PSU-COM Careers in Medicine

USMLE Step 1 Prep Program

Hematology

AKA
aallen1@hmc.psu.edu
January 18, 2014
 Rationale behind this
• You should recognize just about everything I will show you here,
so this should not be too taxing
– Now is the chance to see how these topics tend to come up on boards
– Additionally, these sessions aim to orient you to some of the types of
details you will need to recall later on
– Seeing some Step 1 integrations now may help make reviewing in the
future easier. It may also help you as you prep for Friday
• If something seems unclear, do not hesitate to stop me
• At the end of these 2 hours, you will have many integrations
under your belt
– With any luck, this boosts a little confidence and alleviates a little
stress. It is my hope to communicate how much you already know
 Goals
• Introductory principles and terms
• Anemia
• Hemostasis and thrombosis
• Disorders of platelets and coagulation
• Stem cell disorders
• Cancers
– Acute leukemias
– Lymphoproliferative diseases
• Immunocompromised state
• Blood transfusions and reactions
• Heme pharmacology pearls
 Introductory principles and terms
• Erythropoietin (EPO): Glycoprotein released by the
kidney in response to tissue hypoxia
– Stimulates proliferation of erythroid precursors
– JAK kinase (think ahead about what can go wrong)
 Introductory principles and terms
• Iron processing
– Absorbed by duodenal enterocytes (organic Fe2+ is more efficiently
absorbed through DIVALENT metal transporter-1)
• Ferrireductase facilitates conversion of dietary Fe3+  Fe2+
• Ascorbic acid (vitamin C) helps the enzyme do its job
• Ferroportin controls the exports iron out of the enterocyte (GI cell) and into the
portal (liver) circulation
– Iron (Fe3+) is loaded onto transferrin (2x atoms)
• Ferroxidase facilitates conversion of Fe2+  Fe3+
– Transferrin (iron-binding blood plasma glycoprotein) transports iron in
the blood
• Tfr-1 transmembrane receptor (e.g. on nucleated RBCs) facilitates internalization
of the Fe3+-Transferrin complex
• The complex is internalized in an endosome, and iron is released
– Iron in the cell can be stored as ferritin or used to synthesize heme
 Introductory principles and terms
• Heme synthesis
– This involves a long pathway that occurs both in the cytosol
and the mitochondria that has several important enzymes
(and cofactors) and several important clinical roles
– Boards likes to touch on various aspects of this pathway (so
you essentially must know all of it)
– Whether you choose to deal with this now, though, depends
on how heavily your course emphasized it
• Spending time on something random you see in First Aid (which
might easily be this) could distract you from more important work
Introductory principles and terms
B6

