Hematology 425 Qualitative Alterations of Leukocytes Russ Morrison November 27, 2006 9/17/2018

Leukocyte Alterations - Qualitative Changes in WBCs may be inherited or acquired Benign changes do not correlate with dysplasia or malignancy Inherited changes may be asymptomatic or life threatening Acquired changes are seen in response to circumstances and are interpreted as indicators of disease states 9/17/2018

Leukocyte Alterations - Qualitative Leukocyte alterations can be distinguished by many methods Mode of transmission (inherited or acquired) Frequency (common or rare) Location (nuclear or cytoplasmic) Microscopic manifestation (morphologic or nonmorphologic) 9/17/2018

Nuclear/Morphologic Alterations of Granulocytes Pelger-Huet Anomaly Common (1/6000) inherited nuclear aberration Hyposegmentation of the nucleus Clinically insignificant, no loss of cellular function Inherited as an autosomal dominant 9/17/2018

Nuclear/Morphologic Alterations of Granulocytes Identified by 1. Nuclei that are round, oval or bilobed with pinched appearance Clumping of chromatin Uniformity of appearance of most cells Cells sometimes confused with bands or metas Must be differentiated from “pseudo-Pelger-Huet cells” 9/17/2018

Nuclear/Morphologic Alterations of Granulocytes Pseudo-Pelger-Huet cells are found in high stress situations (burns, drug reactions, infections, myelodysplastic syndromes, CGL and acute leukemias If these cells are seen, report as mature cells resembling those of Pelger-Huet anomaly Genetic studies will verify the status 9/17/2018

Pelger-Huet Anomaly 9/17/2018

Hereditary Hypersegmentation of Granulocytes Hereditary hypersegmentation of granulocyte nuclei is clinically insignificant Autosomal diminant inheritance Must be distinguished from hypersegmentation seen in megaloblastic anemias (B12, folate deficiency) and from acquired hypersegmentation (twinning deformity) 9/17/2018

Hereditary Hypersegmentation of Granulocytes Twinning is a term that describes a nucleus that has axial symmetry Twinning is an acquired anomaly and is clinically significant in stress situations, malignancies and oncologic treatments Figure 26-4 shows hypersegmentation with increases in extrusions of nuclear material Extrusions are found in persons with trisomy some chromosomes, including X 9/17/2018

Hypersegmented Neutrophil 9/17/2018

Cytoplasmic Alterations of Granulocytes, Alder-Reilly Anomaly Alder-Reilly anomaly results from a recessive disorder that causes deposition of mucopolysaccharides (lipids) in the cytoplasm of most cells The lipid deposits stain purple and are called Alder-Reilly bodies Commonly seen in patients with Hurler’s and Hunter’s syndromes 9/17/2018

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Cytoplasmic Alterations of Granulocytes, Chediak-Higashi Syndrome Chediak-Higashi syndrome demonstrates large peroxidase-positive lysosomes in most cells of the body It is a rare autosomal recessive syndrome Large, fused granules also occurs in melanosomes of the sking and may lead to albinism C-H syndrome results in an increased rate of precursor cell death, causing neutropenia and thrombocytopenia 9/17/2018

Cytoplasmic Alterations of Granulocytes, Chediak-Higashi Syndrome C-H syndrome results in increased susceptibility to infections and bleeding problems It progresses through peripheral neuropathy, pancytopenia, systemic infections, hepatosplemomegaly and lymphadenopathy to death 9/17/2018

C-H Syndrome, cytoplasmic inclusions 9/17/2018

Cytoplasmic Alterations of Granulocytes, May-Hegglin Anomaly May-Hegglin anomaly is characterized by the presence of large Dohle body-like formations in all cells It is a rare autosomal dominant condition Patients are at risk for infections and bleeding Bleeding is due to thrombocytopenia and abnormal platelet function with short life span Most patients with M-H anomaly are asymptomatic, but bleeding episodes have been reported 9/17/2018

