BY DR ABIODUN MARK AKANMODE. HEMATOPATHOLOGY.. BY DR ABIODUN MARK AKANMODE.

Identify the components of the PBS

BLOOD SMEAR. The red blood cells here are normal, happy RBC's. They have a zone of central pallor about 1/3 the size of the RBC. The RBC's demonstrate minimal variation in size (anisocytosis) and shape (poikilocytosis). A few small fuzzy blue platelets are seen. In the center of the field are aband neutrophil on the left and a segmented neutrophil on the right.

IDENTIFY THE CELLS ON THE PBS.

LYMPHOCYTE. A normal mature lymphocyte is seen on the left compared to a segmented PMN on the right. An RBC is seen to be about 2/3 the size of a normal lymphocyte.

IDENTIFY THE CELL?

MONOCYTE. Here is a monocyte. It is slightly larger than a lymphocyte and has a folded nucleus. Monocytes can migrate out of the bloodstream and become tissue macrophages under the influence of cytokines. Note the many small smudgy blue platelets between the RBC's.

IDENTIFY THE CELL?

EOSINOPHIL. In the center of the field is an eosinophil with a bilobed nucleus and numerous reddish granules in the cytoplasm. Just underneath it is a small lymphocyte. Eosinophils can increase with allergic reactions and with parasitic infestations.

IDENTIFY THE CELL.

BASOPHILS. There is a basophil in the center of the field which has a lobed nucleus (like PMN's) and numerous coarse, dark blue granules in the cytoplasm. They are infrequent in a normal peripheral blood smear, and their significance is uncertain. A band neutrophil is seen on the left, and a large, activated lymphocyte on the right.

IDENTIFY THE CELLS.

PMN. The RBC's in the background appear normal. The important finding here is the presence of many PMN's. An elevated WBC count with mainly neutrophils suggests inflammation or infection. A very high WBC count (>50,000) that is not a leukemia is known as a "leukemoid reaction". This reaction can be distinguished from malignant WBC's by the presence of large amounts of leukocyte alkaline phosphatase (LAP) in the normal neutrophils.

WHAT IS THE PATHOLOGY HERE?

ROLEUX FORMATION. The RBC's here have stacked together in long chains. This is known as "rouleaux formation" and it happens with increased serum proteins, particularly fibrinogen and globulins. Conditions which cause rouleaux formation include infections, multiple myeloma,  inflammatory and connective tissue disorders, and cancers.

WHAT IS THE PATHOLOGY HERE?

IRON DEFFICIENCY ANEMIA. The RBC's here are smaller than normal and have an increased zone of central pallor. This is indicative of a hypochromic (less hemoglobin in each RBC) microcytic (smaller size of each RBC) anemia. There is also increased anisocytosis (variation in size) and poikilocytosis (variation in shape).

WHAT IS THE PATHOLOGY HERE?

IRON DEFF ANEMIA. Here is data from a CBC in a person with iron deficiency anemia. Note the low hemoglobin (HGB). Microcytosis is indicated by the low MCV (mean corpuscular volume). Hypochromia correlates here with the low MCH (mean corpuscular hemoglobin).

What is the pathology here?

Bite cells & Heinz bodies. Heinz bodies are formed via the oxidation of iron from ferrous to ferric form leads to denatured hemoglobin precipitation and damage to RBC membrane . When this damaged RBC makes their way into the spleen & the splenic macrophages try to engulf them which are then seen as bite cells on a peripheral blood smear.

WHAT IS THE PATHOLOGY HERE?

MEGALOBLASTIC ANEMIA (B12 DEFF) Here is a hypersegmented neutrophil that is present with megaloblastic anemias. There are 8 lobes instead of the usual 3 or 4. Such anemias can be due to folate or to B12 deficiency. The size of the RBC's is also increased (macrocytosis, which is hard to appreciate in a blood smear).

WHAT IS THE PATHOLOGY HERE?

MEGALOBLASTIC ANEMIA. The CBC here shows a markedly increased MCV, typical for megaloblastic anemia. The MCV can be mildly increased in persons recovering from blood loss or hemolytic anemia, because the newly released RBC's, the reticulocytes, are increased in size over normal RBC's, which decrease in size slightly with aging.

IDENTIFY THE CELLS?

SHISTOCYTES. There are numerous fragmented RBC's seen here. Some of the irregular shapes appear as "helmet" cells. Such fragmented RBC's are known as "schistocytes" and they are indicative of a microangiopathic hemolytic anemia (MAHA) or other cause for intravascular hemolysis. This finding is typical for disseminated intravascular coagulopathy (DIC).

