor and precursor cells for
complete formation of mature RBC.

Important cells in the BM for this process are precursor cells which
including:
•Proerythoblast.
•Early normoblasts.
•Intermediate normoblasts.
•Late normoblasts.
•Reticulocytes.

The cell gradually loss their nucleus until formation of reticulocyte as

last precursor cell without nucleus.
•Reticulocytes: non nucleated red cells with diffusely basophilic cytoplasm due
to remaining ribosomal RNA, still able to synthesis the Hb, slightly larger than
mature RBC, it remains in BM about 2 days then release to circulation and
remains 1-2 days to complete their maturation in the spleen. Normal range in
peripheral blood is 0.5-2.5 %.

•Mature RBC: non nucleated cells of 8µm in diameter, biconcave, flexible, able
to pass through microcirculation with minimal diameter 3.5 µm. Life span 120
days, generate energy as ATP and generate reducing power.
NADPH

•Normoblast (precursor of RBC) normally present in the BM and not present in

peripheral blood and when appear called nucleated RBC (NRBC).

where do reticulocytes complete

their maturation Spleen
 Control of erythropoiesis:

• Functional feedback: achieved by Erythropoietin (Epo).

• Certain hormones, like growth hormone and androgen enhance
erythropoiesis, while estrogen suppresses erythropoiesis.
• Nutritional factors like FA, B12, iron, B6, B2, vitamin C and E.
cofacid's
Erythropoietin (Epo):
It is a glycoprotein produced mainly by the kidney in the adult, stimulates red
cell progenitors and precursors cells for RBC formation from the BM.
Secretion of Epo is triggered by reduced oxygen tension of blood:
• Reduced Hb (anemia).
• Hypoxia (cardiac and lung disease).
• Damage to renal circulation.

Epo of great clinical significant in many disorders using recombinant Epo

like end stage renal disease and anemia of chronic disease.
 Initial hematological investigations

Complete blood count; include Hb level, WBC count, platelets

count, RBC indices and WBC differential count.

Blood film stained usually with Leishman stain, to examin red cell
morphology, leucocyte morphology, leucocyte differential count and platelet
morphology.

ESR (erythrocyte sedimentation rate): red cell sedimentation depends mainly

on plasma proteins as fibrinogen and other acute phase proteins that increase
the red cells rouleaux and extend of their sinking.
 Reticulocytes count (Retic count)
•Reticulocyte: are young, immature non nucleated red cells containing
remnant RNA.
• Increase retic count occur in hemolytic anemias, hemolysis and recovery
state from anemia.
•Decrease retic count occur in bone marrow failure.
Retic count: is the estimation of number of reticulocytes among mature
peripheral RBC detected by a special stain, normal range 0.5-2.5 %.

O
O O

RBto non nucleated

Blood film
Definition of terms in RBC disorders
mean cellvolume
• Normocytic: normal size (normal MCV).
Puscular
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• Normochromic: normal Hb amount (normal MCH), RBC showing central
pallor less than 1/3 of cell diameter.

• Hypochromic: decrease in Hb amount (decrease in MCH), central pallor

more than 1/3 of cell diameter.

• Anisocytosis: variation in RBC size as microcytic (decrease in MCV),

macrocytic (increase in MCV).

• Poikilocytosis: variation in RBC shape as spherocytes, target, tear drop,

sickle, fragmented, oval, rod cells, etc..

• Polychromasia, rouleaux formation and agglutination of RBC.

Rouleaux formation Agglutination

Corouleaux formation
Red cell indices

• Hemoglobin (normal range for male 13.5– 17.5 g/dl, female 11.5-15.5
g/dl).
• Packed cell volume (PCV) also called Hematocrit (Male 40-52 %,
Female 36-48 %).
• RBC count (Male 4.5-6.5 x 1012/L, Female 3.9-5.6 x 1012/L).

• MCV: mean cell volume (80-95 fl).

