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509 Cards in this Set

  • Front
  • Back
Name the erythropoesis steps
Basophilic normoblast
Orthocrhomic normoblast
Which RBC precursors are found in the blood normally? and with disease?
Nml - RBCs and reticulocytes

Disease -- all the way back to pro-normoblasts
Production of RBCs by bone marrow per day?
Lifespan of an RBC?

120 days
Oxidized hemoglobin
Iron is ferric rather than ferrous
Cannot carry oxygen
Things that increase hemeoglobin affinity for oxygen
less DPG
Things that decrease hemoglobin affinity for oxgyen
Increased temperature
Increased DPG
Haldane effect
deoxygenated hemoglobin has higher affinity for CO2 than oxygenated
Bohr effect
In presence of CO2, hemoglobin affinity for oxygen decreases
% of total blood volume that is RBC volume
Amount of hemoglobin in the blood-- in grams/deciliter
Mean corpuscular volume

Hct x10/RBCs

Normal = 80-100 femptoliters

Mean corpuscular hemoglobin
average mass of hemoglobin per RBC

Mean corpuscular hemoglobin concentration
concentration of hemoglobin in a give volume of pack RBCs

These define chromicity
Red cell distribution width
SD of red cell size/MCV
indicates the variation in size of RBCs

Normal is 11.5-14.5
Low is never bad
Increased RDW
Immature RBCs, about 1% of circulation normally

Still have ribosomes
Anemia affect on reticulocytes

Measured by?
With worsening anemia, reticulocytes are extruded from bone marrow earlier

RPI - reticulocyte production index

Greater than 2 is a adequate response to an anemia
Anemia sings and symptoms
Pale, jaundice, cold skin
Fatigue, SOB, syncope
Low BP, rapid HR, breathing, heart murmur
transferrin -- protein that binds Fe in blood
transferrin iron binding capacity
transferrin saturation
normal -- 20-50%
Protein that stores many atoms of Fe
Iron deficiency anemia causes
Decreased oral intake
Decreased absorption
gastritis, bypass, bacterial overgrowth, celiac, antacids, tea, spinach
Increased loss (bleeding)
Weird causes of iron deficiency anemia
Exogenous EPO depletion of stores

Hemolytic anemia leading to iron loss into urine
Eating weird stuff
Symptom of iron deficiency
amylophagia - starch
Plummer-Vinson syndrome
Iron deficiency anemia
Esophageal webbing
Atrophic glossitis
Angular cheilosis
Koilonychia (spoon nails)
Iron deficiency anemia smear and labs

RPI <2, Fe, TS, Ferritin all down, TIBC up
Sideroblastic anemia smear
Microcytic anemia
Basophilic stipling creating a ring

Dimorphic populations
Sideroblastic anemia causes
Congenital ALA deficiency
Pyridoxine/copper deficiency
Lead, ETOH, chloremphenicol, isoniozid
RA, myeloma, myelo/lymphoproliferative diseases
Treating sideroblastic anemia
Remove toxins
Treat with pyridoxine
Lead poisoning blood stuff
Sideroblastic anemia of any MCV
Disrupts both heme and globin synthesis
Increased iron and sideroblasts in marrow
Lead poisoning symptoms
Lead line in gums
Motor neuropathy -- lead palsy
Autonomic neuropathy -- ileus/abdominal pain - lead colic
Quantitative disorder of globin synthesis
Not enough is made
(Hemoglobinopathies are qualitative)
Beta thalassemia
Minor: one mutation in beta globin gene
microcytic anemia, usually normal longetivity

Major: two mutations, marked hemolysis, extramedullary hematopoesis (facial bones, hepatospenomegaly, cardiac failure)
Thalessemias treatment
Bone marrow transplant
Microcytic anemias
Iron deficiency
Sideroblastic (lead poisoning)
Thalassemias, hemoglobinopathies
1/3 anemia of chronic disease
Major categories of normocytic anemias
Low reticulocyte -- hyproliferative with decreased production

High reticulocyte -- destruction of blood cells (reticulocyte)
Normocytic anemias with a low reticulocyte
Hypoplastic states
2/3 of the anemias of chronic disease
aplastic anemia
others (renal, endocrine disease)
Normocytic anemias with a high riticulocyte count
Hemolytic states
Mebraneopathies (hereditary spherocytosis, PNH)
Microangiopathic hemolytic anemias
Anemia of Chronic Disease

Associated with diseases w/ inflammation, infection, malignancy
Acute phase protein -- produced during inflammation
Decreased iron absorption in intestine
Decreased iron release from macrophages
Direct inhibition of erothropoesis
Iron studies in anemia of chronic disease
Low iron
High ferritin
Treatment of anemia of chronic disease
Treat underlying disease
Aplastic anemia
Absent hematopoetic precursors in bone marrow
Pancyotopenia including normocytic anemia
Most dangerous are leukopenia and thrombocytopenia
Causes of aplastic anemia
Primary - idiopathic, Fanconi's
Secondary -- radiation, chemotherapy (alkylators), chloremphenicol, antiepileptics, nifedipine, benzene, parvovirus, EBV, hepatitis (non-A, non-B, non-C)
Aplastic anemia treatment
Remove cause (stop radiation, meds)
Anti-thymocyte or antilymphocyte globulin
Cylcosporin, cyclophosphamide
Stem cell transplant
Renal disease mechanism of causing anemia
Hypoplastic, normocytic anemia with low reticulocyte count

Caused by underproduction of erythropoetin
Endocrine causes of anemia
Low testosterone
Primary myelofibrosis
Metaplasia of the bone marrow--replacement with fibroblasts

Smear: teardrops, nucleated red cells, early white cells

Usually with large spleen (extramedullary hematopoesis)
Not possible to get aspirate from bone marrow, need to core
Myelophthistic anemia
Infiltration of the bone marrow by fibrosis, tumor, granuloma

Smear: teardrops, nucleated red cells, early white cells

Look for a cancer
Binds to heme in vasculature
Preventing iron use by bacteria
Heme-haptoglobin is taken up and disposed of by macrophages

Used to monitor levels of intravascular hemolysis
Causes of intravascular hemolysis
Transfusion reactions
G6P deficiency w/ oxidative stress
Paroxysmal nocturnal hemolysis
Infection (clostridial sepsis, severe malaria)
Microangiopathy (aortic stenosis, artifical valve leak)
Fragment of a red blood cell
Intravascular hemolysis

Clinical signs
Pallor, fatigue, tachycardia
Blood tinged urine, plasma

Decreased haptoglobin, increased LDH
Decreased RBC, hemoglobin, hct
Increased bilirubin
Increased reticuloucyte count
Extravascular hemolysis

Intrinsic causes
Membrane defects
Defective hemoglobin
Enzyme deficiencies
Extravascular hemolysis

extrinsic causes
Liver disease
Inflections (malaria)
Oxidant agents (nitrites, dapsone)
Autoimmune hemolytic anemia
Intravenous immune globulin infusion
Extravascular hemolysis

