Rapid Review of Hematology.1E.2014.PDF - unitedVRG

Rapid Review
of
Hematology
Rapid Review
of
Hematology
Ramadas Nayak
MBBS MD
Professor
Department of Pathology
Kasturba Medical College
Manipal University
Mangalore, Karnataka, India
askdr.nayak@gmail.com
Sharada Rai MBBS MD
Associate Professor
Kasturba Medical College
Manipal University
Mangalore, Karnataka, India
askdr.nayak@gmail.com
Foreword
AR Raghupathy
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Rapid Review of Hematology
First Edition: 2014
ISBN 978-93-5090-961-4
Printed at
Dedicated to
Students who inspired us,
patients who provided the knowledge,
our parents and family members who
encouraged and supported us.
Foreword
DEPARTMENT OF PATHOLOGY
BANGALORE MEDICAL COLLEGE

VICTORIA HOSPITAL COMPLEX
BENGALURU - 560002
Phone: 6701150 Ext.: 314, 315, 316, 317
It gives me great pleasure to write a short foreword for this new book on Rapid Review of Hematology.
This is a well-written concise but precise and student-friendly text that will be highly valuable to medical students. It
will help in revising and reinforcing the fundamental concepts in hematology. It is very well organized with optional and
correct usage of good pictures, schematic diagrams and flow charts. Every essential topic has been discussed giving opt
importance and stress on salient features. Each statement mentioned in the text is well written as it carries the required
essential points.
In short, this book provides within one volume a user-friendly review of the basic essential concepts in hematology.
It will be of great help to not only second year MBBS students, but also for students preparing for entrance examinations,
and students of allied sciences.
This book will certainly serve as a valuable gift and a valuable addition to the students library and the user will
definitely appreciate the content and presentation of the information in this book.
In conclusion, I am sure, this book brought out by Dr Ramadas Nayak and Dr Sharada Rai will be a very useful
compendium for second year MBBS students, the students preparing for entrance examinations, and students of allied
health sciences.

I hope the reader of this new book will get as much pleasure and knowledge as I did.
AR Raghupathy MBBS MD PGDHHM (IGNOU)

Professor and Head
Bangalore Medical College and Research Institute
Bengaluru, Karnataka, India
Preface
Hematology is one of the rapidly expanding fields of medicine and emerging as a clinical specialty in its own right.
Hematology is difficult to teach at the undergraduate level, as it is a part of the curriculum in Pathology, during which
undergraduate students do not have enough exposure to diseases of blood. This results in less attention to hematological
diseases at undergraduate level. After many years of teaching undergraduates, we found that undergraduate students
either neglect hematology or find it difficult to understand the subject. It is a nightmare for many students especially
during examinations. There are many hematology textbooks, but undergraduates face difficulties to refresh their
knowledge of hematology during examinations. This encouraged us to write a book to fill the niche, to provide basic
information to an undergraduate in a nutshell. With this view in mind, Rapid Review of Hematology is intended for the
undergraduates from medical, dental and paramedical fields. Most students are fundamentally visually oriented. As
the saying one picture worth thousand words, it encouraged us to provide many illustrations (e.g. etiopathogenesis,
clinical presentation, complications, peripheral blood smear and other relevant laboratory tests).
Organization
This book is organized into four sections namely disorders of red cells, disorders of white cells, disorders of hemostasis
and clinical scenario.

The final section deals with common clinical scenario encountered during theory examination.
How to use this book

We recommend that this book not to be used as a hematology textbook rather than a supplement to Essentials in
Hematology and Clinical Pathology (Authored by Dr Ramadas Nayak, Dr Sharada Rai and Dr Astha Gupta). The
concepts of hematology have been oversimplified in this book, but all the information, the student will ever need to
know, have been provided. The readers are requested to give more emphasis on word in bold letters that represents
the key words to be remembered. The peripheral smear and bone marrow findings have been highlighted in colored
background. Boxes have been provided at the sides of main text. These include some of the key points as well as commonly
expected questions during examinations. This book can serve as a source of rapid review of hematology.
Ramadas Nayak
Sharada Rai
Acknowledgments
Our sincere thanks to Ms Prathiba Bhat for her untiring efforts, patience and excellent support in creating many
illustrations for this book.
Acknowledgments are also due to Dr Astha Gupta (Consultant Pathologist, New Delhi, India), Dr Rakshatha
(KS Hegde Medical college, Mangalore, Karnataka, India), Ms Rekha Nayak, Ms Rashmitha Nayak, and Mr Ramnath Kini
for their contribution in the preparation of the manuscript.
Our sincere thanks to Dr AR Raghupathy, Professor and Head, Department of Pathology, Bangalore Medical College
and Research Institute, Bengaluru, Karnataka, India, for his support and guidance.
We are grateful to Dr K Ramnarayan, Vice Chancellor of Manipal University, Manipal, Karnataka, India, and
Dr M Venkatraya Prabhu, Dean, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India, for their
encouragement.
We are grateful to all our friends, undergraduate and postgraduate students who have inspired and supported us.
We wholeheartedly thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja
(Director-Publishing), Ms Chetna Malhotra Vohra (Sr Manager, Business Development) of M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, for publishing the book in the same format as wanted well in time.
We acknowledge the wonderful work done by Ms Sunita Katla (Publishing Manager), Ms Samina Khan
(PA to Director), Mr KK Raman (Production Manager), Mr Rajesh Sharma (Production Coordinator), Ms Seema
Dogra (Cover Designer), Mr Sarvesh Kumar Singh (Proofreader), Mr Rajesh Ghurkundi (Graphic Designer), and
Mr Raj Kumar (DTP Operator) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.
We thank especially Mr Venugopal V and Mr Vasudev H of M/s Jaypee Brothers Medical Publishers (P) Ltd,
Bengaluru Branch, Karnataka, India, for taking this book to every corner of Karnataka.
Contents
Section 1: Disorders of Red Cells
1. Anemias of Impaired Red Cell Production
Anemia 3
Red cell indices 4
Iron deficiency anemia 5
Megaloblastic anemia 8
Pernicious anemia 11
Aplastic anemia 13
2. Hemolytic Anemias Due to Red Cell Membrane and Enzyme Defects
16
Hemolytic anemia 16
Hereditary spherocytosis 17
Glucose-6-phosphate dehydrogenase deficiency 20
3. Thalassemia Syndrome

22
Classification of hereditary defects in hemoglobin 22

Thalassemia syndrome 22
b-thalassemia22
b-thalassemia major 23
b-thalassemia minor/trait 27
a-thalassemia28
4. Sickle Cell Disease
29
Sickle cell disease 29

Sickle cell anemia 29
Sickle cell trait 34
5. Other Anemias

Immunohemolytic anemias 36
Hemolytic disease of the newborn 36
Antiglobulin (Coombs) test 39
Autoimmune hemolytic anemia 40
Fragmentation syndrome 41
Paroxysmal nocturnal hemoglobinuria 41
Anemias of blood loss 41
Sideroblastic anemias 42
36
xiv
Section 2: Disorders of White Cells

6. Quantitative and Qualitative Disorders of Leukocytes

7. Acute Leukemia

45
Normal differential leukocyte count (DLC)45

Quantitative disorders of leukocytes 45
Qualitative disorders of leukocytes 50
Infectious mononucleosis (Glandular fever) 51
52
Acute leukemia 52
Acute lymphoblastic leukemia/lymphoma 55
Acute myelogenous leukemia 57
Myeloid sarcoma 59
8. Myelodysplastic Syndromes
60
Myelodysplastic syndromes 60
9. Myeloproliferative Neoplasms

62
Myeloproliferative neoplasms (MPN)62

Polycythemia or erythrocytosis 63
Polycythemia vera 63
Essential thrombocythemia 65
Primary myelofibrosis 66
10. Chronic Myelogenous Leukemia
68
Chronic myelogenous leukemia 68

Natural history of chronic myeloid leukemia 70
11. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
73
Chronic lymphocytic leukemia 73

Hairy cell leukemia 75
12. Plasma Cell Neoplasms
76
Plasma cell myeloma (multiple myeloma) 76

Plasmacytoma 80
Immunoglobulin deposition disease 80
Monoclonal gammopathy of uncertain significance (MGUS)80
13. Lymphoid Neoplasms
81
Classification of lymphoid neoplasms 81

Follicular lymphoma (FL)82
Diffuse large B cell lymphoma (DLBCL)83
Burkitt lymphoma (BL)83
Mature T cell and NK cell neoplasms 85
14. Hodgkin Lymphomas

Definition 87
Classification 87
Morphology of neoplastic cells 88
Classical Hodgkin lymphoma 88
Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)92
Etiology and pathogenesis of Hodgkin lymphoma 93
87
Contents
Laboratory findings 93
Staging of Hodgkin lymphoma 94
Differences between Hodgkin lymphoma and non-Hodgkin lymphoma 94
15. Langerhans Cell Histiocytosis/Histiocytosis X
95
Morphology 95
Laboratory findings 95
Section 3: Disorders of Hemostasis

16. Disorders of Primary Hemostasis
99
Normal hemostasis 99
Classification of hemostatic disorders 99
Bleeding disorders caused by vessel wall abnormalities 99
Bleeding disorders due to abnormalities of platelet 100
Thrombocytopenia 100
Immune thrombocytopenic purpura 102
Thrombocytosis 104
Qualitative platelet disorders 104
17. Bleeding Disorders: Due to Abnormalities of Coagulation/Clotting Factor
105
Classification of coagulation disorders 105

Hereditary coagulation disorders 106
Hemophilia 106
Hemophilia A (Factor VIII deficiency) 106
Hemophilia B (Christmas disease, factor IX deficiency) 108
von Willebrand disease (vWD)108
Acquired coagulation disorders 109
Disseminated intravascular coagulation 110
18. Thrombotic Disorders: Hypercoagulable State
113
Hypercoagulable state (Thrombophilia) 113

Inherited hypercoagulable states 114
Acquired hypercoagulable states 114
Section 4: Clinical Scenario

19. Clinical Scenario
119
Symptoms and signs that suggest a blood disease 119

Patterns strongly suggestive of a blood disease 120
Appendix 127
Bibliography 133
Index 135
xv
Anemias of Impaired Red Cell Production CHAPTER 1
SECTION
Disorders of
Red Cells
Anemias of Impaired
Red Cell Production
ANEMIA
1
CHAPTER
Q. Define anemia.
Definition
Decrease below normal of the hemoglobin concentration (Hb)/RBC count/hematocrit
(packed cell volume).
Reduction of the total circulating red cell mass below normal limits.
Decrease in the oxygen-carrying capacity of the blood, which leads to tissue hypoxia.
WHO criteria for anemia:

adult males Hb <13 g/dL
and adult female Hb <12
g/dL.
Anemia may be absolute (decreased RBC mass), or relative (associated with a higher plasma
Grading of anemia:
volume). Anemia is conventionally used for absolute anemia.
mild (Hb 9.110.5 g/dL),

moderate (Hb 6.09.0 g/dL)
and severe (Hb < 6.0 g/dL).
Classification of Anemia
1. Morphological classification (Table 1.1): it is based on:
a. Red cell size (normocytic, microcytic, or macrocytic), and
b. Degree of hemoglobinization (normochromic or hypochromic).
Anemia is characterized by
decreased oxygen carrying
capacity of blood. Shows
decreased Hb and PCV.
TABLE 1.1: Morphological classification of anemia

Type of anemia
Microcytic hypochromic
Normocytic normochromic
Macrocytic
Size of RBCs
Smaller than normal
Normal
Larger than normal
Central pallor in RBCs
More than 1/3
Normal
Normal
Mean corpuscular
volume (MCV)
Reduced (< 80 fL)
Normal (8298 fL)
Increased (>100 fL)
Mean corpuscular
hemoglobin
concentration (MCHC)
Reduced (< 30 g/dL)
Normal (3136 g/dL)
Normal (3136 g/dL)
Examples
Iron deficiency anemia,

thalassemia
During blood loss, anemia of

chronic diseases
Deficiency of vitamin
B12 and folic acid
Morphology of RBC
Q. Classify anemia.
Classification: anemias are

mainly classified based
on 1) morphology and 2)
etiology.
Spurious anemia is the

term used when RBC
concentration decreases
due to hemodilution as
seen in third semester of
pregnancy.
SECTION 1 Disorders of Red Cells
Anemia is the expression

of underlying disease and
from treatment point, the
cause of anemia must be
identified.
2. Etiological classification: The etiological classification of anemia is listed in Table 1.2.

TABLE 1.2: Etiological classification of anemia
1. IMPAIRED RED CELL PRODUCTION

Causes of anemia:
1. Decreased RBC
production
2. Increased RBC
destruction (hemolysis)
or
3. Blood loss.

Iron deficiency anemia is
the most common anemia.
Disturbed Proliferation and Maturation of Erythroblasts

Defective DNA synthesis
Megaloblastic anemias due to deficiency or impaired utilization of vitamin B12 and folic acid
Anemia of renal failure due to deficiency of erythropoietin
Anemia of chronic disease due to iron sequestration and relative erythropoietin deficiency
Anemias of endocrine disorders
Defective hemoglobin synthesis
Defective heme synthesis: iron deficiency, sideroblastic anemia
Defective globin synthesis: thalassemias
Marrow Replacement
Primary hematopoietic neoplasms: acute leukemia, myelodysplastic syndromes
Marrow Infiltration (myelophthisic anemia)
Metastatic neoplasms
Disturbed Proliferation and Differentiation of Stem Cells
Aplastic anemia, pure red cell aplasia
2. INCREASED RED CELL DESTRUCTION (HEMOLYTIC ANEMIAS)

Intrinsic (Intracorpuscular) Abnormalities

Hereditary
Membrane abnormalities: spherocytosis, elliptocytosis
Enzyme deficiencies: glucose-6-phosphate dehydrogenase, pyruvate kinase
Disorders of hemoglobin synthesis
Deficient globin synthesis: thalassemia syndromes
Structurally abnormal globin synthesis (hemoglobinopathies): sickle cell anemia
Acquired
Membrane defects: paroxysmal nocturnal hemoglobinuria
Extrinsic (Extracorpuscular) Abnormalities
Antibody-mediated
Isohemagglutinins: transfusion reactions, Rh disease of the newborn
Autoantibodies: idiopathic (primary), drug-associated, systemic lupus erythematosus
Mechanical trauma to RBCs:
Microangiopathic hemolytic anemia: disseminated intravascular coagulation
Infections: malaria
3. BLOOD LOSS
Acute: trauma
Chronic: lesions of gastrointestinal tract (e.g. carcinoma colon), gynecological disturbances
RED CELL INDICES
Q. Write short notes on red cell

indices.
Red cell indices are useful in morphological characterization and diagnosis of anemias. They
are either directly measured or automatically calculated by specialized instruments. Red cell
indices include:
Red cell indices: MCV, MCH, 1. Mean Corpuscular Volume (MCV)
MCHC and RDW.
MCV is indicative of average volume of the RBC and is expressed in femtoliters (fL).
It is used for classification and differential diagnosis of anemias.
Normal range: 8298 fL.
Microcytic anemia
have MCV < 80 fL and
macrocytic anemia have
MCV> 100 fL.
MCV =
PCV 1000
RBC count in millions
= 0.45 1000/5 = 90 fL
2. Mean Corpuscular Hemoglobin (MCH)

MCH indicates the amount of Hb (weight) per RBC and is expressed as picograms (1 pg
= 10-12 g).
It is of limited value in differential diagnosis of anemias.
Normal range: 2732 pg
MCH < 26 pg is seen in

microcytic anemia and
MCH > 33 pg is seen in
macrocytic anemia.
MCH = Hb (in g/L)/RBC (in millions/L) = 15 10/5 = 30 pg
3. Mean Corpuscular Hemoglobin Concentration (MCHC)

MCHC denotes the average concentration of hemoglobin in the RBC taking volume into
account. It is expressed as g/dL (earlier it was expressed as %).
It is a better indicator of hypochromasia than MCH.
Normal range: 3135 g/dL.

MCHC<31 g/dL is seen in

hypochromic RBC such
as IDA and thalassemia.
MCHC >36 g/dL is an
indication of hyperchromic
RBCs.
MCHC = Hb (in g/dL)/PCV = 15/0.45 = 33 g/dL
4. Red Cell Distribution Width (RDW)

RDW is a quantitative measure of anisocytosis.
Normal RDW is 11.5% to 14.5%.
A normal RDW indicates that RBCs are relatively uniform in size. A raised RDW indicates
that red cells are heterogeneous in size and/or shape. In early iron deficiency anemia,
RDW increases along with low MCV while in thalassemia trait, RDW is normal with low
MCV.
RDW is useful for

differentiating anemia
due to iron deficiency and
thalassemia.
RDW = (Standard deviation mean cell volume) 100
IRON DEFICIENCY ANEMIA

Iron deficiency anemia (IDA) is the most common nutritional disorder.
Etiology (Table 1.3)

IDA is due to deficiency of iron causing defective heme synthesis.
Q. Discuss the etiopathogenesis

of iron deficiency anemia.
TABLE 1.3: Causes of iron deficiency anemia

1. Dietary deficiency/lack

Milk-fed infants
Elderly with improper diet and poor dentition
Low socioeconomical sections
Vegetarians (contains poorly absorbable inorganic iron)
2. Impaired absorption
Total/partial gastrectomy
Intestinal absorption is impaired in sprue, other causes of intestinal steatorrhea and chronic diarrhea
Specific items in the diet, like phytates of cereals, tannates, carbonates, oxalates, phosphates and drugs
can impair iron absorption
3. Increased demand/requirement
Dietary deficiency is the

commonest cause of IDA.
In adult men and
postmenopausal women,
deficiency may be due to
chronic gastrointestinal
blood loss.
Iron is absorbed in the

duodenum.
Growing infants, children and adolescents

Pregnancy and lactation
4. Chronic blood loss: due to bleeding from the
Gastrointestinal tract (e.g. peptic ulcers, gastric carcinoma, colonic carcinoma, hemorrhoids, hookworm
infestation or nonsteroidal anti-inflammatory drugs)
Urinary tract (e.g. renal or bladder tumors)
Genital tract (e.g. menorrhagia, uterine cancer)
Respiratory tract (e.g. hemoptysis)
Infants who consume large

amounts of cow's milk are
susceptible to develop IDA.
Stages of IDA in
sequence: absent of
iron storesdecreased
serum ferritindecreased
serum ironincreased
TIBC decreased iron
saturation microcytic
hypochromic anemia.
Q. Discuss the laboratory findings

in iron deficiency anemia.
MCV, MCH and MCHC are
reduced. RDW is raised.
Q. Write short notes on peripheral

smear findings in iron deficiency
anemia.
Peripheral smear shows
microcytic hypochromic
RBCs.
Pathogenesis of Iron Deficiency Anemia

It is due to decreased synthesis of heme and can be divided into 3 stages.
Stage 1 (Iron depletion): iron adequate to maintain normal hemoglobin level and only
serum ferritin decreased.
Stage 2 (Iron deficient erythropoiesis): lowering of serum iron and transferrin saturation
levels without anemia (Hb, MCV and MCH within normal range). Bone marrow shows iron
deficient erythropoiesis.
Stage 3 (Iron deficiency anemia): low serum iron, serum ferritin and transferrin saturation.
Impaired hemoglobin production. Morphologically, first reduction in the size (microcytic)
and later increase in the central pallor (hypochromia) of RBCs.
Laboratory Findings
Peripheral Blood
Hemoglobin and hematocrit (PCV): decreased
Red cell indices:
MCV: <80 fL (normal 8298 fL)
MCH: <25 pg (normal 2732 pg)
MCHC: <27 g/dL(3136 g/dL)
RDW: increased and >15%. It is earliest sign of iron deficiency (normal 11.514.5%).
Peripheral smear (Figs 1.1 and 1.2):
RBCs: microcytic (small) and hypochromic (pale). Severe anemia shows ring/pessary cells.
Moderate anisocytosis and poikilocytosis pencil/cigar-shaped cells.
WBCs: normal; eosinophilia in hookworm infestation.
Platelets: normal
Reticulocyte count: low for the degree of anemia.
Fig. 1.1: Peripheral blood smear showing microcytic

hypochromic red blood cells
Fig. 1.2: Diagrammatic appearance of peripheral blood smear

with microcytic hypochromic red blood cells
Bone Marrow
Cellularity: moderately hypercellular.

M:E ratio: varies from 2:1 to 1:2 (normal 2:1 to 4:1).
Erythropoiesis: hyperplasia and micronormoblastic maturation.
Myelopoiesis: normal.
Megakaryopoiesis: normal.
Absence of bone marrow iron: Gold standard test, demonstrated by negative Prussian blue reaction.
Serum Iron Profile (Table 1.4)

TABLE 1.4: Serum iron profile in IDA
Normal range
Value in IDA
Serum ferritin
15300 g/L
<15 g/L
Serum iron
50150 g/dL
1015 g/dL
Serum transferrin saturation
3040%
<15%
Total plasma iron-binding capacity (TIBC)
310340 g/dL
350450 g/dL
Serum transferrin receptor (TFR)
0.572.8 g/L
3.57.1 g/L
Red cell protoporphyrin
3050 g/dL
>200 g/dL
Observation
Reticulocyte Hemoglobin
It is decreased and is an early feature of IDA.
Clinical Features of IDA

Nonspecific and related to both severity and the cause of the anemia (e.g. gastrointestinal
disease)
Onset: insidious.
Nonspecific symptoms: fatigue, palpitations, breathlessness, weakness and irritability.
Pharyngeal/esophageal webs formed cause dysphagia.
Patterson-Kelly or Plummer-Vinson syndrome:
Microcytic hypochromic anemia
Atrophic glossitis
Esophageal webs
Congestive heart failure in severe anemia.
Central nervous system: pica-unusual craving for substances with no nutritional value
like clay or chalk. Craving for ice (pagophagia) specific to iron deficiency. Pica may be the
cause rather than effect of IDA.
Physical Findings
Diminished tissue enzymes cause characteristic epithelial changes of iron deficiency anemia.
Angular stomatitis and glossitis
Chronic atrophic gastritis
Koilonychia (spoon nails)
Bone marrow shows

micronormoblastic
eythroid hyperplasia.
Marrow iron is absent.
Prussian blue reaction
negative.
Reduced: serum iron,

ferritin, % transferrin
saturation.
Increased: TIBC, TFR and
red cell protoporphyrin.
The earliest laboratory

indicator of IDA is reduced
reticulocyte hemoglobin.
Q. Mention the various clinical

features of iron deficiency anemia.
Patterson-Kelly or
Plummer-Vinson
syndrome: microcytic
hypochromic anemia,
atrophic glossitis and
esophageal webs.
Koilonychia (spoon nails)

is a physical finding seen
in iron deficiency. First
fingernails become thin
and flat-platonychia, then
brittle and finally spoon
shaped.
Q. Enumerate the causes of

microcytic hypochromic anemia.
Q. Discuss the causes and

pathogenesis of megaloblastic
anemia.
Vitamin B12 is present in
animal products.
Causes of Microcytic Hypochromic Anemia
Iron deficiency anemia

Thalassemia major
Anemia of chronic disorders
Others: alcohol, lead poisoning and drugs
Sideroblastic anemia (rare cause).
MEGALOBLASTIC ANEMIA
Anemias characterized by defective/impaired DNA synthesis and distinct megaloblasts in
the bone marrow. Megaloblastic anemias are common among anemias due to impaired red
cell production.
Etiology of Megaloblastic Anemia (Table 1.5)

TABLE 1.5: Causes of megaloblastic anemia
VITAMIN B12 DEFICIENCY
Deficiency of vitamin B12
and folic acid are the main
causes of megaloblastic
anemia.
1. Decreased Intake: inadequate diet, pure vegetarians (vegans)

2. Impaired Absorption
Gastric: deficiency of gastric acid or pepsin or intrinsic factor
Pernicious anemia
Post-gastrectomy
Intestinal
Loss of absorptive surface
Malabsorption syndromes
Diffuse intestinal disease, e.g. lymphoma, systemic sclerosis
Ileal resection, Crohn disease
Bacterial or parasitic competition for vitamin B12
Bacterial overgrowth in blind loops and diverticula of bowel
Fish tapeworm infestation
3. Increased Demand: pregnancy, hyperthyroidism, disseminated cancer
FOLIC ACID DEFICIENCY
Folic acid is absorbed in

the jejunum.
Deficiency of vitamin B12

and folic acid delayed
nuclear maturation
megaloblast macrocyte.
Ineffective erythropoiesis
and hemolysis are
responsible for anemia.
1. Decreased Intake: inadequate dietalcoholism, malnutrition

2. Impaired Absorption
Malabsorption states: nontropical and tropical sprue
Diffuse infiltrative diseases of the small intestine (e.g. lymphoma)
Drugs: anticonvulsant phenytoin and oral contraceptives
3. Increased Loss: hemodialysis
4. Increased Demand: pregnancy, infancy, disseminated cancer, markedly increased hematopoiesis
5. Impaired Utilization: folic acid antagonists, such as methotrexate
Pathogenesis of Megaloblastic Change

1. Impaired DNA synthesis: megaloblastic anemia is commonly due to deficiency of
vitamin B12 (cyanocobalamin) or folic acid. Both are required for the synthesis of DNA.
a.
Delayed maturation of nucleus. The nuclear maturation lags behind the cytoplasmic maturation and results in abnormally large nucleated erythroid precursors
named as megaloblasts.

b. Cytoplasm matures normally. RBCs are larger than normal macrocytes.

c. Affects all rapidly dividing cells of the body (including skin, GI tract, and bone marrow).
2. Ineffective erythropoiesis: megaloblast precursors undergo intramedullary destruction.
Laboratory Findings of Megaloblastic Anemia

Blood findings in vitamin B12 and/or folic acid deficiency are similar.
Q. Write short note on

the laboratory findings in
megaloblastic anemia.
Peripheral Blood
Hemoglobin and hematocrit (PCV): reduced
Red cell indices
MCV: above 100 fL (normal 8298 fL)

MCH (normal 2732 pg)
Normal MCHC (3136 g/dL)

Peripheral smear (Figs 1.3 and 1.4): pancytopenia (decreased RBC, WBCs and platelets).
RBCs:
Macrocytic and oval (egg-shaped macro-ovalocytes)-diagnostic.
Most macrocytes lack the central pallor (Figs 1.3 and 1.4).
Marked variation in the size and shape of red cells (anisopoikilocytosis).
Evidence of dyserythropoiesis: basophilic stippling, Cabot ring and Howell Jolly bodies.
WBCs:
Decreased WBC count (leukopenia).
Hypersegmented neutrophils (more than five nuclear lobes): first and specific morphological
sign of megaloblastic anemia. These neutrophils are also larger than normal (macropolys).
Platelets: decreased.
Reticulocyte count: normal or low.
Megaloblastic anemia
Pancytopenia
Macro-ovalocytes
Hypersegmented
neutrophils
Macropolys.
In megaloblastic anemia
due to vitamin B12
deficiency, reticulocyte
count may be normal or
low and high reticulocyte
count is seen on 7th day
following vitamin B12
therapy.
Dimorphic Anemia
Combined vitamin B12/folic acid and iron deficiency.
Peripheral smear shows two populations of RBCs namely: macro-ovalocytes and microcytic
hypochromic (Fig. 1.5).
Fig. 1.3: Peripheral blood smear showing macro-ovalocytes (arrows) and

hypersegmented neutrophil (inset )
Fig. 1.4:Diagrammatic peripheral blood smear showing

macro-ovalocytes (thick arrows) and hypersegmented neutrophil (thin arrow )
10
A mixture of microcytic
hypochromic and
macrocytic RBCs is termed
as dimorphic picture and
occurs in mixed deficiency
of iron and folic acid or
vitamin B12.
Fig. 1.5: Diagrammatic peripheral blood smear of dimorphic

anemia showing macro-ovalocytes and microcytes
Megaloblastic anemiabone marrow:

Megaloblasts
Giant metamyelocytes.
Megaloblast are large,
abnormal precursors of
RBCs seen in the bone
marrow of patients with
Bone Marrow
Cellularity: moderately to markedly hypercellular.
M: E ratio: due to marked erythroid hyperplasia, M: E ratio is reversed ranging from 1:1 to 1:6 (normal
2:1 to 4:1).
Erythropoiesis: megaloblastic type (Figs 1.6 and 1.7)
Megaloblasts: large, abnormal counterparts of normal normoblasts. Megaloblast shows asynchrony of nuclear and cytoplasmic maturation. The cytoplasm shows normal hemoglobinization.
Ineffective erythropoiesis: developing megaloblasts die in marrow (intramedullary hemolysis).
Myelopoiesis:
Myeloid cells adequate in number.
Granulocytic precursors display nuclear-cytoplasmic asynchrony in the form of giant metamyelocytes and band forms.
Megakaryopoiesis: normal or increased in number.
Bone marrow iron: moderately increased.
The differences between normoblasts and megaloblasts are shown in Table 1.6
Q. List the differences between
normoblast and megaloblast.
Megaloblasts:
Nuclear maturation lags
behind cytoplasmic
maturation.
Nuclei have open sievelike chromatin.
TABLE 1.6: Differences between normoblast and megaloblast

Characteristics
Normoblast
Megaloblast
Cell size
Normal
Larger than corresponding normoblast
Nuclear chromatin
Normal
Open sieve-like
Nuclear maturation
Normal
Lags behind cytoplasmic maturation
Mitosis
Normal
Increased and abnormal
Maturation in bone
marrow
Normal (Late >

intermediate > early
normoblast)
Increased proportion of more primitive erythroid cells

(Late < intermediate < early megaloblast)
Evidence of
dyserythropoiesis
Absent
Present (irregular nuclei, Howell Jolly bodies)
Myelopoiesis
Normal
Shows giant metamyelocytes
Found in
Normal bone marrow
Bone marrow of megaloblastic anemia
Fig. 1.6:Bone marrow aspirate showing megaloblastic precursors

(arrows) in varying stages of maturation (inset shows early megaloblast)
Fig. 1.7: Diagrammatic picture of bone marrow aspirate showing

megaloblastic precursors (thick arrows) in varying stages of maturation
Biochemical Tests for Megaloblastic Anemia

Common for both vitamin B12 and folic acid deficiency
Deoxyuridine suppression test: it is a sensitive measure of deficiency of 5, 10-methylene THF,
which occurs in both folic acid and vitamin B12 deficiency.
Serum homocysteine
Serum bilirubin: mild increase causes mild jaundice
Serum iron and ferritin
Plasma lactate dehydrogenase (LDH)
Serum vitamin B12/folate decreased.

Diagnostic tests for vitamin B12 deficiency
Serum vitamin B12 levels: decreased
Serum methylmalonic acid

Urinary excretion of methylmalonic acid
Schilling test for vitamin B12 absorption (Refer page 12).
Specific tests for folic acid deficiency
Serum folic acid levels: decreased
FIGLU in urine: excessively excreted.
Deoxyuridine suppression
test is abnormal even
before the morphological
changes.
Schilling test determines

the cause of vitamin B12
deficiency.
PERNICIOUS ANEMIA

and morphology of pernicious
Pernicious anemia (PA) is an autoimmune disease due to deficiency of intrinsic factor causing anemia.
impaired absorption of vitamin B12 and megaloblastic anemia.

Rare in India. A genetic predisposition is suspected.
Age: older agefifth to eighth decades of life
Sex: females are more involved than males (F: M is 1.5: 1).
Vitamin B12 is absorbed

in terminal ileum and
requires IF.
11
12
PA: autoimmune disease

Atrophic gastritis
IF deficiency
Autoantibodies.
Etiopathogenesis
An autoimmune disease due to destruction of gastric mucosa.
Stomach shows damage to parietal cells, dense infiltration by lymphocytes and plasma
cells chronic atrophic gastritis failure of production of intrinsic factor.
Presence of autoantibodies: two major types of autoantibodies
Anti-intrinsic factor (IF) antibody
Type I (blocking) antibody: blocks the binding of vitamin B12 to IF. Present in 5075%
of the cases.
Type II (binding) antibody: attaches to the IFvitamin B12 complex and prevent its
binding to receptors in the ileum. Present in about 40% of patients.
Parietal cell (Type III) antibody: neither specific for PA nor other autoimmune disorders.
It is found in 90% of patients.
Morphology
Alimentary System
Atrophic gastritis may
predispose to carcinoma
stomach.
Atrophic glossitis: tongue shiny, glazed and beefy.

