DISORDERS OF WHITE

BLOOD CELLS
 OBJECTIVES
• Hematopoeisis
• Leukocytes – Types, Proliferative disorders
• Neutropenia & Agranulocytosis
• Leukemia
• Classification
 HEMATOPOIESIS

Vertebrae
Ribs
Sternum
Skull
Pelvis
Proximal epiphysis –
humerus & femur
 LEUKOCYTES/WBC
GRANULOCYTES
NEUTROPHILS
EOSINOPHILS
BASOPHILS
Azurophilic (primary) granules - Lysosomal enzymes
Specific (secondary) granules - Lactoferrin, collagenase,
muramidase, alkaline phosphatase, lysozyme
LYMPHOCYTES
MONOCYTES
 HEMATOPOEITIC STEM CELL

MULTIPOTENT PROGENITOR
cKIT, Sca-1+, LIN-

EARLY PROGENITOR WITH EARLY PROGENITOR

MYELOID POTENTIAL WITH LYMPHOID
IL-3,GM-CSF,IL-6
POTENTIAL

THROMBOPOIETIN,IL-11

CFU - Mix CFU – b/M/E PRO-B PRO-NK PRO-T

IL-5 M-CSF G-CSF

B B
O O
CFU-Meg N N T
CFU-M CFU-G CFU-E CFU-b
CFU-Eo H
THROMBOPOIETIN ERYTHROPOIETIN E E
Y
M M
M U
A A
EOSINOPHILO MONOBLAST MYELOBLAST R S
BLAST R
R R
O O
W W
MEGAKARYOBLAST PROERYTHOBLAST BASOPHILOBLAST

EOSINOPHIL MONOCYTE/ NEUTROPHIL PLATELETS ERYTHROCYTE BASOPHIL PLASMA CELL NK CELL T CELL
MACROPHAGE
 LEUKOCYTOSIS

• Normal WBC count – 4,000 – 11,000cmm

• ↑ WBC Count – Leukocytosis
Physiological
Pathological
Increased Production in the Marrow
• Chronic infection/inflammation
• Myeloproliferative disorders

Increased Release from the Marrow Stores

• Endtoxemia
• Infection
• Hypoxia

Decreased Margination
• Exercise
• Catecholamines

Decreased Extravasation into Tissues

• Glucocorticoids
 NEUTROPENIA & AGRANULOCYTOSIS

Leukopenia -  WBC in peripheral blood

Neutropenia -  neutrophils (<2000/cmm)
AGRANULOCYTOSIS -  in neutrophil count
<500/cmm
PATHOGENESIS
1.  or ineffective production
2. Accelerated removal
 OR INEFFECTIVE PRODUCTION
Suppression of myeloid stem cells
1) Aplastic anemia
2) Marrow infiltration – Tumor, granulomatous disease
Suppression of committed granulocyte precursors
1) Drugs – Alkylating agents & antimetabolites
chloramphenicol, sulphonamides
2) Ineffective granulopoiesis – Megaloblastic anemia
ACCLERATED REMOVAL OR DESTRUCTION

• Immunological mediated injury to neutrophils –

Idiopathic, SLE & Drugs
• Splenic sequestration – enlargement of spleen
• Increased peripheral utilisation – Overwhelming
Infections
 MORPHOLOGY IN BONE
MARROW
HYPERCELLULAR MARROW
Excessive destruction, Ineffective granulopoiesis

HYPOCELLULAR MARROW
Seen in agents that suppress or destroy granulocyte
precursors
 CLINICAL COURSE
• Ulcerating necrotising oropharyngeal ulcers,
infections often bacterial or fungal