May-Hegglin Anomaly 9/17/2018

Cytoplasmic Alterations - Acquired In addition to the genetic alterations already discussed, a number of acquired cytoplasmic changes have been described Toxic granulation demonstrates dominant primary granules as a result of stress The stress response is usually the result of infection or inflammation Cellular stimulation of young neutrophils causes membrane alteration which causes granules to appear larger and darker than normal in common staining methods 9/17/2018

Toxic Granulation Toxic granulation is felt to be clinically significant as it appears to reflect a poorer prognosis when identified It is not significant in patients being treated with granulocyte monocyte colony-stimulating factor (GM-CSF) May look like an artifact produced with poor staining, but TG will be uniform throughout all WBCs, while real TG is unevely spread throughout the cytoplasm of certain cells 9/17/2018

Toxic Granulation 9/17/2018

Dohle Bodies Dohle bodies develop in the cytoplasm of granulocytes of patients with infections Dohle bodies are composed of parallel rows of ribosomal RNA When stained, they are gray to light blue Mechanism of development is unknown, but associated with burns, infections, surgery, pregnancy and use of GM-CSF 9/17/2018

Dohle Bodies 9/17/2018

Vacuolization Phagocytic vacuoles are found in neutrophils as a result of various situations Autophagocytosis (phagocytosis of self) is seen with prolonged drug exposure (antibiotics) and toxins (alcohol and radiation) Ingestion of bacteria or fungi Jordan anomaly is a familial disorder with vacuoles filled with lipids, in the cytoplasm of granulocytes, lymphocytes and monocytes 9/17/2018

Necrobiosis Large numbers of dead granulocytes in the PBS indicate severe strain in granulocyte development pools Figure 26-8 shows a necrobiotic cell, typical of dead or dying white blood cells Box 26-2 summarizes the acquired granulocyte anomalies 9/17/2018

Cytoplasmic Alterations of Granulocytes - nonmorphologic Chronic granulomatous disease (CGD) of childhood is a group of genetic disorders where the intracellular kill mechanism of the granulocyte is defective The two most common forms of CGD are sex linked and autosomal recessive Victims have chronic pyogenic infections of all systems Secondary anemia of chronic disease is often present 9/17/2018

Miscellaneous Deficiencies Other manifestations of neutrophilic dysfunction Congenital C3 deficiency Disorders of neutrophilic movement Myeloperoxidase deficiency WHO cluster of poor leukocyte adherence syndromes 9/17/2018

Cytoplasmic changes of Monocyte/Macrophage Cells of the monocyte/macrophage system are quite rich in lysosomes that contain hydrolytic enzymes These enzymes normally break down products of cellular metabolism Monocytes/macrophages store materials that are not degraded satisfactorily The breakdown of cellular structures requires a series of functioning enzymes 9/17/2018

Cytoplasmic changes of Monocyte/Macrophage Hereditary absence or dysfunction of these enzymes causes an increase in substrate concentration and a decrease or absence of the product These conditions are commonly known as storage cell diseases Table 26-1 summarizes some of the more common storage cell diseases 9/17/2018

Cytoplasmic changes of Monocyte/Macrophage The most common lipid storage disorder is Gaucher disease, in which there is an inability to degrade glucocerbroside due to a deficiency of glucocerebrosidase Glucocerbroside accumulates in the monocyte/macrophage system of the BM, spleen and liver Neurons of the CNS may also be affected Gaucher disease is an autosomal recessive trait with more than 65 mutations known to cause the disease 9/17/2018

Cytoplasmic changes of Monocyte/Macrophage Gaucher disease occurs in three types Chronic adult type (type 1) Acute infantile neuronopathic type (type 2) Less defined subacute neuronopathic type (type 3) Characteristics of the three types of Gaucher disease are listed in Table 26-2 9/17/2018

