White Blood Cells (WBC) Normal and Abnormal Dr. Alia ALFARAEDI Consultant Haematologist

This normal peripheral smear demonstrates a segmented neutrophil and a band neutrophil.

This normal peripheral smear demonstrates a segmented neutrophil and a lymphocyte.

This normal peripheral smear demonstrates a monocyte.

This normal peripheral smear demonstrates an eosinophil and a lymphocyte.

Normal WBCs

Functions of White Blood Cells Phagocytosis The neutrophils and the monocytes engulf foreign particles and bacteria through their phagocytic action, thereby destroying their action. Body defense WBC manufactures anti-bodies and immune bodies to increase the power of resistance against any infection. Formation of fibroblast Lymphocytes may be converted to fibroblasts in the area of inflammation and help the process of tissue repair and regeneration.

Functions of White Blood Cells Secretion of heparin The basophile leucocytes are supposed to secrete heparin (a substance of liver), which prevent, intravascular clotting. Anti histamine functions The eosinophils are believed to defend the body against allergic conditions in which histamine like bodies are produced in excess. Destroy Cancer Cells In addition to recognizing and killing virally infected cells, T lymphocytes can also target and kill tumor cells or abnormal cells that may represent the early beginnings of a tumor.

Functions of White Blood Cells Production of thromboplastic substances Due to the production of such substances, the process of coagulation and the deposit of clot are facilitated. Manufacture of trephones: Leucocytes manufacture certain substances called trephones from plasma protein, which exert great influence on the nutrition, growth and repair of tissues.

WBCs ABNORMALITIES Benign Leukemia Lymphoma Immunosecretory Disorders Quantitative Leukocytosis Leukopenia Qualitative Abnormalities Leukemia Laboratory Evaluation Morphology Cytochemistry Genetic analyses chromosomal molecular Immunology Acute Myeloid Leukemia Lymphoid Leukemia Chronic Myeloproliferative Disorders Myelodysplastic Syndromes Lymphoma Immunosecretory Disorders Myeloma Other Plasma Cell Disorders

Neutrophilia Causes Acute infections: Physical stimuli: Bacterial, viral, fungal, mycobacterial and rickettsial Physical stimuli: Trauma, electric shock, anoxia, pregnancy Drugs and chemicals: Corticosteroids adrenaline, lead, mercury poisoning, lithium Hematological causes: Acute haemorrhage, acute haemolysis, transfusion reactions, post-splenectomy, leukaemia and myeloproliferative disorders. Malignant disease: Carcinoma, especially of gastro-intestinal tract, liver or bone marrow Miscellaneous conditions: Certain dermatoses, hepatic necrosis, chronic idiopathic leucocytosis

Lymphocytosis Non-Malignant causes Virus infections: Infectious mononucleosis Infectious lymphocytosis Cytomegalovirus infection Occasionally mumps, varicella, hepatitis, rubella, influenza Bacterial Infections: Pertussis Occasionally cat-scratch fever, tuberculosis, syphilis, brucellosis Protozoal infections: Toxoplasmosis Occasionally malaria Other rare causes: Hyperthyroidism, congenital adrenal hyperplasia

Monocytosis Causes Chronic bacterial infections: Tuberculosis, subacute bacterial endocarditis, brucellosis Other Specific Infections: Malaria, Kala-azar, trypanosomiasis, typhus, Rocky Mountain spotted fever Malignant diseases: Hodgkin’s disease, carcinoma Leukaemia: Acute myeloid leukaemia Chronic monocytic leukaemia Neutropenias: Familial benign and severe neutropenia Cyclical neutropenia Drug-induced Agranulocytosis Miscellaneous: Cirrhosis, systemic lupus erythematosus, rheumatoid arthritis

Eosinophilia Causes Allergic reactions: Parasitic Infestation: Asthma, hay fever, urticaria, angioneurotic oedema Parasitic Infestation: Tissue parasites – trichinosis, filariasis, visceral larva migrans, etc.. Intestinal parasites – Ascaris, Taenia, etc. (less regularly) Skin disorders: Pemphigus, pemphigoid, eczema, psoriasis, (dermatitis herpetiformis) Drug hypersensitivity reactions:: Especially iodides, penicillin, allopurinol, gold salts, tartrazine Loffler’s pulmonary syndrome and Loffler’s endomyocarditis Tropical eosinophilia (probably filarial)