• Malaise, fever & chills

• <1000/cmm – Severe infections
• <500/cmm – Fulminant infections
• Treatment – Broad spectrum antibiotics/G-CSF
 Case 1
• 49 year old man was admitted for an infected
tooth. Culture was positive or Strep intermedius.
Post extraction he was given ceftriaxone 1 gm twice
a day for 3 weeks
On day 25, he developed a mild rash and fever
Investigations
• Hb - 12gm%
• ANC – 480/cmm
• Platelet count – 2.4 lakhs/mm
 LEUKEMIA
Malignant neoplasm of the hematopoietic stem cell
characterized by unregulated proliferation of one cell
type
Widespread involvement of the bone marrow usually
accompanied by the presence of abnormal cells in the
peripheral blood
CLASSIFICATION
Acute – Lymphoblastic (ALL)/Myeloid (AML)
Chronic – Lymphocytic (CLL)/Myeloid (CML)
 Leukemia
Features Acute Chronic

Cell Blasts Mature

Course Short Prolonged

Prognosis Bad Better

Now good CT*
LYMPHOID LEUKEMIA
NORMAL MATURATION B CELLS
COMMON LYMPHOID PRECURSOR Tdt

Pre-B LYMPHOBLAST Tdt PRECURSOR B LYMPHOBLASTIC LEUKEMIA

NAÏVE B CELL CHRONIC LYMPHOCYTIC LEUKEMIA

MUTIPLE MYELOMA
PLASMA CELL
ACUTE LYMPHOBLASTIC
LEUKEMIA (ALL)
• Group of neoplasms with clonal proliferation of
lymphoid precursors - immature precursor B (pre-B) or
T (pre-T) lymphoblasts
• 85% arise from precursor B cells
• Manifests as childhood acute leukemia with extensive
bone marrow involvement & peripheral blood
involvement
• Peak incidence – 4 years
• Twice common in whites
• Boys>girls
Chromosomal Alterations

B- ALL
• PAX5, E2A,EBF,t(12:21)

T- ALL
• NOTCH 1 mutations
 CLINICAL FEATURES
• Abrupt stormy onset – Presents within 3 months
• Symptoms related to depression of normal marrow
• Fatigue – anemia
• Fever -  WBC  infections
• Bleeding -  platelets (petechiae, ecchymosis, bleeding
gums & epistaxis)
• Bone pain & tenderness – Marrow expansion &
infiltration of the periosteum
• Generalised lymphadenopathy, splenomegaly &
hepatomegaly – neoplastic infiltration
• CNS manifestation – headache, vomiting & nerve
palsies due to meningeal spread
 CLASSIFICATION
1) FRENCH-AMERICAN-BRITISH (FAB)
ALL – L1,L2,L3 (Based on morphology)
2) IMMUNOPHENOTYPE
Terminal deoxynucleotidyltransferase (Tdt) +
B ALL – CD 19, 20 & CD 10 +,PAX5
T ALL – CD 2 & CD 5 +
FAB CLASSIFICATION OF ALL
FEATURES L1 L2 L3

Cell size Small Large, heterogenous Large, homogenous

Cytoplasm Scant Variable Moderate,basophilic

Nucleoli -, Small 1 or more (large) 1 or more

(prominent)
Chromatin Homogenous Heterogenous Finely stippled,
homogenous
Nuclear size Regular Irregular Regular,oval

Cytoplasmic Variable Variable Prominent

vacuolation
IMMUNOLOGICAL CLASSIFICATION
FEATURES B-ALL T-ALL
Incidence 85% 15%
Presentation Usual Mediastinal mass
(thymic
involvement)
Markers CD 19,10 CD 1,2,3,5,7
Cytochemistry PAS + Acid phosphatase
+
Prognosis Good Poor
 ETIOLOGY
1) GENETIC FACTORS – Down syndrome, Fanconi
anemia, Bloom syndrome
2) IATROGENIC FACTORS – Radiotherapy,
Chemotherapy
3) VIRAL INFECTIONS –
• Human T cell leukemia virus -1 (HTLV-1)
• Epstein-Barr virus (EBV)
• Kaposi sarcoma herpes virus (KSHV)
4) CHROMOSOMAL TRANSLOCATIONS &
ONCOGENES