WHAT IS GOING ON HERE?

SPHEROCYTES. The size of many of these RBC's is quite small, with lack of the central zone of pallor. These RBC's are spherocytes. In hereditary spherocytosis, there is a lack of spectrin, a key RBC cytoskeletal membrane protein. This produces membrane instability that forces the cell to the smallest volume--a sphere. In the laboratory, this is shown by increased osmotic fragility. The spherocytes do not survive as long as normal RBC's.

WHAT IS THE PATHOLOGY HERE?

BASOPHILLIC STIPLING. The nucleated RBC in the center contains basophilic stippling of the cytoplasm. This suggests a toxic injury to the bone marrow, such as with lead poisoning.

WHAT IS THE PATHOLOGY HERE?

ATYPICAL LYMPHOCYTES. The WBC's seen here are "atypical" lymphocytes. They are atypical because they are larger (more cytoplasm) and have nucleoli in their nuclei. The cytoplasm tends to be indented by surrounding RBC's. Such atypical lymphocytes are often associated with infectious mononucleosis.

WHAT IS THE PATHOLOGY HERE?

PELGER-HUET ANOMALY. If most of the neutrophils appear bilobed, this is indicative of an uncommon condition known as Pelger-Huet anomaly, an inherited condition. This is the heterozygous form. The homozygous form is fatal. Just be aware of this condition when you get back a manual differential count with mostly bands, but the WBC count is normal or the patient shows no signs of infection or inflammation.

WHAT IS THE PATHOLOGY HERE?

SICKLE CELL ANEMIA. Example of sickled erythrocytes in a patient with Hgb SS who presented with severe abdominal pain in sickle crisis. The sickled cells are prone to stick together, plugging smaller vessels and leading to decreased blood flow with ischemia.

IDENTIFY THE CELLS HERE?

TARGET CELLS. This patient has hemoglobin SC disease, with hemoglobin S and hemoglobin C both present. With SC disease, the RBC's may sickle, but not as commonly as with Hemoglobin SS disease. The hemoglobin C leads to the formation of "target" cells--RBC's that have a central reddish dot.

WHAT IS THE PATHOLOGY HERE?

ALL (ACUTE LYMPHOBLASTIC LEUKAMIA) The WBC's seen here are lymphocytes, but they are blasts--very immature cells with larger nuclei that contain nucleoli. Such lymphocytes are indicative of acute lymphocytic leukemia (ALL). ALL is more common in children than adults. Many cases of ALL in children respond well to treatment, and many are curable.

WHAT IS THE PATHOLOGY HERE?

CHRONIC LYMPHOBLASTIC LEUKAMIA(CLL) These mature lymphocytes are increased markedly in number. They are indicative of chronic lymphocytic leukemia, a disease most often seen in older adults. This disease responds poorly to treatment, but it is indolent.

SMUDGE CELLS IN CLL.

WHAT IS THE PATHOLOGY HERE?

Auer rods in AML

AML Here are very large, immature myeloblasts with many nucleoli. A distincitve feature of these blasts is a linear red "Auer rod" composed of crystallized granules. These findings are typical for acute myelogenous leukemia (AML) that is most prevalent in young adults.

WHAT IS THE PATHOLOGY HERE?

CML. This condition is one of the myeloproliferative states and is known as chronic myelogenous leukemia (CML) that is most prevalent in middle-aged adults. A useful test to help distinguish this disease is the leukocyte alkaline phosphatase (LAP) score, which should be low with CML and high with a leukemoid reaction.

What is the pathology here?

HAIRY CELL LEUKEMIA Hairy cell leukemia is an uncommon hematological malignancy characterized by an accumulation of abnormal B lymphocytes. Hairy cells are abnormal white blood cells with hair-like projections of cytoplasm; they can be seen by examining a blood smear or bone marrow biopsy specimen. The blood film examination is done by staining the blood cells with Wright's stain and looking at them under a microscope. Hairy cells are visible in this test in about 85% of cases.

IDENTIFY THE CELL HERE?

Reed-Sternberg cells. Note the large cells with large, pale nuclei containing large purple nucleoli at the arrowheads. These are Reed-Sternberg cells that are indicative of Hodgkin's disease. There are four main subtypes of classic Hodgkin lymphoma with CD15+ Reed-Sternberg cells and variants: lymphocyte rich, nodular sclerosis, mixed cellularity, and lymphocyte depletion.

Muchas gracias ..Al Final.