29th Chap

CHAPTER 29
Nonmalignant
Leukocyte Disorders
Qualitative Disorders
Morphologic Abnormalities w/ and w/o

Functional Defects
o Pelger- Huet Anomaly
• true or congenital PHA
• autosomal dominant disorder
• decreased nuclear segmentation
(bilobed,unilobed)

• coarse chromatin clumping pattern
• affect all leukocytes
• morphologic changes most obvious in mature
neutrophils
• prevalence: 1 in 4785 in US

• mutation in lamin β-receptor gene
» inner nuclear membrane protein that combines β-
type lamins and heterochromatin
» plays a major role in leukocyte nuclear shape
changes (during normal maturation)

• nuclei appear round, ovoid, or peanut shaped
• bilobed forms= spectacle-like ‘pince-nez’
morphology
» nuclei attached by thin filament

• homozygous: all neutrophils are affected and
has round nuclei
• heterozygotes: 55-93% of neutrophils are
affected, mixture of all aforementioned nuclear
shapes
• neutrophils function normally
o Pseudo- or Acquired Pelger- Huet Anomaly

• seen in patients with hematologic malignancies
(MDS, AML, and chronic myeloproliferative
neoplasms)
• also in patients with HIV infection, tuberculosis,
Mycoplasma pneumoniae, and severe bacterial
infections
• induced by some drugs and chemotherapies
Laboratory Issues in PHA

1. number of cells present
• true PHA: 63-93%
• pseudo PHA: <38%
2. true PHA: all WBC lineages are potentially
affected in terms of nuclear shape and
chromatin structure
3. pseudo PHA: seen only in neutrophils, except for
some cases of MDS where monocytes, eosinophils,
and basophils may exhibit PHA morphology

4. if true PHA is suspected= careful examination of
blood smears of family members may reveal
similar findings
5. hypogranular neutrophils: common findings in
MDS-related pseudo PHA
• true PHA: normal granulation

o in true and pseudo PHA: nuclei of PHA
neutrophils appear round, oval, or peanut-shaped
• cells can be classified and counted as myelocytes,
metamyelocytes, or band
• mimicks neutrophilic left shift and triggers clinical
workup to uncover the cause

o careful examination of chromatin structure=
differentiate PH cells (mature) and neutrophils
(less mature)
• metamyelocytes and myelocytes: show some
degree of cytoplasmic basophilia
• PH cells: mature so cytoplasm is nearly colorless,
except for the color imparted by normal cytoplasmic
granulation

o determining the most appropriate label to use for
reporting PH cells
• unilobed or bilobed
• segmented and band neutrophil: not suitable
• can count PH neutrophils as ‘others’ and then define
‘others’ as PH neutrophils
Morphologic Abnormalities w/
and w/o Functional Defects
Neutrophil Hypersegmentation
o more than five lobes
o most often associated with megaloblastic
anemias, where neutrophil is larger than normal
o seen in MDS
o also found in hereditary neutrophil
hypersegmentation
• asymptomatic patients
o Myelokathexis
• rare hereditary condition
• normal granulocyte production
• impaired release into circulation= neutropenia
• neutrophil morphology is affected= hypermature
• hypersegmentation, hypercondensed chromatin,
pkynotic changes, and cytoplasmic vacuoles
o WHIM
• rare inherited disorder
• warts, neutropenia, hypogammaglobulinemia,
infections, and myelokathexis
• mutations in CXCR4= hyperfunctional CXCR4
receptor and ligand binding
• impairs cellular homeostasis and trafficking
Alder-Reilly Anomaly
o recessive trait
o granulocytes with large, darkly staining
metachromatic cytoplasmic granules (partially
digested mucopolysaccharides)
o heavy toxic granulation
o Alder-Reilly bodies or Reilly bodies= in Hurler
Syndrome, Hunter Syndrome, and Maroteaux-
Lamy polydystrophic dwarfism
o neutrophilia, Dohle bodies, and left shift= not
seen, only associated with toxic granulation
(exclusive for neutrophils)
o granules found in lymphocytes and monocytes
o basic defect: incomplete degradation of
mucopolysaccharides
o leukocyte function is not affected
Chediak-Higashi Syndrome
o rare, fatal, autosomal recessive disease
o abnormal fusion of granules in most cells that
contain granules throughout the body
o large fused granules and mostly dysfunctional
o affected hematopoetic cells
o disease manifestations found in hair, skin,
adrenal, and pituitary glands, and nerves
o giant lysosomal granules in granulocytes,
monocytes, and lymphocytes
o leukocyte dysfunction and recurrent pyogenic
infections
o bleeding issues due to abnormal dense granules
in platelets
o mutation in CHS1 LYST gene on chromosome
1q42.1-2 (encodes for protein involved in vesicle
fusion or fission)
May-Hegglin Anomaly
o rare, autosomal dominant platelet disorder
o variable thrombocytopenia, giant platelets, and
large Dohle body-like inclusions in neutrophils,
eosinophils, basophils, and monocytes
o mutation in MYH9 gene on chrom 22q12-13
May-Hegglin Anomaly
o disordered production of myosin heavy chain
type IIA (affects megakaryocyte maturation and
platelet fragmentation)
o Dohle body-like inclusions: composed of
precipitated myosin heavy chains
May-Hegglin Anomaly
o Dohle bodies: composed of lamellar rows of
rough endoplasmic reticulum
o majority are asymptomatic
o few have mild bleeding tendencies: related to
degree of thrombocytopenia
Normal Morphology with Functional