Stomach:
Diffuse chronic atrophic gastritis and impaired secretion of hydrochloric acid, pepsin
and intrinsic factor.
Histologically atrophy of the glands, with loss of both chief cells and parietal cells.
Nuclei of mucosal cells look similar to that of megaloblasts.
Dense infiltration by lymphocytes and plasma cells.
Intestinal metaplasia.
Central Nervous System

Found in 75% of cases.
Demyelination in the dorsal and lateral tracts: subacute combined degeneration
Peripheral neuropathy.
Q. Write short note on laboratory

findings in pernicious anemia.
Laboratory Findings (Fig. 1.8)

Blood, bone marrow and biochemical test findings are similar to those described earlier for
megaloblastic anemias (Refer page 9 to 11).
Specific Diagnostic Tests for Pernicious Anemia

Schilling test: diagnostic
of PA but now very
infrequently performed.
Schilling test for vitamin B12 absorption: abnormal

Radioactive vitamin B12 is used to assess the status of intrinsic factor (IF) and vitamin B12.
Helps in distinguishing megaloblastic anemia due to IF deficiency (pernicious anemia)
from other causes of vitamin B12 deficiency.
Serum antibodies to intrinsic factor are highly specific for pernicious anemia
Achlorhydria with histamine/pentagastrin stimulation.
Severe deficiency of intrinsic factor.
Pernicious anemia
present with features of
megaloblastic anemia due
to vitamin B12 deficiency.
In addition, it may show
features of atrophic
gastritis and achlorhydria.
PA patients sometimes
have a lemon-yellow color
owing to a combination
of pallor and mild
jaundice caused by excess
breakdown of hemoglobin.
Nonmegaloblastic causes
of macrocytic anemia:
1. Alcohol
2. Liver disease
3. Myxedema
4. Cytotoxic drugs
5. Myeloma
6. Aplastic anemia
7. Reticulocytosis
8. Red cell aplasia.
Fig. 1.8: Clinical features and laboratory findings in pernicious anemia
Clinical Features of Megaloblastic Anemia

The clinical features of vitamin B12 deficiency anemia and pernicious anemia are:
Onset: insidious and progresses slowly.
Classic triad of presentation: weakness, sore throat and paresthesias.
Tongue: painful red beefy tongue.
Neurological manifestations:
Bilateral peripheral neuropathy: glove and sock distribution of numbness or paresthesia
Demyelination of spinal cord: subacute combined demyelination/degeneration
of dorsal and lateral tractsataxia, uncoordinated gait, impairment of vibration and
position sense.
Atherosclerosis: serum homocysteine level is raised and is a risk factor for atherosclerosis
and thrombosis.
APLASTIC ANEMIA
Hematopoietic stem cell (HSC) disorder characterized by:
Pancytopenia (anemia, neutropenia and thrombocytopenia)
With markedly hypocellular bone marrow (less than 30% cellularity).
Etiology
The most common causes associated with aplastic anemia are shown in Table 1.7.
Q. Mention the various clinical

features of megaloblastic anemia.
Folate deficiency anemia

presents with features of
megaloblastic anemia due
to vitamin B12. Unlike with
vitamin B12 deficiency,
neurological symptoms
does not occur.
Q. Write short notes on aplastic

anemia.
13
14
6 I s of the causes of
aplastic anemia:
1. Idiopathic
2. Ingestion of drugs and
chemicals
3. Idiosyncratic
4. Irradiation
5. Infections and
6. Inherited.
TABLE 1.7: Common causes of aplastic anemia

1. ACQUIRED
Idiopathic
Acquired defects in stem cell
Immune mediated
Secondary
Chemical Agents
Cytotoxic drugs: alkylating agents, antimetabolites Benzene
Inorganic arsenicals
Chloramphenicol
Idiosyncratic
Chloramphenicol
Phenylbutazone
Penicillamine
Carbamazepine
Gold salts
Organic arsenicals
Methylphenylethyl hydantoin
Physical Agents: whole-body irradiation
Viral Infections: hepatitis virus, Epstein-Barr virus, cytomegalovirus , herpes zoster (Varicella zoster) , HIV
2. INHERITED: fanconi anemia, telomerase defects
Pathogenesis:
Direct damage to the
hematopoietic stem
cells and progenitor
cells.
Immune-mediated
destruction.
Primary stem cell
abnormalityinherited
defect in the stem cells.
Pathogenesis (Fig. 1.9)
Fig. 1.9: Pathogenesis of aplastic anemia
Clinical Features
Any age of both sexes
Insidious
Progressive weakness, pallor and dyspnea due to anemia
Frequent (mucocutaneous bacterial infections) or fatal infections due to neutropenia
Bleeding manifestations in the form of petechiae, bruises and ecchymoses due to

thrombocytopenia.
Laboratory Findings
Peripheral Blood
Hemoglobin
PCV
Reticulocyte count: markedly decreased.
Reticulocyte count
is markedly low in
aplastic anemia and is
characteristic feature.
Peripheral smear: pancytopenia, i.e. decreased red cells, neutrophils and platelets.
RBCs: normocytic normochromic anemia
WBCs: total leukocyte count decreased. Neutrophils markedly diminished and neutropenia is a
reflection of the severity of aplasia. Initial stages, lymphocytes normal in number as the disease
progresses their count decreases.
Platelets: count is decreased.
Bone Marrow
Marrow aplasiabest appreciated in a bone marrow (trephine) biopsy
Cellularity: marked hypocellularity.
Hematopoiesis: paucity of all erythroid, myeloid and megakaryocytic precursors.
Other cells: lymphocytes and plasma cells are prominent.
No Splenomegaly
Diagnosis: diagnosis is made with peripheral blood and bone marrow biopsy findings.
Differential Diagnosis
Should be distinguished from other causes of pancytopenia (Table 1.8)
TABLE 1.8: Causes of pancytopenia
Decreased bone marrow function
Aplastic anemia
Idiopathic
Secondary
Inherited
Myelodysplastic syndromes
Bone marrow infiltration with
Leukemia
Lymphoma
Myeloma
Tumors (carcinoma)
Granulomatous diseases (e.g. tuberculosis, sarcoidosis)
Nutritional deficiencies:
Megaloblastic anemia (vitamin B12 and folic acid deficiency)
Paroxysmal nocturnal hemoglobinuria
Myelofibrosis (rare)
Hemophagocytic syndrome
Increased peripheral destruction
Hypersplenism
Prognosis: unpredictable.
Bone marrow elements

are replaced by fat and
aspiration usually yields
dry tap.
Absence of splenomegaly
and in its presence the
diagnosis of aplastic
anemia should not be
made.
15
16
2
CHAPTER
Q. Define and classify hemolytic

anemia.
Normal lifespan of red
cell is about 120 days.
In hemolytic anemias
RBC survival time is
considerably shortened.
Hemolytic Anemias Due to

Red Cell Membrane and
Enzyme Defects
HEMOLYTIC ANEMIA
Definition
Hemolytic anemias are due to increase in the rate of red cell destruction (hemolysis).
Classification of Hemolytic Anemias (Table 2.1)

Depending on:
Location of hemolysis: intravascular and extravascular
Source of defect causing hemolysis: intracorpuscular defect and extracorpuscular
defect
Mode of onset: hereditary and acquired disorders.
TABLE 2.1: Classification and causes of hemolytic anemia
Breakdown of normal RBCs

occurs in the macrophages
of the bone marrow, liver
and spleen.
Decreased red cell survival

does not always cause
anemia as there is a
compensatory increase in
red cell production by the
bone marrow.
Intrinsic (intracorpuscular) abnormalities
Extrinsic (extracorpuscular) abnormalities
Hereditary
RBC membrane abnormalities
Membrane skeletal abnormalities:
spherocytosis, elliptocytosis
Membrane lipids: abetalipoproteinemia
Enzyme deficiencies
Enzymes of hexose monophosphate shunt:
glucose-6-phosphate dehydrogenase
Glycolytic enzymes: pyruvate kinase
Disorders of hemoglobin synthesis
Deficient globin synthesis: thalassemia
syndromes
Structurally abnormal globin synthesis
(hemoglobinopathies): sickle cell anemia
Acquired
Membrane defects: paroxysmal nocturnal
hemoglobinuria
Antibody-mediated
Isohemagglutinis: Rh disease of the new-born,
transfusion reactions
Autoantibodies: idiopathic (primary), drugassociated, systemic lupus erythematosus
Mechanical trauma to RBCs
Microangiopathic hemolytic anemia: disseminated
intravascular coagulation
Defective cardiac valves
Infections: malaria
Drugs, chemicals and toxins
Drugs: oxidant drugs, primaquine, dapsone, etc.
Chemicals: naphthalene, nitrites, nitrates, etc.
Toxins: snake venom, lead poisoning, clostridial
sepsis
Hemolytic Anemias Due to Red Cell Membrane and Enzyme Defects CHAPTER 2
Location of Hemolysis

extravascular hemolysis and
It may be intravascular and/or extravascular. The differences between these two types are intravascular hemolysis.
listed in Table 2.2.
TABLE 2.2: Differences between extravascular and intravascular hemolysis

Characteristics
Extravascular hemolysis
Intravascular hemolysis
Site of hemolysis
RE system (spleen, bone marrow)
Within circulation
Splenomegaly
Usual
Uncommon
Laboratory findings
Serum bilirubin-unconjugated
Serum haptoglobin
Hemoglobinemia
Moderately raised
Normal
Not seen
Mildly raised
Decreased
Positive
Urine
Hemoglobinuria
Hemosiderinuria
Absent
Absent
Present
Present
Examples
Thalassemia, sickle cell anemia
G6PD deficiency, PNH
In most hemolytic anemias

red cell destruction is
extravascular.
HEREDITARY SPHEROCYTOSIS
Hereditary spherocytosis (HS) is a rare inherited hemolytic anemia resulting from the defect Q. Describe the etiopathogenesis
in the red cell membrane.
of hereditary spherocytosis.
Normal structure of RBC membrane is depicted in Figure 2.1.
Etiopathogenesis
HS, is due to defect in the

RBC membrane protein.
Autosomal dominant disorder
The common mutations
RBC membrane protein defect caused by various mutations. Most common mutations involve ankyrin, band 3,
spectrin or band protein
involve ankyrin, band 3, spectrin, or band protein 4.2.
4.2.
Mechanism of Hemolysis in HS (Fig. 2.2)
HS: intrinsic defect of RBC
Young HS RBCs are normal in shape. But as they age, they undergo loss of membrane membrane-extravascular
hemolysis.
fragments in the circulation. These small RBCs assume a spherical shape (spherocytes).
Spherocytes are rigid, inflexible and less deformable. They get trapped in the spleen
leading to premature destruction of spherocytes.
Fig. 2.1: Structure of the red cell membrane
17
18
Fig. 2.2: Mechanism of hemolysis in hereditary spherocytosis
Q. Write short notes on laboratory

findings in HS.
In hereditary spherocytosis
MCHC is > 35 g/dL.
Spherocytes and
reticulocytosis are
observed in the peripheral
blood.
Spherocytes may also
be seen in autoimmune
hemolytic anemia and
burns.
Bone marrow shows

erythroid hyperplasia.
Laboratory Findings
Peripheral Blood
Hemoglobin: decreased and level depends on degree of hemolysis.
Red cell indices:
MCV: reduced (normal 8298 fL)
MCHC: raised and > 35 g/dL (normal 3136 g/dL).
Peripheral smear: very important for diagnosis (Figs 2.3 and 2.4).
RBCs:
Spherocytes are most distinctive but not pathognomonic. Spherocytes are small, darkstaining (hyperchromic) RBCs without any central pallor.
Polychromatophilia due to reticulocytosis.
WBCs: total leukocyte count (TLC) increased.
Platelets: normal.
Reticulocyte count: increased (Fig. 2.5).
Bone Marrow
Cellularity: markedly hypercellular

Erythropoiesis: erythroid hyperplasia
Myelopoiesis: normal
Fig. 2.3: Peripheral blood smear with numerous spherocytes (arrows)
Fig. 2.4: Diagrammatic peripheral blood smear

with numerous spherocytes (arrows)
Fig. 2.5: Smear shows reticulocyte with blue filamentous/granular

material (new methylene blue stain) (arrows)
Biochemical Findings
Serum bilirubin: mildly raised.
Urine urobilinogen: increased.
Serum haptoglobin: decreased.
Osmotic Fragility Test

Osmotic fragility is increased and there is shift of the curve to the right (Fig. 2.6).
Clinical Features
Age: anytime from the neonatal period to adulthood.
Family history: most (75%) are inherited as autosomal dominant trait.
Anemia: mild to moderate.
Fig. 2.6: Osmotic fragility test. Normal curve (blue) and increased
osmotic fragility in hereditary spherocytosis
HS: osmotic fragility is

increased with a shift of
curve to the right.
Clinical features of
intermittent jaundice,
splenomegaly and
spherocytes in the
peripheral smear is highly
suggestive of HS.
19
20
Jaundice: intermittent attacks, precipitated by pregnancy, fatigue, or infection.

Splenomegaly: moderate (500 to 1000 g).
Gallstones: pigment gallstones.
Aplastic crises: may be triggered by an acute parvovirus infection.
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE DEFICIENCY
G6PD deficiency is an
intrinsic defect and
hemolysis is primarily
intravascular.
In G6PD, RBCs exposed

to oxidant stress, the
hemoglobin is oxidized
to methemoglobin which
forms Heinz bodies in the
cytoplasm of RBCs.
Hemolytic disease due to red cell enzyme defects.

In G6PD deficiency, RBCs are susceptible to oxidative injury by free radicals.
It is an X-linked recessive disorder and its full expression is seen only in males.
There are different subtypes.
Role of G6PD (Fig. 2.7)

Reduced glutathione (GSH) in the normal RBCs protects them against oxidant injury by
breakdown of compounds such as H2O2 to H2O. The housekeeping enzyme, G6PD is
required for normal GSH.
Sequence of Events in G6PD Deficiency

In G6PD deficiency, oxidants can cause both intravascular and extravascular hemolysis.
In G6PD deficiency, there is decreased synthesis of reduced glutathione.
RBCs when exposed to oxidant stress (during infections, exposure to drugs or chemical,
fava beans) accumulate H2O2. It damages RBC membrane causing hemolysis.
Hemolyzed red cells liberate hemoglobin.
The hemoglobin is oxidized by oxidants leading to formation of methemoglobin, which
forms Heinz bodies (Fig. 2.8) in the cytoplasm of RBCs.
Fig. 2.7: Role of G6PD against injury by oxidants
Fig. 2.8: Peripheral blood smear in G6PD deficiency with bite cells
(arrows). Inset shows Heinz bodies (supravital stain)
Heinz bodies removed from RBC membrane by macrophages in the spleen and produce G6PD deficiency has a
protective effect against
bite cells. These bite cells are removed via erythrophagocytosis in the spleen.
Plasmodium falciparum
malaria.
Clinical Presentation
G6PD deficiency manifests in several distinct clinical patterns. Usually present as acute selflimited acute intravascular hemolytic anemia following exposure to oxidative stress.
Laboratory Findings
Peripheral Blood
Hemoglobin: decreased.
Reticulocyte count: increased.
Peripheral smear:
RBCs: moderate anisopoikilocytosis with polychromatophilia, microspherocytes and bite cells
(Fig. 2.8). Heinz bodies identified with a supravital stain and are best seen during active hemolysis.
WBCs: mild leukocytosis.
Platelets: normal.
G6PD deficiencyoxidant
damage to RBC
Bite cells
Heinz bodies.
Self-limited hemolysis: primarily the old red cells are hemolyzed, hence hemolysis is self-limited.
Urine
Hemoglobinuria will be found during hemolysis and may last for about 16 days.
RBC Enzyme Analysis

Tests for G6PD deficiency are positive and should be assessed a few weeks after the acute
hemolytic episode.
G6PD: enzyme analysis

confirmatory test.
21
22
Thalassemia Syndrome
CHAPTER
Q. Classify hereditary disorders of

hemoglobin.
The term
hemoglobinopathy
is usually used for a
qualitative hereditary
disorder of hemoglobin.
Q. Classify thalassemia
syndromes.
In -Thalassemia, there
is decreased/absence of
synthesis of -chains.
In -Thalassemia, there
is reduced/absence of
synthesis of -chains of
globin.
CLASSIFICATION OF HEREDITARY
DEFECTS IN HEMOGLOBIN
Hemoglobin defects may be quantitative (reduced production of normal hemoglobin) or
qualitative (production of abnormal hemoglobin).
Quantitative defect: genetic mutations in the globin loci (e.g. thalassemia) may quantitatively reduce the synthesis of a-globin or b-globin chain. It leads to net reduction of
hemoglobin.
Qualitative defect: genetic mutations in the a-globin or b-globin locus may produce
abnormal hemoglobin (e.g. sickle cell anemia). The abnormal hemoglobin may be functionally normal, but its physical or physiologic properties differ from normal hemoglobin.
THALASSEMIA SYNDROME
These are group of inherited disorders due to abnormality of globin production.
It is characterized by decreased or absence of synthesis of either a or b-globin chain of
adult hemoglobin, HbA (a2b2).
Classification
They are mainly classified as:
b-Thalassemia syndromes: impaired synthesis of b-chains of globin.
a-Thalassemia syndromes: impaired synthesis of a-chains of globin.
Miscellaneous thalassemia syndromes.
b-THALASSEMIA
Autosomal recessive hereditary disorder
Diminished synthesis of b-globin chains and normal synthesis of a-chains.
Thalassemia Syndrome CHAPTER 3
Molecular Pathology
b-globin chains are encoded by a single gene.
The molecular errors over 200 genetic defects leading to b-thalassemia have been identified.
Different types of mutations in b-globin gene can occur but mainly point mutations
rather than gene deletions (unlike in a-thalassemia). The mutations result in defects in
transcription, RNA splicing and modification, translation via frame shifts and nonsense
codons. Mutations leading to aberrant RNA splicing are the most common cause.
Point mutations leading

to aberrant RNA splicing is
the most common cause of
-thalassemia.
Clinical and Genetic Classification (Table 3.1)

TABLE 3.1: Clinical and genetic classification of b-thalassemias
Clinical syndromes
Genotype
Clinical features
b-thalassemia major
Homozygous (b0/b0,b+/b+)
or double heterozygous ( b0/b+)
Severe form, severe anemia

and transfusion dependent
b-thalassemia intermedia
Variable (b /b , b /b , b /b, b /b)
High level of HbF in the blood

0
b-thalassemia minor/b-thalassemia trait Heterozygous (b0/b, b+/b)
Moderately severe and not

transfusion dependent
0 = Total absence of
-globin synthesis;
+ = Markedly reduced
or diminished -globin
synthesis;
= normal -globin
synthesis.
Mild anemia and asymptomatic
b-THALASSEMIA MAJOR
-thalassemia is the
commonest quantitative
disorder of hemoglobin.
It is a hereditary hemolytic anemia due to absence of synthesis of b-globin chain of

hemoglobin. The synthesis of a-globin chain is not affected.
Homozygous form of b0/b0 or b+/b+ or double heterozygous b0/b+ (Table 3.1)
-thalassemia major also
called Mediterranean or
Most common in Mediterranean countries, parts of Africa and South East Asia.
Cooleys anemia.
Hemolytic anemia is of severe degree.
Pathophysiology of b-thalassemia Major (Fig. 3.1)

Consequence of Defective or Absent b-chains
Q. Describe the pathophysiology/

pathogenesis of -thalassemia
major.
Severe hemolytic anemia due to:

1. Absence of b-globin chain: results in absence of synthesis of HbA (a2b2). This produces -thalassemia major
Absence of synthesis of
RBCs that are poorly hemoglobinized (hypochromic) and small in size (microcytic).
HbA produces severe
2. Ineffective erythropoiesis: unpaired and excess a-chains aggregate into insoluble
precipitates, which bind to and damage the membrane of erythroid precursors. These
anemia
erythroid precursors fail to mature and undergo apoptosis in the marrow.
Increased synthesis of
HbF.
3. Extravascular hemolysis: RBCs with a-chain inclusions are removed by macrophages of
spleen (extravascular hemolysis).
Synthesis of fetal hemoglobin (HbF): the -globin chain synthesis continues even 6 months
after birth and combines with a-globin leading to increased levels of HbF (a22). The level
of HbF varies from 30% to 90%.
Consequences of Ineffective Erythropoiesis

Changes in bone marrow: marked erythroid hyperplasia.
Changes in bone:
Skull X-ray: hair on end (crew-cut) appearance (Fig. 3.2)
Typical facies: thalassemic facies (Fig. 3.3)prominent forehead, cheekbones and
upper jaw.
-thalassemia major
Thalassemic facies
Crew cut appearance on
skull x-ray
Splenomegaly.
23
24
Fig. 3.1: Pathogenesis of -thalassemia major and its consequence
Extramedullary hematopoiesis: in liver and spleen consequent hepatosplenomegaly.

Cachexia: develops in untreated patients.
-thalassemia major
Iron overload damgaes
parenchymal organs
due to hemosiderosis
and secondary
hemochromatosis.
Failure to thrive, retarded

growth, monogoloid face,
and hepatosplenomegaly
are clinical features of
-thalassemia major.
Iron Overload and its Consequences

Causes of iron overload:
1. Increased absorption of dietary iron from duodenum
2. Hemolysis
3. Repeated transfusions (usual mode of treatment).
Consequences: iron overload produces hemosiderosis and secondary hemochromatosis
and damages to parenchyma of organs (e.g. heart, liver and pancreas).
Clinical Features
Age: infants develop moderate to severe anemia 69 months after birth.
Growth and development: untreated/untransfused children fail to thrive and die within
45 years of age.
Bone changes: those who survive longer develop distortion of skull and facial bones. X-ray
skull shows hair on end appearance (Fig. 3.2) and face shows a characteristic thalassemic
facies (Fig. 3.3).
Marked splenomegaly: up to 1500 grams due to hyperplasia and extramedullary
hematopoiesis.
Extramedullary hemopoiesis: liver and lymph nodes may show extramedullary
hematopoiesis.
Fig. 3.2: X-ray appearance of skull in -thalassemia showing hair-onend appearance (Courtesy: Dr Nuthan Kamath)
Fig. 3.3: Appearance of typical thalassemic facies

(Courtesy: Dr Nuthan Kamath)
Iron overload: multiple blood transfusions may lead to iron overload and result in
hemosiderosis and secondary hemochromatosis (heart, liver and pancreas).
Laboratory Findings
Peripheral Blood
Q. Mention the laboratory

findings in b-thalassemia major.
Hemoglobin (ranges from 3 to 8 g/dL) and hematocrit (ranges from 8 to 23%): markedly
reduced
RBC count increased/normal (in contrast to iron deficiency anemia).
Reticulocyte count increased and in the range of 5 to 15%.
Red cell indices:
MCV decreased and in the range of 4570 fL (normal range 8298 fL).
MCHC decreased and in the range of 2230 g/dL (normal range 3135 g/dL).
RDW normal
MCH decreased and in the range of 2028 pg (normal range 2732 pg).
MCV, MCH and MCHC
RDW-within normal limits (in contrast to iron deficiency anemia where it is increased). decreased.
Peripheral smear:
RBCs:
Microcytic hypochromic anemia
Moderate to marked anisocytosis and poikilocytosis
Many target cells (Figs 3.4 and 3.5)
Basophilic stippling
Nucleated red cell precursors (normoblasts) in variable numbers (540%).
WBCs: leukocytosis with mild left shift.
Platelets: normal.
Q. Write short note on peripheral

smear findings in b-thalassemia
major.
Bone Marrow
Bone marrow in thalassemia major shows

marked normoblastic
erythroid hyperplasia.
Marrow iron is markedly
increased.
Cellularity: markedly hypercellular.

M: E ratio: reversed to 1:1 to 1:5 depending upon the degree of erythroid hyperplasia.
Erythropoiesis: normoblastic with marked erythroid hyperplasia.
Bone marrow iron: markedly increased due to increased dietary absorption and hemolysis.
- thalassemia major: RDW

normal. The peripheral
blood smear shows
anemia, target cells and
anisopoikilocytosis.
25
26
Fig. 3.4: Peripheral blood smear in -thalassemia showing target

cells (arrows)
Fig. 3.5: Diagrammatic appearance of peripheral blood smear in -thalassemia

showing target cells (short arrows) and nucleated red cells (long arrows)
Reduced/absence of
synthesis of -chains; the
excess -chains combine
with -chains leading to
increased HbF.
Note: normal adult cell

contains 96% HbA (22),
3% HbA22(2d2) and 1%
HbF(22).
Bilirubin: increasedmainly of unconjugated type.

Urine urobilinogen: increased
Serum haptoglobin: markedly reduced.
Serum iron status:
Serum iron, serum ferritin and transferrin saturation are markedly increased
Total iron binding capacity (TIBC): reduced.
Special Tests
Fetal hemoglobin (HbF): increased to 30% to 90% (normal range 0 1%).
Hemoglobin electrophoresis (Table 3.2):
b+ thalassemia (b+/b+ or b0/b+ genotypes): demonstrates bands of both HbA and HbF.
bo thalassemia (b0/b0 genotype): since no b-chains are formed, there is no HbA. Major
hemoglobin is HbF with normal or low HbA2.
High performance chromatography (HPLC): HbF is increased (3090%). HPLC measures
various fractions of hemoglobin (Hb) and is used for confirmation of diagnosis.
Prenatal diagnosis by molecular analysis of DNA.
Estimation of globin chains: normally a: b ratio is 1:1. Lack of b chain alter this ratio to
530:1
TABLE 3.2: Hemoglobin F and A2 percentage in thalassemia syndromes
Type
HbF
HbA2
-Thalassemia major (homozygous)
3090%
< 3.5%
-Thalassemia intermedia (double heterozygous)
1030%
< 3.5%
-Thalassemia minor/trait (heterozygous)
05%
3.68%
Differences between Iron Deficiency Anemia and

b-Thalassemia Major (Table 3.3)
TABLE 3.3: Differences between iron deficiency anemia and b-thalassemia major
Character
b-thalassemia major
Etiology
Deficiency of iron
Reduced synthesis of chain
Decreased (< 5 million/cu mm)
Increased (> 5 million/cu mm)
Mild to moderate
Absent
Severe
Present
Absent
Markedly increased
Reduced < 15 g/L

Reduced
Increased
Increased (300 1000 g/L)

Increased
Normal
Fetal hemoglobin (HbF)
Normal (01%)
Markedly increased (3090%)
RDW
Increased
Normal
Age
Any age
Presented < 2 years of age
Growth and development
Normal
Retarded
Hepatosplenomegaly
Absent
Present
X-ray findings
Nil
Hair on end appearance
Laboratory findings
RBC count
Peripheral smear
Type of RBCs
Anisopoikilocytosis
Target cells
Bone marrow iron
-thalassemia major
should be differentiated
from iron deficiency
anemia. Treatment with
iron in -thalassemia major
worsens the iron load and
its consequences.
Serum iron profile

Serum ferritin
Serum iron
TIBC
Clinical features
-thalassemia intermedia:
it is a clinical entity
intermediate between
thalassemia trait and
thalassemia major.
Abbreviations: RDW, red cell distribution width; TIBC, total iron-binding capacity.
b-THALASSEMIA MINOR/TRAIT
More common than b-thalassemia major.
Most patients are heterozygous for thalassemic gene.
Usually asymptomatic and anemia is mild.
Laboratory Findings in b-Thalassemia Minor

Peripheral blood: microcytosis, hypochromia, basophilic stippling and target cells.
Bone marrow: mild erythroid hyperplasia.
Hemoglobin electrophoresis: increase in HbA2 (a22) to 4 to 8% of the total hemoglobin
(normal 2.5 0.3%). HbF levels may be normal or slightly increased.
NESTROF test (Naked eye single tube red cell osmotic fragility test): positive.
In this test, 0.02 mL of patients blood is added to 5 mL of 0.35% saline in a test tube.
After half an hour white paper with a dark black line is held behind the tube.
The microcytic hypochromic RBCs of thalassemia minor are resistant to lysis than
normocytic normochromic RBCs.
Hence, the black line on the paper is not clearly visible through the test tube compared
to normal cells.
Estimation of HbA2: HPLC is used for accurate estimation. HbA2 estimation is diagnostic
and level ranges from 4% to 8%.
NESTROF test positive

because the microcytic
hypochromic RBCs of
-thalassemia minor are
resistant to lysis than
normocytic normochromic
RBCs.
27
28
-thalassemia trait should

be differentiated from iron
deficiency (Table 3.4).
TABLE 3.4: Differences between iron deficiency anemia and b-thalassemia minor/trait
Character
b-thalassemia minor
Etiology
Deficiency of iron
Reduced synthesis of b chain
Reduced < 15 g/L

Reduced
Increased
Normal /slightly incresaed

Normal
Normal
HbA2 level
Normal or decreased (2.5 + 0.3 %)
Increased (48 %)
RBC count
< 5 million/cu mm
>5 million/cumm
RDW
Increased
Normal
Laboratory findings
Peripheral smear - RBCs
Serum iron profile
Serum ferritin
Serum iron
TIBC
-Thalassemia:
anemia due to
Lack of adequate
hemoglobin
Effect of excess
unpaired non--chains
(, , ).
a-THALASSEMIA
Inherited disorders characterized by reduced or absent synthesis of a-globin chains.
Autosomal recessive disorder.
Molecular Pathology
In contrast to a single gene coding b-globin chain, each a-globin chain are encoded by two
genes. Deletion of a-gene is the most common cause of reduced a-chain synthesis.
-thalassemia is one of
the cause of non-immune
hydrops fetalis.
Immune hydrops fetalis

is a hemolytic disease
caused by blood group
incompatibility between
mother and fetus.
Clinical Syndromes
Four genes control a-chain synthesis. Severity of a-thalassemia varies greatly depending on
the number of a-globin genes deleted (Table 3.5). Each of the four a-globin genes normally
contributes 25% of the total a-globin chains.
TABLE 3.5: Clinical syndromes associated with a-thalassemia disorders
Clinical syndrome
No. of
a-globin
deleted
Clinicopathological features
Silent carrier state
Asymptomatic
a-Thalassemia trait
Usually asymptomatic. Normal hemoglobin level or minimal anemia
Hemoglobin H disease
Moderate microcytic hypochromic anemia
Hydrops fetalis (Hb Barts)
Severe form, fatal and usually results in intrauterine death
Sickle Cell Disease
4
CHAPTER
SICKLE CELL DISEASE

Definition
Sickle cell disease (SCD) is a group of hereditary disorders of hemoglobin characterized by
production of defective hemoglobin called sickle hemoglobin (HbS). On low oxygen tension
or deoxygenation, HbS imparts sickle shape to RBCs. HbS is produced due to qualitative
defect in hemoglobin production caused by mutation in -globin gene.
Classification of Sickle Cell Disease (Table 4.1)

TABLE 4.1: Classification of sickle cell disease
Sickle cell anemia (SS)
Sickle cell trait (AS)
Homozygous stateboth the -globin chains are

abnormal/defective
Heterozygous stateone gene is defective

(for HbS) and while the other gene is
normal (for HbA)
Other sickling syndromes (Compound heterozygous)
Sickle cell diseases are

hemoglobinopathies
characterized by
qualitative defect in
hemoglobin synthesis.
Sickle cell anemia is a

homozygous state in
which both -globin
chains are abnormal.
Sickle cell trait: one
-globin chain is abnormal
and other -globin chain is
normal.
If both the -globin chains have different abnormalities, (e.g. Hb SC, Hb S--thalassemia)termed as
compound heterozygous
SICKLE CELL ANEMIA

Characteristic Features
Autosomal recessive disorder manifests early in life.
Homozygous state (SS) caused by a mutation in the -globin gene.
HbS constitutes more than 70% of hemoglobin in their RBCs with no HbA.
Etiopathogenesis
Production of abnormal hemoglobin called sickle hemoglobin (HbS).
Sickle cell anemia:

autosomal recessive
disorder with extravascular
hemolysis.
HbS provides protection
against falciparum malaria.

of sickle cell anemia.
30
Fig. 4.1: Replacement of glutamic acid with valine in the sixth position of b-globin
Replacement of the
glutamic acid residue by
valine in 6th position of
-globin chain.
Missense point mutation: in HbS, there is substitution of glutamic acid by valine in the
6th position the -globin chain of hemoglobin (Fig. 4.1). It alters the solubility or stability
of the hemoglobin and produces hemolytic anemia.
HbS is responsible for the characteristics of the disease.
Molecular Basis of Sickling (Fig. 4.2)

During low O2 tension or deoxygenation, HbS molecules undergo aggregation and
polymerization.
During low oxygen tension

or deoxygenation RBCs
assume sickle shape and
predisposes to vessel
occlusion.
RBCs in sickle cell anemia

have shorter lifespan and
causes hemolytic anemia.
Fig. 4.2: Pathogenesis of sickle cell anemia
Sickle Cell Disease CHAPTER 4
If deoxygenation continues, the aggregated HbS molecules form long needle-like fibers
(or pseudocrystalline structures known as tactoids) within RBCs.
The tactoids grow in length beyond the diameter of RBCs and distort RBC shape.
RBC become elongated and assumes a shape like sickle (or crescent moon or holly-leaf or
boat) and predisposes to stasis and vascular occlusion.
When the oxygen tension returns to normal, the sickled red cell returns to normal
shape.
Recurrent sickling causes red cell membrane damage and these RBCs become irreversibly
sickled cells (ISC).
Factors Affecting Sickling (Table 4.2)

TABLE 4.2: Factors affecting sickling
Factors
Favors sickling
Hinders sickling
Type of other associated

hemoglobins
HbA
HbF
HbC
Transit time in microvasculature
Slowing of bloodstream
MCHC
Increased MCHC
Decreased MCHC
Intracellular pH
Decreased pH
Other factors
In sickle cell anemia, HbF

hinders sickling.
Temperature above 37 C
Infections
Abbreviation: MCHC, mean corpuscular hemoglobin concentration.
Mechanism of Red Cell Damage
With repeated sickling the

RBCs become irreversibly
HbS polymerization: when HbS polymerizes, it grows beyond the RBC membrane and sickled cells (ISC) and leads
project through it.
to RBC membrane damage
Dehydration: repeated episodes of sickling leads to increased dehydration of RBCs. These and hemolysis.
RBCs become more rigid and nondefromable (irreversible sickled cells).

