Clinical Internship: Hematology

WBC Anomalies
1. Smudge cell/ Basket cell

- ruptured WBC with free nucleus

- Non pathologic cause: Heavy pressure during smearing

- Pathologic cause: Leukemia

2. Twinning deformity

- neutrophil with diploid nuclei

- hypersegmentation

- Pernicious anemia

3. Jordan’s anomaly/ Foamy cell

- cytoplasm with holes/ vacuoles

- NP cause: 2 hour old oxalated specimen

- P cause: leukemia, infection, chemical poisoning

4. Tart cell

- monocyte with engulfed foreign nucleus

- seen in drug sensitivity

- should not be mistaken with LE cell

5. LE cell

- neut with engulfed nuclear material of a destroyed cell

- Systemic Lupus Erythematosus

6. Drumstick/ Barr body

- drumstick shaped nuclear appendage on neut, baso, eosino

- sex chromatin: Females

- Male: Klinefelter syndrome

7. Auer rods – rod like bodies that stain reddish purple

- acute myelocytic leukemia

8. Reider cell

- Lymphocyte with pseudolobulations

- CLL

- Clover leaf like nucleus

9. Hairy cell

- cytoplasm irregular and gray blue hairlike projections

- TRAP; Hairy cell leukemia

10. Alder Reilly bodies

- Large, course, dark purple, azurophilic granules; heavy granulation

- Mucopolysaccharide storage dse

- Hurler’s/ Hunter’s syndrome (gargoylism)

11. Chediak Higashi granules

- low phagocytic activity

- very large red or blue granules in cytoplasm

12. May hegglin anomaly

- Dohle like bodies;

- TRIAD presence to differentiate with true Dohle body

- Thrombocytopenia, Giant platelets, Inclusion bodies (TRIAD)

13. Toxic granulation

14. Dohle Bodies

15. Downey cell

- transformed, atypical stimulated lymphocytes

- IM with ballerina skirt cell cytoplasm

WBC disorders → Quali and Quanti (page 458)

Qualitative → with morphologic abnormality

➔ Normal morphology
➔ Morphologic changes

Quantitative → Reactive (Non malignant) → Increased or Decreased

➔ Non reactive (malignant) → Myeloproliferative disease or Lymphoproliferative

Quantitative, Non-malignant WBC disorders (Chapter 26 of Rodaks page 458)

Increased Decreased
Neutrophilia – bacterial infection, trauma Neutropenia – medication, immune mediated
Lymphocytosis – viral infection Lymphocytopenia – AIDS, CA
Eosinophilia – parasitic infection Eosinopenia – bone marrow hypoplasia
Basophilia – chronic myelogenous leukemia, Basopenia – stress, radiation
allergies
Monocytosis – inflammation, infection Monocytopenia – Hemodialysis, steroid therapy

Quantitative, Malignant WBC disorders (Chapter 26)

1. Myeloproliferative disease

• Acute myelocytic leukemia

• Chronic myelogenous leukemia
• Polycythemia vera
• Essential thrombocythemia

2. Lymphoproliferative

• Lymphocytes – acute and chronic lymphocytic leukemia

 • Lymphomas – Hodgkin’s and non
• Plasma cell leukemia – Multiple myeloma, Wladenstrom’s, Macroglobulinemia

Qualitative Disorders

1. With morphologic abnormality

• Pelger-Huet anomaly
- Failure of neutrophil to segment properly
- Bi-lobed (dumbbell shaped) nucleus
- Leukemia; Infectious mononucleosis
• Neutrophil hypersegmentation/ Macropolycytes
- 6 to 10 lobes
- Pernicious anemia
• Alder- Reilly
• Chediak Higashi
• May hegglin anomaly