5) CHRONIC INFLAMMATION
• H.pylori infection
• HIV
6) SMOKING
 HEMATOLOGICAL FINDINGS
Peripheral smear
RBC – Normocytic normochromic

WBC – Count , LYMPHOBLASTS 

PLATELETS – Markedly 
HYPERCELLULAR BONE MARROW

TREPHINE BIOPSY
BONE MARROW
Hypercellular marrow
>20% LYMPHOBLASTS
 Normal cells

LYMPHOBLASTS
Condensed chromatin,
inconspicuous nucleoli, scant
ALL-L1
agranular cytoplasm

PAS (Periodic acid schiff) +

MPO (Myeloperoxidase) -
ALL – L2
ALL – L3
PAS positive
Tdt positive blasts
CD 20 POSITIVE
 BAD PROGNOSIS
1) < 2 years
2) Adolescence or adulthood presentation
3) Peripheral blast count >100,000
4) Cytogenetic aberration – t(9;22)
5) Male sex
6) Poor response to treatment
7) ALL – L2,L3 & T-ALL
 CHRONIC LYMPHOCYTIC
LEUKEMIA (CLL)
• Indolent of all leukemias
• Clonal proliferation of B lymphocytes
• Age >60 years
• Accounts for 25% of all leukemia
• Male predominance
• Express B cell antigen – CD19,20
 CLINICAL FEATURES
• Often asymptomatic
• Symptomatic – fatigue, weight loss, anorexia
• 50% Generalised lymphadenopathy,
Hepatosplenomegaly
 HEMATOLOGICAL FINDINGS
• High total WBC count – 200,000/cmm
• Absolute lymphocytosis >4000/cmm
Peripheral smear
Small round lymphocytes with scant cytoplasm
Fragile cells forming Smudge cells + ( crushed nuclei
of lymphocytes) while making smears
CLL
SMUDGE CELLS
 COURSE & PROGNOSIS
• Medial survival – 4-6 years
• Transform to poorly differentiated large cell
lymphoma – Ritcher syndrome
 Myeloid Neoplasms

• Acute Myeloid Leukemia (AML)

• Myelodysplastic Syndromes

• Myeloproliferative Disorders (CML)

ACUTE MYELOID LEUKEMIA ( AML)
• Malignant transformation of myeloid precursor cell
(>20% myeloblasts in marrow)
• Accumulation of immature myeloid forms in the
bone marrow & suppression of normal
hematopoiesis
• Affects predominantly adults (15-39 years)
• 20% childhood leukemia
 MYELOBLAST
• Delicate nuclear chromatin
• 2-4 nucleoli
• Abundant cytoplasm with
fine azurophilic
Myeloperoxidase (MPO) &
Sudan black + granules
• Auer rods
• Markers – CD34 & 15
 WHO Classification of AML
1. AML with Genetic Aberrations
t(8;21), inv16,t(15;17)
2. AML with MDS-like features

3. AML – Therapy related

Alkylator therapy, radiation
4. AML (NOS)
 REVISED FAB CLASSIFICATION OF AML
CLASS INCIDENCE(%) Marrow
morphology
M0 Minimally differentiated 2-3% Myeloblasts MPO -,
AML express myeloid
lineage antigens
M1 AML without differentiation 20% Very immature,
>3% MPO +, Little
maturation beyond
myeloblast stage,
Few Auer
rods/granules
M2 AML with maturation 30-40% Full range myeloid
maturation,
Auer rods ++,
assoc t(8:21)
M3 Acute 5-10% Hypergranular
promyelocyte promyelocytes, Many
leukemia Auer rods+, younger
age, t(15;17)
M4 Acute 15-20% Myelocytic &
myelomonocytic Monocytic
leukemia differentiation
Monoblasts
Nonspecific esterase +
M5 Acute monocytic 10% M5a- >80%
leukemia Monoblasts
(Peroxidase -, NSE +)
M5b – <80%
Monoblasts +
promonocytes
M6 Acute 5% Dysplastic
erythroleukemia erythroid
precursors,>20%
myeloblasts