Ignore the details covered

under this box.
 Introductory principles and terms
• Ringed sideroblast • Basophilic stippling
 Introductory principles and terms
• Heme synthesis
– This ties into the iron discussion because iron is incorporated
into protoporphyrin to form heme
• Iron storage
– Extra iron can be stored as ferritin
• Iron regulation
– Hepcidin: Polypeptide hormone made by the liver that
regulates the inflow of iron into the plasma
• Binds ferroportin of duodenal enterocytes (absorption), macrophages
(recycling), and hepatocytes (storage)
• “Anemia of chronic disease:” Inflammation  IL-6 release 
synthesis of hepcidin
 Introductory principles and terms
• Iron regulation
– Hemochromatosis: A number of inherited iron overload
conditions resulting from increased iron absorption
• Clinical (accumulation): Liver (cirrhosis), pancreas (diabetes),
heart (cardiomyopathy), bones (arthritis), skin (bronzing)
• HFE gene: Thought to encode a protein that regulates Fe
absorption by altering how transferrin interacts with its receptor
• Variations: Hemochromatosis can result from problems
elsewhere in the pathway (e.g. the transferrin receptor, hepcidin,
ferroportin)
– It helps to know iron metabolism when they throw hypothetical situations
at you (or if they give you a situation you can think your way through)
• Treatment: Remove the excess iron (phlebotomy)
 Introductory principles and terms
• Erythrocyte survival
– Cytoskeleton is critical (maintains shape/deformability)
• This requires energy (ATP maintains structural integrity)
– Pyruvate kinase deficiency: Can lead to rigid RBCs (no energy)
• It also requires proper structural proteins (recall
spherocytosis)
– Other energy-requiring processes
• Keeping hemoglobin reduced
• Must be able to respond to hypoxia (2,3-BPG)
• Must protect against oxidation (damaging ROS)
– Remember NADPH?
 Introductory principles and terms
• Erythrocyte turnover
– RBCs last about 120 days, at which point enzyme activity diminishes
• All those energy-requiring processes suffer
• These cells limp on over to the spleen and are destroyed
• Spleen quality control comment
– Globin breakdown: Protoporphyrin ring is broken, and iron + tetrapyrrole are
released
• The tetrapyrrole leaves the macrophages as unconjugated bilirubin and binds albumin
(albumin is a liver protein that aids in transport)
• Unconjugated bilirubin is transported (on albumin) to the liver, where it is processed
(conjugated)
• Conjugated bilirbin is excreted into bile (which itself is secreted into the gut)
• Conjugated bilirubin in the gut is converted to urobilinogen (which can be further oxidized to
urobilin  urobilin gives feces its color)
• Conjugated bilirubin can also be released in the urine
– How is this? Conjugated bilirubin in the gut can be reabsorbed  circulates to kidney
– This gives urine its color
 Anemia
• Anemia: Reduction in RBC mass
– Intuitive iron critical periods (6-month infant,
adolescence, menstruation)
– Relativity of symptoms (acute vs. chronic anemia)
– General features: Pale skin, pale mucous membranes,
tachycardia with exertion
– Hemoglobin and hematocrit: In general, multiply the
hemoglobin by 3 to calculate the hematocrit
• Boards will give you normal values. If you check, you should
easily be able to see if an anemia is present
 Anemia
• Responding to anemia
– Assuming adequate supplies, the RBC production rate
can increase as much as 4-6x its normal rate
– Reticulocyte proliferation index (RPI): Helps indicate
whether the body responds appropriately to anemia
• RPI = Reticulocyte count (%) * (Patient’s HCT/Normal HCT)
– 3% of better indicates a good marrow response to anemia
• Correcting for polychromasia: Divide RPI by 2
 Anemia
• Classifying anemia
– By types: (1) Hypoproliferative, (2) maturation, (3)
hemorrhagic/hemolytic
• Hypoproliferaive: Iron deficiency anemia, inflammation, decreased EPO
response, bone marrow damage
• Maturation disorders: Cytoplasmic defects (thalassemia, sideroblastic
anemia), nuclear defects (B12 deficiency, folate deficiency)
• Hemorrhagic/hemolytic: Acute blood loss, hemolysis (intra- or extra-
vascular), chronic hemolysis (environmental factors, membrane defects,
metabolic defects)
– By features: (1) Size (MCV), (2) amount of hemoglobin (MCH), (3)
red cell distribution width (RDW)
• MCV > 100 typically indicates…
• MCV < ~75 typically indicates…
 Anemia
• Hypoproliferative anemias
– Aplastic anemia: RBCs, granulocytes, platelets reduced
• Failure or destruction of myeloid stem cells
• Hypocellular bone marrow (marrow failure)
• Secondary aplastic anemia (radiation, organic solvents,
viruses like Hep C and parvovirus B19)
• Primary aplastic anemia (immune-related)
– Anemia of chronic disease (and malignancy)
• IL-6 hepcidin-mediated adaptive response
– Reduced EPO
• Recall EPO is made by the kidney. Consider renal failure
 Anemia
• Maturational anemias
– Ineffective erythropoiesis: RPI lower than expected
– Nuclear (DNA) maturation disorders
• B12 and folate
– Cytoplasmic maturation disorders
• Decreased heme or globin synthesis, but normal DNA synth.
• Severe iron deficiency anemia, thalassemia, sideroblastic
anemia, lead poisoning (and its consequent anemia)
 Anemia
• Maturational anemias
– Thalassemia: Defective RBC maturation from reduced globin
chain synthesis