Eosinophilia Causes (Cont…) Malignant diseases: Especially Hodgkin’s disease, carcinoma of ovary, lung stomach, angioimmunoblastic lymphadenopathy. Following irradiation or splenectomy: Hypereosinophilic syndromes Eosinophilic leukaemia Miscellaneous Conditions: Polyarteritis nodosa, ulcerative colitis, sardoidosis, scarlet fever, pernicious anaemia, chronic active hepatitis, eosinophilic granuloma, familial eosinophilia

Leukaemoid Reaction or Leucoerythroblastic Anaemia Causes Severe infections, especially in children: a. Pneumonia, septicaemia, meningococcal meningitis b. Infectious mononucleosis, pertussis Intoxications: Eclampsia, severe burns, mercury poisoning Neoplasia: Especially with bone-marrow infiltration Severe haemorrhage or haemolysis

Neutropenia Causes Drugs: Infections: Megaloblastic anaemia: Selective neutropenia Agranulocytosis (Aplastic anaemia) Infections: Viral – including hepatitis, influenza, rubella Bacterial – typhoid fever, brucellosis, miliary tuberculosis Rickettsial and protozoal infections (Sometimes) Megaloblastic anaemia: Vitamin B12 or folate deficiency Chronic neutropenia: Chronic idiopathic neutropenia Immune neutropenia Congenital neutropenias Cyclical neutropenia --------------------------------------------------------------------------------------------------------------------------------------------------------------

Neutropenia Causes (cont…) Hypersplenism: Primary In association with cirrhosis, Felty’s syndrome, etc… Ionizing radiation and cytotoxic drugs: Radiotherapy Alkylating agents, antimetabolites, others Malignant disease: Acute leukaemia Leuco-erythroblastic anaemia due to metastatic carcinoma, multiple myeloma or lymphoma Micscellaneous conditions: Systemic lupus erythematosus, myxoedema, hypopituitrism, iron deficiency, anaphylactic shock

Lymphopenia Causes Loss: Maturation: Pharmacological agents: Mostly from gut as in intestinal lymphangiectasia, Whipple’s disease and rarely Crohn’s disease Thoracic-duct fistula Maturation: Primary, or secondary to gut disease Vit B12 or folate deficiency Zinc deficiency Pharmacological agents: Antilymphocyte globulin Corticosteroids Cytotoxic drugs

Lymphopenia Causes (Cont…) Infections: Severe septicaemias Influenza, occasionally other virus infections Colorado tick fever Miliary tuberculosis Other miscellaneous conditions: Collagen vascular diseases, especially SLE Malignant disease Other conditions with lymhocytotoxins Radiotherapy Graft-versus-host disease

Leukocyte Morphological Abnormalities Congenital and Aquired

Leucocytes Congenital Abnormalities Alder Reily Anomaly May-Hegglin Anomaly Alder Reily Anomaly Pelger Huet Anomaly Chediac Higashi Anomaly

Leucocytes Congenital Abnormalities Pelger Huet Anomaly (MPO) (MPO) (MPO) Myeloperoxidase (MPO) Deficeincy

Leukocyte Abnormalities Dohle Body Cytoplasmic Vaculation Toxic Granulation Hypersegmented Neut.

Case Studies

CASE 1 History: This 20 year old male came to the emergency room with severe abdominal pain in the right lower quadrant. He had a fever of 39 0C. On examination, he had a rigid abdomen & rebound tenderness in the right lower quadrant. There were no other abnormalities.

CASE 1

CASE 1 Urinalysis was within normal limits. A CBC showed Hgb 140 g/l, WBC 25 X 109/L, and platelet count 350 X 109/L.

What are the WBCs predominantly seen? CASE 1 What are the WBCs predominantly seen? Mainly neutrophils Notice that the WBC count is higher than in a normal smear. In addition a small but increased number of band forms are seen. The platelets are moderately increased in number.

What is the name for this type of leukocyte reaction? CASE 1 What is the name for this type of leukocyte reaction? This reaction is known as neutrophilia.

What do you think the diagnosis is? CASE 1 What do you think the diagnosis is? The diagnosis is acute appendicitis (most, but not all, cases of acute appendicitis are associated with neutrophilia).

CASE 2 History: This 17 year old female was sent home from summer camp because of weakness, lassitude, and sore throat. On examination she was found to have an inflamed pharynx, enlarged tonsils, several enlarged and slightly tender lymph nodes in the neck, a palpable spleen, and a tender palpable liver edge.

CASE 2

CASE 2 CBC showed Hgb 149 g/l, WBC 12.5 X 109/L, and platelet count 282 X 109/L

What are the WBCs predominantly seen? CASE 2 What are the WBCs predominantly seen? The predominant cells are lymphocytes with many atypical lymphocytes.