• MCH: mean cell Hb (27-34 pg).
• MCHC: mean cell Hb concentration (32-36 g/dl).
• RDW: red cells distribution width (12-15 %).
 Example of complete blood counts and blood film
Red blood cells indices Platelets count: ×109/L.
332
Hb: 14.1 gm/dl. Total WBC count: 9.7 × 109/L

PCV (Hematocrit): 43.2 % Differential count (%)

Neutrophils: 62
RBC: 4.8 × 10 /L
12
Lymphocytes: 35
MCV: 88 fl Monocyte: 3
Eosinophils: 0
MCH: 28 pg Basophiles: 0
MCHC: 32 gm/dl.
RDW: 15 %

Retic count: % Blood film ESR:

morphology
8 mm/hr.

RBC: Normocytic normochromic red cells.

WBC: Look normal in total, differential count

and morphology
Platelets: Look normal in count and
 Bone marrow examination: There are two types of marrow procedures:
1.Bone marrow aspirate: done from iliac crest or sternum, in which a specimen is
aspirated using a wide bore needle from the active marrow, smeared, stained and
then examined for any abnormalities.
2.Bone marrow biopsy: here a core of bone marrow tissue is taken,
processed and stained as in histopathological specimens.

The most common site for a bone marrow exam (aspiration or biopsy) is the
posterior iliac crest

Main indications of BM examination:

1.Marrow infiltration with leukemia, lymphoma, secondary carcinomas
and myelofibrosis.
2.Cytopenias of unexplained causes: leucopenia, thrombocytopenia, anemia.
 Bone marrow examination

Bone marrow aspiration Bone marrow biopsy

 Red blood cells disorders
(Anemias and Polycythaemia)

Normal Hb is:
• Male: 13.5-17.5 gm/dl (PCV 40-52 %)
• Female:11.5-15.5 gm/dl (PCV 36-48%)

Anemia: decrease in Hb concentration below normal range

for age and sex.

Polycythemia: increase in the Hb concentration above the

upper limit of normal for age and sex
In male Hb <13 g/dL or PCV < 40%
In female Hb <11.5 g/dL or PCV < 36 %
 Classification of
Anemia
I. Etiological classification.
II. Morphological classification.
III. Classification based on reticulocyte response.
 Etiological Classification:
I) Impaired RBC production:
1.Iron deficiency anemia (IDA).
2.Megaloblastic anemia (MBA). redcell
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3.Aplastic anemia (AA), pure RC aplasia (PRCA).
4.Anemia of chronic disease (ACD). Bloody
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5.Sideroblastic anemia. Mrs Eden

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6.Bone marrow infiltration.
II) Blood loss: Acute or chronic blood loss
III) Increase in RBC destruction
Hemolysis (Hemolytic anemia): intavascular or extravascular hemolysis
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 Morphological classification
Hypochromic Microcytic anaemia:
Iron deficiency anaemia
Thalassemia
Sideroblastic anaemia
Lead poisoning
Normochromic normocytic anaemia: MY Normal
Anaemia of chronic disorder
Hemolytic anaemia
bone marrow failure and Stem cells defects
Macrocytic anaemia
Megaloblastic anaemiaMEP
Myelodysplastic syndromes
Liver disease
Drugs
Alcoholism
 Classification of anemia

( Retic count low or normal ) ( Retic count increase )

BM defect Peripheral blood loss

Like: Like:
1.Iron deficieny anemia 1.Bleeding
2.Megaloblastic anemia 2.Hemolysis (hemolytic anemia)
3.Aplastic anemia
4.Anemia of chronic dis.
5.Anemia associated with
BM infilteration.
 General clinical features of anemia:
•Symptoms: tiredness,easy fatigability, lethargy,palpitation,
dyspnea, headache, tinnitus, anorexia, nausea.
•Signs; pallor, tachycardia, jaundice and splenomegaly (in
hemolytic
anemia), delay growth and sexual maturation in chronic anemia.
due to accumulation
of distrusted RBC
 General initial laboratory investigations of anemia:

(1) CBC, blood film and retic count should be done for all cases
presented as anemia.
(2) ESR in recommended cases.
(3) BM examination in certain conditions
(4) special investigations done according to suspected cause of
anemia, like serum iron indices, Hb electrophoresis, coomb's test,
etc.
 pancytopenia female
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• Reduction of all major cells lines of blood
135 Emare
• WHO defines pancytopenia as: Anemia (Hb < 12 gm/dl in
female or < 13 gm/dl in male) Leucopenia or neutropenia
(WBC <4000/ml or absolute neutrophile count <1800/ml)
and thrombocytopenia (< 150000) 11500 1800 20007
. 40165 450000 7 00
 Mechanism

1) Bone marrow infilteration : leukemia, lymphoma, multiple

myloma, metastatic carcinoma, mylofibrosis, infections.
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2) Bone marrow aplasia: nutritional deficiency (B12 and
folate). Aplastic anemia, drugs, infections, immune
mediated.

3) Cell sequestration and destruction : hypersplinism, DIC,

autoimmune.
 Management
1) History: severity and duration. Associated symptoms,
medical or surgical history, medications
2) Physical examination: splenomegaly, lymphadenopathy,
rashes, jaundice 8dtt49s
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3) Laboratory investigations: CBP, retic, PT PTT, bone
marrow examination, cytogenetic studies thrombin
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4) Treatment: according to underlying cause Similar to PT it
evaluates bloodclotting
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intrinsic Pathway
Pancytopenia
 Aplastic Anemia

Aplastic anemia is defined as pancytopenia resulting from

aplasia of the bone marrow.
 Causes
Primary:
Congenital e.g. Fanconi’s anemia
Idiopathic Acquired morethan
Secondary: of cases
Ionizing radiation ofapatite
Chemicals: benzene & other organic solvents, insecticides, hair dyes
Drugs: Which regularly cause marrow depression e.g. busulphan,
cyclophosphamide, chloramphenicol, sulfonamides,
anti-inflammatory, anti-depressant drugs.
Infection: viral hepatitis (non-A non-B),EBV
Autoimmune diseases as SLE
Transfusion associated Cosiga
 Mechanism

• The underlying defect in all cases appears to be a substantial

reduction in the number of stem cells & a fault in the
remaining stem cells or an immune reaction against them.
This makes them unable to divide & differentiate
sufficiently to populate the bone marrow.
 Fanconi anemia
appear
cogently
disease
renal

• Autosomal recessive inheritance

no TY

• The usual age of presentation of FA is 3–14 years, but some

patients present in adulthood.
• Associated with: growth retardation and congenital defects
of :
Skeleton (e.g. microcephaly, absent radii or thumbs)
Renal tract (e.g. pelvic or horseshoe kidney)
Skin (areas of hyper- and hypopigmentation)

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 Clinical Features
• The onset is at any age with bimodal peak incidence at
10-25 and over 60 years & a slight male predominance.
• It can be insidious or acute with symptoms & signs
resulting from anemia, neutropenia or
thrombocytopenia.
• Infections, particularly of the mouth & throat, are
common. Generalized infections are frequently life
threatening.
• Bruising, bleeding gums, epistaxis & menorrhagia are
the most frequent hemorrhagic manifestations & the
usual presenting features.
• Symptoms of anemia.
• The lymph nodes, liver & spleen are not enlarged.
Comixed with
lymphoma pancytopenia
becauseit cancause
 Laboratory Finding

• Anemia is usually normochromic normocytic.

• The retic count is extremely reduced.
• Leucopenia. There is selective neutropenia usually
but not always to below 1.5 x 109/L. The neutrophils
appear normal.
• Thrombocytopenia is always present & in severe
cases is less than 50x109/L.
• There are no abnormal cells in the peripheral blood.
• Bone marrow shows hypoplasia with loss of
hemopoietic tissue & replacement by fat cells >75%.
Bone marrow biopsy is essential & may show patchy
cellular areas in a hypocellular background.
 hypocellow
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bone
fat
 hypoplasia
severe
no
Good Luck