• Globin chains normally 4 alpha + 2 beta globin gene alleles
• Beta thalassemia  excess alpha chains
• Alpha thalassemia  excess gamma and beta chains (can form
dysfunction tetramers each)
– Beta thalassemia (Mediterranean)
• Beta-thalassemia minor: Usually asymptomatic, with increased HbA2
• Beta-thalassemia major: Absent beta chain, leading to severe
anemia necessitating blood transfusion
– Increased HbF (alpha-2-gamma-2)
 Anemia
• Maturational anemias
– Beta thalassemia (Mediterranean)
• Beta-thalassemia minor: Usually asymptomatic, with increased HbA2
• Beta-thalassemia minor: Absent beta chain, leading to severe anemia
necessitating blood transfusion
– Increased HbF (alpha-2, gamma-2)
– Alpha thalassemia (Asian & African; 4 genes = 4 possibilities)
• 4 genes deleted: Gamma tetramers (Hb barts)
– Stillbirth
• 3 genes deleted: Hemoglobin H (HbH) forms due to excess beta-globin
(Beta-4 = HbH)
• 2 genes deleted: Hypochromic/microcytic RBCs; no anemia
• 1 gene deleted: Silent carrier
 Anemia
• Hemorrhagic/hemolytic anemias
– Hemolytic anemia
• Shortened RBC lifespan in peripheral blood
• Elevated RPI
• Increased hemoglobin catabolism (more unconjugated bilirubin)
– Intrinsic vs. extrinsic hemolysis
• Intrinsic refers to a defect in the RBC itself
• Extrinsic refers to something outside the RBC acting on it
– Intravascular vs. extravascular hemolysis
• Intravascular refers to hemolysis in peripheral circulation
– Mechanical, osmotic, antibody, and/or complement destroy the RBC
• Extravascular refers to hemolysis outside circulation (e.g. spleen)
– The aberrant RBC makes it to the spleen where it is destroyed
 Anemia
• Hemorrhagic/hemolytic anemias
– Intravascular vs. extravascular hemolysis
• Intravascular refers to hemolysis in peripheral circulation
– Mechanical, osmotic, antibody, and/or complement destroy the RBC
– Free hemoglobin is released into the plasma and urine
– Haptoglobin is depleted (carrier for hemoglobin)
• Extravascular refers to hemolysis outside peripheral
circulation (e.g. spleen)
– The aberrant RBC makes it to the spleen where it is destroyed
– Recall that hemoglobin is split to release iron and the tetrapyrrole
(which  unconjugated bilirubin  travels on albumin  etc…)
 Anemia
• Hemorrhagic/hemolytic anemias
– Sickle cell anemia
• HbS involves Glutamic acid  valine in the beta-chain
• Low O2 or dehydration causes HbS to sickle (deoxygenated HbS
polymerizes)
• Sickling can lead to anemia and vaso-occlusive disease
• Newborns initially okay because of increased HbF
• Complications in homozygotes (sickle cell disease)
– Aplastic crisis (B19 infection)
– Autosplenectomy (infarction of the spleen)
– Vaso-occlusive crisis: Dactylitis (painful hand swelling), acute chest
syndrome, avascular necrosis
– Renal damage (from low oxygen and infarcts)
• Treatment: Hydroxyurea (incr. HbF) and marrow transplant
 Nutritional anemias
• B12 (cobalamin) absorption
– Bound by soluble “R” binders (from salivary gland)
• Protects cobalamin from gastric acid in the stomach
• “R” binders digested in duodenum (by pancreatic enzymes)
– Cobalamin binds intrinsic factor (IF) in the duodenum
• IF is made by parietal cells
– Cell membrane receptors in the terminal ileum bind the cobalamin-IF
complex (so it can be taken up)
– Schilling test: Investigates pernicious anemia (see notes field)
• Give oral “labeled” B12 + injected “unlabeled” B12
• The injected B12 saturates the liver, so the oral “labeled” B12 is not stored in the liver
• This allows the “labeled” B12 to pass into the urine
• If the “labeled” B12 ends up in the urine, absorption occurred
• Ultimately, this helps demonstrate intrinsic factor is working properly
 Nutritional anemias
• B12 (cobalamin) functions (all separate)
1. Cobalamin removes the methyl group from N 5-
methyltetrahydrofolate to form tetrahydrofolate
• “Single carbon metabolism”
• Tetrahydrofolate is used to make dTMP for DNA synthesis
2. Transfers methyl groups to homocysteine to form
methionine
• Increased homocysteine can damage blood vessels (increase
risk for thrombosis)
3. Converts methylmalonyl CoA to succinyl CoA
• “Odd chain fatty acid metabolism”
 Nutritional anemias
• Folate absorption and function
– Ingested folate polyglutamate is hydrolyzed by brush
borders enzymes in the jejunum
– Monoglutamate transported to the mucosa where it is
methylated (N5-methyltetrahydrofolate) and sent to
the blood stream
• This brings us back to the previous slide
• Cobalamin helps convert the N5-methylTHF into THF, which
goes on to “do some biochemistry”
 Nutritional anemias
• Clinical manifestations
– Cobalamin: Weakness, sore tongue, paresthesias,
ataxia, dementia, personality changes, memory
problems (sounds like a lot of “neuro”)
• “Subacute combined degeneration” of the spinal cord
– Folate: Neural tube defects
• Yes, there is more, but this is the big one I see them ask
about often
 Nutritional anemias
• Iron deficiency
– Total iron binding capacity (TIBC)
• Binding capacity of what? Transferrin
• High TIBC: Iron deficiency anemia (attempting to salvage as
much iron as possible)
• Low TIBC: Anemia of chronic disease (keep iron away from
the invader)
– Ferritin: Storage form of iron
• Low ferritin: Iron deficiency anemia
• Ferritin directly correlates with serum iron
 Iron handling
Iron deficiency Chronic disease Hemochromatosis