Abnormalities
o Chronic Granulomatous Disease
• rare inherited disorder
• decreased ability of phagocytes to produce super-
oxide and reactive oxygen species
• no respiratory burst that normally results in
production of these antimicrobial agents
Normal Morphology with
Functional Abnormalities
Chronic Granulomatous Disease

o basic defect: one or more mutations in genes
responsible for proteins that make up a complex
known as NADPH oxidase
o normal conditions: phagocytosis of foreign organisms
• leads to phosphorylation and binding of cytosolic
p47phos and p67phos

o phagocytosis of foreign organisms
• primary granules containing antibacterial
neutrophil elastase and cathepsin G
• secondary granules containing cytochrome
complex gp91phox and gp22phox
• NADPH oxidase forms when p47phos and p67phos
along with p40phox and RAC2 combine with
cytochrome complex

o phagocytosis of foreign organisms
• superoxide: generated in phagolysosome when an
electron from NADPH is added to oxygen
o most cases: due to mutations in gp91phox or p47
o majority: X-linked recessive (60-65%) or autosomal
recessive (35-40%)

o heterogenous, survival based on type of mutation
(determines level of superoxide produced)
o bacterial and fungal infections
o macrophage-rich granulomas: causing obstruction
o advancements in treatment eg antifungal agents:
increased survival rates

o in nitroblue tetrazolium reduction test: normal
neutrophils reduce the yellow water-soluble dye to a
dark blue insoluble formazan
o neutrophils in CGD: cannot perform reduction
o diagnosed through flow cytometry= fluorescent probe
such as dihydrorhodamine-123 to measure
intracellular production of reactive oxygen species
Leukocyte Adhesion Disorders

o recruitment of leukocytes to inflammation site
• involves capture of leukocytes from peripheral blood
• rolling along a vessel wall
o mediated through selectins (interact with their
ligands on the surface of leukocytes)

o ligand binding: induces high-affinity binding of
integrins with endothelial cell receptors
o cytoskeleton in leukocytes is reorganized
o dell spreading occurs= leads to transmigration of
leukocyte out of the blood and into the tissues
o rare autosomal recessive inherited disorders

o inability of neutrophils and monocytes to adhere to
endothelial cells and to transmigrate from blood to
the tissues
o increased and potentially lethal bacterial infection
o basic defect: mutation in genes responsible for
formation of cell adhesion molecules
o subdivided into 3 subcategories

o LAD I
• mutation in exons 5-9 in genes responsible for β2
integrin subunits
• decreased or truncated form of β2 integrin
» necessary for adhesion to endothelial cells, recognition
of bacteria, and outside-signaling

o LAD I
• recurrent infections, neutrophilia, lymphadenopathy,
splenomegaly, and skin lesions
• clinical severity (number of infections and survival)
» depends on the amount of β2 integrins produced

o LAD II
• rarer than LAD I
• presents in similar manner: recurrent infection and
neutrophilia
• leukocytes have normal β2 integrins
• molecular defects in SC35C1
» codes for fucose transporter that moves fucose from
endoplasmic reticulum to Golgi region

o LAD II
• fucose: needed for posttranslational fucosylation of
glycoconjugates
» required for synthesis of selectin ligands
• growth retardation, corase face, and other physical
deformities

o LAD II
• defective fucose transporter
» leads to inability to produce functional selectin ligands
and defective leukocyte recruitment
» absence of blood group H antigen, growth retardation,
and neurological defects

