Hematology: Presented by Alyazeed Hussein, BSC
Hematology: Presented by Alyazeed Hussein, BSC
Hematology: Presented by Alyazeed Hussein, BSC
Presented by
Alyazeed hussein, BSc
Tubes and anticoagulants
EDTA (Ethylene Diamine Tetra-Acetate)
Mechanism: forming Ca salts to remove Ca.
Uses: CBC, PCR, blood films and HbA1c.
Sodium citrate:
Anticoagulant: 3.2%
Mechanism: Calcium chelation.
Use: Coagulation studies and platelet function.
Black:
3.8% of sodium citrate
Action: Remove calcium.
Uses: Erythrocyte Sedimentation Rate (ESR).
Heparin:
Sodium Heparin or Lithium Heparin
Mechanism: inactivation of thrombin and
thromboplastin.
Uses: Use for osmatic fragility test and blood gases
Hemolyzed, clotted and lipemic sample!!!!
:Red blood cells and RBCs indices
• Morphology characteristics:
• Cell size: 7-8 µm.
• No nucleus.
• Cytoplasm: pink to salmon to
light red.
• Zone of central pallor is one-
third of cell diameter.
• Reference values:
• Adult male: 4.7-6.1 million/µL.
• Adult female: 4.2-5.4
million/µL.
• Newborn: 4.4-5.8 million/µL.
• Hemoglobin, M: 14-17 g/dL, F: 12.5-15g/dL.
• Hematocrit (HCT) is the volume of whole blood occupied by packed RBCs.
RBC Indices
• MCV (mean corpuscular volume): Reference range is 80-100 femtoliters (fL), and it is an
indicator of the average cell (RBCs).
a. Increased in megaloblastic anemia, hemolytic anemia with reticulocytosis, liver
.disease, and normal newborn
b. Decreased in iron deficiency anemia, thalassemia, sideroblastic anemia, and lead
.poisoning
• MCH (mean corpuscular hemoglobin): Reference range is 26-34 picograms (pg), and it
is an indicator of the average weight of hemoglobin in individual RBCs.
.a. Increased in macrocytic anemia
.b. Decreased in microcytic, hypochromic anemia
• MCHC (mean corpuscular hemoglobin concentration): Reference range is 32-37 g/dL,
and it is a measure of the average concentration of hemoglobin in grams per deciliter.
.a. 32-37 g/dL MCHC indicates normochromic RBCs
b. Lesser than ( <) 32 g/dL MCHC indicates hypochromic RBCs, which is seen in iron
.deficiency and thalassemia
c. Greater than(>) 37 g/dL MCHC indicates a possible error in RBC or hemoglobin
.measurement, or the presence of spherocytes
• RDW (RBC distribution width): Reference range is 11.5-14.5 %,
.a. Increased proportional to the degree of anisocytosis (variation in size)
b. High RDW: Post-treatment (e.g., Iron, B 12, or folic acid therapy), in the presence of two
.concurrent deficiencies (iron and folic acid deficiencies)
Normal MCV Low MCV shift left High MCV shift right
White blood cells:
Supravital stain
ESR: Erythrocyte Sedimentation Rate
False decreased ESR False increased ESR
Air bubbles in the tube Tube tilted (not vertical position)
Vibration of tube during test Time
RT <20 C RT >25 C
Clotted sample
Hemoglobinopathies
Structure of Hemoglobin
• Hemoglobin molecule is tetramer
consisting of two pairs of similar Newborn reference Adult reference Hb type
polypeptide chains called globin chains.
• To each of the four chains is attached 10-40% 95%> Hb A
heme which is a complex of iron in
ferrous from and protoporphyrin.
• The major (96%) type of hemoglobin
60-90% 0-2% Hb F
present in adults is called HbA it has
2 alpha globin chains and 2 beta globin 0-3.5% Hb A2
chains (α2β2).
In 7 months the HbF switch to HbA.
Sickle cell anemia
Hb S disease: formed when a valine is substituted for a glutamic acid at the 6th
position in the beta chain,(low O2 > insolubility of Hb S > polymerization)
Sickle anemia: 25%
:Lab diagnosis
• Normocytic/normochromic RBCs, sickle
cells.
• Sickle solubility test: positive (depend on
the Hb S solubility and concentration).
Hb-electrophoresis:Hb S: 90-100%.
• Sickle solubility test and sickling test:
blood mixed with a reducing solution
(sodium metabisulfute), if there is HbS it
will precipitate and form a turbidity.
• Hb-electrophoresis: Hb S 90-100%.
• Hb-F vs Hb-S!!
Favism
G6PD - Pathophysiology
• G-6-PD enzyme reduces NADP to NADPH producing
sufficient reduced Glutathione (GSSH). Reduced
glutathione protects the RBC from oxidative injury.