Serum iron Decreased Decreased Increased

Transferrin or TIBC Increased Decreased Decreased

(indirect)

Ferritin Decreased Increased Increased

% transferrin
saturation (serum Very low No change Very high
iron/TIBC)
 Hemostasis and thrombosis
• Platelet adhesion and aggregation
– Platelets form a plug to arrest bleeding
– They also provide the surface for coagulation to occur
– Formation and cross-linking of fibrin stabilizes a clot
– Adhesion: vWF (made by endothelial cells and megakaryocytes)
allows platelets to stick (like glue)
• vWF interacts with Gp1b (glycoprotein on platelet surface)
• ADP helps platelets adhere to endothelium
– Aggregation: Results from fibrinogen and GpIIb-IIIa
• Think of GpIIb-IIIa as the fibrinogen receptor
• ADP binding induces expression of GpIIb-IIIa on platelet surface
• The clotting cascade turns soluble fibrinogen into insoluble
fibrin
 Hemostasis and thrombosis
• Clotting cascade 
• Zymogens: XII, XI, X, IX, VII, II,
prekallikrein
• Cofactors: HMWK, VIII, V, tissue
factor (III)
• Prothrombin group: II, VII, IX, X
– Consumed
– Require Vitamin K
– Require Ca2+
• XIII: Cross-links fibrin
• PT: Common & extrinsic pathway
(I, II, V, VII, X)
• PTT: Common & intrinsic pathway
(all except VII and XIII)
 Hemostasis and thrombosis
• Terminating coagulation
– Antithrombin (AT): Liver glycoprotein made in the liver that inactivates Xa,
thrombin (IIa), and other serine proteases
• Amplified by heparinoid substances (heparin sulfate on the surface of endothelial cells)
– Proteins C and S
• Protein C is a vitamin K dependent protein made in the liver
• Protein S is also a vitamin K dependent protein
• Process: Thrombin binds thrombomodulin (receptor on endothelial cell surface) 
activates protein C  protein C complexes with protein S  inactivates VIIIa and Va
• Boards point: Warfarin affects proteins C and S, which causes a PRO-coagulative state
– Tissue factor pathway inhibitor
• Inhibits VIIa and inhibits activation of the extrinsic pathway
• Fibrinolytic system
– Plasmin: Forms from plasminogen via tissue plasminogen activator (tPA)
• Degrades fibrin & generates small fibrin or fibrin split products (FDPs)
– Regulation: Plasminogen activator inhibitor 2 and alpha-2 antiplasmin
 Anticoagulants
• Heparin: Binds & activates anti-thrombin-III
– AT-III inactivates thrombin (II) and IX, X, XI, XII
• It will NOT inactivate thrombin already bound to a clot
– Also has antiplatelet effects (blocks vWF)
– Does NOT cross the placenta (can use during pregnancy)
– Monitor PTT
– Protamine sulfate can be used as an “antidote”
– Heparin-induced thrombocytopenia and thrombosis (HITT):
Heparin can incite antibody production against platelets
• Platelets are activated by the antibodies
• Platelets can set off the coagulation cascade
• This can cause both thrombosis and thrombocytopenia
 Anticoagulants
• Fondaparinux: Activates anti-thrombin-III
– Less antigenic (less likely to cause HITT)
• Enoxaparin (--parin): Preferentially inactivates X
• Rivaroxaban: Oral X inhibitor
• Direct thrombin inhibitor
– Lepirudin
– Rivalirudin
– Desirudin
– Agatroban
– Dabigatran
 Anticoagulants
• Warfarin: Blocks hepatic activation of vitamin-K dependent clotting factors
by inhibiting vitamin K epoxide reductase
– Vitamin K gamma-carboxylates clotting factors II, VII, IX, X
– Site of action is in the liver
– Crosses the placenta (do NOT give during pregnancy)
– Takes a while to work, so you start with heparin while waiting for warfarin to take
effect
• Must wait for activated II, VII, IX, and X to be degraded
– Monitor by PT (INR)
• When the INR reaches a certain point, you stop heparin
– Metabolized by P450 enzymes (subject to interactions)
– If bleeding, stop therapy and administer vitamin K
• The fastest way to respond to a major bleed is to transfuse clotting factors directly (this is
faster than giving vitamin K to the patient)
– Warfarin can cause skin necrosis and purple toe syndrome
• Recall the comment I made about proteins C and S
 Heparin vs. warfarin
Feature Heparin Warfarin

Small and lipid-soluble (will

Structure Large (not crossing placenta) and ionic
cross placenta)

Site of action Blood Liver

Slow (normal clotting factors

Onset Rapid (seconds)
must deplete)

Mechanism Activates antithrombin Impairs synthesis of active

vitamin K-dependent factors

Duration Acute (hours) Chronic (days)

Reversing IV vitamin K (slower)

anticoagulation Protamine sulfate Fresh frozen plasma (rapid)