Percentage of ISC: degree of the hemolysis correlates with the percentage of irreversibly
sickled cells.
Impaired cation homeostasis: structural changes in the RBC membrane causes the influx
of Ca+ ions, which activate an ion channel resulting in the efflux of K+ and H2O.
Pathogenesis of the Microvascular Occlusions

Most serious clinical features are due to occlusion of microvasculature.
Deformability: sickle cells are rigid and tend to aggregate. The aggregated sickle cells block
the small blood vessels.
Factors that slow the blood flow: RBC cytoskeletal damage slow the movement of RBCs
through microvascular beds.
Higher expression of adhesion molecules: sickle cells express higher levels of adhesion
molecules and thus become abnormally sticky to the endothilium.
Inactivation of nitric oxide: lysed sickle cells liberate free hemoglobin, which binds and
inactivates nitric oxide (NO). This narrows the vessels and produces microvascular stasis
and sickling.
Most serious clinical

features of sickle cell
anemia are due to
microvascular occlusion.
31
32
Clinical Features (Fig. 4.3)

The cardinal clinical
features are due to
chronic hemolytic anemia,
crises (recurrent painful
episodes), infections and
chronic organ damage.
Presence of HbF in the first 6 months of life has a protective role.

Symptoms appear after 6 months of age as the HbF disappears.
Infants and children present with acute problems like severe infection, acute chest
syndrome, splenic sequestration and stroke.
Chronic hypoxia in children is responsible for generalized impairment of growth and
development. Adults manifest with chronic organ damage.
Chronic Hemolytic Anemia

Lifelong hemolysis (mainly extravascular) and causes chronic hemolytic anemia, which
is of moderate degree. This produces raised unconjugated (indirect) bilirubin, and
predisposes to pigment bilirubin gallstones (cholelithiasis) and cholecystitis.
Four crises encountered

in sickle cell anemia:
sickling crisis, hemolytic
crisis, aplastic crisis and
sequestration crisis.
Recurrent splenic
infarction due to
sickling crisis lead to
autosplenectomy.
Crises
Four types of crises are encountered. These are:
1. Sickling crisis (vaso-occlusive/pain/painful/infarctive crisis)
Most common
Blockage of microcirculation by sickled red cells produces hypoxic injury and infarction.
Bone: manifest as the hand-foot syndrome, dactylitis of the bones of the hands or feet or both.
Lung: acute chest syndrome (dangerous).
Spleen: acute abdominal pain due to infarcts of abdominal viscera caused by occlusion
of vessels. Recurrent splenic infarction results in autosplenectomy.
Infants most commonly

present with dactylitis.
Most common cause of

death in adults is acute
chest syndrome.
Fig. 4.3: Various effects of vascular occlusion and hemolysis in sickle cell anemia
2. Hemolytic crisis
Rare type and presents with marked increase in hemolysis.
3. Aplastic crisis
Associated with parvovirus B19.
Reticulocytopenia.
Reticulocytopenia is
seen in aplastic crisis
and reticulocytosis in
sequestration crisis.
4. Sequestration crisis
Usually occurs in children.
Sudden trapping of blood in spleen or liver causes rapid enlargement of the organ and
drop in hematocrit leading to hypovolemic shock.
Other crises encountered rarely are hypoplastic crisis and megaloblastic crisis (due to
inadequate folate).
Increased Susceptibility to Infections
Susceptible to acute
Common infections are pneumonia due to Pneumococcus, meningitis due to S. infections with
encapsulated organisms.
pneumoniae and osteomyelitis due to Salmonella. Increased frequency of osteomyelitis is

due to bone infarcts, which act as a nidus for infection.
Septicemia and meningitis are the most common causes of death in children.
Causes of susceptibility to infections:
Hypofunction of spleen:
In children: due to congestion and poor blood flow.
In adults: due to multiple infarcts and resultant autosplenectomy.
Defects in the alternative complement pathway.
Impairs opsonization of encapsulated bacteria such as pneumococci and Haemophilus influenzae.
Chronic Organ Damage

Particularly seen in the spleen, bones, kidneys, heart, lungs, brain and skin.
Spleen
Children after 6 months of life present with splenomegaly (up to 500 g).
After 56 years of age, the spleen gets fibrosed and gradually reduces in the size due to
multiple infarcts.
Gradual loss of splenic function secondary to infarcts results in autosplenectomy.
Bone: osteomyelitis, particularly with Salmonella typhimurium
Extremities: skin ulcers over the lower extremities
Laboratory Findings in Sickle Cell Anemia

Peripheral Blood
Hematocrit (PCV): decreased.
ESR: reduced.
Reticulocyte count: increased and range from 3% to 10%.
Peripheral smear
RBCs:
Normocytic normochromic to mildly hypochromic.
Moderate to severe degree of anisopoikilocytosis.
Characteristic cell is the sickle cellappear as long, curved cells with pointed ends (Figs 4.4
and 4.5); may also show target cells (due to red cell dehydration) and ovalocytes.
Polychromatophilia due to reticulocytosis.
WBCs: mildly increased with shift to left.
Platelets: mildly increased.
Common pathogens:
S. pneumonia,
Salmonella and
Pneumococcus.
SCA: severe hemolytic

anemia
Sickling crisis
Autosplenectomy.
Q. Laboratory findings in sickle

cell anemia.
Sickle cell anemia: ESR is

reduced because sickle
cells do not form rouleaux.
Peripheral smear shows

characteristic sickle cells
number of which varies.
33
34
Fig. 4.4: Peripheral blood smear with sickle cells (arrows)
In severe cases, skull

bone shows crewcut appearance in
roentgenograms.
Fig. 4.5: Diagrammatic peripheral blood smear with sickle cells (arrows)
Bone Marrow
Cellularity: hypercellular.
Erythropoiesis: compensatory normoblastic erythroid hyperplasia, which expands the marrow and
causes resorption of bone and secondary new bone formation.
Iron stores: usually increased.
Serum Findings
Extramedullary
hematopoiesis can also
Serum bilirubin: raised and predisposes to pigment gallstones.
develop as a compensatory
Iron status: raised serum iron, serum ferritin and transferrin saturation.
mechanism.
Serum haptoglobin: reduced.
Urine Urobilinogen: increased.
Diagnostic/Confirmatory Tests
Sickle cell anemia:HbS

7090%, HbF 1030%,
no HbA.
Sickling test:
Sickling is induced by adding a reducing (oxygen-consuming) agent like 2% sodium
metabisulfite or sodium dithionite to blood sample.
Red cells with HbS show sickled (Fig. 4.6) and holly leaf appearance.
It is diagnostic of sickle cell anemia.
Hemoglobin electrophoresis: HbS is a slow moving compared to HbA and HbF.
Estimation of HbF: in homozygous state constitutes about 1030% of hemoglobin.
HPLC: useful for confirmation of diagnosis.
Prenatal diagnosis: by analysis of fetal DNA obtained by amniocentesis or chorionic villous
biopsy, to detect the point mutations.
SICKLE CELL TRAIT

Heterozygous state for the hemoglobin S mutation and shows both HbA and HbS (HbAS). One
defective gene (from one parent with HbS) and while the other gene is normal.
Sickling test is a diagnostic

test for sickle cell anemia.
Fig. 4.6: Sickling test. Sickled red cells (arrows) induced by reducing agent
(2% sodium metabisulfite)
Pathogenesis
In sickle cell trait, the hemoglobin A in RBCs prevents hemoglobin S polymerization. However,
RBCs may sickle under extreme conditions (e.g. flight at high altitude in unpressurized aircraft,
deep sea diving).
Clinical Features
Sickle cell trait:

Usually no anemia
No significant clinical
features
Amount of HbS varies
from 25% to 40%
Hb A in RBCs prevents
polymerization of Hb S.
Usually asymptomatic. Normal growth and development, lifespan and life expectancy.
Laboratory Findings
Peripheral Blood
Hemoglobin: normal or mildly decreased.
Peripheral smear:
RBCs: normocytic normochromic picture with very few target cells and mild degree of anisopoikilocytosis.
WBCs: normal.
Platelets: normal.
Bone Marrow
Hypercellular because of a compensatory normoblastic erythroid hyperplasia.
Diagnostic Tests
Hb electrophoresis: demonstrates two bands of HbS and HbA.
Sickling test: sickling test is positive.
High-performance liquid chromatography (HPLC): useful for confirmation of diagnosis.
In sickle cell trait: HbS

4045% and HbA 5560%.
35
Other Anemias
CHAPTER
Immunohemolytic
anemias are characterized
by the destruction of
RBCs by either allo or auto
antibodies.
Immunohemolytic
anemias are mainly
classified as:
1. Alloimmune and
2. Autoimmune hemolytic
anemia.
IMMUNOHEMOLYTIC ANEMIAS
Anemias due to premature RBC destruction (hemolysis) mediated by antibodies that bind to
RBCs. The antibodies may be either allo or auto type.
Classification of Immunohemolytic Anemias (Table 5.1)

TABLE 5.1: Classification of immunohemolytic anemias
Alloimmune hemolytic anemia
Hemolytic disease of the newborn
Hemolytic transfusion reactions: mismatched blood transfusion
Autoimmune hemolytic anemia
Hemolytic transfusion
reactions are due to ABO
mismatch. The antibodies
present in the recipients
serum coat donors RBCs
and lead to intravascular
hemolysis.
Warm antibody type (IgG antibodies active at 37C)

Primary (Idiopathic)
Secondary: autoimmune disorders (systemic lupus erythematosus), drugs, lymphomas
Cold agglutinin type (IgM antibodies active at 4C18C)
Acute: mycoplasmal infection, infectious mononucleosis
Chronic: idiopathic, lymphomas
Cold hemolysin type (Donath-Landsteiner antibodies)
Alloimmune Hemolytic Anemia

Production of antibody against foreign antigen not present on individuals red blood cell.
Allo-antibodies are present either in the serum or bound to red cells.
Q. Write short notes on hemolytic
disease of newborn.
HEMOLYTIC DISEASE OF THE NEWBORN

It is an allo-immune hemolytic anemia developing in the fetus and newborn baby.
Hemolysis is extravascular.
HDN develops when the IgG antibodies against blood group of fetus passes from mother to
fetus through the placenta.
Other Anemias CHAPTER 5
Occurs in two forms:

HDN may be either due to
Rh incompatibility in which mother is Rh negative and fetus is Rh positive. The anti-D Rh or ABO incompatibility
antibodies are responsible for the hemolytic anemia.
ABO incompatibility in which mothers blood group is O and fetus is either of A or B

blood group. Either anti-A or anti-B antibodies cause hemolysis.
between mother and fetal

RBCs.
Rh Hemolytic Disease of the Newborn (Fig. 5.1)

Rh hemolytic disease of the newborn is more important than due to ABO incompatibility.
Pathogenesis
Occurs when mother is Rh (D antigen) negative and fetus is Rh positive.
Sensitization occurs when fetal Rh positive RBCs enter into Rh negative mothers. Rh
negative mother develops anti-Rh antibodies.
Sensitization occurs only at the time of delivery or during miscarriage. So, it does not
manifest in the first pregnancy.
HDN usually does not

manifest during first
pregnancy. Sensitization
develops during delivery
or miscarriage.
Rh HDN develops when

mother is Rh-ve and fetus
is Rh+ve.
Fig. 5.1: Pathogenesis of Rh hemolytic disease of the newborn
37
38
Hydrops fetalis is fatal

condition, characterized
by left and right-sided
heart failure producing
generalized edema and
may result in death.
In subsequent pregnancy, anti-Rh antibodies from mother cross placenta and coat the
Rh positive fetal red cells. These antibodies cause immune destruction of fetal red cells
results in severe hemolytic anemia leading to jaundice of the newborn.
Fetus may develop cardiac failurehydrops fetalis (immune type).
Clinicopathological Features
In Rh HDN, high levels of
unconjugated bilirubin can
cross blood brain barrier
causing kernicterus and
death of infant.
Infants may have jaundice at birth.

When the disease is severe, the levels of unconjugated bilirubin in the blood are high and
bilirubin can pass the blood brain barrier.
Bilirubin is deposited in the central nervous system (especially the basal ganglia) producing
neurological damage and is known as kernicterus (yellow coloration of cerebellum and
basal ganglia due to bilirubin deposition). It can cause death of the infant.
Prevention of Rh HDN: by the prophylactic removal of fetal cells entering the maternal
circulation before sensitization develops, by injecting anti-D into the Rh D negative mother.
Laboratory Findings
Peripheral blood
Reticulocyte count: increased.
Peripheral smear:
normocytic
normochromic anemia
with nucleated RBCs and
polychromatophils.
Peripheral smear:
RBCs: normocytic normochromic anemia with numerous nucleated RBCs, polychromatophils
and occasional spherocytes.
WBCs: normal.
Platelets: normal.
Antiglobulin test (Coombs test): antibodies in the mother and baby are detected by indirect
and direct Coombs test respectively (Fig. 5.2).
In direct antiglobulin
test, patients RBCs are
used where as in indirect
antiglobulin test patients
serum is used for the test.
Fig. 5.2: Direct and indirect methods of antiglobulin test (Coombs test)
Serum findings
Serum bilirubin: increased.
Lactate hydrogenase (LDH): increased.
Haptoglobin: decreased.
ABO Hemolytic Disease of the Newborn

It is less severe.
The fetus may be affected in the first pregnancy of a mother with blood group O.
The IgG antibodies to A or B from maternal blood cross placenta and enter the fetal
circulation. These anti-A or anti- B antibodies react with A and B antigenic determinants
present in fetal fluids and tissues.
This results in consumption of major portion of the maternal IgG and the small portion,
which is left combines with fetal red cells causing only mild hemolysis.
ANTIGLOBULIN (COOMBS) TEST

It is useful to detect the presence of incomplete antibody (IgG) and/or complement on the
RBC membrane.
Antiglobulin test is useful

for diagnosis of HDN.
ABO HDN is more common

but less severe. It may be
seen in first pregnancy.
Q. Write short notes on Coombs

(antiglobulin) test.
Principle
RBCs coated with incomplete antibody (IgG) or C3 complement does not cause agglutination of RBCs.
Coombs reagent contains antibodies (antiglobulins) against human IgG/IgM/complement.
If the RBCs coated by incomplete antibody or complement, are treated with Coombs
reagent, the antiglobulins in the reagent will induce agglutination of such RBCs.
Types of Antiglobulin Test (Fig. 5.2)

Direct (Coombs) antiglobulin test (DAT)
Indirect (Coombs) antiglobulin test (IAT)
Direct Antiglobulin Test (Fig. 5.2)

Direct antiglobulin test (DAT) (direct Coombs test) detects antibodies (IgG) and/or complement coated on the surface of patients RBC membrane.
Patients RBCs are taken in a test tube and washed three times in normal saline.
Coombs (anti-globulin) reagent is added and observed for agglutination.
Agglutination indicates the presence of antibody on the RBC membrane and interprets as
positive DAT.
Uses of Direct Antiglobulin Test

Hemolytic disease of the newborn (HDN), in which direct Coombs test is performed on the
newborn babys red cells from the cord blood.
Autoimmune hemolytic anemia: to demonstrate in vivo attachment of antibodies to red
cells.
Drug induced red cell sensitization.
Investigation of hemolytic transfusion reaction.
There are 2 types of

antiglobulin test: direct
and indirect.
Patients red cells are used

in direct antiglobulin test.
39
40
In HDN, newborn babys RBCs from cord blood is used for direct antiglobulin test, which
will be positive.
Patients serum is used for

indirect antiglobulin test.
Indirect Antiglobulin Test (Fig. 5.2)

Indirect antiglobulin test (IAT) (indirect Coombs test) detects the presence of incomplete
(IgG) antibodies and/or complement in the patients serum.
In this test, patients serum is taken and O Rh positive cell suspension of any normal
individual is added.
O Rh positive RBCs are coated with (lgG) anti-Rh antibodies (if present) in the patients serum.
Add Coombs (antiglobulin) reagent and examine for agglutination.
Agglutination of RBCs indicates the presence of antibodies in the patients serum and test is
reported as positive for indirect antiglobulin test.
Patients serum + O Rh positive RBC suspension + Coombs reagent Agglutination (test positive).
Uses of Indirect Antiglobulin Test

Hemolytic disease of newborn: mothers serum is tested to detect anti-Rh antibody.
Cross-matching for blood transfusion: to detect incompatibility of recipients serum with
donors cells.
The type of antibody

causing autoimmune
hemolytic anemia may
be warm antibody or
cold agglutinin or cold
hemolysin.
Warm AIHA: mediated

by IgG autoantibodyoptimally active at 37C.
AUTOIMMUNE HEMOLYTIC ANEMIA

Antibodies against self-antigens on the RBC membrane cause premature destruction of
RBCs.
Anti-RBC antibodies can be divided into three general categories (Table 5.1). Interaction of
the autoantibody with the red cell antigen is dependent on the temperature, i.e. warm or
cold type.
Warm Antibody Type
Most common type (5070%).

Idiopathic (primary) or secondary to drug exposure or predisposing disease.
IgG type antibodies combine with RBC antigen at 37Cwarm antibody.
Direct antiglobulin test: DAT (Coombs test) positive in 9095% cases.
LE cell test: positive in SLE with secondary autoimmune hemolytic anemia (AIHA).
Cold Agglutinin Type

Caused by cold agglutinins.
Mediated by IgM antibodies optimally active below 30C.
Occurs as a complication of infections (e.g. infectious mononucleosis, Mycoplasma
infections) and lymphoid neoplasms.
Cold Hemolysins Type

(Donath-Landsteiner Antibodies)
Autoantibodies directed against the P antigen system on red cells.
Responsible for a rare disorder known as paroxysmal cold hemoglobinuria.
Direct antiglobulin test is usually negative.
FRAGMENTATION SYNDROME
The RBCs subjected to trauma (physical or mechanical) in the circulation can undergo
fragmentation and result in intravascular hemolysis leading to hemolytic anemias. These are
known as fragmentation syndrome.
Classification
According to the site of hemolysis it is classified as:
Macroangiopathic (large vessels) hemolytic anemia: red cell trauma from an abnormal
vascular surface (e.g. prosthetic heart valve, synthetic vascular graft).
Microangiopathic hemolytic anemia (MAHA): it occurs in capillaries due to abnormal
narrowing of the lumen (e.g. disseminated intravascular coagulation).
PAROXYSMAL NOCTURNAL
HEMOGLOBINURIA
It is a rare and is the only hemolytic anemia acquired mutation in the hematopoietic stem cell.
Etiology and Pathogenesis
PNH is an acquired
disorder in which there is
deficiency of GPI linked
proteins, which normally
protect the red cells
against complement
mediated lysis.
Acquired mutations in the phosphatidylinositol glycan-group A (PIGA) gene in the

hematopoietic stem cell.
PIGA gene mutation causes deficient synthesis of GPI-linked proteins in blood cells
and loss of anchor for decay-accelerating factor (DAF). Normally, DAF responsible for In PNH, RBCs are very
complement degradation.
sensitive to complementmediated hemolysis.
RBCs are abnormally sensitive to complement-mediated intravascular hemolysis.
Clinical Features
Intravascular hemolysis: hemoglobin in acidic urine is converted into acid hematin and
results in dark brown urine.
Thrombosis: in the hepatic, portal or cerebral veins.
Laboratory Findings
Hams acidified serum test and sucrose hemolysis test: patients RBCs undergo lysis when PNH: Hams acidified serum
incubated with acidified serum (Ham test) or sugar (sucrose hemolysis test).
test and sucrose hemolysis
Flow cytometry: detects RBC deficient in GPI-linked proteins (CD55 and CD59) and is test +ve.
useful for diagnosis of PNH.
ANEMIAS OF BLOOD LOSS

Acute Blood Loss (Hemorrhage)
Causes loss of intravascular volume and if massive can lead to hypovolemic shock and
death.
Bleeding may be external (e.g. open fracture, knife wound) or internal (e.g. ruptured
spleen, ruptured abdominal aneurysm).
During recovery phase

of acute blood loss,
peripheral smear show
reticulocytosis.
41
42
Peripheral smear:
RBCs: normocytic normochromic anemia. Polychromasia during the recovery phase due to
increased reticulocytes.
WBCs: leukocytosis.
Platelets: increased in number (thrombocytosis) during recovery phase.
Chronic Blood Loss

Produces anemia when the rate of blood loss exceeds the regenerative capacity of the bone
marrow or when iron reserves are depleted and results in iron deficiency anemia.
Sideroblastic anemias are

rare refractory anemias
which may be hereditary
or acquired.
SIDEROBLASTIC ANEMIAS
Rare heterogeneous group of refractory anemias characterized by:
Ring sideroblasts in the bone marrow aspirate (Fig. 5.3).
Dimorphic peripheral blood picture: microcytic hypochromic red cells in hereditary form
and macrocytic in the acquired forms of the disease mixed with normochromic cells.
Iron-containing inclusions (Pappenheimer bodies) in the
RBCs.
Increased serum iron concentration and markedly
increased storage iron.
Ineffective erythropoiesis.
It is classified as:
1. Hereditary sideroblastic anemia
2. Acquired sideroblastic anemia: idiopathic or secondary.
Fig. 5.3: Ring sideroblasts with partial perinuclear ring of iron granules
SECTION
Disorders of
White Cells
Quantitative and
Qualitative Disorders of
Leukocytes
CHAPTER
NORMAL DIFFERENTIAL LEUKOCYTE COUNT (DLC)
Differential leukocyte
count (DLC) is one of
the routine, useful and
important investigations.
The normal range of DLC in an adult is presented in Table 6.1.

TABLE 6.1: Normal range of different leukocytes in an adult
Type of white blood cell
Normal range
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
4070% (2.07.0 109/L)

2040% (1.03.0 109/L)
210% (0.21.0 109/L)
16% (0.020.5 109/L)
Less than 1% (0.020.1 109/L)
QUANTITATIVE DISORDERS OF LEUKOCYTES

Leukocytosis
Q. Define leukocytosis and list

An increase in the total number of leukocytes in the blood more than 11,000/cu mm (11 10 /L). its causes.
9
Causes: common causes of leukocytosis are shown in Table 6.2.

TABLE 6.2: Common causes of leukocytosis
Infections
Bacterial
Viral infections (e.g. infectious mononucleosis)
Leukemia
Acute
Chronic: chronic lymphocytic leukemia and chronic myeloid leukemia
Leukemoid reactions
Physiological
Pregnancy
Exercise
Leukocytosis is usually
due to increase in the
neutrophils, but may
also be due to increased
lymphocytes (or
rarely monocytes and
eosinophils).
46
SECTION 2 Disorders of White Cells
Leukopenia is the decrease

in the WBC count below
4,000/cumm.
Leukopenia
Total leukocyte count is less than 4,000/cu mm (4 109/L).
Causes: common causes of leukopenia are shown in Table 6.3.
TABLE 6.3: Common causes of leukopenia
The causes of leukopenia

include typhoid and
paratyphoid fever and
aplastic anemia.
Typhoid and paratyphoid

Anemia
Aplastic anemia
Hypersplenism
Drugs including cytotoxic drugs
Radiation
Rarely leukemia
Q. Define neutrophilia and

mention its causes.
Disorders of Neutrophils
Neutrophilia (Fig. 6.1)
Neutrophilia: absolute
neutrophil count more
than 8000 cells/mm.
An absolute neutrophil count of more than 8000/cu mm (8 109/L). Differential count shows
more than 70% neutrophils and is usually accompanied by leukocytosis (1530 109/L).
Common causes of
neutrophilia are infections,
inflammatory conditions
and tissue necrosis.
Causes of neutrophilia: major causes of neutrophilia are shown in Table 6.4.
TABLE 6.4: Major causes of neutrophilia

1. Pathological:
Acute bacterial and fungal infections:
Localized: pyogenic microorganisms causing infections, e.g. pneumonias, pyogenic meningitis,
cellulitis, diphtheria, abscess, tonsillitis, etc.
Generalized: septicemia, acute rheumatic fever
Acute inflammatory processes: inflammatory conditions (acute appendicitis), vasculitis
Tissue necrosis: burns, myocardial infarction, gangrene, neoplasms (tumor necrosis)
Acute stress or hypoxic states: following hemorrhage, hemolysis and surgery
Myeloproliferative neoplasms: chronic myeloid leukemia, polycythemia vera
Metabolic: uremia, acidosis, gout
Miscellaneous: eclampsia, steroid therapy
2. Physiological:
Exercise (shift from marginating pool to circulating pool), newborns, extremes of temperature, pain,
emotional stress and during obstetric labor
Fig. 6.1: Peripheral smear showing neutrophilia
Quantitative and Qualitative Disorders of Leukocytes CHAPTER 6
Leukemoid Reaction
Benign leukocytic proliferation characterized by a total leukocyte count of more than 25
109/L with immature white cells (like band forms, metamyelocytes and myelocytes).
It is different from chronic myelocytic/myeloid leukemia (Table 6.5).
TABLE 6.5: Differences between leukemoid reaction and chronic myeloid leukemia
Clinical features
Leukemoid reaction
Chronic myeloid leukemia
Features of causative disease
Splenomegaly, and bone pain

are common
Leukemoid reaction:
benign exaggerated
leukocyte proliferation
to be differentiated from
leukemia.
Q. Tabulate the differences

between leukemia and leukemoid
reaction.
Neutrophils in bacterial
infections show toxic
granules.
Peripheral blood findings

WBC
Total WBC count
Moderately increased, rarely exceeds Markedly increased and usually

50 109/L
50 109/L
Differential leukocyte count
Shift to the left with few immature

forms. Toxic granulation seen
Shift to the left with numerous

immature forms. Myelocyte and
neutrophil peak
Eosinophilia and basophilia
Variable
Present
Leukocyte alkaline phosphatase

(LAP)
Increased
Decreased
Usually minimal or absent
Severe and progressive
Number
Variable
Normal or increased
Extramedullary myeloid tumors
Absent
Present
Philadelphia chromosome
Absent
Present
Dohle bodies are small

round to oval structures
seen in the cytoplasm
can also be observed in
bacterial infections.
RBC
Anemia
Platelets
Neutropenia (Agranulocytosis)
Reduction in the absolute neutrophil count (total WBC % segmented neutrophils and
band forms) below 1.5 109/L (1500/cu mm).
In leukemoid reaction
LAP score is raised and
neutrophils may show
toxic granulation.
Neutropenia: absolute
neutrophil count below
1500 cells/cu mm.
Etiology: the causes of neutropenia are presented in Table 6.6.
Eosinophilia (Fig. 6.2)

Eosinophil count of more than 450/cu mm (0.45 109/L).
Causes of eosinophilia are presented in Table 6.7.
Fig. 6.2: Peripheral smear showing eosinophilia
Eosinophilia: eosinophil
count more than 450 cells/
cu mm.
47
48
TABLE 6.6: Causes of neutropenia

1. Inadequate production:
Agranulocytosis:
neutrophil count below
0.5 109/L. The patients
are highly susceptible
to bacterial and fungal
infections.
Suppression of stem cells: in these disorders granulocytopenia represents a component of

pancytopenia
Aplastic anemia
Marrow infiltration
Metastatic tumors
Granulomatous disorders
Suppression of committed granulocytic precursors
Drugs and chemicals (e.g. sulfonamides, analgesics, arsenicals)
Ionizing radiation
Diseases associated with ineffective hematopoiesis
Megaloblastic anemias: vitamin B12 or folate deficiency
Congenital: Kostmann syndrome (rare)
Severe infections
Bacterial (e.g. typhoid, paratyphoid, septicemia)
Viral (e.g. influenza, infectious mononucleosis, hepatitis, measles)
Rickettsial (e.g. scrub typhus)
Protozoal (e.g. malaria, kala-azar)
2. Increased destruction of neutrophils:
Immunologically mediated destruction
Idiopathic
Secondary
Drugs
Autoimmune disorders, e.g. systemic lupus erythematosus
Splenic sequestration may be associated with pancytopenia
3. Shift from the circulating pool to marginating pool:
Hemodialysis and cardiopulmonary bypass
4. Idiopathic: mechanism not known
Q. Define eosinophilia and list

its causes.
Hodgkin and non-Hodgkin lymphoma

Chronic lymphocytic leukemia
Viral infections (HIV, hepatitis)
Cyclic neutropenia
TABLE 6.7: Causes of eosinophilia

1. Allergic/atopic conditions
Asthma
Hay fever
Allergic rhinitis
Urticaria
Drug reactions
2. Parasitic infestations (with tissue invasion)

Roundworm infestation
Filariasis
Eosinophilia is seen in
allergic reactions and
parasitic infestations with
tissue invasion.
Hookworm infestation
3. Fungal infections (e.g. coccidioidomycosis)

4. Skin diseases
Dermatitis (eczema)
Scabies
Pemphigus
Dermatitis herpetiformis
5. Hematological diseases
Hodgkin lymphoma
Eosinophilic leukemia
Polycythemia
Acute myelomonocytic leukemia
6. Miscellaneous
Tropical eosinophilia
Lefflers syndrome
Eosinophilic granuloma
Pulmonary eosinophilia
Hypereosinophilic syndrome
Basophilia
Normally basophils (Fig. 6.3) are less than 1% of WBCs in peripheral blood.
Causes of basophilia include chronic myeloid leukemia, immediate hypersensitivity reactions,
mastocytosis, etc.
Monocytosis (Table 6.8)

More than 10% of differential count or an absolute monocyte (Fig. 6.4) count exceeding 500/
cu mm (0.5 109/L).
Fig. 6.3:Diagrammatic
appearance of basophil
TABLE 6.8: Causes of monocytosis

1. Infections
Bacterial: tuberculosis, bacterial endocarditis, brucellosis

Protozoal: malaria, kala-azar
Spirochetal: syphilis
Rickettsial: typhus, rocky mountain fever
Recovery phase of neutropenia and acute infections
2. Inflammatory diseases
Inflammatory bowel disease: ulcerative colitis, Crohn disease
Autoimmune diseases: systemic lupus erythematosus, rheumatoid arthritis
Sarcoidosis
appearance of monocyte
3. Hematologic malignancies
Acute monocytic, myelomonocytic and myelocytic leukemias

Chronic myelomonocytic leukemia
Hodgkin lymphoma
Multiple myeloma
Lymphocytosis
Lymphocytosis:
lymphocyte count more
Lymphocyte (Fig. 6.5) count more than 4,000/cu mm (4 109/L) in adults and more than than 4,000/cu mm in
adults and more than
8,000/cumm (8 109/L) in child.
8,000/cumm (8 109/L)
Common causes of lymphocytosis are given in the Table 6.9
in child.
TABLE 6.9: Causes of lymphocytosis

1. Acute infections
Viral infections: infectious mononucleosis, mumps, measles, chickenpox, infectious hepatitis
Toxoplasmosis
2. Chronic infections/inflammatory diseases
Dengue fever is caused

by flavi virus transmitted
by freshwater mosquito
(Aedes egypti). Peripheral
smear shows transformed
lymphocytes and
thrombocytopenia.
Tuberculosis
Syphilis
Brucellosis
Inflammatory bowel disease: Crohn disease and ulcerative colitis
3. Hematologic malignancies
Acute lymphoblastic leukemia

Chronic lymphocytic leukemia
Non-Hodgkin lymphoma with spill over
Adult T cell leukemia/lymphoma
Hairy cell leukemia
appearance of lymphocyte
49
50
Lymphocytopenia
Lymphocyte count below 1,500/cu mm (1.5 109/L) in adults and below 3000/cu mm
(3 109/L) in children.
Some of the important causes of lymphocytopenia are listed in the Table 6.10.
TABLE 6.10: Causes of lymphocytopenia
1. Increased destruction
Corticosteroids
Cytotoxic drugs
Radiation
2. Decreased production
Aplastic anemia
Advanced malignancy: Hodgkin lymphoma
Infections: AIDS, miliary tuberculosis
3. Increased loss via GI tract
Obstruction to intestinal lymphatic drainage (e.g. tumor)
Congestive heart failure
QUALITATIVE DISORDERS OF LEUKOCYTES

Qualitative disorders of leukocytes are rare familial disorders that manifest as morphologic
changes in the leukocytes (Fig. 6.6).
Chediak-Higashi anomaly
is associated with
increased susceptibility to
pyogenic infections.
CGD is associated with

impaired phagocytosis and
killing of organisms.
Fig. 6.6: Various quantitative disorders of leukocytes
INFECTIOUS MONONUCLEOSIS
(GLANDULAR FEVER)
Acute, benign, self-limiting lymphoproliferative disorder caused by Epstein-Barr virus (EBV).
Incubation period: 4 to 8 weeks.
Mode of transmission: oropharyngeal secretions (kissing), hence the nickname kissing
disease.
EBV infects B cells but the

peripheral blood shows
CD8 + T cells, which appear
as atypical lymphocytes.
Pathogenesis
EBV infects B lymphocytes by binding to CD21 (CR2) receptor.

