•  12

Rib
Posterior Thoracic Landmarks Reference Lines
–  midway b/t spine & side

•  Vertebra Prominens
Posterior Thoracic Landmarks
–  Flex head, feel most prominent bony •  Anterior Chest
Reference Lines
CD-A (PHYSICAL • DIAGNOSIS)
projec2on at base of neck = C7 next
Vertebra Prominens REFERENCE LINES
lower one is T1
2.2 Thorax and Lungs (Part –  Flex head, feel most prominent bony
1) ANTERIOR CHEST – • Midsternal line
Anterior Chest
projec2on at base of neck = C7 next
- Midsternal –  Midclavicular line
line–  Midsternal line
Lecturer: Dr.•  Jessica Catalan lower one is T1
Spinous Processes
–  spinal column
- line
Midclavicular –  Midclavicular line
OUTLINE: •  Spinous Processes
1. ANATOMIC STRUCTURES –  spinal column

•  Scapula
2. SUBJECTIVE DATA AND DIFFERENTIALS
–  symmetrical , lower 2p at the 7 -8
•  Scapula th Rib

2.1. CHEST PAIN –  symmetrical , lower 2p at the 7 -8th Rib
2.2. DYSPNEA
•  12th Rib
2.3. COUGH AND HEMOPTYSIS •  12th Rib
–  midway b/t spine & side
3. OBJECTIVE DATA –  midway b/t spine & side POSTERIOR CHEST
•  Posterior Chest
3.1. INSPECTION - Vertebral line – midspinal
3.2. PALPATION - –  Vertebral line – midspinal
Scapular line
3.3. PERCUSSION –  Scapular line
3.4. AUSCULTATION

ANATOMIC STRUCTURES 3/10/20

THORACIC CAGE /CAVITY
- Shape- bony, conical shape, narrower at top borders – it is
defined by:
•  Posterior Chest LATERAL CHEST •  Lateral Chest
o Sternum–3parts: manubrium, body, xiphoid process
o
•  Posterior Chest
–  Vertebral line – midspinal
Ribs – 12 pairs, 1st seven attach to the sternum (costal - Lateral Chest
Anterior• Axillary line
–  Anterior Axillary line
Vertebral line – midspinal
cartilages) Ribs– 8, –  Scapular line
9, &10 attach to the costal cartilage - Posterior Axillary line
–  Anterior Axillary line
–  Posterior Axillary line

above, Ribs 11– &Scapular line
12 are floating ribs - Mid–Axillary line
–  Mid–Axillary line
–  Posterior Axillary line
o 12 Thoracic vertebrae
The Thoracic Cavity
–  Mid–Axillary line
o Diaphragm– the floor, separates
the thoracic cavity from
the abdomen •  Medias2num middle of •  A
the thoracic cavity &
contains;
–  Esophagus
–  Trachea
The Thoracic Cavity
–  Heart •  L
- Mediastinum middle
–  Great Vessels of the thoracic cavity & contains;
o Esophagus
•  Pleural Cavi2es on either
o Trachea •  P
side of the medias2num
o Heart
contain the lungs
o Great Vessels 2
-
Pleural Cavities on either side of the mediastinum contain the lungs

Anterior Thoracic Landmarks Lung Borders 2

- Anterior Chest
o Apex 3 -4 cm. above inner 1/3 of the clavicles
•  Suprasternal Notch – U shaped depression o Base – rests on the diaphragm, 6th rib, MCL
•  Sternum – “breastbone” = 3 parts - Lateral Chest
1.  Manubrium o Extends from Axilla apex to 7th –8th rib
2.  Body - Posterior Chest
• ANTERIOR THORACIC LANDMARKS o Apex of lung is at C7 – Base T10 (on deep inspiration
3.  Xiphoid process
- Suprasternal Notch – U shaped depression to T12)
Ø  Angle of Louis – manubriosternal angle con2nuous with
- Sternum – “breastbone” = 3 parts
the 2nd Rib
1. Manubrium
Ø  Costal angle- usually 90
2. Body
0 or <. (increases when rib cage

is chronically overinflated)
3. Xiphoid process
o Angle of Louis – manubriosternal angle continuous with the
2nd Rib ANTERIOR VIEW POSTERIOR VIEW
o Costal angle- usually 900 or <. (increases when rib cage is
chronically overinflated)

•
POSTERIOR THORACIC LANDMARKS
- Vertebra Prominens
o Reference Lines
Flex head, feel most prominent bony projection at base
of neck = C7 next lower one is T1 RIGHT LATERAL VIEW LEFT LATERAL VIEW
- Spinous Processes

•  Anterior Chest
o spinal column
SUBJECTIVE DATA AND DIFFERENTIALS
- Posterior Thoracic Landmarks
Scapula
PULMONARY SYMPTOMS
Reference Lines
o symmetrical , lower tip at the 7 -8th Rib
–  Midsternal line
-
•  Vertebra Prominens
12th Rib CHEST PAIN
o midway b/t spine
–  Flex head, feel most prominent bony • TRACHEOBRONCHITIS
•  Anterior Chest
–  Midclavicular line
projec2on at base of neck = C7 next
& side - PROCESS: Inflammation of trachea and large bronchi
lower one is T1 - Midsternal line
LOCATION:– Upper sternal or on either side of the sternum
- –  Midclavicular line
QUALITY: Burning
CHEST PAIN
–  spinal column
•  Spinous Processes - SEVERITY: Mild to moderate
- TIMING: Variable
- FACTORS THAT AGRAVATE: Coughing
•  DISEASE: TracheobronchiSs So
•  Scapula •  PROCESS: Inflamma2on of trachea and large bronchi My
- FACTORS THAT RELIEVE: Lying on the involved side may relieve
LOCATION: Upper sternal or on either side of the
–  symmetrical , lower 2p at the 7 -8th Rib it•  sternum Pe
- ASSOCIATED SYMPTOMS: Cough
•  QUALITY: Burning Ao
•  12th Rib Tra
–  midway b/t spine & side
•  SEVERITY: Mild to moderate
•  TIMING: Variable Pa

•  FACTORS THAT AGRAVATE: Coughing

Sources of Chest Pain and Related Causes • DIFFUSE INTERSTITIAL LUNG DISEASES
Source of Chest pain - PROCESS: abnormal and widespread infiltration of cells, fluid and
Myocardium Angina pectoris, Myocardial infarction, collagen into interstitial space
myocarditis - TIMING: Progressive dyspnea
Pericardium Pericarditis - FACTORS THAT AGGRAVATE: exertion
Aorta Dissecting aortic aneurysm - FACTORS THAT RELIEVE: Rest
Trachea and large bronchi Bronchitis - ASSOCIATED SYMPTOMS: weakness fatigue Cough less common
Parietal Pleura Pericarditis, pneumonia, pneumothorax,
pleural effusion • PNEUMONIA
Chest wall Costochondritis, herpes zoster - PROCESS: Inflammation of lung parenchyma from the respiratory
Esophagus Reflux esophagitis, esophageal spasm, bronchioles to the alveoli
esophageal tear
- TIMING: Acute illness
Extrathoracic structures such Cervical arthritis, biliary colic, gastritis
- ASSOCIATED SYMPTOMS: Pleuritic pain, cough, sputum, fever
as the neck, gallbladder,
stomach
• SPONTANEOUS PNEUMOTHORAX
- PROCESS: leakage of air into pleural space through blebs on
• PLEURITIC PAIN
visceral pleura, with resulting partial or complete collapse of the
- PROCESS: Inflammation of the parietal pleura, as in pleurisy, lung
pneumonia, pulmonary infarction, or neoplasm
- TIMING: sudden onsets of dyspnea
- LOCATION: Chest wall
- ASSOCIATED SYMPTOMS: Pleuritic pain, cough
- QUALITY: Sharp, knifelike
- SETTING: Omen a previously health adult
- SEVERITY: Omen severe
- TIMING: Persistent
• ACUTE PULMONARY EMBOLISM
- FACTORS THAT AGGRAVATE: Inspiration, coughing, movements
- PROCESS: Sudden occlusion of all or part of pulmonary artery
of the trunk
tree by a blood clot that usually originates in deep veins of legs or
pelvis.
DYSPNEA
- TIMING: Sudden onset of dyspnea
• LEFT SIDED HEART FAILURE
- SETTING: Postpartum or postoperative periods; prolonged bed
- PROCESS: Elevated pressure in pulmonary capillary bed with rest; congestive heart failure, chronic lung disease, and fracture of
transudation of fluid into interstitial spaces and alveoli, decreased hips or leg; deep venous thrombosis
compliance à ( increased stiffness) of the lungs à increased work
of breathing
• ANXIETY WITH HYPERVENTILATION
- TIMING: May progress slowly or sudden
- PROCESS: over breathing, with resultant respiratory alkalosis and
- FACTORS THAT AGGRAVATE: Exertion, lyingdown
fall in the partial pressure of carbon dioxide in the blood
- FACTORS THAT RELIEVED: Rest, sitting up - TIMING: Episodic, often recurrent
- ASSOCIATED SYMPTOMS: Cough, orthopnea, PND, sometimes - FACTORS THAT AGGRAVATE: More often occur at rest than
wheezing
- after exercise.
- SETTING: History of heart disease or its predisposing factors
- FACTORS THAT RELIEVE: Breathing in and out of a paper or
- plastic bag sometimes helps the associated symptoms.
• CHRONIC BRONCHITIS
- ASSOCIATED SYMPTOMS: Sighing, lightheadedness, numbness or
- PROCESS: Excessive mucus production in bronchi, followed by
tingling of the hands and feet, palpitations, chest pain
chronic obstruction of airways
- SETTING: Other manifestation of anxiety may be present
- TIMING: Chronic productive cough followed by slowly progressive
dyspnea
COUGH AND HEMOPTYSIS
- FACTORS THAT AGGRAVATE: Exertion, inhaled irritant, PROBLEM COUGH AND SPUTUM ASSOCIATED SYMPTOMS
respiratory infection AND SETTING
- FACTORS THAT RELIEVE: Rest, expectoration ACUTE INFLAMMATION
- ASSOCIATED SYMPTOMS: Chronic productive cough, recurrent Laryngitis Dry cough, may become productive Hoarseness associated with
respiratory infection, wheezing may develop. viral nasopharyngitis
- SETTING: History of smoking, air pollutants recurrent respiratory Tracheobronchitis Dry cough may become productive Viral illness with burning
retrosternal discomfort
infections
Mycoplasma and Dry hacking cough often becoming Chills , high grade fever,
viral pneumonia productive dyspnea and chest pain
• CHRONIC OBSTRUCTIVE PULMONARY DISEASE (EMPHYSEMA) often preceded by acute URI
- PROCESS: Overdistention of air spaces to terminal distal Bacterial PNEUMOCOCCAL: sputum mucoid Typically occurs in older
bronchioles, with destruction of alveolar septa and chronic Pneumonia or purulent; may be blood alcoholic men
obstruction of airways streaked, diffusely pinkish or rusty
KLEBSIELLA: similar, sticky red and
- TIMING: slowly progressive dyspnea; relatively mild cough jellylike
- FACTORS THAT AGGRAVATE: exertion CHRONIC INFLAMMATION
- FACTORS THAT RELIEVE: Rest Postnasal Drip Chronic cough; sputum mucoid and Repeated attempts to clear
- ASSOCIATED SYMPTOMS: Cough with scant mucoid sputum mucopurulent the throat. Allergic rhinitis
- SETTING: History of smoking, air pollutants , familial deficiency in Chronic Bronchitis Chronic cough, purulent w/ Blood History of smoking, wheezing
alpha antitrypsin streaked or bloody and dyspnea
Bronchiectasis Chronic cough copious foul smelling Recurrent bronchopulmonary
purulent infection,+ sinusitis
• BRONCHIAL ASTHMA Sputum with blood
- PROCESS: Bronchial hyperresponsiveness involving release of Pulmonary Dry cough or mucoid sputum with Fever, night sweats weight
inflammatory mediators, increased airway secretions, and Tuberculosis blood streak Loss fatigue and anorexia
bronchoconstriction Lung Abscess Sputum purulent and Foul smelling; febrile illness
- TIMING: Acute episodes separated by symptom- may be bloody poor dental hygiene
- free periods. Nocturnal episodes common impaired consciousness
Asthma Cough with thick mucoid sputum esp. Episodic wheezing and
- FACTORS THAT AGGRAVATE: Allergen near end of attack dyspnea. History of allergy
- ASSOCIATED SYMPTOMS: Wheezing, cough, tightness in chest Gastroesophageal Chronic cough esp. at night Or Wheezing at night, early
- SETTING: Environmental and emotional conditions Reflux early in the morning morning hoarseness
Repeated attempts to clear
the throat
 History of heartburn and - • Causes:
Breathing punctuated
exercise, by frequent
anxiety and metabolic sighs
acidosis. •
regurgitation - Inshould alertpatient,
the comatose you to the possibility of
NEOPLASM Cough dry to productive Blood Hx of smoking, dyspnea And o Infarction, hypoxia, or hypoglycemia affecting the
(LUNG) streaked or bloody weight loss hyperventilation
midbrain or pons.
Left ventricular Dry cough esp. on exertion or at Dyspnea, orthopnea,
failure or Mitral night, pink frothy paroxysmal nocturnal - Kussmaul breathing is deep breathing due to metabolic acidosis.
o It may becommonfast, normalcause
in rate orofslow. •
stenosis Sputum of pulmonary edema or dyspnea •  syndrome—a dyspnea
frank hemoptysis • BRADYPNEA
Pulmonary Emboli Dry to productive may be dark, Dyspnea, anxiety, chest - and dizziness.
Slow Breathing Occasional sighs are
bright red or mixed With blood pain, fever factor leading to
- normal.
Causes
deep vein thrombosis
Irritating Particles, Variable Exposure to irritants. Nose, o diabetic coma, drug induced respiratory depression
Chemicals, or Latent period eyes and throat may be and increased intracranial pressure
gases Between exposure and symptoms affected • CHEYNE-STOKES BREATHING
- Periods of deep breathing alternate with periods of apnea (no
OBJECTIVE DATA -
breathing).
Children and aging people normally may show this pattern in
INSPECTION sleep.
- Assess the shape of the chest and how the chest moves including - Other causes:
o Deformities or asymmetry in chest expansion o heart failure, uremia, drug-induced respiratory
o Abnormal retraction of the interspaces during depression, and brain damage
3/10/20

o
inspiration
Impaired respiratory movement on one or both sides of
• ATAXIC BREATHING P
- Biot’s Breathing
the chest
NORMAL CHEST - Ataxic breathing is characterized by unpredictable irregularity.
· Thorax is wider than its depth •
· Lateral diameter is larger than - Breaths may be shallow or deep and stop for short periods.
its anteroposterior diameter
SIGHING RESPIRATION
- Causes
OBSTRUCTIVE BREATHING •
o Respiratory depression and brain damage, typically at

• • 
the medullary level. PALPATION •
•
•  Breathing punctuated by frequent sighs In SIGHING RESPIRATION
obstructive lung disease, expiration is
should alert you to the possibility of -
prolongedBreathing
because ofpunctuated
narrowed airwaysby frequent
thereby sighs should alert you to the
BARREL CHEST · Increased anteroposterior
hyperventilation possibility
increasing of hyperventilation
the resistance to air flow.
diameter - syndrome—a common cause of dyspnea and dizziness. Occasional
· Shape is normal during infancy •  Causes sighs are normal.
•  syndrome—a common cause of dyspnea –  asthma, chronic bronchitis and COPD
– aging and COPDOccasional sighs are
and dizziness.
normal. • OBSTRUCTIVE BREATHING
- In obstructive lung disease, expiration is prolonged because of
TRAUMATIC FLAIL · Multiple rib fractures may result narrowed airways thereby increasing the resistance to air flow.
CHEST in paradoxical
- Causes
· movements of the thorax o asthma, chronic bronchitis and COPD
· As descent of the diaphragm
decreases intrathoracic
PALPATION
pressure
o inspiration the injured - Identify tender areas
area caves inward Palpa2on
- Assess any visible abnormalities
o expiration, it moves - Test chest expansion
•  Iden2fy tender areas
-
FUNNEL CHEST
outward
· PECTUS EXCAVATUM CHEST EXPANSION
Feel for tactile fremitus
•  Assess any visible abnormali2es

· Depression in the lowerPALPATION

•  Test chest expansion
• CHEST EXPANSION
portion of the sternum •  Feel for tac2le fremitus
· Compression of the heart and
great vessels
PIGEON CHEST · PECTUS CARINATUM
· Sternum displaced anteriorly,
increasing the anteroposterior
diameter
· The costal cartilages adjacent
to the protruding sternum are
depressed
THORACIC · Abnormal spinal
CHEST EXPANSION
curvatures TACTILE FREMITUS TACTILE FREMITUS
KYPHOSCOLIOSIS and vertebral rotation • TACTILE FREMITUS
deform the chest.
· Distortion of the underlying
lungs may make
interpretation of lung findings
very difficult.
NORMAL RESPIRATORY RATE
- The respiratory rate is about 14–20 per min in normal adults
- Infants up to 44 per min
• TACHYPNEA PERCUSSION
- Rapid Shallow Breathing - Percussion sets the chest wall and underlying tissues in motion,
- Causes: producing audible sound and palpable vibrations
o restrictive lung disease, pleuritic chest pain, and an - Helps to establish underlying tissues
elevated diaphragm o Air filled
• HYPERPNEA o Fluid filled
- Rapid Deep Breathing o Solid Percussion 9
- Also called hyperventilation •  Percussion sets the chest wall and underlying
2ssues in mo2on, producing audible sound
and palpable vibra2ons
•  Helps to establish underlying 2ssues
–  Air filled
 –  Air filled Tympany Loud High Gastric air
bubble or
–  Fluid filled puffed-out
–  Solid cheek
PERCUSSION NOTES Tracheal Inspiratory & Very loud Relatively Over the
PERCUSSION NOTES
RELATIVE RELATIVE RELATIVE
INTENSITY BREATH SOUNDS
PITCH DURATION
EXAMPLE
OF
expiratory
are equal
high trachea in the
neck
LOCATION
DuraSon of Intensity of Pitch of LocaSons Where
Flatness RELATIVE
Soft Sounds RELATIVE RELATIVE
HighExpiratory ShortEXAMPLE OF
Expiratory Heard Normally Thigh
INTENSITY PITCH Sound DURATION Sound LOCATION
Dullness Medium
Vesicular Medium
Inspiratory sounds Som Medium
Rela2vely low Over most of both Liver
Flatness Som High
Resonance Loud last longer than Low Short LongThigh
expiratory sounds
lungs
Healthy Lung
Dullness
Hyperresonance Medium
VeryBroncho- Medium
loudInspiratory and
Lower Medium
Intermediate Longer
Intermediate Liver
Omen in the 1 Usually
st and none
Vesicular expiratory sounds nd 2 interspaces
Resonance
Tympany Loud
Loud Low High
are about equal Long Healthy Lung
anteriorly and Gastric air
between the
Hyperresonance Very loud Lower Longer Usually none
scapulae bubble or
Tympany Loud
Bronchial
High
Expiratory sounds Loud
last longer than
Rela2vely
high
Gastric air
Over the manubrium,
if heard at all puffed-out
inspiratory sounds bubble or cheek
Tracheal Inspiratory and
expiratory are
Very loud Rela2vely
high
puffed-out
Over the trachea in
the neck
equal cheek
ADVENTITIOUS / ADDED BREATH SOUNDS
Crackles ( or rales) Wheezes and Rhonchi
Discontinuous Continuous
Intermittent, nonmusical, and brief >250 msec, musical, prolonged
Like dots in time Like dashes in time
FINE CRACKLES : soft, high- WHEEZES11 : relatively high pitched
pitched, very brief ( 5-10 msec)
ADVENTITIOUS LUNG SOUNDS
( > 400 Hz) with hissing or shrill
quality
•  Late inspiratory crackles of interstitial
COARSE CRACKLES : somewhat RHONCHI
lung disease: andrelatively low heart
congestive –pitched
failure
louder, lower in pitch, brief ( 20- (– <result
200 Hz)
from withofsnoring
a series quality
tiny explosions when small
airways, deflated during expiration, pop open
30 msec) 3/10/20 during inspiration.
ADVENTITIOUS LUNG SOUNDS
3/10/20 - Late inspiratory crackles of•  Coarse
interstitial lung disease and
crackles
congestive heart failure – result from air bubbles flowing through secretions
o result from a series oroflightly
tiny closed airways during
explosions whenrespiration
small
airways, deflated during expiration, pop open during
inspiration.
Ausculta2on
- Coarse crackles
Ausculta2on •  It is used for assessing air flow through the o result from air bubbles flowing through secretions or
tracheobronchial tree lightly closed airways during respiration
•  It is used for assessing air flow through the
•  It involves:
AUSCULTATION
tracheobronchial tree
–  Listening to the sounds generated by breathing Late Inspiratory Crackles
•  It involves: Late inspiratory crackles 10
AUSCULTATION –  Listening for any adven22ous sounds
–  Listening to the sounds generated by breathing
–  If abnomali2es are suspected, listening to the
–  Listening for any adven22ous sounds
Early Inspiratory Crackles
•  may begin in the first half of inspiration but must
sounds of the pa2ent’s spoken or whispered voice
–  If abnomali2es are suspected, listening to the continue into late inspiration
sounds of the pa2ent’s spoken or whispered voice Mid Inspiratory & Expiratory
•  fine and fairly profuse Crackles
AUSCULTATION •  persist from breath to breath
- It is used for assessing air flow through the tracheobronchial tree Wheezes & Rhonchi
•  appear first at the bases of the lungs, spread
upward as the condition worsens, and shift to
- It involves: dependent regions with changes in posture
o Listening to the sounds generated by breathing Stridor
•  Causes: interstitial lung disease (such as
o Listening for any adventitious sounds fibrosis) and early congestive heart failure
o If abnormalities are suspected, listening to the sounds of Pleural Rub
the patient’s spoken or whispered voice
• Late inspiratory crackles
10 - may begin in the first half of inspiration but must continue into late
inspiration
- fine and fairly profuse
- persist from breath to breath
- appear first at the bases of the lungs, spread upward as the
condition worsens, and shift to dependent regions with changes in
posture
BREATH SOUNDS - Causes: interstitial lung disease (such as fibrosis) and early
Duration of Intensity of Pitch of Locations congestive heart failure
Sounds Expiratory Expiratory Where Heard • Early inspiratory crackles
Sound Sound Normally
- appear soon after the start of inspiration and do not continue into
Vesicular Inspiratory Soft Relatively Over most of
late inspiration
sounds last low both lungs
longer than - They are often but not always coarse and are relatively few in
BREATH SOUNDS number
BREATH SOUNDS
expiratory
DuraSon of
Sounds
Intensity of Pitch of
Expiratory sounds
Expiratory
LocaSons Where
Heard Normally - Expiratory crackles are sometimes associated
Sound DuraSon of
Sound Intensity of Pitch of LocaSons Where
esicular Broncho-
Inspiratory sounds Som
Sounds
Inspiratory
Rela2vely low
Expiratory Expiratory
Over most of both
Sound Sound
Intermediate
Heard Normally
Intermediate Omen in the 1st - Causes: Chronic bronchitis and asthma
last longer than lungs
expiratory sounds Vesicular
Vesicular and
Inspiratory sounds
last longer than
Som Rela2vely low Over most of both
lungs
and 2nd • Midinspiratory and expiratory crackles
oncho-
esicular
Inspiratory and
expiratory sounds
Intermediate
expiratory
Intermediate Omen in the 1 and
expiratory sounds 2 interspaces
nd
st
interspaces - Wheezes and rhonchi may be associated
are about equal
Broncho- Inspiratory and sounds are
anteriorly and Intermediate Omen in the 1 and
Intermediate st
anteriorly and
Vesicular expiratory sounds
between the nd2 interspaces - Causes: Bronchiectasis
are about equal about equal between the
scapulae
anteriorly and
onchial Expiratory sounds Loud Rela2vely Over the manubrium, between the
last longer than high if heard at all scapulae scapulae
inspiratory sounds
Rela2vely Expiratory Loud Relatively Over the DISCONTINOUS SOUNDS
acheal Inspiratory and Bronchial
Bronchial Expiratory sounds Loud
Very loud
last longer than
Rela2vely
Over the trachea in
high
Over the manubrium,
if heard at all
expiratory are
equal
high
inspiratory sounds
the neck
sounds last high manubrium, if • CRACKLES OR RALES
Tracheal Inspiratory and Very loud Rela2vely Over the trachea in
expiratory are longer thanhigh the neck heard at all - are intermittent, nonmusical, and brief—like dots in time
equal
inspiratory - Fine crackles are soft, high pitched, and very brief (5–10 msec)
sounds - Coarse crackles are somewhat louder, lower in pitch, and not quite
so brief (20–30 msec)
11

