Dr.

Manel Rathnayake
Consultant Haematologist
Objectives
 To understand the meaning of the terms leucopenia,
neutropenia,leucocytosis, lymphopenia, lymphocytosis,
eosinophilia, basophilia, monocytosis and common causes

 To understand the significance of neutropenic sepsis and

the importance of early identification and treatment

 To know the common disorders associated with white cells

LEUCOCYTES BENIGN DISORDERS
 Quantitative
 Change in number
 Terminology
 Cytosis / philia

 Increase in number above the reference range

 Cytopenia

 Decrease in number below the normal range

 Qualitative
 Morphologic changes
 Functional changes
LEUCOCYTES BENIGN DISORDERS
Quantitative changes (LEUCOCYTOSIS)
 Leucocytes
 Phagocytes
 Granulocytes
 Neutrophils

 Eosinophils

 Basophils

 Mononuclear phagocytic cells

 Monocytes

 Lymphocytes
 B-cells
 T-cells
LEUCOCYTES BENIGN DISORDERS
Quantitative changes

 Total white blood cell count

 Differential count
 Absolute count
 Differential gives the relative percentage of each WBC
 Absolute value gives the actual number of each
WBC/mm3 of blood
 Calculation: absolute count= Total WBC x percentage
Regulation of Haemopoiesis
Under the influence of specific cytokines, common myeloid progenitors
(CMP) in the marrow undergo differentiation into granulocytes
(neutrophils, eosinophils, and basophils) and monocytes,

Maturation stages of granulocytes

Myeloblast, promyelocyte, myelocyte, metamyelocytes, mature granulocyte
(neutrophil, eosinophil, basophil) are.

Granulocytes have primary and

secondary granules
 Blood neutrophils themselves spend little time- (6-10 hours in blood) in the
circulation, and instead rapidly enter inflamed tissues Then, Spend 4-5 days in
tissues.
Physiology of white cells
 Granulocytes and monocyte production is restricted to bone
marrow after birth.
 Some lymphocytes are produced outside the bone marrow ie. in
lymph nodes
 Most neutrophils remain in reserve within the marrow storage
pool, ready to enter the circulation when triggered by infection or
inflammation
 In the bloodstream there are two pools usually of about equal size:
the circulating pool (included in the blood count) and a
marginating pool -found loosely adherent to vascular
endothelium(not included in the blood count).
 Neutrophils in the marginal pool rapidly enter the circulation by
de-marginating in response to physical or emotional stress.
 Function of the Circulating Neutrophils
Circulating neutrophils enter inflamed tissues by responding to chemotaxis.
Neutrohils have adhesion molecules on cell surface which react with
endothelium by first rolling along and firmly binding to activated endothelium
and then passing transendothelially through postcapillary venules and into
inflamed tissues.

Attachment/rolling Adhesion
Activatio
n

Migratio
Chemoattractant

Main Functions:
migration, phagocytosis, Phagocytosis
killing
J. Levine
12
Neutrophilia

Neutrophil count
11x109/L in adults
 Causes of Neutrophilia
1. Physiological conditions- 1. Drugs (e.g. corticosteroid therapy
Pregnancy/ age related(neonates) (inhibits margination):lithium,
2. Bacterial infections (especially tetracycline)
pyogenic bacterial, localized or 2. Myeloproliferative disease,
generalized) 3. Chronic myeloid leukaemia,
3. Inflammation and tissue necrosis polycythaemia vera, myelofibrosis,
4. (e.g. myositis, vasculitis, cardiac essential thrombocythaemia
infarct, trauma, autoimmune 4. Treatment with G‐CSF
disorders
5. Metabolic disorders (e.g. uraemia,
eclampsia, acidosis, gout)
6. Neoplasms of all types
(e.g.carcinoma,
lymphoma,melanoma)

Acute haemorrhage or haemolysis

 Infections is the commonest cause of
neutrophilia.
 Left Shift: When increase numbers of
band forms of and some maturation
stages of granulocytes in circulation
 Leukaemoid reaction: When we see
blast cells as well

 NAPScore is useful to confirm

leukaemoid reaction from chronic
myeloid leukaemia,
 NAP score is low in CML

 Leucoerythroblastic reaction

 Causes of leucoerythroblastic blood film.