2. Normal Morphology

• Chronic granulomatous disease

• Leukocyte adhesion disorder

3. With morphologic changes

• Toxic granulation
- Blue black cytoplasmic granules (basophil like)
- Acute infection, burns, drug posioning
• Dohle bodies
- Small, pale blue, periphery located
- - remnants of ribosome and ER
- Sever infection and sever burns
- Non gigantic platelets: Difference with May hegglin
• Cytoplasmic vacuolation
• IM

PLATELET ABNORMALITIES

1. Giant platelets

- indicate premature release from BM due to increased demand

- usually bigger than RBC

2. Platelet clumping

- NP causes: Slow veni, EDTA induced, age of sample >24 hours

- P cause: Glanzmann thrombasthenia

3. Platelet / thread

- activated platelets

- Spider-like projections

- fibrin thread

4. Platelet satellitosis

- adherence of platelets to WBC

- in vitro; no clinical significance

- pseudothrombocytopenia

Platelet anomaly category: Hemorrhagic

Thrombotic

Quantitative

Qualitative

Hemorrhagic – Severe Bleeding

• Localized – single location; isolated

• Generalized – Multiple sites, recurrent, spontaneous
• Acquired – Developed; Vit. K def
• Congenital – uncommon; repeated hemorrhage; ex: VWF dse, coag factor def

Factor deficiencies:

Factor I – afibrinogenemia

Factor VIII – Hemophilia A

Factor IX – Hemophilia B

Factor XI – Hemophilia C
Thrombosis – inappropriate formation of platelets or fibrin clots that obstruct vessels

• DIC
- Defibrination syndrome/ consumption coagulopathy
- Secondary to systemic disease
- All hemostatic systems

Quantitative

• Thrombocytosis
- >450,000/ micro liter
- Causes: Polcythemia vera, CML, myelofibrosis with myeloid metaplasia, essential
thrombocythemia
• Reactive thrombocytosis
– secondary to conditions
– Causes: Blood loss/ surgery, splenectomy, IDA, stress or exercise
• Thrombocytopenia
- <100,000/ micro liter; MC of bleeding
- Cause: Decreased production → Bernard Soulier – giant plt
→ Wiskott Aldrich Syndrome – small plt

Increased destruction → Thrombotic thrombocytopenic purpura

→ Hemolytic Uremic Syndrome

• Bleeding common presenting symptoms

- Mucocutaneous bleeding
- Purpura, petechiae, echymosis, epistaxis, gingival bleeding

Qualitative – platelet function

• Thrombocytopathy
- Change in platelet function
❖ Glanzmann thrombasthenia – disease in platelet aggregation;Defect in GP IIb/IIIa
❖ Bernard Soulier – platelet adhesion; GP Ib/V/IX
❖ Hermansky-Pudlak/Storage pool disease – platelet secretion (dense granules); swiss cheese
platelet

RBC abnormalities
Disorder of RBC size

MACROCYTOSIS MICROCYTOSIS ANISOCYTOSIS

Large RBC; MCV Small RBC; MCV Wide range of RBC size;
RDW
Altered DNA synthesis Iron deficiency, thalassemia, lead
posioning

Disorder of RBC color

Hypochromasia

- RBC with too little hemoglobin; MCH

Polychromasia

- Grayish blue retics

Disorder of RBC shape (PAGE 268 OF RODAKS)

Poikilocytosis Anisocytosis
Vary in shape Vary in size

Target cells (codocytes)

- Related to liver disease, thalassemias, Hgb C, post-splenectomy

Spherocytes

- Loss of central pallor

- Autoimmune hemolysis

Schistocytes

- Sharp edges; caused by plaque on RBC wall

- MAHA

Sickle cell

- Point mutation that changes to glutamic acid to valine

- Polymerization of Hb at low pH, pO2, high temperature

Echinocytes

- Burr cells; associated with renal dse

Disorder of RBC distribution

Rouleaux

- Immunoglobulin neutralize the charges that keep RBC from sticking; hence allowing RBC to
stick

Agglutination

- Less orderly than rouleaux

- Coated with IgM which bridges RBC to cause clumps