CASE 2 What is your diagnosis in this case? infectious mononucleosis.

What is the differential diagnosis? CASE 2 What is the differential diagnosis? - Other viral infections including hepatitis and cytomegalovirus. - It should not be confused with leukemia.

CASE 2 What other laboratory test that may be helpful in arriving at a specific diagnosis? serologic test for infectious mononucleosis like Paul-Bunnell test would confirm the diagnosis in most cases.

CASE 3 History: This 40 year old male complains of progressive weakness for a month. On examination, few small lymph nodes were palpable in both axillae with tip spleen and sternal tenderness detected.

CASE 3

CASE 3 CBC showed Hgb 102 g/l, WBC 67 X 109/L, and platelet count 36 X 109/L

What are the WBCs predominantly seen? CASE 3 What are the WBCs predominantly seen? The WBC's in this smear are myeloblasts. Platelets are reduced in number with some large forms are seen.

Auer rod CASE 3 The diagnostic marker is What do you think the name of the intracytoplasmic marker which is seen and diagnostic in this case? The diagnostic marker is Auer rod

Acute myeloblastic leukemia (AML). CASE 3 What is your diagnosis? Acute myeloblastic leukemia (AML). Most patients with acute leukemia have a markedly decreased platelet count. Myeloblasts will be positive for peroxidase or Sudan black stain which is characteristic of granulocytic series.

M0 M1 M2 M3 M4 M5a M5b M6 M7 Acute Myelogenous Leukemia

CASE 4 History: This 70 year old male was in good health except for mild hypertension., A CBC showed at his last check-up a very high WBC count and his examination revealed several slightly enlarged lymph nodes in the neck and the axillae with a palpable spleen.

CASE 4

CASE 4 CBC showed Hgb 128 g/dl, WBC 130 X 109/L, and platelet count 330 X 109/L

CASE 4 What are the WBCs predominantly seen? Those are small to medium-sized lymphocytes with smudged lymphocytes. In addition, fewer number of prolymphocytes is seen. What is the differential diagnosis? The only real diagnostic consideration in this case is chronic lymphocytic leukemia (CLL).

CASE 5 History: This 46 year old male presented with increasing fatigue and discomfort in the left upper quadrant. His examination revealed a moderately enlarged spleen, liver edge and few slightly enlarged cervical lymph nodes.

CASE 5

CASE 5

CASE 5 CBC shows Hgb 132 g/l, WBC 56 X 109/L, and platelet count 754X 109/L

CASE 5 What are the types of white blood cells seen? The WBCs show a wide range of granulocytes at various stages of maturation (rare blasts and promyelocytes, myelocytes, metamyelocytes, bands and neutrophils). There is an increase in eosinophils and basophils. Platelets are moderately increased in number with some large forms seen.

What is the differential diagnosis and how could it be resolved? CASE 5 What is the differential diagnosis and how could it be resolved? - The differential diagnosis is leukaemoid reaction versus chronic granulocytic leukemia. - The increase in eosinophils and basophils suggests leukemia. - A neutrophil alkaline phosphatase (NAP) score would also be of help (high with leukaemoid reaction, low with chronic myelogenous leukaemia). - A positive Philadelphia chromosome and BCR-ABLE gene mutaton would confirm the diagnosis of CML.

CASE 5 What is your diagnosis in this case? The diagnosis is chronic granulocytic (myelogenous) leukaemia (CML).

CASE 6 History: A 5 year old boy presented with high fever for the last few days and easy fatigability for four weeks. His mother complained that he gets big bruises after any minor hits.

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CASE 6 CBC shows Hgb 98 g/l, Hct 28.2, MCV 95, platelet count 64x109/l and WBC count 2.1x109/l. Differential WBC count: 25% segs, 13% bands, 11% monos, 46% lymphs, 4% eos, and 1% baso. Bone marrow examination showed replacement by blast cells which have high nuclear / cytoplasmic ratio with fine chromatin and indistinct nucleoli. Those blasts showed no Auer rods and were positive for CD10 (CALLA) antigen.

CASE 6 Acute Lymphocytic Leukemia What are the WBCs predominantly seen? They are predominantly lymphoblasts. 2. What is the most likely diagnosis? The most likely diagnosis is acute lymphocytic leukemia (ALL).

M0 M1 M2 M3 M4 M5a M5b M6 M7 Acute Myelogenous Leukemia

Acute Lymphoblastic Leukaemia Laboratory Diagnosis - FAB Classification ALL (L1) ALL (L2) ALL (L3)

MULTIPLE MYELOMA Mott Cell