11
 Coarse Crackles Fine Crackles - Whispered words louder, clearer (whispered pectoriloquy)
- Increased tactile fremitus

VOICE SOUNDS
- Normal voice transmission is soft, muffled & indistinct
- Pathology that ↑ lung density make words clearer
o Bronchophony – “99”
o Egophony- ee-ee-ee if disease sounds like aa-aa- aa
Record as “E → A changes”
o Whisper pectoriloquy 1-2-3
CONTINUOUS SOUNDS
o These tests are only done if lung pathology is suspected
- > 250 msec, notably longer than crackles— like dashes in time
- do not necessarily persist throughout the respiratory cycle
- Unlike crackles, they are musical
- Wheezes
o relatively high pitched (around 400 Hz or higher) and
have a hissing or shrill quality
- Rhonchi
o relatively low pitched (around 200 Hz or lower) and have
a snoring quality
• WHEEZES
- Air flows rapidly through bronchi that are narrowed nearly to the
point of closure.
- Often audible at the mouth as well as through the chest wall.
- Causes: asthma, chronic bronchitis, COPD, and congestive heart
failure (cardiac asthma)
- In asthma, wheezes may be heard only in expiration or in both
phases of the respiratory cycle
• RHONCHI
- suggest secretions in the larger airways.
- In chronic bronchitis, wheezes and rhonchi often clear with
coughing.
- Occasionally in severe obstructive pulmonary disease, the patient
is no longer able to force enough air through the narrowed bronchi
to produce wheezing. The resulting silent chest should raise
immediate concern and not be mistaken for improvement.
- A persistent localized wheeze suggests a partial obstruction of a
bronchus, as by a tumor or foreign body. It may be inspiratory,
expiratory, or both.
• STRIDOR
- A wheeze that is entirely or predominantly inspiratory
- It is often louder in the neck than over the chest wall
- It indicates a partial obstruction of the larynx or trachea, and
demands immediate attention
• PLEURAL RUB
- Inflamed and roughened pleural surfaces grate against each other
as they are momentarily and repeatedly delayed by increased
friction.
- These movements produce creaking sounds known as a pleural rub
(or pleural friction rub).
- Resemble crackles acoustically, although they are produced by
different pathologic processes
- Sounds may be discrete, but sometimes are so numerous that they
merge into a seemingly continuous sound
- Usually confined to a relatively small area of the chest wall
- Heard in both phases of respiration
- When inflamed pleural surfaces are separated by fluid, the rub
often disappears
• MEDIASTINAL CRUNCH
- A mediastinal crunch is a series of precordial crackles synchronous
with the heart beat, not with respiration
- Best heard in the left lateral position, it is due to mediastinal
emphysema (pneumomediastinum)

NORMAL AIR-FILLED LUNG

- Predominantly vesicular
- Spoken words muffled and indistinct
- Spoken “ee” heard as “ee”
- Whispered words faint and indistinct, if heard at all

LOBAR PNEUMONIA
- Bronchial or bronchovesicular over the involved area
- Spoken words louder, clearer (bronchophony)
- Spoken “ee” heard as “ay” (egophony)
 CHEST & LUNG FINDINGS
CONDITION PERCUSSION TRACHEA BREATH SOUNDS ADVENTITIOUS TACTILE FREMITUS
NOTE SOUNDS
NORMAL CHEST The tracheobronchial tree and Resonant Midline Vesicular, except None, except Normal
alveoli are clear; pleurae are perhaps perhaps a few
thin and close together; bronchovesicular and transient
mobility of the chest wall is bronchial sounds over inspiratory
unimpaired. the large bronchi and crackles at the
trachea respectively bases of the lungs
CHRONIC The bronchi are chronically Resonant Midline Vesicular None; or scattered Normal
BRONCHITIS inflamed and a productive coarse crackles in
cough is present. Airway early inspiration
obstruction may develop and perhaps
expiration; or
wheezes or rhonchi
LEFT SIDED HEART Increased pressure in the Resonant Midline Vesicular Late inspiratory Normal
FAILURE pulmonary veins causes crackles in the
congestion and interstitial dependent
edema ( around the alveoli) portions of the
bronchial mucosa may become lungs; possibly
edematous. wheezes
CONSOLIDATION Alveoli fill with fluid or blood Dull over the Midline Bronchial over the Late inspiratory Increased over the
cells, as in pneumonia, airless area involved area crackles over the involved area, with
pulmonary edema, or involved area bronchophony
pulmonary hemorrhage egophony, and
whispered
pectoriloquy
ATELECTASIS Lobar obstruction. When a plug Dull over the May be Usually absent when None Usually absent when
in a mainstem bronchus ( as airless area shifted bronchial plug the bronchial plug
from mucus or a foreign object) toward persists. Exceptions persists. In
obstructs air flow, affected lung involved include right upper excep2ons ( right
tissue collapses into an airless side lobe atelectasis, upper lobe
state where adjacent atelectasis) may be
tracheal sounds may increased
be transmitted.
PLEURAL Fluid accumulates in the pleural Dull to flat Shifted Decreased to absent, None, except a Decreased to
EFFUSION space, separates air- filled over the fluid toward but bronchial breath possible pleural absent, but may be
lung from the chest wall opposite sounds may be heard rub increased toward
blocking the transmission of side in a near top of large the top of a large
sound large effusion effusion
effusion
PNEUMOTHORAX When air leaks into the pleural Hyperresonant Shifted Decreased to absent None; except for Decreased to
space, usually unilaterally, the or tympanitic toward over the pleural air a possible pleural absent over the
lung recoils from the chest wall. over the opposite rub pleural air
Pleural air blocks transmission pleural air side if much
of sound air
CHRONIC Slowly progressive disorder in Diffusely Midline Decreased to absent None, or the Decreased
OBSTRUCTIVE which the distal air spaces hyperresonant crackles, wheezes,
PULMONARY enlarge and lungs become and rhonchi of
DISEASE ( COPD ) hyperinflated Chronic bronchitis associated chronic
often associated bronchitis
ASTHMA Widespread narrowing of the Resonant to Midline Omen obscured by Wheezes, possibly Decreased
tracheobronchial tree diminishes diffusely wheezes crackles
air flow to a fluctuating hyperresonant
degree. During attacks, air flow
decreases further, and lungs
hyperinflate

6/6
 CD-A (PHYSICAL DIAGNOSIS) • Tender nodes
2.2 Examination of the Neck o inflammation
Dr. Jessica Catalan • Hard or fixed nodes
o malignancy
Learning Objectives: • Generalized adenopathy
1. Establish a good patient-physician relationship. o HIV or AIDS, infectious mononucleosis, lymphoma, leukemia,
2. Demonstrate skill in performing a complete physical sarcoidosis
examination.
3. Identify the physical findings in health and in disease. THE TRACHEA
4. Record in a standard format the results of the physical
examination. • Tracheal deviation
5. Analyze and correlate history with physical examination - neck mass
- mediastinal mass
findings in an attempt to arrive at a diagnosis.
- atelectasis (ipsilateral deviation)
THE NECK - large pneumothorax
Anatomy The Thyroid
THE THYROID - SYMPTOMS
Thyroid function:
INCREASED DECREASED
HYPERTHYROIDISM HYPOTHYROIDISM
• nervousness • fatigue, lethargy, weight gain
• heat intolerance, excessive w/ anorexia
sweating • dry coarse skin, swelling of
• palpitations face, hand, legs
• involuntary weight loss • constipation
• frequent BM • weakness, muscle cramps
• tremors • arthralgias
• proximal muscle weakness • paresthesia
• impaired memory & hearing
• cold intolerance, decreased
sweating
For descriptive purposes, divide each side of the neck into two triangles - retrosternal goiter can cause hoarseness, SOB, stridor, dysphagia
bounded by the sternomastoid muscle. Visualize the borders of the two - flushing from arm elevation and neck hyperextension –
triangles as follows: Pemberton’s sign (due to external jugular vein dilation &
• For the anterior triangle: the mandible above, the sternomastoid obstruction of the thoracic outlet)
laterally, and the mid- line of the neck medially - Note:
• For the posterior triangle: the sternomastoid muscle, the trapezius, o size
and the clavicle. Note that a portion of the omohyoid muscle o shape
crosses the lower portion of this triangle and can be mistaken for a o consistency
lymph node or mass. § soft – Graves’ disease
§ firm – Hashimoto’s thyroiditis, malignancy
LYMPH NODES o bruit systolic or continuous – hyperthyroidism
- Swollen glands or lumps in the neck – commonly accompany o tenderness - thyroiditis
pharyngitis • Goiter - enlarged thyroid gland
- When you detect a malignant or inflammatory lesion, look for - Diffuse no discretely palpable nodules – Graves’ disease,
enlargement of the regional lymph nodes that drain it; when a Hashimoto’s thyroiditis, endemic goiter
node is enlarged or tender, look for a source such as infection in its - Multinodular – 2 or more nodules; metabolic rather than neoplastic
nearby drainage area. (usually with + family history, continuing enlargement)
The lymph nodes of the • Single nodule – cyst, benign tumor or malignancy
head and neck are - risk factors:
classified in a variety of o prior irradiation
ways. o hardness
The deep cervical chain is o rapid growth
largely obscured by the o fixation to surrounding tissues
overlying sternomastoid o enlarged cervical nodes
muscle, but at its two o occurrence in men
extremes, the tonsillar
node and supraclavicular SIGNS:
nodes may be palpable. INCREASED DECREASED
The submandibular HYPERTHYROIDISM HYPOTHYROIDISM
nodes lie superficial to
• warm, smooth, moist skin • dry, coarse, cool skin, maybe
the submandibular gland,
• increased BP yellowish
and should be
differentiated. • tachycardia or AF • nonpitting edema
• hyperdynamic cardiac • loss of hair
pulsations • periorbital puffiness
• accentuated S1 • decreased BP, bradycardia,
• tremor • decreased intensity of heart sounds
• proximal muscle • hypothermia
- Nodes are normally round or ovoid, smooth, and smaller than this weakness • impaired memory, mixed loss,
gland. The gland is larger and has a lobulated, slightly irregular • Graves’ disease – stare, somnolence
surface. lid lag, exophthalmos • peripheral neuropathy, carpal
- Note that the tonsillar, submandibular, and submental nodes drain tunnel syndrome
portions of the mouth and throat as well as the face.
• Enlargement of supraclavicular node (esp. left) end
- metastasis from thoracic or abdominal malignancy References: Bates (Chapter 7) and PPT

1/1
 CLINICAL DIAGNOSIS A RADIOLOGY: CHEST RADIOGRAPHY 2. EXPIRATORY RADIOGRAPH
- Obtained at residual volume (end of maximal forced expiration)
PART I: INTERSTITIAL AND ALVEOLAR DISEASES
- Detection of a small pneumothorax
5 RADIOGRAPHIC DENSITIES

IMAGING TECHNIQUES
RADIOGRAPHY 3. APICAL LORDOTIC VIEW
1. CONVENTIONAL CHEST RADIOGRAPH - Caudocephalad angulation of the tube projects the clavicles and first
- Posteroanterior (PA) and lateral costochondral junctions superiorly, providing an unimpeded view of the
chest radiographs are the mainstays apices.
of thoracic imaging
- Initial imaging study in patients with
thoracic disease
- Focus-to-film distance of 6 feet

2. PORTABLE RADIOGRAPH
- Obtained when patients cannot be safely mobilized
- Taken on AP view (sitting or supine)
- Focus-to-film distance of 40 inches
- Technical and patient-related compromises 4. CHEST FLUOROSCOPY
- Assess chest dynamics on patients with suspected diaphragmatic
3. SUPINE AP CHEST RADIOGRAPH paralysis
- Requires longer exposures to penetrate
cardiomediastinal structures
- Magnification of intrathoracic structures
- Widening of the upper mediastinum
- Normal gravitational effect

POSTEROANTERIOR ANTEROPOSTERIOR
Ribs: angulated Straighter
Clavicle: V- shape Horizontal
Scapula: Winging No winging COMPUTERIZED TOMOGRAPHY SCAN
Heart: Not magnified Magnified Advantages:
Gastric bubble: Present Absent - Superior contrast resolution and cross-sectional display format
- Superior contrast resolution allows for the differentiation of calcium, soft
tissue, and fat within lung nodules or mediastinal structures
- Intravenous enhancement improves contrast within structures or
masses, as well as within blood vessels

1. CHEST CT SCAN
- Lung windows: window width of 1,000 to 2,000 H and window levels of
about 500 to 600 H
- Mediastinal window: WW = 400 and WL = 40 and for the lungs are WW =
1,500 and WL = 600
SPECIAL TECHNIQUES
1. LATERAL DECUBITUS 2. HIGH RESOLUTION CT (HRCT)
- Obtained with a horizontal x-ray beam while the patient lies in the - Involves incremental thinly collimated scans (1.0 to 1.5 mm) obtained at
decubitus position; Used to detect small effusions or pneumothorax evenly spaced intervals through the thorax
- Image acquisition time is limited to minimize the effects of respiratory and
cardiac motion

3. THORACIC CT
Indications:
o Evaluation of an abnormality identified on conventional
radiographs
o Staging of lung cancer
o Detection of occult pulmonary metastases

1
 o Detection of mediastinal nodes
o Distinction of empyema from lung abscess
o Detection of central pulmonary embolism
o Detection and evaluation of aortic disease: aneurysm,
dissection, intramural hematoma, aortitis, trauma

PARENCHYMAL LUNG DISEASE

PULMONARY OPACITY abnormal increase in lung density
A. AIRSPACE DISEASE
- Develop when air normally present within the terminal spaces are
MAGNETIC RESONANCE IMAGING replaced by material of soft tissue density.
Morphologic studies usually require only spin-echo T1W and T2W sequences in the NORMAL LUNG AIRSPACE LUNG
axial plane.
The major advantages of MR are:
- superior contrast resolution between tumor and fat
- ability to characterize tissues based on T1 and T2 relaxation times
- the ability to scan in direct sagittal and coronal planes
- lack of need for intravenous iodinated contrast
- superior to CT in the diagnosis of chest wall or mediastinal invasion

The major disadvantages of thoracic MR scanning are:

- limited spatial resolution
- inability to detect calcium, and the difficulties in imaging the pulmonary
parenchyma
- more time-consuming and expensive than CT Individual alveoli are too small to resolve, Filling of alveoli by: water, blood, pus,
- the ability of CT to provide superior or equivalent information in most but together they appear radiolucent. proteinaceous fluid, or cells. opacities
situations and consolidation

INDICATIONS FOR MR OF THE THORAX Lobar or segmental distribution

- Evaluation of aortic disease in stable patients: Dissection, aneurysm, Poorly marginated
intramural hematoma, aortitis Tendency to coalesce
- Assessment of superior sulcus tumors Airspace nodules
- Evaluation of mediastinal, vascular, and chest wall invasion of lung cancer
Bat s wing or butterfly distribution
- Staging of lung cancer patients unable to receive intravenous iodinated
Rapidly changing over time
contrast
Air bronchogram
- Evaluation of posterior mediastinal masses
- Airways are not normally seen in a normal

Silhouette Sign the effacement of a normal structure
ULTRASOUND
- Used for the detection, characterization, and sampling of pleural,
peripheral parenchymal, and mediastinal lesions
- Confirm phrenic nerve paralysis
- Detects subpulmonic and subphrenic fluid collections
s
- When the aerated lung opacify, the bronchi
becomes visualized because of the surrounding
contrast effect.
- Intrathoracic lesion will obliterate borders of shadows of similar
radiodense structures that it contacts
- Example: Airspace disease may silhouette:
o right heart margin with right middle lobe pneumonia
o diaphragm with lower lobe pneumonia

2
 SILHOUETTE ADJACENT LOBE/SEGMENT - Coarse reticular pattern - 1 cm; seen Langerhans cell histiocytosis of
Right Diaphragm RLL/Basal Segment the lung, sarcoidosis and idiopathic pulmonary fibrosis.
Right Heart Margin RML/Medial Segment
Ascending Aorta RUL/Anterior Segment
Aortic Knob LUL/Posterior Segment
Left Heart Margin Lingula/Inferior Segment
Descending Aorta LLL/Superior & Medial Segments
Left Diaphragm LLL/Basal Segments

Differential Diagnosis: 3. Reticulonodular

- Pneumonia - May be produced by overlap of reticular shadows or
- Pulmonary Edema presence of both nodular and
- Hemorrhage reticular opacities
- Neoplasm - Silicosis, sarcoidosis and
- Alveolar Proteinosis lymphangitic carcinomatosis

B. INTERSITITAL DISEASE
- Produced by processes that thicken the interstitial compartments of the
lung with water, bleed, tumor, cells, fibrous tissue or any combination of
these
NORMAL LUNG INTERSTITIAL DISEASE

Primary Lung Cancer with Lymphatic Spread

4. Nodular
- Homogenous, well defined, small rounded lesions within the pulmonary
interstitium.
o Miliary < 2 mm
o Micronodules 2 to 7 mm
o Nodules 7 to 30 mm
o Masses > 30 mm
In a normal chest radiograph, the visible interstitium is the branching pulmonary
vessels. The branching disappears peripherally because they are beyond resolution of
the x-ray.

Patterns of Interstitial Disease:

1. Linear
- Thickened axial (bronchovascular) or peripheral
interstitium of the lung
- Parallel linear opacities radiating from the hila
when visualized in length
- Peribronchial cuffing when visualized end-on
5. ATELECTASIS
- Incomplete expansion of the lungs
- Opacified hemithorax from volume loss

A linear pattern is seen when a. Obstructive/Resorptive Atelectasis

there is thickening of the - Most common form
interlobular septa, producing
A - Secondary to complete endobronchial
Kerley lines. The most common
cause of interlobular septal obstruction of lobar bronchus with
thickening, producing Kerley A resorption of gas distally.
B and B lines, is pulmonary
edema. b. Passive/Relaxation Atelectasis
- Result from mass effect of an air or fluid
collection within the pleural space on the
2. Reticular adjacent lung
- Results from the summation or superimposition of irregular linear opacities - COMPRESSIVE ATELECTASIS
- The term reticular is defined as meshed, or in the form of a network. o Form of passive atelectasis in
- Fine reticular or ground glass pattern 1 to 2 mm of intervening lucent which intrapulmonary mass
spaces; seen in interstitial pulmonary edema and interstitial compresses adjacent lung
pneumonitis parenchyma
- Medium reticulation or honeycombing 3 to 10 mm; seen in o Causes include bullae, abscess, and tumors.
pulmonary interstitial fibrosis

3
 c. Cicatricial Atelectasis
- Produced by processes resulting in parenchymal fibrosis and reduce
alveolar volume.

d. Adhesive Atelectasis B. Bilateral Hyperlucency

- Occurs in association with surfactant deficiency disease - May be simulated by an overpenetrated film or by a thin patient
- Radiograph show diminution in lung volume - Result of diminished pulmonary blood flow
- Congenital pulmonary stenosis
- Pulmonary emphysema
- Asthma

e. Lobar Atelectasis
- Displacement of an interlobar fissure
- Diminished aeration results in increased density in the affected portion of
lung, plus bronchovascular crowding
- Indirect signs of lobar atelectasis:
Ipsilateral shift of the trachea, heart, or mediastinum and hilar
Shift of the entire mediastinum FOCAL RADIOLUCENT LESIONS
Compensatory hyperinflation A. CAVITIES
- Form when a pulmonary mass undergoes necrosis and communicates
with an airway
- The wall is usually irregular or lobulated
- Wall is greater than 1 mm thick
- Lung abscess and necrotic neoplasm are the most common cavitary
pulmonary lesions

f. Segmental Atelectasis
- Atelectasis of one or several segments of a lobe
- Thin linear opacity to a wedge-shaped opacity
that does not abut an interlobar fissure

g. Subsegmental (Platelike) Atelectasis

- Linear collapse of deep invaginations of visceral
pleura formed by incomplete fissures or scars
- Linear shadows are 2 to 10 cm in length
- Commonly associated with hypoventilation
- Tends to occur at the lung bases

PULMONARY LUCENCY abnormal decrease in lung density

1. DIFFUSE LUNG LUCENCY B. AIR CYSTS
A. Unilateral Hyperlucency - well-circumscribed
- Result in decrease in blood flow to the lung. intrapulmonary gas
- Hypoplasia of the right or left pulmonary artery collection
- Lobar resection or atelectasis - smooth thin wall >1 mm
- Pulmonary arterial obstruction thick
- Swyer-James syndrome
- Emphysema; most common with severe bullous disease

4
 C. BULLAE - Airways are usually spared
- Gas collection within the pulmonary parenchyma - Air bronchograms are common and significant volume loss is unusual.
- >1 cm in diameter and has a thin wall <1 mm thick
- Represents a focal area of parenchymal destruction (emphysema)

B. BRONCHOPENUMONIA
- Most common pattern
- Typical of staphylococcal pneumonia.
- Early stages of inflammation is centered primarily in and around lobular
bronchi
- Exudative fluid extends peripherally along the bronchus to involve the
entire pulmonary lobule.
- Multifocal opacities: patchwork quilt appearance.
D. BLEBS - Absence of air bronchograms
- Collection of gas <1 cm in size within
the layers of the visceral pleura
- Usually found in the apical portion
- Not seen on plain radiographs but may
be visualized on chest CT rupture can
lead to spontaneous pneumothorax

C. INTERSTITIAL PNEUMONIA
- Seen in viral and mycoplasma
infection
- Inflammatory thickening of
bronchial and bronchiolar walls
and the pulmonary interstitium
E. PNEUMATOCELES - Radiographic pattern of airways
- Thin-walled, gas-containing structures thickening and reticulonodular
- Represent distended airspaces distal to a opacities
check-valve obstruction of a bronchus or
bronchiole PRIMARY TUBERCULOSIS
- Most commonly secondary to Classically a disease of childhood
staphylococcal pneumonia Ranke complex: calcified parenchymal
- A check-valve mechanism involves focus (the Ghon lesion) and nodal
accumulation of air distal to an calcification.
airway obstruction. Airways dilate during Nonspecific focal pneumonitis seen as
inhalation, permitting air to pass by a small, ill-defined areas of segmental or lobar
partial bronchial obstruction. Airways opacification.
constrict tightly around an obstruction during exhalation, effectively Unilateral/bilateral hilar or mediastinal lymph
limiting the expiration of air distal to the obstruction. node enlargement.