Clinical Signs
Pallor, tachycardia, fatigue, jaundice

decreased RBC, hemoglobin, HCT
increased bilirubin
increased reticulocyte count
Differentiating between extravascular and intrasvascular hemolysis
Haptoglobin will be decreased in intravascular
Hemoglobinuria or hemoglobinemia in intravascular only
Autoimmune hemolytic anemias
Antibodies to RBC antigens
can be auto or cross reactive
Distinguished from others by Coombs test
Coombs test
Direct -- anti Ig antibodies are added to a tube of whole blood -- agglutination reveals that there were antibodies stuck to the RBC

Indirect -- Donor RBCs are added to patient serum, then anit Ig Abs are added, agglutination means that there were anti-RBCs-Abs in serum
Warm type autoimmune hemolytic anemias
SLE, RA, sjorgen's
CLL, lymphomas
Drug induced (methyldopa)
Warm type alloimmune hemolytic anemias
Drug induced
Transfusion reactions
Cold type autoimmune hemolytic anemias
Infections (mycoplasma pneumonia, mononuclesosis)
Paroxysmal noctural hematuria
Spherocyte formation
Antibodies coat RBC
Splenic macrophages Fc receptors bind antibody
Fragment red cell
Producing spherocyte
Treating autoimmune hemolytic anemias
Underlying condition
Anti-CD20 (rituximab)
Folic acid
Hereditary spherocytosis


Genetic disorder, usually autosomal dominant
Spectrin deficiencies result in less membrane stability
Splenic macrophages chomp of bits of cells

Anemia with high MCHC, extravascular hemolytic anemia

Increased MCHC
High mean corpuscular hemoglobin volume
Hereditary spherocytosis or acquired hemolytic anemias

Cause and pathophys
Paroxysmal Nocturnal Hemoglobinuria
Acquired mutation in a hematopoetic stem cell making blood cells glycophosphatidylinositol deficient and complement vulnerable
Acidity increases liklihood complement mediated intravascular hemolysis - this happens at night

Wake up with blood tinged urine

Smooth muscle dystonia
Decreased quality of life

Can have problems with other lines
PNH treatment
Fe and folate supplements
Eculizmab (anti-complement antibody)
Stem cell transplant
GP6D deficiency
Deficiency of glucose-6-phosphate dehydrogenase
X-linked (affected males or female mosaics w/ mutation in RBCs)
Extravascular hemolysis either after stress or all the time

Hemoglobin oxidize to methHbg--sulfHbg--Heinz bodies
GP6D oxidative stress triggers
Fava beans
quinine and quinidine
primaquine, cholorquine
acetylsalicilic acid
vitamin K
Bite cells with Heinz bodies
Heinz bodies cannot make it through the splenic sinus space and that part of the cell gets chopped off
Most common enzyme deficiency in the world?
400 million
Pyruvate kinase deficiency
Autosomal recessive
2nd most common enzyme deficiency

Rigid cells are sequestered by spleen and hemolyzed
Drug induced hemolytic anemias
3 kinds

Innocent bystander - drug combines with plasma protein and sticks to RBCs becoming an antigen (quinidine)

Anitgenic - drug induces Ab production that cross reacts with a platlet
difference between thalassemias and hemoglobinopathies
Opathies -- qualitative disorders, hemoglobin does not function appropriately

Thalaseemias -- quantitative disorders, not enough hemoglobin
Sickle cell anemia mutation
Valine for glutmine in Beta globin chain

S hemoglobin is more likely to aggregate, creating structural problems in RBCs
Sickle cell anemia RBC destruction
Sickle cells lives only 10-20 days
Some destroyed intravascularly, most in spleen
Sickle cell clinical manifestation
Aplastic episodes (parvovirus)
Delayed growth
Pigment gallstones
Vasooculusion -Avascular hip necrosis, priapism, pain, acute chest, stroke
Leg uclers
Precipitating factors of sickle cell crisis
Oxygen deprivation (altitude, operations, OB delivery)
Heavy exercise
Prevalence of sickle cell anemia
2 million Americas
1 in 5000 African Americans
Homozygous - 0.3-1.3% African Americans
Heterozygous - 8% of African Americans
Sickle cell disease penetrance
Heterozygotes - typically wildtype, sometimes small renal infarcts can lead to hematuria

Homozygotes - variable, from infant crises to almost normal
Sickle cell diagnosis
Hemoglobin electrophoresis
Trait -- some S and some A
Disease -- just S and no A
Sickle treatment
Prophylaxis with hydration, oxygenation, warmth, vaccines

Crisis -- oxygen, hydration, analgesiacs
Hydroxyurea- increase hemoglobin

Stem cell transplant
Macrocytic anemias
Increased MCV

Increasd reticulocyte production
DNA synthesis abnormalities
Megaloblastic anemias
Anemias where problem is DNA synthesis, end up with mature cytoplasm, immature nuceli

Macrocytic anemia

B12 deficiency, folate deficiency, drug induced, some hereditary
Drugs causing megaloblastic, macrocytic anemias
Hydroxurea, methotrexate, 5FU, capecitabine
Phenytoin, valproic acid
omezoprole, rantindin
Cannot be produced by body
Animal products (meat, milk, eggs) only dietary source
Needs intrinsic factor to be absorbed
B12 deficiency
Decreased oral intake (vegans, alcohol)
Decreased absorption
deficiency in intrinsic factor
pancreatic insufficiency
gastrectomy, ileal resection
crohn's disease
neomycin, metformin, proton pump inhibitors
B12 deficiency anemias
Macrocytic anemias
Hypersegmented PMNs

Demyelination of spinal cord
loss of some sensations (deep touch, vibration, ataxia, reflex abnormalities)
Schilling's Test
Determining where B12 deficiency is coming from

Have to first give an IM shot to avoid deprived tissues from sucking up all the B12

Then give radioactive B12 by mouth, with oral intrinsic factor, give antibiotics and try again (absorptive issue)

Looking for B12 in urine
Folate sources
leafy greens, beans, fortified grains

Needed for thiamine synthesis and DNA replication/repair
Folate deficiency symptoms
Macrocytic, megaloblastic anemia
Hypersegmented PMNs

Same as B12 deficiency histologically but lacks the spinal cord part
Why not just give folate?
Treatment of b12 deficiency with folate will treat anemia but not spinal cord degeneration
Folate deficiency causes
Decreased oral intake (alcoholics, poor diet, overcooked foods)
Decreased absorption (celiacs, bowel disease)
Drugs (methotrexate, trimethoprim, phenytoin)
Increase utilization (pregnancy, lactation, chronic hemolysis, exfoliative dermatitis)
Reticulocytes in macrocytic anemias
Reticulocytosis alone can cause increased MCV
Labs to differentiate between folate and B12 deficiency
MMA- increased with B12 deficiency and normal with folate

Homocysteine - increased with both

Can also test for serum folate level
Myelodysplastic disorders
Malignant change in hemotopoetic stem cell
Myeloid precursors in bone marrow are dysplasic
Inadequate blood cell production