Viral infection begins in the submucosal lymphoid tissues of nasopharynx and oropharynx.
Virus remains dormant inside the B cells.
B cells are immortalized and are capable of proliferation indefinitely.
Lesions caused by EBV:
1. Infectious
mononucleosis
2. Burkitt lymphoma
3. Nasopharyngeal
carcinoma
Age: young adults among upper socioeconomic classes in developed nations and children
4. Hodgkin lymphoma
of low socioeconomic status.
5. X-linked
Signs and symptoms: classical triad
lymphoproliferataive
Fever
disorders, and
6. Body cavity lymphoma.
Pharyngitis (sore throat)
Clinical Features
Lymphadenopathy.
Laboratory Findings
Q. Mention the laboratory

findings in infectious
Total leukocytes count increased (12,000 to 25,000 cells/cu mm): absolute lymphocytosis.
mononucleosis.
Atypical lymphocytosis (mononuclear cells): these are CD8 + subset (cytotoxic) of T cells
and not the virus-infected B cells.
Serological tests
Demonstration of heterophile antibodies
Paul Bunnell test is characteristically positive.
Demonstration of specific
Monospot test is a sensitive slide test.
antibodies to EBV is the
Demonstration specific antibodies against EBV antigens:
most specific test for
Antibody against viral capsid antigens (anti-VCA).
Antibodies to Epstein-Barr nuclear antigen (EBNA).
infectious mononucleosis.
51
52
Acute Leukemia
CHAPTER
ACUTE LEUKEMIA
Q. Define and classify leukemia.
Definition
Acute leukemia is a malignant disease of the bone marrow stem cell and its characteristic
features are:
Normally blast cells are less Bone marrow: diffuse replacement with proliferating neoplastic blast cells that fail to
mature. Blast cells more than 20% (WHO criteria) of the nucleated cells in the marrow.
than 5% of nucleated cells
in the marrow.
Peripheral blood: abnormal numbers and forms of immature white blood cells.
Leukemia: malignant
disease of bone marrow
stem cell, arises in the
marrow and spreads.
Aleukemic/subleukemic leukemia is characterized by very few/no blasts in the peripheral

blood.
Acute leukemia are mainly divided into two groups namely acute lymphoblastic leukemia
(ALL) and acute myeloblastic leukemia (AML).

Risk Factors: risk factors (Table 7.1) may cause mutations in the proto-oncogenes and tumor
suppressor genes.
TABLE 7.1: Risk factors for acute leukemia
ENVIRONMENTAL FACTORS
Ionizing radiation
Drugs:
Alkylating agentsnitrogen mustard, chlorambucil, etc.
AML occurs in myeloma patients treated with melphalan
Leukemia follows chemotherapy of lung and ovarian cancer
Chemicals: benzene (used in paint industry, plastic glues, etc.)
GENETIC DISORDERS
Example: Down syndrome (ALL or AML), Fanconi anemia (AML), ataxia telangiectasia (ALL, NHL)
ACQUIRED DISORDERS
PNH and aplastic anemia may transform into acute leukemia
AML may develop de novo or secondary to myelodysplastic syndrome (MDS)
Acute Leukemia CHAPTER 7
Classification
Q. Classify acute leukemia.
Traditional classification depending on microscopic appearance of the involved cell and the
course of leukemias is presented in Table 7.2.
TABLE 7.2: Traditional classification of leukemia
Acute leukemia
Acute myelogenous/myeloblastic/myelocytic/myeloid leukemia (AML)
Acute lymphoblastic/lymphocytic leukemia (ALL)
Chronic leukemia
Chronic myeloid leukemia (CML)
Chronic lymphocytic leukemia (CLL)
FAB Classification of Acute Leukemias
FAB criteria for the
First French, American and British (FAB) classification (1976) was based on the diagnosis of acute
leukemia: bone marrow
1. morphological and 2. cytochemical characteristics of blast cells.
should show a blast count
Revised FAB classification (Table 7.3): it includes
of 30% or more.
1. M: Morphology and cytochemistry of blast cells
2. I: Immunophenotyping
3. C: Cytogenetics
4. M: Molecular genetics.
TABLE 7.3: Revised French, American and British (FAB) classification of acute leukemias
Acute Lymphoid Leukemia
L1
Small homogenous cells with inconspicuous nucleoli
L2
Large cells with variable size and 12 nucleoli
L3
Large, homogeneous cells with finely stippled chromatin and prominent nucleoli. Cytoplasm is
basophilic and vacuolated
Acute Myeloid Leukemia

M0
Minimally differentiated AML
M1
AML without maturation
M2
AML with maturation
M3
Promyelocytic leukemia
M4
Myelomonocytic leukemia
M5
Monocytic leukemia
M6
Erythroleukemia
M7
Megakaryocytic leukemia
WHO Classification (2008) of Acute Leukemia (Table 7.4)
WHO classification of
ALL: two main categories
namely,
1.Precursor-B
lymphoblastic
leukemia/lymphoma,
and
2.Precursor T
lymphoblastic
leukemia/lymphoma.
TABLE 7.4: WHO classification (2008) of acute lymphoblastic and myeloid leukemia
A. Acute Lymphoblastic Leukemia
I. Precursor-B lymphoblastic leukemia/lymphoma
II. Precursor -T lymphoblastic leukemia/lymphoma
B. Acute Myeloid Leukemia
I. AML with recurrent genetic abnormalities
AML with t(8;21)(q22;q22); RUNX1-RUNX1T1
AML with inv(16)(p13;1q22); CBFB-MYH11
Contd...
53
54
Contd...
WHO classification
of AML: based on
clinical, morphological,
immunophenotypic and
genetic features.
Minimum blast cells in
bone marrow should be
more than 20%.

myeloblast and lymphoblast.
It is important to
differentiate between
lymphoblast and
myeloblast because of
difference in treatment
and prognosis of AML and
ALL.
Myeloblast: comparison
with lymphoblast has 4 Ms
M: more in size
M: more nucleoli (35)
M: moderate cytoplasm
M: myeloperoxidase +ve
Auer rod :+.
appearance of lymphoblast
appearance of myeloblast
APL with t(15;17)(q22;q12); PML-RARA

AML with t(9;11)(p22;q23); MLLT3-MLL
II. AML with MDS-related changes
III. Therapy-related myeloid neoplasms
IV. AML not otherwise specified
AML minimally differentiated
AML without maturation
AML with maturation
Acute myelomonocytic leukemia
Acute monoblastic and monocytic leukemia
Acute erythroid leukemia
Acute megakaryoblastic leukemia
V. Myeloid sarcoma
VI. Myeloid proliferation related to Down syndrome
Abbreviations: AML, Acute myeloid leukemia; APL, Acute promyelocytic leukemia; MDS, Myelodysplastic syndrome
Differences between Myeloblast and

Lymphoblast (Table 7.5)
TABLE 7.5:Differences between myeloblast and lymphoblast based on morphology and
cytochemistry
Size
Cytoplasmic characters
Amount
Color
Cytoplasmic granules
Auer rod
Nuclear characters
Nuclear chromatin
Nucleoli
N:C ratio
Accompanying cells
Cytochemistry
Myeloperoxidase
Sudan Black
PAS
Nonspecific esterase
Fig. 7.3: Periodic acid

Schiff (PAS) stain showing
lymphoblast with block
positivity
Lymphoblast (Figs 7.1 and 7.3)
Myeloblast (Figs 7.2, 7.4 and 7.5)
23 times the size of lymphocyte
35 times the size of lymphocyte
Scanty (less cytoplasm than myeloblast) Scanty to moderate (more cytoplasm

than lymphoblast)
Blue
Gray
Agranular
May have cytoplasmic granules
Negative
Positive
Uniform, coarse
Inconspicuous or 1 to 2
High
Lymphocytes
Uniform, fine
3 to 5, prominent
High
Promyelocytes, myelocytes, metamyelocytes, band forms and neutrophils
Negative
Negative
Block positivity
Negative
Positive
Positive
Negative
Positive in M4 and M5
Fig. 7.4:Myeloblast
stained positively with
myeloperoxidase (MOP)
Fig. 7.5:Myeloblast
stained positively with
Sudan Black
ACUTE LYMPHOBLASTIC
LEUKEMIA/LYMPHOMA
Acute Lymphoblastic Leukemia/Lymphoma (ALL) is a group of neoplasms consisting of
lymphoblasts.
Lymphoblast is immature, precursor B (pre-B) or T (pre-T) lymphocyte.
WHO classification (Table 7.4):
Precursor B cells ALL (about 85%) seen in childhood and present as acute leukemias.
Precursor T cells ALL (15%) present in adolescent males as lymphomas, often with
involvement of mediastinum (thymus).
Molecular Pathogenesis
Differentiating
malignant pre-B and
pre-T lymphoblasts on
morphology is difficult.
Requires
immunophenotyping for
subclassification of ALL.
Chromosomal abnormalities are found in about 90% of ALLs.

Numerical abnormality: hyperploidy (>50 chromosomes) and hypoploidy.
Structural abnormality: balanced chromosomal translocations (e.g. Philadelphia
chromosome).
Most T-ALLs have mutations in NOTCH1 gene.
Most B-ALLs have mutations in genes PAX5, E2A and EBF or a balanced translocation T-ALL has worse prognosis
compared to B-ALL.
t (12; 21) involving the genes TEL and AML1.
Classification of Acute Lymphoblastic

Leukemia (Tables 7.3, 7.4 and 7.6)
TABLE 7.6: Characteristics of FAB subtypes of acute lymphoid leukemias (ALL)
FAB type
L1
L2
L3
Cell size
Small cell size
Large heterogeneous
cell population
Large, homogeneous
cell population
Shape
Regular
Irregular, clefting and

indentation common
Regular, oval or round
Chromatin
Condensed
Dispersed chromatin
Finely stippled
Nucleolus
Small and
inconspicuous
Visible, 12 in number
Usually prominent
Amount
Scanty
Variable, often
abundant
Moderately abundant
Cytoplasmic basophilia
Slight to moderate
Variable
Strong
Cytoplasmic vacuolation
Absent
Variable
Prominent and oil red O

stain positive
Nuclear characteristics
Morphologically, as per
the FAB classification
lymphoblast are classified
as L1, L2 and L3.
ALL-L1 has better prognosis

than ALL-L3.
Cytoplasmic characteristics
ALL-L3 is a leukemic
counterpart of Burkitt
lymphoma.
Clinical Features
Age: most common hematological malignancy of children. Most common between 1 and 5
years of age and between 30 and 40 years.
Sex: slight male preponderance.
Onset: abrupt.
ALL is the most common

leukemia in children and
is usually associated with
lymphadenopathy.
55
56
Symptoms are due to bone

marrow infiltration by
blasts.
Bone marrow failure
anemia
neutropenia
thrombocytopenia.
Q. Write short note on laboratory/

peripheral smear findings in acute
lymphoblastic leukemia.
Symptoms:
Bone marrow failure:
Anemia: causes fatigue, weakness.
Neutropenia: infections by bacteria or opportunistic fungi. Develop sore throat and
respiratory infections.
Thrombocytopenia: bleeding into the skin and mucosa in the form of purpura or
ecchymoses.
Bone pain and sternal tenderness.
Extramedullary infiltration:
Lymphadenopathy: 75% of patients, usually involve cervical lymph nodes.
Bone pain and tenderness.
Hepatosplenomegaly: splenomegaly is more common than hepatomegaly.
Mediastinal thymic mass: more common in T-ALL.
CNS involvement: spread into the meninges causes leukemic meningitis ALL (pre-B).
Testicular involvement (ALL).
Laboratory Findings
Peripheral Blood
Total WBC count: markedly raised ranging from 20 109/L to 200 109/L
Platelet count: reduced (thrombocytopenia).
Subleukemic leukemia:
total WBC count lower than Hemoglobin: decreased and may be as low as 3 g/dL.
4 109/L and peripheral
blood shows very few
blasts.
Aleukemic leukemia: total

white cell count is low
(< 4 109/L) with no blasts
in the peripheral blood.
Lymphoblasts should
be differentiated from
myeloblasts (see Table 8.3).

RBCs: normocytic normochromic anemia.
WBCs: total count markedly increased and 20% or more lymphoblasts.
Morphology of lymphoblasts:
Larger than small lymphocyte
High N:C ratio
Nucleus with condensed chromatin and nucleoli are either absent or inconspicuous
Scant to moderate agranular basophilic cytoplasm.
Platelets: thrombocytopenia.
Fig. 7.6:Peripheral blood smears in acute lymphoblastic leukemia

showing lymphoblasts (arrows). Inset shows lymphoblast with block
positivity with PAS stain
Fig. 7.7: Diagrammatic peripheral blood smear in acute

lymphoblastic leukemia showing lymphoblasts (arrows)
Cytochemistry of Lymphoblasts
PAS: cytoplasmic aggregates of PAS positive (Figs 7.3 and 7.6) material (block positivity).
Myeloperoxidase (MPO) negative.
Sudan black B negative.
Lymphoblast: cytoplasm
shows block positivity with
PAS stain.
Bone Marrow
Cellularity: markedly hypercellular due to proliferation of blasts.

Erythropoiesis and myelopoiesis: reduced.
Megakaryopoiesis: megakaryocytes gradually decrease.
Blasts: constitute 20100% of the marrow cells.
Immunophenotyping
Terminal-deoxynucleotidyl-transferase (TdT) + in pre-B and pre-T lymphoblasts.
Immature B cells + positive for pan B cell marker CD19 and CD10 (CALLAcommon ALL Distinction between
precursor B and T cell ALL
antigen).
requires lineage-specific
Precursor T ALL cells are positive for CD2, CD5 and CD8.
markers.
Serum uric acid: raised due to destruction of leukemic cells during chemotherapy leading
to hyperuricemia.
LDH: raised, because of increased turnover of leukemic cells.
CSF Examination
To know/rule out CNS involvement.
Prognosis: prognostic features of ALL are presented in Table 7.7.
TABLE 7.7: Prognostic factors in ALL
Unfavorable prognosis
Favorable prognosis
Age
Below 2 years and above 10 years

(adolescence or adulthood)
Between 2 to 10 years
Sex
Males
Females
Total WBC count
High (more than 50,000 cells/cu mm)
Low
Meningeal involvement
Present
Absent
Cytogenetic
abnormalities
t(9;22) (the Philadelphia chromosome)
Hyperploidy, trisomy of chromosomes 4, 7

and 10 and t(12;21)
Time required for clearing

blasts from blood
More than 1 week
Less than 1 week
ACUTE MYELOGENOUS LEUKEMIA

Definition: neoplasm of hematopoietic progenitors characterized by proliferation resulting in
accumulation of immature myeloblasts in the marrow.
Classification of acute myelogenous leukemia (AML): refer Tables 7.3 and 7.4.
Presence of Philadelphia
chromosome in ALL:
prognosis unfavorable.
Prognosis is far better in

ALL than AML.
95% of children develop
complete remission.
75 to 85% are cured with
current chemotherapy.
57
58
AML synonyms: acute

myeloid/myeloblastic/
myelocytic leukemia.
Many recurrent genetic abnormalities can disrupt genes encoding transcription factors
involved in normal myeloid differentiation.
Mutated tyrosine kinase activation is a common.
Clinical Features
AML: develop at any age.
Usually 1560 years of age.
Symptoms are due to

anemia, neutropenia and
thrombocytopenia.
Acute promyelocytic
leukemia (AML-M3)
may be associated with
widespread bleeding due
to DIC.
Age: AML may develop at any age, but is more common in adults.
Onset: acute leukemias are abrupt in onset.
Symptoms: related to depressed marrow function.
Bone marrow failure:
Anemia: fatigue and weakness.
Neutropenia: life-threatening infections by bacteria or opportunistic fungi.
Thrombocytopenia: bleeding, patient may also develop disseminated intravascular
coagulation (DIC) in AML M3 and primary fibrinolysis.
Bone pain and tenderness
Extramedullary infiltration
Gingival hypertrophy (M4 and M5) and infiltration of skin (leukemia cutis).
Hepatosplenomegaly: usually more than in ALL.
Laboratory Findings
Q. Write short note on laboratory/
peripheral smear findings in AML.
Subleukemic leukemia:
total WBC count lower than
4 109/L and peripheral
blood shows very few
blasts.
Aleukemic leukemia: total
white cell count is low
(< 4 109/L) with no blasts
in the peripheral blood.
AML: Auer rods in the
cytoplasm of myeloblasts,
seen in AML; not in CML.
Peripheral Blood
Total WBC Count: markedly raised ranging from 20 109/L to 100 109/L.
Hemoglobin: decreased and ranges from 5 to 9 g/dL.
RBCs: normocytic normochromic type of anemia.
WBCs: total WBC count markedly increased.
Differential count: more than 20% myeloid blasts. May show more than one type of blast or
blasts with hybrid features.
Morphology of myeloblasts
3 to 5 times larger than the diameter of a small lymphocyte.
High N:C ratio.
Fine nuclear chromatin with 2-4 variably prominent nucleoli.
More cytoplasm than lymphoblastsazurophilic, peroxidase-positive granules.
Presence of Auer rods is definitive evidence of myeloid differentiation.
Auer rods are azurophilic needle-like peroxidase-positive structures in the cytosol of myeloblasts (M2 and M3 subtype).
Platelets: moderate to severe thrombocytopenia and causes bleeding from skin and mucosa.
Myeloblasts stain positively Cytochemistry of Myeloblasts (Figs 7.10 and 7.11)

with myeloperoxidase and Stain positively with myeloperoxidase (MPO) and Sudan black B.
Sudan black B.
Monoblasts stain with nonspecific esterases.
Both in subleukemic and

aleukemic leukemia bone
marrow contains blasts
more than 20%.
Bone Marrow
Cellularity: markedly hypercellular.
Erythropoiesis: markedly suppressed.
Myelopoiesis: suppression of myeloid maturation and myeloblasts constitute more than 20% of
marrow cells.
Megakaryopoiesis: gradually decreased.
Fig. 7.8: Peripheral smear in AML with myeloblasts. Inset shows

myeloblast with Auer rod
Fig. 7.9: Diagrammatic peripheral blood smear in AML with

myeloblasts. One myeloblast with two Auer rods (arrow)
Fig. 7.10: Myeloblast stained positively with myeloperoxidase
Fig. 7.11: Myeloblast stained positively with Sudan black
Immunophenotyping
Diagnosis of AML is confirmed by using stains for myeloid specific antigens.
Cytogenetics
AML prognosis:
Fulminant course and
has worse prognosis
than ALL.
Cytogenetic markers are
major determinants of
prognosis.
Very important in the WHO classification of AML (Table 7.4).
MYELOID SARCOMA
Tumor mass consisting of myeloid blasts with or without maturation occurring at extra
medullary sites.
On sectioning: tumor is green (hence the term chloroma)
Microscopically myeloblasts with or without features of promyelocytic or neutrophilic
maturation.
Myeloid sarcoma synonym:

Extramedullary myeloid
tumor/granulocytic
sarcoma/chloroma.
Myeloid sarcoma is
frequent in skin, lymph
node, GI tract, bone, soft
tissue and testis.
59
Myelodysplastic
Syndromes
CHAPTER
MYELODYSPLASTIC SYNDROMES
MDS: cytopenias with
hypercellular bone
marrow.
About 30% progress to
AML.
Myelodysplastic Syndromes (MDS) are a heterogeneous group of acquired clonal stem cell
disorders affecting stem cells.
MDS is characterized by:
Progressive cytopenias
Dysplasia in one or more cell lines
Ineffective hematopoiesis
Risk of development of AML.
Classification
Idiopathic or primary MDS
Secondary/therapy-related MDS (t-MDS): complication of previous cytotoxic drug or
radiation therapy.
WHO classification of myelodysplastic syndromes is presented in Table 8.1.
Clinical Features
Elderly above 60 years

Slightly more common in males
Symptoms are due to cytopenias
About 10% to 40% of MDS patients progress to AML.
Laboratory Findings
Peripheral smear: cytopenias in the peripheral blood
RBCs: mild to moderate degree of macrocytic or dimorphic anemia.
WBCs: normal or low total leukocyte count.
Platelets: variable thrombocytopenia, large hypogranular or giant platelets.
Myelodysplastic Syndromes CHAPTER 8
TABLE 8.1: WHO classification of myelodysplastic syndromes

Disease
Peripheral blood picture
Bone marrow features
1. Refractory cytopenia with

unilineage dysplasia (RCUD):
refractory anemia (RA), refractory
neutropenia (RN), refractory
thrombocytopenia (RT)
Unicytopenia or bicytopenia 1
Unilineage dysplasia in > 10% of

the cells in one myeloid lineage
< 5% blasts
< 15% ring sideroblasts
2. Refractory anemia with ring

sideroblasts (RARS)
Anemia
No blasts
Dyserythropoiesis >15% ring

sideroblasts <5% blasts
3. Refractory cytopenia with

multilineage dysplasia (RCMD)
Bi/pancytopenia
Rare blast
No Auer rods
<1 109/L monocytes
Dysplasia in > 10% of cells in 2

myeloid lineages (neutrophil
and/or erythroid and/or
megakaryocytes) < 5% blasts
No Auer rods 15% ring
sideroblasts
4. Refractory anemia with excess

blasts-1 (RAEB-1)
< 5% blasts2
Bi/pancytopenia
No Auer rods
<1 109/L monocytes
59% blasts
Unilineage or multilineage
dysplasia
No Auer rods
5. Refractory anemia with excess

blsts-2 (RAEB-2)
519% blasts
Cytopenia
Auer rods 3
<1 109/L monocytes
1019% blasts
Unilineage or multilineage
dysplasia
Auer rods 3
6. MDS unclassified (MDS-U)
< 1% blasts
Cytopenia only
< 5% blasts
Unequivocal dysplasia in less
than 10% of cells in one or
more myeloid cell lines when
accompanied by cytogenetic
abnormalities considered as
presumptive evidence for
diagnosis of MDS
7. MDS with isolated del (5q)
No or rare blasts
Anemia
Platelets increased or normal
< 5% blasts
Increased to normal
megakaryocytes with
hypolobated nuclei. Isolated 5q
deletion. No Auer rods
1. Cases with pancytopenia should be classified as MDS-U

2. If marrow blasts < 5% with 24% myeloblasts in blood = RAEB-1. Cases with RCUD and RCMD with 1% myeloblasts in blood
should be classified as MDS-U
3. Cases with Auer rods and < 5% myeloblasts in blood and 10% in marrow = RAEB 2
Bone Marrow
Dysplasia of all non-lymphoid lineages (erythroid, granulocytic, monocytic and megakaryocytic)
associated with cytopenias.
Erythropoiesis: dysplastic changes in erythroid precursors with megaloblastoid change and presence
of ringed sideroblasts in iron stain.
Myelopoiesis: hyperplasia with dysgranulopoiesis.
Megakaryopoiesis: dysmegakaryopoiesispawn ball megakaryocytes.
Iron stores: increased with ring sideroblasts.
Ineffective hematopoiesis
Bone Marrow Trephine Biopsy

Abnormal localization of immature precursors (ALIP) in (refractory anemia with excess blasts
(RAEB).
Bone marrow in MDS:

pawn ball megakaryocytes,
dysgranulopoiesis,
erythroid precursors with
megaloblastoid change
and presence of ringed
sideroblasts.
61
9
CHAPTER
Myeloproliferative
Neoplasms
MYELOPROLIFERATIVE NEOPLASMS (MPN)

MPN peaks in the 5th to
7th decade.
All MPN show splenomegaly.
Definition: clonal hematopoietic stem cell disorders characterized by proliferation of one or

more of the myeloid lineages (erythroid, granulocytic, megakaryocytic and mast cells).
Splenomegaly and hepatomegaly due to sequestration of excess hematopoietic cells or
proliferation of abnormal hematopoietic cells.
WHO Classification of MPN

It is presented in Table 9.1.
TABLE 9.1: WHO (2008) classification of myeloproliferative neoplasm (MPN)
WHO (2008) Myeloproliferative neoplasms
Chronic myelogenous leukemia, BCR-ABL-1 positive
Chronic neutrophilic leukemia
Polycythemia veraJAK2 V617F or exon 12 mutation
Primary myelofibrosisJAK2 or MPL mutation
Essential thrombocythemia
Platelet count > 450 109/L
JAK2 mutation
Chronic eosinophilic leukemia, NOS
No BCR-ABL1, PDGFRA, PDGFRB or FGFR1 translocation
MastocytosisKIT mutation
Myeloproliferative neoplasm, unclassifiable
Pathogenesis
Presence of mutated, constitutively activated tyrosine kinases leads to proliferation of
hematopoietic stem cells and results in hypercellular marrow.
Myeloproliferative Neoplasms CHAPTER 9
POLYCYTHEMIA OR ERYTHROCYTOSIS
Polycythemia is characterized by increase in the RBC mass, usually with a corresponding
increase in hemoglobin level.
Pathophysiologic classification of polycythemia is given in Table 9.2.
TABLE 9.2: Pathophysiologic classification of polycythemia
ABSOLUTE
Primary (low erythropoietin level)
Polycythemia vera
Secondary (high erythropoietin level)
Physiologically appropriate
Compensatory
Lung disease
Living in high-altitude
Cyanotic heart disease (Tetralogy of Fallot)
Physiologically inappropriate (with increased erythropoietin)
Paraneoplastic: erythropoietin-secreting tumors (e.g. renal cell carcinoma, uterine leiomyoma,
hepatocellular carcinoma)
Increase in red cells can be

absolute or relative.
RELATIVE
Reduced plasma volume
Hemoconcentration (dehydration due to diarrhea, vomiting)
Gaisbcks syndrome (spurious polycythemia)
POLYCYTHEMIA VERA
Definition: polycythemia vera (PV) is an acquired myeloproliferative neoplasm arising from
malignant transformation of hematopoietic stem cell.
It is characterized by trilineage (erythroid, granulocytic, and megakaryocytic) hyperplasia
in the bone marrow.
It leads to uncontrolled production of red cells, granulocytes and platelets (panmyelosis)
and leads to erythrocytosis (polycythemia) and or granulocytosis and thrombocytosis.
Q. Write short notes on polycythemia vera.
Molecular Pathogenesis (Figs 9.1 and 9.2)

Normally, a tyrosine kinase protein called JAK2 (Janus 2 kinase gene), is activated following
binding of the growth hormone erythropoietin.
JAK2 then activates a signaling pathway causing cells to replicate.
This process is strictly regulated by various feedback pathways.
Polycythemia vera (PV) is due to mutation in tyrosine kinase JAK 2 V617F, which causes
proliferation of not only erythroid lineage but also granulocytic and megakaryocytic lineage.
JAK2 mutation is
diagnostic of polycythemia
vera.
PV: erythropoietin is
decreased.
Clinical Features
1. Insidious.
2. Late middle age (median age at onset is 60 years).
3. Plethora and cyanosis, headache, dizziness and visual problems result from vascular PV: most symptoms are
disturbances in the brain and retina.
due to the increased red
4. Thrombotic episodes: e.g. deep venous thrombosis, myocardial infarction, thrombosis of cell mass and hematocrit.
hepatic veins (producing Budd-Chiari syndrome).
63
64
Fig. 9.1: Normal signaling by JAK2
Fig. 9.2: In polycythemia vera, the presence of a mutant

version of JAK2 results in dysregulated downstream
signaling in the absence of erythropoietin
Phases
PV develops into acute
myelogenous leukemia in
2% to 5%.
There are three phases of Polycythemia vera

Proliferative phase: erythroid proliferation and increased red cell mass.
Spent phase: in 10%, excessive proliferation of erythroid cells ceases with stable or
decreased RBC mass.
Myelofibrosis: about 10% progress to myelofibrosis.
Laboratory Findings
Peripheral Blood (Fig. 9.3)
Polycythemia vera is a
chronic myeloproliferative
neoplasm with RBC count
of more than 6 million/
cu mm.
Hemoglobin: increased and are more than 18.5 g/dL in men and 16.5 g/dL in women.
Hematocrit: increased and about 60%.
Red cell count: increased and usually about 6 million/cu mm (6 1012/L).
White cell count: normal or increased.
Platelet count: normal or increased.
Peripheral smear:
RBCs: show normocytic normochromic picture.
WBCs:
Mild to moderate leukocytosis
Neutrophils are morphologically normal
Basophils often increased
NAP (LAP) score is increased to 150300 (Normal 40100).
Platelets: abnormally large and functionally defective.
PV: hematocrit is increased

and > 60%.
Fig. 9.3: Normal hematocrit in comparison with anemia and

polycythemia vera
Bone Marrow
Hypercellular due to hyperplasia of all elements (trilineage hyperplasia/panmyelosis) namely
erythroid, myeloid and megakaryocytic series with prominence of erythroid precursors in the bone
marrow.
Bone Marrow Biopsy

Shows increased reticulin fibers and fibrosis as the disease progresses.
Other Findings
Extramedullary hematopoiesis in the liver and spleen that causes hepatosplenomegaly.
Arterial oxygen saturation (pO2): normal (75100 mm Hg) and is useful for differentiating
it from secondary polycythemia.
Erythropoietin levels: decreased in contrast to secondary polycythemia.
Serum vitamin B12 and uric acid: increased indicating increased cell turnover.
JAK2 V617F mutation: it can be demonstrated.
ESSENTIAL THROMBOCYTHEMIA
Definition: chronic myeloproliferative neoplasm (MPN) primarily of megakaryocytic
lineage. It is characterized by increased megakaryopoiesis and thrombocytosis (more than
450 109/L).
Etiology
In PV arterial oxygen
saturation (pO2) is normal
(>92%) whereas in
secondary polycythemia it
is <90%.
ET synonym: primary
(essential/idiopathic)
thrombocytosis.
ET: mutation of JAK2 gene

Thrombocytosis with a
Most due to point mutations in JAK2 gene and constitutive activation of JAK2, and count of > 450 109/L.
thrombopoietin-independent proliferation of megakaryocytes.
65
66
ET: throbbing and burning

sensation of hands and
feet due to blocking of
arterioles by aggregates
of platelets is known as
erythromelalgia.
Clinical Features
Age: 5060 years
Thrombosis and hemorrhage
Erythromelalgia: one of the characteristic features.
Laboratory Findings

Megakaryocytic
hyperplasia and abnormal
(giant) platelets are
characteristic features.
ET course: indolent.
Peripheral smear:
RBCs: normocytic normochromic.
WBCs: mild leukocytosis.
Platelets:
Increased number (thrombocytosis)> 600,000/cu mm.
Variation in size and shape-abnormally large platelets are common.
Bone Marrow
Cellularity: mild to marked hypercellularity.