M7 Acute 1% Blasts of
megakaryoblastic megakaryocytic
leukemia
lineage,
Megakaryocyte
specific antibody +
FEATURES LYMPHOBLASTS MYELOBLASTS MONOBLASTS
(L1)
NUCLEUS ROUND IRREGULAR FOLDED/LOBATED

NUCLEOLI Occ 2-4 +

CYTOPLASM SCANT ABUNDANT ABUNDANT
GRANULES - + +
AUER RODS -- + --
STAINS PAS + MPO+ NSE+
SBB+
MARKERS CD19,20 CD34,15 CD 14, 11b
 AML – M0
• Blasts lack definitive cytologic & cytochemical
markers of myeloblasts
• Resemble myeloblasts ultrastructurally
 AML – M1
• Blasts – agranular
• Auer rods infrequent
 AML – M2

• Most common
• Auer rods frequent
• Good prognosis
 AML – M3
• Hypergranular promyelocytes with numerous
azurophilic granules
• Many Auer rods/cell(Faggot cells)
• High incidence of DIC
Release of procoagulant &
fibrinolytic factors released
by leukemic cells
 t(15;17)
• Results in fusion of a
retinoic acid receptor - 
(RAR -) gene on Ch 17 to a
protein called PML on Ch
15 PML-RARα fused gene
• Interferes with the terminal
differentiation of
granulocytes
 TREATMENT
• High doses of Vit A derivative - all trans retinoic
acid (ATRA) overcomes this block in differentiation
 AML – M4
Infiltration of skin (leukemia cutis) & gingiva
 AML – M5
• Occur in older patients
• High incidence of organomegaly, lymphadenopathy
& tissue infiltration

FOLDED LOBULATED
NUCLEUS
LACK AUER RODS
NONSPECIFIC ESTERASE
POSITIVE
MONOBLASTS
 AML-M5A

POSITIVE

MYELOBLASTS NEGATIVE

MONOBLAST
 AML – M5b

MONOBLASTS PROMONOCYTES

FOLDED NUCLEAR
MEMBRANES
 AML – M6
Seen in advanced age

DYSPLASTIC
ERYTHROID
PRECURSORS

ERYTHROBLASTS
 AML - M7
• Blasts react with platelet specific antibodies
directed against Factor VIII, CD61
• Associated with marrow fibrosis due to release of
fibrogenic cytokines

MEGAKARYOBLASTS
 INVESTIGATIONS
Blood count: RBC - 
WBC - 
Platelets - 

Peripheral smear – Myeloblasts +++

Bone marrow - >20% blasts (M0-M7)

Immunophenotype – Myeloblasts – CD 15+, 34+

Monoblasts – CD 14, 11b
 GRANULOCYTIC SARCOMA
Uncommon presentation
Extramedullary localised masses
composed of myeloblasts &
immature myeloid cells in the
absence of marrow or peripheral
blood involvement
Invariable progress to systemic AML
over a period upto several years
Also called as CHLOROMA – freshly
cut tissue turns light green due to
large amounts of peroxidase being
oxidized on exposure to air
CHLOROMA
CHLOROMA
 CHRONIC MYELOID LEUKEMIA(CML)
• Most common myeloproliferative disorder
• 15-20% of all leukemias
• Cause - Radiation , Benzene exposure
• Clonal proliferation of pluripotent stem cells with
ability to differentiate along myeloid pathways
• Peak incidence – 5th- 6th decade
• Slight male preponderance
 t(9:22)
• Reciprocal balanced translocation of chromosome 9
&22
• BCR (break point cluster region) gene on
Chromosome 22 fused to ABL (Abelson) gene on
Chromosome 9  Chimeric BCR-ABL gene
(Philadelphia Chromosome)
• BCR-ABL gene ↑ Tyrosine Kinase activity  cell
proliferation
 Investigations
• RBC count - ↓
• WBC Count - ↑↑ 100,000/cmm
Peripheral smear
RBC – Normocytic normochromic
WBC – Leuocytosis with left shift(Myelocyte bulge)
All myeloid cells (full maturation) – neutrophils,
bands, metamyelocytes, myelocytes, eosinophils &
↑basophils. Myeloblasts <10%
Platelets - ↑
LAP score (Leucocyte Alkaline Phosphatase)↓ N(30-185)
Peripheral smear
 CLINICAL FEATURES
• Fatigue, anorexia, weight loss, moderate anemia
• Abdominal discomfort - Massive Splenomegaly
 COURSE OF DISEASE
• Slow progression
• Median survival – 3 years
• Progress to accelerated phase
↑Anemia
Thrombocytopenia
↑ Basophils
• Blast phase – Myeloid/lymphoid
TREATMENT – Drugs BCR-ABL inhibitors
 LEUKEMOID REACTION
Benign leucocyte proliferation characterised by a
total WBC count >30,000/cmm with many immature
leucocyte precursors
LEUKEMOID REACTION
 CAUSES
1) Myelocytic – Infections – septicemia,
pneumonia, Burns, Carcinoma colon