o LAD III
• very rare autosomal recessive disease
• leukocytes and platelets have normal expression of
integrins
• failure in response to external signals that would
normally result in leukocyte activation
• mutations in Kindlin-3
» for activation of β integrin and leukocyte rolling (along
with talin)

o LAD III
• mild LAD I-like immunodeficiency with recurrent
bacterial and fungal infetion
• decreased platelet integrin GPIIbβ3
» bleeding similar to what is seen in Glanzmann
thrombasthenia
Miscellaneous Granulocyte Disorders

o Myeloperoxidase (MPO) deficiency
• deficiency in MPO in the primary granules of
neutrophils and lysosomes of monocytes
• MPO: normally stimulates production of hypochlorite
and hypochlorous acid
» oxidant agents that attack phagocytized microbes

• autosomal dominant inheritance
• mutation in MPO gene on chrom 17
• patients do not experience problematic recurring
infections
» due to compensatory pathways utilized for microbe
killing that do not involve MPO

• acquired forms: in association with hematologic
neoplasms and lead poisoning
• easily detected by Siemens Advia analyzer
» uses MPO to identify cells in automated differential
Monocyte/Macrophage
Lysosomal Storage Diseases
Mucopolysaccharidoses (MPSs) group

o inherited disorders of GAG degradation
o deficient activity of an enzyme necessary for
degradation of dermatan sulfate, heparan sulfate,
keratan sulfate, and/or chondroitin sulfate
o partially degraded GAG: builds up in lysosomes and
results in physical abnormality and sometimes
mental retardation
Monocyte/Macrophage

o subdivided acc to which enzyme is defective, which
GAG is being stored, and whether symptoms are
severe or attenuated
o normal peripheral blood
o metachromatic Reilly bodies may be seen in
neutrophils, monocytes, and lymphocytes
Monocyte/Macrophage

o BM: macrophages with large amounts of
metachromatic material
o diagnosis relies on assays for specific enzymes
involved
o treatment: enzyme replacement therapy or HSC
transplantation
Monocyte/Macrophage
Lipid Storage Diseases

o defective lipid catabolism
o macrophages with distinctive morphology
Monocyte/Macrophage
Gaucher Disease
o most common lysosomal lipid storage diseases
o autosomal recessive
o defect or deficiency in catabolic enzyme β-
glucocerebrosidase (at 1q21)
• for glycolipid metabolism
o >300 genetic mutations reported
Monocyte/Macrophage
Gaucher Disease
o majority of cases (phenotypes): cannot be
predicted by genotype
o accumulation of unmetabolized substrate
sphingolipid glucocerebroside in macrophages
throughout the body (osteoclasts in bone and
microglia in brain)
Monocyte/Macrophage
Gaucher Disease
o triad: hepatomegaly, Gaucher cells in BM, increase
serum phosphatase
o subdivided into 3 types based on clinical signs and
symptoms
o neurologic symptoms: key role in differentiating
between the 3 subtypes
Monocyte/Macrophage
Gaucher Disease
o phenotype: quite heterogenous with some patients
being completely asymptomatic (Type I)
o anemia and thrombocyopenia: result of
hypersplenism common in these patients
o BM replacement by Gaucher cells: contribute to
peripheral cytopenias
Monocyte/Macrophage
Gaucher Disease
o Gaucher cells
• distinctive macrophages occurring individually or
in clusters
• abundant fibrillar blue-gray cytoplasm with
striated or wrinkled appearance (onion skin-like)
Monocyte/Macrophage
Gaucher Disease
o chitotriosidase
• test to determine the level of glucocerebrosidase
in storage
• biomarker used in diagnosis and monitoring
o Periodic Acid-Schiff stain test
• for mucopolysaccharides
Monocyte/Macrophage
Gaucher Disease
o Polymerase Chain Reaction
• used in Ashkenazi Jews to screen for the most
common mutations
o Gene Sequencing
• for confirmation
• in all three forms: fifteenfold increase for developing
hematologic malignancies
Monocyte/Macrophage
Gaucher Disease
o treatment
• enzyme replacement therapy with recombinant
glucocerebrosidase
• agents to reduce amount of substrate
glucocerebrosidase
• stem cell transplantation
• pharmacologic chaperones: active site-specific
competitive glucocerebrosidase inhibitors
Monocyte/Macrophage
Gaucher Disease
o Pseudo-Gaucher cells
• in bone marrow of thalassemia, CML, and ALL patients
• form as a result of excessive cell turnover and
overwhelming glucocerebrosidase enzyme rather than
true decrease in enzyme
• electron microscopy: distinguish between the two
cells
» pseudo-Gaucher cells: do not contain tubular inclusions
Monocyte/Macrophage
Niemann-Pick Disease
o autosomal recessive lipid storage disease
o three subtypes
Monocyte/Macrophage
o Type A and B
• recessive mutations in SMPD1 gene
» deficiency in lysosomal hydrolase enzyme acid
sphingomyelinase (ASM) and subsequent buildup of
substrate sphingomyelin in liver, kidney, and lungs
• Niemann-Pick cells found in bone marrow
» macrophages with foamy cytoplasm packed with lipid-
filled lysosomes that appear as vacuoles after staining
Monocyte/Macrophage
o Type A
• brain is also affected
• presents in infancy
• failure to thrive, hepatosplenomegaly, and rapid
neurodegenerative decline= death usually by age 3
• <5% of normal sphingomyelinase activity
Monocyte/Macrophage
o Type B
• 10-20% normal enzyme activity
• presents later in life with variable clinical course
• little or no neurologic symtpoms
• many experience severe and progressive
hepatosplenomegaly, heart disease, and pulmonary
insufficiency
Monocyte/Macrophage
o Type C
• decrease in cholesterol effluxing fro the intracellular
endosome/ lysosome to the cytosol
• under control of two proteins: Niemann-Pick C I and II
• cholesterol, biphosphate, and sphingolipids build up in
lysosomal storage organelles of macrophages
Monocyte/Macrophage
o Type C
• systemic, neurologic, and psychiatric symptoms
• poor prognosis
• most patients die before 25 yo
• confirmation: gene sequencing that identifies
mutations in NPC1 in 95% of cases
• NPC2 mutations in 5% of patients
Genetic B and T
Lymphocyte Abnormalities
• decreased production of B cells, T cells, or both