Monitoring PTT PT/INR

 Erythrocyte sedimentation rate (ESR)
(a brief aside)
• RBCs aggregate in response to acute-phase reactants
– RBC aggregates have a higher density than plasma
– We can measure this aggregation to say something about what is
going on in the body (with respect to inflammatory state)
• Acute-phase reactants: A class of proteins that increase or
decrease in response to inflammation
– They have some role in immunity
– Haptoglobin: Binds hemoglobin (keeps it away from bugs)
– Hepcidin: Internalizes ferroportin (similar end goal)
– Fibrinogen/prothrombin/VIII/vWF: Trap bugs in clots
• Increased ESR: Infections, autoimmune diseases (like lupus),
GI disease, pregnancy
 Disorders of bleeding and coagulation
• Testing platelet function
– Bleeding time (BT): Time required for bleeding from a standardized
skin wound to stop
• Nothing to do with coagulation
• Inversely relates to circulating platelet count (makes sense)
• Testing coagulation system
– Partial thromboplastin time (PTT): Mostly tests the intrinsic pathway
(XII, XI, IX, VIII, X, V, II, or fibrinogen)
– Prothrombin time (PT): Mostly tests extrinsic pathway (VII, V, X, II,
or fibrinogen)
– Thrombin time: Tests for fibrinogen
– Fibrinogen: Simply checking its levels
– D-dimer: Cross-linked fibrin destroyed by plasmin (usually low)
 Coagulation and bleeding tests
PT PTT PC BT

Hemophilia
No change Increased No change No change
A or B
Vitamin K Increased Increased No change No change
deficiency

Bernard-Soulier No change No change Decrease* Increased

Glanzmann No change No change No change Increased

ITP No change No change Decrease Increased

TTP No change No change Decrease Increased

vWD No change Possibly up No change Increased

DIC Increase Increased Decreased Increased

 Disorders of bleeding and coagulation
• Platelet disorders
– Clues suggesting a platelet disorder: Petechiae,
ecchymoses, epistaxis, and bleeding from superficial
wounds (interpreting the patient’s clinical presentation)
– Thrombocytopenia: Can involve problems of
production (bone marrow disease), abnormal
distribution (splenomegaly), or destruction (immune)
• Production: Aplastic anemia, leukemia, metastasis
• Distribution: Splenomegaly causes platelets to pool
• Destruction: More on this to come
– Bernard-Soulier vs. Glanzman Thromboasthenia
• Use the alphabet
• These represent some genetic conditions affecting platelets
 Disorders of bleeding and coagulation
• Platelet disorders
– Idiopathic thrombocytopenia purpura (ITP): Immune-
mediated platelet destruction
• Acute ITP in children (infection); chronic ITP in adults
• Peripheral smear shows large platelets
• May involve autoantibodies against platelet membrane
• Manage by suppressing the immune system (steroids) or by
removing the spleen (if drugs fail)
 Disorders of bleeding and coagulation
• Coagulation disorders
– Bleeding: Deep hematomas or bleeding into joints and
muscles (delayed onset, prolonged, recurrent)
– Hereditary disorders: Most commonly VIII, vWF, IX
– Von Willebrand disease (vWD): Most common
inherited disorder (several types of it); AD
• vWF: Large multimeric protein made (and stored) by
endothelial cells and megakaryocytes that mediates platelet
function and carries VIII in circulation (important)
• Treat with desmopressin (synthetic analog of ADH), which
induces release of vWF from endothelial cells
 Disorders of bleeding and coagulation
• Coagulation disorders
– Hemophilia: Second most common disorder (sex-
linked) with two types (clinically indistinguishable)
• Treat by infusing VIII or IX
• Desmopressin increases VIII levels
– Acquired coagulation deficiencies: Consider in
patients with serious underlying diseases
• Liver disease may affect II, V, VII, IX, X, and fibrinogen
 Disorders of bleeding and coagulation
• Disseminated intravascular coagulation (DIC)
– Widespread intravascular deposition of fibrin and
consumption of platelets and coagulation factors
• Fibrinolysis throughout this process produces D-dimers
– Results from the release of thromboplastic substances in
the blood (which activate coagulation)
• “Serious medical conditions” cause this to happen
• Sepsis, Trauma, Obstetrics, acute Pancreatitis, Malignancy,
Neoplastic syndromes, Transfusions (STOP Making New
Thrombi)
– Laboratories: Can help to think your way through this
• Schistocytes form in the chaos of thrombosis/thrombolysis
– Target treatment at the inciting condition and support
• May require transfusions (opens the door to transfusion ?s)
 Disorders of bleeding and coagulation
• Thrombocytic thrombocytopenia purpura (TTP)
– Congenital or acquired deficiency of vWF-cleaving protease
(which is in endothelial cells)
• ADAMTS-13 is the gene encoding the protease
• The protease cleaves vWF, inactivating it
• Leads to spontaneous aggregation of platelets
– Pentad of (1) neurologic issues, (2) renal issues, (3) fever, (4)
thrombocytopenia, (5) microangiopathic hemolytic anemia
(schistocytes)
– Laboratory studies: PT, PTT, fibrinogen are NORMAL
• LDH elevated (can indicate hemolysis)
• Elevated indirect bilirubin (can indicate hemolysis)
• Increase plasma and urine free-hemoglobin (again, hemolysis)
– Treatment: Plasmapheresis  exchange with fresh frozen
plasma
 Disorders of bleeding and coagulation
• Hereditary thrombosis syndromes
– Factor V Leiden: Most common hereditary syndrome
• Mutation in factor V such that it cannot be degraded by
proteins C and S
 Stem cell disorders
• Responding with EPO
– Appropriate response: Hypoxemia, decreased O2-carrying capacity,
sleep apnea, impaired O2 delivery
– Inappropriate: Renal problems (cysts, cancer, artery stenosis,
hydronephrosis), hepatomas, uterine fibroids, cerebellar
hemangioblastomas, pheochromocytoma
• Better summarized: “Things that don’t belong”
• Secondary polycythemia: Increased RBC mass and increased
EPO
• Absolute vs. relative polycythemia (think “RBC” mass)
– Relative polycythemia involves an “apparent” rise in RBC level
– Absolute polycythemia refers to an “actual” rise in RBC level
 Polycythemia
Plasma O2 Associated
Polycythemia volume RBC mass diseases
saturation

