15. Thalassemia

Thalassemia RBC Morphology: Normochromic 2+ polychromasia 3+ irregularly shaped spherocytes 2+ fragments 1+ echinocytes Thalassemia: X-ray film of the skull showing new bone formation on the outer table, producing perpendicular radiations resembling a crewcut

16. Hereditary Spherocytosis and Sickle Cell Dz

Hereditary Spherocytosis RBC morphology: Normochromic 2+ polychromasia 2+ anisocytosis 2+ spherocytes 1+ echinocytes

Sickle Cell Dz Figure 1A Note the irreversibly sickled cells (ISCs). Figure 1B Note the ISCs and the nucleated RBC.

17. Immunohemolytic anemia

Autoimmune hemolytic anemia Figure 2 Warm AHA - blood film - note spherocytes & polychromasia (i.e. grey tint to some red cells indicating they are reticulocytes) Figure 3 Increased reticulocytes in warm AHA - the blood film has been stained with brilliant cresyl blue to show the ribosomal RNA in the immature red cells

Autoimmune hemolytic anemia FIGURE 5  Microangiopathic hemolytic anemia. A peripheral blood smear from a person with hemolytic-uremic syndrome shows several fragmented red cells.   Figure 4 Urine in patient with suspected immunohemolytic anemia - note the dark blue hemosiderin deposits (stained by Perl’s reaction)

18. Megaloblastic Anemia

RBC Morphology: Normochromic 3+ macrocytosis 3+ anisocytosis Numerous oval macrocytes Occasional teardrop cells and fragments

FIGURE 4 Megaloblastic anemia FIGURE 4  Megaloblastic anemia. A peripheral blood smear shows a hypersegmented neutrophil with a six-lobed nucleus Bone Marrow aspirate

FIGURE 5 Megaloblastic anemia (bone marrow aspirate) FIGURE 5  Megaloblastic anemia (bone marrow aspirate). A to C, Megaloblasts in various stages of differentiation. (B) Note that the orthochromatic megaloblast is hemoglobinized (as revealed by cytoplasmic color), but in contrast to normal orthochromatic normoblasts, the nucleus is not pyknotic. The early erythroid precursors and the granulocytic precursors (A & C) are also large and have abnormally immature chromatin.

19. Iron Deficiency Anemia

RBC Morphology: 2+ hypochromasia 3+ microcytosis 2+ anisocytosis 2+ elliptocytes and target cells occasional teardrop cells and cell fragments

Bone marrow aspirate Prussian blue stain (the blue stain)

Bone marrow Normal Hypocellular Hypercellular

20. Aplastic anemia and anemia of chronic disease

Aplastic Anemia Bone Marrow Biopsy – Low Magnification  The hypocellularity of the marrow is reflected in the peripheral blood smear, which shows granulocytopenia (the nucleated cell shown is a lymphocyte) and leukopenia (normally, at this magnification, you should be able to identify 5 to 7 leukocytes). Also notice that there is ample space between red cells, a reflection of this patient's anemia, and few, if any, platelets. Bone Marrow Biopsy – Low Magnification  virtually devoid of hematopoietic elements. Bone Marrow Biopsy – High Magnification  hypocellularity

Anemia of Chronic Disease The red cells in anemia of chronic disease are reduced in number and may be normocytic as shown in the first image, or mildly microcytic and minimally hypochromic as shown in the second image. The anemia is usually of mild to moderate degree.

21. Hemorrhagic diatheses

HUS Glomerulus with fibrin thrombi (The red stained material within the glomerular capillaries)

Microangiopathic Hemolytic Anemia Fragmented red blood cells

22. Hypercoagulable diseases

Warfarin-Induced Skin Necrosis (WISN)

23. Leukopenia and Leukocytosis

WBC Morphology: Both mature and immature stages of neutrophils have intense azurophilic granulation. Some bands and segmented forms contain Döhle bodies. Some have bubbly, vacuolated cytoplasm. Neutrophil nuclei are deeply stained, and nuclear projections are seen. Some promyelocytes are extremely large

Normal marrow biopsy (A normal marrow is said to show trilineage hematopoiesis (TLH) meaning that elements of all three major cell lines are represented. These cell lines include myelomonocytic cells, erythroid cells, and megakaryocytic cells. However, other cells types are also present including lymphocytes, plasma cells, connective tissue cells and stromal cells. Two histiocytes are present (arrowheads) engulfing cellular debris. The nucleated erythroid precursors are also dispersed (two long arrows) throughout the marrow and immature precursors have dark blue cytoplasm and large nuclei that progesses to a small dense nucleus with eosinophilic cytoplasm, while granulocytic precursors acquire granules in the cytoplasm. Two normal megakaryocytes are apparent in this field (two big arrows). A bilobed eosinophil is identified with an arrow with tail.

Lymphocytosis Secondary follicle has a clear zone, in the presence of immune stimulation that contains cytoplasm rich, activated lymphocytes (immunoblasts)containing a germinal center and a mantle zone. Mantle zone cells are like primary follicle. Follicular hyperplasia compresses surrounding naïve B lymphocytes to form a dense collar or mantle zone. Primary follicle in the absence of immune stimulation (small lymphocytes)

Reactive follicle polarization: The light zone is toward the capsule and has centrocytes (B cells with irregular, cleaved nuclei; follicle center cells from centroblasts) and follicular dendritic cells. Centroblast (blast-like B cells; large, noncleaved follicle center cells,) are in the dark zone, mitoses are frequent.