• increased risk of infection and secondary malignancy
T lymphocyte abnormality
o best presented by DiGeorge syndrome
o absence or underdevelopment of thymus
o markedly decreased numbers of T lymphocytes
Genetic B and T
T lymphocyte abnormality
o microdeletion in chromosome band 22q11.2
• most common chrom deletion
• individuals have broad range of abnormalities (defective
parathyroid glands, cardiac abnormalities, abnormal facial
development, neurologic disorders, and hypocalcemia)
• <1% of patients are athymic (complete DiGeorge
Syndrome)
• treatment: thymus transplantation with 75% survival rate
Genetic B and T
Sex-linked Agammaglobulinemia (XLA)

o B cell disease
o mutation in the gene encoding Bruton tyrosine
kinase (BTK)
o decreased BTK production (important for B cell
development, differentiation, and signaling)
Genetic B and T
Sex-linked Agammaglobulinemia (XLA)

o without BTK: B lymphocytes fail to reach maturity
and will die prematurely
o infants: display symptoms after 1-2 months, once
maternal antibodies are cleared
o recurring bacterial infections: life-threatening
Genetic B and T
Combined B/T lymphocyte abnormalities

o Severe Combined Immunodeficiency (SCID)
• result in depletions of T,B and NK lymphocytes
• adenosine deaminase deficiency
» excess amounts of natural substrates (adenosine and
2’deoxyadenosine)
» lymphocyte depletion through a variety of mechanisms
Genetic B and T

o Severe Combined Immunodeficiency (SCID)
• X-linked SCID
» more common
» mutation in gene encoding IL-2 receptor γ chain
(shared by several interleukins)
» T cell lymphopenia, dysfunctional B cells, and lack of NK
cells
Genetic B and T