 Metastatic neoplasm in the marrow
 Primary myelofibrosis
 Acute and chronic myeloid leukaemia
 Myeloma, lymphoma
 Miliary tuberculosis
 Severe megaloblastic anaemia
 Severe haemolysis
 Osteopetrosis
LEUCOCYTES BENIGN DISORDERS
Quantitative changes -LEUCOPENIA

 Definition
Total WBC lower than the reference range for the
age is defined as leucopenia

 Leucopenia may affect one or more lineages and it is

possible to be severely neutropenic or lymphopenic
without a reduction in total white cell count.
Quantitative changes- NEUTROPENIA contd.

 Neutropenia is an absolute reduction in the number of

circulating neutrophils
 Mild (1- 1.5 x 109/L)
 Moderate (0.5 – 1 x 109/L)

 Severe (<0.5 x 109/L)

 Symptoms are rare with the neutrophil count above 1 x 109/L

 Bacterial infections are the commonest
 Fungal, viral and parasitic infection are relatively uncommon
Clinical features
Severe neutropenia is associated with
infections of the mouth and throat.
Painful and often intractable
ulceration may occur.
Septicaemia is a life threatening
condition.
Organisms carried as commensals
by normal individuals, such as
Staphylococcus epidermidis
or Gram‐negative organisms in the
bowel, may become pathogens.
Culture :
Blood – peripheral vein
– central venous cannulae
Urine
Swab at potential site of sepsis
FBC
Biochemistry
CRP
Consider CXR
Quantitative changes -NEUTROPENIA contd.
 Causes of Neutropenia
 Racial  Immune disorders
 Congenital  HIV
 Cyclical neutropenia  SLE
 Felty’s syndrome
 Neonatal isoimmune and
Bone Marrow autoimmune neutropenia
 Marrow aplasia
 Marrow infiltration  Hyperslplenism
 Megaloblastic anemia
 Irradiation exposure

 Infections
 Typhoid, Miliary TB, viral
hepatitis

 Drugs( chemothrapy,
carbimazole)
Quantitative changes -NEUTROPENIA contd.
 Management of Neutropenia
 Remove the cause if possible

 Isolation and other supportive treatment

 Treat any infection aggressively or prophylactic antifungal

agents or antibacterial agents

 Other possible options

 Growth factors, corticosteroids, monoclonal antibody- Rituximab
 Splenectomy
Management of Neutropenia
 Early recognition and vigorous treatment with antibiotics, antifungal or
antiviral agents, as appropriate, is essential.
 Prophylactic antifungal agents or antibacterial agents to prescribed.eg.
fluconazole, are often given and antibacterial agents, e.g. ciprofloxacin,
may reduce the risk but resistance is of concern(discuss with the
microbiology team)
 G‐CSF is effective at raising the neutrophil count in a variety of benign
chronic neutropenic states.
 Corticosteroid therapy or splenectomy has been associated with good
results
in some patients with autoimmune neutropenia.
 Corticosteroids impair neutrophil function and should not be used
indiscriminately in patients with neutropenia.
 Rituximab (anti‐CD20) may also be effective, although it may itself be a
cause of neutropenia.
 Cyclical neutropenia