PNEUMONIA
Microorganisms enter the lung thru three
potential routes: tracheobronchial tree,
pulmonary vasculature, or direct
spread
Patterns:
A. LOBAR PNEUMONIA
- Typical of pneumococcal pulmonary
infection.
- Inflammatory exudate begins within the Unilateral/bilateral hilar or mediastinal lymph node enlargement.
distal airspaces.

5
 Cavitation: may lead to transbronchial spread of organisms and result in a multifocal
bronchopneumonia.
EMPHYSEMA
Defined as an abnormal, permanent enlargement of the airspaces distal to
the terminal bronchiole accompanied by destruction of alveolar walls and
without obvious fibrosis.
Hyperinflation - most important plain radiographic finding

Radiologic Findings:
Destruction of pulmonary capillary bed
Diffuse hyperlucency (panlobular)
and alveolar septa
Flattening and depressions of the
Hyperinflation caused by loss of elastic
hemodiaphragms; increased retrosternal
recoil of lung
Parenchymal healing is associated with fibrosis, bronchiectasis, and volume loss airspace (panlobular > centrilobular)
(cicatrizing atelectasis) in the upper lobes. Thin-walled region of confluent
Bulla (panlobular > centrilobular)
emphysematous destruction
Loss of pulmonary capillary bed;
Enlarged central pulmonary arteries; right
associated chronic hypoxemia causes
heart enlargement (centrilobular)
increased pulmonary vascular resistance
Increased peripheral vascular markings Small airways disease; increased
Rasmussen Aneurysm
(centrilobular) pulmonary vascularity

MILIARY TUBERCULOSIS
Results from
hematogenous
dissemination of tubercle
bacilli
Produces diffuse bilateral
2- to 3-mm pulmonary
micronodules.

ASPERGILLUS INFECTION SURFACTANT DEFICIENCY DISEASE

Responsible for a spectrum of pulmonary diseases which include
aspergilloma or mycetoma formation within preexisting cavities
ASPERGILLOMA (fungus ball) - a ball of hyphae, mucus, and cellular
debris that colonizes a preexisting bulla or a parenchymal cavity created
by some other pathogen or destructive process.
Progressive apical pleural thickening adjacent to a cavity is a common
radiographic finding
Absence of surfactant leads to increased alveolar surface tension,
lessened alveolar distensibility and persistent collapse or atelectasis of the
alveoli.
Prematurity most common predisposing factor
Infant of diabetic mothers more prone to develop this condition
Classic Radiologic Findings Include:
- Pronounced underaeration leading to
small lung volume
- Fine granular appearance of pulmonary
parenchyma (ground glass)
- Peripherally extending air-bronchogram
characteristic finding

NEONATAL RETAINED FLUID SYNDROME

(TRANSIENT TACHYPNEA OF THE NEWBORN/WET LUNG DISEASE)
Represent a problem of clearance of fluid from the newborn infant s lung
Increased incidence in infants delivered via Cesarean section.
ASTHMA Resolution usually occurs before 48 hours
An airway disorder characterized
by the rapid onset of bronchial
narrowing with spontaneous
resolution or improvement as a
result of therapy.

Radiologic Findings of Asthma:

- Hyperinflation
- Bronchial wall inflammation and
thickening (peribronchial cuffing and tram tracking)
- Prominent hilum

6
Radiologic Findings:
Symmetrical parahilar radiating congestion
Mild to moderate overaeration of the lungs
Occasional pleural effusion
Variety of patterns of intraalveolar fluid
Other cases demonstrate reticulonodular or streaky infiltrates
May present with generalized homogenous haziness or granularity
PART II: PULMONARY NEOPLASMS
SOLITARY PULMONARY NODULE
An opacity completely stable in size for more than 2 years is considered
BENIGN and further evaluation is unnecessary
New or enlarging SPN needs a series of investigation to determine
whether the nodule has benign features, high suspicious for malignancy or
indeterminate.
Radiologic evaluation of a SPN remains one of the most common and
most difficult diagnostic dilemmas in thoracic radiology.
General considerations:
Is the lesion truly solitary?
Is the lesion intrapulmonary?
Is the lesion a nodule?
Is the lesion intrapulmonary?
CLINICAL FACTORS
Patients <35 yrs, non smoker, without history of malignancy SPN:
Follow-up with plain radiographs
1. Granuloma
2. Hamartoma
3. Inflammatory lesion
Patients >35 years, current/recent smoker significant incidence of
malignant SPN (50%) Should never be followed radiographically w/o
tissue confirmation unless with benign pattern of calcification or
presence of intralesional fat and lack of growth over minimum of 2 years
SPN in patient with an extrathoracic malignancy raises possibility of SP
metastasis. SPN that arises >2 years after the diagnosis of an
extrathoracic malignancy is almost always a primary lung tumor rather
than metastasis.
GROWTH PATTERN
Growth rate are expressed in doubling time or the time it takes for a
nodule to double its volume. Doubling time of <1 month or >2 years
characterizes a solid lesion as benign.
Lack of growth or a doubling >2 years: hamartomas and histoplasmomas
Giant cell carcinomas, subtype of large cell carcinoma & pulmonary
carcinosarcoma, blastomas may have a doubling time of <1 month
Pulmonary adenocarcinoma and carcinoid tumors may have doubling time
of greater than 2 years.
SIZE
Does not reliably discriminate benign from malignant SPN
Larger lesions are likely malignant (>4 cm in diameter)

Is the lesion a nodule?

PATIENT DIAGNOSED OF BORDER (Margin, Edge)

NEUROFIBROMATOSIS 1 AND CAME IN
FOR BIOPSY OF LUNG MASS Best evaluated on HRCT

CT Scan
Benign Malignant
Rare primary pulmonary
Round, Smooth Nodule malignancy: Carcinoid
Granuloma or hamartoma
tumor, adenocarcinoma,
or solitary metastasis
Carcinoid tumors and
Notched, Lobulated Hamartomas some bronchogenic
carcinomas
Lipoid pneumonia,
In our 52-years old lady, a CT scan shows the lesion to be in the right upper lobe Spiculated organizing pneumonia,
intrapulmonary tuberculomas

7
 Solitary Pulmonary Nodule: What would
you do next?

1. Compare with any available previous

CORONA RADIATA used to describe the PLEURAL TAIL - peripherally radiograph
2. Computed tomography
spiculated appearance; linear densities situated SPN may contact the costal
radiate from the edge of the nodule into the pleura or interlobular fissure via a
adjacent lung. linear opacity.
BRONCHOGENIC CARCINOMA
***Both are highly suspicious of malignancy.
Malignant neoplasm that arises from the bronchial or alveolar epithelium.
Four main histologic subtypes:
1. Adenocarcinoma
2. Squamous cell carcinoma
3. Small cell carcinoma
4. Large cell carcinoma

ADENOCARCINOMA
Presence of small SATELLITE NODULES around the periphery of a dominant
- Most common type of lung cancer (1/3 of all bronchogenic carcinomas)
nodule is strongly suggestive of BENIGN LESION.
- Most common subtype in non-smokers
- Found to occur more on the lung periphery, ¼ cases are seen in the
DENSITY
central portions
The internal density of an SPN is probably the single most important
- Irregular or spiculated appearance with fibrosis
factor in characterizing the lesion as benign or indeterminate.
- Arise from the bronchiolar or alveolar epithelium year survival: 17%
Lesions that are calcified are benign.

Four (4) Patterns of Benign Calcifications:

1. Complete or central calcification specific for healed granuloma from
tuberculosis or histoplasmosis
2. Concentric or laminated calcification granuloma
3. Popcorn calcification - diagnostic for pulmonary hamartoma, in which
cartilaginous component has calcified
4. Peripheral calcification

Approximately 10% of malignant nodules contain calcification on CT.

Eccentric calcification: bronchogenic carcinoma
Small or microscopic foci of calcification: adenocarcinoma
Irregular or spiculated appearance
Indeterminate Patterns:
Stippled
SQUAMOUS CELL CARCINOMA
Eccentric
- 2nd most common subtype of
Amorphous
bronchogenic carcinoma (25%).
- Arises centrally within a lobar
or segmental bronchus
- Central necrosis is common
- Radiographic findings: usually
present as a hilar mass with or
without obstructive pneumonitis
or atelectasis.
- Year survival rate of 15%

SMALL CELL CARCINOMA

Air bronchogram or bubbly lucencies
within an SPN
Fat within an SPN pulmonary
highly suspicious for adenocarcinoma
hamartoma
- 25% of bronchogenic carcinomas and arise centrally within the main or
lobar bronchi.
- Most malignant neoplasm arising from bronchial neuroendocrine
(Kulchitsky) cells.
- Produces a hilar or mediastinal mass with extrinsic bronchial
compression.
- 5 year survival rate of 5%

8
LARGE CELL CARCINOMA
- 15 % of bronchogenic carcinomas
- Arise peripherally as a large solitary mass
- Majority are cigarette smokers over 40 yrs old
- Commonly affects male patients
- 5 year survival rate of 11%

END
Sources:
1-Pulmo Radiology PPT
2-Pulmonary Neoplasms PPT

9
 CLINICAL DIAGNOSIS A RADIOLOGY:
PLEURA AND DIAPHRAGM
PLEURA
Serous membrane subdivided into:
VISCERAL PLEURA covers the lung and forms the
interlobar fissures
PARIETAL PLEURA lines the mediastinum, diaphragm and
thoracic cage
Pleural space potential space between the visceral and parietal pleura
which contains small amount of fluid of about 2 5mL. Large pleural effusion
Radiologically detectable manifestations of pleural diseases include:
Effusion
Thickening
Calcification

PLEURAL EFFUSION
Form when imbalance occurs between formation and reabsorption.
Bloody, chylous, purulent, serous
Transudative vs. exudative
Lateral decubitus
Specific causes of pleural effusion
1. Congestive Heart Failure Pleural Effusion in Supine Patient
- Most common; transudative pleural effusion
- Typically bilateral and larger on the right

2. Parapneumonic effusion
- Effusion associated with pneumonia
- Peripheral parenchymal infection Exudative pleural effusion
- Staphylococcus aureus and gram negative pneumonias

3. Empyema
Pleural effusion layers posteriorly in a supine position; causes diffuse increased
- Results when parenchymal infection extends into the pleural space
density
- Most often appear as loculated pleural fluid collection.
- Bacterial pneumonia, septic emboli, and lung abscess
PNEUMOTHORAX
Results from air entering the pleural space
Natural history of parapneumonic effusion has 3 stages:
Traumatic or spontaneous
Stage 1: Exudative stage
Sudden onset of dyspnea and pleuritic chest pain.
Stage 2: Fibrinopurulent pleural fluid collection; produces loculations
Stage 3: Develops 2-3 weeks after initial fluid formation characterized by
UPRIGHT RADIOGRAPHY
pleural fibrosis and dystrophic pleural calcification following resolution of
- Non-dependent lucency that parallels the chest wall and displaces the visceral
the infection.
pleural line medially
Other causes
SUPINE
Neoplasms lung, breast, pelvis, gastric CA and lymphoma
- Can be undetectable as air in the pleural space rises non-dependently and
Result from pleural involvement by tumor or from lymphatic
creates indiscernible increased lucency over the lower thorax and upper
obstruction from the parietal pleura to the mediastinal nodes.
abdomen.
Exudative and bloody
Trauma
Collagen vascular and autoimmune disease
Abdominal disease Pancreatitis (left sided effusion because of the
proximity of the pancreatic tail to the left HD); exudative and bloody

Normal: sharp
angles

Blunted posterior
costophrenic sulcus

Small pleural effusion

1
 CT Scan

Inspiration Expiration
SIMPLE PNEUMOTHORAX TENSION PNEUMOTHORAX
No shift of the heart or mediastinal Most often from iatrogenic trauma
structures in mechanically ventilated patients.
Air in the left hemithorax balances Result from check-valve pleural
the air in the right hemithorax defect that allows air to enter but not
exit the pleural space.
Complete collapse of underlying lung
and impairing venous return
Respiratory function severely
compromised
Involved hemithorax is expanded
and hyperlucent, medially retracted
lung, ipsilateral diaphragmatic
Lateral left decubitus depression or inversion, and
contralateral mediastinal shift.
Signs of pneumothorax on supine radiographs:
- Hyperlucent upper abdomen (particularly
on the right over the normally dense liver)
-
-
- The epicardial fat pad sign (for left
pneumothorax)
- Unusually sharp heart border

Tension pneumothorax requires chest tube

Deep Sulcus Sign: It represents lucency of the lateral costophrenic angle extending
toward the hypochondrium. The abnormally deepened lateral costophrenic angle may FOCAL PLEURAL DISEASE
have a sharp, angular appearance.
A. LOCALIZED PLEURAL
THICKENING
- From fibrosis
A hyperlucent upper quadrant with visualization of - End result of parenchymal and
the superior surface of the diaphragm and pleural inflammatory disease with
visualization of the inferior vena cava; Double pneumonia as the most common
diaphragm sign cause.

Unusually sharp heart border

2
 B. PLEURAL CALCIFICATION PLEURAL MALIGNANCY
- Most often unilateral Metastatic disease to the pleura
- Involves the visceral pleura Irregular or nodular pleural thickening
- Result from prior hemothorax or empyema Usually associated with pleural effusion
- Punctate to sheet-like Adenocarcinoma of the lung, breast, ovary, kidney and GI tract.
Malignant mesothelioma seen almost exclusively in asbestos exposed
individual

Mesothelioma

DIAPHRAGM
DIAPHRAGMATIC HERNIAS
A. ESOPHAGEAL HIATAL HERNIA
- Most common; represents herniation of a portion of the stomach through
C. PLEURAL MASS the esophageal hiatus
- Usually benign neoplasm - Esophagram is confirmatory
- Thoracic lipomas
- Subpleural lipomas produce pleural mass and can change in shape
during respiration or with changes in position.
- Homogenous fat attenuation on CT (-30 to -100 HU) is diagnostic.

DIFFUSE PLEURAL DISEASE

Represents diffuse pleural fibrosis (fibrothorax), pleural malignancy or
multiloculated pleural effusion.

FIBROTHORAX
- Diffuse pleural fibrosis
- Pleural thickening extending over
more than one fourth of the costal
pleural surface.
- Results from resolution of an
exudative pleural effusion, empyema, Seen as mass projecting behind the heart on frontal chest radiographs in the
or hemothorax. immediate supradiaphragmatic region of the posterior mediastinum; Air fluid level may
- Can encompass the entire lung and be seen in the hernia.
produce entrapment.

CT shows widening of the esophageal hiatus and depicts the contents of the hernia
sac, which often include stomach, omental fat, and, rarely, ascitic fluid

3
 B. BOCHDALEK HERNIA END
- Defect in the hemidiaphragm at the site of the embryonic pleuroperitoneal Source: 4-Pleura and Diaphragm PPT
canal
- Predominantly seen on the left side
- Typically appears as a posterolateral mass above the left hemidiaphragm

U GOT DIS,
DOC!

CT shows the diaphragmatic defect with herniation of retroperitoneal fat, omentum,

spleen, or kidney

C. MORGAGNI HERNIA
- Least common type of diaphragmatic hernia
- Invariably right sided
- Appears as an cardiophrenic angle mass
- Presence of omental vessels within a fatty paracardiac mass is diagnostic

Diagnosis is made by noting herniation of omental fat, liver, or transverse colon

through the paracardiac portion of the right hemidiaphragm on CT scans through the
lung bases

4
 CD-A (LABORATORY DIAGNOSIS) Lineage – Specific Markers:
2.1 Non Neoplastic Disorders of Leukocytes - Helpful in identifying blood cells involved (Leukemia in flow
Lecturer: Ivy Marie M. Viola-Cruz, MD, DPSP cytometry)
Hematopoietic Growth Factors (Cytokines)
OBJECTIVES: - Ex. GM-CSF, G-CSF
1. To describe the white blood cells as to development/maturation, - Produced by hematopoietic and nonhematopoietic cells
function, signaling biomolecules and distribution. - Functions:
2. To differentiate the various white blood cells. o Regulate proliferation, survival, and differentiation of
3. To explain the various categories of diseases involving WBCs. hematopoietic precursor cells
4. To discuss the different disorders of neutrophils, eosinophils, o Facilitate the functions of mature blood cells
basophils, monocytes lymphocytes and plasma cells. Chemokines
5. To differentiate leukemoid reaction from leukemia. - Regulate honing of hematopoietic stem cells (similar to antigen –
LEUKOCYTES -
antibody interactions)
Ex. Hematopoietic stem cells and their cytoplasm has CXCL4
- Found in the bone marrow, peripheral blood and tissues (marker) and in the bone marrow stroma, it has a partner CXCL12
- Protect the body from infection and other foreign insults (marker) that will match to mark them to stay in their designated
area

IMMATURE FORMS
Myeloblast

Promyelocyte

Myelocyte

Metamyelocyte

Band

Mature forms

Eosinophil Neutrophil Basophil

- Usually seen in a bone marrow specimen

- Normally, immature cells are not seen in the peripheral blood.
- But in patients with leukemia, immature cells are present in the
circulation.
- Sometimes if there is an overwhelming infection, immature cells
until myelocyte may be seen in the periphery but never the
blasts.
- As the cell grows older, the cell size decreases

Type GRANULOCYTES AGRANULOCYTES

BASOPHIL EOSINOPHIL NEUTROPHIL LYMPHOCYTES MONOCYTES
Microscopic
Image

MORPHO- 12 um, large
LOGY round purple-black
cytoplasmic granules,
2 nuclear segments
FUNCTION Immediate
hypersensitivity reactions,
some delayed
hypersensitivity reactions
LIFESPAN Maturation time =7D
Circulation = days
Not found in tissues
12-17 um, large,
red- orange rounded
granules
predominantly bilobed
nucleus
Phagocytosis, anti-
helminthic activity, allergic
response, dampen
inflammatory reactions
Maturation time = 14D
T 1⁄2 in blood 18H
At least 6D in tissues
9-15um, 7-12 um;
slightly acidophilic scanty bluish cytoplasm;
cytoplasm w/ many
very fine granules
2-5 nuclear segments round or slightly
indented nucleus with
condensed nuclear
chromatin
Phagocytosis, • T CELLS: Cell-
bactericidal activity mediated immunity
• B CELLS: humoral
immunity
Maturation time = 14D T CELLS: Medulla =
Circulation <1D 12D Recirculate once
every 12- 24H
B CELLS/ PLASMA
CELLS: Days
15-30 um,
abundant grayish-blue
cytoplasm w/ few - many
azurophilic granules;
large, eccentric, rounded/
kidney- shaped/
horseshoe- shaped/
lobulated nucleus
Phagocytosis, antigen
processing, cell-mediated
immunity
Maturation time = 50-60H
T 1⁄2 in blood= 8.4H
In tissues = months (as
macrophages)

1/8
 GRANULOCYTES MATURATION - During this time, T cells with the ability to recognize foreign
• Myeloblast • Myelocyte antigens are retained, and T cells with the ability to recognize
- Earliest - Smaller nucleus self-antigens are eliminated.
precursor - Chromatin starts to - Undergoes gene rearrangement to give rise to CD8 or CD4 T-cells
- High N:C clump

-
ratio
Less cytoplasm
- Produce primary
granules
NEUTROPHILS
Factors affecting neutrophil count
- Large to oval, • Metamyelocyte
quadrangular nucleus - Affected by:
- Kidney shaped nucleus
o Rate of inflow of cells from the bone marrow to the
- Very fine chromatin • Band peripheral blood
pattern - Nucleus has deeper o Rate of outflow from the peripheral blood to the tissues
• Promyelocyte indentations but no - Increased production = Increased count
- Largest cell segments - In the circulation:
- Lower N:C ratio o Circulating Granulocyte Pool
- Start to produce § Samples obtained for CBC, not adhering to
granules the blood veseels
MONOCYTE MATURATION o Marginal Granulocyte Pool
• Monoblast § Attached to the walls of blood vessels
- Largest blast in all of the hematopoietic cell • NEUTROPHILIA
lines in the bone marrow Physiologic Pathologic
- Round, large centrally placed nucleus - Demargination - Acute inflammation
- Fine-scanted chromatin - “pseudoneutrophilia” - Infection
- Single and large nucleolus - Severe exercise, hypoxia, - Drugs, toxins,
- Abundant cytoplasm with fine creamy stress or epinephrine metabolic disorders,
texture injection, smoking, pregnancy tissue necrosis,
• Promonocyte neoplasms
- Shouldn’t be seen on the PBS à may • NEUTROPENIA
indicate neoplastic changes - ~1.5 to 2 x 109/L (whites)
- Reported as blasts - ~1.2 to 1.3 x 109/L (blacks)
B-CELL LYMPHOCYTE MATURATION - MECHANISMS:
o Decreased or ineffective production
o Increased removal from the blood (survival defect)
o Altered distribution between CGP and MGP
o Combination of these mechanisms
- Causes of Neutropenia
o Absolute Neutrophil Count <0.5 x x 109/L
§ Agranulocytosis
§ Severe Chronic Neutropenia
o Proliferation Defect
§ Fanconi’s anemia
§ Kostmann’s syndrome
§ Shwachman-Diamond syndrome
§ Cyclic neutropenia
- Consists of an antigen independent phase happening on the BM o Maturation Defect
and an antigen dependent phase happening on the secondary § Myelokathexis
lymphoid organs and the spleen § Chediak-Higashi syndrome
- Differentiation of pre-B cells into B cells occurs independently of o Congenital Familial Neutropenia
antigen, whereas proliferation and terminal differentiation of B o Congenital Neutropenia
cells are antigen driven. Hematopoietic stem cells with stromal cell o X-linked Agammaglobulinemia – BTK mutations
help give rise to pre-B cells. o Felty’s Syndrome à chronic neutropenia and
- A small, resting pre-B cell becomes an immature B cell and leave rheumatoid arthritis
the bone marrow. o Autoimmune Myelofibrosis
o Drugs (Methimazole, Clozapine, TMP-SMX)
- Antigen triggers the resting B cell to enlarge and present
o Radiation
processed antigen and DR to the antigen-specific T cell receptor–
o Metastatic Carcinoma, Disseminated TB, Gaucher’s
CD3 complex.
Disease
- The activated B cell can be induced to differentiate into plasma o Megaloblastic Anemia
cells, which secrete their abundant cytoplasmic IgG. o Starvation
- Alternatively, it can become a memory B cell with refined o Infections (Brucella, Salmonella, Measles, Rubella,
specificity poised to deliver an anamnestic immune response on its Hepatitis, IM, Influenza)
next encounter with antigen. o Hypersplenism
T CELL MATURATION MORPHOLOGIC ALTERATIONS IN NEUTROPHILS
- Maturation happens in the Thymus • TOXIC GRANULATION
- Pro-T cells from the bone marrow or fetal liver migrate to the - Dark blue to purple cytoplasmic granules
thymus, where they undergo T cell receptor (TCR) gene - Metamyelocyte, band, neutrophil
rearrangement and are processed into functionally mature T cells
- Peroxidase positive
for circulation in the blood and to the peripheral or secondary
lymphoid tissues. - Infections and other toxic conditions
- The maturation of T cells have at least three stages.
- In the first stage, pro-T cells migrate from the bone marrow or the • DÖHLE BODIES
fetal liver to the cortex of the thymus. - Small oval inclusions
- In the second stage, pro-T cells migrate from the subcapsular - Peripheral cytoplasm of PMNs
cortex to the inner cortex and then to the thymic medulla - Pale blue in Wright’s stain
- Remnants of free ribosomes or RER