Erythropoiesis: normal or mild hyperplasia.
Myelopoiesis: normal or mild hyperplasia.
Megakaryopoiesis: markedly increased in number with abnormally large megakaryocytes (giant
megakaryocytes).
Extramedullary hematopoiesis: mild hepatosplenomegaly.
PRIMARY MYELOFIBROSIS
Myelofibrosis: mutation in
JAK2 gene.
Clonal MPN characterized by a proliferation of predominantly megakaryocytes and

granulocytes in the bone marrow.
Fully developed disease results in reactive marrow fibrosis and replaces hematopoietic
cells leading to cytopenias and extensive extramedullary hematopoiesis.
Most show JAK2 mutations.
Massive splenomegaly
due to extramedullary
hemopoiesis.
Clinical Features
Age: above 60 years of age.
Progressive anemia.
Splenomegaly.
Laboratory Findings
Peripheral smears:
RBCs: moderate to severe degree of normochromic normocytic anemia accompanied by
leukoerythroblastosis. Tear drop-shaped red cells (dacryocytes), probably due to damage in the
fibrotic marrow can also be found.
WBCs: total white cell count is usually normal or reduced, but can be markedly elevated 80 to 100
109/L in early stages of the disease.
Platelets: they may be abnormally large. The platelet count is usually normal or elevated, but as
the disease progresses the count decreases.
Primary myelofibrosis:
peripheral smear shows
leukoerythroblastosis and
tear drop cells.
Bone Marrow
Primary myelofibrosis:
bone marrow fibrosis leads
to cytopenias.
Cellularity: in early stages, it is often hypercellular due to increase in maturing cells of all lineages. In
later stages, it is replaced by fibrosis and becomes hypocellular and diffusely fibrotic resulting in a dry
tap.
Erythroid and granulocytic precursors: these are morphologically normal.
Megakaryocytes: these are large, dysplastic and abnormally clustered.
Bone Marrow Biopsy

Stages: two stages have been recognized.
1. Prefibrotic (cellular) stage: hypercellular bone marrow. Megakaryocytes increased and
markedly abnormal.
2. Fibrotic stage: fibrosis distorts the marrow and prematurely releases nucleated erythroid
and early granulocyte progenitors (leukoerythroblastosis).
Reticulin stain demonstrates the increase in reticulin fibers (fibrosis).
Extramedullary hematopoiesis in spleen and liver produces hepatosplenomegaly.
Course: variable.
Bone marrow biopsy is

essential for the diagnosis
of myelofibrosis as aspirate
results in a dry tap late in
the course of the disease.
67
10
CHAPTER
CML synonyms: chronic

myelocytic/myeloid/
granulocytic leukemia.
CML is an acquired MPN of
pluripotent hematopoietic
stem cell.
Chronic Myelogenous
Leukemia
CHRONIC MYELOGENOUS LEUKEMIA

Definition
Chronic myelogenous leukemia (CML) is one of the myeloproliferative neoplasm (MPN) of
pluripotent hematopoietic stem cell characterized by overproduction of cells of the myeloid
series which results in marked splenomegaly and leukocytosis.
Distinguished from other myeloproliferative neoplasms by the presence of:
1. Chimeric fusion BCR-ABL gene.
2. Philadelphia (Ph) chromosome in more than 90% of cases.

Risk factor: exposure to ionizing radiation and benzene.
Q. Write short notes on
Philadelphia chromosome.
Philadelphia (Ph) Chromosome (Fig. 10.1)
Philadelphia (Ph)
chromosome is a
shortened chromosome
22 and is due to balanced
reciprocal translocation
between chromosome 9
and 22-t (9; 22).
Acquired chromosomal abnormality in all proliferating hematopoietic stem cells

(erythroid, myeloid, monocytic and megakaryocytic precursors).
Balanced reciprocal translocation between long arm of chromosome 9 and 22, i.e. t (9; 22)
(q 34; q 11.2). It increases the length of chromosome 9 and shortening of 22. This shortened
chromosome 22 is known as Philadelphia chromosome (Fig. 10.1).
BCR-ABL Fusion Gene (Fig. 10.2)

Translocation results in
a BCR-ABL fusion gene,
which produces neoplastic
proliferation.
ABL proto-oncogene from chromosome 9 joins the BCR on chromosome 22.

It produces a new chimeric (fusion) gene called BCR-ABL, thus converting ABL protooncogene into oncogene. The product of the fusion gene plays a central role in the
development of CML
Chronic Myelogenous Leukemia CHAPTER 10
CML: translocation results

in the head-to-tail fusion
of the breakpoint cluster
region (BCR) gene on
chromosome 22 with
the ABL (named after the
abelson murine leukemia
virus) gene located on
chromosome 9.
Fig. 10.1: Balanced reciprocal translocation between long arm of chromosome 9 and chromosome 22 resulting in
shortened chromosome 22 known as Philadelphia chromosome
Fig. 10.2: Fusion of ABL gene from chromosome 9 with BCR on chromosome 22 and its consequences
The product of this oncogene i.e., oncoprotein (e.g. p210) causes cell division and
inhibition of apoptosis.
Clinical Features
Age: usually occurs between 40 to 60 years of age.
Sex: males slightly more affected than females.
Onset: insidious.
Symptoms:
Nonspecific symptoms: fatigue, weakness, weight loss, anorexia.
CML: usually occurs

between 40 and 60 years
of age.
69
70
CML: moderate to massive

splenomegaly.
CML has three phases:

chronic stable, accelerated
and blast phase.
Fullness of abdomen due to splenomegaly (caused by leukemic infiltration and extra

medullary hematopoiesis). Splenomegaly is moderate to severe and is characteristic feature
in majority (8090%) of patients.
Hepatomegaly: mild or moderate seen in 6070% of cases.
NATURAL HISTORY OF CHRONIC

MYELOID LEUKEMIA
Three different phases: 1. chronic phase, 2. accelerated phase and 3. blastic phase.
Chronic/Stable/Indolent Phase (CP)

Most are diagnosed in this phase.
Lasts for 2 to 6 years.
If not treated, progresses gradually to accelerated phase or abruptly to blastic phase.
findings /peripheral smear in CML.
CML: neutrophilia with the

whole spectrum of mature
myeloid precursors.
CML is characterized
by anemia, extreme
leukocytosis, granulocytic
immaturity, basophilia,
thrombocytosis.
The preponderance of
myelocyte is called as
myelocyte bulge.
In CML LAP (NAP) is markedly reduced.
Laboratory Findings
Peripheral blood
Hemoglobin: usually less than 11 g/dL
Peripheral smear:
RBCs: normocytic normochromic anemia
WBCs:
Marked leukocytosis (12600 109/L) total leukocyte count usually exceeds 100 109/L
(1,00,000/cu mm).
Shift to left (shift to immaturity)granulocytes at all stages of development (neutrophils,
metamyelocytes, myelocytes, promyelocytes and an occasional myeloblasts).
Predominant cells are neutrophils and myelocytes.
Blasts are usually less than 10% of the circulating WBCs (Figs 10.3 and 10.4).
Basophilia and eosinophilia.
Decreased NAP/LAP score: NAP score in CML is decreased below 20 (normal score range is
40100). Helpful in differentiating CML from leukemoid reaction (see Table 7.5).
Platelets: platelets range from normal (150450 109/L) to greater than 1000 109/L. Up to 50%
have thrombocytosis.
Bone Marrow
Cellularity: markedly hypercellular due to myeloid hyperplasia.

M: E ratio: often exceeds 20:1.
Erythropoiesis: diminished erythropoiesis as disease progresses.
Myelopoiesis: marked hyperplasia. Blast cells usually less than 10%. Basophils, eosinophils and their
precursors are usually found.
Megakaryopoiesis: megakaryocytes are either normal or increased. Dwarf megakaryocytes.
Sea-blue histiocytes (Gaucher-like cells/pseudo Gaucher cells) are seen.
Biochemical findings:
Serum uric acid raised
Serum LDH raised.
Philadelphia chromosome and BCR-ABL fusion gene: demonstrated either by chromosomal
analysis or fluorescent in situ hybridization (FISH) or PCR based tests.
Chronic Myelogenous Leukemia CHAPTER 10
Fig. 10.3: Peripheral blood picture in chronic/stable phase of chronic

myeloid leukemia
Fig. 10.4: Diagrammatic peripheral blood picture in

chronic/stable phase of chronic myeloid leukemia
Accelerated Phase (AP) (Figs 10.5 and 10.6)
More aggressive and lasts for few months.

Myeloblasts: 1019% in the blood or bone marrow.
Striking basophilia (20% or more).
Persistent thrombocytopenia (less than 100 109/L) unrelated to therapy or persistent
thrombocytosis (more than 1000 109/L) uncontrolled by therapy.
Megakaryocyte proliferation in sheets or clusters in association with fibrosis.
Persistent or increasing splenomegaly unresponsive to therapy.
Fig. 10.5: Peripheral blood picture in accelerated phase of chronic myeloid

leukemia showing numerous blasts (1019%) and striking basophilia
CML: accelerated phase

is more aggressive and
myeloblasts range from
10% to 19%.
Fig. 10.6:Diagrammatic peripheral blood picture in accelerated

phase of chronic myeloid leukemia showing numerous blasts
(1019%) and striking basophilia
71
72
Blast Phase/Crisis (BP)

CML blast crisis: blasts 20% Blood picture resembles acute leukemia and has poor prognosis.
or more, myeloblast (no
Auer rods) or lymphoblasts. Peripheral smear (Figs 10.7 and 10.8):
Prognosis: poor with
accelerated phase or blast
crisis.
Blasts 20% or more. May be either myeloblast (70% cases) or lymphoblast (30% cases).
Myeloblast does not contain Auer rods.
Thrombocytopenia causes bleeding episodes.
Fig. 10.7: Peripheral blood picture in blast phase of chronic myeloid

leukemia showing numerous blasts (20% or more) and striking basophilia
Fig. 10.8: Diagrammatic peripheral blood picture in blast phase of

chronic myeloid leukemia showing numerous blasts (20% or more)
and striking basophilia
Chronic Lymphocytic
Leukemia/Small
Lymphocytic Lymphoma
11
CHAPTER
CHRONIC LYMPHOCYTIC LEUKEMIA

Definition
Q. Write short notes on chronic

lymphocytic leukemia.
Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) is a tumor

composed of monomorphic small B lymphocytes in the peripheral blood, bone marrow and
lymphoid organs (spleen and lymph nodes).
Both CLL and SLL is a single entity with different presentations.
Small lymphocytic lymphoma (SLL) is tissue equivalent of chronic lymphocytic leukemia
CLL/SLL are tumors derived
(CLL).
from B lymphocytes.
CLL/SLL tumor cells coexpress CD5 and CD23.

Environmental factors: suggested but none proved.
Hereditary factors: families with higher risk of CLL or other lymphoid neoplasms.
Cytogenetic Abnormalities
Common mutations are deletions of 13q14.3, 11q22-23, and 17p13. About 20% of CLL show
trisomy 12.
Clinical Features
Age: between 5060 years of age.
Sex: more in males than in females (2:1).
Symptoms:
Asymptomatic in about 2530%
Nonspecific symptoms: fatigue, loss of weight and anorexia
Generalized lymphadenopathy
Immunological defects either as immune deficiency or autoimmunity.
CLL patients may

be asymptomatic or
present with generalized
lymphadenopathy.
74
Laboratory Findings
CLL: absolute lymphocyte
Peripheral Blood
count is more than 5
9
10 /L. It is the characteristic Hemoglobin: decreased and usually below 13 g/dL.
Total leukocyte count is increased (2050 109/L).
feature.
CLL: lymphocytosis with
smudge cells in the
peripheral smear. Smudge
cells are fragile leukemic
cells produced due to
rupture while making the
peripheral smear.
Lymphocytes constitute
more than 30% of the
nucleated cells of the bone
marrow cellsdiagnostic
feature of CLL.
Bone Marrow

WBCs:
Differential leukocyte count shows lymphocytosis and constitutes more than 50% of the white cells.
Lymphocytes mature typesmall with scant cytoplasm, nuclei round with clumped coarse
chromatin (soccer ball/block-type chromatin). Nucleoli absent.
Smudge cells or basket cells (fragile leukemic cells).
Platelets: initially normal count and later may be decreased.
Cellularity: hypercellular marrow due to infiltration by mature lymphocytes.

Erythropoiesis: normal.
Lymphocytic infiltrate: as the disease advances neoplastic lymphocytes replace the normal erythroid, myeloid
and megakaryocytic series in the bone marrow resulting in anemia, neutropenia and thrombocytopenia.
Immunophenotype
Tumor cells express the pan-B cell markers CD19 and CD20. CD5+ and CD23+ are distinctly
positive in CLL.
Lymph Node
Show loss of normal architecture
Diffuse infiltration by monomorphic, small, round lymphocytes
Fig. 11.1: Peripheral blood smears in chronic lymphocytic leukemia showing

numerous small lymphocytes (long arrows) and few smudge cells (short arrow)
Fig. 11.2: Diagrammatic peripheral blood smears in chronic

lymphocytic leukemia showing numerous small lymphocytes (long
arrows) and few smudge cells (short arrows)
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma CHAPTER 11
Lymphocytes have nuclei with coarse chromatin and scanty cytoplasm

CLL/SLL: lymph node with
Small, nodular aggregates of medium to large-sized lymphocytes known as proliferation centers proliferation centers are
or pseudo-follicles or growth centers and when found are pathognomonic for CLL/SLL. pathognomonic.
Course and prognosis: median survival rate is 4 to 6 years. They may progress to B cell
prolymphocytic transformation or into diffuse large B cell lymphoma (Richter syndrome).
HAIRY CELL LEUKEMIA

Definition
Uncommon neoplasm of small mature B cells having abundant cytoplasm with fine hairlike cytoplasmic projections (hence the name hairy cell leukemia) when viewed under the
phase-contrast microscope.
Laboratory Findings
Peripheral Blood
Total leukocyte count: decreased (leukopenia).
Platelet count: decreased (less than 50 109/L)
Hairy cells have hair-like

cytoplasmic projections.
HCL: it is B cell neoplasm

and involves peripheral
blood, bone marrow,
spleen and liver and
usually seen in old age.
Peripheral smear: pancytopenia

RBCs: normocytic normochromic.
WBCs: leukopenia with few hairy cells (Fig. 11.3).
Platelets: reduced.
Bone Marrow Aspiration

Dry tap
Hairy cells may be seen in the marrow
Moderate to marked reduction in myeloid, erythroid and megakaryocytic cell lines.
Fig. 11.3: Hairy cell
Bone marrow trephine biopsy: neoplastic cells have fried egg or honeycomb appearance. HCL: bone marrow biopsyhairy cells have fried egg
Reticulin stain shows marked increase of thin reticulin fibers surrounding neoplastic cells.
appearance.
Spleen
Enlarged due to leukemic infiltrate
Sinuses lined by hairy cells and grossly impart a beefy red appearance.
Immunophenotype and Molecular Characteristics
Tartrate resistant acid

phosphatase (TRAP)
Express the CD20, CD22, CD11c and CD25 (the IL-2 receptor -chain) positivity. Annexin A 1 positivity in the cytoplasm
is a characteristic feature
is the most specific marker of hairy cell leukemia.
of HCL.
Clinical Features
Affects middle-aged to elderly men.

Male-to-female ratio of 5:1.
Massive splenomegaly.
Pancytopenia.
HCL: only leukemia

without lymphadenopathy.
HCL prognosis: indolent
course and prognosis is
excellent.
75
12
Plasma Cell Neoplasms
CHAPTER
Plasma cell neoplasms are

of B cell origin in which
single clone of plasma cells
proliferate.
Plasma cell neoplasms:

tumor cells secrete
single type of complete
or fragment of
immunoglobulins.
INTRODUCTION
Definition
Plasma cell neoplasms are group of B cell neoplasms associated with the proliferation of single
clone (monoclonal) of immunoglobulin-secreting plasma cells (also known as dyscrasias).
Characteristics of Plasma Cell Neoplasms

Monoclonal neoplastic plasma cells secrete complete single type of immunoglobulin (Ig) or
Ig fragment. Hence, are known as monoclonal gammopathies.
Serum: single Ig proteins detected as monoclonal spike [M protein (M for myeloma)] on
electrophoresis.
Urine: excess of free light chains is excreted in the urine as Bence-Jones (BJ) proteins.
Classification of Plasma Cell Neoplasms (Table 12.1)

TABLE 12.1: Classification of plasma cell neoplasms (WHO 2008)
Plasma cell myeloma
Plasmacytoma
Immunoglobulin deposition diseases
Monoclonal gammopathy of undetermined significance (MGUS)
Osteosclerotic myeloma (POEMS syndrome)
PLASMA CELL MYELOMA (MULTIPLE MYELOMA)

Definition
Multiple myeloma is a
multifocal malignant
tumor of plasma cell and
arises in the bone marrow.
Plasma cell myeloma is a malignant, multifocal plasma cell neoplasm of the bone marrow
associated with M-protein in the serum and/or urine.
Most common monoclonal gammopathy.
Presents as multiple tumor masses throughout the skeletal system.
Plasma Cell Neoplasms CHAPTER 12
Etiology
Plasma cell neoplasms

arise from post-germinal
center B cells.
Risk Factors
Genetic predisposition
Exposure to ionizing radiation
Chronic antigenic stimulation associated with chronic infections (HIV and chronic
osteomyelitis) and chronic inflammatory disorders (e.g. rheumatoid arthritis)
Exposure to chemicals like benzene, herbicides and insecticides.
Laboratory Findings
Q. Write short notes on the

laboratory diagnosis of multiple
myeloma.
Peripheral Blood
Hemoglobin: decreased and ranges from 6 to 10 g/dL.
Peripheral smear:
RBCs: normocytic normochromic anemia, red blood cells show rouleaux formation (Fig. 12.1) due
to increased immunoglobulins.
WBCs: normal.
Platelets: normal.
MM: hypergammaglo
bulinemia is responsible
for high ESR and rouleaux
formation seen in peri
pheral smear.
ESR: high and is due to high gamma globulin (immunoglobulin) and rouleaux formation.
Bleeding time: increased.
Bone Marrow
Cellularity: hypercellular due to myeloma plasma (myeloma) cells (neoplastic plasma cells) (Figs 12.2
and 12.3).
Myeloma plasma cells: more than 30% are diagnostic.
Myeloma plasma cells are neoplastic plasma cells (Fig. 12.2), which are large oval cells having
abundant pale blue cytoplasm.
The nucleus is round to oval, eccentric and shows perinuclear clearing/hof.
The nuclear chromatin appears like a clock-face/spoke wheel.
These cells are usually uninucleated or may show binucleation.
Other cells can also be seen in myeloma (Fig. 12.4).
Erythropoiesis: diminished and is normoblastic.
Fig. 12.1: RBCs showing rouleaux formation in the peripheral

blood
Bone marrow in MM:

hypercellular, and contains
more than 30% neoplastic
plasma cell.
Myeloma plasma cells
are commonly called as
myeloma cells.
Fig. 12.2: Bone marrow aspirate in multiple myeloma. With numerous myeloma
plasma cells. Inset shows flame cell (left lower corner) and mott cell (right upper corner)
77
78
Serum Findings
Serum 2 microglobulin: prognostic marker and
high values signify poor prognosis.
Hypercalcemia
Renal function tests: blood urea, serum creatinine
and uric acid levels are raised with renal involvement.
Serum albumin: decreases in advance stages of the
disease.
Electrophoretic Studies on Serum and

Urine (Figs 12.5 and 12.6)
Fig. 12.3:Diagrammatic appearance of bone marrow in multiple

myeloma showing plasmablasts (short arrow) and plasma cells (long
arrow)
Monoclonal spikes in 80% to 90% of cases.

Raised monoclonal immunoglobulins in the blood.
Immunoglobulin may be IgG (most common)/IgD/
IgA/IgE type.
Light chains or Bence Jones (BJ) proteins in the urine
may be seen in 60% to 80% of cases. BJ protein may be
of or type of light chain.
Fig. 12.5: Serum electrophoresis showing normal pattern
Fig. 12.4: Diagrammatic appearance of the various cells that can be

seen in bone marrow in multiple myeloma
Fig. 12.6: Serum electrophoresis showing monoclonal

immunoglobulin (M Band) in multiple myeloma
Plasma Cell Neoplasms CHAPTER 12
Morphology of Organs Involved

Bone: destructive -punched-out lytic lesions (Fig. 12.7).
Renal lesions:
Myeloma kidney: light-chain cast of BJ protein damages renal tubules.
Amyloidosis of the AL type and leads to nephrotic syndrome.
Hypercalcemia leads to nephrocalcinosis
Prone to acute and chronic pyelonephritis
Renal failure.
Clinical Manifestations (Fig. 12.8)

Onset: insidious.
Age and sex: affects old age between 50 and 60 years with slight male preponderance.
MM: IgG is the most

common immunoglobulin
secreted.
MM:
Monoclonal
gammopathy peak 50
to 60 years
Multiple lytic lesions in
bones
Hypercalcemia.
MM: involved bone shows

multiple punched out lytic
lesions.
Fig. 12.7: Skull X-ray showing multiple punched out lytic lesions
Fig. 12.8: Clinical features and laboratory findings in myeloma
79
80
MM: renal failure and

sepsis are common causes
of death.
MM: higher levels of

serum 2 microglobulin
are associated with poor
prognosis.
MM: prognosis
progressive course with
poor prognosis.
Extra-osseous
plasmacytoma is usually
found in the upper
respiratory tract, especially
in the nasal cavity and
sinuses, nasopharynx and
larynx.
The clinical features of multiple myeloma are

1. Due to tumor cells causing bone lesions:
Resorption of bone: this results in pathologic fractures, chronic bone pain and
tenderness.
Compression: lesion in the vertebra may compress the spinal cord nerve root.
Hypercalcemia.
Pallor: due to anemia and result in weakness and fatigue.
2. Production of M-proteins (increased immunoglobulins):
Bleeding tendency
Coagulation abnormalities
Amyloidosis of the AL type.
3. Humoral immune deficiency: humoral immune deficiency predisposes to recurrent
bacterial infections.
4. Renal disease: renal insufficiency, infections or nephrotic syndrome.
PLASMACYTOMA
Localized proliferation forms a single discrete plasma cell tumor in bone (usually) or soft
tissue.
Solitary plasmacytoma of bone (osseous plasmacytoma)
Extra-osseous (extramedullary) plasmacytoma
IMMUNOGLOBULIN DEPOSITION DISEASE

Primary Amyloidosis
Plasma cell neoplasm secretes abnormal immunoglobulin light chains, which may get
deposited in tissues and form a -pleated sheet structure (AL amyloid).
MONOCLONAL GAMMOPATHY OF
UNCERTAIN SIGNIFICANCE (MGUS)
MGUS: prognosismost of
the patients remain stable.
Presence of serum M protein concentration lower than 3 g/dL.

Bone marrow clonal plasma cells less than 10% in an asymptomatic patient.
Etiology: may represent an early stage of myeloma development.
Clinical manifestations: asymptomatic.
Lymphoid Neoplasms
13
CHAPTER
CLASSIFICATION OF LYMPHOID
NEOPLASMS (TABLE 13.1)
TABLE 13.1: WHO classification of the lymphoid neoplasms (2008)
I. PRECURSOR LYMPHOID NEOPLASMS

B lymphoblastic leukemia/lymphoma
T lymphoblastic leukemia/lymphoma
Majority (80 to 85%) of

lymphoid neoplasms are of
B cell origin and remaining
of T cell/NK cell type.
II. MATURE B CELL NEOPLASMS

Chronic lymphocytic leukemia/small lymphocytic lymphoma

B cell prolymphocytic leukemia
Splenic B cell marginal zone lymphoma
Hairy cell leukemia
Lymphoplasmacytic lymphoma
Heavy chain disease
Plasma cell neoplasm
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B cell lymphoma
Burkitt lymphoma
III. MATURE T AND NK CELL NEOPLASMS

T cell prolymphocytic leukemia

T cell large granular lymphocytic leukemia
Mycosis fungoides
Szary syndrome
Peripheral T cell lymphoma, NOS
Angioimmunoblastic T cell lymphoma
Anaplastic large cell lymphoma
Adult T cell leukemia/lymphoma
Extranodal NK/T cell lymphoma, nasal type
IV. HODGKIN LYMPHOMA

Classical Hodgkin lymphoma
Nodular sclerosis classical Hodgkin lymphoma
Mixed cellularity classical Hodgkin lymphoma
Lymphocyte-rich classical Hodgkin lymphoma
Lymphocyte depleted classical Hodgkin lymphoma
Nodular lymphocyte predominance Hodgkin lymphoma
Lymphoid neoplasms:
most resemble some stage
of B or T cell differentiation.
Lymphoid neoplasms:
second most common
malignant tumor in HIV.
Lymphoid neoplasms:
about 1/3rd arise from
extranodal sites.
T-cell lymphoblastic
lymphoma or Burkitt
lymphoma usually seen in
childhood.
82
WHO classification of lymphoid neoplasms depends on clinicopathological and immunological profile (Table 13.2) and has clinical and therapeutic importance.
TABLE 13.2: Cell type and its antigens detected by monoclonal antibodies
Cell type
Antigen detected
T cell
CD1, CD3, CD4, CD5, CD8
B cell
CD10, CD19, CD20, CD21, CD23, CD79a
Monocyte or macrophage
CD11c, CD13, CD14, CD15, CD33, CD64
NK cell
CD16, CD56
Stem cell and progenitor cell
CD34
All leukocytes
CD45 (LCA)
Abbreviations: CD, cluster designation; NK, natural killer; LCA, leukocyte common antigen
Q. Write short notes on follicular

lymphoma.
FL: arises from follicle

center B cells.
FOLLICULAR LYMPHOMA (FL)

Composed of follicle center (germinal center) B cells of lymphoid follicles (centrocytes and
centroblasts).
Morphology
Gross
Involves lymph nodes, spleen and bone marrow.
Architecture of lymph node is lost; frequently infiltrate the perinodal tissue (Fig. 13.1).
Microscopy
FL: centrocytes and
centroblasts form poorly
defined follicles.
Follicular (nodular) growth pattern, neoplastic follicles are poorly defined (Fig. 13.2).
Two types of B cells.
Centrocytes (small cleaved cells)
Cleaved nuclei
Inconspicuous nucleoli.
Centroblasts (large non-cleaved cells)
FL: grade ranges from 1 to
Round or oval nuclei with open nuclear (vesicular) chromatin
3. Grade 1 with less than 5
Multiple (1 to 3) nucleoli.
centroblasts/hpf and grade
Usually 3 times the size of lymphocyte.
3 with more than 15/hpf.
Fig. 13.1: Diagrammatic appearance of follicular lymphoma. Neoplastic follicles are seen in both the cortex
and medulla and infiltration of the perinodal tissue
Fig. 13.2: Follicular lymphoma shows nodular

aggregates of malignant lymphoid cells
Lymphoid Neoplasms CHAPTER 13
Immunophenotype: expresses CD19, CD20 (pan-B cell markers), CD10 (CALLA), surface
immunoglobulin and BCL2 protein.
Cytogenetics and molecular genetics: t (14; 18) (q32:q21), with IgH and BCL2 as partner
genes and leads to constitutive overexpression of BCL2 protein.
Clinical Features
Peak in sixth and seventh decades.
Generalized lymphadenopathy.
DIFFUSE LARGE B CELL LYMPHOMA (DLBCL)

Heterogeneous group of aggressive, neoplasm of large B cell with diffuse growth pattern.
Constitutes about 20 to 30% of NHL and 60% to 70% of aggressive lymphoid neoplasms.
Microscopy
Loss of lymph node architecture with diffuse growth pattern.
Neoplastic cells:
Large round or oval cells, 4 to 5 times of a small lymphocyte.
Moderate pale or basophilic cytoplasm
Nucleus equals or larger than the nucleus of a macrophage with different appearances.
FL: peripheral blood smear

may show lymphocytosis
[less than 20 109/L
(20,000/cu mm)].
FL: bone marrow involved

in 85%.
FL: prognosis indolent.
DLBCL: aggressive, diffuse

large B cell neoplasm.
DLBCL may involve lymph

nodes or extranodal sites.
Immunophenotype
Express pan-B cell markers such as CD19, CD20, CD22 and CD79a.
Also express germinal center markers like CD10 and BCL6.
Negative for TdT.
Cytogenetics and Molecular Profile

Translocation of BCL2 gene: t (14; 18) translocation
Mutations of the BCL6 gene.
Clinical Features
More common between 65 and 70 years of age.
Slight male preponderance.
Rapidly enlarging mass at a single or multiple nodal or extranodal sites.
BURKITT LYMPHOMA (BL)

Highly aggressive B cell neoplasm, often presents as extranodal lymphoma or as an acute
leukemia.
Composed of medium-sized, monomorphic lymphoid cells with basophilic vacuolated
cytoplasm.
DLBCL: prognosis
aggressive and rapidly fatal
if untreated.
Q. Write short notes on Burkitt

lymphoma.
83
84
Clinical Variants
BL: aggressive B cell

lymphoma, 3 clinical
variants. Endemic: involves
jaw and associated with
EBV.
BL: medium sized B cells.

Starry sky pattern.
Endemic (African) Burkitt lymphoma (BL):

Occurs in Africa, affects children and adolescents.
Associated with Epstein-Barr virus infection and malaria.
Usually involves the jaw and present as a mandibular mass.
Sporadic (nonendemic) BL:
Occurs in children or young adults.
Abdominal mass and involves ileocecum and peritoneum.
Immunodeficiency-associated (HIV) BL:
Involves lymph nodes and bone marrow.
Microscopy
Burkitt lymphomas, irrespective of the categories, are histologically similar.
Lymph node shows loss of architecture.
Involved tissues show diffuse infiltrate of monotonous medium-sized lymphoid cells (Figs
13.3 and 13.4).
Appearance of neoplastic lymphoid cells:
Medium-sized cells.
Round or oval nuclei having clumped coarse chromatin with several (2 to 5) nucleoli.
Moderate amount of deeply basophilic cytoplasm, multiple, small, round lipoid (clear)
vacuoles which stain positive with oil red O.
Numerous mitotic figures.
Starry sky pattern: tumor cells undergo apoptosis and nuclear remnants of these apoptotic
cells are phagocytosed and cleared by benign macrophages. These macrophages in the
background of lymphoid cells creates starry sky appearance (Figs 13.3 and 13.4).
Fig. 13.3: Burkitt lymphoma composed of medium-sized lymphoid cells admixed

with benign macrophages giving a starry sky appearance
Fig. 13.4:Diagrammatic appearance of Burkitt lymphoma

composed of medium-sized lymphoid cells admixed with
benign macrophages giving a starry sky appearance
Lymphoid Neoplasms CHAPTER 13
Immunophenotype
Express surface IgM, monotypic or light chain.