Can become an actue leukemia (30-40%)
Chromosomal changes important
MDS counts
Hypocelluarlarity in periphery
can be anemia, bicytopenia, pancytopenia

Hypercellularlity in bone marrow
Etiology of MDS
MDS treatment
Supportive-transfusions, growth factors, iron chelation (prevent transfusion toxicity)
Stem Cell transplant
Alcoholics and MCV
90% of alcoholic have increased MCV

Can be b12, folate deficient
Liver disease results in lipids deposited into cell membrane
Acetaldehyde may have direct effect on RBCs
Alcoholic blood smear
Ovalocyte, hypersegmented PMNs
Target cells
Star like cells, out pouchings in membrane from fat deposition from failing liver
Howell-Jolly bodies
Rements of DNA in circulating RBCs

Splenectomy, sickle cell
Pleger-Huet cells
Hyposegement PMNs

Seen in MDS
Neutropenia define
Too few white blood cells
Neutrophilia define
Too many white blood cells
PMN precursors in the proliferation compartment of the bone marrow

This are dividing and differentiating
PMN precursors in the differentiation compartment of the bone marrow
Distribution of neutrophils in peripheral blood
50% circulating and 50% marginated
Growth factor most important in PMN development

Myeloid precursor proliferation
Induction of myeloid maturation
Protection from apoptosis
Enhancement of PMN function
Lifespan of a PMN
8-12 days in bone marrow maturong
3-6 hours circulating
2-3 days in tissue
WBC Distribution
20% Myeloid precursors
75% storage pools
3% marginating pool
2% circulating pool
Pathogenesis of increased white blood cell counts
Acute - demargination
Chronic -- changes in production and release from storage pools
Pathogenesis of decreased white blood cell counts
Defect in production
Increased margination
Increase sequestration
Normal differential
Neutrophils -- 35-65%
Bands -- 1-5%
Monos - 4-8%
Eosin/basos - 1-2%

Lymphocytes 20-50%
Normal lymphocyte % distribution
T cells - 85%
2/3 CD4
1/3 CD8
B cells - 15%
Absolute Neutrophil Count

WBC X (% segs (PMNs) + % bands)
Normal ANC
Risk of infection with low neutrophils
Rises with decreasing number of neutrophils
With ANC less than 1000, manage fever as outpatient
ANC<500, admit and manage with IV antibiotics
ANC <200 -- fungals and opportunistic a problem
Neutropenic infections sources/types
Most common is autoinfection
Gram negatives -- can rapidly progress to sepsis

Fungal/mucor -- related to the duration, not depth of neutropenia
Symptoms of infection in neutropenia patient?
Take low grade fever seriously

There may be no symptoms
Causes of acquired, extrinsic neutropenia
Drugs, toxins
Immune mediated
Infections causes neutropenia
Anything overwhelming

typhoid, influenza, varicella, CMV, HIV, EBV, dengue, yellow fever, rubella

Mechanism -- consumption, bone marrow suppression, egress, circulating antibodies
Drugs that can induce neutropenia
Antimicrobials - penicillin, cephs, vanco, bactrim
Antihistamines - H2 blockers, cimetidine, rantidine

Mechanism -- bone marrow suppression, maturation arrest, anti-neutrophil antibody production
Neutropenia caused by bone marrow infiltration by
Nutritional deficiency causing neutropenia
B12. folate deficiency results in ineffective myelopoesis

Causes, mechanism of causing neutropenia
Sequestration, immune, and infiltrative effects

Cirrohsis with portal HTN
Felty syndrome
Gaucher's disease
Chronic hemolysis (hereditary spherocytosis, malaria)
Felty syndrome
Rheumatoid arthritis
Neutropenia acquired, intrinsic causes
Myeloproliferative disorders
Aplastic anemia -- also extrinsic -- immune mediated
Idiopathic or
Chronic benign neutropenia
Low ANC <1500, up 35% of those with incidentally discovered neutropenia

More common in African Americans (5%)
Much more common in Africans (50%)
Cyclic neutropenia
Autosomal dominant (ELA2)
15-30 day cycles of neutropenia
> than 10^7 PMN/ml

Causes: stress, infection, inflammation
Most common etiologies for neutrophilia in the community
Shift neutrophilia
Moderate leukocytosis (15 - 20 x 10^9)
Demargination of neutrophils
Mature forms only

Prednisone, epinephrine, excercise, seizures
Leukomoid reaction
Severe leukocytosis >50 x 10^9 cell/L
Demargination and increased production
Mature and young forms in periphery

Infection, inflammation, metastatic cancer, GCSF
Leukoerythrobastic reaction
Early forms of white and red blood cells in periphery, nucleated RBCs, tear drops

Seen with myelophthysic (marrow infiltration) and myelofibrosis
Leukemia on differential
Large increase in young forms -- acute

Increase in all forms with shift toward young - chronic
Sever congenital neutropenia
AD (ELA2 and others)
Multiple subtypes with static neutropenia
Kostmann congenital neutropenia
Infantile agranulocytosis
Presents with multiple severe infections
AR (LYST gene)
Neutropenia, giant lysosomes, oculocutaneous albinism, lymphoma like syndrome

Failure in phagolysosome formation (lyso enzymes do not get to phagosome)

Treated with chemo, steroids, transplant
Hyper IgE syndrome
Problem with neutrophil chemotaxis
Presents with dermatitis, pulmonary/sinus infections, staph, candida
High IgE and IgD

May use prophylaxis with antibiotics
Leucocyte adhesion deficiency
Problem w/ PMN rolling and adhesion
Presents with neutrophilia, recurrent pus-less infections
staph and fungal infections

75% mortality by age 5 with no treatment
Chronic granulomatous disease
Problem with neutrophil microbial activity -- lacks H202, superoxide burst

Presents with recurrent pyogenic infections (staph, seratia, fungi)

Managed with longerterm antibiotic prophylaxis
Myeloperoxidase deficiency
Usually not clinical problems unless diabetic --- then candidal infections
Major cause of acquired neutrophil dysfunction?
Myelodysplastic disorders

Most common?
>1500 cells/ul for 6 weeks, severe is >5000
Most common - atopic in developed nations, parasites in developing

Primary - clonal disease of myeloid lineage
Secondary- infections, allergies, toxins, reactive to lymphomas
Toxocaria canis
Human infection by roundworms of dogs

Dogs as pets suggestive of this potential cause of eosinophilia
Hypereosinophilia syndrome
Dysregulation of normal eosinophil production signaling
Eosins must invade organs and cause end organ damage
Sometimes reversible with treatment
Steroids are used

Must rule out cancers, other causes
Cell line to return first after chemotherapy

Precursors to macrophages, DCs
Monocytes elevated in
Autoimmune, connective tissue disorders
Granulomatous disease (sarcoid, ulcerative colitis, etc)
Highest monocyte counts seen in?
Hematologic malignancies

Chronic myelomonocytic leukemia
Acute monocytic leukemia

Define, suseptibilities, etiologies
ALC < 1000 cell/ul (going to be mostly T helper cell loss, as that is most of the cells)
Suseptible to viral, fungal, mycobacterial, atypical infections