o Wiskott-Aldrich Syndrome
• X-linked
• mutation in gene that encodes a protein called WASp
• low levels or absence of the protein
• immunodeficiency, eczema, and thrombocytopenia
• WASp absence: affects migration, adhesion, and
activation of a variety of leukocytes (T, B, NK cells)
Quantitative Abnormalities
of Leukocytes
Neutrophils
o neutrophilia
9
• above 7.0 x 10 9/L in adults and 8.5 x 10 /L in children
o normal relative neutrophil count: 50-70%
o absolute neutrophil count (ANC): adding the number
of segmented and band neutrophils
• some laboratories: include metamyelocytes and
myelocytes
of Leukocytes
Neutrophils
o neutrophilia
• can be caused by cathecolamine-induced
demargination or a shift in neutrophils from the
marginal pool to the circulating pool
• from strenuous exercise, emotional stress, shock,
burns, trauma, labor, or increase in epinephrine
of Leukocytes
Neutrophils
o neutrophilia
• occurs in condition resulting to increase BM production
or shift of neutrophils from BM storage pool to
peripheral blood
» accompanied by a shift to the left (presence of
immature neutrophils)
of Leukocytes
Neutrophils
o Leukemoid Reaction
• reactive leukocytosis above 50 x 109/L with
neutrophilia and marked left shift
• result of acute and chronic infection, metabolic disease,
inflammation, or response to malignancy
• most often refers to neutrophils, but increased count
may be due to increase in other types of leukocytes
• may be confused with CML
of Leukocytes
Neutrophils
o Leukoerythroblastic Reaction
• presence of immature neutrophils, nRBCs, and
teardrop RBCs
• often accompanied by neutrophilia, but not always
• also associate with primary myelofibrosis
of Leukocytes
Neutrophils
o Leukoerythroblastic Reaction
• possibility of space occupying lesion in bone marrow
» can be a metastatic tumor, fibrosis, lymphoma,
leukemia, or simply marked increase in one of the
normal marrow cells
» erythroid hyperplasia seen in hemolytic anemia
of Leukocytes
Neutrophils
o Neutropenia
• decrease in absolute neutrophil count below 2.0 x 10 9 /L
in white adults and 1.3 x 10 9 /L in black adults
• risk of infection increases as ANC lowers
• severe (<0.5 x 109/L): increases the risk
of Leukocytes
Neutrophils
o Agranulocytosis
9
• neutrophil counts of <0.5 x 10 /L
o Neutropenia
• also caused by: increased rate of removal/destruction of
neutrophils from the blood;
• fewer neutrophils being released from the BM to the
blood as a result of decreased production of ineffective
hematopoiesis
of Leukocytes
Neutrophils
o Neutropenia
• neutrophils present in BM but not released into the
blood because they are defective
• changes in ratio of circulating versus marginal pool of
neutrophils;
• or combination of the above
of Leukocytes
Neutrophils
o Neutropenia
• acquired causes more common than inherited causes
• immune-mediated neutropenia: caused by antibody
binding to neutrophil antigens
of Leukocytes
Neutrophils
o Neutropenia
• Alloimmune Neonatal Neutropenia
» maternal IgG crosses the placenta and binds to
neutrophil-specific antigen inherited from the father
(FcγRIIIb, NB1, or HLA)
» varying severity
» neutrophil counts rise after a few months, consistent
with the half-life of maternal antibody
of Leukocytes
Neutrophils
o Neutropenia
• Autoimmune Neutropenia in Children
» primary illness with moderate to severe neutropenia
» antibodies to HNA-1
» self-limiting with resolution of neutrophil counts after 7-
24 months
of Leukocytes
Neutrophils
o Neutropenia
• Secondary Autoimmune Neutropenia
» associated with autoimmune disorders (rheumatoid
arthritis and associated Felty syndrome, SLE, and
Sjogren syndrome)
» antineutrophil antibodies
» induced by immune complex deposition, granulopoiesis-
inhibiting cytokines, and splenomegaly
of Leukocytes
Neutrophils
o Neutropenia
• Secondary Autoimmune Neutropenia
» drug-induced neutropenia: related to dose-dependent
toxicity on cell replication in hematopoiesis
» may be immunologic and occurs when particular drug is
given subsequent to the initial exposure that resulted in
antibody formation
of Leukocytes
Neutrophils
o Neutropenia
• may also result from infection (viral infection of
hematopoietic progenitor cells, suppression of
hematopoiesis by inflammatory cytokines, and increased
usage of neutrophils due to overwhelming infection)
of Leukocytes
Neutrophils
o Neutropenia
• Intrinsic (constitutional/congenital) neutropenia
» rare group of inherited disorders present at birth
» due to either decreased production from marrow
hypoplasia or proliferation defect
» heterogenous clinical presentation
» bacterial infections: biggest risk
of Leukocytes
Neutrophils
o Neutropenia
• Intrinsic (constitutional/congenital) neutropenia
» life-threatening and/or diminish quality of life
» antibiotic prophylaxis and therapy, use of C-SF: lowered
risk and improved quality of life
» increased risk for developing secondary leukemia
of Leukocytes
Neutrophils
o Shwachman-Bodian-Diamond Syndrome
• autosomal recessive disorder
• marrow failure, pancreatic insufficiency, and skeletal
abnormalities
• intermittent neutropenia that fluctuates from severely
low to near normal: most common hematologic finding
of Leukocytes
Neutrophils
o Shwachman-Bodian-Diamond Syndrome
• mild normocytic to macrocytic normochromic anemia
• reticulocytopenia and thrombocytopenia
• dysplastic changes involving all 3 granulocyte lineages
• increased risk for transformation to myelodysplasia and