Lymphadenitis Tingle body macrophage

Lymphadenitis The sinus on the right is loosely filled with lymphocytes and histiocytes. The left sinus is packed with histiocytes.

24. Lymphoid and myeloid neoplasms

Sezary Syndrome - CTCL Normal The abnormal cells have convoluted cerebriform nuclei. The cytoplasm is basophilic, and occasionally contains small vacuoles. Both small and large cell types are seen.

Types of bone marrow examinations: (Top left) trephine core biopsy section (biopsy)-H&E stain, overall structure including bone trabecula; (top right) clot section- H&E, any coagulated material not in core for thorough examination; (bottom left) aspirate smear-Wright’s or Giemsa stain, marrow aspirate shows cell details well; (bottom right) touch preparation (touch prep)-like aspirate and shows organization too, used when no aspirate yield.

The normal bone marrow smear (aspirate) shows erythroid, myeloid, and lymphoid cells at various stages of maturation: 1 = Myeloblast, 2 = Promyeloocyte, 3 = Myelocyte, 4 = Metamyelocytes, 5 = Band neutrophil, 6 = Segmented neutrophil, 7 = Eosinophil, 8 = Monocyte, 9 =Proerythroblast, 10 = Basophilic erythroblasts, 11 = Polychromatic erythroblast, 12 = Orthochromatic erythroblast, 13 = Lymphocyte.

Various normal marrow cells are shown: 1 = Proerythroblast, 2 = Basophilic erythroblast, 3 = Polychromatic erythroblast, 4 = Promyelocyte, 5 = Myelocyte, 6 = Early band neutrophil, 7 =Late band neutrophil, 8 = Segmented neutrophil, 9 = Band eosinophil, 10 = Monocyte, 11 = Small lymphocyte. there is a large blast cell in the upper left group and a large promyelocyte at upper center. The latter is recognizable by the non-specific azurophilic granules in its cytoplasm, foretelling that it is heading toward one of the granulocyte lines. A basophilic normoblast with blue cytoplasm is in lower center. To the right of it are two early orthochromatic normoblasts:

Normal marrow morphologic difference between a proerythroblast (#1) and a myeloblast (#2). Both are the earliest recognizable stages in their respective series. Note that a proerythroblast has a more basophilic cytoplasm than a myeloblast. Other cells are: 3 = Myelocyte, 4 = Neutrophil, 5 = Samll lymphocyte, 6 = Smudged cell of unknown lineage, 7 = erythrocyte. Normal marrows with various stages of erythroid maturation are shown: 1 = Proerythroblasts, 2 = Polychromatic erythroblasts, 3 = Orthochromatic erythroblast.

Monocytic maturation from left to right: monoblast, promonocyte, monocyte, and macrophage Various normal marrow cells are shown: 1 = Proerythroblast, 2 = Basophilic erythroblast, 3 = Polychromatic erythroblast, 4 = Lymphocyte, 5 = Plasma cell, 6 = Eosinophilic precursor.

Lymphoid aggregate: Bone marrow biopsy (left), and two plasma cells noted with arrows (right) (Left) Large granular lymphocyte, (middle) prolymphocyte, (right) activated lymphocyte

Myeloperoxidase (A) and sudan black B (B) in granulocytic precursors; alpha naphthyl butyrate esterase (nonspecific esterase) in monocytic precursors; and chloroacetate esterase (D) in a segmented and band granulocytes.

Lymphoma

Acute Lymphoblastic Leukemia/Lymphoma Lymphoblasts represented by the red dots express terminal deoxynucleotidyl-transferase (TdT) and the B-cell marker CD22. The same cells are positive for two other markers, CD10 and CD19, commonly expressed on pre-B lymphoblasts. Thus, this is a B-ALL.

Small Lymphocytic Lymphoma/Chronic Lymphocytic Leukemia Lymph node architecture is totally effaced (upper right.) The node is packed with small, dark nuclei with visible nucleoli, and scant cytoplasm. Peripheral blood may contain the same immature cells (lower right.)

Lymphoplasmacytic Lymphoma Follicular Cell Lymphoma: • Follicles are clearly enlarged (left); cells are mixed small cleaved and large non-cleaved (right). Mantle Cell Lymphoma

Mucosa Associated Lymphoid Tissue (MALT) Diffuse, large B-cell lymphoma (left panel) usually causes a single, large mass (here in the spleen). Follicular lymphoma in (right panel) affects each follicle Multiple Myeloma

Peripheral T-Cell Lymphoma Burkitt’s Lymphoma Mycosis Fungoides

Leukemia Normal Variable cellularity with both hyper- and hypocellular areas, and a predominance of immature granulocytes. Megakaryocytes appear decreased in number.

Myelodysplastic Syndrome Myelodysplasia forms of dysplasia: A, marrow aspirate with nucleated red cell progenitors with multilobated or multiple nuclei. B, marrow aspirate with ringed sideroblasts, erythroid progenitors with iron-laden mitochondria seen as blue perinuclear granules (Prussian blue stain). C, peripheral blood smear with Pseudo-Pelger-Hüet cells, neutrophils with only two nuclear lobes instead of the normal three to four, are observed at the top and bottom of this field.

25. Splenomegaly and Hypersplenism

Normal Splenomegaly

26. Polycythemia vera

Polycythemia vera