Congenital, meds, infectious, hematologic malignancies (esp Hodgkin's), starvation
Infectious causes of lymphopenia
Medication causes of lymphopenia

define, causes
>4000 cells/ul
Acute infection--pertussis, EBV, hepatitis
Chronic infection - brucellosis, TB, syphillis
Hypersensitivity rxn to drug
Cancer - lymphomas, leukemias
Deciding whether a lymphocytosis is malignant or not?
Based on clonality
B cells -- use flow to check kappa:lamba ratio (should be 70:30)
T cells -- PCR/southern blot looking at t cell receptor

Vastly altered kappa:lambda ratio - light chain restriction
Signs concerning for chronic neutropenia
Recurrent bacterial infections (esp systemic)
Infections at unusual sites (osteomyelitis)
Unusual pathogens
Chronic gingivitis, aphthous ulcers
Congenital lymphocytopenia
Reed-sternberg cell
Giant cells
Multinucleate or biolobed nuceli
Bone marrow aspirates of Hogdkin's disease
Five stages of hemostasis
1. Vasoconstriction
2. Formation of platelet plug
3. Thrombus formation via coagulation cascade
4. Termination of thrombus formation by control mechanisms
5. Removal of clot by fibrinolysis
Role of endothelium in steady state
Intact endothelium is antithrombotic

Prostacylin and NO secreting keeps plts from aggregating
General description
150k-400k is normal
Life 7-10 days

Alpha, dense, glycogen granules
Platelets role in coagulation
Primary plug

Provide reactive phospholipid surface for coagulation cascade
Alpha granules of platelets
Pro/anti-coagulation factors

vWF, fibrinogen, Factor V, Protein S, platelet factor 4, ADP, Ca2+
Bridging protein in platelet adhesion to subendo
Factor VIII chaperon to site of injury

Made by endothelial cells and megakaryocytes
monomers that are modified to multimers
Stored in --Weibel-Palade in endo, alpha granules in plt

Cleaved in plasma to smaller multimers by ADAMTS13
Fibrinogen in thrombus formation
Bridging protein platelet aggregation
Result of vascular endothelial damage
Vasoconstriction, reducing blood flow and allows procoagulant factors to bind

Platelets aggregate

Coagulation cascade initation
Platelets are activated by?
and activation results in?
Exposure to subendothelial collagen and matrix proteins

Thrombin, collagen -- potent activators

Activation results in degranulation, shape change, TxA2 secretion (vasoconstriction)

define and mechanism
Platelets bridging to surface

GPIb-IX (also IIb/IIIa) binds to vWF whcih connect to subendothelial collagen
Platelet aggregation

Define, mechanism
Platelet to platelet bridging

GPIIb/IIIa changes conformation with activation
Resulting in high affinity for fibrinogen
Bernard-Soulier syndrome
Lack of GP1b-IX-V receptor

Bleeding disorder
Glanzmann thrombasenia
Deficiency in GPIIb/IIIa receptor

Bleeding disorder
Platelet plug
Primary hemostasis
Collagen-vWF-activated plts-fibrinogen-other activated plts
TxA2 production and vasoconstriciton

Not enough--coagulation cascade occurs on plt surface to convert fibrinogen to fibrin
Outcome of the coagulation cascade
Which convert fibrinogen to fibrin
Fibrin polymerizes around platlets and stabilizes
Creating the secondary hemostatic plug
Dense granules of platelets
Agonists of platelet aggregation
Thromboxane A2
Platelet factor 3 activity
Exposure of phosphatidyl serine and phosphatidyl ethanolamine to platelet surface

Allows coagulation factors to bind
Scott syndrome
Defect in platelet factor three

Bleeding disorder
Coagulation cascade generally
Amplification cascade
Zymogen conversion to active serine proteases
Protease actives subsequent zympogen
Factors synthesized in liver

VIII is also made in endothelial cells
vWF is made only megakaryocytes and endothelial cells
First step in coagulation cascade
Vascular endothelial cell injury induces tissue factor production by monocyte or vascular endothelium

Circulating factor XII complexes with TF and is activated
Action of TF/XII complex
Activates X to Xa

Activates IX to IXa
Which activates X to Xa
In the presence of VIII
Factor VIII
Vastly accelerates the conversion of X to Xa

Carried in circulation by vWF

Necessary cofactor, along with calcium, for IX to bind to platelet membrant
Factor X
Converts II to IIa
(prothrombin to thrombin)
In the presence of V
Factor V
Secreted by platelets when the are activated, therefore it is at the site of injury

Helps hold IIa and X close together on platelet phospholipid membrane
---prothrombinase complex

Vastly increases conversion to thrombin
Thrombin role in thrombosis
Converts fibrin to fibrinogen

Converts XI to XIa, which converts IX to IX---thrombin burst--amplifies signal

Also activates V and VIII

Regulates (prevents breakdown and then activates anticoagulation)
Helps crosslink fibrin into strong sheets
Cessation Coagulations
4 things
1. Hemodilution of of activated factors by systemic circulation
2. Hepatic clearance -- activated factors are metabolized
3. Endogenous anticoagulants
4. Fibrinolysis
Endogenous anticoagulants
Protein C/protein S
Tissue factor pathway inhibitor
Protein Z
Made by liver, endothelial cells

Binds and inactivates Xa and IIa

Activity vastly increased by heparin
Activated protein C
With cofactor protein S
Inactivates Va and VIIIa

Activated by thrombin after thrombomodulin has changed its conformation

After thrombomodulin binding (on endothelial surface) thrombin cannot activate coagulation factors
Tissue Factor Pathway Inhibitor
Made by endothelial cells
Binds to and inactivates Xa
Xa/TFPI inactivate TF/VIIa complex
Fibrinolysis process
Plasminogen made by liver and circulates
Plasminogen binds to fibrin
Plasminogen activated to plasmin by TPA/UPA
Plasmin cleaves fibrin into degradation products like D-dimers
Major inhibitor of plasmin

Deficiencies result in bleeding disorders
Plasminogen activator inhibitor-1
Major inhibitor of tPA
Stored in platelets

Deficiencies result in bleeding disorders
Testing for coagulation?
What tube?
Blue top tube
Citrate is the anticoagulant -- binds Ca making it unable to be a cofactor for coagulation cascade
Testing for cellular blood elements?
What tube
Purple top EDTA (anticoagulant)
Platelet count where spontaneous bleeding is a problem
Usually not until under 10K
EDTA sometimes results in platelet clumping
Automated counter returns low platelet count that is artifactual
Look at the smear! or run again with a blue top tube
Platelets on smear
10 plts on a 100x field = 150K
20 = 300K
Bleeding time
Measures the platelet/blood vessel wall interaction

How long does it take a person to stop bleeding? Hopefully less than 9 minutes.