Positive for common B cell antigens (CD19, CD20, and CD22).
Positive for CD10 and BCL6.
BCL2 negative.
Cytogenetic and Molecular

Genetic Features (Fig. 13.5)
Translocations of c-MYCgene
BL: translocation of c-MYC

gene.
MYC (c-MYC) is a proto-oncogene-on chromosome 8.

Most common translocation t (8:14) (q24; q32).
Translocations of c-MYC gene, converts proto-oncogene into MYC oncogene, which
leads to overexpression of MYC protein (oncoprotein). This causes uncontrolled cell BL: prognosisvery
aggressive but responds
proliferation and stimulation of apoptosis.
well chemotherapy.
Mutations inactivate p53.
Poor prognostic factors:
Involvement of blood, bone marrow and central nervous system.
Bulk of the disease-unresected tumor of more than 10 cm in diameter.
High serum LDH levels.
Presence of residual disease after excision.
Fig. 13.5: Chromosomal translocation and activated MYC oncogene in Burkitt lymphoma
MATURE T CELL AND NK CELL NEOPLASMS

Peripheral T Cell Lymphoma (PTCL), NOS
Mainly involves lymph node.
Peripheral T cell tumors

constitute less than 15% of
non-Hodgkin lymphomas.
NK cell tumors very rare.
85
86
PTCL: clinical features

Fifth to seventh decade.
Generalized
lymphadenopathy.
Microscopy
PTCL: prognosishighly
aggressive with a poor
response to therapy.
Immunophenotype
Mycosis fungoides and

Szary syndrome: T cell
neoplasms with skin
involvement.
Mycosis fungoides has
three stages:
1. Patch stage
2. Plaque stage
3. Tumor stage.
Immunophenotype:
Express pan-T-CD2+, CD3+
and CD5.
Szary cells are neoplastic

T cells with cerebriform
nuclei.
Lymph node with effacement of the normal architecture.

Paracortical or diffuse infiltration by neoplastic T cells.
Neoplastic T cells
Small, intermediate to large cells with sparse or abundant; clear, eosinophilic or
basophilic.
Vesicular or hyperchromatic nuclei, prominent nucleoli.
Lack TdT (expressed by immature T cells).

Express pan-T cell-CD2, C3, CD5 and either or T cell receptors (TCR).
Mycosis Fungoides
Cutaneous T cell lymphoma
Lymphoid cells with irregular nuclear outlines
Limited to skin.
Age: most are adults or elderly.
Microscopy
Epidermis (epidermotropism) and upper dermis is infiltrated by neoplastic T cells.
Groups of neoplastic cells in the epidermisPautriers microabscess.
Tumor cells have convoluted (cerebriform) nuclear contours.
Szary Syndrome
Rare disease and is defined by the triad namely:

1. Widespread exfoliative erythroderma
Immunophenotype: tumor
2. Generalized lymphadenopathy
cells express-CD2+, CD3+
3. Presence of characteristic Szary cells in the skin, lymph nodes and peripheral blood.
and CD5+.
Prognosis: aggressive disease and most die of opportunistic infections.
Hodgkin
Lymphomas
DEFINITION
HL: Malignant lymphoid neoplasms with following characteristics:
Minority (13%) of specific neoplastic cells (Hodgkin cells and Reed-Sternberg cells).
Majority background of reactive non-neoplastic cells.
Usually involves lymph nodes.
Majority occurs in young adults.
CLASSIFICATION (TABLE 14.1)
14
CHAPTER
Hodgkin
lymphoma synonym:
Hodgkin disease.
Q. Classify Hodgkin lymphoma.
Hodgkin lymphoma (HL) is broadly divided into two types, which differ in clinical features,
behavior, morphology and immunophenotype.
Cell of Origin and Immunophenotype

Classical Hodgkin lymphoma
Cell of origin: germinal center or post-germinal center B cell
Immunophenotype: CD15 and CD 30 positive
Nodular lymphocyte predominant Hodgkin lymphoma
Cell of origin: germinal center B cell at the centroblastic stage of differentiation.
Immunophenotype: CD15 and CD30 negative.
TABLE 14.1: WHO classification (2008) of Hodgkin lymphoma
Classical Hodgkin lymphoma (CHL)
Nodular sclerosis classical Hodgkin lymphoma (NSCHL)

Mixed cellularity classical Hodgkin lymphoma (MCCHL)
Lymphocyte-rich classical Hodgkin lymphoma (LRCHL)
Lymphocyte depleted classical Hodgkin lymphoma (LDCHL)
Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)
HL is mainly divided into:

1. Classical and
2. Nodular lymphocytic
Hodgkin lymphoma.
Classical HL: CD15 + and

CD30 +,
NLPHL: CD15-,CD 30-,
CD20+, and CD 45+.
88
Q. Write short note on RS cell and

its variants.
MORPHOLOGY OF NEOPLASTIC CELLS

Reed-Sternberg (RS) Cells are neoplastic cells (Fig. 14.1) pathognomonic of Hodgkin
lymphoma.
Appearance and description of diagnostic Reed-Sternberg cells and its variants are shown
in Figure 14.2.
Various types of cells found in Hodgkin lymphoma are listed in Table 14.2.
TABLE 14.2: Types of cells found in Hodgkin lymphoma
HL: majority are nonneoplastic cells and

minority are neoplastic
cells.
Non-neoplastic cells
Neoplastic cells
Reactive lymphocytes
Reed-Sternberg cells (classical)
Macrophages/histiocytes
Variants
Granulocytes
Eosinophils
Neutrophils
Plasma cells
Mononuclear
Lacunar
Mummified
Anaplastic/pleomorphic
Lymphocyte predominant (LP) cell/popcorn
CLASSICAL HODGKIN LYMPHOMA

Classical Hodgkin lymphoma (CHL) account for 95% of Hodgkin lymphomas and has 4 subtypes.
Q. Write short note on nodular
sclerosis HL.
Nodular Sclerosis Classical

Hodgkin Lymphoma (NSCHL)
Nodular sclerosis is the

most common subtype
of CHL. Lacunar cells are
commonly seen.
Subtype of CHL characterized by collagen bands that surround nodules and have lacunar cell
variant of Reed-Sternberg cells.
Most common: 40% to 70% of cases.
Most between 20 and 30 years of age with equal frequency in males and females.
Rarely associated with EBV.
Involves mediastinal lymph nodes.
Fig. 14.1: Microscopic appearance of Hodgkin lymphoma showing RS

cells (short arrow and inset) and Hodgkin cells (long arrow) within the
background of mixed population of reactive cells
Hodgkin Lymphomas
CHAPTER 14
Classical RS cell is
binucleated with owl-eyed
nuclei having mirror image
appearance.
Lacunar cell has clear

cytoplasm and seen in
nodular sclerosis CHL.
LP/popcorn cell is seen

in nodular lymphocyte
predominant HL.
Fig. 14.2: Diagrammatic appearances and characteristic features of Reed-Sternberg cells and its variants
Microscopy of NSCHL (Fig. 14.3)
NSCHL
Nodules separated by
Loss of lymph node architecture.
broad bands of collagen
Sclerosis and nodules: broad collagen bands (sclerosis) divide the lymphoid tissue into CD15+,CD30+, EBV-ve
and CD 45-ve.
nodules of varying sizes and shapes.
Presence of lacunar cell.

Background: small T lymphocytes, eosinophils, plasma cells, and macrophages.
Immunophenotype
RS cells are CD15+ and CD30+; CD45- and T cell markers negative.
EBV negative.
NSCHL Prognosis: better

than other types of CHL,
with a cure rate of 80% to
85%.
89
90
Fig. 14.3: Nodular sclerosis classical Hodgkin lymphoma with nodules

separated by bands of collagen. Also seen are lacunar cells and RS cells
in each nodule within the background of lymphocytes, eosinophils,
plasma cells and macrophages
Q. Write short note on Mixed

cellularity HL.
MCCHL: scattered classical

RS cells and mixed
inflammatory background,
CD15+, CD30+ and EBV+.
Fig. 14.4: Mixed cellularity classical Hodgkin lymphoma with classical

RS cells, Hodgkin cells in the background of mixed cellular population
consisting of lymphocytes, eosinophils, plasma cells and macrophages
Mixed Cellularity Classical Hodgkin Lymphoma (MCCHL)
Second common subtype: 20% to 25% of cases

More common in males
Strongly associated with EBV
Older age, with systemic symptoms (such as night sweats and weight loss) and advanced
tumor stage
Involves peripheral lymph nodes.
Microscopy of MCCHL (Fig. 14.4)

MCCHL: prognosisvery
good.
Lymph node architecture obliterated

Plenty of Reed-Sternberg cells and Hodgkin cells
Back ground: small lymphocytes, eosinophils (sometimes numerous), neutrophils,
plasma cells and benign macrophages (histiocytes).
Immunophenotype: RS cells are CD15+, CD30+ and EBV+ (about 70%).
Lymphocyte-rich Classical Hodgkin Lymphoma (LRCHL)
Subtype of classical Hodgkin lymphoma with scattered Hodgkin and RS cells.

Uncommonabout 5% of classical HL.
More in elderly patients, associated with EBV in 40% of cases.
Involves peripheral lymph nodes.
Hodgkin Lymphomas
Microscopy of LRCHL (Fig. 14.5)
CHAPTER 14
LRCHL:
Uncommon
Few RS cells
Abundant lymphocytes
CD15+, CD30+, CD45and CD20-.
Growth patterns: may show two patterns

Nodularcommon
Diffuserare
Only few Reed-Sternberg cells and Hodgkin cells
Background: abundant reactive small lymphocytes.
Immunophenotype: CD45, CD20, CD15+ and CD30+.
LRCHL: prognosisgood
to excellent prognosis.
Lymphocyte-depleted Classical
Hodgkin Lymphoma (LDCHL)
Subtype of classical Hodgkin lymphoma rich in Hodgkin and RS cells in a background
depleted in non-neoplastic lymphocytes.
Rarestless than 5% of cases
Predominantly in older, HIV-positive patients, often EBV-associated (over 90%)
Predominantly retroperitoneal lymph nodes, abdominal organs and bone marrow.
LDCHL:
Rarest
Paucity of lymphocytes
Plenty of RS cells
CD15+, CD30+; majority
are EBV+.
Microscopy of LDCHL (Fig. 14.6)

Paucity of lymphocytes.
Plenty of RS cells or their anaplastic/pleomorphic variants.
Histological types
Reticular: numerous Hodgkin and RS cells with depletion of lymphocytes.
Diffuse sclerosis/fibrosis: hypocellular infiltrate containing bizarre RS cells with fine
fibrosis.
LDCHL: prognosis
Immunophenotype: RS cells are CD15+, CD30+; majority are EBV+.
Fig. 14.5: Lymphocyte-rich classical Hodgkin lymphoma. One RS cell is

seen in a background of many small lymphocytes and few histiocytes
outcome less favorable

than with other subtypes.
Fig. 14.6: Lymphocyte-depleted classical Hodgkin lymphoma with

the pleomorphic variant of RS cells surrounded by fibrous tissue
91
92
NODULAR LYMPHOCYTE PREDOMINANT

HODGKIN LYMPHOMA (NLPHL)
NLPHL:
Uncommon
Abundant lymphocytes
LP cells
No Hodgkin/RS cells
CD20+, CD 45+ and
CD15 -, C30- and
EB -ve.
Uncommon5% of all Hodgkin lymphomas.

Not associated with EBV.
Majority males, usually 3050 year of age.
Involves mainly cervical or axillary lymph nodes.
Microscopy of NLPHL (Fig. 14.7)

Loss of lymph node architecture.
Nodular and/or diffuse infiltrate of abundant small lymphocytes with histiocytes and
scattered LP cells.
Lymphocyte predominant cells (LP cells)/"popcorn" cells (Fig. 14.2):
Specific to NLPHL.
Large with relatively abundant, pale cytoplasm.
Single large delicate multilobulated nucleus or folded nuclei resembling bubbly outlines
of popcorn kernels.
One or more inconspicuous nucleoli.
Hodgkin and RS cells are not found.
Immunophenotype: LP cell are CD20+, CD 45+ and CD15, C30 and EBVve. Express
BCL6.
NLPHL: prognosismore
likely to recur than the
classical subtypes, but the
prognosis is very good.
Fig. 14.7: Nodular lymphocyte predominant Hodgkin lymphoma with popcorn

cells in a background of reactive lymphocytes and few macrophages
Hodgkin Lymphomas
CHAPTER 14
ETIOLOGY AND PATHOGENESIS OF

HODGKIN LYMPHOMA
EBV: previous EBV infection (infectious mononucleosis) risk of HL.
Genetic factors: HLA-B18 higher in HL.
Immune status: HL more frequent in immunocompromised patients and autoimmune
diseases (e.g. rheumatoid arthritis).

EBV and HL: HL is associated with EBV infection.
Activation of nuclear factor (NF-B) common event in classical HL rescue germinal
center B cells from apoptosis produces Reed-Sternberg cells.
Accumulation of reactive cells in response to cytokines (such as IL-5, IL-6 and TGF-) and
chemokines secreted by Reed-Sternberg cells.
LABORATORY FINDINGS
Peripheral smear:

WBCs: leukocytosis occurs in 1/3rd of the patients. Eosinophilia is frequent.
Platelets: normal or increased.
ESR: raised.
Bone marrow: involved in
the later stages.
Fine Needle Aspiration Cytology (FNAC)

RS cells/its variants against a background of inflammatory cells (depending on the subtype).
Clinical features:
Painless enlargement of
lymph nodes.
Systemic/constitutional
symptoms: fever, night
sweats and weight loss.
Fig. 14.8: Pathogenetic mechanism and interaction of various cell types in Hodgkin lymphoma
HL: Pel-Ebstein fever

is characterized by
alternating bouts of fever
followed by remissions.
93
94
Spread
Mainly by contiguity
First nodal disease then splenic disease, hepatic disease and finally marrow
involvement and extranodal disease.
STAGING OF HODGKIN LYMPHOMA (TABLE 14.3)

TABLE 14.3: Clinical staging of Hodgkin lymphomas (Cotswold revision of Ann Arbor staging
classification)
Stage
Definition
Involvement of a single lymph node region or lymphoid structure (e.g. spleen, Waldeyer ring, thymus)
II
Involvement of two or more lymph node regions on the same side of the diaphragm (the mediastinum
is a single site; hilar lymph nodes are lateralized); the number of anatomic sites should be indicated by
suffix (e.g. II3)
III
Involvement of lymph node regions or structures on both sides of the diaphragm

III1 With or without splenic, hilar, celiac or portal nodes
III2 With para-aortic, iliac or mesenteric nodes
IV
Involvement of extranodal site(s) beyond those designated E
Einvolvement of a single extranodal site, or contiguous or proximal to known nodal site of disease
DIFFERENCES BETWEEN HODGKIN

LYMPHOMA AND NON-HODGKIN LYMPHOMA
HL differs from NHL in several respects and their main differences are shown in Table 14.4.
HL and NHL.
HL: extranodal
involvement uncommon.
TABLE 14.4: Differences between Hodgkin and non-Hodgkin lymphomas

Sl. No. Characteristics
Hodgkin lymphoma
Non-Hodgkin lymphoma
1.
Site of involvement
Arises in a single node or

chain of nodes (cervical,
mediastinal, para-aortic)
Mainly involves multiple

peripheral nodes
2.
Pattern of spread
Orderly spread by contiguity

in a predictable fashion
Noncontiguous spread in an
unpredictable fashion
3.
Mesenteric nodes and Waldeyer ring
Rarely involved
Commonly involved
4.
Extranodal involvement
Uncommon
Common
5.
Characteristic of neoplastic cells
Neoplastic cellsHodgkin
or Reed-Sternberg cells form
minor tumor cell mass (15%)
Neoplastic cells form the

major tumor cell mass
Langerhans Cell
Histiocytosis/
Histiocytosis X
15
CHAPTER
INTRODUCTION
Histiocytic and dendritic cell neoplasms
Clonal proliferative disorder arising from Langerhans cells
Langerhans cell histiocytosis (LCH) spectrum ranges from unifocal to multifocal and
unisystem to multisystem disease.
MORPHOLOGY
Light microscopy: the characteristic feature is proliferations of Langerhans cells.
These are large cells 1015 m in diameter, moderate slightly eosinophilic cytoplasm
folded, indented, grooved or lobulated nucleus having fine chromatin.
Background: mixed background of eosinophils, histiocytes (mononuclear and Langerhans cell contains
multinuclear), neutrophils and small lymphocytes.
pathognomonic Birbeck
Electron microscopy: Langerhans cell contains pathognomonic Birbeck granulestennis granules.
racket-like shape, with a zipper-like appearance.
Immunological markers: express CD1a, langerin and S-100 protein.
LABORATORY FINDINGS
Peripheral blood: pancytopenia (anemia, neutropenia and thrombocytopenia).
Bone marrow: extensive infiltration by histiocytes.
Prognosis: depends on the age at presentation, extent of disease and rate of progression.
Groups: depending on the site involved and distribution of lesion, LCH can be divided into
three groups (Table 15.1).
96
TABLE 15.1: Types of Langerhans cell histiocytosis

Terminology/site
Involved tissue/ organ
Clinical features
Eosinophilic granuloma
Localized to a single site/solitary
(unifocal)
Bone and adjacent soft issue (skull,

femur, vertebra, pelvic bones and
ribs). Less commonly lymph nodes
Usually seen in older children or

adults. Presents with lytic bone
lesion
Hand-Schller-Christian disease
Multiple sites within a single
system (multifocal unisystem)
Usually bone and soft issue
Usually seen in young children

Multiple destructive bone lesions
with adjacent soft tissue masses
Letterer-Siwe disease
Disseminated and multisystemic
disease (multifocal multisystem
disease)
Skin, bone, liver, spleen and bone

marrow
Usually seen in infants.

Present with fever, cytopenias,
skin and bone lesions and
hepatosplenomegaly
SECTION
Disorders of
Hemostasis
Disorders of
Primary Hemostasis
16
CHAPTER
NORMAL HEMOSTASIS
Platelet sequence in
hemostasis: platelet
Hemostasis is the bodys response to vascular damage/injury.
adhesion release of
granule contents
Includes several sequences of events at the site of vascular injury. They are as follows:
platelet aggregation
primary (temporary)
hemostatic plug
activation of coagulation
system fibrin
Platelet adhere to subendothelial structures at the site of injury. The platelets change their secondary (permanent)
shape and release granule contents. The released contents cause platelet aggregation and hemostatic plug.
Primary Hemostatic Plug

form primary hemostatic plug.
Secondary Hemostatic Plug

Exposure of tissue factor at the site of vascular injury activates the extrinsic coagulation
system. The fibrin formed develops into a secondary hemostatic plug.
CLASSIFICATION OF HEMOSTATIC
DISORDERS (TABLE 16.1)
1. Bleeding disorders (hemorrhagic disorders/hemorrhagic diathesis): bleeding disorders
have an abnormal tendency to bleed (hemorrhage) due to failure of hemostasis.
2. Thrombotic disorders: they cause thrombus formation.
BLEEDING DISORDERS CAUSED BY

VESSEL WALL ABNORMALITIES
Vascular purpura (nonthrombocytopenic purpura) is group of disorders of blood vessels
that results in bleeding. They should be distinguished from bleeding disorders due to
abnormalities of platelets.
Q. Classify bleeding disorders.
100
SECTION 3 Disorders of Hemostasis
Hemostatic disorders
are broadly classified as
bleeding disorders and
thrombotic disorders.
Bleeding disorders may be
due to
Diseases of blood
vessels
Platelet disorders
Coagulation disorders.
Vascular purpuras
are also known as
nonthrombocytopenic
purpuras.
TABLE 16.1: Classification of disorders of hemostasis

1. Bleeding disorders
Disorders of primary hemostasis
Vessel wall abnormalities
Congenital, e.g. Ehlers-Danlos syndrome
Acquired, e.g. Henoch-Schnlein purpura
Platelet abnormalities
Quantitative: thrombocytopenia (e.g. ITP, drug-induced, congenital)
Qualitative: platelet function disorders
-- Inherited, e.g. Glanzmann thrombasthenia, Wiskott-Aldrich syndrome, Bernard Soulier
syndrome
-- Acquired, e.g. Uremia, drugs
Disorders of coagulation system (disorders of secondary hemostasis)
Congenital: hemophilia A, B; von Willebrand disease; other coagulation factor deficiencies [XI, VII, II, V, X]
Acquired: vitamin K deficiency, liver disease, disseminated intravascular coagulation
2. Thrombotic disorders
Inherited
Deficiency of antithrombotic factors: antithrombin III deficiency, protein C deficiency, protein S

deficiency
Increased prothrombotic factors: activated protein C (APC) resistance (Factor V mutation/factor
V Leiden)
Prothrombin (G20210A mutation)
Acquired: fibrinolytic system defects
Classification of bleeding disorders caused by vessel wall abnormalities are presented in

Table 16.2.
TABLE 16.2: Classification of bleeding disorders caused by vessel wall abnormalities
Acquired disorders
Senile purpura is due to
vessel instability.
Henoch-Schnlein purpura
is characterized by
hypersensitivity vasculitis
and palpable purpura.
1. Due to decreased amount of connective tissue

Senile purpura
Scurvy
Cushing syndrome and steroid therapy
2. Due to vasculitis
Henoch-Schnlein purpura
Infections
Drug reactions
3. Associated with plasma cell neoplasms
Amyloidosis
4. Miscellaneous
Simple easy bruising
Congenital/inherited disorders
Hereditary hemorrhagic telangiectasia
Ehlers-Danlos syndrome
Marfan syndrome
BLEEDING DISORDERS DUE TO

ABNORMALITIES OF PLATELET
Classification of Platelet Disorders (Table 16.3)
THROMBOCYTOPENIA
Decrease in the platelet count below the lower limit of 150,000/cu mm (150 109/L).
Disorders of Primary Hemostasis CHAPTER 16
TABLE 16.3: Classification of platelet disorders

Quantitative platelet disorders
Thrombocytopenia
Increased destruction
Sequestration
Decreased production
Dilutional
Thrombocytosis
Qualitative platelet disorders

Hereditary
Defective adhesion of platelets

Defective platelet aggregation
Acquired
Disorders of platelet secretion
Clinical Features of Thrombocytopenia

Cutaneous bleeding appears as pinpoint hemorrhages (petechiae) and ecchymoses.
Mucosal bleeding.
Intracranial bleed (subarachnoid and intracerebral hemorrhage) rare but serious.
Severity of Bleeding
Post-traumatic bleedingwhen the platelet count is 20,000 to 50,000/cu mm
Spontaneous bleedingwhen the platelet count falls below 20,000/cu mm
Intracranial bleedingwhen platelet count is <10,000/cu mm.
Petechiae are pinpoint

hemorrhages seen only
with thrombocytopenia.
Intracranial bleeding
occurs-when platelet
count is <10,000/cu mm.
Causes of Thrombocytopenia (Table 16.4)

TABLE 16.4: Causes of thrombocytopenia
1. Increased platelet destruction
Immune mediated
Autoimmune
Primary: immune thrombocytopenic purpura (acute and chronic)
Secondary: systemic lupus erythematosus, B cell lymphoid neoplasms
Alloimmune: post-transfusion or pregnancy
Drug-induced: quinidine, heparin, sulfa compounds
Infections: HIV infection, infectious mononucleosis, cytomegalovirus
Non-immune mediated
Disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura, hemolytic uremic syndrome
Mechanical destruction: prosthetic heart valves, malignant hypertension
Microangiopathic hemolytic anemias
2. Decreased production of platelets
Generalized primary diseases of bone marrow: aplastic anemia (congenital and acquired)
Bone marrow invasion/infiltration: leukemia, disseminated cancer
Selective impairment of platelet production
Drug-induced: alcohol, thiazides, cytotoxic drugs
Infections: measles, human immunodeficiency virus (HIV)
Ineffective megakaryopoiesis
3. Sequestration
Hypersplenism
4. Dilutional
ITP is the most common

form of thrombocytopenia.
101
102
IMMUNE THROMBOCYTOPENIC PURPURA

Most common form of thrombocytopenia.
Due to increased destruction of platelets by immune mechanismsmainly autoimmune
mechanism.
Types of Immune Thrombocytopenic Purpura (ITP)

Acute Immune Thrombocytopenic Purpura
Acute ITP is seen mainly
in children between 2 to
4 years.
Acute ITP: autoimmune

disease, sudden onset,
shorter duration and
usually resolves within 6
months.
Chronic ITP: autoimmune

disease and the antibodies
are directed against
glycoprotein IIb/III a of
platelets.
Spleen is the major site of

destruction of platelets
and important site of
autoantibody synthesis.
ITP: splenomegaly and

lymphadenopathy are
uncommon and in their
presence one should
consider the diagnosis
other than ITP.
Self-limited disease.
Children: 2 to 4 years and seen equally in both sexes.
Presents 1 to 3 weeks after viral (measles, rubella, EBV)
infection.
Platelet destruction by antiplatelet autoantibodies.
Platelet count is decreased, sometimes even below
10,000/cu mm (10 109/L).
Clinical Features
Sudden onset.
Petechiae, gum bleeding, epistaxis and mild fever.
Usually resolve spontaneously within 6 months.
Excellent prognosis.
Chronic Immune Thrombocytopenic Purpura

Persistent thrombocytopenia for more than 6 to 12
months
Indolent, females are more affected than males (F:M=3:1).
More common and usually seen in adults (20 to 40
years).
Pathogenesis of ITP (Fig. 16.1)
Autoimmune disorder characterized by formation of
antiplatelet antibodies, directed against membrane
glycoproteins (most often IIb-IIIa or Ib-IX of platelets).
Antiplatelet antibodies in about 80% of patients and are
of the IgG type.
Antiplatelet antibodies act as opsonins and are
recognized by IgG Fc receptors present on mononuclear
phagocytes of RE system (mainly spleen) and are
destroyed there resulting in thrombocytopenia.
Splenectomy causes marked improvement in 75% to
80% of patients.
Clinical Features
More common in females (F:M ratio is 3:1).
Age between 20 and 40 years.
Clinical features are due to thrombocytopenia: skin
bleeding, mucosal bleeding, menorrhagia in females,
etc.
Fig. 16.1: Pathogenesis of idiopathic

thrombocytopenic purpura
Disorders of Primary Hemostasis CHAPTER 16
Laboratory Findings

findings in ITP.
Peripheral Blood
Platelet count: markedly reducedbelow 80,000/cu mm (80 109/L).
Hemoglobin: ranges from 7 to 12 g/dL.
Peripheral smear
Platelets: markedly reduced (thrombocytopenia) and abnormally large sized platelets (megathrombocytes/giant platelets).
RBCs: chronic blood loss (e.g. menorrhagia) due to ITP may lead to microcytic hypochromic
anemia.
WBCs: normal.
Bone Marrow
Megakaryopoiesis:
Moderate increase in number (Fig. 16.2) of both immature and mature forms of megakaryocytes.
Immature megakaryocytes predominate-large nonlobulated single nuclei and basophilic
cytoplasm (Fig. 16.3).
Erythropoiesis:
Prolonged bleeding may cause anemia leading to normoblastic erythroid hyperplasia.
Constant bleeding leads to iron deficiency and micronormoblastic erythroid hyperplasia.
Storage iron: severe and chronic bleeding causes iron deficiency with reduced iron stores.
ITP: platelets markedly

reduced below 80,000/
cu mm.
Bone marrow in chronic

ITP shows megakaryocytic
hyperplasia with immature
megakaryocytes.
ITP: bone marrow

decreased megakaryocytesagainst the
diagnosis of ITP.
ITP: bleeding time

prolonged
PT and APTT normal.
Bleeding time (BT): prolonged, but PT and PTT are normal.

Tourniquet test: positive.
Clotting time (CT): normal.
Tests for platelet autoantibodies: may be positive.
Spleen: normal size.
3
Fig. 16.2: Bone marrow in ITP showing moderate increase in number of
megakaryocytes (arrows)
Fig. 16.3: Diagrammatic appearance of megakaryocytes in

different stages of maturation (1-immature to 3-mature)
103
104
THROMBOCYTOSIS
Platelet count more than 4,50,000/cu mm is known as thrombocytosis.
Causes: various causes of thrombocytosis are shown in Table 16.5.
TABLE 16.5: Causes of thrombocytosis
Idiopathic/primary (autonomous production)
Essential thrombocytosis
Polycythemia vera
Secondary (reactive thrombocytosis)
Iron deficiency
Malignancy
Following hemorrhage
Following splenectomy
QUALITATIVE PLATELET DISORDERS

Classification of platelet functional (qualitative) disorders are presented in Figure 16.4 and
Table 16.6.
Fig. 16.4: Functional disorders of platelet
TABLE 16.6: Classification of platelet functional (qualitative) disorders

A. Hereditary
Aspirin blocks the cyclooxygenase enzyme of
platelets and prevents
aggregation of platelets.
1. Disorders of platelet adhesion: Bernard-Soulier syndrome

2. Disorders of platelet secretion: storage pool deficiency
3. Disorders of platelet aggregation: Glanzmann thrombasthenia
B. Acquired
1. Drugs: aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), dipyridamole, sulfinpyrazone
2. Renal failure: uremia
3. Hematologic malignancies: myeloproliferative neoplasms and myelodysplastic syndromes
Bleeding Disorders:
Due to Abnormalities of
Coagulation/Clotting
Factor
INTRODUCTION
Bleeding due to coagulation disorders must be distinguished from those due to platelet/
vascular disorders (Table 17.1).
TABLE 17.1: Distinguishing patterns of bleeding in platelet/vascular and coagulation disorders
Characteristics
Platelet/vascular disorders
Coagulation disorders
Onset
Spontaneous and develops

immediately after trauma/surgery
Delayed bleeding after trauma/

surgery
Type of lesion
Petechiae, ecchymoses
Hematomas
Sites
Skin, mucous membrane
Deep tissues
Mucous membrane
Common from nose, mouth,

gastrointestinal and genitourinary
tracts
Uncommon except from

gastrointestinal or genitourinary tract
Into the joint
Absent
Common in severe factor deficiencies
Into the muscle
Following trauma
Spontaneous
CLASSIFICATION OF COAGULATION
DISORDERS (TABLE 17.2)
TABLE 17.2: Classification of coagulation disorders
A. Hereditary coagulation disorders
1. Hemophilia A
3. von Willebrand disease
2. Hemophilia B
4. Others
B. Acquired (secondary) coagulation disorders

1. Vitamin K deficiency
3. Others
2. Liver disease
17
CHAPTER
106
HEREDITARY COAGULATION DISORDERS

Usually, due to deficiency of single coagulation factor.
vWF is synthesized by
endothelial cells and
megakaryocytes.
Factor VIII-vWF Complex
Factor VIII-vWF complex has two components:

Plasma factor VIII
von Willebrand factor.
vWF may be located in the vWF protects factor VIII and important for its stability. Subendothelial vWF promotes
plasma and subendothelial
platelet adhesion.
tissue.
Whenever there is vascular endothelial injury, plasma vWF gets adsorbed to exposed
subendothelial matrix and augments adhesion of platelets.
Three common hereditary
disorders are:
1. Hemophilia A
(deficiency of factor VIII)
2. Hemophilia B
(deficiency of factor IX)
3. von Willebrand disease
(deficiency of vWF).
HEMOPHILIA
Hemophilia A and B are similar in both clinical and pathological features, the difference
being in the deficient factor.
Both are sex-linked recessive disorders resulting in inherited deficiency of the clotting
factor or synthesis of a defective clotting factor.
Males are affected and females are carriers.
HEMOPHILIA A (FACTOR VIII DEFICIENCY)
Common hereditary X-linked recessive disease.