Relative Decreased No change No change

Lung disease,
Appropriate absolute No change Increased Decreased congenital heart
disease, high
altitude
Ectopic EPO
Inappropriate absolute No change Increased No change
(cancers)

Highly
P. vera Increased No change
increased
 Stem cell disorders
• Polycythemia rubra vera
– Elevated RBC, WBC, basophils
– Associated with JAK2 mutation
• Intracellular, non-receptor tyrosine kinase
• JAK activates and phosphorylates STAT  STAT to nucleus
– Clinical features (4 Hs): Hyperviscosity, Histaminemia,
Hyperuricemia, Hepatosplenomegaly
• Each of these encompasses particular clinical findings
– Treatment: Phlebotomy and possibly low-dose
chemotherapy
 Stem cell disorders
• Chronic myelogenous leukemia (CML)
– Myelocytes vs. lymphocytes
– Phases: Chronic phase  accelerated  blast crisis
• Progressively “undifferentiated” hematologic picture
• The end is “blast” crisis. These are immature forms
– Philadelphia chromosome (9; 22 translocation)
• Tyrosine kinase becomes more active  cells transform
– Imatinib: Binds the tyrosine kinase and blocks it
• Problems with resistance developing to the drug
• This only suppresses activity (necessitates indefinite use)
 Stem cell disorders
• Myelofibrosis/myeloid metaplasia
– Clonal proliferation of cells in the bone marrow, causing a
reactive fibrosis
• Hematopoietic species replaced with fibrous tissue
• “Myeloid metaplasia:” Hematopoiesis occurring elsewhere (outside
the bone marrow, such as in the spleen)
– Massive splenomegaly
– Tear-drop cells (squeezing out of the fibrotic marrow)
– Cause?
• Consider JAK2, growth factor problems (PDGF, transforming growth
factor) that up fibroblast proliferation
• Squela of P. vera?
 Stem cell disorders
• Essential thrombocythemia
– High platelet count (often inadvertently discovered)
– Thrombopoietin (TPO)
– Peripheral smear will show “bizarre platelets”
 Stem cell disorders
• Paroxysmal nocturnal hemoglobinuria
– Unusual sensitivity to RBCs to serum complement
• Normal RBCs have complement-degrading proteins to prevent the system
from attacking the body
• Lacking these “degrading proteins” leaves the body susceptible to
complement
• Respiratory acidosis (which can occur during sleep) can cause complement
deposition on RBCs
• Complement-degrading proteins normally prevent this from resulting in
hemolysis at night
– Can cause hemoglobinuria, anemia (from ongoing hemolysis leading
to iron deficiency), thrombocytopenia, predisposition for thrombosis
– Diagnosis: Sucrose hemolysis test, Ham’s test (acidifying serum), flow
cytometry (for abnormal surface proteins)
 Stem cell disorders
• Myelodysplastic syndrome
– Decreased peripheral blood counts and increased
abnormal circulating RBCs and WBCs
– Bone marrow cells die by apoptosis (may relate to a
problem with genes encoding growth factors)
– A disease of older patients
– May see ringed sideroblasts
 Acute leukemias (ALL, AML)
• Acute lymphocytic leukemia (ALL)
– Most common childhood cancer (75% before age 6)
– B-cell lineage (85%) – CD19, CD10, Tdt positive
• Tdt is a DNA polymerase expressed in immature (Pre-B and Pre-T)
cells
• CALLA (common acute lymphoblastic leukemia antigen) is another
one you should keep in mind here
– Manifestations include those of an acute leukemia
– Diagnosis requires flow cytometry
– Treatment is complicated (and rarely assessed)
– Numerous complications from treatment (brain tumors,
cardiomyopathy, encephalopathy, thyroid problems)
 Acute leukemias (ALL, AML)
• Acute myelogenous leukemia (AML)
– A diverse group of diseases, representing the most
common form of leukemia in adults
• Complex classification system (APL is the big variant)
– Auer rods (and potential complications)
– t(8; 21) translocation involving a transcription factor
– APL variant
• T(15; 17)
• Faggot cells (many Auer rods looking like a bundle of sticks)
• Treat with vitamin A (retinoic acid)
– Treatment is complicated
 Myeloproliferative disorders
Myeloproliferative
disorder RBCs WBCs Platelets Philadelphia JAK2 mutation