 Regular recurring episodes of severe neutropenia

(<0.2 x 109/L) usually lasting for 3-6 days

 Can be familial & inherited with maturation arrest

 Three suggested mechanisms for cyclical

neutropenia
 Stem cell defect & altered response to growth factors
 Defect in humoral or cellular stem cell control
 Periodic accumulation of an inhibitor
LEUCOCYTES BENIGN DISORDERS
Quantitative changes -EOSINOPHILIA
 Increase in the eosinophil count (>0.5 x 109/L)
 The causes of eosinophilia can be considered under following
headings
 It is most frequently due to
 allergic diseases,
 parasites,
 skin diseases or
 drugs.
 Eosinophilia-causes
 Allergic diseases, especially tumours
hypersensitivity of the atopic type (e.g.  Metastatic malignancy with tumour
bronchial asthma, hay fever, urticaria necrosis
and food sensitivity)  Chronic eosinophilic leukaemia
 Parasitic diseases (e.g. amoebiasis,
hookworm, ascariasis,tapeworm
infestation, filariasis, schistosomiasis  Hypereosinophilic syndrome
and trichinosis)  Pulmonary syndromes
 Recovery from acute infection  Eosinophilic pneumonia, transient
 Certain skin diseases (e.g. psoriasis, pulmonary infiltrates (Loeffler's
pemphigus and dermatitis syndrome), allergic granulomatosisa
herpetiformis, urticaria and (Churg– Strauss syndrome), tropical
angioedema, atopic pulmonary eosinophilia
 dermatitis)  Myeloproliferative diseases
 Autoimmune conditions  Drugs
 Polyarteritis nodosa, vasculitis, serum  GM‐CSF, granulocyte–macrophage
sickness colony‐stimulating factor.
 Graft‐versus‐host disease
 Malignancy
 Hodgkin disease and some other
Quantitative changes -EOSINOPHILIA -Contd.
 Hypereosinophilic syndrome
 Criteria of diagnosis
 Peripheral blood eosinophil >1.5 x 109/L
 Persistence of counts more than 6 months
 End organ damage
 Absence of any obvious cause for eosinophilia
 Organ most commonly involved
 Heart

 Lung

 Skin

 Neurological
Quantitative changes- LYMPHOCYTOSIS

 The blood contain only few percent of total body lymphocytes

 Lymphocytosis often occurs in infants and young children in
response to infections that produce a neutrophil reaction in
adults.
 The most consistent variation is seen with age
 Recall- physiology
 In postnatal life, the bone marrow and thymus are the
primary lymphoid organs in which lymphocytes develop.
 The secondary lymphoid organs in which specific
immune responses are generated are the lymph nodes,
spleen and lymphoid tissues of the alimentary and
respiratory tracts.
 The immune response depends upon two types of
lymphocytes, B and T cells , which derive from the
haemopoietic stem cell.
 B cells mature in the bone marrow and circulate in
the peripheral blood until they undergo recognition of
antigen.
 Recall- physiology
 The B‐cell receptor (BCR) is membrane‐bound immunoglobulin and
binds to a specific antigen

 The B cell then matures into a memory B cell or plasma cells

 T cells develop from cells that have migrated to the thymus

where they differentiate into mature T cells during passage
from the cortex to the medulla.

 The mature helper cells express CD4 and cytotoxic cells

express CD8
 Natural killer (NK) cells are cytotoxic CD8+ cells that lack the T‐cell
receptor (TCR). They are large cells with cytoplasmic granules
Lymphocytosis
 Causes of lymphocytosis.
 Infections
 acute:
 infectious mononucleosis, rubella,
pertussis, mumps, acute infectious
lymphocytosis, infectious hepatitis,
 cytomegalovirus, HIV, herpes
simplex or zoster
 chronic:
 tuberculosis, toxoplasmosis,
brucellosis, syphilis
 Thyrotoxicosis
 Malignancy
 Chronic lymphoid leukaemias
 Acute lymphoblastic leukaemia
 Non‐Hodgkin lymphoma (some)
Quantitative changes -LYMPHOCYTOSIS
 Infectious Mononucleosis
 Epstein-Barr virus infection
 IMN occurs only in minority of infected patients(most
infections are subclinical)
 Saliva from infected person is the main contagion
 Virus infect epithelial cells and B cells
 Lymphocytosis caused by clonal expansions of T cells
reacting against B lymphocytes Infected with EBV
 The majority of patients are between the ages of 15 and 40
years.
 Clinical features- IMN
 Fever may be mild or severe.
 Over half of patients have a sore throat with inflamed oral
and pharyngeal surfaces. Follicular tonsillitis is frequently
seen.
 A morbilliform rash, severe headache and eye signs
(e.g.photophobia, conjunctivitis and periorbital oedema)
are not uncommon.
 The rash may follow therapy with amoxicillin or ampicillin.
.
 Clinical features- IMN
 Bilateral cervical lymphadenopathy is present in 75% of
cases.
 Symmetrical generalized lymphadenopathy occurs in 50%
of cases. The nodes are discrete and may be tender.
 Palpable splenomegaly occurs in over half of patients and
hepatomegaly in approximately 15%.
 Approximately 5% of patients are jaundiced.
 Peripheral neuropathy, severe anaemia (caused by
autoimmune haemolysis) or purpura (caused by
thrombocytopenia) are less frequent complications
Infectious mononucleosis-
Diagnosis
 WBC/DC, Blood picture
 A moderate rise in white
cell count (e.g. 10–20 ×
109/L) with an absolute
lymphocytosis is usual,
and some patients have
even higher counts.
 Large numbers of
atypical lymphocytes are
seen in the peripheral
blood film
Infectious mononucleosis- Diagnosis
 serological tests to detect heterophil antibodies
(monospot test, Paul Bunnel test –during 2nd to 3rd week.)
 a rise in the titer of IgM antibody against the EBV capsid
antigen (VCA) may be demonstrated during the first 2–3
weeks
 Do not do lymph node biopsy.
 Histological appearances are very similar to large cell
lymphoma.
 Self limiting infection
 Differential diagnosis
 HIV or toxoplasmosis infection; acute leukaemia;
 influenza; rubella; bacterial tonsillitis; and infectious
 clinical application of GCSF
 Post‐chemotherapy, radiotherapy or stem cell
transplantation
 In these situations, G‐CSF accelerates granulocytic recovery and shortens the period of neutropenia
 This may translate into a reduction of length of time in hospital, antibiotic usage and frequency of infection
but periods of extreme neutropenia after intensive chemotherapy cannot be prevented. The injections may also
allow repeated courses of chemotherapy, e.g. for lymphoma, to be given on schedule rather than being delayed
because of prolonged neutropenia, particularly a problem in older patients.

