leucocytes csbrp

Disorders of LeucocytesDisorders of Leucocytes

Dr.CSBR.Prasad, M.D.

In the center of the field are a band neutrophil on the left and a segmented neutrophil on the right. 2CSBRP-Sep-2011

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. 3CSBRP-Sep-2011

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

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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. 5

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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.

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• Name different types of T-cells

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• Name some cells without nucleus

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• What are stab cells?

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• What is a plasma cell?

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This hypersegmented neutrophil is present along with macro-ovalocytes in a case of pernicious anemia. Compare the size of the RBC's to the lymphocyte at the lower left center.

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Lymphocyte (blue circle), spherocytes and polychromatic cells (Red circle). 12CSBRP-Sep-2011

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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.

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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). 15CSBRP-Sep-2011

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).

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The nucleated RBC in the center contains basophilic stippling of the cytoplasm. This suggests a toxic injury to the bone marrow. Such stippling may also appear with severe megaloblastic anemia.

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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.

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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. 19CSBRP-Sep-2011

Here is another view of a peripheral blood smear in a patient with CML. Often, the numbers of basophils and eosinophils, as well as bands and more immature myeloid cells (metamyelocytes and myelocytes) are increased. Unlike AML, there are not many blasts with CML.

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Here is a smear of bone marrow aspirate from a patient with multiple myeloma. Note that there are numerous well-differentiated plasma cells with eccentric nuclei and a perinuclear halo of clearer cytoplasm. There is also an abnormal plasma cell with a double nucleus.

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This is a normal plasma cell as seen in a bone marrow smear at high magnification. Note the eccentric nucleus as well as the perinuclear halo containing the Golgi apparatus. The remaining cytoplasm containing abundant rough endoplasmic reticulum is dark blue.

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A history of recurrent bacterial infections and giant granules seen in peripheral blood leukocytes is characteristic for Chediak-Higashi syndrome. This disorder results from a mutation in the LYST gene on chromosome 1q42 that encodes a protein involved in intracecellular trafficking of proteins. Microtubules fail to form properly, and the neutrophils do not respond to chemotactic stimuli. Giant lysosomal granules fail to function. Soft tissue abscesses with Staphylococcus aureus are common. Other cells affected by this disorder include platelets (bleeding), melanocytes (albinism), Schwann cells (neuropathy), NK and cytotoxic T cells (aggressive lymphoproliferative disorder).

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White Cell Differential Count

• Manual methods• Automated methods

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An example of a CBC with automated WBC differential count is shown above. The absolute numbers for total WBC count and each type of leukocyte are in thousands per cubic millimeter (or alternatively, per microliter). 25CSBRP-Sep-2011

Absolute counts

The absolute white blood cell counts are most useful, and are calculated by multiplying the % of each cell type counted by the total WBC count. Simple percentages may be misleading, since an apparent percentage increase in one constituent may actually be due to a significant and absolute decrease of another type of WBC. For example, 99% lymphs with an absolute WBC count of 1300/microliter means neutropenia, not lymphocytosis. Always consider the WBC percentages in the context of the total WBC count.

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Hematopoiesis Hematopoiesis

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• Upto 2months --- Yolk sac• Upto 7th month --- Liver• After 7th month --- BM major site (starts producing from 3rd month)

• At birth --- BM is the only site

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• Distribution of hemopoietic BM in children and adults.


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• Two critical properties of STEM CELLs:

1-Self Renewal (regenerate their own population) & 2-Differentiate towards matured cells

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• Hemopoietic stem cells (HSCs) - have great capacity for self renewal

- Pleuripotent - most of them are not in cycle• Committed progenitors (lineage restricted) - self renewal is very limited - there after a fraction divide actively - they acively generate matured cells• Early recognizable precursors (ex: Mye.blast, Proerythroblast)

- cannot self renew - proliferate, differentiate and die


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Differentiation of blood cells

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HematopoiesisHematopoiesis

• Stem cell proliferation and differentiation -- is mediated by many soluble factors -- stem cell and stromal cell interaction in BM

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Examples for soluble factors: c-kit and FLT-3 ligand at stem cell level GM-CSF at CFU-GM level

Clinical application: some of the factors are available by recombinant

technology for therapeutic use include:1. EPO2. GM-CSF3. G-CSF4. TPO


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Differentiation of blood cells

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Stem cell and stromal cell interaction:

BONE MARROW MICROENVIRONMENT


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HematopoiesisHematopoiesis BONE MARROW MICROENVIRONMENT

BM is a vast network of thin walled BVs (sinusoids) lined by

--single layer of endothelium and --discontinuous basement membrane--and adventitial cells.--extracellular matrix (cell adhesion proteins-

fibronectin, laminin, Type-IV collagen, hemonectin & glycosaminoglycans)

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BONE MARROW MICROENVIRONMENT

Erythroblasts and also progenitors exhibit the property of adherence to stromal cells.