2/8
 - PRIMARY
o Congenital
o Easily identifiable with automated cell counters
TOXIC GRANULATION AND DÖHLE BODIES incorporating measurement of MPO activity in
differential count
- SECONDARY
o Transient and corrected with treatment of underlying
• MAY-HEGGLIN ANOMALY disease (myeloid neoplasms, drugs, severe infectious,
- Autosomal dominant DM, pregnancy)
- Pale blue inclusions resembling Dohle bodies in
neutrophils, eosinophils, basophils, • LEUKOCYTE ADHESION DEFICIENCY DISEASES
monocytes - Defective leukocyte adhesion and migration
• Larger and more prominent - Recurrent infection and leukocytosis
• RNA - Diagnosed by flow cytometry (lack of CD18 or CD15a)
- Giant platelets - Treatment: HSC transplantation
- +/- thrombocytopenia
• ALDER-REILLY ANOMALY
- Dense, prominent, larger than normal
EOSINOPHILS
azurophilic granulation in ALL WBCs • Eosinophilia (>0.35 to 0.5 x 109/L)
- Not related to infection - More severe if parasite invades tissues rather than when they
- Patients with mucopolysaccharidoses or inhabit the lumen of a viscus
in healthy persons - Taenia solium (cysticercosis) – little inflammation while alive but
• PELGER-HUËT ANOMALY trigger an inflammatory condition upon degradation of the
organism
- Autosomal dominant
- Trichinella spiralis (trichinosis) – incite eosinophilia upon larval
- Mutation of laminin B receptor gene
invasion of muscles and encystment
- Failure of normal segmentation of
- Toxocariasis / Visceral larva migrans – leukocytosis and eosinophilia
granulocytic nuclei
extending over months
- Most nuclei are bilobed and rounded,
- Loffler’s syndrome (simple eosinophilic pneumonia)
characteristic spectacle or pince-nez shape
o Repeated, transient pulmonary exudates associated
- Mistaken as bands with fever and clinical symptoms of bronchitis
- Functionally normal cells o Due to drugs, inhaled antigens or helminth infestation,
• PSEUDO-PELGER-HUËT ANOMALY idiopathic
- Similar appearing, acquired disorder of - Tropical pulmonary eosinophilia
nuclear segmentation in granulocytes o Paroxysmal cough and bronchospasm with marked
- Granulocytic leukemia, myelodysplastic eosinophilia
and some myeloproliferative disorders, o Often associated with Wuchereria bancrofti
some infections, exposure to some drugs BASOPHILS
- Bands, neutrophils, mature cells with round, • Basophilia (> 0.2 x 109/L)
non-segmented nuclei and coarse
- Most frequently in hypersensitivity and allergic reactions, chronic
chromatin
myeloid leukemia, primary myelofibrosis and polycythemia vera
- Ring-shaped and other abnormal nuclei - Relative basophilia after irradiation
seen - Sometimes in helminth infections
• CHÉDIAK-HIGASHI SYNDROME
MONOCYTES
- Autosomal recessive
- Partial oculocutaneous albinism, • Monocytosis (> 1.0 x 109/L)
photophobia, immune deficiency, - Most common: recovery from neutropenia (favorable sign) and
neurologic defects, frequent pyogenic indolent infections
infections - Subacute bacterial endocarditis – monocytes phagocytosing other
- Abnormally large granules in WBC and blood cells
other granule-containing cells - Hematologic neoplasms: Acute monocytic and granulocytic
o Abnormal lysosomes leukemias, lymphoma, multiple myeloma and myeloproliferative
- Lymphoma like phase with disorders
lymphadenopathy, hepatosplenomegaly • Monocytopenia (< 0.2 x 109/L)
and pancytopenia, death at an early age - First few hours of therapy with prednisolone
- Hairy cell leukemia, MonoMac syndrome due to GATA2 mutation,
FUNCTIONAL DISORDERS OF NEUTROPHILS other rare immunodeficiencies and B-lymphoblastic leukemia
• CHRONIC GRANULOMATOUS DISEASE LYMPHOCYTES
- Rare primary immunodeficiency
- Absolute numbers of lymphocytes and T cells are highest in young
- affects neutrophils, eosinophils, macrophages and monocytes children
- Inability of phagocytic cells to kill intracellular microorganisms - Normal CD4/CD8 ratio between 1.0 to 3.4
- Recurrent bacterial and fungal infections o May be as high as 12 in reactive conditions
- Symptoms appear early in life -
- Autosomal recessive (~66%) and x-linked (~33%) LYMPHOCYTOSIS
- Genetic defects in any of the membrane- bound or cytoplasmic A. VIRAL INFECTION
components of the NADPH oxidase B. PERTUSSIS
C. CHRONIC LYMPHOCYTOSIS
• MYELOPEROXIDASE DEFICIENCY D. RETROVIRUS-ASSOCIATED DISEASES AND CONDITIONS
- Myeloperoxidase is the most abundant pro-inflammatory enzyme - HIV1
stored in azurophilic granules of neutrophils o infects both monocyte/macrophages and T cells
o Can generate reactive molecules which can crosslink o Ultimately causes progressive loss of CD4+
proteins à defective killing of foreign bodies lymphocytes, disrupts normal immune function and
produces immunodeficiency and disease
o Plays an indirect role in the development of lymphoma

3/8
 - HIV2 CYTOMEGALOVIRUS
o Less virulent - Similar syndrome with IM
- HTLV - After massive blood transfusion or spontaneous
o Infect and transform T cells; HTLV-1 (CD4+) and HTLV-2 - Leukocytosis with absolute lymphocytosis
(CD8+) o 20% or more are atypical lymphocytes
o Transmitted by breast milk or exposure to blood - BM: increased numbers of normal and atypical lymphocytes
o Acute infection: few clinical symptoms – fever, - Abnormal liver function tests – most frequent abnormal lab finding
lymphadenopathy, occasional skin rash - Cold agglutinins, rheumatoid factor, antinuclear antibodies
o Lymphocytosis: <20 x 109/L - Dx: isolate CMV from urine, saliva, tissue biopsy or serology
o 90-95% of patients with antibodies are symptom free
o 3-5% manifest ATL or tropical spastic paraparesis after LYMPHOCYTOPENIA
a long latency
- < 1.8 x 109/L (adults) and < 2.0 x 109/L (children)
E. INFECTIOUS MONONUCLEOSIS AND EBV INFECTION
- Causes:
- Due to Epstein-Barr Virus
o Impaired lymphopoiesis
Entry: oropharyngeal epithelial and lymphoid
o Increased adrenocortical hormones
- tissues o Administration of chemotherapeutic drugs/irradiation
- Attaches to and enters B cells à stimulates DNA synthesis à o Impaired drainage of intestinal lymphatics
induces formation of several new viral antigens
o Viral capsid antigen, early antigen, Epstein-Barr nuclear ACQUIRED IMMUNODEFICIENCY SYNDROME
antigen – viral proteins most important for - Progressively fatal infectious disorder
serodiagnosis in immunocompetent patients
- HIV-1 and HIV-2
- Earliest phase: infection of B cells that proliferate, develop o Cytotropic for CD4+ T cells, macrophages, monocytes,
neoantigens, circulate, stimulate an immune response and megakaryocytes, CNS microglial cells
synthesize immunoglobulin
- Hematologic Features:
HUMORAL RESPONSE CELLULAR RESPONSE
o Anemia of chronic disease
o IgG and IgM VCA– rise during the o T cells activated o Lymphopenia, particularly CD4 subset
incubation and early prodrome period during 2nd week of o Thrombocytopenia
o IgM VCA – falls during 2nd and 3rd illness o Neutropenia
weeks of illness; undetectable in months o CD8+ cytotoxic T o Atypical lymphocytes with plasmacytoid appearance
o IgG VCA– falls during convalescence; cells kill infected B
detectable for life cells PLASMACYTOSIS
o Antibodies to EA – rise 2-3 weeks o NK cells kill infected
- Plasma cells are NOT normally present in the peripheral blood
after onset of illness then fall B cells
o Antibodies to EBNA – rise during o Some resting - Causes:
convalescence, detectable for life memory cells remain o Viral – IM, measles, rubella, HIV
latently infected o Bacterial – TB, syphilis, streptococcus, staphylococcus
o Parasitic – malaria, trichinosis
- Leukocytosis (12 to 25 x 109/L), rarely as high as 80x109/L
o Inflammatory – SLE, RA, IBD, alcoholic liver disease
- Lymphocytosis (60% to 90%) composed of atypical lymphocytes o Neoplastic – plasma cell leukemia, myeloma
o Nuclear alterations and increase in the amount and o Immune stimulation – immune complex disease, drug
basophilia of cytoplasm sensitivity, transfusion
o Monocytoid and plasmacytoid lymphocytes o Trauma
- Total leukocyte count returns to normal
within 3 weeks LEUKEMOID REACTIONS
- Cold agglutinins, rheumatoid factor, - Excessive leukocytic response in the peripheral blood
antinuclear factor - > 50 x 109/L or higher with a shift to the left
• Serologic Findings: - Can be neutrophilic, eosinophilic, lymphocytic or monocytic
- Spot test for IM Large Activated - Causes: severe infections, intoxication, malignancies, severe
o Agglutination of horse Lymphocyte hemorrhage, acute hemolysis
erythrocytes by serum - Ddx: Chronic Myelogenous Leukemia (CML)
absorbed with guinea pig kidney
- Workup: Exclude a clonal disorder, ID other causes
- Antibody to VCA – immunofluorescence
- WBC count: mostly mature neutrophils, left shift
- EBV viral load by PCR – for immunocompromised patients
- Leukocyte Alkaline phosphatase (LAP) score:
o ALP present in PMNs, bands, metamyelocytes,
myelocytes = increased LAP score
- Bone Marrow Aspiration & Biopsy: marked proliferation &
orderly maturation
- Cytogenetic testing = absent Philadelphia chromosome
o (+) Philadelphia Chromosome à CML

End

References:
- Dr. Viola-Cruz’ 2020 PPT
- Lecture recording
- Tin Faller trans (2019)
- Henry's Clinical Diagnosis and Management by Laboratory
Methods 22nd ed.
- Complications occur in < 5% of patients
- X-linked lymphoproliferative disease
o Fulminant IM
o Life-threatening lymphoproliferative disease & B cell
lymphoma
o Dysgammaglobulinemia

4/8
 CD-A (LABORATORY DIAGNOSIS)
2.1 Lab: WBC Count, Smear & Differential
Lecturer: Dr Linda Tamesis

WBC count
- A sample of whole blood is mixed with a weak
acid solution that lyses red blood cells.
Principle - Following adequate mixing, the specimen is
introduced into a counting chamber where the
white blood cells in a diluted volume are
counted
- Capillary blood collected in red tip capillary
Sample
tube
- Venous blood with EDTA –WBC pipette First Chamber Second Chamber
- WBC pipette 35 45
–Sucking apparatus 40 37
- Sucking apparatus
- Hemocytometer with –Hemocytometer with 44 36
Materials Example
Cover slip Cover slip 39 44
Materials 158 162
- Tally counter –Tally counter
- Acetic Acid (Hac ) the average number of WBCs per chamber
–Acetic Acid (Hac) 158 + 162 = 160
- Microscope
–Microscope 2
Procedure #cells counted x 20 x 10 / 4
1. Draw well -mixed blood exactly to the example
0.5 mark in a white blood cell diluting Calculation
160x20x10/4 =8,000 (8x109/L)
pipette. This blood column must be free 160 x 50 = 8,000 or 8 x 109/L
of air bubbles.
Adults
Reference
4.4 – 11 x 109/L
Value
2. Wipe the excess blood from the outside 4.4 - 11 x 103/uL
of the pipette to avoid transfer of cells 4,400-11,000 cm3
to the diluting fluid. Take care not to Procedural Notes
touch the tip of the pipette with the - A variation of
tissue. o >10 cells between any of the four areas counted or
o > 20 cells between sides of the hemocytometer
3. Immediately draw diluting fluid to the à indicates uneven distribution and requires that the
"11" mark while rotating the pipette procedure be repeated.
between the thumb and forefinger to - In cases where the WBC count is exceptionally high, as in
mix the specimen and diluent. Hold the leukemia, the dilution should be made in the red blood cell
pipette upright to prevent air bubbles in diluting pipette.
the bulb. - In cases of leukopenia, the white pipette should be filled to the
1.0 mark and diluted to the 11mark with 2 percent acetic acid.
- The resulting dilution is 1:10 instead of 1:20
4. Mix the contents of the pipette for 3-5
- If nucleated erythrocytes are present, the count must be
minutes to ensure even distribution of
corrected
cells.
5. Expel unmixed and relatively cell-free
fluid from the capillary portion of the SMEAR
pipette (usually 4 drops)
- Blood, with EDTA, (from finger print with red
tip capillary tube)
Materials - Microscope slide
- 2 applicator sticks
6. Place the forefinger over the top of the - stain
pipette, hold the pipette at a 450 Procedure
angle, and touch the pipette tip to the 1. Mix sample well. Remove stopper. Using a
junction of the cover glass and the wooden applicator stick rim the tube and
counting chamber. check for fibrin clots.

7. Allow the mixture to flow under the

cover glass until the chamber is
completely charged. Similarly, fill the 2. Place a 2-3 mm drop of blood about 1/4
opposite chamber of the hemocytometer inch from the end of the slide (use two
wooden applicator sticks).

8. Allow the cells to settle for about 3

minutes. Under lowpower magnification 3. Grasp a second slide (spreader slide) in
and reduced light, focus on the ruled the right hand between thumb and
area and observe for even distribution forefinger.
of cells.
9. Count the white cells in the four corner
”pink” areas

5/8
4. Place the spreader slide onto the lower Staining
slide in front of the blood drop, and pull 1. Let smear air dry completely
the slide back until it touches the drop. before staining

5. Allow the blood to spread by capillary

action almost to the edges of the lower
slide. 2. Once dry, staining is done
following directions on Coplin jars

6. Push the spreader slide forward at a 15-

20o angle, using a rapid, even motion.
7. Do NOT press down.
8. Perform this step quickly. 3. Smear should be an indigo color
and have a metallic sheen
4. Color uniform

5. Again let smear dry before

viewing under microscope

6. Place oil on the feather edge and

view using oil immersion lens

- No vacuoles in blood cells

- RBC are pink
Ideal stain - Nuclei of WBC are purple
- Eosinophilic granules are red- orange
- Minimal precipitates

DIFFERENTIAL
Characteristics of a Good Smear
- Thick at one end, thinning out to a smooth rounded feather
edge
- Should occupy 2/3 of the total slide area
- Should not touch any edge of the slide
- No holes or gaps present

- The slide is horizontally moved to

the next field
- The procedure is repeated until
100 leukocytes have been
counted (for a 100-cell count).

- Using a Schillings counter,

classify cells based on
Adjustment - Increasing the angle of the spreader slide will morphology
of smear decrease the length of the smear. Decreasing
length the angle will increase the smear length.

6/8
 1) Neutrophil BASOPHIL
2) Lymphocyte(reactive/atypical)
3) Monocyte
Included in the
4) Eosinophil
“normal” diff
5) Stab/Band
6) Basophil
7) Metamyelocyte /Juvenile
PERIPHERAL BLOOD CELLS

BAND OR STAB

METAMYELOCYTE

NEUTROPHIL

CELLS SEEN IN NON-NEOPLASTIC DISEASE

HYPER
SEGMENTED
NEUTROPHIL

LYMPHOCYTE

DOHLE BODIES

MONOCYTE

ATYPICAL
REACTIVE
LYMPHOCYTES

EOSINOPHIL TOXIC GRANULES

7/8
 PELGER HUET

CHEDIAK HIGASHI

WBC COUNT & DIFFERENTIAL

AUTOMATED
• Electrical Impedance
- blood is passed between 2 electrodes through a narrow aperture
1 cell at a time
- The impedance changes as a cell passes through, is proportional to
cell volume, resulting in a cell count and measure of volume.
- Results in count and 3-part differential (PMNs, Lymphs, and Monos)

• Flow Cytometry
- A single-cell stream passes through a laser beam. The absorbance
is measured, and the scattered light is measured at multiple angles
to determine the cell’s granularity, diameter, and inner complexity.
- Results in a 5-part WBC differential.

• Fluorescent Flow Cytometry

- Adding fluorescent reagents extends the use of flow cytometry to
measure specific cell populations.
- Fluorescent dyes reveal the nucleus-plasma ratio of each stained
cell.
- Results in > 5 cell differential

Fluorescent Cytometry
scatter plot

end

8/8
 CD-A (LABORATORY DIAGNOSIS) o malaise,
2.2: Leukocytic Disorders o progressive splenomegaly;
o later bleeding/bruising
Dr Aida Lat
- Laboratory Features:
OUTLINE o WBC ct >5x109 /L and may exceed 30x109/L;
1. OVERVIEW OF HEMATOPOIETIC NEOSPAMS o complete spectrum of granulocytic cells;
1.1. Chronic Myeloproliferative Disorders o myelocytes & neutrophils predominant;
1.2. Acute Myeloid Leukemia o <10% myeloblasts;
1.3. Precursor Lymphoid Neoplasms o basophilia ; eosinophilia;
1.4. Mature B-cell Neoplasms o monocytosis;
1.5. Mature T- and Natural Killer Cell Neoplasms o BCR-ABL present
1.6. Hodgkin Lymphoma - Bone marrow: markedly
hypercellular
NEOPLASTIC DISORDERS PRIMARILY INVOLVING LEUKOCYTES - PBS basis for diagnosis
OVERVIEW OF HEMATOPOIETIC NEOSPAMS - NAP: reduced or absent;
- Diverse disorders from hematopoietic stem cells of the BM or increases in accelerated and
lymphoid organs, known or assumed to be clonal processes due to blastic phase; infection
genetic errors - Cytogenetics:
- differs in predominant cells within a neoplasm, degree of o t(9:22)(q34;q11) in 95% cases;
differentiation, rates of proliferation and apoptosis, clinical o BCR-ABL1 fusion gene
features, and response to therapy - Other findings: increase cobalamine and transcobalamine
- classified by morphology, clinical features, and location of the - Prognosis: dependent on response to TKI
abnormal proliferations - Blast phase: >20% blasts in blood or bm (Acute leukemia, AML,
o Myeloid vs. lymphoid – subtypes based on cytochemical 2/3; ALL, 1/3)
stains
o Acute vs. chronic POLYCYTHEMIA VERA
o Blood and bone marrow vs. soft tissue - clonal stem cell proliferation affecting primarily the erythroid
- can now be characterized at the level of the genetic abnormality series,
and the resultant intracellular pathway perturbations. o characterized by excessive proliferation of erythroid and
- opportunity to develop targeted therapies also usually granulocytic and megakaryocytic elements in
A. Chronic Myeloproliferative Disorders the marrow (panmyelosis)
B. Acute Myeloid Leukemia - RBC production is autonomous with endogenous erythroid colonies
C. Precursor Lymphoid Neoplasms (EECs)
D. Mature B-cell Neoplasms - Absolute increase in red cell mass, leukocytosis and thrombocytosis
E. Mature T- and Natural Killer Cell Neoplasms - Initially, proliferative, eventually, spent phase with anemia,
F. Hodgkin Lymphoma marrow fibrosis, more splenomegaly, and extramedullary
G. Immunodeficiency-Associated Lymphoproliferative Disorders hematopoiesis
H. Histiocytic and Dendritic Cell Neoplasms - Demographics: M>W; middle age
- Clinical Features: ruddy cyanosis, and splenomegaly, 2/3;
A. CHRONIC MYELOPROLIFERATIVE DISORDERS (18) o
o
Thrombotic or hemorrhagic phenomena,1⁄2;
upper GI bleeding 2o PU;
- are clonal proliferations of a pluripotential stem cell that can o pruritus after bathing
differentiate along - Laboratory Features:
o granulocytic, o Blood:
o erythroid, and § RBC, >6-12X1012/L
o megakaryocytic lines
§ Hb,>18.5g/dL, males; >16.5g/dL, females
- Each has a chronic course that may terminate as
§ MCH, MCHC: normal to low
o acute leukemia,
§ Blood viscosity, high; ESR, decreased
o myelofibrosis, or a
o coagulopathy. § Increased platelet with functional defect; increased
neutrophils with immature forms
INCLUDES:
1. Chronic Myelogenous Leukemia § NAP, markedly elevated
2. Chronic Neutrophilic Leukemia § Transcobalamin and serum muramidase, increased
3. Polycythemia Vera o Bone Marrow: moderately to markedly hypercellular;
4. Primary Myelofibrosis panmyelosis; stored iron,
5. Essential Thrombocythemia § decreased to absent in 95%
6. Chronic Myeloproliferative Disease, Unclassifiable o Cytogenetics: JAK2 mutation, all PV;
7. Chronic Eosinophilic Leukemia, Not Otherwise Specified, and § 50% of patients with thrombocythemia and primary
Idiopathic Hypereosinophilic Syndrome myelofibrosis.
8. Mastocytosis
9. Myeloproliferative Neoplasm, Unclassifiable WHO CRITERIA FOR DIAGNOSIS:
10. Myeloid and Lymphoid Neoplasms with Eosinophilia and • Major criteria:
Abnormalities of PDGFRA, PDGFRB, or FGFR1 1. Elevated Hb >18.5 (males) or 16.5 (females) g/dL, or other
11. Myelodysplastic and Myelodysplastic/Myeloproliferative evidence of increased red cell volume.
Neoplasms 2. Presence of JAK2 B617F or similar mutation such as JAK2
12. Types of Abnormal Cellular Maturation exon 12 mutation.
13. Myelodysplastic/Myeloproliferative Neoplasms • Minor criteria:
14. Myelodysplastic/Myeloproliferative Disease, Unclassifiable 1. BM biopsy showing panmyelosis with prominent erythroid and
15. Myelodysplastic Syndromes megakaryocytic proliferation,
16. Myelodysplastic Syndrome with Isolated del(5q) 2. low serum erythropoietin,
17. Myelodysplastic Syndrome, Unclassified 3. endogenous colony formation in vitro.
18. Childhood Myelodysplastic Syndrome; Refractory Cytopenia of • Both of these major criteria must be
Childhood present, along with any single minor
CHRONIC MYELOGENOUS LEUKEMIA criterion or first major and two minor
- Demographics: young and middle-age, >50 criteria.
- Clinical Features: insidious and discovered incidentally; - A chronic disease, lifespan of 10-
o anemia, 20 yrs with good control
o weight loss,
Panmyelosis
1/9
 - Treatment: Phlebotomy, chlorambucil, radioactive phosphorus
(32P), and hydroxycarbamide (hydroxyurea)
- Complications: 20%–40% of patients, spent or postpolycythemic
phase, acute leukemia, or myelodysplastic syndrome
- DDx: Myelofibrosis with myeloid metaplsia

