EMILIO AGUINALDO COLLEGE

SCHOOL OF MEDICINE

Department of Physiology

Small Group Discussion – Case Files Blood Physiology

TASK DISTRIBUTION

TASK CASE 1 CASE 2

Salient Features Pusekar, Krutika R. Gade, Rutuja

Differential and Working Gade, Rutuja Gade, Rutuja

Diagnosis

Objectives

1 Methuku, Akshita Shrinivas Gade, Adinath

2 Pusekar, Krutika R. Methuku, Akshita Shrinivas

3 Marpu, Sreshta Pusekar, Krutika R.

4 Gade, Rutuja Gade, Adinath

5 Gade, Adinath —

Pathophysiology Methuku Akshita Shrinivas Methuku, Akshita Shrinivas

Questions

1 Pusekar, Krutika R. Marpu, Sreshta

2 Gade, Adinath Pusekar, Krutika R.

3 Gade, Adinath Gade, Rutuja

4 Methuku, Akshita Shrinivas Gade, Adinath

Treatment and Management Marpu, Sreshta Marpu, Sreshta

Case 1. Immunoglobulin and Thrombocytopenia – Dengue Hemorrhagic Fever

Objectives

1. Differentiate the different types of White Blood Cells

● Neutrophils: These are the most abundant type of white blood cell, making up
about 50-70% of all WBCs. They are the first line of defense against infection,
and they are responsible for engulfing and destroying bacteria and fungi.
● Lymphocytes: These are the second most abundant type of white blood cell,
making up about 20-30% of all WBCs. There are two main types of lymphocytes:
B cells and T cells. B cells produce antibodies, which are proteins that help the
body fight infection. T cells help to regulate the immune response, and they also
attack and kill infected cells.
● Monocytes: These are the largest type of white blood cell, and they make up
about 2-8% of all WBCs. Monocytes circulate in the bloodstream for a short
period of time, before migrating to tissues where they mature into macrophages.
Macrophages are responsible for cleaning up dead cells and debris, and they
also play a role in fighting infection.
● Basophils: These are the least abundant type of white blood cell, making up
about 0.1-1% of all WBCs. Basophils release histamine and other chemicals that
cause allergic reactions. They also play a role in the inflammatory response.
● Eosinophils: These make up about 1-4% of all WBCs. Eosinophils are involved in
fighting parasitic infections, and they also play a role in the allergic response.

2. Differentiate the different types of Immunoglobulin

3. Explain and discuss Antibody-dependent Enhancement as an immune response

4. Explain and discuss the principle of vaccination

Vaccines contain weakened or inactive components of a certain organism (antigen),
which causes an immunological reaction in the body. Rather than the antigen itself,
these vaccinations contain the blueprint for generating antigens. Whether the vaccine is
made up of the antigen itself or the blueprint for the body to produce the antigen, this
weakened version will not cause the disease in the person receiving the vaccine, but it
will prompt their immune system to respond similarly to how it would have responded to
the actual pathogen.

Some immunizations necessitate repeated doses administered weeks or months apart.

This is occasionally required to allow for the creation of long-lasting antibodies and the
establishment of memory cells. In this approach, the body is educated to resist the
specific disease-causing organism, storing pathogen memory in order to combat it
quickly if and when it is exposed in the future.
 5. Explain and discuss platelet plug formation and the coagulation cascade in the
prevention of bleeding

CASE

A 7-year old girl was brought to the emergency room due to epistaxis. She has a 3-day history
of fever, accompanied by headache, body malaise, arthralgia, anorexia and abdominal pain.
According to the grandmother, who brought the patient to the ER, they live near an auto shop
and they have old tires in their shop.

On examination, the patient was weak-looking with dry lips. Vitals signs: BP 90/60 mm Hg, CR
108 beats/min, RR 24 breaths/min, T 37.4oC. There was minimal active bleeding from the left
nostril and dried blood in the right nostril. There were petechial rashes on both antecubital
fossa. Abdomen was soft, with normoactive bowel sound and slight tenderness over the
epigastric area. Pulses were full and equal.

Nasal packing of the left nostril was done by the ENT-ROD. Epistaxis stopped after
approximately 3 mins.