About 30% of hemophiliacs may be due to acquired mutations.
Reduced amount or activity of factor VIII is associated with life-threatening bleeding
Bleeding is due to both inadequate coagulation and inappropriate clot removal (fibrinolysis).
Mode of Inheritance (Fig. 17.1)

Hemophilia A: X-linked
recessive disorder.
X-linked recessive disease. Genes for factor VIII are located on the long arm of the
X-chromosome.
Does not manifest when there is a normal copy of X-chromosome.
Males with a defective/mutant factor VIII gene (hemophiliac gene) on their single X
chromosome (XH) suffer from hemophilia.
Heterozygous females are carriers and do not express the full clinical disease because of
the paired normal X-chromosome.
However, females with two copies of the defective XH chromosome may rarely suffer from
hemophilia.
Molecular Genetics
Causative mutations include deletions, inversions, point mutations and insertions.
Clinical Features
Clinical severity depends on the level of factor VIII activity with normal range expressed as
percentage (Table 17.3). Severe cases have less than 1% residual factor VIII activity.
Bleeding Disorders: Due to Abnormalities of Coagulation/Clotting Factor CHAPTER 17
Hemophilia A: males are

suffers and females are
carriers.
Fig. 17.1: Mode of inheritance in hemophilia
TABLE 17.3: Factor VIII level and clinical severity in hemophilia A

Clinical severity
Level of factor VIII activity in

percentage
Clinical features
Mild
More than 6
In the mildest form, it may be

unnoticed. Bleeding develops after
trauma only
Moderate
25
Bleeding after trauma, including

dental and other surgical trauma
Easy bruising
Severe
Less than 1
Frequent and spontaneous

hemorrhage into joints
(hemarthrosis) and soft tissues
Normal range for factor

VIII: 45158 IU/dL.
Common clinical presentations include:

Frequent and spontaneous hemorrhage into the joints-hemarthrosis.
Hemorrhage into soft tissues.
Prolonged bleeding following trauma
Hemophilia A: percentage
of level of factor VIII
activity correlates with
severity of disease.
Laboratory Findings
Hemophilia A: common
presentation
Hemarthrosis
Hemorrhage into soft
tissues.
Bleeding time: normal

Clotting time: prolonged, but is not a sensitive test
Platelet count: normal
Prothrombin time: normal
Activated partial thromboplastin time (APTT): increased (normal 3040 seconds)
107
108
Hemophilia A:
decreased: factor VIII
Increased: APTT and
clotting time.
Factor VIII assay: essential for the diagnosis and to assess the levels and severity of disease
Fibrinogen assay: normal
FDP: negative
Detection of carriers: by DNA markers
To detect female carriers
Prenatal diagnosis of affected fetuses.
Complications
Causes of death
Intracranial hemorrhage
Prolonged bleeding.
Treatment
Factor VIII concentrate
Recombinant factor VIII.
Hemophilia B:
X-linked recessive
disorder
Mutation in factor IX
Deficiency of factor IX.
Hemophilia B: clinical
features
Usually milder than
hemophilia A.
Hemarthrosis is the
common presentation.
Hemophilia B:
decreased: factor IX
increased: APTT and
clotting time.
vWF: causes platelet
adhesion and prevents
degradation of Factor
VIII in plasma. Platelet
adehsion molecule
is synthesized in the
Weibel-Palade bodies in
endothelial cells.
Due to Hemophilia
Deforming arthritis and contractures: this is due to repeated bleeding into the joints.
Organization and fibrosis of intramuscular hematomas contractures of involved muscles.
Anemia: excessive, spontaneous or repeated bleeding leads to anemia.
Due to Therapy
Viral hepatitis: hepatitis B, C and D in patients who received multiple transfusions of
FFP/cryoprecipitate.
AIDS: in individuals who received fresh frozen plasma (FFP) or cryoprecipitate, when
screening tests for HIV were not available.
Factor VIII inhibitors: makes further management difficult.
HEMOPHILIA B (CHRISTMAS DISEASE,

FACTOR IX DEFICIENCY)
Clinically indistinguishable from hemophilia A

X-linked recessive disorder
Variable clinical severity
Assay of factor IX should be done to diagnose Christmas disease (named after the first
patient).
Laboratory Findings
Similar to hemophilia A.
Bleeding time: normal
Clotting time: prolonged
Activated partial thromboplastin time (APTT): increased (normal 3040 seconds)
Factor IX assay: factor IX is decreased.
VON WILLEBRAND DISEASE (vWD)

Most common inherited bleeding disorders
Most cases are autosomal dominant disorders
Variable clinical picture with more than 20 variants.
Categories
Grouped into two major categories:
Quantitative deficiency of vWF: decreased circulating vWF
Type 1- autosomal dominant, mild disorder and form about 75% of all cases
Type 3-autosomal recessive, severe disorder and least common type.
Qualitative defects in vWF:
Type 2-autosomal dominant, accounts for 25% with several subtypes.
vWD: autosomal dominant

disorders caused by
mutations in vWF.
Clinical Features
Most cases are of mild bleeding
Common symptoms
Spontaneous bleeding from mucous membranes (e.g. epistaxis)
Excessive bleeding from wounds or menorrhagia
In severe cases, similar to hemophilia A.
Laboratory Findings

Bleeding time: prolonged
Clotting time: prolonged
Tourniquet test (Hess test): positive due to defect in platelet adhesion
APTT: prolonged APTT
PT: normal
vWF assay: plasma level of active vWF is decreased
Platelet function test: defective ristocetin induced platelet aggregation test is diagnostic
of vWF.
vWD: increased
bleeding time, clotting
time and prolonged
APTT. Plasma vWF is
decreased. Defective
ristocetin induced platelet
aggregation test is
diagnostic.
Laboratory tests in hereditary disorders are summarized in Table 17.4.

TABLE 17.4: Summary of laboratory tests in hereditary coagulation disorders
Hemophilia A
Hemophilia B
von Willebrand disease
Bleeding time
Increased
APTT
Increased
Increased
Increased
Factor VIII
Decreased
Low or Normal
Factor IX
Decreased
vWF
Decreased
Hemophilia A, B and
vWD: prothrombin time,
thrombin time and platelet
count are normal. APTT
increased in all the three.
Abbreviation: N, normal
ACQUIRED COAGULATION DISORDERS

Coagulation Factor Abnormalities
Usually characterized by multiple clotting abnormalities
Vitamin K deficiency: in neonates, low levels of vitamin K levels may produce life-threatening hemorrhage during the first week of life known as hemorrhagic disease of the newborn.
Liver disease: liver synthesizes all the clotting factors and severe liver disease is associated
with a hemorrhagic diathesis.
Other causes: disseminated intravascular coagulation that involves deficiency of several
coagulation factors.
Vitamin K dependent
coagulation factors: II, VII,
IX and X.
109
110
DISSEMINATED INTRAVASCULAR
COAGULATION
Widespread disorder with combination of thrombosis and hemorrhage.
Etiology
Develops as a secondary complication of wide variety of disorders (Table 17.5).
DIC:
Sepsis, major trauma,
obstetric complications
and certain cancers are
the common triggers.
TABLE 17.5: Major disorders associated with disseminated intravascular coagulation

Infections
Gram-negative bacterial sepsis
Fungi, viruses, Rocky Mountain
spotted fever, malaria
Meningococcemia and other bacteria
Obstetric Complications
Retained dead fetus
Abruptio placentae
Toxemia and pre-eclampsia
Septic abortion
Amniotic fluid embolism
Neoplasms
Carcinomas of pancreas, prostate, lung and stomach
Acute promyelocytic leukemia
Massive Tissue Injury
Traumatic
Fat embolism
Burns
Surgery
Vascular Disorders
Aortic aneurysm, giant hemangioma
Immunologic Reactions
Transfusion reactions
Transplant rejection
Respiratory Distress Syndrome

Miscellaneous
Snakebite, liver disease, acute intravascular hemolysis, shock, heat stroke, hypersensitivity, vasculitis
DIC: widespread thrombohemorrhagic disorder

secondary to wide variety
of disorders.

Disseminated intravascular coagulation (DIC) is a disorder that shows combination of 1.
thrombosis and 2. hemorrhage.
1. Thrombi/Clot Formation
Mechanism of thrombi formation:
A. Initiation of thrombotic process: two major mechanisms initiate the thrombotic process
of DIC namely entry of thromboplastic (procoagulant) substances into the circulation
and widespread endothelial injury.
Entry of thromboplastic (procoagulant) substances into the circulation: source of
thromboplastic/procoagulant substance in majority is tissue factor, which activates.
Widespread endothelial injury: endothelial injuries expose the thrombogenic sub
endothelial matrix.
Fig. 17.2: Pathogenesis of thrombosis, ischemic tissue necrosis and bleeding in disseminated intravascular coagulation
B. Development of thrombi:
DIC:
Both procoagulant substances (tissue factor) and endothelial injury activate coagulation Consumption of
coagulation factors
system resulting in fibrin-platelet thrombi formation in the microvasculature.
Widespread thrombosis
During this process there is consumption of clotting factors, fibrin and platelets. Hence,
in small blood vessels.
it is also referred to as consumptive coagulopathy or defibrination syndrome.
C. Consequences of thrombi formation: widespread deposition of fibrin-thrombi within
the microcirculation leads to:
Ischemic necrosis: microvascular thrombi produces micro-infarcts or large areas of
infarction and multiorgan failure.
Microangiopathic hemolytic anemia: RBCs trapped in the intravascular fibrinthrombi deposits undergo fragmentation. These RBCs appear as schistocytes in blood
smears; but, frank hemolytic anemia is unusual in DIC.
2. Hemorrhagic Diathesis
A. Causes of hemorrhagic/bleeding diathesis:
Consumption of platelets
Consumption of coagulation factors
Activation of fibrinolytic system.
B. Mechanism of hemorrhagic diathesis fibrin-thrombi activate secondary fibrinolytic
system and generate plasmin. The plasmin cleaves fibrinogen and fibrin and generates
fibrin split products (FSPs) [or fibrin degradation products (FDP)]. FSPs are potent
anticoagulant and antiplatelet effect and produces hemorrhagic diathesis.
Clinical Features
Prognosis
Depends on the
underlying disorder.
Mortality is high in
severe cases.
Serious, often fatal, clinical condition

Signs and symptoms are related to:
Treatment
Hemorrhagic diathesis/bleeding: most common, manifest as ecchymoses, petechiae or Removal of the
bleeding from mucous membranes or at the sites of venipuncture.
underlying cause
Microvascular thrombi: tissue hypoxia and infarction of the organ leading to multiorgan Replacement of clotting
factors and platelets.
failure.
111
112
Laboratory Findings in DIC

DIC laboratory findings:
Increased: APTT, PT, BT,
D-dimer
Decreased: platelets,
fibrinogen.
Screening Assays
Coagulation abnormalities
APTT: increased as a result of consumption and inhibition of the function of clotting
factors.
Prothrombin time: increased.
Thrombin time (TT): increased because of decreased fibrinogen.
Fibrinogen: decreased.
Bleeding time: increased due to decreased platelet count.
Platelet count: decreased due to utilization of platelets in microthrombi.
Peripheral smear: microangiopathic hemolytic anemia with schistocytes.
Confirmatory Tests
Fibrinolysis abnormalities
FDP (fibrin degradation/split products): secondary fibrinolysis results in generation of
FDPs, which can be measured by latex agglutination
DIC: D-dimer test is specific
diagnostic test.
D-dimer test: it is specific for diagnosing DIC.
Thrombotic Disorders:
Hypercoagulable State
HYPERCOAGULABLE STATE (THROMBOPHILIA)

Group of inherited or acquired conditions that are associated with increased tendency or risk
to develop thrombosis.
Causes of Hypercoagulability State (Table 18.1)

TABLE 18.1: Major causes of hypercoagulable state
A. Inherited (genetic/primary)

Deficiency of antithrombotic (anticoagulant) factors

1. Antithrombin III deficiency
2. Protein C deficiency
3. Protein S deficiency
Increased prothrombotic factors
1. Activated protein C (APC) resistance (Factor V mutation/ factor Va/ factor V Leiden)
2. Excessive levels of prothrombin (prothrombin G20210A mutation)
3. High levels of factors VII, XI, IX, VIII; von Willebrand factor; fibrinogen
B. Secondary (acquired)
1. Antiphospholipid antibody syndrome
2. Venous stasis
Prolonged immobilization
Congestive cardiac failure
Prolonged bed rest
3. Increased platelet activation
Hematological disorders: myeloproliferative neoplasms (polycythemia vera, essential
thrombocythemia, myelofibrosis), paroxysmal nocturnal hemoglobinuria
Cancer
Nephrotic syndrome
Atrial fibrillation
Myocardial infarction
Heparin-associated thrombocytopenia
Thrombotic thrombocytopenic purpura (TTP)
4. Increased hepatic synthesis of coagulation factors and reduced anticoagulant synthesis
Oral contraceptive pill
Hyperestrogenic states
(pregnancy and postpartum)
5. Release of procoagulant substances: disseminated cancers
6. Tissue injury: surgery, fracture, extensive burns
7. Reduced endothelial PGI2: old age
8. Endothelial injury: homocysteinemia
9. Fibrinolytic system defects
10. Unknown: smoking, obesity, sickle cell anemia
18
CHAPTER
114
INHERITED HYPERCOAGULABLE STATES

Clinical Presentation
Thrombosis develops at young age (less than 45 years)

Recurrent thromboembolism
Family history of thromboembolic episodes
Thrombosis develops in the venous system and at unusual anatomical sites like visceral
veins.
Deficiency of Antithrombotic Factors

Antithrombin (AT) III Deficiency
Autosomal dominant disorder
Deficiency of antithrombineither quantitative or qualitative
Risk of a thrombosis20% to 80%.
Protein C and S Deficiency

Normally, activated proteins C (APC) and protein S act as a complex, which degrades
activated factors V and VIIl.
When there is deficiency of these proteins, the activated factor V and VIII are not neutralized.
This leads to activation of the clotting system and formation of thrombus.
Increased Prothrombotic Factors

Factor V Leiden/Leiden
mutation is characterized
by factor V variant.
Factor V Leiden is resistant
to inhibition by activated
protein C (APC). It is
associated with familial
thrombophilia.
Activated Protein C (APC) Resistance (Factor V Leiden)

Most common genetic disorder associated with familial thrombophilia.
Activated proteins C (APC) and protein S complex inhibits activated factor normal V and
VIII. The variant clotting factors cannot be degraded.
Point mutation in the factor V gene synthesis of a factor V variant. This variant is known as
factor V Leiden/Leiden mutation.
Factor V variant has normal procoagulant activity but is resistant to inhibition by activated
protein C (APC).
ACQUIRED HYPERCOAGULABLE STATES

Causes
Causes of the acquired hypercoagulable states are listed in Table 18.1.
Antiphospholipid Antibody Syndrome (APLA/APS)

Presence antiphospholipid antibodies (APAs) in the plasma are associated with hyper
coagulable state.
Antiphospholipid antibody reacts with plasma proteins, which are bound to phospholipids
(Fig. 18.1).
Two important antiphospholipid antibodies: lupus anticoagulant antibody and anti-2
glycoprotein antibody.
1. Lupus anticoagulant antibody: prolongs the phospholipid-dependent coagulation
tests in vitro (e.g. prolongation of APTT).
Thrombotic Disorders: Hypercoagulable State CHAPTER 18
2. Antibodies against the phospholipid2-glycoprotein com

plex: it also bind to cardiolipin antigen used in the serological
test for syphilis.
Antiphospholipid
antibodies includes lupus
anticoagulant antibody
and anti-2 glycoprotein
antibody.
Types
Primary antiphospholipid syndrome: no predisposing cause.
Secondary antiphospholipid syndrome: association with
autoimmune diseases, like systemic lupus erythematosus, hence
known as lupus anticoagulant syndrome.
Clinical Features
Fig. 18.1: Antiphospholipid anti

body against plasma proteins
Hypercoagulable state: commonest acquired hematologic bound to phospholipids
Triad of thrombosis,
recurrent spontaneous
cause of recurrent thromboembolic events.
Repeated spontaneous abortions: normally, tissue plasminogen activator (t-PA) is neces- abortions and immune
thrombocytopenia
sary for the invasion of uterine blood vessels by placental trophoblastic tissue. Recurrent may be the presenting
spontaneous abortions develop due to antibody-mediated inhibition of t-PA activity.
clinical features of
antiphospholipid
Immune thrombocytopenia.
syndrome.
Laboratory Tests
Coagulation tests
APTT: prolonged
Factor VIII levels: normal
Thrombin time: normal
Fibrinogen level: normal.
Confirmatory test
Test for lupus anticoagulant:
Dilute Russells viper venom test (DRVVT): Russells viper venom (RVV) activates factor
X leading to fibrin clot. Lupus anticoagulant prolongs clotting time by binding to RVV
and preventing the action of RVV.
Antibodies against the phospholipid2-glycoprotein complex:
Detected by enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay
(RIA).
115
SECTION
Clinical
Scenario
19
Clinical Scenario
CHAPTER
INTRODUCTION
Medical undergraduates in pathology are frequently required to analyze clinical-oriented
cases. These cases are provided with symptoms and signs and laboratory findings. Students
are expected to often diagnose these cases with history alone. Some of the classical scenarios
in hematology, which are frequently asked in pathology examination, are presented in this
chapter. First, symptoms, signs and general characteristics of blood diseases are given. Next
common patterns of clinical features observed in hematology are discussed, which will help in
suggesting the diagnosis. This is followed by clinical scenarios and their interpretations.
SYMPTOMS AND SIGNS THAT SUGGEST A

BLOOD DISEASE (TABLE 19.1)
TABLE 19.1: Symptoms and signs that favor a blood disease
Symptoms and signs
During pregnancy
anemia may develop due
to combination of iron
deficiency and/or folate
deficiency.
Suggestive of blood disease
Tiredness, weakness, malaise, lightheadedness

and easy fatigability
Dyspnea (breathlessness) on mild exertion
relieved by lying flat
Anemia
Pallor: appreciated better

in the conjunctiva, mucous
membrane of tongue and
nail beds.
Pallor
Tachycardia, palpitation and systolic murmur
Pica (craving for ice or soil)
Spoon-shaped nails (koilonychia)
Cheilosis (fissures at the corners of the mouth)
Pica is a craving for certain

substances with no
nutritional value like clay
or chalk.
Vitamin B12 deficiency
Vitamin B12 -peripheral

neuropathy: glove and
sock distribution of
tingling and numbness or
paresthesia in the fingers
and toes.
Dysphagia
Painful red beefy tongue (glossitis)
Pain or weakness in legs
Peripheral neuropathy
Psychosis
Contd...
120
SECTION 4 Clinical Scenario
Contd...
Passage of dark urine (? red cells, ? hemoglobin)
Hemolytic anemiaintravascular hemolysis
Jaundice/recurrent jaundice
Hemolytic anemia, megaloblastic anemia (lemonyellow jaundice)
Enlarged spleen
Chronic hemolytic anemias, malaria, leukemia,

lymphoma
Splenic infarction producing severe abdominal
pain
Massive splenomegaly
causes abdominal
discomfort.
Sickle cell anemia
Leg ulcers
Frontal bossingthalassemic facies
Chronic hemolytic anemia, e.g. thalassemia major
Massive splenomegaly (greater than 20 cm in size)
Chronic myelocytic leukemia, myelofibrosis, kala-azar
PATTERNS STRONGLY SUGGESTIVE OF

A BLOOD DISEASE
Various patterns that favor a blood disease are mentioned below.
Pattern 1: Iron Deficiency Anemia

Craving for ice
(pagophagia), is believed
to be the most specific to
iron deficiency.
Cheilosis and are
koilonychia (spoon
shaped or flattened)
are characteristically
and specifically seen in
advanced cases of IDA.
1. History strongly indicative of iron deficiency (IDA): a pale patient with tiredness,
weakness, malaise, a sore tongue (glossitis), pica (craving for ice) and spoon-shaped nails
(koilonychia). Signs and symptoms are usually due to both anemia and the underlying
cause of anemia.
2. Diagnosis of IDA would be strengthened in a patient who has underlying cause of anemia
such as gastrointestinal (e.g. carcinoma colon, hemorrhoids) or gynecologic disease
(e.g. menorrhagia/excessive menstrual blood flow), malnutrition, pregnancy, and
malabsorption.
3. IDA: diagnosis is typically based on laboratory results. Microcytic hypochromic anemia,
low MCV, MCH, MCHC, reduced serum ferritin and other serum profile observed in IDA
(refer Table 1.4).
Inference (case No. 1):

spoon shaped nails and
pica indicates IDA.
Case No. 1

spoon shaped nails and
cheilosis indicates IDA.
Menorrhagia is the cause.
Case No. 2

cause of IDA is bleeding
from GI tract.
Case No. 3
History: A 28-year-pregnant lady comes to hospital with complains of weakness, easy fatigability and
breathlessness of 4 months duration. She is a laborer of low economic status and used to eat clay. On
examination, she is pale and had spoon shaped (koilonychia) nails.
History: A 20-year-old girl complains of weakness, easy fatigability and breathlessness of 6 months
duration. She also complains of heavy menstrual bleeding every month. On examination, she is pale
and had spoon shaped (flattened) brittle nails and cheilosis.
History: A 73-year-old male complains of increasing weakness, malaise, and easy fatigability for the past
10 months. On examination, he is pale without hepatosplenomegaly. He also complains of black tarry
stool (Stool for occult blood was positive).
Clinical Scenario CHAPTER 19
Laboratory findings for cases 1, 2, 3: Hb 9.1 g/dL, hematocrit 27.3%, RBC count 3 million/cumm, WBC
count 6,700/cumm and platelet count 4,20,000/cumm. MCV 70 fL, MCH 26 pg, MCHC 28 g/dL and RDW
18.
Cause of IDA: the causes for iron deficiency:

Case 1 is probably due to inadequate intake (due to low socioeconomic status) or increased
demand of iron during pregnancy.
Case 2 is caused by chronic blood loss, due to excessive menstrual flow.
Case 3 is due to chronic blood loss through gastrointestinal tract. The black tarry stool
indicates that the patient has occult bleeding probably from GI tract malignancy.
Pattern 2: Megaloblastic Anemia

History strongly indicative of megaloblastic anemia (vitamin B12 deficiency and/or
pernicious anemia): middle-aged, pale patient with prematurely gray hair, severe glossitis
and stomatitis and a smooth painful tongue, significant neuropathy and difficulty in
walking, uncoordinated gait, impairment of vibration sense and position sense with
delirium/dementia.
Patients with megaloblastic anemia due to folic acid/folate deficiency present with
symptoms of anemia or of the underlying cause.
Peripheral smear with macro-ovalocytes, hypersegmented neutrophils, raised MCV,
bone marrow with megaloblasts are features of megaloblastic anemia.
Case No. 4
History: A 34-year-male, pure vegetarian, executive complains of anorexia, premature graying of hair,
weight loss and tingling and numbness in fingers and toes. On examination, he is pale and anemic. The
tongue is shiny and has glazed appearance (glossitis).
Laboratory findings for

cases 1 to 3: The decreased
hemoglobin, RBC count,
MCV, MCH and MCHC
favors iron deficiency
anemia.
Increased RDW helps in
differentiating IDA from
thalassemia (refer Table
3.3).
Unlike with B12 deficiency,

folic acid deficiency is not
associated with significant
neuropathy.
Inference (case No. 4): in a

pure vegetarian, tingling
and numbness, glossitis,
raised MCV point towards
vitamin B12 deficiency.
Laboratory findings: Hb 9 g/dL, WBC count 3,800/cumm, platelet count 60,000/cumm, RBC count 2.5
million/cumm. MCV is 104 fL, MCH 32 pg and MCHC is 32 g/dL.
Case No. 5
History: A 45-year-old female complains of tiredness, mild breathlessness while climbing steps and
tingling and numbness. On examination, she is pale, has raspberry-red tongue, and shows numbness
and paresthesia. Biochemical investigation reveals normal serum iron profile.
Laboratory findings: Hb 8.2 g/dL, WBC count 4,800/cumm, platelet count 1,20,000/cumm, MCV is 108 fL,
MCH 33 pg and MCHC is 32 g/dL. Peripheral smear and bone marrow examination confirms the clinical
diagnosis. Patient is further subjected to gastric biopsy and shows atrophic gastritis. Other test including
serological tests is done.
Case No. 6
History: A 50-year-old male complains of loss of appetite, increasing fatigue tingling and numbness of
both lower limbs and difficulty in walking for the past 10 months. On physical examination, he is pale
and tongue was beefy red.
Laboratory findings: Hb 9.2 g/dL, hematocrit 27.9%, MCV 132 fL, platelet count 242,000/cumm, and
WBC count 7590/cumm. Peripheral smear shows macro-ovalocytes and hypersegmented neutrophils.

raised MCV, history of
tingling and numbness,
raspberry tongue point
to megaloblastic anemia
due to vitamin B12
deficiency. The evidence of
atrophic gastritis points to
pernicious anemia.

characteristic history
with increased MCV,
macro-ovalocytes
and hypersegmented
neutrophils in the
peripheral smear points to
121
122
HS may present during

anytime from the neonatal
period to adulthood. When
there is a family history, it
is usually easy to suspect
the diagnosis.
Pattern 3: Hereditary Spherocytosis

History strongly indicative of chronic extravascular hemolysis, usually but not always
hereditary spherocytosis: normal patient presenting with pallor, mild jaundice, an enlarged
spleen (classic triad) and a family history of a relative who had been cured of the same
problem by splenectomy. Also family history of pigment gallstones in a young person.
Peripheral smear with spherocytes and raised osmotic fragility test are features of HS.
Case No. 7
Inference (cases No. 7
and 8): mild jaundice,
anemia and splenomegaly
constitute a classical
triad, and along with
family history/pigment
gallstones favor hereditary
spherocytosis.
History: A 24-year-women complains of chronic fatigue since childhood and mild icterus. On examination
she is anemic, jaundiced and has moderate splenomegaly. Her mother had similar complaints and has
multiple pigment gallstones.
Positive osmotic test

fragility confirms the
diagnosis of HS.
Laboratory findings for cases 7 and 8: Hb 11.1 g/dL, RBC count 3.6 million/cumm. WBC count 6,800/cumm
and platelet count 1,75,000/cumm. MCV is 78 fL, MCH is 32 pg and MCHC is 38 g/dL. In a laboratory test,
her RBCs lyse at a higher concentration of saline (osmotic fragility test) compared to normal patients.
Case No. 8
History: A 15-year-old girl presents with weakness and fatigue. On examination, her sclera shows mild
jaundice and mild splenomegaly. Family history indicated about her father having recurrent gallstones.
Pattern 4: Thalassemia Major

History strongly indicative of thalassemia major: short stature, failure to thrive, severe
pallor, jaundice, maxillary over-growth (bossing), frontal bossing, sallow complexion and
splenomegaly.
Laboratory finding of microcytic hypochromic anemia with many target cells, reduced
MCV,MCH and MCHC, increased serum iron normal RDW are features of thalassemia
major.
failure to thrive, severe
pallor, jaundice,
splenomegaly, microcytic
hypochromic anemia
with target cells, reduced
MCV and normal RDW
points to the diagnosis
of -thalassemia major.
Increased iron stores and
raised serum ferritin is
against the diagnosis of
IDA (refer Table 3.3).
Case No. 9
History: An 11-month-old male child was brought to the pediatric outpatient by his parents and
complained that the child was failing to thrive. On examination, jaundice, pallor and a palpable spleen
was detected.
Laboratory findings: Hb 7.8 g/dL, hematocrit 23.4%, MCV 66 fL, platelet count 1,75,000/cumm, and
WBC count 8,200/cumm. His serum ferritin was 3250 ng/mL. Peripheral examination showed microcytic
hypochromic anemia with many target cells. A bone marrow aspiration performed and reveals a
myeloid: erythroid ratio of 1:4, and increased iron stores.
Pattern 5: Sickle Cell Anemia

Inference (case No. 10): the
recurrent episodes of pain
abdomen and backache
points to a vaso-occlusive
crisis in sickle cell anemia.
History strongly indicative of sickle cell anemia: recurrent episodes of vaso-occlusion in

connective and musculoskeletal structures anywhere in the body producing ischemia and
manifesting as acute pain, tenderness and fever. Child may show generalized impairment
of growth and development. Adults manifest with chronic organ damage.
Presence of sickle cells in the peripheral smear, positive sickling test, along with
demonstration of HbS by hemoglobin electrophoresis and HPLC is diagnostic of sickle
cell anemia.
Case No. 10
History: A 10-year-old boy complains of severe pain in the chest, abdomen and bones. On enquiry, his
mother reveals that he had several episodes of severe abdominal and back pain since early childhood.
Physical examination shows anemia, jaundice and leg ulcer.
Presence of sickle cells in

the peripheral smear and
presence of more than
70% Hb S on hemoglobin
electrophoresis is
confirmative.
Laboratory findings: Hb 11.0 g/dL, RBC count 3.2 million/cumm, WBC count 8,800/cumm and platelet
count 1,95,000/cumm. Peripheral smear examination, hemoglobin electrophoresis and HPLC confirms
the diagnosis.
Pattern 6: Immune Thrombocytopenic Purpura (ITP)

History strongly indicative of acute immune thrombocytopenic purpura: sudden
development of bruising, petechiae and muco-cutaneous bleeding in a child following
a bacterial or nonspecific viral (upper respiratory or gastrointestinal) infection without
features of acute leukemia (such as anemia and bone tenderness).
Laboratory findings of markedly reduced platelet count and megakaryocytic hyperplasia
with immature megakaryocytes. In the bone marrow favors the diagnosis of acute immune
thrombocytopenic purpura.
Case No. 11
History: A 14-year-male comes to the OPD with petechial rashes of 2 days duration. He has no history of
bleeding in past. He had an attack of viral infection 3 weeks before this complaint.
The severity/nature of
bleeding depends on the
platelet count.

petechial rashes of short
duration in a child, low
platelet count is due to
acute idiopathic thrombocytopenic purpura.
Laboratory findings: Hb 14.5 g/dL, hematocrit 45%, RBC count 5.1 million/cumm. WBC count 7,200/
cumm and platelet count 75,000/cumm. MCV is 85 fL, MCH is 32 pg and MCHC is 31 g/dL and RDW is 14.
Pattern 7: Hemophilia
History strongly indicative of one of the hemophilias (A or B): a male child presenting with
a serious bleeding disorder, particularly with hemarthrosis.
Decreased factor VIII/IX and increased APTT is diagnostic of one of the hemophilias
(A or B).
Case No. 12
History: An 18-year-male complains of knee joint swelling after minor trauma. On examination, the joint
appears tense, red and swollen. Family history revealed similar complaints by his uncle.
Case No. 13
History: A 6-year-old boy gives a history of easy bruising and episodes of passing blood in urine since
infancy. On examination, many ecchymoses are noted in the skin of lower limbs. Family history reveals
similar complaints in members of the family involving only males and history of hemarthrosis in few of
them.
Inference (cases No. 12 and

13): the development of
ecchymosis, family history
with disease affecting
males, hemarthrosis,
normal platelet count and
prolonged APTT favor
hemophilia A/B.
123
124
Laboratory findings for cases 11 and 12: Hb 13 g/dL, hematocrit 36%, RBC count 4.4 million/cumm, WBC
count 8,200/cumm and platelet count of 2,35,000/cumm. MCV is 84 fL, MCH 32 g and MCHC is 33 g/dL.
Bleeding time, clotting time and prothrombin time are within normal limits. APTT is prolonged.
ALL: pallor, fatigue,

bleeding, fever, and
infection are due
to peripheral blood
cytopenias resulting from
bone marrow failure.
Pattern 8: Acute Lymphoblastic Leukemia (ALL)

History strongly indicative acute lymphoblastic leukemia: child (1 to 6 years of age)/adult
(30 to 40 years) presenting with rapid onset (few weeks) of pallor, fatigue, bleeding, fever,
and infection. Presence of lymphadenopathy, hepato- or splenomegaly, CNS disease,
testicular enlargement.
Laboratory findings of marked raised WBC count, presence of more than 20% lymphoblasts
in the blood and bone marrow, blasts + with PAS (block positivity) and TdT + are features
of acute lymphoblastic leukemia.
Inference (cases No. 14 to