PRIMARY MYELOFIBROSIS
Chronic idiopathic myelofibrosis
- Chronic idiopathic myelofibrosis Myelodysplastic/ Myelodysplastic Syndrome
- chronic, progressive clonal panmyelosis Myeloproliferative Neoplasms
o megakaryocytic and granulocytic hyperplasia - Chronic Myelomonocytic - Refractory cytopenia with
o varying degrees of reactive fibrosis of the marrow Leukemia Unilineage Dysplasia
o extramedullary hematopoiesis - Atypical Chronic Myeloid - Refractory anemia
- leukoerythroblastic anemia occurs with Leukemia, BCR-ABL1 - Refractory Neutropenia
o marked red cell abnormalities, Negative - Refractory thrombocytopenia
o circulating normoblasts, immature granulocytes, and - Juvenile Myelomonocytic - RA with Ring Sideroblasts
atypical platelets. Leukemia - Refractory cytopenia with
- Prefibrotic stage: 20-30%; mild normocytic anemia with - Myelodysplastic/myeloprolif multilineage Dysplasia
poikilocytosis, including dacryocytes, nucleated RBCs, erative neoplasm, - Refractory Anemia with Excess
thrombocytosis, and mild leukocytosis with some immature forms unclassifiable Blasts
- Fibrotic stage: moderate normochromic, normocytic anemia (often MYELODYSPLASTIC AND MYELODYSPLASTIC/MYELOPROLIFERATIVE
with some hypochromic cells and basophilic stippling), moderate NEOPLASMS
anisocytosis, and marked poikilocytosis, including prominent - Myeloproliferative diseases: disorders in which proliferation of
teardrop forms (dacryocytes) and elliptocytes. hematopoietic cells outpaces apoptosis, and cellular elements in
- Splenomegaly due to extramedullary hematopoiesis the blood are increased while the morphology of hematopoiesis is
- Demographics: >50 near normal
- Clinical Features: insidious onset, weight loss, anemia, abdominal - Myelodysplastic diseases or syndromes: disorders in which
discomfort, hepatomegaly, osteosclerosis in 50% +/- osteoporosis apoptosis predominates, hematopoiesis is ineffective, and
- Laboratory Features: leukocyte count, mod increased; cytopenias occur
o immature neutrophils and occationally myeloblasts present; - Myelodysplastic/myeloproliferative disorders: show features of
o basophilia; both, with variable increases in cells, as well as cytopenias and
o platelets, normal to decreased, often atypical morphologic dysplasia.
- Marrow: atypical, enlarged, and immature megakaryocytes with
cloud-like immature nuclei ; • CHRONIC MYELOMONOCYTIC LEUKEMIA
o fibrotic phase, impossible to aspirate marrow, do biopsy; - clonal stem cell disorder with
- Cytogenetics: JAK2 V617F mutation, 50% persistent monocytosis (>1 × 109/L
- Course: increasing fibrosis with progressive anemia and for longer than 3 months) for which
splenomegaly other causes have been excluded
CHRONIC IDIOPATHIC MYELOFIBROSIS - cytopenias are present in the blood
but neutrophilia with morphologic
abnormalities also occurs
- absence of a Philadelphia chromosome or BCR/ABL, dysplasia of
one or more myeloid lineages, and less than 20% blasts plus
promonocytes in the marrow
- Eosinophilia, basophilia, plasmacytoid monocytes
- Eosinophils >1.5x109/L = CMML with eosinophilia
- CMML-1= blast percentages typically are <5% in the blood and
<10% in the marrow,
- CMML-2 = 5%–19% blasts in the blood, with 10%–19% in the
marrow, or with the presence of Auer rods;
ESSENTIAL THROMBOCYTOPENIA
o indicates aggressive disease with impending transformation
- a clonal myeloproliferative disorder primarily affecting the to acute leukemia.
megakaryocytic lineage with the principal manifestation of
- older age (median, 65–75 years); M>F
sustained thrombocytosis. - Sx: related to cytopenias (fatigue, infection, bleeding) or
- 40% - 50% carry a JAK2 V617F mutation hypermetabolic state (fever, weight loss, night sweats);
- Demographics: 5th decade; M=F; 2nd peak female, 30s
Hepatosplenomegaly
- Clinical features: - Lymphadenopathy: granulocytic sarcoma, acute leukemia
o asymptomatic thrombocytosis;
- Median survival: 20 -30 months; progression to AML, 15% - 30%
o 50%, hemorrhage or thombosis;
o mild splenomegaly, 50%
- Laboratory features: MYELODYSPLASTIC SYNDROMES
o Marked thrombocytosis; platelets ≥450 × 109/L; usually - clonal hematopoietic neoplasms characterized by cytopenias
>1000 × 109/L; due to ineffective hematopoiesis and increased apoptosis.
o Neutrophilic leukocytosis, - show morphologic dysplasia of at least one and usually more
o hypochromic microcytic anemia; lineages and have varied cytogenetic findings (but not typically
o platelet functional defect those associated with myeloproliferative neoplasms)
- Marrow: increased and enlarged megakaryocytes with mature - dysmyelopoietic syndromes or preleukemias, have a propensity
cytoplasm and multilobulated nuclei to progress to acute leukemia
- Scoring system for predicting survival and risk of acute leukemic
WHO CRITERIA FOR DIAGNOSIS: transformation developed based on
1. Sustained platelet count ≥450 × 109/L o percentage of blasts: blast count >5% elevates risk;
2. BM biopsy showing proliferation of mainly megakaryocytes with greater if >10%
enlarged mature nuclei, no increase or left shift of granulopoiesis or o Cytogenetics: complex chromosomal abnormalities or
erythropoiesis. chromosome 7 abnormalities are high risk
3. Not meeting WHO criteria for polycythemia vera, PMF, BCRABL1– o extent of cytopenias: more than one cytopenia increases
positive CML, MDS, or other myeloid neoplasm. risk
4. Demonstration of JAK2 V617F mutation or, in its absence, no - persons over age 50
evidence of reactive thrombocytosis.

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 - usually present as an anemia refractory to hematinics, with or o antibodies including antilysozyme, CD68, CD64, and
without neutropenia and thrombocytopenia CD36.
- liver, spleen, or lymph nodes are not usually enlarged. - For monocytic differentiation, promonocytes are considered
- hypercellular marrow with abnormal maturation in one or more of equivalent to blasts
the three hematopoietic cell lines, and blast cells are often - Promonocytes are immature recognizable monocytes with some
increased. chromatin condensation with fine nuclear convolutions
Study table 33-13; p 624 - Basis for dx: >20% blast in blood or
TYPES OF ABNORMAL CELLULAR MATURATION marrow
• Dyserythropoiesis - AML-erythroleukemia: >50% of BM
- resembles megaloblastic change and includes nuclear cells are erythroid precursors +
fragmentation or karyorrhexis, multinuclearity, nuclear budding or myeloblasts >20% of nonerythroid cells
bridging, basophilic stippling, and ring sideroblasts - MDS: <20% of nucleated marrow cells
• Dysgranulopoiesis or <20% of NE cells, when RBC
- nuclear/cytoplasmic asynchrony, hypogranulation, nuclear precursors >50%, are myeloblasts
hyposegmentation with increased chromatin condensation, - Auer rods – eosinophilic rod-like cytoplasmic
occasionally abnormal large azurophilic granules, inappropriately inclusions; seen in any subtype of AML but
prominent nucleoli, or other abnormalities especially those with granulocytic
• Dysmegakaryocytopoiesis differentiation
- includes large megakaryocytes with unsegmented nuclei, - Phi bodies – eosinophilic bead-like granules;
micromegakaryocytes, and megakaryocytes with two or more seen in AML & MDS
small, unconnected nuclei

B. PRECURSOR LYMPHOID NEOPLASM (9)

• Leukemias: hematopoietic malignancies primarily involving BM and
• Lymphomas: primarily involve lymphoid organs or other soft tissues;
• WHO classification focuses on cytogenetic and molecular findings
1.
2.
3.
4.
5.
B. ACUTE MYELOID LEUKEMIA (6)
C. 1. Acute Leukemia with Recurrent Genetic Abnormalities (10) 6.
D. 2. Acute Myeloid Leukemia with Myelodysplasia-Related Changes 7.
E. 3. Therapy-Related Myeloid Neoplasms 8.
F. 4. Acute Myeloid Leukemia, Not Otherwise Specified (10)
G. 5. Myeloid Proliferations Related to Down Syndrome (3) 9.
H. 6. Acute Leukemias of Ambiguous Lineage (7)
I.
A. ACUTE MYELOGENOUS LEUKEMIA
Clinical and Laboratory Features of Acute Myeloid Leukemia
- Affects all ages, but increases with older age (>60 years)
- May resemble acute infection at presentation
- Requires 20% blasts in blood or marrow for diagnosis
- Key myeloid antigens: myeloperoxidase, CD13, CD33, CD117,
and CD14/CD64
- Recurrent cytogenetic abnormalities that characterize defined
subtypes
- Classification made by morphology, cytogenetics, flow cytometry,
cytochemistry
- With advances in molecular cytogenetics and FISH, and with
widespread adoption of these and other methods, it is likely that
most cases will eventually be categorized by their genetic
abnormalities
- particularly important because targeted therapies to the
biochemical pathways or even to the nucleic acid perturbations
involved
CURRENT CLASSIFICATION BASED ON WHO:
- Primitive myeloblasts: identified by monoclonal antibodies
against myeloid-associated antigens (MPO, CD13, CD33, CD117)
- More mature myeloblasts: cytochemical reactions with
granulocyte-associated enzymes using MPO, Sudan black B (SBB),
and chloroacetate esterase (CAE) assays
- flow cytometric assays are utilized more often in current practice
- Monoblasts: strong reaction with
o α-napthyl acetate esterase (ANA),
o α-napthyl butyrate esterase (ANB), or
blood
classification schemes evolved rapidly because of advances in
immunology, oncology, and genetics
whenever possible
B Lymphoblastic Leukemia/Lymphoma
B Lymphoblastic Leukemia/Lymphoma with t(9;22)(q34;q11.2); BCR-
ABL1
B Lymphoblastic Leukemia/Lymphoma with t(v;11q23); MLL
Rearranged
B Lymphoblastic Leukemia/Lymphoma with t(12;21) (p12;q22); TEL-
AML1 (ETV6-RUNX1)
B Lymphoblastic Leukemia/Lymphoma with t(1;19) (q23;p13.3);
E2A-PBX1 (TCF3-PBX1)
B Lymphoblastic Leukemia/Lymphoma with t(5;14)(q31;q32); IL3-IGH
B Lymphoblastic Leukemia/Lymphoma with Hyperdiploidy
B Lymphoblastic Leukemia/Lymphoma with Hypodiploidy (Hypodiploid
Acute Lymphoblastic Leukemia)
B Lymphoblastic Leukemia/Lymphoma, Not Otherwise Specified
(Refers to all Other B-All)
B LYMPHOBLASTIC LEUKEMIA/LYMPHOMA
- Most often presents as leukemia;
o T lymphoblastic tends to present as lymphoma or both
- Prototype of ALL
- Most common malignancy of children and adolescents
- Cure rates of 80% in children with combination chemotherapy,
CNS treatment, and intensified therapy for high-risk categories
- Favorable factors: age 5–10 years, hyperdiploidy and normal or
low WBC
- Poor risk factors: younger than 1 year, t(9;22), and t(4;11)
- Adults: 30%-40% cure rate due to higher frequency of adverse
genetic abnormalities
o Middle to older age group
o SX: fatigue, fever, and bleeding; generalized
lymphadenopathy, splenomegaly, and hepatomegaly;
other symptoms 2o to infiltrates
- Lymphoma: skin, bone, and/or lymph node without BM
involvement (<25% blasts in the marrow)
- Young, <18 y/o, overlapping features with precursor B-ALL, TdT,
and B-lineage markers
- Morphology:
o diffuse infiltrations of small cells with diffuse chromatin,
inconspicuous nucleoli, scant cytoplasm, high mitotic rate,
o frequently a “starry-sky” pattern of admixed
histiocytes
- Marrow:
o by the time the patient is symptomatic, hematopoietic
cells and fat are usually replaced by a diffuse
infiltration of lymphoblasts.

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 o Blast percentage is usually >50% DIFFUSE LARGE B CELL LYMPHOMA
o TdT, cytoplasmic CD22 and CD79a, CD19, & HLA-DR - Demographics: M > F, all ages
- Cytogenetics: - Clinical Features: moderately
o increasingly important in diagnosis and prognostication aggressive but responds to chemo
in ALL and anti-CD20
- Laboratory: Biopsy
C. MATURE B CELL NEOPLASMS (37) - Morphology: Diffuse infiltrate of
large B cells, variable morphology
1. Monoclonal B Cell 21. Primary Cutaneous Follicle - Cell Surface Markers: CD19, CD20,
Lymphocytosis Center Lymphoma CD22, CD79a, sIg, bcl- 2―/+, bcl-6―/+, MUM1 in post-GC
2. Chronic Lymphocytic 22. Mantle Cell Lymphoma types
Leukemia/Small Lymphocytic 23. Diffuse Large B Cell
Lymphoma Lymphoma, NOS BURKITT LYMPHOMA
3. B Cell Prolymphocytic 24. Cell/Histiocyte-Rich Large B Demographics:
Leukemia Cell Lymphoma 1. Endemic: children in Africa, jaw
4. Splenic Marginal Zone 25. Primary DLBCL of the CNS mass, M > F; associated with EBV
Lymphoma 26. Primary Cutaneous DLBCL, Leg 2. Sporadic: children to young adults,
5. Hairy Cell Leukemia Type worldwide, M > F; not associated
6. Splenic B Cell 27. EBV-Positive DLBCL of the with EBV
Lymphoma/Leukemia, Elderly 3. Immunodeficiency associated: HIV
Unclassifiable 28. DLBCL Associated with patients
7. Hairy Cell Leukemia Variant Inflammation - Clinical Features: rapidly fatal if
8. Lymphoplasmacytic Lymphoma 29. Lymphomatoid Granulomatosis untreated; 90% survival in pedia; 50 -70% in adults
9. Heavy Chain Diseases 30. Primary Mediastinal (Thymic) - Morphology: uniform cells with round to oval nuclei, multiple
10. γ Heavy Chain Disease Large B Cell Lymphoma nucleoli, high mitotic rate, “starry sky”
11. α Heavy Chain Disease 31. Intravascular Large B Cell - Cell Surface Markers: CD19, CD20, CD10, bcl-6, sIg
12. μ Heavy Chain Disease Lymphoma
13. Plasma Cell Neoplasms 32. ALK-Positive Large B Cell MULTIPLE MYELOMA
14. Monoclonal Gammopathy of Lymphoma - neoplastic proliferation of plasma
Undetermined Significance 33. Plasmablastic Lymphoma cells, occurring primarily in the BM
15. Plasma Cell Myeloma 34. Large B Cell Lymphoma - mean age, 62 y/o, M=F; rare <40
16. Immunoglobulin Deposition Arising in HHV8-Associated y/o
Diseases Multicentric Castleman’s - Sx:
17. Extranodal Marginal Zone B Disease o bone pain,
Cell Lymphoma of Mucosa- 35. Primary Effusion Lymphoma o pathologic fractures,
Associated Lymphoid Tissue 36. Burkitt Lymphoma o neurologic sx,
18. Nodal Marginal Zone 37. B Cell Lymphoma, o metastatic calcification
Lymphoma Unclassifiable, with Features - marked degree of rouleaux formation;
19. Pediatric Nodal Marginal Intermediate Between DLBCL - Symptomatic myeloma (WHO):
Zone Lymphoma and Burkitt Lymphoma o M-protein in serum or urine,
20. Follicular Lymphoma o BM clonal plasma cells or
- constitute the most numerous and possibly the most diverse group plasmacytoma,
of hematopoietic neoplasms o presence of related organ or
- Involve the cells of the humoral immune system tissue impairment
- Clinical behaviors relate to clonal escape from regulation, the - Dx: based on both pathology and clinical findings, including serum
balance of proliferation and apoptosis, and modulation by monoclonal immunoglobulin and radiologic evidence of lytic bone
therapy lesions
- Diagnostic criteria:
CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA o protein in serum or urine
- Demographics: M>F; >60 y/o o Bone marrow clonal plasma cells
- Clinical Features: insidious onset o Organ or tissue impairment (hyperCalcemia, Renal
of fatigue, lymphadenopathy insufficiency, Anemia, Bone lesions; CRAB)
- Laboratory: DIAGNOSTIC CRITERIA
o WBC >5 K/μL,
• Monoclonal Gammopathy of Undetermined Significance
o anemia, - M-protein in serum <30 g/L
o thrombocytopenia, - Marrow plasmacytosis <10%
occasionally AIHA - No lytic bone lesions
- Morphology: Small lymphocytes with condensed chromatin - No myeloma-related symptoms (no CRAB)
- Cell surface markers: CD19, CD20, CD5, CD22, CD23, CD79a,
dim sIg • Asymptomatic (Smoldering) Myeloma
- Serum M-component >30 g/L
HAIRY CELL LEUKEMIA - Marrow plasmacytosis >10%
- Demographics: M > F, median age 50 - No organ or tissue impairment (no CRAB)
years
Study Table 33-21, p 646
- Clinical Features: insidious onset with
splenomegaly,
- Laboratory: leukopenia with
monocytopenia
- Morphology: Medium-sized cells with
round to oval indented nuclei, reticular
chromatin, frayed cytoplasmic borders
- Cell surface markers: CD20, CD22, CD79a, CD103, CD25,
CD11c

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 D. MATURE T AND NATURAL KILLER CELL NEOPLASMS (16) -
-
may follow a prolonged chronic course
Following lymph node infiltration, the disease becomes more
1. T-Prolymphocytic Leukemia progressive, and death, usually due to infection, occurs within 2
2. Large Granular Lymphocyte Leukemia years.
3. Chronic Lymphoproliferative Disorders of NK Cells - Treatment: PUVA, retinoids, α-interferon, and, more recently,
4. Aggressive NK Cell Leukemia – asian teens to young adults; alemtuzumab
constitutional sx, HSM
5. EBV-Positive T Cell Lymphoproliferative Disorders of Childhood
6. Adult T Cell Leukemia- Lymphoma- HTLV1 associated, LN, skin,
and hypercalcemia
7. Extranodal NK/T Cell Lymphoma, Nasal Type
8. Enteropathy-Associated T Cell Lymphoma -Celiac dse
9. Hepatosplenic T Cell Lymphoma – adolescents and young adults
, chronic immunosuppressive tx; liver, spleen, BM
10. Subcutaneous Panniculitis-like T Cell Lymphoma
11. Mycosis Fungoides and Sézary Syndrome –CTCL,middle-aged to
older; dermatitisàulcerated lesions
12. Primary Cutaneous CD30-Positive T Cell Lymphoproliferative
Disorder
13. Primary Cutaneous γδ T Cell Lymphoma - The nuclei of at least a portion of neoplastic cells typically have a
14. Angioimmunoblastic T Cell Lymphoma – generalized disease, cerebriform appearance.
systemic sx, hypergammaglobulinemia - Phenotype is usually mature T cell with CD8 expression
15. Peripheral T/NK Cell Lymphoma, Unspecified - Rare atypical mononuclear cells with
16. Anaplastic Large Cell Lymphoma- young adults, peripheral, cerebriform nuclei (Sézary cells)
abdominal, extranodal, and BM involvement may be present in the peripheral
- uncommon to rare compared with B cell lymphomas blood
- account for only about 12% of lymphomas overall - Lymphocytosis with these cells
- clonal rearrangement of genes encoding CD3, the T cell receptor (especially in the erythremic patient)
complex is called Sézary syndrome.
- T cell clonality studies in the laboratory usually focus on γδ-
receptor rearrangement, which is present in all or most T cells
- TCR-γ PCR assay for routine use; Flow cytometry assays using E. HODGKIN LYMPHOMA (5)
antibodies, useful and rapid 1. Classical Hodgkin Lymphoma: similar biology
a. Mixed cellularity
ADULT T CELL LEUKEMIA-LYMPHOMA (ATLL) b. Nodular sclerosis,
- is a highly variable, clinically aggressive T cell c. Lymphocyte depletion
leukemia/lymphoma associated with HTLV-1 d. Lymphocyte-rich classical
retrovirus infection 2. Nodular Lymphocytic Predominant HL
- It is most endemic in southwestern Japan but
also in the Caribbean basin, the southeastern HODGKIN LYMPHOMA, NLP
United States, and central Africa. - Demographics: M>F, 30 -50 y/o
- Transmission of HTLV-1 may occur vertically - Clinical Features: with peripheral
(from mother to child), or through sexual lymphadenopathy
contact, intravenous drug abuse, or blood - Morphology: Mononuclear cells
transfusion. with convoluted nuclei (popcorn or
- Only a minority of individuals infected with HTLV-1 (2.5%) L&H cells) loosely aggregated in
develop ATLL, typically after a latent period of many years. nodules of small B cells
- Acute infection results in a flu-like syndrome. - Cell surface markers: CD45,
- Skin lesions resemble mycosis fungoides CD20, bcl-6, J-chain, Oct-2, BOB.1, EBV absent in LP cells
- The immunophenotype of ATLL is CD2/CD3/CD5/CD25 positive, - Prognosis: Excellent for stages I, II
usually CD4+ and CD7 negative.
- The acute variant typically shows leukemia, skin involvement, HODGKIN LYMPHOMA, NODULAR SCLEROSIS
generalized lymphadenopathy, lytic bone lesions, and - Demographics: M = F, <30 years
hypercalcemia. - Clinical Features: with mediastinal
- PBS demonstrates anemia and thrombocytopenia with the mass, occasional spleen or lung
presence in blood and marrow of moderately large blastic cells involvement;
with convoluted or clover-leafed nuclei and condensed chromatin o 40% have B symptoms;
(floret cells) most patients present
- Marrow involvement is often patchy with increased osteoclastic with stage II disease
activity - Morphology: Broad bands of
collagen, nodules of lymphoid tissue with aggregates of HRS cells
MYCOSIS FUNGOIDES and lacunar cells, multinucleated variants
- 2X frequently in men as in women. - Cell surface markers: CD15, CD30, CD45-EBV in 1%–40%
- individuals in their middle to late years. - Prognosis: Good with systemic therapy
- an eczematoid, psoriasiform, or nonspecific exfoliative dermatitis.
- lesions tend to form plaques and then tumors that often ulcerate. HODGKIN LYMPHOMA, MIXED CELLULARITY
- Some patients develop generalized erythroderma. - Demographics: > F; median age,
- Biopsies of the skin reveal band-like lymphocytic infiltrates in the 38 years;
dermis, often with admixed histiocytes and occasional eosinophils - Clinical Features: peripheral
- T cells with irregular nuclei show single-cell infiltration of the lymphadenopathy common,
epidermis and often form clusters known as Pautrier’s abscesses spleen, BM; B symptoms common;
patients often stage III or IV
- Morphology: Classic HRS cells in
mixture of lymphocytes, plasma
cells, eosinophils, histiocytes
- Cell surface markers: CD15, CD30, CD45-EBV in 75%
- Prognosis: Good with systemic therapy