Not great at predicting surgical bleeding, operator dependent
In vitro test of plt fnc (adhesion and aggregation)
How long does it take for stimulated platelets to occlude an aperture

Collagen/ADP-- tests for vWF
Collagen/epi -- tests for aspirin, other dysfunction
Thrombocytopenia and platelet function studies?
Will increase time without their necessarily being a functional deficit
Time to clot when (TF + phospholipid + Ca) are added to citrated plasma

"Extrinsic pathway"

Prolonged by deficiencies in VII, X, V, II, I

DHMC--12.2-14.8 sec
Standardization of PTs based on analysis of the thromboplastin reagent based on a WHO standard

Normal INR - 1
Normal for anticoagulates 2-3
partial thromboplastin time
Citrated plasma + Ca + phospholipid + contact activator
glass, cellite, kaolin, ellagic acid

"Intrinsic pathway" test

Prolonged by
Deficiencies in-- HMWK, pre-kalikrein, XII, VIII, IX, XI
X, V, II
Prolong aPTT with no risk of bleeding
Deficiencies in HMWK, pre-kalikrein, XII
Prolonged PT and normal PTT
Factor VII deficiency, polymorphism, inhitor
Early liver disease or Vit K deficiency
Early warfarin
Prolonged PTT and normal PT
Hemophilia -- A (def in VIII), B (IX), C (XI)

vWF disease

Inhibitor of intrinsic pathway


HMWK, pre-kal, XII deficiencies
Prolonged PT and PTT
Common pathway/multiple factors effected

Severe liver disease
Therapeutic warfarin
Consumptive coagulopathy
Sever Vit K deficiency
Low fibrinogen or dysfunctional fibrinogen
Direct thrombin inhibitors
Mixing study
50:50 ratio of patient and pooled normal plasma

correction of prolonged clotting studies indicates factor deficiency
--if prolongs again after time-- likely VIII inhibitor

persistence indicates inhibitor
Coagulation factor assays
How much factor is there compared to normal pooled plasma?

normal considered 50-150%
except XII: 30-150%
Thrombin clotting time
Exogenous thrombin added to plasma
Time to clot

Detect fibrinogen abnormalities
hypo, dys, heparin, thrombin inhibitors
Fibrin breakdown product
Elevated in acute thrombosis

DIC, cancer, infection, surgery, inflammation
Quantitative platelet disorders
Decreased production
Increased consumption
Sequestration in spleen
Autoimmune thrombocytopenia
like ITP
Autoantibodies against platelets

Self-limited in kids with viral infections

Chronic and requiring immune suppression in adults
Medication induced thrombocytopenia
Immune mediated

Quinine -- low plts and bleeding
Heparin -- HIT, low plts and clotting
Thrombocytopenia thrombotic purpura (TTP)
microangiopathic hemolytic anemia thrombocytopenia
neurologic changes
renal failure


Failure of ADAMT13 to cleave vWF resulting in too many large vWFs
(autoimmune or medication induced)

Treat with plasma exchange, immunosuppression)
HELLP in pregnancy
Similar to TTP

hemolysis, elevated liver enzymes, low platelets
Thrombocytopenia 2/2 sequestration

Enlarged spleen can have 90% of plts

(normal sized has 30%)

Happens in myeloproliferative disorders, portal hypertension, portal/hepatic thrombosis
Thrombocytopenia 2/2 decreased production
Leukemia, MDS, aplastic anemia
Bone marrow infiltration
Virus (HIV, heps are toxic to megakary)
Toxins (alcohol, xrt, chemo, meds)
Nutritional deficiencies (B12, folate)
Hereditary (rare)
Gaucher's disease
Lysosomal storage disorder
glucocerebrosidase builds up

Bone marrow fills with fat not hematopoetic cells
Acquired plt function disorders
Usually medication
aspirin, NSAIDs, anticoagulants

SSRIs, herbal supplements

Uremia (circulating toxin)

MDS, myeloproliferative disorders

Cardiopulmonary bypass
Gray plt disorder
Absent alpha granules
Quebec platelet syndrome
Elevated uPA in plt granules
Granule contents degraded
Delta granule disorders
Less ADP released

Scott syndrome
Defect in assembling coagulation factors on plt surface
vWF epidemiology
Most common inherited bleeding disorder
1% of population had deficiency
Autosomal dominant

Levels vary between normal individuals
Type O blood has less
vWF deficiency Type 1
Low levels of activity
70-80% of affected
vWF deficiency Type 2
Normal levels
Reduced activity -- abnormal molecule or reduced number of high molecular weight multimers

20-30% of affected
vWF deficiency type 3
Absent vWF factor and factor VIII activity

Acquired vW disease
Due to autoantibody
Bleeding phenotype of vWD
Ranges in severity
Mucocutaneous predominates
(mennorhagia, epistaxis, easy brusing, GI bleeding, oralpharyngeal)
Hemarthroses rare

Excessive bleeding with trauma, surgery

Long bleeding with minor cuts

Worse with aspirin
Lab testing in vWF
PT, TCT are normal
PTT may be normal or prolonged (2/2 factor VII effect)

Prolonged bleeding time, PFA-100

Abnormal aggregation on ristocetin test (1,2,3 are slow to aggregate, 2b is fast)
vWD type 2b
Gain of function
Hyperaggregation at low ristocetin doses

Plts normal but thrombocytopenia common

(pseudo vWD is a gain of funciton in GPIb)
vWD treatment
DDAVP (desmopressin, synthetic vasopressin)
Stimulates release of vWF
Good in 1 and mild 2, BAD in 2b

Factor replacement
Anti-fibrinolytics to stabilize clots
Contraceptive for mennorhagia

Avoid aspirin

Deficiency and inheritance
Hemo A - VIII deficient -- X-linked
Hemo B - IX deficient -- X-linked
--christmas disease
Hemo C - XI deficient-- AR
Parahemophilia - V deficient - AR
Symptom of female carriers with hemophila a or b
Hemophila A/B subtypes
80% A and 20 % B

Mild: 5-40% factor, bleed with trauma/surg, may have normal aPTT

Mod: 2-5% factor, may bleed spontaneous, prolonged aPTT

Severe: 0-1%, spontaneous bleeding common, prolonged aPTT
Hemophila bleeding phentype
May be delayed because primary hemostasis is fncal

Hemarthroses common -- target joint
Muscle hematomas
CNS bleeds
Bleeding after trauma, dental work, etc
Effect on hemophila on coagulation cascade
Markedly reduced thromin burst
Labs in hemophila
aPTT prolongs with factor less than 30%
Corrects with mixing
Specific factor levels low

PT normal, PFA normal
Treatment of hemophila
Treat with recombinant factor replacement
(mild VIII may respond to DDAVP)

Either for acute bleeding
Prophylaxis 3x/week to keep trough level >1%
-- only considered in severe
Complications of hemophila
Joint destruction (arthropathy)
-80% of severe hemophiliacs in 80s, 50% of all
-no HIV since 1986

Inhibitors to missing factors
these antibodies can complicate treatment
-might have to bypass using VIIa
Acquired hemophilia
Autoantibody to factor VIII