 Myelodysplasia and aplastic anaemia

 G‐CSF has been given alone or in conjunction with erythropoietin in an attempt to improve bone marrow function
and the neutrophil count.

Severe benign neutropenia

Both congenital and acquired neutropenia, including cyclical and drug‐induced neutropenia,
often respond well to G‐CSF.
 Peripheral blood stem cell mobilisation
 G‐CSF is used to increase the number of circulating multipotent progenitors from donors or the patient, improving the
harvest of sufficient peripheral blood stem cells for allogeneic or autologous transplantation.
Myeloproliferative diseases
Myeloproliferative Neoplasms (MPN)
 Myeloproliferative Neoplasms (MPNs): are a
group of neoplastic conditions in which genetic
alteration occurs in hematopoietic progenitor cells
leading to proliferation . The result is an increase in
white blood cells (WBCs), red blood cells (RBCs),
platelets, or a combination of these cells.

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Myeloproliferative Neoplasms
(MPN)
- Overproduction of terminally differentiated cells of
the myeloid lineage

Polycythemia Vera (PRV)

Essential Thrombocythemia (ET)
Primary Myelofibrosis (PMF)
Chronic Myeloid Leukemia (CML))

41
 Primary
Polycythemia
 Polycythemia Rubra Vera
Due to genetic alteration in haemopoietic progentors
Eythropoietin level is low

02/12/2020 42
 Secondary polycythemia
 Compensatory increase in EPO
 High altitude, cardiac disease, high affinity Hb, heavy
smoking,lung disease, obesity, sleep apn0ea, life at
high altitude, or cyanotic heart disease.
 Inappropriate EPO secretion
 EPO secreting tumours
 HCC, Cerebellar Haemangioblastoma, renal disease

02/12/2020 43
 Relative polycythemia
(decrease in plasma volume)
Two common causes:
▪ Dehydration
(e.g., from vomiting, diarrhoea, excessive sweating, or
diuretics) can deplete plasma volume, leading to a relative
polycythemia.

02/12/2020 44
Polycythaemia Rubra Vera

02/12/2020 45
Treatment of Polycythemia Vera
(PV)
 Control and maintain Hct levels <45%
 Manage disease-related complications of PV
 Venesection to maintain Hct levels <45%
 Low-dose aspirin in appropriate patients
 Hydroxyurea or IFNα as first-line cytoreductive
therapy
 Patients with inadequate response to or intolerance of
HU JAK2 inhibitor( Ruxolitinib) can be given

Hct = hematocrit; HU = hydroxyurea; IFNα = interferon- α

46
 The leukaemias
 The term leukemia refers to a family of malignant
neoplasms of the bone marrow characterized by clonal
proliferation of hematopoietic cells and often
accompanied by circulating immature cells in the
peripheral blood.
Leukaemia
 Leukemia is often accompanied by suppression of normal
hematopoiesis, leading to pancytopenia.

