1. Hematology 425 Qualitative Alterations of Leukocytes
Russ Morrison
November 27, 2006
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2. 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
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3. 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)
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4. 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
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5. 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”
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6. 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
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7. Pelger-Huet Anomaly
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8. 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)
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9. 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
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10. Hypersegmented Neutrophil
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11. 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
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13. 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
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14. 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
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15. C-H Syndrome, cytoplasmic inclusions
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16. 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
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17. May-Hegglin Anomaly
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18. 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
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19. 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
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20. Toxic Granulation
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21. 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
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22. Dohle Bodies
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23. 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
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24. 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
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25. 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
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26. Miscellaneous Deficiencies
Other manifestations of neutrophilic dysfunction
Congenital C3 deficiency
Disorders of neutrophilic movement
Myeloperoxidase deficiency
WHO cluster of poor leukocyte adherence syndromes
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27. 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
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28. 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
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29. 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
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30. 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
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31. 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
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32. Gaucher Cell
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33. 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
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34. 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
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35. 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
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36. Neimann-Pick Cell
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37. 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)
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38. 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
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39. 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
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40. 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
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41. 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
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42. Reactive Lymphocytes
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43. 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.
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44. 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
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45. 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
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46. 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
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47. 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
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48. 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
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49. 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
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50. 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
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51. 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
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52. 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
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53. 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 x 109/L
Lymphocytosis is present in an adult when the absolute lymphocyte count is higher than 5.5 x 109/L
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54. 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
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55. Alterations in Lymphocyte Number
Causes of Reactive Lymphocytosis
Beta-streptococcus
CMV
Drugs
EBV (IM)
Syphilis
Toxoplasmosis
Vaccination
Viral hepatitis
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56. 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
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