Cytoplasmic changes of Monocyte/Macrophage A characteristic Gaucher cell is large with an eccentric nucleus and a cytoplasm that has been described as “chicken scratch” Many patients with Gaucher disease have a normal life span, but the clinical span is large from asymptomatic to severely incapacitated 9/17/2018

Gaucher Cell 9/17/2018

Niemann-Pick disease N-P disease is another type of storage cell disease caused by a deficiency of sphingomyelinase This deficiency allows sphingomyelin to accumulate in the spleen, liver, lungs, BM and sometimes the brain Cholesterol and other lipids accumulate as well along with a decrease in ceramides Inheritance is autosomal recessive. Genetic locus is C18 9/17/2018

Niemann-Pick disease N-P disease is described in 4 types with a broad range of symptoms Many of the patients eventually exhibit symptoms related to brain damage Presentation with difficulty of motor functions (swallowing, walking talking) is typical Progressive dementia and psychosis leading to a nonambulatory vegetative state may result 9/17/2018

Niemann-Pick disease The typical N-P Cell is large with an accentric nucleus and foamy cytoplasm The cytoplasm is filled with uniformly sized droplets of accumulated lipid The N-P cell is not unique to N-P disease, but may be seen in other lipid storage diseases There is no successful treatment 9/17/2018

Neimann-Pick Cell 9/17/2018

Other Storage Cell Diseases Other inherited storage cell diseases do not have significant hematologic implications These include gangliosidosis, Tay-Sachs disease and Fabry disease Acquired hyperlipidemias occur when a condition produces too much lipids for monocyte/macrophage cells to process May be primary disease (hypercholesterol-emia), or secondary (diabetes or chronic leukemia) 9/17/2018

Morphologic Alterations of Lymphocytes Morphologic variations in lymphocytes are not as frequent or as potentially debilitating as those seen I neutrophils Lymphocyte changes are most often directly related to antigenic stimulation and are considered “normal” Lymphocytes demonstrating these normal changes as a result of stimulation are termed reactive, stimulated or committed 9/17/2018

Reactive Lymphocytes Stimulated B cells undergo morphologic changes to both the nucleus and cytoplasm Once proliferation begins, the cells mature into plasma cells that synthesize and secrete large quantities of immunoglobulin whose binding specificity is the same as the one from the initially stimulated cell These changes progress and regress over time T cells also undergo “reactive” changes as a result of clonal expansion 9/17/2018

Reactive Lymphocytes Characteristics of reactive lymphocytes Vacuolated cytoplasm Radial basophilia Cytoplasm indented by adjacent cells Peripheral basophilia Large azurophilic granules Nucleoli may be present Chomatin appears finer and dispersed Cytoplasm may be deeply basophilic 9/17/2018

Reactive Lymphocytes Infectious mononucleosis is an example of a viral illness that exhibits reactive lymphocytes Infectious mononucleosis is caused by two strains of the Epstein Barr virus; EBV-1 (type A) and EBV-2 (type B) Childhood forms seem to be less severe that that seen in teenagers IM is also known as “kissing disease” as the virus is found in body fluids, especially saliva, and can directly transmitted through sharing of body fluids 9/17/2018

Reactive Lymphocytes 9/17/2018

Lymphocyte – Nuclear Abnormalities Nuclear abnormalities associated with lymphocytes will be discussed in chapter 36 and include clefting (Butt Cells) and Sezary Cells seen with Sezary syndrome. 9/17/2018

Lymphocyte – Cytoplasmic Abnormalities Vacuolization of the cytoplasm is seen in mucopolysaccharidoses, Gaucher disease and others. Azurophilic granulation can be seen in response to antigenic stimulation and in Hunter’s syndrome Increased amounts of non-staining materials may also be seen Box 26-3 summarizes morphologic alterations in lymphocytes 9/17/2018

