1. Normal Red Blood Cells - Peripheral Blood Smear

2. Peripheral Blood Cells
A. Erythrocytes; B. Large Granular Lymphocyte; C. Neutrophil; D. Eosinophil;
E. Neutrophil; F. Monocyte; G. Platelets; H. Lymphocyte; I. Band Neutrophil; J. Basophil

3. The red blood cells here are normal, happy RBC's
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).

4. Hypochromic Microcytic Anemia (iron deficiency)

5. 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).

6. Koilonychia - Iron Deficiency

7. Macroovalocytes and Hypersegmented Neutrophil

8. 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

9. Bone marrow -- Megaloblastic anemia -- nuclear/cytoplasmic asynchrony,

10. Markedly hypocellular BM - Aplastic Anemia

11. Breast cancer replacing BM

12. Spherocytes
Lab: moderate anemia, spherocytes, reticulocytes
BM - erythroid hyperplasia
Coomb’s test - negative

13. Hemoglobin Precipitates -- Heinz bodies G6PD Deficiency

14. Bite Cell -- G6PD Deficiency
Clinical?
X linked, African American Males, only symptomatic during oxidative stress (meds, fava beans)

15. Sickle Cells -- Clinical stuff:
microvascular occulusions lead to tissue infarcts and pain, autosplenectomy (so no splenomegaly), increased Salmonella osteomyelitis, some aplastic crises (Parvovirus)

16. Sickle cell anemia in sickle cell crisis
Sickle cell anemia in sickle cell crisis. The abnormal hemoglobin SS is crystalizes when oxygen tension is low, and the RBC's change shape to long, thin sickles that sludge in capillaries, further decreasing blood flow and oxygen tension. Persons with sickle cell trait (Hemoglobin AS) are much less likely to have this happen.

17. Mechanical trauma -- schistocytes

18. Malaria in RBCs -- most common hemolytic anemia
Cyclical hemolysis produces fever and chills, splenomegaly

19. Activated neutrophil - Dohle body

20. Leukemoid reaction (toxic granulation)

21. Reactive Lymphocyte - Infectious Mononucleosis

22. Normal bone marrow. Note the presence of megakaryocytes, erythroid islands, and granulocytic precursors. This marrow is taken from the posterior iliac crest in a middle aged person, so it is about 50% cellular, with steatocytes mixed with the marrow elements.

23. Bone Marrow, Acute Leukemia Age distributions?
ALL -- kids (4 yrs peak incidence)
AML -- Adults

24. Bone marrow acute leukemia Symptoms?
Fatigue (Anemia), Bleeding (thrombocytopenia), Bone pain, infections, masses, CNS symptoms

25. Lympoblasts -- ALL
Diagnostic criteria?
30+% lymphoblasts in BM, Tdt+, MPO-

26. AML -- myeloblasts with Auer Rod, worse prognosis than ALL, allogenic Bone Marrow Transplant curative

27. Myeloblasts -- myeloperoxidase positive

28. Acute Promyelocytic Leukemia (FAB - M3)
Hypergranular promyelocytes, more Auer rods, DIC from tissue thromboplastin, tx w/retinoic acid

29. Monoblasts -- Acute Myelogenous Leukemia (M5), nonspecific esterase

30. Non-specific esterase + monoblasts (left) negative control (right)

31. Chronic Myeloid Leukemia Features?
WBC>50,000 with 80% immature, Philadelphia chromosome

32. Chronic Myeloid Leukemia bone marrow
Clinical Course?
Slow progressive and then blast phase (80%)

33. Essential Thrombocythemia - Bone marrow with greatly
increased numbers of megakaryocytes

34. Myeloid metaplasia with myelofibrosis - Bone marrow fibrosis

35. Reactive lymphadenitis - Follicular hyperplasia

36. Reactive lymphadenitis - Sinus histiocytosis

37. Necrotizing lymphadenitis - high power

38. Cat Scratch Disease - Bartonella henselae bacteria

39. Reactive lymphocytes - Infectious Mononucleosis -- Tcells proliferate, but B cells are infected

40. Follicular lymphoma - lots of follicles, B cells, common in Europe and America, adults 40+yoa

41. Follicular lymphoma, usually diagnosed at a high stage, when bone marrow is involved, angular cells = cleaved cells

42. Mycosis fungoides - Sezary Syndrome, T cell lymphoma
Early skin lesions (left); Skin plaques (right)

43. Sezary cells in blood (right); Pautrier abcess in skin (left)
Mycosis Fungoides -
Sezary cells in blood (right);
Pautrier abcess in skin (left)

44. Mycosis fungoides - Sezary cells

45. Burkitt’s Lymphoma -- starry sky pattern due to macros
Endemic type in Tropical Africa

46. Burkitt’s Lymphoma -- B cells, EBV associated, myc translocated t(8;14)

48. Hodgkins’ Disease -- cervical and mediastinal lymphadenopathy, spreads sequentially along lymph node chain, adolescents and older adults

49. Hodgkin’s disease -- Nodular Sclerosis type, most common subtype, dense band s of collagen/fibrosis, few Reed-Sternberg cells, young adult females

50. Reed-Sternberg cell -- owl eyes -- Hodgkin’s Disease

51. Chronic Lymphocytic Leukemia - little cytoplasm

52. These mature lymphocytes are increased markedly in number
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.

53. CLL smudge cell

54. CLL bone marrow

55. Hairy cell leukemia -- single light chain expressed, (CD19 or CD20), TRAP positive, splenomegaly, pancytopenia, usually older males

56. Electronmicrographs of a Hairy Cell
transmission EM (left); scanning EM (right)

57. Stained gel image Albumin Tracing of serum protein electrophoresis -
Multiple Myeloma
Stained gel
image
Albumin
Tracing of
serum protein
electrophoresis -
abnormal
M spike  2 1 

58. Multiple Myeloma -- Rouleaux

59. Plasma cell myeloma, right is normal , left filled with plasma cells

60. Plasma cell myeloma, large cytoplasm, IL-6 mediated effects,
Symptoms?
Bone pain, pathologic fractures, hypercalcemia, anemia, amyloidosis

61. Plasma cell myeloma - lytic lesions in the skull

62. Plasmacytoma -- solid tumor of plasma cells, osseous usually vertebral, soft tissue usually upper respiratory tract