P. Vera Increased Increased Increased Negative Positive

Essential No change No change Increased Negative Sometimes +

thrombocytosis

Myelofibrosis Decreased Variable Variable Negative Sometimes +

CML Decreased Increased Increased Positive Negative

 Lymphoproliferative disorders
• Some overview
– B-cell surface antigens: CD19, CD20, CD22, CD79
– T-cell surface antigens: CD2, CD3, CD5, CD7, CD4, CD8
• Lymphoma: Malignant proliferation of lymphocytes
– Probably did not need to be said
– May or may not arise in lymphoid tissue (node, spleen,
marrow, skin/mucosa)
– Painful lymphadenopathy suggests inflammation (and
not malignancy)
– Benign or reactive conditions are heterogeneous
– By comparison, a lymphoma proliferation is monoclonal
• Hodgkin lymphoma: A variation on this theme
 Lymphoproliferative disorders
• Hodgkin Lymphoma
– Presentation: Painless, rubbery, cervical adenopathy in a
30-year-old individual with fever, night sweats, weight
loss, pruritus w/o rash
– Histology: Reed-Sternberg cells (pathognomonic)
• CD15 and CD30 (B-cell in origin)
• Reactive background: Small lymphocytes, plasma cells,
histiocytes, eosinophils, and neutrophils (from R-S cytokines)
– Immunotype: R-S + aforementioned
• The better the lymphocytic reaction, the better the prognosis
– Complications: Infection, organ damage, abnormal
growth, sterility, secondary malignancies (e.g. lung)
 Lymphoproliferative disorders
• Non-Hodgkin lymphomas
– Follicular lymphoma
– Chronic lymphocytic leukemia (also called small
lymphocytic lymphoma)
– Burkitt’s lymphoma
– Hairy cell leukemia
– Waldenstrom’s macroglobulinemia
 Lymphoproliferative disorders
• Follicular (center) lymphoma (B-cells)
– Malignant neoplasm resembling germinal centers (histologically relevant)
– t (14; 18) involving BCL2 (anti-apoptotic gene)
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (B-cells)
– Smudge cells on histology (about as far as they go)
• Burkitt’s lymphoma
– t (8; 14) involving c-myc (cell cycling)
– No tdt expressed (but will have CD19, CD10, CD79)
– “Starry sky” (macrophages + apoptotic debris + tumor cells)
– Highly aggressive + remember tumor lysis syndrome
• Hairy cell leukemia (B-cell neoplasm)
– Pancytopenia
– Histology shows cells with filamentous projections
– Stain with TRAP (Tartrate-resistant acid phosphatase)
• “B-eez in the TRAP”
• Waldenstrom’s macroglobulinemia
– Lymphoma of small lymphocytes and plasma cells (IgM secreted)
– Epistaxis (IgM interferes with platelets), oral bleeding, lymphadenopathy,
organomegaly, anemia, thrombocytopenia (IgM interferes with coagulation)
 Lymphoproliferative disorders
• Multiple myeloma
– Malignant proliferation of plasma cells
– Back pain, anemia, lytic bone lesions (punched out skull)
– Elevated immunoglobulins (IgG > IgA)
– Hypercalcemia (due to cytokines released by the myeloma
cells, which activate osteoclasts)
– CRAB: hyperCalcemia, Renal dysfunction, Anemia, Bone
lesions
• Renal problems? All the immunoglobulins have to go somewhere
(so they deposit in the kidney)
• Connection with amyloidosis (exam-relevant)
– Diagnosis: Aforementioned lab values + Ig light chains in
the urine (called Bence-Jones protein)
• “M-spike:” Monoclonal spike seen on protein electrophoresis
• Histology shows plasma cells with chromatin inclusions
 Hodgkin and Non-Hodgkin lymphoma
Features Hodgkin Non-Hodgkin

• Localized (single group of nodes) • Affects multiple peripheral nodes

Location • Extranodal spread is rare • Extranodal involvement common
• Spreads contiguously • Spreads non-contiguously

Cells • Reed-Sternberg cells • Mainly B-cells

• Bimodal distribution (young

Age adulthood & > 55 years) • Peak incidence 20-40 years
• More common in men
Associated • May be associated with HIV and
viruses • 50% associated with EBV immunosuppression