Nonmorphologic Alterations of Lymphocytes Most of the nonmorphologic changes of lymphocytes are seen in diseases of immunologic function The alteration results from a lack of the specific cell type or from failure of a cell to act in a mature manner B cell alterations include hypogammaglobulin-emias, agammaglobulinemias and dysgamma-globulinemias (qualitative and quantitative) T cell alterations can be described by cell marker phenotypes 9/17/2018

Quantitative Alterations of Leukocytes Alterations of leukocyte numbers must be determined using the absolute leukocyte count Absolute counts may be provided by auto-mated equipment or may be calculated by multiplying the total WBC count by the percentage of the population on the differential 10.0 x 109/L (WBC) x 0.4 (% neutrophils) = 4.0 x 109/L neutrophils 9/17/2018

Quantitative Alterations of Leukocytes WBC count is dependent on several factors Age of the patient Ethnicity Granulocyte kinetics are influenced by Input from bone marrow pools Changes in proportion of marginating to circulating pools Changes caused by disease 9/17/2018

Quantitative Alterations of Leukocytes Spuriously elevated granulocyte counts may be seen when the marginating pool is decreased, increasing the circulating pool Decreased counts can occur when a large number of granulocytes are in the storage pool Causes of both leukocytosis and leukopenia are many and the causes for both may be the same 9/17/2018

Alterations in Granulocyte Number Neutrophilia Acute infections Hemorrhage/hemolysis Inflammatory changes Intoxications/poisons Medications Myeloproliferative disorders Malignancy Physiologic response to stress Neutropenia Acute infections Hemodialysis Overwhelming inflammation/infection Medications Physical agents (x-rays) Secondary to autoimmune disorders Aplastic/hypoplastic states 9/17/2018

Alterations in Eosinophil Number Eosinophilia is definced as >0.5 x 109 eosinophils per Liter Conditions associated with eosinophilia Allergic responses Medication usage Skin diseases, dermatitis Parasitic infestations Some autoimmune disorders Some malignancies Eos may be reduced in response to adrenocorticotropic hormone (ACTH) and emotional stress 9/17/2018

Alterations in Basophil Number Basophilia (>0.15 x 109/L) is seen in patients with hypoactive thyroid conditions, ulcerative colitis and some types of nephrosis as well as certain malignancies (CML) Increases in tissue basophils are seen in patients with contact dermatitis and delayed hypersensitivity reactions Basophil counts may be low in patients with hyperthyroidism and stress 9/17/2018

Alterations in Monocyte/Macrophage Number Monocytosis (> 0.8 x 109/L) is seen whenever there is an increased amount of cell damage Conditions causing monocytosis include active TB, subacute bacterial endocarditis, syphilis, parasitic and rickettsial infections, some autoimmune diseases and truama Monocytes are also increased during recovery from acute infections 9/17/2018

Alterations in Lymphocyte Number Normal lymphocyte range in adults is 34% of WBCs or 0.6 to 5.5 x 109/L The value is higher in children at 70% or 2.0-7.0 x 109/L Lymphocytosis is present in an adult when the absolute lymphocyte count is higher than 5.5 x 109/L 9/17/2018

Alterations in Lymphocyte Number Relative lymphocytosis can be seen in patients with skin rashes from viral diseases such as measles and mumps It is also seen in patients with thyrotoxicosis and those convalescing from acute infections Lymphocytosis is rare in children with the exception of pertussis infection 9/17/2018

Alterations in Lymphocyte Number Causes of Reactive Lymphocytosis Beta-streptococcus CMV Drugs EBV (IM) Syphilis Toxoplasmosis Vaccination Viral hepatitis 9/17/2018

Alterations in Lymphocyte Number Relative lymphopenia may be seen in patients with heart failure, uremia, SLE and malaria, among other causes Absolute lymphopenia (<0.6 x 109/L) may be seen in infectious hepatitis, secondary to malignancies, some Hodgkin lymphomas, active TB, SLE or endocrine disorders, also as a result of drug exposure It may also be seen in the elderly with bone marrow depletion 9/17/2018