This is mainly mediated by FibronectinWhen the cells differentiate they become

non-adherent


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BONE MARROW MICROENVIRONMENT For blasts & progenitor cells of granulocytic

leneage hemonectin acts as anchoring molecule

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Sources of CSF:

1. Activated MØ – M-CSF, G-CSF

2. Activated T-cells – Lymphokines, GM-CSF, IL-3, γ-IF

3. Endotoxins (stimulate T-cells) – G-CSF secretion

4. Fibroblasts & Endothelial cell (when they are exposed to IL-1 & TNF)- M-CSF, G-CSF, GM-CSF

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Neutrophilia An increase in the absolute neutrophil count, it can be

increased transiently with stress and exercise by a shift of neutrophils from the marginating pool to the circulating pool. Pathologic processes that result in neutrophilia include:

• Infection• Toxins: metabolic (uremia), drugs, chemicals• Tissue destruction or necrosis: infarction, burns, neoplasia,

etc• Hemorrhage, especially into a body cavity• Rapid hemolysis• Hematologic disorders: leukemias, myeloproliferative

disorders

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Neutropenia – A decrease in the absolute neutrophil count. Pathologic processes that

result in neutropenia include processes that decrease production or increase destruction. Diseases that decrease neutrophil production include:

• Aplastic anemia• Toxins that damage marrow• Collagen vascular diseases (such as SLE)• Myelphthisic marrow processes such as marrow infiltration by infections or

metastatic carcinomas• Hematologic malignancies such as leukemias• Myeloproliferative disorders• Radiation therapy• Chemotherapy• Congenital disorders

– Diseases that increase neutrophil destruction include:• Splenomegaly with hypersplenism• Infection• Immune destruction

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Lymphocytosis – An increase in the number of circulating lymphocytes

may normally be observed in infants and young children. Pathologic processes with lymphocytosis may include:

• Acute infections, including pertussis, typhoid, and paratyphoid

• Infectious mononucleosis, with "atypical" lymphocytosis• Viral infections, including measles, mumps, adenovirus,

enterovirus, and Coxsackie virus• Toxoplasmosis• HTLV I

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Lymphopenia

– A decrease in the number of circulating lymphocytes may be seen with:

• Immunodeficiency syndromes, including congenital (DiGeorge syndrome, etc) and acquired (AIDS) conditions

• Corticosteroid therapy• Neoplasia, including Hodgkin's disease, non-

Hodgkin's lymphomas, and advanced carcinomas• Radiation therapy• Chemotherapy

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Monocytosis

• An increase in the number of circulating monocytes may be seen with:– Infections: such as brucellosis, tuberculosis and

rickettsia, Bacterial endocarditis– Myeloproliferative disorders– Hodgkin's disease– Gastrointestinal disorders, including inflammatory

bowel diseases and sprue

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Monocytopenia

• A decrease in the number of circulating monocytes may be seen with:

– Early corticosteroid therapy– Hairy cell leukemia

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Eosinophilia

• An absolute increase in the number of circulating eosinophils may occur with:– Allergic drug reactions– Parasitic infestations, especially those with tissue

invasion– Extrinsic asthma– Hay fever– Extrinsic allergic alveolitis ("farmer's lung")– Chronic infections– Hematologic malignancies: CML, Hodgkin's disease

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Eosinopenia

• An absolute decrease in the number of circulating eosinophils may occur with:– Acute stress reactions with increased

glucocorticoid and epinephrine secretion– Acute inflammation– Cushing's syndrome with corticosteroid

therapy

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Basophilia and Basopenia

– An absolute increase in the number of circulating basophils may occur with myeloproliferative disorders and with some allergic reactions.

– An absolute decrease in the number of circulating basophils may occur with the same conditions that lead to eosinopenia

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Left shift An absolute increase in neutrophils with an increase in bands, and sometimes an increase in immature forms such as metamyelocytes or myelocytes

Hypersegmentation Polymorphonuclear leukocytes normally have 3 or 4 lobes, but 5 or 6 or more lobes indicate hypersegmentation; seen most often with megaloblastic anemias, sometimes with myeloproliferative disorders, or following chemotherapy (methotrexate)

Toxic granules Increased number and prominence of the azurophilic (primary) granules; seen most often with bacterial infections and in association with cytoplasmic vacuolization

Döhle body Irregularly shaped blue staining area in the cytoplasm due to free ribosomes or RER; seen with infections

Smudge cell / Basket cell A ruptured cell remnant, classically associated with fragile lymphocytes in CLL

Pelger-Huet anomaly An autosomal dominant condition with neutrophils that are mostly bilobed in the heterozygote (normal function) and unilobate in the homozygote (fatal )

May-Hegglin anomaly Rare disorder with large, prominent Döhle-like bodies

Chediak-Higashi syndrome Rare disorder with large neutrophilic granules representing abnormal lysosomes

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Agranulocytosis

• Deficiency of granulocytes• Recognised as a distinct entity in

1922• Drugs are the common culprits• Early recognition is associated with

good prognosis

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Symptomatology:• Chills & fever• Extreme prostration• Ulceration of gums, tonsils, soft

palate, tongue, pharynx (in severe cases ulcerations may be gangrenous)

• Sepsis• Death

Agranulocytosis

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Drugs that are associated with AGC:1. Analgesics: phenylbutazone, phenacetin,

indimethacin, acetyl salicylic acid, ibuprofen

2. Antiepileptics: barbiturates, hydantoin3. Antibacterials: chloramphenicol,

vancomycin, INH, PAS4. Miscellaneous: penicillamine, cimetidine,

quinine, gold salts5. Chemicals: benzene

Agranulocytosis

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Mechanism: Immunologically mediated Evidences: 1-Reintroduction of the drug is associated with

reduction in polys2-Serum from the patient, reduces the granulocyte

count in normal persons3-Patient’s serum lysed granulocytes in vitro

Agranulocytosis

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Hematological findings:

1. Deficiency of granulocytes2. No anemia3. No thrombocytopenia4. BM may show mild hypoplasia

Agranulocytosis

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Monitoring blood counts is mandatory when the following drugs are used:

1. Gold salts2. Thiouracil3. Anticancer drugs

Agranulocytosis

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