 Neutropenia (<500 neutrophils per microliter of blood)

and thrombocytopenia (<20,000 platelets per microliter of
blood) increase the risk of life-threatening sepsis and
bleeding in patients with leukemia
 Pathogenesis
 Leukemia is a genetic disease associated with
mutations of cellular oncogenes
 Cellular oncogenes are genes that, when expressed
under normal circumstances, support essential cellular
functions such as mitosis and cell death inhibition.
 However, when expressed inappropriately, these same
oncogene products drive mitosis or block apoptosis
in an unregulated fashion.
 Aetiology
 Genetic Abnormalities
 Downs’s syndrome
 Fancony’s anaemia
 Chemical agents (benzene)
 Cytotoxic chemotherapeutic agents
 Infections
 HTLV1 : east Asian countries
 EBV: Burkits lymphoma / ALL
 HIV
 Radiation
 Immunological deficiencies

51
 Classification of leukaemia
Acute Chronic
 Agressive clinical course  Chronic clinical course

 Dominant cell is an  Dominant cell is more

immature blast cell mature

 Classified to
lymphoblastic and  Classified to lymphatic
myeloblastic and myeloid
Clinical features of Acute
leukaemia
 • Weakness, tiredness, malaise
 • Bruising and bleeding secondary to
 thrombocytopenia
 • Otitis media, pharyngitis, pneumonia or fever
 due to bacterial infection caused by profound
neutropenia
 • Bone pain
 • Enlarged lymph nodes
 • Headache and vomiting resulting from CNS
 involvement leading to increased intracranial
 pressure
 Physical findings
 • Pallor
 • Petechial haemorrhages, purpura and bruising
 • Lymphadenopathy
 • Hepatosplenomegaly
 • Bone tenderness
 • Fever
 Gum hypertrophy in some leukaemias
 Laboratory features

 • Anaemia
 • Leucopenia
 • Thrombocytopenia
 • Blood film may show circulating blast cells
 • Bone marrow usually heavily infiltrated with blast
cells (>20%)
Differential diagnosis: clinically
 Other causes of ulceration of mouth
 Infectious mononucleosis:
sore throat
lymphadenopathy
splenomegaly

 Joint and bone pain:

Acute osteomyelitis
Rheumatic fever
Fever and malaise
 Treatment
 General considerations
 Symptomatic and supportive therapy
 Specific therapeutic agents
 Therapy in individual patients
 Bone marrow transplantation
 Symptomatic and supportive
therapy
 Insertion of a central venous catheter
 Blood product support
 Anti‐emetic therapy
 Tumour lysis syndrome
 Psychological support
 Reproductive issues
 Nutritional support
 Pain
 Prophylaxis and treatment of infection
 Role of nursing in acute
leukaemia
Neutropenic sepsis
A protocol for the management of fever in the
neutropenic patient
Cultures, line care, mouth care, monitoring for septic
shock, antibiotics etc
Physiological support patient and the family
Chronic leukaemias
Chronic lymphocytic leukaemia
 Clonal proliferation of mature lymphocytes
 Disease of old age (over the age of 40yrs)
 Males affected twice the females
 Onset insidious
 Very often the incidental finding.
 Without treatment 10 yrs
 Often patients die of some other reason
Clinical features
 Enlargement of superficial lymph nodes
 Anaemia:
 Constitutional symptoms
 Splenomegaly
 Respiratory and other infections
 Lesions of the skin
Chronic myeloid leukaemia
 Due to proliferation of more mature myeloid cells
(myelocyte and mature neutrophils) is the most
prominent cell.
 Associated with Philadelphia chromosome (9/22
translocation).
 Triphasic disease: Chronic phase
Accelerated phase
Blastic phase
CLL CML
Chronic Myeloid Leukemia
Clinical Presentation
 ▪A disease of middle life, rare under the age of 20yrs.
Onset insidious
 Asymptomatic (~ 30%)

▪ Fatigue, weight loss, fever

▪ Abdominal fullness, pain and/or early satiety due to splenomegaly

(~ 50-90%)

▪ Easy bruising and purpura

▪ Leukostasis
▪ Pulmonary symptoms
▪ Neurologic symptoms
Other malignancies of White cells
 Lymphoma
 Multiple Myeloma