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 HODGKIN LYMPHOMA, LYMPHOCYTE DEPLETION
- Demographics: M > F; median age,
30–37 years
- Clinical Features: B symptoms,
advanced stage common; associated
with HIV
- Morphology: Classic HRS cells
common with paucity of background
lymphocytes; pleomorphic HRS cells
mimic sarcoma
- Cell surface markers: CD15, CD30, CD45-EBV pos in HIV
affected patients
- Prognosis: Associated with advanced stage

HODGKIN LYMPHOMA, LYMPHOCYTE-RICH, CLASSICAL

- Demographics: M > F, older age
- Clinical Features: peripheral lymphadenopathy; B symptoms rare;
most patients with stage I or II disease Study Table 33-22, p. 651
- Morphology: Scattered classic HRS cells among numerous small REFERENCES:
lymphocytes; nodular growth pattern - Henry’s Clinical Diagnosis and Management by Laboratory
- Cell surface markers: CD15, CD30; Oct2 and BOB.1 vary; J- Method; 22nd edition;
chain absent; EBV in 40%–75% - Pathologic Basis of Disease, 8th edition
- Prognosis: Good, similar to NLPHL - 2020 PPT
Additional notes
TABLE 33-22: KEY FEATURES OF HODGKIN LYMPHOMA

TABLE 33-13: KEY FEATURES OF THE MAJOR MYELODYSPLASTIC SYNDROMES

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TABLE 33-21: KEY FEATURES OF THE MAJOR T AND NK CELL NEOPLASMS

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 CD-A (LABORATORY DIAGNOSIS) Acute Acute Chronic Chronic
Lymphoblastic Myelogenous Lymphoblastic Myelogenous
2.2 DIAGNOSIS OF LEUKEMIA (LAB) Leukemia Leukemia Leukemia Leukemia
Dr. Linda Tamesis (ALL) (AML) (CLL) (CML)
Tests used for the diagnosis of leukemia Cell type Lymphoid Myeloid Cells Lymphoid Myeloid Cells
1. Complete Blood Count Cells Cells
2. Peripheral blood smear Growth Quickly Quickly Slowly Slowly
3. Bone marrow aspiration/biopsy Age Children Adults and Adults +55 Adults
(Common) children
4. Fluorescent flow cytometry
5. Cytogenetic analysis
Cases 6000 18,000 15,000 6,000
per Year
Peripheral Blood Smear
- Descriptive analysis of: WBC, RBC & Platelets
PBS (10x) - Assess quality of preparation
- Assess RBC agglutination or rouleaux
formation
- Assess number, distribution and staining of
leukocytes
PBS 40x - Find an area where RBC are evenly
distributed/not distorted
- Obtain a WBC estimate
WBC count - Count the number of WBC in each of 10 high
estimation dry(40x)power fields.
- Average the numbers.
- Multiply the average by 2,000
(Average # WBC per 10 fields) x 2,000

Example: you see an average of 4 WBC in each high

dry field
4 x 2,000 = 8,000 WBC/cm3. or 8 x 109/l MYELOGENOUS NEOPLASTIC DISEASES
Descriptive - Predominant cell type ACUTE MYELOGENOUS AML M3 APL
analysis of - Level of maturity (shift to the left?) LEUKEMIA
WBC - Toxic change/reactive change
- Abnormal forms/infectious agents Auer Rod
NORMAL
AML M3
WBC ESTIMATE
6,000 cm3 APL
Normal
6 X 109/L

AUER ROD FAGGOT CELL

INCREASED DECREASED

NORMAL BM vs AML
AML MYELOMONOCYTIC PLATELET LEUKEMIA
Nucleated RBC

Platelet
Leukemia

CHRONIC MYELOGENOUS LEUKEMIA (BLOOD)

COMPARISON OF ACUTE AND CHRONIC LEUKEMIAS

ACUTE CHRONIC
Age All ages Usually adults
Clincial onset Sudden Insidious
Course (Untreated) 6 mo. Or less 2-6 years
Leukemic cells Immature > 30% blasts More mature cells
Anemia Prominent Mild
Thrombocytopenia Prominent Mild
WBC Count Variable Increased
Lymphadenopathy Mild Present; often
prominent
Splenomegaly Mild Present; often
prominent

8/9
 LYMPHOCYTIC NEOPLASIA 4. Identify the cell A. Mott cell
Acute Lymphocytic Leukemia ALL (bone marrow) B. Hairy cell
(Blood) C. Faggot cell
D. Match stick cell

5. TRUE of cell at pointer A. Does not belong to the

myelocytic series
Chronic Lymphocytic Leukemia CLL bone marrow aspirate B. Seen only in leukemia
blood C. Normally found in the
peripheral circulation
D. Also known as orthochromic
normoblast

6. What leukemia is this? A. ALL

B. CLL
C. AML
D. CML
HAIRY CELL LEUKEMIA MYCOSIS FUNGOIDES
(T cell leukemia)

7. What disease is this? A. Hairy cell leukemia

B. T cell leukemia
C. Multiple myeloma
D. Megakaryocyte leukemia

Abnormal B cells with hair-like Sezary cells

projections with cerebriform nucleus
MULTIPLE (plasma cell) MYELOMA (BMA) 8. CCommonly seen with this type of A. Hypersegmented
oleukemia neutrophils
m B. Bence jones protein
m C. DIC
D. Skin rash

Mott cell with Russel body inclusions 9. TRUE of this type of leukemia A. Has a chromosomal
translocation 15;17
B. Most common seen in
adults
C. Associated with gum
SAMPLE EXAM hyperplasia
1. Estimate the number of WBC A. 18,000 D. Has an insidious onset
B. 9,000
C. 15,000 10. Under what power do you A. 10X
D. Cannot be estimated estimate WBC B. 100X
C. 40X
D. Scanner

2. Identify the picture A. Leukemia, bone marrow

B. Leukemia, blood
C. Normal bone marrow
D. Normal blood smear
Answer key:
1. A. 18,000
2. C. Normal bone marrow
3. A. Granules and enzymes
4. C. Faggot cell
5. D. Also known as an orthochromic normoblast
6. B. CLL
7. B. T cell leukemia
3. What is the composition of the A. Granules and enzymes 8. B. bence jones protein
9. A. Has a chromosomal translocation 15;17
structure at the pointed B. Nuclear fragments 10. C. 40x
C. Endoplasmic reticulum
D. Spindle from mitosis end

9/9
 CD-A (LABORATORY DIAGNOSIS) • BODY WATER BALANCE
2.3: Water and Electrolytes - 1 L of water weighs 2.2 lbs
Dr. Linda Tamesis - a sudden weight gain or loss is the BEST indicator of fluid status
- patients need to have their fluid status monitored (input/output)
OUTLINE:
1. INTRODUCTION • Body Water Gain and Loss
2. WATER Body gains water by Body loses water through
3. ELECTROLYES o Ingestion of liquids/moist o Kidneys (1500mL/day)
Take note of the! and those in bold
foods (2300mL/day) o Evaporation from skin
Introduction o Metabolic synthesis of water (600mL/day)
- Three types of homeostatic balance (200mL/day) o Exhalation from lungs
o Water balance (300mL/day)
o Electrolyte balance o Feces (100mL/day)
o Acid–Base balance • Daily Water Gain and Loss
- Balances maintained by collective action of urinary, respiratory,
digestive, integumentary, endocrine, nervous, cardiovascular, and
lymphatic systems
WATER
Total Body Water !
- A percentage of lean body weight
- Values decrease with age (80% infancy-60% adult)
- Is lower
o in females than in males (50% versus 60%)
o with increasing obesity/loss of muscle mass
- 2 compartments separated by cell membrane
o extracellular fluid (ECF)
o intracellular fluid ( ICF)
BODY FLUID COMPARTMENTS
WATER BALANCE !
- Regulation of Water Intake
o The thirst mechanism of hypothalamus
- Regulation of Water Output
o The distal convoluted tubules and collecting ducts of the
nephrons
§ (↓) water loss = ADH, Aldosterone
§ (↑) water loss = ANP

FLUID IMBALANCES !
A. Dehydration
B. Hypovolemia
C. Hypervolemia
D. Water intoxication
• EXTRACELLULAR FLUID (ECF) VOLUME !
DEHYDRATION - Loss of body fluids - increased concentration
- is greater in infants and young children compared with older patients
of solutes in the blood and a rise in serum
- In normal adults, ECF constitutes approximately 33% of the TBW
Na+ levels
- is determined by the absolute amounts of sodium and water that are
- Fluid shifts out of cells into the blood to
present.
restore balance
Extracellular Fluid (ECF) types !
- Cells shrink from fluid loss and can no
- Interstitial Fluid between cell (80%)
longer function properly
- Plasma in blood (20%)
Clinical Manifestations:
- Transcellular Fluid lymph, cerebrospinal fluid, synovial fluid, aqueous
humor, vitreous body, endolymph, perilymph, pleural, pericardial, and o Irritability o Fever
peritoneal fluids o Confusion o Dry skin/mucous
o Dizziness membranes
o Weakness o Sunken eyes
• INTRACELLULAR FLUID VOLUME (ICF) ! o Extreme thirst o Poor skin turgor
- In normal adults, the ICF volume constitutes approximately 67 % of Tachycardia
o ↓ urine output o
TBW.
HYPOVOLEMIA - Isotonic fluid loss from the extracellular space
- Potassium salts are the main intracellular solutes
- ICF volume is larger than the ECF volume because there are more - Can progress to hypovolemic shock
- Caused by:
potassium salts in the cells than sodium salts in the ECF.
o Excessive fluid loss (hemorrhage)
BODY FLUID COMPARTMENTS ! o Decreased fluid intake
o Third space fluid shifting
- 2 barriers separate ICF, interstitial fluid and
plasma Clinical Manifestations:
- Plasma membrane separates ICF from o Mental status o Orthostatic
surrounding interstitial fluid deterioration hypotension
- Blood vessel wall divide interstitial fluid from o Thirst o Urine output < 30
plasma o Tachycardia ml/hr
o Delayed capillary o Cool, pale
refill extremities
• BODY WATER SPACING !
o Weight loss
a) First spacing – normal distribution of fluid in ECF
and ICF HYPERVOLEMIA - Excess fluid in the extracellular compartment
b) Second spacing – excess accumulation of fluid in interstitial space as a result of fluid or sodium retention,
(edema) excessive intake, or renal failure
c) Third spacing – fluid accumulates in areas that normally have no - Occurs when compensatory mechanisms fail to
fluid or minimal amount of fluid (ascites, edema associated w/ restore fluid balance
- Leads to CHF and pulmonary edema
burns) à relative hypovolemia

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 Clinical Manifestations: MOST ABUNDANT ELECTROLYTES !
o Tachypnea o Increased CVP, EXTRACELLULAR INTRACELLULAR
o Dyspnea pulmonary artery o Cation: Sodium o Cation: Potassium
o Crackles pressure and pulmonary o Anion: Chloride o Anions: proteins and
o Rapid, artery wedge pressure phosphates (HPO42-)
bounding pulse (Swan-Ganz) SODIUM
o Hypertension o JVD - 90% of extracellular cations
o S3 gallop o Acute weight gain - Combines with chloride and bicarbonate to help regulate acid-base
o Edema balance
WATER - Hypotonic extracellular fluid shifts into cells to - IMPORTANT: always monitor Na+ in head injuries because it usually
INTOXICATION attempt to restore balance causes cerebral edema
- Cells swell HYPONATREMIA Types
- Causes a) DILUTIONAL - results from Na+ loss; water
o SIADH gain
o Rapid infusion of hypotonic solution b) DEPLETIONAL - insufficient Na+ intake
o Excessive tap water NG irrigation or c) HYPOVOLEMIC - Na+ loss > water loss; can
enemas be renal (diuretic use) or non-renal (vomiting)
o Psychogenic polydipsia d) HYPERVOLEMIC - water gain > than Na+
gain; edema occurs
PRESSURE FORCES - Fluid Electrolyte & Particle Movement e) ISOVOLEMIC - normal Na+ level; too much
1. Hydrostatic pressure fluid
- pressure of blood fluid against capillary wall; if HP > pressure in Causes
interstitial space, fluids & solutes forced out of blood; if <, come back - loss via Gl fluids
into blood - excess sweating
2. Osmosis - diuretics
- water movement from area of higher to lower concentration through - aldosterone deficit (Addison’s)
membrane permeable to water, but not to solute; no energy needed; - burns & wound drainage
stops when solution concentrations equalize - hypotonic IVs (D5W, 0.45 NaCl)
3. Plasma colloid oncotic pressure - CHF, SIADH, renal failure
- pulling force of albumin in the intravascular space - water intoxication
- Opposes hydrostatic pressure to maintain equilibrium of fluid leaving Signs and Symptoms
& returning - primarily neurological
- Hypertension or hypoproteinemia causes HP to surpass COP and o headache, mental status
edema results. changes (short attention span,
lethargy, confusion, stupor,
LECTURE NOTES: coma, seizures)
• Extracellular fluid constitutes 1/3 of total body fluid
• Intracellular fluid constitutes 2/3 of total body fluid - may also have nausea, abdominal
• Make sure you know the difference between second and third spacing cramps, muscle twitching, tremors, or
o Second spacing – excess fluid in interstitial space (edema) weakness plus s/s volume disturbances
o Third spacing – excess fluid in areas that normally have no fluid or HYPERNATREMIA Causes
minimal amount of fluid (ascites, edema associated w/ burns) - Dehydration, fever, heat stroke,
• A sudden weight gain or loss is the BEST indicator of fluid status sweating
• Body gains water mostly through ingestion of liquids and lose water mostly
- watery diarrhea, diabetes insipidus
through the kidneys
• Water intake regulation is by the hypothalamus, water output regulation is - water deprivation
mainly enzymatic - sodium gain from excessive intake
• The most important symptomatology for dehydration: dry skin/mucous - hyperaldosteronism (Cushing’s)
membranes, sunken eyes and poor skin turgor Signs and Symptoms
• In hypovolemia, the presence of cool, pale extremities is the most important - slight puffiness of the face à early
• The most important symptoms for hypervolemia are the increased CVP sign
(Central venous pressure) and JVD (Jugular vein distention)
• To differentiate hypervolemia from water intoxication, remember that water - Think S-A-L-T
intoxication is hypotonic (tonicity is the difference) o S kin flushed
• The rarest fluid imbalance is water intoxication o Agitation
o Low grade fever
o Thirst
Electrolytes - weakness, lethargy, stupor, & coma
ELECTROLYTE BALANCE - Intracranial bleeding
Electrolytes move between ICF & ECF via concentration & electric
gradients CHLORIDE
1. Diffusion - movement from higher to lower concentration HYPOCHLOREMIA Causes
2. Facilitated Diffusion - specific carrier molecule added to - Chronic kidney disease
aid/accelerate diffusion - Congestive heart failure
3. Active Transport - molecules moved from area of low to higher - prolonged diarrhea, vomiting
concentration with external energy (ATP) - chronic lung disease
Electrolyte o from food or drink or produced as a by- product - metabolic alkalosis
Intake of metabolism - Drugs: laxatives, diuretics corticosteroids,
Electrolyte o through sweating, in feces and urine and chemotherapy
Output Regulation of Electrolyte Output ! Signs and Symptoms
a) aldosterone on the kidneys regulates sodium and - Agitation, irritability
potassium ions - Slow, shallow respirations
b) Potassium ions are excreted when sodium ions are - Dehydration
conserved HYPERCHLOREMIA Causes
c) Calcium concentration is regulated by parathyroid - Dehydration
hormone, which increases the concentrations of - increased intake with Na drugs
calcium and phosphate ions in extracellular fluids - hyperaldosteronism
and by calcitonin which does basically the reverse Signs and Symptoms
- hyperventilation

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 - Arrhythmias HYPERCALCEMIA Causes
- Tachycardia - increased intake
- Lethargy - intestinal absorption (e.g., vitamin A & D
- Weakness overdose)
- Edema - bone release
- major s/s related to metabolic acidosis - Hyperparathyroidism
- Malignancies (paraneoplastic)
POTASSIUM ! Signs and Symptoms
- Monitoring of potassium is important in heart and muscular diseases - decreased neuromuscular excitability, GI
HYPOKALEMIA Causes - motility and neurological irritability
- Spurious (not really low) - ECG: shortened ST
o Leukocytosis segment, widened T wave
o Insulin injection - Stones, bones, groans
- Diarrhea and psychic overtones
- Laxatives and diuretics
- Fasting MAGNESIUM
- Licorice excess - Needed for more than 300 biochemical reactions in the body
- Renal loss - Helps maintain normal nerve and muscle function
Signs and Symptoms - Supports a healthy immune system
S-U-C-T-I-O-N - Helps bones remain strong
- Skeletal muscle weakness - Aids in the production of energy and protein.
- U wave (EKG changes) - Regulates glucose levels
- Constipation, ileus HYPOMAGNESEMIA Causes
- Toxicity of digitalis glycosides - Alcohol use
- Irregular, weak pulse - Burns
- Orthostatic hypotension - Chronic diarrhea
- Numbness (paresthesias) - Polyuria
HYPERKALEMIA Causes - Hyperaldosteronism
- Spurious - Kidney tubule disorders
o Hemolysis, delayed separation - Malabsorption syndromes
o Prolonged tourniquet application - Malnutrition
- Digitalis overdose - Medicines
- Aldosterone deficiency - Pancreatitis
- Renal failure - Excessive sweating
- Many drugs Signs and Symptoms
Signs and Symptoms - Nystagmus
- irregular pulse, peaked T & prolonged PR - Convulsions
- irritability, anxiety - Fatigue
- abdominal cramping & diarrhea - Muscle spasms or cramps
- lower extremity weakness & paresthesias - Muscle weakness
(tingling sensation) Numbness
- ECG
o Tall T wave
o ST depression
HYPERMAGNESEMIA Causes
- Renal failure / Dialysis
- Excessive intake
- Lithium therapy
- Hypothyroidism
HYPOKALEMIA HYPERKALEMIA - Addison disease
- Familial hypocalciuric hypercalcemia
CALCIUM ! - Milk alkali syndrome
- Ionized calcium is approximately 1⁄2 of total calcium - Depression
- To get accurate ionized calcium results blood must be: Signs and Symptoms
o Collected with dried heparin - Decreased reflexes
o Analyzed within 30minutes - Muscle weakness
- Very small reference range - Confusion
HYPOCALCEMIA Causes - decreased breathing rate
- Chronic Renal Failure - Hypotension,
- alcoholism bradycardia
- loop diuretics - ECG
- Mg or vit. D defic. o Prolonged PR
- decreased albumin o QRS widening
- Elevated phosphorus
- GI losses COMPLETE METABOLIC PANEL
- Hypoparathyroidism o Calcium o BUN
- Decrease in ionized calcium from Alkalosis, o Chloride o Creatinine
- Transfusion of large amounts citrated o Potassium o TPAG
blood o Sodium o Tbili
- Donation of blood by apheresis
o CO2 o ALP
Signs and Symptoms o ALT
- Circumoral paresthesias, hyperactive o Glucose o AST
- reflexes, tetany, laryngospasm
- Chvostek’s &Trousseau’s signs References: 2020 PPT and lecture recording
- diarrhea, anxiety, seizures End
- Fractures
- prolonged QT & ST

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LECTURE NOTES:
• Magnesium problems are usually linked to problems in Potassium, so it is very
hard to differentiate between the two
• Sodium accounts for half of the osmolality of your extracellular fluid. It
attracts and helps preserve fluid volume. Always monitor Na+ in head injuries
because it usually causes cerebral edema.
• Sodium is very important for the brain. Decreased sodium can most commonly
cause headache, lethargy, and seizures.
• Hypernatremia is the most common type of electrolyte disorder. (Take note of
the clinical manifestations)
o Dehydration (1st cause), DIABETES INSIPIDUS (2nd cause)
• Slow, shallow respirations is symptom common and unique to
HYPOCHLOREMIA
• Remember: monitor Na for brain problems, monitor K for heart problems
• Licorice excess can cause hypokalemia (favorite daw ni doc so she might ask
this)
• U wave EKG changes is unique to Hypokalemia (diagnostic)
• Spurious factors are the most common cause of hyperkalemia. (i.e Hemolysis,
delayed separation, prolonged tourniquet application)
o That’s why it’s not advisable to use tourniquet when extracting blood :P
• Hypokalemia is much more common than hyperkalemia
• Ionized calcium is calcium that is not bound (free and ionic). To get your
ionized calcium, you can request for total calcium and divide it by 2
• Chronic Renal Failure and Hypoparathyroidism are the most common cause of
hypocalcemia
• Transfusion of large amounts of citrated blood à In people who received
more than 6 units of blood transfusion, you might have to give calcium
supplements
• In aphaeresis, your blood is removed, put in a machine, mixed with
anticoagulant and transfused back. So the premise is, you are receiving anti
coagulated blood to avoid thrombus/emboli. This anticoagulant actually
chelates (captures) calcium à hypocalcemia
• Circumoral paresthesias (in hypocalcemia) à lips become extremely numb
and tingling
• Chvostek’s sign (twitching of muscles of the Facial Nerve); Trousseau’s signs
(search niyo nalang di ko marinig)
• Reference range for Calcium is very very small, so it’s very easy to have
hypocalcemia and hypercalcemia
• Hyperparathyroidism and malignancies (paraneoplastic) are the most common
causes of hypercalcemia
o Number one cause of hypercalcemia is paraneoplastic syndrome!
• Stones, bones, groans, and psychic overtones of hypercalcemia (important,
take note)
o Stones – urinary tract stones (almost always composed of calcium)
o Bones – osteoclastic activities pull out calcium out of your bone. Prone
to fractures
o Groans – because you are constipated, you need calcium for your
action potential
o Psychic overtones - may present with severe depression (because of
the above reasons)
• You do not have to memorize all the ECG tracings. Memorize only those in
Potassium (Cardiac marker)
• Electrolytes have the worst ACCURACY among all laboratory exams (2019
lec)

Disclaimer: These lecture notes are phrased based on my understanding so it may not be
verbatim of Dr. Tamesis’ lecture. Use at your own risk.
-Ikigai J