AML (terminal event)
of Leukocytes
Neutrophils
o Congenital Severe Neutropenia
• Kostmann syndrome or infantile genetic agranulocytosis
» autosomal recessive disease
9
» severe neutropenia (<0.2 x 10 /L) presents shortly after
birth and BM granulocyte hypoplasia with maturation
arrest at premyelocyte stage
of Leukocytes
Neutrophils
o Congenital Severe Neutropenia
• cyclic neutropenia
» mutations in ELANE/ELA2: for neutrophil elastase
» severe neutropenia every 21 days
» increased risk for fevers, bacterial infections, mouth
ulcers, and gangrene, bacteremia, and septic shock
» G-CSF administration: reduced these events
of Leukocytes
Neutrophils
o Chronic Idiopathic Neutropenia
• in adults affecting women 18-35 years of age
• BM is quite variable between patients, but generally
shows more immature neutrophils than mature ones
(cells are lost during maturation)
• clinical severity related to degree of neutropenia
• G-CSF: useful treatment
of Leukocytes
Neutrophils
o Fanconi Anemia
• rare autosomal recessive or X-linked inherited disease
• variable degrees of BM failure, peripheral cytopenias,
and increased risk for hematologic malignancies and
other cancers
of Leukocytes
Neutrophils
o Dyskeratosis congenita
• sex-linked recessive, autosomal dominant or recessive
• heterogenous presentation
• mucocutaneous abnormalities, abnormal skin
pigmentation, nail dystrophy, and leukoplakia
• BM failure and increased risk for malignancy
of Leukocytes
Eosinophils
o factors influencing the number of eosinophils in
circulation:
• BM proliferation rate and release into the bloodstream
• movement from the blood into extravascular tissues
• cell survival/destruction once the eosinophils have
moved into the tissues
of Leukocytes
Eosinophils
o Eosinophilia
9
• AEC: >0.4 x 10 /L
• nonmalignant causes: cytokine stimulation, especially
from IL-3 and IL-5
• seen in patients with parasite infection (helminthes and
protozoa)
• major function of eosinophils: degranulation where
substances are released that damage an offending
organism or target cell
of Leukocytes
Eosinophils
o Eosinophilia
• in developed countries: most often associated with
allergic conditions (asthma, hay fever, urticarial, and
atopic dermatitis)
• in scarlet fever, HIV, fungal infections, autoimmune
disorders, and hypersensitivity to antibiotics and anti-
seizure medications
of Leukocytes
Eosinophils
o Eosinophilia
• reactive eosinophilia: abnormalities in cytokine
regulation and expression in some neoplasms
» in ALL subtype t(5;14)
» penetrate solid tumors, allowing tumoricidal cytokines
to bring tumor necrosis
of Leukocytes
Eosinophils
o Eosinophilia
• Hypereosinophilic Syndrome (HES)
» if lasts >6 months without identifiable cause
» a myeloproliferative neoplasm
of Leukocytes
Eosinophils
o Eosinopenia
9
• AEC: <0.09 x 10/L
• difficult to detect because normal eosinophil reference
range is very low
• most often associated with marrow hypoplasia,
especially involving leukocytes
of Leukocytes
Eosinophils
o Eosinopenia
• also in infection or inflammation with neutrophilia
» eosinophils move into tissues and marrow release may
be inhibited
» Absolute eosinopenia: in autoimmune disorders,
steroid therapy, stress, sepsis, and acute inflammatory
states
of Leukocytes
Basophils
o Basophilia
9
• ABC: <0.15 x 10/L
• most common cause: presence of malignant
myeloproliferative neoplasm (eg CML)
• nonmalignant cause (rare): allergic rhinitis,
hypersensitivity to drugs or food, chronic infections,
hyotheroidism, radiation therapy, and bee stings
of Leukocytes
Monocytes
o Monocytosis
9 9
• AMC: >1.0 x 10 /L in adults and <3.5 x 10/L in neonates
• nonmalignant causes: acute and chronic inflammation
and infections, immunologic conditions, hypersensitivity
reactions, and tissue repair
• first sign of recovery from acute overwhelming infection
or severe neutropenia= positive sign
of Leukocytes
Monocytes
o Monocytosis
• when due to G-CSF or GM-CSF administration
» accompanied by reactive changes in monocyte
morphology
» associated with neutropenic disorders
» cyclic neutropenia: monocytosis occurs inversely with
neutropenia in 21-day cycle
of Leukocytes
Monocytes
o Monocytopenia
9
• AMC: <0.2 x 10 /L
• very rare conditions that do not involve cytopenias of
other lineages
• absolute monocytopenia: in patients receiving
steroid therapy or hemodialysis or in sepsis
• also cause by Epstein-Barr virus
of Leukocytes
Lymphocytes
o Lymphocytosis
• children older than 2 weeks and younger than 8-10:
normally have higher absolute lymphocyte counts than
adults
• ALC: >10.0 x 10 9/L (children) and >4.5 x 109/L (adult)
• relative lymphocytes: 20-40%
» not used to define lymphocytosis
of Leukocytes
Lymphocytes
o Lymphocytopenia
• age-dependent
• ALC: <2.0x 109/L (children) and <1.0 x 10 9/L (adult)
• nonmalignant causes: onherited and acquired
TABLE 29-5
Qualitative (Morphologic) Changes
Neutrophils
o neutrophil reaction to infection, inflammation, stress,
or administration of recombinant CSF therapy
• affect the number and types of circulating neutrophils (left
shift), induce morphologic change, or both
• abnormal changes but normal, reactive response
• left shift range from mild (increase in band neutrophils and
metamyelocytes) to moderate (metamyelocytes,
myelocytes, and occasional promyelocyte) to marked
(myelocytes, promyelocytes, and occasional blast form)
Neutrophils (reactive morphologic changes)