NEUTROPHILIC LEUKEMOID REACTION

D/D CML
LAP Score – Increased
Philadelphia chromosome - Negative
2) LYMPHOCYTIC – Infectious mononucleosis, TB,
Chicken pox

3) MONOCYTIC - TB
FEATURE CML LEUKEMOID

WBC Count >100,000 <50,000

WBC Myeloid Mature cells with

precursors <10% bands

LAP score  

RBC Nucleated RBC -

Bone marrow Abnormal Hyperplastic

 LEUCOERYTHROBLASTIC
REACTION
Presence of nucleated RBC’s + immature myeloid cells in
the peripheral smear
• Indicates a space occupying disturbance in marrow
CAUSES
Myelofibrosis
Metastatic tumors
Multiple myeloma
Granulomatous disease
LEUCOERYTHROBLASTIC
REACTION

NUCLEATED RBC

METAMYELOCYTE

NEUTROPHIL

MYELOCYTE
 MYELODYSPLASTIC SYNDROME (MDS)

Clonal stem cell disorder characterized by

maturation defects associated with ineffective
hematopoiesis and an increased risk of
transformation to AML
1) Idiopathic or primary MDS - >50 years
2) Secondary related MDS – Complication of drug or
radiation therapy (t-MDS) appears 2-8 years after
treatment
 PATHOGENESIS
• Mutated genes
• Loss of function of tumor suppressor gene TP53 
assoc with poor outcome
• Chromosomal abnormalities – monosomies 5 &,
del 5q,7q & 20q, trisomy 8
 PERIPHERAL SMEAR
• Pancytopenia
• Macrocytes with poikilocytosis
• Pseudo-Pelger Hüet cells
• Giant platelets
• Blasts<10%
 BONE MARROW
• Hypercellular marrow
• <20% myeloblasts
• Dysplastic differentiation affecting nonlymphoid lineage
ERYTHROID – Megaloblastoid maturation, nuclear
budding, Ringed sideroblasts
MYELOID – Pseudo- Pelger Hüet cells
MEGAKARYOCYTES – Single nuclear lobes or multiple
separate nuclei
RINGED SIDEROBLASTS

PERL’S PRUSSIAN BLUE –

DEMONSTATE IRON
WBC CHANGES
PSEUDO-Pelger Hüet
PSEUDO PELGER HüET CELLS
PAWN BALL MEGAKARYOCYTES
DYSPLASTIC MEGAKARYOCYTES
 CLINICAL FEATURES
• Disease of older age group ( Mean 70 years)
• Incidental detected
• Weakness, infections & hemorrhage 
pancytopenia
• Progression to AML in 10-40%
• Median survival – 9-29 months
• Median survival in t-MDS – 4-8 months
TREATMENT – Allogenic stem cell transplantation
Thalidomide – like drugs & DNA methylation
inhibitors
Myeloproliferative Disorders (MPD)