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 CD-A (LABORATORY DIAGNOSIS) • CERVICAL, ENDOMETRIAL ADENOCARCINOMA
2.4 NEOPLASIA TESTING § Endometrioid type: ER/PR ASSAY
Humphrey C. Bitun, MD, FPSP, MMHoA § CK7 positive, CK20 negative
§ Endometrial: VIMENTIN
§ Cervical: P63
INDICATIONS VIMENTIN P63
1. Characterization or confirmation of neoplastic conditions Primary cervical adenocarcinoma - +
i.e. to determine if hematologic or lymphomatous, because Primary endometrial adenocarcinoma + -
management would depend on the type of tumor present
2. Determination of treatment • OVARIAN CANCER
i.e. chemotherapy, surgery, radiotherapy, etc. § CK7 positive, CK20 negative;
3. Confirmation of remission, relapse, and/or progression of the
versus colon primary which are CK7 negative, CK20
disease positive
4. Staging the disease and monitoring the course of treatment
§ Mucinous: CEA
Staging of disease is very important to determine the
§ Serous, clear cell: CA-125 and HE4
course of treatment
5. Information about prognosis HE 4 & CA-125 à good markers for prognostication and
6. Histological information of extent and nature of solid tumors monitoring patients; can also be positive for endometriod
Histological type is also very important in the management CA-125 is a general marker for Ovarian malignancy
because it is another indicator of prognosis of solid tumors § Yolk sac tumor: AFP / Alpha fetoprotein [noninvasive]
§ Dysgerminoma w/ syncytiotrophoblasts: B-HCG
SPECIMEN TYPES § Endometrioid: ER/PR Assay
• PERIPHERAL BLOOD § Fallopian Tube, pancreas, breast: BRCA 1 & 2
most accessible; i.e. for circulating tumor cells
• BONE MARROW (ASPIRATE/CORE) • THYROID
• ASCITIC FLUID § TTF1 / Thyroid transcription factor 1
• PLEURAL FLUID Primarily found to be positive for px with lung
Malignancy in the thorax/lungs, adenocarcinoma
Evaluate pleural effusions in breast ca for possibility of § Follicular and/or papillary: TSH & Thyroglobulin
malignant effusions from the breast § Medullary: Amyloid
• CEREBROSPINAL FLUID (CSF) (i.e ALL) Apple green bifringence w/ Congo Red Stain in
• URINE (i.e Kidney, Urinary Bladder tumors) Immunofluorescence microscopy
• ASPIRATION/CORE/INCISION/EXCISION BIOPSY OF SOLID
TUMORS • LUNG
• LYMPH NODES § Adenocarcinoma: TTF1
LNs are usually taken out for diagnosis of lymphoma § K-RAS +
• FORMALIN-FIXED, PARAFFIN-EMBEDDED TISSUE for special § ALK +
diagnostic tests § Squamous: P53, Rb
§ Non-small cell: EGFR, PD1/PDL1
TEST TYPES § CK7 positive/CK20 negative
- G-banded chromosome analysis and karyotyping § Small cells: Chromogranin, synaptophysin, NSE / neuron specific
- Genomic microarray analysis enolase
More advanced. Particularly useful in hematologic
malignancies, but can also be used for solid tumors • COLON
- Interphase fluorescence in-situ hybridization (IFISH) § Screening: (noninvasive)
- Immunophenotyping FOBT / fecal occult blood test
- Immunohistochemical staining FIT / fecal immunochemical test
Useful in zero-ing an undifferentiated lesion Stool DNA test (sDNA)
- Special staining § CK7 negative/CK20 positive
- Routine histopathologic examination § PD1/ PDL1 +
- Cytologic evaluation § CEA +
§ CTC test-metastatic
TUMOR MARKERS
• BREAST CK7 CK20
§ BRCA1 & BRCA2 mutation- familial type cervical, endometrial + -
BRCA 2 is more common in male patients adenocarcinoma
§ ER/PR Assay- immunohistochenical stain ovarian cancer + -
ER/PR positive would benefit from hormonal therapy
colon - +
§ Her2 neu assay- immunohistochemical stain or FISH
lung + -
A Her2 that is 2+ or borderline must be confirmed using
FISH
Her2 positive breast ca would benefit from targeted • PROSTATE
therapy of trastuzumab § PSA (Prostate specific antigen) / PAP (Prostatic acid phosphatase)
If negative for both ER/PR and Her2 neu, they won’t are used for monitoring
benefit from both. Cytotoxic therapy may be most PSA is organ specific; but elevation of PSA is not always
effective. due to malignancy. In patients with PSA
§ CA 15-3 + PSA reference range: 0-4 nanograms/mL
§ CTC test / circulating tumor cells (CellsearchTM)-metastatic i.e. even with a PSA of 10 – 20 may not be indicative of a
malignancy, but then sometimes even a PSA of 7 can
already be indicative of malignancy.
• NASAL / NASOPHARYNGEAL/ TONSILLAR MASS
Although, very high amounts of PSA would definitely be
§ Carcinoma: CK
indicative of malignancy
§ Lymphoma: LCA/CD45
§ CTC test-metastatic
Lymphoma is also positive for Vimentin
Positive: Breast, Colon & Prostrate
§ Rhabdomyosarcoma: Vimentin, desmin
If it positive for DESMIN, but negative for CK & LCA à
• PANCREAS
Rhabdomyosarcoma
§ CA 19-9

1/5
• LYMPHOMA
§ CD45 +
CD-A (LABORATORY DIAGNOSIS)
§ T CELL Non-Hodgkin: CD3 2.4 Tests for the Detection and Diagnosis of
§ B CELL Non-Hodgkin: CD20
Cancer
More common
§ Hodgkin: CD15, CD30 Tumor Markers
For Hodgkin’s lymphoma, you should look for the presence - Biomarker found in
of Reed-Sternberg cell / RS cell blood, urine, or body
§ Basal neoplasm: Kappa, Lambda light chain tissues that can be
elevated by the
• LEUKEMIA presence of one or
§ CD45 + more types of cancers.
§ Myeloid: CD13, CD33 - Blood is used for most
§ Myeloid: CD38, CD138 - Most done in
§ lymphoblastic: Tdt / Terminal deoxynucleotidyl transferase immunology section
§ lymphocytic: Sig / Surface immunoglobulin - NOT DIAGNOSTIC
§ B lymphoblastic: CALLA (CD10) Functions:
- Monitor
• GASTRIC - Help diagnose
§ CEA + - Stage
§ Her2 neu - Determine prognosis
for prognostication and targeted therapy
- Tumor Markers
- Guide treatment
• Small round/spindle cell undifferentiated tumors
- Monitor treatment
§ Carcinoma: CK & Epithelial membrane antigen (EMA)
- Determine recurrence
§ Leukemia/lymphoma: LCA/CD45
§ Sarcoma, lymphoma: Vimentin
RAPID TESTS FOR CANCER SCREENING
§ Rhabdomyosarcoma: Desmin, MyoD1
FECAL OCCULT BLOOD TEST (FOBT)
§ Leiomyosarcoma: Smooth muscle actin (SMA) PURPOSE
§ Angiosarcoma: CD31, CD34
- The fecal occult blood test (FOBT) is used to check stool samples
§ Small cell undifferentiated: Chromogranin A, synaptophysin for hidden (occult) blood.
§ Neuroblastoma: S-100, PNET / Primitive Neuro-Ectodermal Tumors
- Occult blood (2.5 ml of blood in 150 g of stool) may indicate
colon cancer or polyps in the colon or rectum.
- Typically, occult blood is passed in such small amounts that it can
be detected only through the chemicals used in a fecal occult
blood test.
- This test is requested to
o Screen for colon cancer
o Evaluate possible causes of anemia.

PREPARATION
- 3 days before the test, patient must avoid:
o Certain fruits and vegetables (broccoli, turnips)
o Red meat
o Horseradish
o Vitamin C supplements
o Pain relievers, (aspirin and ibuprofen)
SAMPLE: Stool
METHODOLOGY
- Chemical
o Guaiac fecal occult blood test – described below
o Flushable reagent pad or tissue
- Immunochemical fecal occult blood test * requires not patient
preparation

FOBT GUAIAC
- The principle of chemical tests to detect occult blood is based on
the fact that hemoglobin and its derivatives react in a similar way
to peroxidase enzymes, catalyzing the transfer of an oxygen
atom from the peroxide to a chromogen such as benzidine, o-
toluidine, guiac or aminophenazone.
- Oxidation of the chromogen is indicated by the production of a
blue, blue-green or pink color.
Colorless Blue
Hgb à H2O2 à Guiac à Oxidized guiac

- test card with room for two or three samples

- stool sample from each of two or three bowel
movement
- usually taken on consecutive days (3-6 days)

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PROCEDURE
1. With applicator apply thin smear of stool to window A
2. Use same applicator to obtain another sample from a different
area of stool. Apply inside window B.
3. Close cover and allow to dry.
4. Turn over test pack. Lift flap and place 2 drops of developer over
each smear.
5. Apply one drop of developer onto control area. Wait for color
development.
6. Read result in 30-60 seconds
INTERPRETATION
• False positive results can occur if
other urease containing
organisms are present in
sufficient quantity or if one allows
contact of the specimen and the
media for a prolonged period,
typically longer than 24 hours.
• False negative if low volume of
(<105 ) bacteria and anything
INTERPRETATION: Blue color seen on test area signifies the presence of that reduces the bacterial density
occult blood. such as the use of antibiotics,
bismuth-containing compounds, or
RESULTS proton pump inhibitors.

CYTOLOGY
Papanicolaou Staining
- Polychromatic dyes used to differentially stain various components
of the cell
- several specimen can be used: cervical, sputum, urine, CSF,
abdominal fluid, synovial fluid, etc.
- Only a screening test! Low sensitivity with limited accuracy.
Positive Negative Positive FOBT( guaiac)
PURPOSE
Immuno Fecal Occult Blood Tests (IFOB)
- Newer type of FOBT - A Pap smear, also called a Pap test, is a screening procedure for
cervical cancer. It tests for the presence of precancerous or
- Fecal immunochemical testing (FIT), and
cancerous cells on the cervix. The Pap test can also find
immunochemical fecal occult blood tests
noncancerous conditions, such as infections and inflammation.
(IFOBT).
PATIENT PREPARATION
- FIT products utilize specific antibodies
to detect globin. - Avoid intercourse, douching and vaginal medications at least one
day before the test Best if test is done when female is not
IFOB Interpretation menstruating.
METHODOLOGIES : Slide method or liquid prep

PRINCIPLE
- Exfoliative cells are shed into the vaginal cavity or scrapped from
the surface of the cervix. Assessing these cell give information
about the condition of the cervix.

UREASE TEST Cervical Smear: Obtaining the sample

- The test involves incubating a gastric
biopsy in a urea broth that contains the
pH indicator phenol red.
- If gastric helicobacters are present,
helicobacter urease breaks down the
urea; with the release of ammonia, a rise
in pH and a color change occur.
- The change in color can occur within 1 to
3 hours, although the broth is generally incubated at room
temperature for 24 hours.
- This test is very sensitive, but false negative results can occur if
distribution within the stomach is patchy or if organism loads are
low. False-positive results have rarely been reported when other
urease producing bacteria are present in the stomach, such as
Proteus spp..
Rapid Urease Test
- Detection of helicobacter pylori and other camphylobacter like
organisms
PROCEDURE
1. Prepare the equipment: Gloves, Speculum, Endo-cervical
brush/Spatula/Cytobrush, Slide/vial, Ethanol/Methanol fixative
for slide
2. The woman will lie on the examination table on her back with her
knees up and bent and her feet in stirrups (rests).
3. A small speculum is used to open the vagina so that the walls of
the vagina and cervix can be seen clearly.
4. A sample of mucus and cells will be obtained from the cervix and
endocervix using a wooden scraper or a small cervical brush or
broom.
5. The sample of cells is either evenly applied to a glass slide and
sprayed with a fixative, or rinsed into a vial of liquid preservative.
6. The fixed slide or vial is sent to laboratory for microscopic
assessment.
7. At the laboratory, the sample will be stained with Papanicolaou
stain so that cellular detail can be enhances and is viewed by a
cytologist/pathologist.

3/5
 FLUORESCENT FLOW CYTOMETRY
• Flow cytometry
counters: A single-cell
stream passes through a
laser beam. The
absorbance is measured,
and the scattered light is
measured at multiple
angles to determine the
cell’s granularity,
INTERPRETATION/REFERENCE RANGE diameter, and inner
- The Bethesda System is used to report neoplastic screening results. complexity.
The report may also note certain benign (non-neoplastic) findings,
such as common infections or inflammation. Remarks can also be • Fluorescent flow
made about the sample adequacy for examination. cytometry: Adding
o no cell abnormalities fluorescent reagents
o negative for intraepithelial lesion or malignancy extends the use of flow
o Atypical squamous cells (ASC):ASC-US and ASC-H. cytometry to measure
specific cell populations.
o Low-grade squamous intraepithelial lesions (LSILs) Fluorescent dyes reveal
o High-grade squamous intraepithelial lesions (HSILs): the nucleus-plasma ratio
CIN-2, CIN-2/3, CIN-3, CIS of each stained cell.
o Squamous cell carcinoma
o Atypical glandular cells (AGC)
o Endocervical adenocarcinoma in situ (AIS)
o Adenocarcinoma
Cells seen

Neoplastic Changes
Normal Low Grade High Grade

Squamous cells
Koilocyte
- A squamous cell that has undergone a number of structural
changes, which occur as a result of infection by human
papillomavirus.
- May have the following cellular
changes
o Nuclear enlargement.
o Irregular nuclear contour.
o Hyperchromasia.
o Perinuclear halo or
perinuclear cytoplasmic
vacuolization.

TURNAROUND TIME: 1 to 7 days

CLINICAL/PROCEDURAL NOTES
• False positive and false negative results are common, thus clinical
impression will dictate further clinical actions.
• Advantage of liquid-based testing is that the same cell sample can
also be tested for the presence of high-risk types of HPV and
yields more satisfactory specimen.
HISTOPATHOLOGY (definitive diagnosis)
BIOPSIES
PURPOSE
- A biopsy is a procedure to remove a piece of tissue or a sample
of cells from the body so that it can be analyzed in a laboratory.
It is usually done when there is a mass or suspicion of neoplastic
growth. Tissue may also be needed to make a definitive diagnosis
of inflammatory diseases.

4/5
PATIENT PREPARATION Genomic
- Biopsies vary greatly according to how difficult the tissue is to • Gene Sequencing
obtain. A minimally invasive biopsy (for example, most skin - To detect specific mutations
biopsies) may be done in the doctor's office. More invasive o Sanger Technique with probe amplification
biopsies may be done in a hospital or surgical center. In most o Next Generation Sequencing (NGS)
cases, sedating and pain relief medicines are given, reducing any
discomfort.
PROCEDURE/TYPES OF BIOPSY
• ENDOSCOPIC BIOPSY uses a thin, flexible tube (endoscope) with
a light on the end to see structures inside the body. Special tools
are passed through the tube to obtain a small sample. The
endoscope can be inserted through the mouth, rectum, urinary tract
or small incision in your skin. Examples include cystoscopy,
bronchoscopy, and colonoscopy.
End
• NEEDLE/ASPIRATION BIOPSY- uses a special needle to extract
cells from a suspicious area that can felt through the skin.
procedures include fine- needle aspiration, core needle biopsy, References:
vacuum-assisted biopsy, image- guided biopsy (CT and - Dr. Bitun’s PPT and lecture
ultrasound).
- Dr. Tamesis’ PPT and lecture
• SKIN BIOPSY- sample tissue is removed from an external surface. - CD GUIDEBOOK 2020 for additional lab notes
• SURGICAL BIOPSY- preformed when mass or suspicious tissue is
deep within the body. A part of an abnormal area of cells can be If you see any errors on my transes/have any comments, message me on TG
removed (incisional biopsy) or the entire area itself (excisional [IkigaiMD] J Again, always use at your own risk. Don’t use my transes if you hate it
biopsy). that much L
Punch Needle Open/Surgical

POST PROCEDURE CARE

- Patient should not drive or travel alone if given sedative or
anesthetic. Wound care must be done when necessary.
COMPLICATIONS
- Depend on procedure, may range from soreness/pain at site of
biopsy to bleeding and infection.
CLINICAL NOTES
- Laboratory/Operating Room will provide container and formalin
if requested prior to biopsy.

WORKFLOW
1. Fixing (i.e Formalin)
2. Processing
3. Embedding
4. Cutting
5. Staining (i.e H&E stain)
6. Microscopy

GENETIC TESTS
Cytogenetic (chromosomal)
• Fluorescent in Situ Hybridization
- Detection of chromosome
rearrangements with site specific
probes
- Used to detect the Philadelphia
chromosome, ABL-BCR, (t22;9)
- Highly specific and sensitive

5/5
 CD - A LABORATORY DIAGNOSIS 2.4
Neoplasia Testing (Lec) & Tests for Cancer (Lab)
(BITUN, MD & TAMESIS, MD)
² TTF1- adeno ² EFGR
INDICATIONS: ² K-RAS ² CK7+ / CK20 -
ü Characterization or confirmation of neoplastic conditions ² ALK ² Chromogranin, synaptophysin
² p53, Rb ² NSE- small cells
ü Determinant of treatment
² PD1/PDL1
ü Confirmation of remission, relapse, and/or progression of the
disease COLON
ü Staging of the disease and monitoring the course of ² FOBT - Fecal Occult Blood test
treatment ² FIT - Fecal Immunochemical test
ü Information about prognosis ² Stool DNA test (sDNA)
ü Histological information of extent and nature of solid tumors ² CK7-/CK20+
² PD1 / PDL1
² CEA
SPECIMEN TYPES:
² CTC test - metastatic
l Peripheral Blood l Aspiration/Core/Incision/
l Bone Marrow Excision Biopsy of Solid PROSTATE
(Aspirate/Core) Tumors ² PSA
l Ascitic Fluid l Lymph Nodes ² PAP
l Pleural Fluid l Formalin-Fixed, Paraffin- ² CTC test - Metastatic
l Cerebrospinal Fluid (CSF) Embedded Tissue
l Urine PANCREAS
² CA 19-9
TEST TYPES
l G banded chromosome l Immunohistochemical LYMPHOMA
analysis and karyotyping staining ² CD45
l Genomic microarray analysis l Special Staining ² CD3 - T CELL - Non Hodgkin
l Interphase fluorescence in- l Routine Histopathologic ² CD20 - B CELL - Non Hodgkin
situ hybridization (IFISH) Examination ² CD15, CD30 - Hodgkin
l Immunophenotyping l Cytologic evaluation ² Kappa, Lambda light chain

LEUKEMIA
BREAST ² CD45
² BRCA1 & BRCA2 mutation-familial type ² CD13, CD33 - Myeloid
² ER/PR Assay - Immunohistochemical stain ² CD38, CD138 - Myeloid
² Her2 neu assay - Immunohistochemical stain or FISH ² Tdt - Lymphoblastic
² CA 15-3 ² Sig-Lymphocytic
² CTC test-circulating tumor cells (!"##$"%&'ℎ!" ) - Metastatic ² CALLA (CD10) - B lymphoblastic

NASAL / NASOPHARYNGEAL / TONSILLAR MASS GASTRIC

² CK-carcinoma ² Her2 neu
² LCA/CD45 - lymphoma ² CEA
² Vimentin, desmin-rhadomyosarcoma
SMALL ROUND/SPINDLE CELL UNDIFFERENTIATED TUMORS
CERVICAL, ENDOMETRIAL ADENOCARCINOMA ² CK - Carcinoma
² ER/PR Assay - endometrioid type ² Epithelial Membrane Antigen (EMA) - Carcinoma
² CK7+, CK20- ² LCA/CD45 - Leukemia / Lymphoma
² VIMENTIN - endometrial ² Vimentin - sarcoma, lymphoma
² P63-cervcial ² Desmin, MyoD1-rhabdomyosarcoma
² Smooth Muscle Actin (SMA) - leiomyosarcoma
OVARIAN CANCER ² CD31, CD34 - angiosarcoma
² CK7+, CK20-, versus colon primary CK7-, CK20+ ² Chromogranin A, syntaptophysin - small cell undifferentiated
² CEA - MUCINOUS ² S-100 - PNET, Neuroblastoma
² CA-125 and HE4 - serous, clear cell
² AFP - yolk sac tumor REFERENCES:
² B-HCG - dysgerminoma with syncytiotrophoblasts → PPT of Dr. Bitun (2020)
² ER/PR Assay - endometrioid → Sleepy Crammers Trans
² BRCA 1 & 2 - including FT, pancreas, breast

THYROID
² TTF1
² TSH-follicular and papillary
² Thyroglobulin-follicular and papillary
² Amyloid-medullary

LUNG

1 Transcribed by: jisoo

 CD - A LABORATORY DIAGNOSIS 2.4
Neoplasia Testing (Lec) & Tests for Cancer (Lab)
(BITUN, MD & TAMESIS, MD)
Outline
1. Tumor Markers
2. Rapid Tests for Cancer Screening Another Positive Result
3. Cytology Blue arrow = test result
4. Histopathology Red arrow = control window
5. Genetic Tests

TUMOR MARKERS
² Biomarkers found in blood, urine, or body tissues that can be elevated by
the presence of one or more types of cancers
² Blood is used for most
² Most done in immunology section IFOB (Immuno Fecal Occult Blood)
USES: ² Newer type of FOBT
ü Monitor ü Guide Treatment ² Aka Fecal Immunochemical Testing (FIT) or Immunochemical Fecal
ü Help diagnose ü Monitor treatment Occult Blood Test (IFOBT)
ü Stage ü Determine recurrence ² FIT products utilizes specific antibodies to detect globin
ü Determine prognosis

RAPID TESTS FOR CANCER SCREENING

FECAL OCCULT BLOOD TEST (FOBT) pg 30 in Manual
² Widely used screening
² Screen for colon cancer
² Cause of unexplained anemia
Preparation:
3 days before the test, patient must avoid:
ü Certain fruits and vegetables (broccoli, turnips)
Interpretation:
ü Red meat
ü Horseradish
ü Vitamin C supplements
ü Pain relievers (aspirin, ibuprofen)
GUAIAC METHOD (oldest method):
l Test card with room for two or three samples
l Stool samples from each of two or three bowel movements
l Usually taken on consecutive days
UREASE TEST
² The test involves incubating a gastric biopsy in a urea broth that contains
the pH indicator phenol red
² If gastric helicobacters are present, helicobacter urease breaks down the
urea; with the release of ammonia, a rise in pH and a color change
occur.
² The change in color can occur within 1 to 3 hours, although the broth is
generally incubated at room temperature for 24 hours.
² Detection of Helicobacter pylori and other Campylobacter like organisms
² The test is very sensitive, but false-negative results occur if the
Results: distribution within the stomach is patchy or if organism loads are low.
False-positive results rarely been reported when other urease-producing
bacteria are present in the stomach, such as Proteus spp.

A = Negative Result
A B
B = Positive Result (bluish
discoloration around the
sample)

2 Transcribed by: jisoo

 CD - A LABORATORY DIAGNOSIS 2.4
Neoplasia Testing (Lec) & Tests for Cancer (Lab)
(BITUN, MD & TAMESIS, MD)
Cells seen (pg 87):

Interpretation:
l False positive results can
occur if other urease Neoplastic Changes (pg 87):
containing organisms are
present in sufficient quantity
or if one allows contact of the
specimen and the media for a
prolonged period, typically
longer than 24 hours
l False negative if low volume
of (<10# ) bacteria and
anything that reduces the
bacterial density such as the
use of antibiotics, bismuth-
containing compounds, or KOILOCYTE
proton pump inhibitors. ü A squamous cell that has undergone a number of structural changes,
which occur as a result of infection by human papillomavirus
ü May have the following cellular changes:
n Nuclear enlargement
n Irregular nuclear contour
n Hyperchromasia
CYTOLOGY n Perinuclear halo or perinuclear cytoplasmic vacuolization
PAPANICOLAOU STAINING
ü Polychromatic dyes used to differentially stain various components of
the cell
ü Several specimen can be used: Cervical, Sputum, Urine, CSF, Abdominal
fluid, Synovial fluid, etc.
ü Only a screening test! Low sensitivity with limited accuracy

CERVICAL SMEAR pg 75
Obtaining the sample:

FLOURESCENT FLOW CYTOMETRY

² Detects changes in cell size, shape & density
² It usually scatters cells and offers a ‘scatterplot’ result

3 Transcribed by: jisoo

 CD - A LABORATORY DIAGNOSIS 2.4
Neoplasia Testing (Lec) & Tests for Cancer (Lab)
(BITUN, MD & TAMESIS, MD)
² Detection of chromosome rearrangements
with site specific probes
² Used to detect the Philadelphia
chromosome, ABL-BCR, (t22;9)
² Highly specific and sensitive

GENOMIC GENE SEQUENCING

² To detect specific mutations:
n Sanger Technique with probe amplification
n Next Generation Sequencing (NGS)

HISTOPATHOLOGY
BIOPSIES

REFERENCES:
→Video and PPT of Dr. Tamesis (2020)
PUNCH/CORE
Activity
1. Tumor markers are used in the A. To diagnose tumors
following situation/s, except: B. For prognostication
C. For cancer staging
2. Imaging guided fine needle A. Surgical Pathology
aspiration biopsies falls under which B. Cytology
section?
NEEDLE 3. Which of this 2 results is positive for
presence of occult blood?