• Heinz bodies – denatured hemoglobin that precipitates
out.
• Bite cells-RBC’s with a piece cut out (where Heinz
bodies were located) abnormal cells, gets trapped in
the spleen and destroyed.
• Normocytic, normochromic anemia.
Beta & Alpha thalassemia
• Beta thalassemia:
The gene of beta globin protein is missing, resulting excess alpha globin in RBCs.
• Alpha thalassemia:
Alpha globin protein is missing > excess beta globin.
zidovudine)
Red blood cell morphology
Anisochromia
stomatocyte spherocytes
Rouleaux formation in
MM
Microfilaria
Trypomastigotes (trypanosomes) Leishmaniasis (Amastigotes)
inside macrophage
Babesia
Ring stages in thick film Ring stages in thin film
White blood cells
(Morphology)
Leukopoiesis
metamyelocytes
Band cells
Mature monocytes
Lymphoblasts
prolymphocytes
Plasma cell
Reactive lymphocyte
Blood smear under microscope
Allergy and
leukemia
Chronic
infection: TB
Bacterial
infection viral
1. May-Hegglin anomaly.
2. Chediak-Higashi syndrome.
3. Alder-Reilly anomaly.
4. Pelger-Huet anomaly.
May-Hegglin anomaly, congenital defect:
• Autosomal dominant Mutation in MYH9 gene in chromosome 22,
a cytoskeletal protein in platelets that may be responsible for the
platelets abnormal diameter.
• Thrombocytopenia.
• Purpura and bleeding.
• Giant platelets.
• Large basophilic cytoplasmic (granulocyte) inclusion body called
Dohle body.
Chediak-Higashi syndrome:
• Rare autosomal recessive.
• Recurrent bacterial infection (defective chemotaxis) impaired
motility, defect in granulocyte degranulation.
• Oculocutaneous albinism.
• Giant lysosomal granules in granulocyte, monocyte, lymphocyte,
melanocyte, tissue macrophage and platelets.
• Moderate Neutropenia and thrombocytopenia.
Alder-Reilly anomaly:
• Autosomal recessive disorder of mucopolysaccharidosis.
• Dark staining coarse cytoplasmic granules in neutrophils,
eosinophils, basophils, monocytes and lymphocytes.
• Precipitation of mucopolysaccharides (Hunter and Hurler
syndromes).
Pelger-Huet anomaly:
• Autosomal dominant disorder of neutrophil morphology,
bilobed nucleus or a nucleus with no lobulation.
• 70-90% of the neutrophils are bilobed (sun glasses) or
have no lobulation of the nucleus.
Hypersegmented neutrophil:
• May hereditary autosomal dominant or acquired which
seen in anemia such as megaloblastic anemia.
• Neutrophil with six or more nuclear lobes.
Platelets and
morphology
• 8-20 PLT/OIF: adequate.
• 150,000-450,000: adequate,
• > 450,000: increased,
• >150,000: decreased.
Pseudo-Thrombocytopenia
Platelet clumps seen in EDTA anti- No platelet clumps seen and platelet count
coagulated blood sample in a patient normal in the blood sample from the same
with EDTA Dependent platelet patient anti-coagulated with sodium citrate
agglutinins.
Giant platelet
Bizarre platelet
Leukemia
55 – 60 years Acute myelogenous leukemia(AML)
“ Reed-Sternberg cell’’
Leukoerythroblastic reaction
Immature WBCs + immature RBCs
• Chronic myeloid leukemia (CML) is an acquired clonal
myeloproliferative neoplasm of the pluripotent hematopoietic stem
cell.
• It is characterized by anemia, extreme leukocytosis, granulocytic
immaturity, basophilia, thrombocytosis and splenomegaly.
• LAP (NAP) score is markedly reduced vs leukemoid reaction.
• It is distinguished from other chronic myeloproliferative neoplasm by
the presence of Philadelphia chromosome in more than 90% of cases.
• Philadelphia chromosome result from a translocation between long
arm of chromosome 9 and chromosome 22 t (9; 22). The resulting
BCR-ABL1 fusion gene is responsible for autophosphorylation and
constitutive tyrosine kinase activity (p210BCR/ABL). The net
outcome is neoplastic cell proliferation of mainly myeloid precursors
and inhibition of apoptosis.
JAK2 (Janus kinase) oncogene
• JAK2(V617F) mutation.
• Polycythemia vera (PV).
• High RBCs (major).
• Hb > 20 g/dL.
• High WBCs and PLTs.
• chronic idiopathic myelofibrosis.
• Essential thrombocythemia.
Flow cytometry
(TdT)