o toxic granulation
• dark, blue-black granules in the cytoplasm
• peroxidase positive and reflect increase in acid
mucosubstance within primary, azurophilic granules
• lowered pH in phagolysosomes that enhances microbial
killing
• positive correlation between levels of CRP and
percentage of neutrophils

o toxic granulation
• intensity: general measure of degree of inflammation
• seen in various infections and patients who received CSF
• mimic granulation found in mucopolysaccharidoses and
Alder-Reilly anomaly
• defining characteristic: in most patients not all
neutrophils are equally affected

o Dohle Bodies
• cytoplasmic inclusions consisting of remnants of RNA
arranged in parallel rows
• found in band and segmented neutrophils and often in
cells containing toxic granulation
• appear as intracytoplasmic, pale blue round or
elongated bodies between 1-5 um in diameter

o Dohle Bodies
• located in close apposition to cellular membranes
• delay in preparing blood: may affect Dohle body
appearance= more gray than blue and in some cases
may not be visible
• relatively nonspecific
• in wide range of conditions (bacterial infections, sepsis,
and normal pregnancy)

o Cytoplasmic Vacuolation
• seen less often
• reflect phagocytosis
» self/autophagocytosis: small (2 um) and distributed
throughout the cytoplasm, induced by drugs, storage in
EDTA (artefactual) for >2 hours, autoantibodies, acute
alcoholism, and exposure to high doses of radiation
» or of extracellular material)

• phagocytic vacuoles: caused by either bacteria or
fungi in septic patients
» large (6 um) and frequently accompanied by toxic
granulation
• artefacts: if vacuoles not accompanied by toxic
granulation or Dohle bodies
• blood collection time should be compared with when
smear was made

• when phagocytic vacuoles are seen= careful
examination made for bacteria or yeast within vacuoles
• Ehrlichia and Anaplasma: small, obligate,
intracellular bacteria transmitted by ticks to humans
and other hosts
» grow as cluster(morula) in neutrophils and in monocytes
» leukopenia, thrombocytopenia, elevated liver enzymes,
and anemia may develop

• intracellular aggregates detected in first week of
infection
• immunofluorescent antibody titers or PCR: confirmation
• early diagnosis is essential
» antibiotic treatment with doxycycline= very effective and
prevent serious complications

o Pyknotic Nuclei
• indicates imminent cell death
• nuclear water has been lost and chromatin becomes
very dense and dark
• filaments still seen between segments
• should not be confused with necrotic nuclei found in
dead cells
» necrotic nuclei: rounded fragments of nucleus with no
filaments and no chromatin pattern

o Degranulation
• in activated neutrophils and eosinophils
• both primary and secondary granules: emptied into
phagosomes
» 2° granules: secreted into extracellular space
• in vitro degranulation in eosinopils
» occurs when cellular membranes are disrupted during
process of making the blood film