Bleeding disorder in previously healthy


Mostly idiopathic and in the elderly, sometimes w/ cancer, post partum

treats acquired hemophilia
Fibrinolytic bleeding disorders
Typically delay (12-24 hrs later)
Mucocutaneous, GU

Rare hereditary -- quebec plt disorder, alpha-2-antiplasmin, pai-1 deficiency,

More commonly acquired -- cancer, liver disease, DIC, prostate surgery
Labs in fibrinolytic bleeding disorders
Prolonged PT and PTT
Increased D-dimers

(may look like DIC)
Treating fibrinolytic bleeding disorders
Supportive plasma infusions

Anto-fibrinolytic drugs (epsion aminocaproic acid, tranexamic acid)
Most common cause of bleeding due to vit K deficiency
Over anti-coagulation
Causes of vit K deficiency
Dietary -- poor intake, malabsorption, alcoholism

Meds - antibiotics, salicyates, herbs, vitamins a and e, comarins
Labs in Vit K deficiency
Prolonged PT and PTT, correct with mixing
Normal plt studies
Low II, VII, IX, X with preserved V
Treatment of Vit K deficiency
Oral Vit K
- IV only in emergency b/c rare anaphylaxis
- substantial restorate at 24 hours

add FFP in emergencies, will temporarily correct
Liver disease
Problems with synthesis of coagulants and anticoagulants

Bleeding is the result usually, although clotting can also happen
Liver disease and coagulation labs
INR is part of the liver disease end stage assessment

Low factors levels including V but not VIII

PT/INR may not accurately predict bleeding
Treatment of coagulopathy of liver disease

Supportive hemostatic treatments don't really work but...Vit K, FFP
Disseminated intravascular coagulation
Insult results in excessive thrombin generation

Activating both coagulation and anticoagulation

Results in clotting and bleeding

Insults-- infections, cancer, trauma, brain injury, snake bite, burns, etc
DIC presentation
Bleeding at surgical, IV sites
Purpura fulminans
-skin necrosis, usually with infection --> amputation
Thromboses -- micro w/ end organ damage common, large venous/arterial less

Sometimes asymptomatic-- usually with cancer pts
Lab evidence of DIC
Prolonged PT and PTT
Elevated D-dimers
Decreased fibrinogen
Decreased plts
RBC schistocytes
Endogenous anticoagulants low (antithrombin, C, S)
Treating DIC
Treat underlying cause

Support with plasma (factors), cryoprecipitate (fibrinogen), and plts RBCs

Heparin will stop, but with high risk of bleeding

general idea
Mutated bone marrow cells that divide but do not mature normally

Dysfunctional cells with premature apoptosis
Hypercellular bone marrow the peripheral cytopenias
Cells proliferate quickly but are arrested at immature level of differentation
Acute leukemia
High grade lymphoma
Cells proliferate and mature normally but accumulate because of additional divisions or problems with cell death regulation
Chronic leukemia
Myeloproliferative disorders
Increased number of myeloblasts in bone marrow
Normally less than 5%
5-19% -- myelodysplasia
>20% -- acute leukemia
Presentation of MDS
Asymptomatic -- on CBC
Cytopenia symptoms -- infections, fatigue, bleeding

15% have autoimmune disorders
incidence increases with age

primary is idiopathic, secondary due to mutagenic insult
Lab findings in MDS
Microcytic anemia-- most common
Multiple cytopenias common

Smear -- macrocytes, acanthocytes, elliptocytes, nucleated RBCs, pseudo-pelger-huet, hypogranulated neutrophils
MDS with 5q minus
Thrombocytosis in common
Bone marrow biopsy in MDS
Hypercellular with at least one dysplastic lineage

Megakaryocytes dysplasia -- clustered cells, micromegakaryocytes, abnormal disorder

Erythroid -- delayed nuclear to cytoplasmic maturation, erythroid hyperplasia with megaloblastiod hyperplasia
-ringed sideroblasts can be seen
Peripheral findings of MDS

PMNs -- hypogranular, segemental abnormalities

Erythrocytes -- macrocytes, ovalocytes, anisopolkicytosis, basophilic stipling, nucleated froms

Plts - large, hypogranular

Monocytes - monocytosis
MDS subtypes with less than 5% blasts
Refractory anemia +/- ringed sideroblasts

Refractory anemia with multiple lineage dysplasia +/- ringed sideroblasts

5q- syndrome
5q minus in MDS prognostics
Good prognosis, lower risk of progression to AML
Poor cytogenic prognostics in MDS
Multiple cytogenetic abnormalities

Changes in 5 or 7 that are not 5q-

secondary mds almost always has these bad markers
Prognostic scale in MDS
Number of basts
Number of cytopenias

Worst - 5 months median survival, best -- 5 years median survival
Treatment of MDS
Treat when symptomatic

Supportive w/ transfusions, growth factors, immunomodulatory agents, demethylating chemotherapy, induction chemotherapy

Bone marrow transplant is only cure
Difference between acute and chronic leukemias in presentation
Sick at presentation with acute
Immature cells seen in bone marrow and peripheral blood in acute, mature in
With chronic, bone marrow function until late stages
Symptomatic presentation of AML
Fatigue, dyspnea
Bruising, bleeding

DIC, bone pain, myeloid sarcoma/chloroma, organomegaly, CNS/gingival, cutaneous infilitration
Diagnosing AML
Bone marrow biopsy w/ >20% blasts
-hypercellular, monotonous population
Determine lineage with cytochemical/flow
Determine cytogenetics
Cytochemical stains to determine linease
Myeloperoxidase + sudan black --granulocyte

Butyrate esterase--monocytic

PAS - lymphocytic
Surface marker for hematologic stem cells
Surface marker for myeloid lineage?

Surface profile of myeloid leukemia

CD33+, CD34+
Surface markers for t cell lineage
CD3, CD4
Surface markers for a b cell lineage
C19, CD20, CD22
Favorable karyotypes in AML
t (8;12)
t (15;17) -- m3
inversion (16) - M4Eo
Bad karyotypes in AML
Any 5 or 7 changes (including 5q)

Trisomy 8
Monsomy 7
Good prognosis mutations in AML
Poor prognosis mutations in AML
Classification of AMLs
AML w/ recurrent genetic abnormalities
AML w/ multilineage dysplasia
AML/MDS that is therapy related
divided into M0-7 based on histology
Prognostics in AML
h/o previous hematologic malignancy
t (8;12) AML1/ETO
AML w/ recurrent genetic change
10% of AML
Younger adults, some kids
Generally favorable prognosis

RUNX1-CBFA2T1 fusion protein represses transcription of genes related to differentiation -- differentiation block - AML

Associated with extramedullary disease (skin, cns, myeloid sarcs)
inv(16)(p13;q22) AML
AML with recurrent genetic changes

Eosinophils affected
Generally good prognosis

CBFbeta/MYH11 fusion protein blocks transcription of differentiation related genes -- differentation block -- AML
Acute Promyelocytic Leukemia (M3)
AML with recurrent cytogenetic changes