Laboratory tests revealed the following results:

Hgb = 150g/L WBC = 3.5 Dengue Blot Test NS1Ag = ( + )

 Hct = 0.48 segmenters = 0.35 IgG = ( + )
Platelet ct = 110 lymphocytes = 0.65 IgM = ( - )

Impression: Dengue Hemorrhagic Fever grade 2

They were advised to take admission for monitoring and management.

PATHOPHYSIOLOGY:

Dengue Hemorrhagic Fever (DHF) is a severe form of dengue fever that is caused by a virus of
the Flaviviridae family. DHF is characterized by a rapid onset of fever, headache, muscle pain,
rash, and bleeding. DHF grade 2 is a moderate form of DHF that is characterized by
thrombocytopenia (low platelet count), hemoconcentration (increased hematocrit), and evidence
of increased vascular permeability.

The pathophysiology of DHF is not fully understood, but it is thought to involve a complex
interaction between the virus and the host immune system. The virus can damage the lining of
blood vessels, which leads to increased vascular permeability. This can cause fluid to leak out of
the blood vessels and into the tissues, which can lead to a decrease in blood pressure and
shock.

In DHF grade 2, the patient may also have bleeding from the gums, nose, or gastrointestinal
tract. This is due to a decrease in the number of platelets, which are responsible for clotting
blood.

The treatment for DHF grade 2 is supportive care, which includes fluid replacement, blood
transfusions, and pain medication. In some cases, patients may also need to be treated in an
intensive care unit.
QUESTIONS

1. What is the cause of the patient’s elevated Hgb and Hct results?
2. What is the interpretation of the patient’s WBC and differential count results?
3. What is the interpretation of the patient’s Dengue Blot Test results?
4. Which blood component is responsible for the epistaxis?

There is no single blood component responsible for epistaxis, or nosebleeds. However, the most
common cause of epistaxis is the rupture of a small blood vessel in the nasal septum. This can
be caused by a variety of factors, including:
● Trauma: This is the most common cause of epistaxis, and can be caused by
anything from picking your nose to a blow to the face.
● Dry air: Dry air can irritate the lining of the nose and make it more likely to bleed.
● Allergies: Allergies can also irritate the lining of the nose and lead to epistaxis.
● Viral infections: Viral infections, such as the common cold, can also cause
epistaxis.
● High blood pressure: High blood pressure can increase the risk of epistaxis.
● Medications: Some medications, such as aspirin and anticoagulants, can
increase the risk of epistaxis.
● Inherited bleeding disorders: Some people are born with inherited bleeding
disorders, such as hemophilia, that can increase the risk of epistaxis.

In most cases, epistaxis is a minor problem that can be easily treated at home. However, if you
have frequent nosebleeds or if they are severe, you should see a doctor to rule out any
underlying medical conditions.

The blood component that is most responsible for the clotting of blood and stopping epistaxis is
fibrinogen. Fibrinogen is a protein that is produced by the liver and helps to form clots. When a
blood vessel ruptures, fibrinogen molecules clump together to form a plug that stops the
bleeding.

Other blood components that are involved in clotting include platelets, von Willebrand factor,
and factor VIII. These components work together to form a clot that stops the bleeding.

Case 2. Erythropoiesis & RBC Recycling – Glucose-6-Phosphate Dehydrogenase

Deficiency

Objectives:

1. Illustrate and discuss the Pentose Phosphate Pathway in relation to erythropoiesis

2. Illustrate and discuss the destruction and recycling of red blood cells
 ● Red blood cells (RBCs) are the most abundant type of blood cell, and they play a
vital role in transporting oxygen throughout the body.
● However, RBCs have a lifespan of only about 120 days, after which they are
destroyed and recycled.
● The destruction of RBCs begins in the spleen, where old or damaged cells are
filtered out of the blood.
● The spleen also contains macrophages, which are cells that engulf and destroy
old RBCs.
● Once the RBCs are destroyed, their components are recycled.
● The iron is stored in the body for use in the production of new RBCs, and the
protein hemoglobin is broken down into amino acids, which can be used to make
new proteins.
● The destruction and recycling of RBCs is an important process that helps to
maintain a healthy blood supply.
● By breaking down old or damaged RBCs, the body can recycle their components
and use them to make new, healthy RBCs.
● Here are some of the factors that can affect the destruction and recycling of
RBCs:
○ Age: The rate of RBC destruction and recycling increases with age.
○ Disease: Certain diseases, such as sickle cell anemia, can damage RBCs
and increase their rate of destruction.
○ Medications: Some medications, such as chemotherapy drugs, can also
damage RBCs and increase their rate of destruction.
If the process is disrupted, it can lead to anemia, a condition in which the body
does not have enough healthy RBCs.