RBC – Polycythemia Vera (PCV)

WBC - Chronic Myeloid Leukemia (CML)

PLATELETS – Essential Thrombocytosis (ET)

STROMA - Idiopathic Myelofibrosis (IM)

 Polycythemia

• Increased Red cell count, Hemoglobin & PCV above

the normal levels

• Primary or Secondary
 Secondary Polycythemia
Hypoxia
• High altitude
• Cynotic CHD
• Hypoxic lung disease
Inappropriate secretion of erythropoietin
• Renal tumors
• Hepatoma
 Polycythemia Vera

• Myeloproliferative disorder associated with

↑marrow production of RBCs, Granulocytes &
Platelets  Panmyelosis

• 97% assoc with JAK2 mutations – signaling

molecule
 CLINICAL FEATURES
• Incidence 1-3/100,000 per year
• ↑ RBC + Hct + Hyperviscosity responsible for
clinical symptoms
• ↑ total blood flow on venous circulation-
distention of vessels
• Plethora & Cynosis stagnation & deoxygenation of
blood in peripheral vessels
• Headache, dizziness, hypertension
• Pruritis & peptic ulceration  ↑release of
histamine from basophils
• ↑ cell turnover  Hyperuricemia  Gout
Abnormal blood flow & platelet function  bleeding
& thrombotic episodes
Thrombotic episodes
• Myocardial infarction, DVT & Stroke
• Budd Chiari syndrome due to thrombosis of hepatic
veins
 Bleeding episodes
• Minor bleeds  epistaxis, bleeding gums
• Major bleeds
PLETHORA CONJUCTIVAL
CONGESTION
 INVESTIGATIONS
• Hb – 14-28gm/dl
• Hematocrit – 60% or more
• Microcytic anemia – Chronic bleed Iron
deficiency anemia
• WBC – 12,000-50,000/cmm, ↑basophils
• Platelets – 5,00,000/cmm with abnormalities in
morphology, giant platelets
• Erythropoietin levels – normal or low
 Bone Marrow
• Hypercellular
• ↑ RBC & Granulocytic precursors & Megakaryoytes
 TREATMENT
Phelobotomy
• 1 unit of blood removed weekly until Hct <45%
then maintain Hct<45% with occasional
phelobotomy
• Reduce RBC mass extends median survival by 10
years
JAK2 inhibitors
 COURSE OF DISEASE
• Evolve to a “spent phase”  Primary myelofibrosis
& Extramedullary hematopoiesis in the Spleen (
Splenomegaly)

• 2% progress to AML
 MULTIPLE MYELOMA
• Clonal proliferation of abnormal plasma cells
originating in the marrow & characterised by
involvement of skeleton at multiple sites
• Neoplastic plasma cells synthesize complete &/ or
incomplete monoclonal immunoglobulins identified
in the blood & referred to as an M component
• Usually seen in older patients (65-70 years)
 PRESENTATION
• Multiple osteolytic bone lesions – vertebrae, ribs, skull
 Bence Jones Protein
• Free light chains of Ig excreted in the urine
• Diagnosis: Heat coagulation test (40-60◦appear; on
boiling 100◦ disappears & reappears on cooling
• Damages the kidney
 BONE MARROW
• Bone marrow infiltration by neoplastic plasma cells
 Serum Electrophoresis
• Monoclonal gammopathy – M band monoclonal
immunoglobulin
Causes RBC to stick together – Rouleaux formation
 CLINICAL FEATURES
• Pain & pathological #
• Neurological manifestations – Confusion,
weakness, lethargy – Hypercalcemia
• Recurrent bacterial infections – Severe suppression
of normal immunoglobulins
• Renal insufficiency- Bence Jones protein casts in
DCT & CT
 Classic Tetrad of Multiple
Myeloma
CRAB
• Calcium elevation
• Renal Impairment (↑BUN & Creatinine)
• Anemia
• Bone (Bone pain, lytic lesions, fractures)