Differentiation block is at promyelocyte stage
5-8% of AML
Most are t (15;17) -- 95%
creating PML/RARalpha fusion
others are also RARalpha mutants

Large granules with Auer rods
Extremely prone to clotting

Responsive to all-trans retinoic acid
Microgranular Acute Promeylocytic Leukemia
Subtype of acute promyelocytic leukemia

Appear agranular or hypogranular
Butterfly or bilobed nuclei
High WBC count
AML w/ 11q23 (MLL) abnormalities
AML with recurrent genetic changes

Approximately 5% of AMLs, associated with topoisomerase inhibitors

Mixed Lineage Leukemia gene involved in multiple translocations
(9;11), (11,19)

Intermediate prognosis
AML w/ multiple dysplastic lines
Bad prognosis
Severe pancytopenia in elderly
>50% dysplasia in at least 2 cell lines

Can arise from MDS or not
AML, therapy related
Generally poor prognosis

1) with ionizing radiation or alkylating agents (cyclophosphamide, chlorambucil)
--presents as MDS years later

2) with topoisomerase 2 inhibitors (often associated with 11q23 changes)
--presents as overt leukemia, sometimes as soon as 12 months out
AML -- M0
Minimally differentiated
No myeloid maturation
Blasts vary in size with 1-2 nucleoli

myeloperoxidase, sudan back, PAS, NSE--negative

No granules
No Auer rods
AML -- M1
Arrest at myeloblast stage
Blasts vary in size w/ 1-2 nucleoi
>3% are MPO, sudan black +

Can have granules, Auer rods
AML-- M2
AML with Maturation
30-45% of all AML

>10% pros, myelos, neutrophils in marrow

usually have granules and Auer rods
M4: Acute Myelomonocytic leukemia
Mixed monocyte/granulocyte population
15-25% of AML

>20% blats
>20% neutrophils + precursors
>20% monocytes + precursors
M5: Acute Monoblastic leukemia
80% of cells in monocytic lineage
monoblast, promonocyte, monocytes

Gingival infiltration, extramedullary disease are clinical features
M6: Acute Erythrocytic leukemia

>50% erythroid precursors in marrow
>20% of myeloblasts are non-erythroid

Pure erythroid leukemia
80% of precursors are erythroid
M7: Acute Megakaryocytic leukemia
Can get bone marrow fibrosis

Two ages
Infants, kids <3
w/ downs -- good prognosis
t (1,22)
Older adult
usually de novo, occasionally MDS
Initial stabilization concens in AML
Treat infections
Check cardiac fnc (adriamycin)
Manage leukostasis
Manage hyperuricemia
Tumor lysis syndrome
Treatment of AML
Goal -- remission w/ fewer than 5% blasts in marrow

Myeloablative doses of chemotherapy resulting in transfusion dependent cytopenia for 3 weeks
70% remission
5-20% complications stop treat
15-% - resistant disease

Followed by 3-4 doses of consolidation and/or autologous transplant

Allogenic transplant used in high risk patients
Granules in acute promyelocytic leukemia contain procoagulants
TF activates factor VII
Cancer procoagulant activates factor X

10-20% die of hemorrhagic events
t (15,17) with PML/RARalpha fusion protein APMLs respond to high doses of all trans retinoic acid

these doses push through the mutant retinoic acid receptor to progress differentiation normally

ATRA shortens DIC, with chemo puts 80-90% in remission
Retinoic acid syndrome
Potentially fatal syndrome occuring in 20% of APML patients treated with ATRA

Fever, edema, pulmonary infiltrates, respiratory distress

Usually in first 3 weeks, unclear etiology

Stop ATRA temporarily, give steroids
Hyperleukocytosis in ATRA treatment
Probably due to white cell maturation
Can cause leukostasis
APML and arsenic
Second line therapy
Induces differentiation and apoptosis through interaction with PML/RARalpha fusion product
Characteristics of myeloproliferative disorders
Increase numbers in one or more cell lines, clonal marrow expansion

Extramedullary hematopoesis w/ hepatosplenomegally

Hypercatabolism (fevers, night sweats, weight loss)

Loss of sensitivity to growth factors

Predisposition to develop AML
Mutations often seen in myeloproliferative disorders
Activating tyrosine kinase mutations
Chronic myeloid leukemia
Must be t(9;22)

Present with fevers, chills, weight loss, early satiety, splenomegaly
Bone marrow
Bone marrow -- hypercellular w/ increased myeloid:erythroid ratio

Peripheral-- immature myeloid cells, but few blasts
CML labs
Elevated WBC and plts early, low late
Maybe elevated LDH
CML pathogenesis
t(9;22) creates fusion product BCR-ABL

BCR-ABL is an unregulated tyrosine kinase that stimulates proliferation
Natural history of CML prior to TKIs
Chronic phase - Counts/spleen easily controlled with hydroxyurea, pts well, can be cured with stem cell transplant (3 years)
Acute -- counts more difficult to control with hydroxyurea, spleen grows, constitutional symptoms reappear (1 yr)
Blast -- AML/ALL - like, unresponsive to therapy/transplant, (3-6 months)
Current treatment for CML
First line with dasatinib -- BCR-ABL tyrosine kinase inibitor

Monitor-- counts, t(9;22) by fish, Bcr-ABL mRNA by RT-PCR

With treatment fail, try other BcrABL TKs...then stem cell transplant
Important prognostic in CML
Remission at 1 yr
Polycythemia Vera

Increased hemoglobin, red cell mass
-this can fall late
Low serum EPO
Presence of Jak2 mutation
Hypercellular mone marrow

No other reason for the high red cells
Polycythemia Vera

Median age 60

sweats, fatigue, weight loss, HA, visual disturbances, abd pain, thrombosis, puritis, erythromelalgia (neurovascular peripheral pain)

splenomegally (70%), plethora (70%), haptomegally (40%)
Polycythemia Vera

Treatment and prognosis
Poor prognosis if untreated, good w/

Treatment of choice -- phlebotomy (to Hct-40) to the point of iron depletion and decreased proliferation

Can develop resistant AML/ALL or meylofibrosis
Essential Thrombocythemia

plts consistently >450K
increased/weird megakaryocytes in BM

Not CML, inflammation, iron deficiency
Essential Thrombocythemia

50% have JAK2 mutation, others have MPL (myeloproliferatie leukemia virus gene-- the thrombopoetin receptor)
Essential thrombocythemia

HA, lightheadedness, syncope, atypical chest pain, visual changes, mild splenomegaly

Some clot, some bleed
Essential thrombocythemia

Treatment and prognosis
Low risk --
<60, no h/o thrombosis, plts <1000K
No treatment

High risk
Hydroxyurea, sometimes aspirin, anagrelide

Usually normal life span, rarely get clotting complication, AML, ALL, myelofibrosis
Primary myelofibrosis

Collage fiber deposited in bone marrow
Anemia -- can be severe
w/ teardrop cells
Increased, abnormal megakaryoctes in BM
Plts, WBC can be up or down
Primary myelofibrosis