16): presence of anemia,
thrombocytopenia and
leukocytosis with presence
of PAS positive blasts in the
peripheral smear and bone
marrow in a child is in favor
of acute lymphoblastic
leukemia.
Case No. 14
Bone pain is due to

expansion of the marrow
caused by proliferation of
blasts.
Case No. 16
History: A 6-year-old boy presents with fatigue, bone pain, weakness and low-grade fever of 1-week
duration. Physical examination shows anemia, sternal bone tenderness and lymphadenopathy.
Case No. 15
History: A 5-year-old boy complains of sudden onset of fever, tiredness and pallor. On examination,
there are many enlarged cervical lymph nodes, hepatosplenomegaly, bone tenderness, and petechial
hemorrhages on the skin.
History: A 4-year-old boy is becoming increasingly lethargic for the past 1 month. On examination, he is
having fever, ecchymoses on the skin of his lower legs and shoulder, generalized lymphadenopathy and
tenderness on palpation of long bones.
Laboratory findings of cases 14 to 16: Hb 8 g/dL, hematocrit 24%, WBC 18,200 cells/cumm and platelet
count of 90,000/cumm. Serum LDH is markedly increased. Peripheral blood smear shows abnormal
cells, which are PAS positive. A bone marrow examination shows 100% cellularity with replacement
by primitive cells. These abnormal primitive cells have scanty cytoplasm and large nuclei with indistinct
nucleoli.
Following blood smear examination, the child is admitted to the medical oncology ward.
Pattern 9: Acute Myeloblastic Leukemia (AML)

History strongly indicative acute myeloblastic leukemia: adult presenting with rapid onset
(few weeks) of pallor, fatigue, bleeding, fever, and infection.
Laboratory findings of marked raised WBC count, presence of more than 20% myeloblasts
in the blood and bone marrow, presence of Auer rods (not seen in all subtypes), blasts +
with MPO and Sudan Black B are features of acute myeloblastic leukemia.
Case No. 17
History: A 45-year-old man presents with fatigue, episodes of epistaxis, bleeding from gums, and low
grade fever of 1 week duration. Physical examination reveals temperature of 37.4C and hepatosplenomegaly.

the high WBC count with
the blasts and Auer rods
are very characteristic
for acute myelogenous
leukemia.
Laboratory findings: Hb 7 g/dL, WBC count 51,000/cumm and platelet count 80,000/cumm. Peripheral
blood smear shows abnormal large cells with Auer rods.
Pattern 10: Chronic Myelogenous Leukemia (CML)

History strongly indicative of chronic myelogenous leukemia: patient in fifth and sixth
decades of life presenting with gradual development of fatigue, weakness, weight loss,
anorexia and fullness of abdomen, early satiety and left upper quadrant pain or mass (due
to splenomegaly).
Laboratory finding of very high WBC count with myeloid precursors, neutrophils and
myelocyte peak, low LAP and presence of Ph chromosome is diagnostic of chronic
myelogenous leukemia.
Case No. 18
History: A 50-year-old male comes to the hospital with complaints of generalized weakness, weight loss,
easy fatigability, abdominal discomfort and dragging sensation in the left hypochondrium for the last
8 months. On examination, he is pale and has marked splenomegaly.
Laboratory findings: Hb 11.9 g/dL, hematocrit 36%, WBC count 1,20,000/cumm, platelet count 4,12,000/
cumm. Peripheral smear examination shows characteristic blood picture with myeloid precursors,
neutrophils and myelocyte peak confirms the clinical diagnosis. The leukocyte alkaline phosphatase
(LAP) score is low. Chromosomal analysis shows t(9:22) positivity. He is admitted to the oncology
department for treatment.

massive splenomegaly
with very high WBC
count, peripheral smear
with myeloid precursors,
neutrophils and myelocyte
peak t (9:22) positivity and
low LAP score are features
of chronic myelogenous
leukemia (chronic phase).
Pattern 11: Chronic Lymphocytic Leukemia (CLL)

History strongly indicative of chronic lymphocytic leukemia: marked splenomegaly,
generalized lymphadenopathy (any nodes can be involved), involvement of spleen in an
elderly patient with fatigue, loss of weight and anorexia.
Peripheral blood with lymphocytosis which constitute more than 50% of the white cells
and smudge cells; bone marrow with more than 30% lymphocytes of the bone marrow
cells is diagnostic of chronic lymphocytic leukemia.
Case No. 19
History: A 60-year-old male complains of increasing fatigue and shortness of breath with minimal
exercise for the last 6 months. He has noted some abdominal discomfort over the past month. On
examination, he has non-tender cervical lymphadenopathy. The liver is enlarged, smooth and palpable
just below right costal margin. The spleen is palpated 3 cm below left costal margin.

older patient,
abdominal discomfort
(splenomegaly) nontender lymphadenopathy,
hepatosplenomegaly,
high WBC count with
lymphocytosis and
smudge cells in the
peripheral smear are
features of chronic
lymphocytic leukemia.
125
126
Laboratory findings: WBC count 22,000/ cumm with 78% lymphocytes on DLC. Hb 10.1 g/dL, hematocrit
33%, platelet count 2,32,000/cumm. Peripheral smear shows many smudge cells.
Pattern 12: Multiple Myeloma

History strongly indicative of multiple myeloma: Patient over 50 years of age presenting
with severe bone pain, pallor, and renal failure.
Laboratory findings shows nonspecific findings such as raised ESR, rouleaux formation of
RBC in the peripheral smear and lytic lesions in the bone. Bone marrow with more than
30% myeloma cells and M spike on electrophoresis confirms the diagnosis of multiple
myeloma.
patient over 50 years
of age with bone pain,
pallor, lytic lesions in bone,
peripheral smear with
marked rouleaux formation
and markedly raised ESR
suggest multiple myeloma.
Case No. 20
History: A 61-year-old man has dull, constant back pain for 3 months. On physical examination, he is
pale. A plain film radiograph of the spine and skull reveals several 1 to 2 cm lytic lesions of the vertebral
bodies.
Laboratory findings: Peripheral smear shows marked rouleaux formation, ESR is 110 mm at 1st hour.
Bone marrow aspiration, urine and serum electrophoresis showed characteristic findings.
Pattern 13: Hodgkin Lymphoma (HL)

History strongly indicative of Hodgkin lymphoma: weight loss, fever, night sweats,
lassitude, pruritis, and enlarged cervical nodes. Sometimes accompanied by pain in one
or more sites almost immediately after ingestion of alcohol. Extranodal involvement is very
rare.
Histologically/cytologically presence of RS cells is diagnostic of Hodgkin lymphoma.
non-tender
lympadenoapthy, lowgrade fever, weight
loss, night sweats and
presence of characteristic
Reed-Sternberg cells is
diagnostic of Hodgkin
lymphoma.
Case No. 21
History: A 33-year-old female complains of low-grade fevers, 6 kg weight loss, night sweats, and
generalized malaise for the past 3 months. On physical examination, she has non-tender right cervical
and supraclavicular lymphadenopathy.
Investigation: Fine needle aspiration followed by a biopsy of cervical lymph node is performed. On
microscopic examination, the lymph node showed loss of architecture and characteristic cell that
confirmed the clinical diagnosis. He was admitted to the oncology ward for further management.
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Saunders. 2009.
11. Kumar V, Abbas AK, Aster JC. Robbins Basic Pathology, 9th edn. Philadelphia, WB Saunders. 2013.
12. Lewis SM, Bain BJ, Bates I. Dacie and Lewis Practical Hematology, 10th edn. London, Churchill Livingstone. 2006.
13. Lichtman MA, Kipps TJ, Kaushansky K, Beutler E, Seligsohn U, Prchal JT. Williams Hematology, 7th edn. USA,
McGraw-Hill Companies. 2006.
14. Longo DL. Harrisons Hematology and Oncology. USA, McGraw-Hill Companies. 2010.
15. Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J. Harrisons Principles of Internal Medicine, 18th
edn. USA, McGraw-Hill Companies. 2012.
16. McPherson RA, Pincus MR. Henrys Clinical Diagnosis and Management by Laboratory Methods, 22nd edn.
Philadelphia, WB Saunders. 2011.
17. Rodak BF, Fritsma GA, Doig K. Hematology: Clinical Principles and Applications, 3rd edn. Philadelphia, WB
Saunders. 2007.
18. Rubin R, Strayer DS. Rubins Pathology: Clinicopathologic Foundation of Medicine, 6th edn. Philadelphia, Lippincott
Williams and Wilkins. 2012.
19. Stevens A, Lowe J. Pathology, 2nd edn. Edinburgh, Mosby. 2000.
20. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., WHO Classification of Tumours of Haematopoietic
and Lymphoid Tissues. IARC, Lyon. 2008.
21. Underwood JCE, Cross SS. General and Systemic Pathology, 5th edn. Edinburgh, Churchill, Livingstone. 2009.
Appendix
Different stages of hematopoiesis.

Abbreviation: BFU, bursa forming unit, CFU, colony forming unit
128
Stages of erythropoiesis
Variations in color of RBCs and associated conditions
Appendix
Variations in shape of RBCs and associated conditions
129
130
Inclusions in RBCs and associated conditions
Rouleaux formation and associated conditions
Appendix
Variations in size of RBCs and associated conditions
Stages of megakaryopoiesis
131
132
Hemoparasites
1. Malarial parasites:
Most common are
Plasmodium vivax and
falciparum
2. Microfilaria
3. Trypanosomes
4. Leishmania donovani
5. Babesiosis.
Stages of myelopoiesis
HEMOPARASITES
A
Peripheral blood smear
showing microfilaria
Peripheral blood smear A. Plasmodium vivax ring form, B and C Plasmodium vivax schizont and
D. Plasmodium falciparum gametocyte
Index
Page numbers followed by f refer to figure and t refer to table
A
Abdominal discomfort 125
Abnormal localization of immature
precursors 61
Abnormalities of
coagulation/clotting factor 105
globin production 22
platelet 100
Abnormally large megakaryocytes 66
ABO
hemolytic disease of newborn 39
incompatibility 37
Achlorhydria 12
Acquired
clonal stem cell disorders 60
coagulation disorders 105, 109
disorders 52, 100
hypercoagulable states 114
mutations 41
myeloproliferative neoplasm 63
Activated
partial thromboplastin time 107
protein C resistance 114
Acute
abdominal pain 32
bacterial and fungal infections 46
blood loss 41
chest syndrome 32
erythroid leukemia 54
immune thrombocytopenic purpura
102, 123
leukemia 52, 52t, 53, 55, 72
lymphoblastic
leukemia 49, 52, 53, 55, 56f, 124
lymphoma 55
lymphoid leukemias 55t
megakaryoblastic leukemia 54
monoblastic leukemia 54
monocytic leukemia 49, 54
myeloblastic leukemia 52, 53, 124
myelocytic leukemia 49, 53
myelogenous leukemia 53, 57
myeloid leukemia 53, 54
myelomonocytic leukemia 48, 49, 54
promyelocytic leukemia 54
Adult T cell
leukemia 49, 81
lymphoma 49, 81
Agranulocytosis 47
Aleukemic leukemia 52
Alimentary system 12
Allergic rhinitis 48
Alloimmune hemolytic anemia 36
Amyloidosis 79, 80
Anaplastic large cell lymphoma 81
Anemia 3, 19, 36, 65f
of blood loss 41
of chronic disorders 8
of impaired red cell production 3
Angioimmunoblastic T cell lymphoma 81
Angular stomatitis and glossitis 7
Anisopoikilocytosis 33
Antiglobulin test 38, 39
Anti-intrinsic factor antibody 12
Antiphospholipid antibody syndrome 114
Antiplatelet autoantibodies 102
Antithrombin III deficiency 114
Aplastic
anemia 13, 15, 46, 48, 50
crises 20, 33
Appearance of
neoplastic lymphoid cells 84
typical thalassemic facies 25f
Arterial oxygen saturation 65
Asthma 48
Asynchrony of nuclear and cytoplasmic
maturation 10
Atherosclerosis 13
Atrophic
gastritis 121
glossitis 7, 12
Atrophy of glands 12
Atypical lymphocytosis 51
Autoimmune
diseases 49
disorder 102
hemolytic anemia 36, 39, 40
Autosomal
dominant
disorder 17, 108
trait 19
recessive hereditary disorder 22
Autosplenectomy 33
B
B cell
neoplasms 76
prolymphocytic leukemia 81
Basophilia 49
Bence Jones proteins 76, 78
Benign leukocytic proliferation 47
Bernard-Soulier syndrome 100, 104
Biochemical tests for megaloblastic
anemia 11
Black tarry stool 120
Bleeding
disorders 99, 100, 105
tendency 80
time 103, 107
Blockage of microcirculation 32
Blood
brain barrier 38
loss 4
Bone 79
marrow 7, 10, 15, 18, 25, 27, 34, 35, 52,
57, 65, 66, 67, 77, 95, 103
aspiration 75
biopsy 65, 67
failure 56, 58
iron 27
trephine biopsy 61
pain 56
and tenderness 56
Brucellosis 49
Budd-Chiari syndrome 63
Burkitt lymphoma 81, 83, 84f, 85f
C
Carcinoma 15
Causes of
aplastic anemia 14t
136
eosinophilia 48t
hemolytic anemia 16t
hemorrhagic/bleeding diathesis 111
hypercoagulability state 113
iron
deficiency anemia 5t
overload 24
leukocytosis 45t
leukopenia 46t
lymphocytopenia 50t
lymphocytosis 49t
megaloblastic anemia 8t
microcytic hypochromic anemia 8
monocytosis 49t
neutropenia 48t
neutrophilia 46
pancytopenia 15t
thrombocytopenia 101, 101t
thrombocytosis 104t
Central nervous system 7, 12, 38
Cervical lymph nodes 56
Chickenpox 49
Christmas disease 108
Chronic
antigenic stimulation 77
atrophic gastritis 7, 12
blood loss 5, 42, 121
eosinophilic leukemia 62
hemolytic anemia 32
hypoxia 32
immune thrombocytopenic purpura
102
infections 49
leukemia 53
lymphocytic leukemia 45, 48, 49, 53,
73, 74f, 81, 125
myelogenous leukemia 62, 68, 125
myeloid leukemia 45, 47t, 48, 53, 70,
72f, 104
myelomonocytic leukemia 49
myeloproliferative neoplasm 65
neutrophilic leukemia 62
organ damage 33
Classical Hodgkin lymphoma 81, 87, 88
Classification of
acute myelogenous leukemia 57
anemia 3, 4t
bleeding disorders 100, 100t
coagulation disorders 105, 105t
disorders of hemostasis 100t
hemolytic anemias 16
hemostatic disorders 99
hereditary defects in hemoglobin 22
immunohemolytic anemias 36, 36t
lymphoid neoplasms 81
plasma cell neoplasms 76, 76t
platelet
disorders 100, 101t
functional disorders 104t
sickle cell disease 29, 29t
Clonal
hematopoietic stem cell disorders 62
proliferative disorder 95
Combined vitamin B12 9
Common hereditary X-linked recessive
disease 106
Complement-mediated intravascular
hemolysis 41
Confirmatory test 112, 115
Congestive heart failure 7, 50
Consequences of
ineffective erythropoiesis 23
thrombi formation 111
Coombs test 38, 38f, 39
Crohn disease 49
Cutaneous T cell lymphoma 86
Cyclic neutropenia 48
Cytochemistry of
lymphoblasts 57
myeloblasts 58
D
Defective
DNA synthesis 4
heme synthesis 5
hemoglobin synthesis 4
Deficiency of
antithrombotic factors 113, 114
intrinsic factor 11
Degeneration of dorsal and lateral tracts
13
Degree of hemoglobinization 3
Dehydration 31
Delayed maturation of nucleus 8
Demonstration of heterophile antibodies
51
Demyelination of spinal cord 13
Deoxyuridine suppression test 11
Dermatitis 48
herpetiformis 48
Development of thrombi 111
Diffuse
chronic atrophic gastritis 12
large B cell lymphoma 81, 83
Dilute Russells viper venom test 115
Dimorphic
anemia 9
peripheral blood picture 42
Direct antiglobulin test 39, 40

Disorders of
neutrophils 46
platelet
adhesion 104
aggregation 104
secretion 104
primary hemostasis 99, 100
white cells 43
Disseminated intravascular coagulation
110, 110t, 111f
Distinct megaloblasts in bone marrow 8
Donath-Landsteiner antibodies 40
Down syndrome 54
Dry tap 75
Dwarf megakaryocytes 70
Dysmegakaryopoiesis 61
Dysplasia 60
E
Eczema 48
Ehlers-Danlos syndrome 100
Endemic Burkitt lymphoma 84
Endothelial injury 110
Enlarged cervical lymph nodes 124
Eosinophilia 47
Eosinophilic
granuloma 48, 96
leukemia 48
Epstein-Barr virus 51
Erythrocytosis 63
Erythroleukemia 53
Erythromelalgia 66
Erythrophagocytosis 21
Erythropoiesis 18, 66, 77
Esophageal webs 7
Extramedullary
hematopoiesis 24, 65-67
hemopoiesis 24
infiltration 56, 58
myeloid tumors 47
Extravascular hemolysis 23
F
Fab classification of acute leukemias 53
Fetal hemoglobin 26, 27
Fever 51
Fibrinolysis abnormalities 112
Fibrotic stage 67
Filariasis 48
Fine needle aspiration cytology 93
Fluorescent in situ hybridization 70
Folate deficiency 48
Index
Folic acid 8
and iron deficiency 9
deficiency 8, 11, 15
Follicular lymphoma 81, 82, 82f
Fragmentation syndrome 41
Functional disorders of platelet 104f
Fungal infections 48
G
Gallstones 20
Gaucher-like cells 70
Giant
megakaryocytes 66
metamyelocytes 10
Glandular fever 51
Glanzmann thrombasthenia 100, 104
Glucose-6-phosphate dehydrogenase
deficiency 20
Gold standard test 7
Granulomatous
diseases 15
disorders 48
Gum bleeding 102
H
Haemophilus influenzae 33
Hairy cell 75
leukemia 49, 75, 81
Hand-Schller-Christian disease 96
Hay fever 48
Heavy
chain disease 81
menstrual bleeding 120
Heinz bodies 21, 21f
Hematologic malignancies 49, 104
Hematopoietic stem cell 63
Hemoglobin 6, 9, 21, 25, 58
concentration 3
electrophoresis 26, 27, 34
Hemolytic anemia 4, 16, 23
Hemolytic
crisis 33
disease of newborn 36, 39
Hemophagocytic syndrome 15
Hemophilia 106
A 106
B 108
Hemorrhage 41
Hemorrhagic
bleeding 111
diathesis 99, 111
disorders 99
Henoch-Schnlein purpura 100
Hereditary
coagulation disorders 105, 106, 109t
disorders 29
hemolytic anemia 23
spherocytosis 17, 122
High-performance liquid
chromatography 35
Hodgkin
cells 87, 90, 91
lymphoma 48-50, 81, 87, 88t, 90f, 93,
93f, 94, 94t, 126
Hookworm infestation 48
Humoral immune deficiency 80
Hydrops fetalis 38
Hypercoagulable state 113, 115
Hypereosinophilic syndrome 48
Hypersegmented neutrophil 9f
Hypocellular bone marrow 13
Hypochromia 6
Hypofunction of spleen 33
Hypovolemic shock 33, 41
I
Immune
thrombocytopenia 115
thrombocytopenic purpura 102
Immunoglobulin deposition disease
76, 80
Immunohemolytic anemias 36
Impaired
absorption 5, 8
DNA synthesis 8
red cell production 4
Inactivates nitric oxide 31
Inactivation of nitric oxide 31
Incubation period 51
Indirect antiglobulin test 39, 40
Infectious
hepatitis 49
mononucleosis 45, 49
Inflammatory
bowel disease 49
diseases 49
Inherited hypercoagulable states 114
Intestinal metaplasia 12
Intravascular hemolysis 41
Iron
deficiency 104, 120
anemia 5, 6, 8, 27, 28t, 42, 120
deficient erythropoiesis 6
depletion 6
overload 24
Irreversibly sickled cells 31
Ischemic necrosis 111
J
Jaundice 20
K
Koilonychia 7
nails 120
Kostmann syndrome 48
L
Lacunar cell. 89
Langerhans cell 95
histiocytosis 95
LE cell test 40
Letterer-Siwe disease 96
Leukemia 15, 55
Leukemic meningitis 56
Leukemoid reaction 47
Leukocyte
alkaline phosphatase 47
common antigen 82
Leukocytosis 45, 66
Leukoerythroblastosis 67
Leukopenia 46
Life-threatening bleeding 106
Location of hemolysis 16, 17
Lefflers syndrome 48
Loss of
architecture 84
intravascular volume 41
lymph node architecture 89
membrane fragments in circulation 17
Lupus anticoagulant antibody 114
Lymph nodes 74, 82, 86, 87
Lymphoblast 54
Lymphocyte
depleted classical Hodgkin lymphoma
81, 87, 91
predominant cells 92
rich classical Hodgkin
lymphoma 81, 87, 90
Lymphocytopenia 50
Lymphocytosis 49
Lymphoid neoplasms 81
Lymphoma 15, 55
Lymphoplasmacytic lymphoma 81
M
Macroangiopathic hemolytic anemia 41
Malignant
disease of bone marrow stem cell 52
lymphoid
cells 82f
neoplasms 87
137
138
Mantle cell lymphoma 81

Marrow
aplasia 15
infiltration 4, 48
Massive splenomegaly 75
Mature
B cell neoplasms 81
T and NK cell neoplasms 81
T cell and NK cell neoplasms 85
Mean corpuscular
hemoglobin 5
concentration 5, 31
volume 4
Measles 49
Mediastinal
lymph nodes 88
thymic mass 56
Medium-sized cells 84
Megakaryocytic
hyperplasia 123
leukemia 53
Megakaryopoiesis 18, 66, 77
Megaloblastic
anemia 8, 9, 11, 13, 15, 46, 48, 121
precursors 11f
Menorrhagia 102
Metastatic tumors 48
Microangiopathic hemolytic anemia 41,
111
anemia 7, 25, 120
red blood cells 6f
Micronormoblastic maturation 7
Microscopically myeloblasts 59
Microvascular thrombi 111
Mild erythroid hyperplasia 27
Miliary tuberculosis 50
Missense point mutation 30
Mixed cellularity classical Hodgkin
lymphoma 81, 87, 90
Mode of
inheritance 106
onset 16
transmission 51
Monoclonal
gammopathy of
uncertain significance 80
undetermined significance 76
spikes 78
Monocytic leukemia 53
Monocytosis 49
Monomorphic lymphoid cells 83
Mononuclear cells 51
Morphological classification of anemia 3t
Morphology of
myeloblasts 58
neoplastic cells 88
Mucosal bleeding 102
Multiple
myeloma 49, 76, 78f, 125
tumor masses 76
Mumps 49
Mutated tyrosine kinase activation 58
Mycosis fungoides 81, 86
Myelodysplastic syndromes 15, 48, 54,
60, 104
Myelofibrosis 15, 64
Myeloid
hyperplasia 70
proliferation 54
sarcoma 54, 59
Myeloma 15
kidney 79
plasma cells 77
Myelomonocytic leukemia 53
Myelophthisic anemia 4
Myelopoiesis 18, 66, 77
Myeloproliferative neoplasms 62, 68, 104
N
Neoplastic
cells 88
follicles 82
T cells 86
Nephrotic syndrome 79
Neutropenia 47
Neutrophilia 46
Nodular
lymphocyte predominant Hodgkin
lymphoma 87, 92
sclerosis classical Hodgkin lymphoma
81, 87, 88
Non-Hodgkin lymphoma 48, 49, 94, 94t
Non-neoplastic cells 87, 88
Non-steroidal anti-inflammatory drugs
104
Non-tender cervical lymphadenopathy
125
Nonthrombocytopenic purpura 99
Normochromic normocytic anemia 67
Normocytic normochromic anemia
38, 42, 70
Nucleated red cell precursors 25
Nucleus of macrophage 83
Numbness of both lower limbs 121
Nutritional deficiencies 15
O
Osmotic fragility test 19, 19f, 122
Osteosclerotic myeloma 76
P
Pancytopenia 13, 75
Pappenheimer bodies 42
Parietal cell antibody 12
Paroxysmal
cold hemoglobinuria 40
nocturnal hemoglobinuria 15, 41
Pathogenesis of
iron deficiency anemia 6
megaloblastic change 8
Rh hemolytic disease of newborn 37f
sickle cell anemia 30f
thrombosis 111f
Pathognomonic
Birbeck granules 95
of Hodgkin lymphoma 88
Pathophysiologic classification of
polycythemia 63t
Patterson-Kelly syndrome 7
Paul Bunnell test 51
Pemphigus 48
Periodic acid Schiff stain 54f
Peripheral
blood smear 6f, 9f, 56
lymph nodes 90
T cell lymphoma 81, 85
Pernicious anemia 11, 12
Persistent thrombocytopenia 71
Pharyngitis 51
Philadelphia chromosome 47, 68, 69f, 70
Pigment gallstones 122
Plasma
cell 89
myeloma 76
neoplasm 76, 81
lactate dehydrogenase 11
Plasmacytoma 76, 80
Plasmodium falciparum gametocyte 132
Platelet
count 64, 107
function disorders 100
Plummer-Vinson syndrome 7
Poems syndrome 76
Polychromatophilia 21, 33
Polycythemia 48, 63
vera 62, 63, 64f, 65f, 104
Precursor lymphoid neoplasms 81
Index
Premature
destruction of spherocytes 17
RBC destruction 36
Primary
amyloidosis 80
antiphospholipid syndrome 115
hemostatic plug 99
myelofibrosis 62, 66
Produces hemolytic anemia 30
Progressive cytopenias 60
Proliferating hematopoietic stem cells 68
Promyelocytic leukemia 53
Protein C and S deficiency 114
Prothrombin time 107
Pseudo Gaucher cells 70
Pulmonary eosinophilia 48
Q
Qualitative
disorders of leukocytes 50
platelet disorders 101, 104
Quantitative
and qualitative disorders of
leukocytes 45
deficiency of vWF 109
disorders of leukocytes 45
platelet disorders 101
R
Raspberry-red tongue 121
RBC enzyme analysis 21
Reactive marrow fibrosis 66
Recurrent splenic infarction 32
Red cell
count 64
distribution width 5
indices 43, 6, 9, 18, 25
protoporphyrin 7
size 3
Reed-Sternberg cells 87, 88, 89f, 90, 91
Refractory
anemia with
excess blasts 61
ring sideroblasts 61
cytopenia 61
with multilineage dysplasia 61
Renal
disease 80
failure 79, 104
function tests 78
Repeated spontaneous abortions 115
Respiratory distress syndrome 110
Reticulocyte
count 6, 25, 15, 18, 21, 33, 38
hemoglobin 7
Rh
hemolytic disease of newborn 37
incompatibility 37
Rheumatoid arthritis 49
Ring sideroblasts 42
Rouleaux formation 131
Roundworm infestation 48
Russells viper venom 115
S
Salmonella typhimurium 33
Sarcoidosis 15, 49
Scabies 48
Schilling test 11, 12
Secondary
antiphospholipid syndrome 115
hemostatic plug 99
Sequestration crisis 33
Serum
albumin 78
bilirubin 11, 34
ferritin 7, 26
folic acid levels 11
haptoglobin 26, 34
homocysteine 11
iron 7, 26
and ferritin 11
status 26
transferrin
receptor 7
saturation 7
vitamin B12 11
and uric acid 65
Severe
anemia 7
hemolytic anemia 23, 38
infections 48
Severity of bleeding 101
Sex-linked recessive disorders 106
Szary
cells 86
syndrome 81, 86
Sickle
cell
anemia 29, 32f, 33, 122
disease 29
trait 34
hemoglobin 29
Sickled red cells 35f
Sickling
crisis 32
test 34, 35, 35f
Sideroblastic anemia 8, 42
Skin
bleeding 102
diseases 48
Small
lymphocytic lymphoma 73, 81
T lymphocytes 89
Sore throat 51
Spherocytes and raised osmotic
fragility test 122
Splenic B cell marginal zone
lymphoma 81
Spoon shaped nails 120
Stages of
erythropoiesis 128
Hodgkin lymphomas 94t
megakaryopoiesis 129
myelopoiesis 132
Starry sky appearance 84f
Striking basophilia 71
Structure of red cell membrane 17f
Subacute combined demyelination 13
Subleukemic leukemia 52
Substitution of glutamic acid 30
Sudden trapping of blood 33
Suppression of stem cells 48
Synthesis of fetal hemoglobin 23
Syphilis 49
Systemic lupus erythematosus 49
T
T cell
large granular lymphocytic
leukemia 81
prolymphocytic leukemia 81
T lymphoblastic leukemia/lymphoma 81
Target cells 122
Thalassemia syndrome 22
Thrombocytopenia 100, 101
Thrombocytosis 101, 104
Thrombotic disorders 99, 100, 113
Total
iron binding capacity 26
leukocyte count 46, 47, 51, 70
plasma iron-binding capacity 7
WBC count 58
Tourniquet test 103
Toxoplasmosis 49
Traditional classification of leukemia 53t
139
140
Tropical eosinophilia 48
Tuberculosis 15, 49
Tumors 15
Types of
antiglobulin test 39
immune thrombocytopenic
purpura 102
Langerhans cell histiocytosis 96t
white blood cell 45
U
Ulcerative colitis 49
Unconjugated bilirubin 38
Urine urobilinogen 26, 34
Urticaria 48
Uses of
direct antiglobulin test 39
indirect antiglobulin test 40
V
Vascular
disorders 110
purpura 99
Vessel wall abnormalities 99
Viral
hepatitis 108
infections 45, 48, 49
Vitamin
B12 8, 15, 48
absorption 12
deficiency 8, 11
K deficiency 105
von Willebrand disease 105, 108
W
White cell count 64
WHO classification of
acute
leukemia 53
lymphoblastic and myeloid
leukemia 53t
Hodgkin lymphoma 87t
lymphoid neoplasms 81t
MPN 62
myelodysplastic syndromes 61t
myeloproliferative neoplasm 62t
Widespread exfoliative erythroderma 86
Wiskott-Aldrich syndrome 100

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Rapid Review

Sharada Rai MBBS MD

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd

Jaypee-Highlights Medical Publishers Inc

Jaypee Medical Inc

Jaypee Brothers Medical Publishers (P) Ltd

Jaypee Brothers Medical Publishers (P) Ltd

BANGALORE MEDICAL COLLEGE

AR Raghupathy MBBS MD PGDHHM (IGNOU)

How to use this book

2. Hemolytic Anemias Due to Red Cell Membrane and Enzyme Defects

Classification of hereditary defects in hemoglobin 22

4. Sickle Cell Disease

Sickle cell disease 29

Rapid Review of Hematology

Section 2: Disorders of White Cells

Normal differential leukocyte count (DLC)45

Myeloproliferative neoplasms (MPN)62

10. Chronic Myelogenous Leukemia

Chronic myelogenous leukemia 68

11. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Chronic lymphocytic leukemia 73

12. Plasma Cell Neoplasms

Plasma cell myeloma (multiple myeloma) 76

13. Lymphoid Neoplasms

Classification of lymphoid neoplasms 81

14. Hodgkin Lymphomas

15. Langerhans Cell Histiocytosis/Histiocytosis X

Section 3: Disorders of Hemostasis

17. Bleeding Disorders: Due to Abnormalities of Coagulation/Clotting Factor

Classification of coagulation disorders 105

18. Thrombotic Disorders: Hypercoagulable State

Hypercoagulable state (Thrombophilia) 113

Section 4: Clinical Scenario

Symptoms and signs that suggest a blood disease 119

Anemias of Impaired Red Cell Production CHAPTER 1

WHO criteria for anemia:

mild (Hb 9.110.5 g/dL),

TABLE 1.1: Morphological classification of anemia

Smaller than normal

Larger than normal

Central pallor in RBCs

More than 1/3

Reduced (< 80 fL)

Normal (8298 fL)

Increased (>100 fL)

Reduced (< 30 g/dL)

Normal (3136 g/dL)

Normal (3136 g/dL)

Iron deficiency anemia,

During blood loss, anemia of

Classification: anemias are

Spurious anemia is the

SECTION 1 Disorders of Red Cells

Anemia is the expression

2. Etiological classification: The etiological classification of anemia is listed in Table 1.2.

Disturbed Proliferation and Maturation of Erythroblasts

2. INCREASED RED CELL DESTRUCTION (HEMOLYTIC ANEMIAS)

Intrinsic (Intracorpuscular) Abnormalities

RED CELL INDICES

Q. Write short notes on red cell

Anemias of Impaired Red Cell Production CHAPTER 1