o Cytoplasmic Swelling
• caused by actual osmotic swelling of cytoplasm or by
increased adhesion to the glass slide by stimulated
neutrophils
• result to variation in neutrophil size or anisocytosis
Monocytes
o occasional immature monocytes seen in peripheral
blood in response to infection or inflammation
• not a common left shift
o reactive changes seen in infections, during recovery
from BM aplasia, and after GM-CSF administration
• nucleus: thin and band-like in areas and segmenting
Monocytes
o reactive changes: increased cytoplasmic volume,
increased numbers of cytoplasmic granules, and
evidence of phagocytic activity
o large numbers of immature monocytes: most often
in hematologic neoplasms involving monocytic
series
Lymphocytes
o atypical: commonly used but least suitable
• cells are abnormal when in fact they are reacting to
antigen in a normal manner
• in cytology lab: suspicious, precancerous lesion
o reactive lymphocytes: result of complex
morphologic and biochemical events
• occur as lymphocytes are stimulated when interacting
with antigens in peripheral lymphoid organs
Lymphocytes
o B and T lymphocyte activation
• results in transformation of small, resting lymphocytes
into proliferating larger cells
• lymphocytes spill into circulation and seen in smears
o reactive lymphocytes: present as heterogenous
population of various shapes and sizes
Lymphocytes
o reactive lymphocytes
• variation in nuclear/cytoplasmic ratio, nuclear shape,
and chromatin pattern (clumped or less mature/ less
clumped)
• visible nucleoli
• increase basophilic cytoplasm
• cytoplasm may be indented by surrounding RBCs
Lymphocytes
o plasmacytoid lymphocytes
• has some of the morphologic features of plasmacytes
• morphologic term and does not imply lineage
BOX 29-5C
Infectious Mononucleosis (IM)
o symptomatic illness that ensues whenever

adolescents and adults are infected
o incubation period: 3-7 weeks
• virus preferentially infects B lymphocytes through
attachment of viral envelope glycoprotein 350/220 to
CD21 (C3d complement receptors)
o oropharynx epithelial cells are also infected
• unclear mechanism because they do not express CD21
o cellular response: important in the control of

infection
• characterized by proliferation and activation of NK
lymphocytes, CD4 T cells and CD8 memory cytotoxic
T cells (EBV-CTLs)
o most circulating reactive lymphocytes seen in
circulation: activated T cells
o clinical manifestations
• sore throat, dysphagia, fever, chills, cervical
lymphadenopathy, fatigue, and headache
• hematologic findings: resemble those in viral disorders
o WBC count: elevated (10-30 x 10 9/L) or more with
absolute lymphocytosis
o wide variation of lymphocyte morphology (50% or
higher exhibiting reactive features)
o complications
• mild and include hepatoplenomegaly (elevated
transaminases), hemolytic anemia, and moderate
thrombocytopenia
• rare cases: aplastic anemia, DIC, TTP, HUS, Guillain-
Barre syndrome, or neurologic complications
o highest frequency in young adults (15-24 years)
o Rapid Screening Tests

• detection of heterophile antibodies
» stimulated by EBV that cross react with antigens found
on sheep and horse red cells
» not everyone will produce this especially children
o Definitive testing
• panel of antigen and antibody tests for VCA, EBNA,
and IgG/IgM antibodies against VCA and EBNA

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29th Chap

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CHAPTER 29

Morphologic Abnormalities w/ and w/o

o Pelger- Huet Anomaly

o Pelger- Huet Anomaly

o Pelger- Huet Anomaly

o Pelger- Huet Anomaly

o Pseudo- or Acquired Pelger- Huet Anomaly

Laboratory Issues in PHA

Laboratory Issues in PHA

Laboratory Issues in PHA

Laboratory Issues in PHA

Laboratory Issues in PHA

Normal Morphology with Functional

Chronic Granulomatous Disease

Chronic Granulomatous Disease

Chronic Granulomatous Disease

Chronic Granulomatous Disease

Chronic Granulomatous Disease

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Leukocyte Adhesion Disorders

Miscellaneous Granulocyte Disorders

Miscellaneous Granulocyte Disorders

Miscellaneous Granulocyte Disorders

Mucopolysaccharidoses (MPSs) group

Mucopolysaccharidoses (MPSs) group

Mucopolysaccharidoses (MPSs) group

Lipid Storage Diseases

• decreased production of B cells, T cells, or both

Sex-linked Agammaglobulinemia (XLA)

Sex-linked Agammaglobulinemia (XLA)

Combined B/T lymphocyte abnormalities

Combined B/T lymphocyte abnormalities

Combined B/T lymphocyte abnormalities

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

Neutrophils (reactive morphologic changes)

o symptomatic illness that ensues whenever

o cellular response: important in the control of

o Rapid Screening Tests

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