3. Differentiate the types of anemia

4. Explain and discuss the response of reticulocyte in relation to the level of red blood cell
in the blood

CASE

An 8-year old boy was brought to a pediatrician due to progressive abdominal distention.
According to the mother, her son does not experience vomiting and has regular bowel
movement. The mother went on further to mention that she also noticed her son to be pale and
complains of easy fatigability during their PE class and when he plays with his classmates. The
pediatrician asked if a Newborn Screening Test was done when the child was born. However,
the mother cannot recall. Asked about her son’s food preference, she mentioned that he likes to
eat fave beans and ‘taho’.
On examination, the patient was tachycardic, afebrile, with pale lips and palpebral conjunctivae.
He has icteric sclera and jaundice. On PE of the abdomen, it was found to be globular, with
normoactive bowel sound, non-tender, liver edge is palpable 3cm below the right subcostal
margin and the Traube’s space was obliterated upon percussion.

Laboratory work-ups were done and revealed the following results:

Low levels of hemoglobin (Hgb), hematocrit (Hct) and RBC count

Normal MCV, MCH and MCHC, WBC count and differential count
Elevated level of reticulocyte count
Increased level of total bilirubin & indirect bilirubin, with normal direct bilirubin level
Liver Function Tests (LFTs) – ALT/SGPT, AST/SGOT, ALP and TPAG (total protein, albumin &
globulin) are deranged/abnormal
Abdominal Ultrasound revealed hepatosplenomegaly Glucose-6-Phosphate
Dehydrogenase Assay is decreased.

Impression: G6PD Deficiency

Management: The parents were given a list of food and medications and were advised to avoid
giving those to their son.

PATHOPHYSIOLOGY:

G6PD deficiency is a genetic disorder that affects the ability of red blood cells to produce a
substance called glucose-6-phosphate dehydrogenase (G6PD). G6PD is an enzyme that helps
protect red blood cells from damage caused by oxidative stress.

When G6PD is deficient, red blood cells are more susceptible to damage from oxidative stress.
This can lead to hemolysis, which is the breakdown of red blood cells.

The pathophysiology of G6PD deficiency is complex, but it is thought to involve a number of

factors, including:
● Oxidative stress: Oxidative stress is a condition in which there is an imbalance between
the production of free radicals and the body's ability to neutralize them. Free radicals are
unstable molecules that can damage cells.
● Red blood cell metabolism: Red blood cells need G6PD to produce a substance called
NADPH. NADPH is an antioxidant that helps protect red blood cells from damage.
● Red blood cell membrane: The red blood cell membrane is made up of a number of
proteins and lipids. G6PD is thought to play a role in the maintenance of the red blood
cell membrane.
QUESTIONS

1. What are the roles of NADPH and G6PD in erythropoiesis?

2. In a patient with a healthy bone marrow, what is the expected response of reticulocytes
in cases of anemia?
3. What type of anemia does the patient have?

Hemolytic anemia is a type of blood condition in which red blood cells break down or die
quicker than your body can replace them with new blood cells. People can get hemolytic
anemia through inheriting anemia-causing genetic disorders, infections, or drugs. This
condition is treated by healthcare providers by addressing the underlying cause.
 There are numerous types of anemia. Hemolytic anemia occurs when your red blood
cells degrade or die faster than usual. Red blood cells have a lifespan of roughly 120
days. When they break down or die sooner, your bone marrow does not have enough
time to manufacture enough new red blood cells, resulting in a low red blood cell count.
Other types of anemia can arise when:
Excessive bleeding from an injury or illness depletes your red blood cell supply quicker
than your body can replace it.
Something impacts red blood cell production, causing your body to generate fewer or
aberrant red blood cells.

4. What has caused the hepatomegaly? Splenomegaly?