OPEN/SURGICAL
Can either be excisional
(removal of whole) or
incisional (removal of a
portion only)

Answer: A
4. This cells in cervical cytology are A. Superficial
abundantly seen among post B. Intermediate
menopausal women: C. Parabasal
5. FISH is ideally used in this type of A. Breast Cancers
malignancies: B. Leukemias
C. Soft Tissue Sarcomas

GENETIC TESTS
CYTOGENETIC (CHROMOSOMAL) FLUORESCENT IN SITU HYBRIDIZATION

4 Transcribed by: jisoo

 CD-A (LABORATORY DIAGNOSIS) ® Demonstration of at least a fourfold rise (or fall) in titer of specific
2.5 SEROLOGIC TECHNIQUES & APPLICATIONS IgG to an organism during the interval between each specimen
Cheryl May Cabrera, MD, FPSP, MPM-HG collection is serologic verification of a recent infection.
® It is mandatory that both specimens be tested in the same run with the
same lots of reagents if titer comparisons are to be meaningful.
IMMUNOLOGY AND SEROLOGY
• Immunology is the study of the body's immune system and its functions IgA
and disorders. - Antibodies are formed in response to
• Serology is the study of blood serum (the clear fluid that separates infections of cells with secretory
when blood clots). activity (e.g. cells lining the
respiratory, gastrointestinal, &
ANTIBODY VERSUS ANTIGEN genitourinary tracts).
- Antibodies, also called immunoglobulins, are Y- shaped proteins - Secretory IgA is released at the sites of
manufactured by the body that help fight against foreign infection, & serum IgA is found in the
substances called antigens. bloodstream.
- Antigens are any substance that stimulates the immune system to
produce antibodies. Nature of Interferences
1. Interferences that alter the measurable analyte concentration in
the sample
o Hormone binding proteins
o Pre-analytical factors, e.g. anticoagulants, sample storage
o Autoanalyte antibodies
2. Interferences that alter antibody binding
o Heterophile antibodies
DETECTION OF o Human anti-animal antibodies
MICROBIAL ANTIGENS MICROBIAL ANTIBODIES o High-dose hook effect
- provides direct evidence - diagnostically more
as to the etiology of useful ® Heterophilic antibodies are poorly defined human antibodies that
infection, & in almost - evidence of past cause interference by noncompetitive binding mostly to the Fc
every instance, is infection or immunization region of assay antibodies
preferred for diagnosis against an infectious ® Heterophilic antibodies are found more often in sick and
of infection over agent hospitalized patients, with reported prevalences of 0.2–15%.
antibody detection - furnishes only indirect
evidence of infection HIGH-DOSE HOOK EFFECT

ANTIBODY TITER
- The antibody titer is a test that detects the presence and measures
the amount of antibodies within a person’s blood. The amount and
diversity of antibodies correlates to the strength of the body’s
immune response.
Types and Characteristics of Antibodies Distribution in the body
IgG Highest opsonization and
neutralization activities
Classified into four subclasses (IgG1,
IgG2, IgG3, igG4)
IgM Produced first upon antigen invasion
IgA Expressed on mucosal tissues. Forms
dimers after secretion - Due to limited amounts of reagent antibodies in the coated wells
IgD Unknown function and extremely high concentrations of analyte in the sample leads
IgE Involved in allergy to decrease in the formation of antigen-antibody complex and
ultimately resulting in false low values of the analyte.

METHODS FOR DETECTION OF ANTIBODIES

- Immunoprecipitation
- Complement fixation
- Neutralization
- Particle agglutination/agglutination inhibition
- Immunofluorescence
- Enzyme immunoassay
- Radioimmunoassay

IMMUNOPRECIPITATION
1. IMMUNODIFFUSION ASSAYS
- Ouchterlony Double
Immunodiffusion Assays
o Identification of
specific precipitin
bands
APPEARANCE OF HUMAN IgG & IgM IN SERUM FOLLOWING ONSET OF
INFECTION For the detection of infectious agent: Antigens and Antibodies
• SERUM IgG ANTIBODY TITERS
- typically begin rising 2-3 weeks after infection
- Immunoelectrophoresis
- may persist at detectable levels for life - Counter immunoelectrophoresis
• More useful
- Simultaneous assays of paired sera collected at least 2 & 2. IMMUNOELECTROPHORESIS
preferably 4 weeks apart - An antigen mixture is first electrophoresed to separate its
components by charge
- Diffusion & producing lines of precipitation

1/7
 PARTICLE AGGLUTINATION/AGGLUTINATION INHIBITION ASSAYS
- For detection of infectious agent antibodies
- Most can detect lower antibody titers
- Commercially available assays utilize
o Antigen-coated latex
o Charcoal particles
o Bentonite particles
o Erythrocytes
- Quantitation of antigens/antibodies by
immunoprecipitation/ hemagglutination
- U or V shaped wells on microplates: RBC (or latex)
3. COUNTERIMMUNOELECTROPHORESIS pellet into small clots if not precipitated. Immune
- 3-countercurrent elextrophoresis reaction causes large spots of Ab-Ag networks.
- In this test, the antigen and antibody are placed in wells punched
out of an agar gel and the antigen and antibody are
electrophorosed into each other where they form a precipitation
line
- This test only works if conditions can be found where the antigen
and antibody have opposite charges. This test is primarily
qualitative, although from the thickness of the bands you can get
some measure of quantity. Its major advantage is its speed.

COMPLEMENT FIXATION TEST

- Based on inactivation (fixation) of
complement ff. binding of
complement factors to antigen--
antibody immune complexes.
- Once bound, the complement is not
available to induce lysis (hemolysis)
of antibody (hemolysin)- coated
IMMUNOFLUORESCENCE ASSAYS
sheep erythrocytes, which are
added to the assay tubes to detect - Require microscope with UV
immune complex formation. illumination or an instrument
capable of detecting
- Tedious & time consuming
fluorescence of a reaction
- Test of choice for serologic mixture with a UV light-
confirmation of certain infectious equipped fluorometer.
diseases
- Only large-scale reference
laboratories

• DIRECT FLOURESCENT ANTIBODIES

- Is a rapid microscopic procedure for
detecting the presence of a particular
antigen (typically a specific protein on the
surface of a virus, bacterium, or other
microbes) using a fluorescently labeled
monoclonal antibodies (mAb).
- DFA technique is a valuable tool for visualizing certain bacteria
NEUTRALIZATION ASSAYS and viruses that are difficult to isolate or culture from patient
samples.
- Infectivity of a microorganism or the activity of a toxin is
neutralized by specific antibody
- Rarely for diagnostic purposes • INDIRECT IMMUNOFLUORESCENT-ANTIBODY
TEST (IFA)
- Restricted to screening of patients for immunity or past exposure
to infectious agents - Assays for antibodies
- Typically require less than 4 hours to perform
(due to incubation period)

ENZYME IMMUNOASSAY (EIA)

• NEUTRALIZING ANTIBODIES
- Commonly prevent viral infection of the
host or nullify toxin activity by blocking
adherence of the virus or toxin to its
target (protective)
- Measured to predict efficacy of new
vaccine preparations
- For detection of infectious- agent antibodies
- Most sensitive of the antibody detection assays (together with
radioimmunoassays)
- Use anti-human IgG or IgM antibody-enzyme conjugate
• INDIRECT ENZYME IMMUNOASSAY
- 2 to 24 hours to complete
- Conversion of substrate to colored endproduct (spectrophotometer
/ visualization)
- Degree of color development directly correlates with amount of
antibody present

2/7
• COMPETITIVE ENZYME IMMUNOASSAY STREPTOCOCCAL INFECTIONS
- More appropriate for antibody detection Screening tests
- Amount of color development inversely correlates with the amount - Simultaneously detect antibodies to 5 different Streptococcal
of antibody present in the specimen antibodies:
1. Streptolysin o
2. DNAase B
3. Hyaluronidase
4. NADase
5. Streptokinase
- Demonstration of a 4-fold or greater rise in antibody titer is
considered as evidence of recent infection
- Streptococcal pyogenes (Group A Streptococcal) infections are the
RADIOIMMUNOASSAY (RIA) only Streptococcal infections for which antibody detection is clinical
- Continue to be used today but at declining rates, owing to the useful
inconvenience & expense of radioactive waste disposal & - Confirmed diagnosis of Poststreptococcal Acute Rheumatic Fever
increasing availability of comparably sensitive EIA methods or Acute Glomerulonephritis requires serologic documentation of a
recent S. pyogenes infection
• DIRECT & INDIRECT RIA
- Identical in principle in EIA, with 2 exceptions: • ANTISTREPTOLYSIN O (ASO) TEST
o Endpoint reading of RIA- need gamma or beta scintillation - Enzyme neutralization procedure
counter performed when it is desirable to
o Proper handling of radiolabeled reagents & disposal of know whether the ASO titer
radioactive waste requires extra precautions to protect the specifically is elevated or rising
lab workers & the environment - A clinically significant ASO titer is
greater than or equal to 1:240
SEROLOGIC DIAGNOSIS OF SPECIFIC INFECTIONS (greater than or equal to 240 TODD
units) in a single specimen, or a rise in
I. BACTERIAL INFECTIONS titer of at least two dilutions between
acute & convalescent specimens
- Most readily diagnosed by culture
- rapid and simple test for the
- Serologic tests for bacterial antibodies are primarily used for
qualitative and semi-quantitative measurement of antibodies to
1. Seroprevalence surveys for documentation of past infection
Antistreptolysin-O in human serum
2. Diagnosis of current or recent infection in patients whose
cultures are negative (partially treated with broad- - based on an immunological reaction between streptococcal
spectrum antimicrobial agents, or fever of unknown origin exoenzymes bound to biologically inert latex particles and
for > 2-3 weeks streptococcal antibodies in the test sample.
- The reagent has been adjusted in the way that presence of an
COMMONLY PERFORMED SEROLOGIC TESTS FOR DIAGNOSIS OF ASO titer of 200 IU/mL or higher in the serum gives a visible
RECENT BACTERIAL INFECTIONS agglutination of the latex particles.
ORGANISM TEST CLINICALLY
SIGNIFICANT RESULT Procedure
Streptococcus Antistreptolysin O > 1:240 1. one drop (50 μl) of positive control and 50 μl of the patient
pyogenes serum into separate circles on the glass slide
AntiDNAase B > 1:240 2. Shake the ASO latex reagent gently then add one drop (45
Antihyaluronidase > 1:512 μl) on each circle next to the sample to be tested and control
Salmonella typhi Widal test (S. typhi) > 1:160 3. Mix well using disposable stirrer spreading the mixture over
Legionella Indirect > 1:256 the whole test area and tilt the slide gently
pneumophila Immunofluorescence 4. Agitate for about 2 minutes with rotator or by hand and
Treponema Rapid Plasma Reagin Positive observe for the presence or absence of agglutination
pallidum
Treponema VDRL Positive
pallidum
FTA-ABS (IgG or IgM) Positive
Borrelia Indirect > 1:64
burgdorferi Immunofluorescence (IgG) - Greatest value is the serologic confirmation of Acute Rheumatic
Enzyme immunoassay Positive Fever following S. pyogenes pharyngeal infection
Western blot (IgG) > 1:4 of 9 bands - Unreliable for diagnosis of Acute Glomerulonephritis following S.
Western blot (IgM) > 1:2 of 9 bands pyogenes skin infection
Helicobacter Enzyme immunoassay Positive
pylori • ANTI-DNAase B (ADB)
Mycoplasma Cold agglutinins > 1:128
- Enzyme Neutralization assay
pneumoniae
- Dilutions of the patient’s serum are mixed with a standard amount
Complement fixation > 1:32
of Streptococcal DNAase B & incubated
Enzyme immunoassay Positive
- Assay endpoint: highest dilution of the patient’s serum that retains
Rickettsia Weil-Felix (OX-19) > 1:320
sufficient ADB activity to prevent DNA hydrolysis
rickettsii
- Detects antibodies produced after both pharyngeal & skin S.
Indirect > 1:64
pyogenes infections
Immunofluorescence
Ehrlichia Indirect > 1:64 - Superior to the ASO test for serologic confirmation of
chaffeensis Immunofluorescence (IgG) Poststreptococcal Acute Glomerulonephritis
Bartonella Indirect > 1:128 - ADB antibodies persist longer than ASO antibodies & can serve as
henselae immunofluorescence (IgG) proof of recent S. pyogenes infection when the ASO titer has
fallen to normal levels
- A single specimen ADB titer of greater than or equal to 1:240 is
considered elevated

3/7

• ANTIHYALURONIDASE TEST (AHT)
- One final enzyme neutralization assay for streptococcal antibodies
- Performed by incubating dilutions of patient’s serum with
streptococcal hyaluronidase
- AHT Endpoint: highest dilution of the patient’s serum in which a
definite clot forms
- Like the ADB test, is positive subsequent to either pharyngeal or
skin S. pyogenes infection
- Fourfold or greater rise in titer between acute & convalescent sera
is regarded as documentation of recent S. pyogenes infection
- Most find ADB test results easier to interpret than AHT results &
reserve the AHT for circumstances when a third- line test is called
for
SALMONELLOSIS- WIDAL TEST
- Assay for S. typhi antibodies in which salmonella organisms are
agglutinated by patient sera
- Performed by mixing serum dilutions with killed salmonella
suspensions harboring known O (Somatic) & H (Flagellar) antigens
- Serodiagnosis of typhoid fever is based on a fourfold or greater
rise between acute & convalescent antibody titers, or a single titer
that is significantly higher than the mean baseline titer for the
population
- Not recommended for diagnosis of infection caused by other
species or bioserotypes of Salmonella
LEGIONELLOSIS (LEGIONNAIRE’S DISEASE)
- Direct fluorescent antibody test for legionella antigens in lower
respiratory specimens &
- By the ability of selective media for recovery of legionella
organisms from specimens harboring mixed respiratory flora
• IFA TEST FOR L. PNEUMOPHILA ANTIBODIES
- Second choice (test)
- Assay endpoint: highest dilution of the patient’s serum that results
in organisms exhibiting at least 1+ fluorescence or a single titer
greater than or equal to 1:256 is presumptive evidence of recent
infection
SYPHILIS
- Help in diagnosis: visualization of organisms by dark-field
microscopy or DFA staining & to detect antibodies in serum & CSF
- 2 antibodies may be sought
1. Nontreponemal antibodies (reagin)
2. Treponemal antibodies
NONTREPONEMAL ANTIBODY TESTS
- For screening patients for syphilis & for monitoring the therapeutic
response during antimicrobial treatment for syphilis
- A positive RPR or VDRL test in a patient not being treated for
syphilis should be confirmed by a test for Treponemal antibodies
- Appear 1 to 4 weeks after infection & remain elevated until
antimicrobial therapy begins or, in some cases, when the patient
enters the late phase of the infection.
I. RAPID PLASMA REAGIN (RPR)
A. QUALITATIVE RPR
- Screening assay
- Patient’s undiluted serum is mixed with cardiolipin-coated charcoal
particles on a cardboard slide
- The rapid plasma reagin (RPR) test is a macroscopic,
nontreponemal flocculation card test used to screen for syphilis.
- The RPR test measures IgM and IgG antibodies to lipoidal material
released from damaged host cells as well as to lipoprotein-like
material, and possibly cardiolipin released from the treponemes.
B. QUANTITATIVE RPR
- Serial dilutions of the patient’s serum are prepared
- Endpoint: highest dilution of the patient’s serum that results in
charcoal particle agglutination
End-Point Titer (1:64)
II. VENEREAL DISEASE RESEARCH LABORATORY (VDRL) TEST
- Slide microflocculation test
- Detects antibodies produced against antigens released by
damaged host cells in patients suffering from syphilis
- Uses the VDRL antigen containing 0.03% cardiolipin, 0.21%
lecithin, and 0.9% cholesterol
- The antigen, suspended in a buffered saline solution, forms
flocculates when combined with lipoidal antibodies in serum or
cerebrospinal fluid from syphilis patients.
- A drop of antigen is placed on a slide and then a drop of serum is
added to it.
- The slide is rotated to mix the content. u In case of positive test,
flocculation occurs which are read using a microscope.
- Clumping or agglutination indicate reactive specimen or presence
of autoantibody in patient’s specimen while non-reactive specimens
appear as homogeneous suspension.
TREPONEMAL ANTIBODY TESTS
1. Fluorescent Treponemal Antibody-absorbed Double Stain (FTA-
ABS DS) test
2. Microhemagglutination-T. Pallidum test (MHA-TP)
3. Hemagglutination Treponemal Test for Syphilis (HATTS)
® CONFIRMATION: Positive Nontreponemal antibody test results
(VDRL or RPR)
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1. FLUORESCENT TREPONEMAL ANTIBODY- ABSORBED DOUBLE STAIN MYCOPLASMA PNEUMONIA INFECTIONS
(FTA-ABS DS) TEST SEROLOGIC TESTS
- indirect fluorescent antibody technique 1. COMPLEMENT FIXATION (CF)
used as a confirmatory test for syphilis - Suggestive of infection: a single specimen cf titer greater than or
- FTA-ABS is the first serological test equal to 1:32 in a patient with pneumonia
(cardiolipin or specific treponemal) to 2. COLD AGGLUTININS TEST (CA)- nonspecific
become positive following infection i.e., 3. INDIRECT ENZYME IMMUNOASSAY (EIA)
3-4 weeks after Infection. - Positive assay: conversion of the colorless substrate to a colored
endproduct (unaided eye or with a spectrophotometer)
2. MHA-TP & 3. HATTS ASSAYS
- Both agglutination tests EHRLICHIOSIS
- Performed in the wells of microdilution trays - Human monocytic ehrlichiosis
- Positive result: hemagglutination of the sensitized erythrocytes & o Due to E. chaffinensis
no hemagglutination of the nonsensitized erythrocytes - Human granulocytic ehrlichiosis
o Due to E. equi-like organism
- Diagnosis of most: serologically by
detecting antibodies reactive by
immunofluorescence (IF assay)

WEIL-FELIX (WF) TEST

- Dependent on cross- reactions that exist between the antigens of
certain Rickettsiae & those of selected strains of proteus vulgaris &
p. Mirabilis
• TREPONEMAL ANTIBODIES - Endpoint: highest dilution of the patient’s serum that results in
- First to appear following infection bacterial agglutination
- Remain elevated in most patients for life - Procedure
- FTA-ABS DS antibodies appear slightly before MHA-TP & HATTS o The Weil-Felix Test can be done as either a slide or a
antibodies tube test. The antigens necessary (OX2, OX19 and OXK
- Principal use: to confirm positive antibody test results can be obtained commercially)
- Reported qualitatively only
• OTHER SEROLOGIC ASSAYS FOR RICKETTSIAL ANTIBODIES
- No value for monitoring the patient’s response to antimicrobial
1. INDIRECT FLUORESCENT ANTIBODY
therapy
2. INDIRECT HEMAGGLUTINATION
3. LATEX PARTICLE AGGLUTINATION
• DIAGNOSIS OF CONGENITAL T. PALLIDUM INFECTION 4. ENZYME IMMUNOASSAY
- Best available laboratory option: serial nontreponemal antibody 5. COMPLEMENT FIXATION
tests in infant sera for 3 to 6 months & observe for increasing or
disappearing antibody levels
II. FUNGAL INFECTIONS
LYME DISEASE - Assays for fungal antibodies are of little or no use for diagnosis of
- Zoonotic infection (from bite of a deer tick) superficial fungal infections or infections in immunocompromised
- Causative agent: borrelia burgdorferi patients unable to mount a significant humoral immune response.
- Serologic confirmation
o IFA & EIA detect B. Burgdorferi antibodies (tendency to
cross- react) III. PARASITIC INFECTIONS
- Serologic confirmation- more reliable: WESTERN BLOT IgG & IgM- - Diagnosed either by direct visualization of the agent itself or by
specific ANTIBODY ASSAYS detection of antibodies in patient specimens.
- Serologic testing plays a critical role

COMMONLY PERFORMED SEROLOGIC TESTS FOR DIAGNOSIS OF

RECENT PARASITIC INFECTIONS
ORGANISM TEST CLINICALLY
SIGNIFICANT RESULT
Entamoeba Indirect hemagglutination >/=1:256
histolytica
Counterimmunoelec- Positive
trophoresis
Enzyme immunoassay Positive
Toxoplasma Indirect >/=1:64
gondii immunofluorescence
Enzyme immunoassay Positive
Cysticercosis Indirect hemagglutination >/=1:128
Enzyme immunoassay >/=1:160
Toxocara spp. Enzyme immunoassay >/=1:32
Trichinella Bentonite flocculation >/=1:5
spiralis
Enzyme immunoassay Positive

HELICOBACTER PYLORI
IV. VIRAL INFECTIONS
- implicated as the primary cause of antral gastritis & peptic ulcer
disease PREFERRED METHODS FOR DIAGNOSIS
- with epidemiologic link with gastric carcinoma • Culture
- SEROLOGY: plasma/serum, rapid results, relatively inexpensive • Direct detection of viral antigens or nucleic acid in clinical
specimens

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SEROLOGIC TESTS FOR VIRAL ANTIBODIES ARE FAVORED MAINLY IN
THE FOLLOWING SITUATIONS:
1. CONGENITALLY INFECTED NEONATES, in whom IgM-specific
antibody assays can lead to a speedy diagnosis
2. Patients infected with viruses that are very difficult or impossible to
culture
3. Patients or patient populations in whom past evidence of infection is
sought
4. Screening of blood or organ donors

TESTS ON BLOOD DONATIONS

Screening for Infectious Agents
At each donation, the following mandatory tests are performed:
• Hepatitis B – HbsAg
• Human immunodeficiency virus – Anti-HIV1 and 2 and HIV NAT
(nucleic acid testing)
• Hepatitis C – anti-HCV and HCV NAT
• Human T-cell lymphotropic virus – anti-HTLC I and II
• Syphilis – syphilis antibodies

® Some donations are tested for cytomegalovirus (CMV) antibodies

to provide CMV negative blood for patients with certain types of
impaired immunity

Additional tests, performed in special circumstances include:

• Malarial antibodies
• West Nile Virus antibodies
• Trypanosoma cruzi antibodies

end

references:
- Dr. Cabrera’s 2020 PPT
- Vision Trans

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