• Constitutional “B” symptoms

Symptoms (low grade fever, night sweats, • Fewer constitutional
signs/symptoms
weight loss)
 Blood component therapy
• Note: It appears the lecture you have for this occurs next
week (i.e. after this current talk)
– This means you may not be very familiar with what follows on the
next couple slides
– I will quickly frame what you want to take from these lectures and
just leave you with the slides if you want to look at them again
• Screening blood (general things we care about)
– HIV, HCV, HBV, HTLA-1/II, West Nile, syphilis, Chagas
• Whole blood: Separated into individual components
– Whole blood  RBCs and platelet-rich plasma
– Platelet-rich plasma Platelets and fresh frozen plasma
– Fresh frozen plasma: Separated into a cryoprecipitate and plasma
derivatives
 Blood component therapy
• Packed RBCs
– Indicated during a symptomatic anemia
– 1 RBC unit increases Hgb by 1 and Hct by 3%
– Know when and when NOT to give (study exactly what the lecture says)
• Fresh frozen plasma
– Raises coagulation levels by 20% (enough to achieve hemostasis)
– Indicated for
• Multiple coagulation factor deficiencies (DIC, liver failure)
• Factor II, V, VII, X, XI, or XIII deficiency (when a specific factor concentrate is not available)
• Quickly reversing anticoagulation (warfarin overdose or vitamin K deficiency)
• Cryoprecipitate
– Consists of fibrinogen, factor XIII, factor VIII, and vWF
– If you know this, you can think your way through situations in which you need cryo (some
listed in the notes field)
– The fibrinogen in cryo is more concentrated than in fresh frozen plasma
• Platelets: Indicated thrombocytopenia or thrombocytopathy
– Consider when bleeding with < 50,000 platelets
– Consider before procedures when platelets < 50,000
– Consider when platelet count < 10,000 in bone marrow hypoplasia
 Blood transfusions
• Terminology
– Rh antigen: Refers to something called the “D”
antigen
• What we call “positive” or “negative”
 Blood transfusions
• Direct vs. indirect Coombs
– Direct looks at antibodies already bound to patient’s
RBCs
– Indirect looks for antibodies in the patient’s serum
• Reagents for the Coombs tests
– Direct involves (1) patient’s RBCs alone + (2) anti-
human globulin (the Coombs reagent)
– Indirect involves (1) patient’s serum alone + (2)
reagent RBCs
 Blood transfusions
• Acute hemolytic transfusion reaction
– ABO group incompatibility
– Leads to an extravascular hemolysis (jaundice) and
intravascular hemolysis (hemoglobinuria)
– Fever, back pain, hypotension
– Can set off DIC and cause renal failure
– Positive direct Coombs (coated RBCs) and indirect
(antibody present in serum)
– Management: Stop the transfusion, keep the IV in,
send unit to blood bank
 Blood transfusions
• Hemolytic disease of the newborn (HDN)
– Transplacental passage of maternal IgG antibodies that incite an
extravascular hemolytic anemia in the fetus
– ABO HDN: Most common, with O mother and A/B kid
• Jaundice w/in 24 hours after birth (benign)
• Mild anemia
• Positive direct Coombs’
• Spherocytes
– Rh HDN: Much more serious (mother is Rh negative and child is Rh positive)
• During the last trimester, the absence of cytotrophoblast increases risk for bleed 
mom makes anti-D-IgG antibodies
• Severe anemia results (along with other things from other blocks you cannot
appreciate too well just yet)
• “Kernicterus” is your buzz word
• Treat with anti-D globulin (prevents the mother from being sensitized)
• Blue fluorescence light (makes unconjugated bilirubin excretable)
 Pharmacology
• Sickle cell
– Hydroxyurea
• Inhibits ribonucleotide reductase and induces Hb F gene
• Effects vary relative to concentration (high for inhibiting ribonucleotide
reductase and low for inducing Hb F)
• Steroids
– Dexamethasone
• Glucocorticoid that has anti-inflammatory and immunosuppressant
properties
• Blocks PMN migration, production of inflammatory mediators, and reverses
capillary permeability
– Prednisone
• Corticosteroid gene transcription to reduce inflammation
• Can disturb neutrophil adhesion to the endothelium, which can INCREASE
the number of neutrophils measured in serum
 Pharmacology
• The cancer drugs
– There are many of them. Know their mechanisms
– Anthracyclines (--rubicin) can cause cardiotoxicity
– Anti-mitotic agents (vincristine, vinblastine) can cause
peripheral neuropathy (nerve damage)
• They interfere with microtubules. Neurons need microtubules
• Drugs starting with “O”
– Ondansetron
• 5-HT3 (serotonin) receptor antagonist
• Has anti-emetic activity (used to treat nausea/vomiting)
– Omeprazole
• Proton pump inhibitor that blocks H/K-ATPase in gastric parietal cells
• Suppresses gastric acid secretion