Prognosis and COD
Worse with
WBC<4 or >30
Plts <100
Monocytes >1.0

range is from 175 months to 26 months

COD: transformation to MDS, AML, bleeding, infection
Primary myelofibrosis

Stem cell transplant is curative

Hydoxyurea, transfusions, splenectomy
Systemic symptoms of lymphoma
Weight loss
Night sweats
Function of T cells
Direct kills of organisms or infected cells
Modulation of immune response through helper and suppressor Ts
Function of B cells
Produce antibodies

Antigen present to T cells
Locations of maturation and differentiation of lymphocytes
Maturation to competence: thymus and marrow

Differentiation and antigen driven replication: lymph nodes, spleen, MALT, others

LN in aggregate is the largest
Seven divisions of lymph node
Subcapsular sinus: afferent lymph enters this space
Cortex with follicles
Medulla with cords and sinuses
Medullary vessels: artery and vein
Primary lymphoid follicle
Small B cells
Virgin or recirculating memory cells
Secondary lymphoid follicle
Antigenic stimulation for differentiation
Creates germinal center with follicular dividing cells
Surrounded by mantle of transient small lymphocyytes
Sites of B cell homing
Primary and secondary follicles
--for stimulation and differentation/proliferation

Medullary cords, plasma cells release Igs into efferent lymph
Site of T cell homing
Normal lymphocyte circulation
Blood into
Lymph node
Surveilling for presentation of specific antigen
Leave through efferent lymphatics
Small lymphocytes appearance
Small round blue dots
Round nucleus
Clumped chromatin
Small/not visible nucleous
Small lymphocytes identities
T or B
Virgin or effector or memory
Where are B cells in LN?
Primary follicles
Mantle zones of secondary follicles
Medullary cords
Where are T cells in LN?
A few in the germinal center
Noncleaved cells in lymph node
Replicating population
Small and large (based on comparison with macrophage nucleus
Expanding the number of antigen specific cells
Small cleaved cells
Post mitotic plasma or memory cell precursors
Look a lot like lymphocytes but are irregularly folded and cleaved

Large cleaved cells
Bigger version of small cleaved
Replicaiton potential not clear
Cells of the germinal center
Follicular cells

Non cleaved, large cleaved
Proliferating large cell outside of germinal center of lymph node
May be B or T

Looks like dividing cell: vesicular chromatin, nulceoli visible
APCs in LNs
To T cells - interdigitating reticulin cells
To B cells - dendritic reticulin cells
Macrophages in lymph node
Main cell of medullary sinus
Abundant pale cytoplasm, oval nucleus, one nucleolus

A few in germinal center
Reactive hyperplasia
Proliferation in one or all of lymph node zones based on stimulus
Not cancer
Follicular hyperplasia

Associated with
Type of reactive hyperplasia
Expansion of germinal centers (can go into paracortex, medullary areas

Collagen vascular disease
Systemic toxo
Interfollicular hyperplasia
A reactive hyperplasia
Paracortical expansion

Skin disease, viruses, drug reactions
Sinus histiocytosis
Expansion of macrophages in the sinus

Indicative of adjacent cancer or infections
Factors predicting lymphoma course
Dominant cell type (or transformed cell type)
Patient's health status
Working Formula and lymphoma?
Divides lymphoma into
low, intermediate, high grades


Based on clinical history, dominant cell type, "follicularity"-- do the cells form normalish LNs
WHO lymphoma classification
Cell of origin: B vs T/NK vs Hog

Peripheral vs precursor
Leukemia vs lymphoma
Is most of the disease in the lymph organs or the bone marrow/blood?
IHC profile in B cell small lymphocytic lymphoma
Monoclonal light chain

CD10 negative
IHC profile in B cell small cleaved lymphoma
Monoclonal light chain

CD5 negative
Indolent lymphomas, name some
marginal zone
Indolent lymphomas general course, treatment goals
Slowly progressive
Difficult to cure

Goals of chemo are extension of life with good quality

Only cure is allogenic HSCT
Aggressive lymphomas general course, treatment goals
Grow rapidly
Can be rapidly fatal

Immediate aggressive treatment with the goal of cure
Aggressive lymphomas name some
ALL, Burkitt's
Intermediately aggressive lymphomas name some
diffuse large cell
peripheral T cell
mantle cell
Staging in Lymphoma
I -- involvement of a single LN region
II - multiple regions on same side of diaphragm
III - disease on both sides of the diaphragm
IV - multifocal extranodal involvement or regionally distant extrnodal invovlement

A or B (symptoms)
B symptoms
Night sweats
Greater than 10% weight loss
Diffuse large B cell lymphoma
Originates from large replicating cells of germinal center and paracortex
Oval/cleaved cells with nucleoli and vesicular chromatin
Diffiuse infiltration of LN

CD19/20 positive
May overexpress bcl-2/6
Diffuse large B cell lymphoma prognosis
Intermediate aggressiveness lymphoma
30-40% cure rate
Diffuse large B cell lymphoma presentation
Children or adults (median age 64)
Present with an enlarging, painless mass in lymph node region
Diffuse or localized
Prognostics in diffuse large B cell lymphoma
Age (>60 bad)
Stage (III or IV)
LDH elevation
Poor performance status
Extranodal involvement
Diffuse large B cell lymphoma treatment
For localized: chemo + xrt

Anthracycline based chemo
R-CHOP used -- rituxin, cyclophosphamide, adriamycin, vincristin, prednisone

Rituxin increases OS by 10%
Relapsed large B cell lymphoma treatment
Chemo + autologous transplant

Transplant helps up cure rate by 20%
Follicular lymphoma pathology
Cancer of small cleaved cells of germinal center
Clumped chromatin, irregular nuclear profile
Retain follicular structure of LN but monotonous cells
More large cells -- worse grade
Follicular lymphoma IHC/molecular changes
bcl-2 overexpression

CD19, 20, 10, bcl2+
CD5, cyclinD1 -
Follicular lymphoma epi
Most common of indolent lymphomas
22% of NH lymphomas

Disease of adults >40
Typically presents as stage III or IV
Follicular lymphoma prognosis
No curable
7-10 years, but highly variable
Transformation to large cell has more aggressive course

Prognosis as FLIPI score based on:
Age >60, elevated LDH , stage III/IV, >4 LN sites, hemoglobin <12
When to treat follicular lymphoma
treat with gentle chemo including rituximab when
bulky, painful adenopathy
organ system invovlement
severe B symptoms
high FLIPI score
Marginal zone lymphoma pathology
Origin is post germinal center memory B cell
CD20+, CD5-, CD10-

Arising in muscosal tissue of GI tract, tear duct, salivary gland, lung
Marginal zone lymphoma prognosis
Marginal zone lymphoma AKA
MALT lymphoma
Extranodal marginal zone B cell lymphoma
Marginal zone lymphoma treatment paradigm
Same as follicular
Watch and wait until meets criteria
Gastric MALT lymphoma
Marginal zone lymphoma arising from gastric mucosa
Usually with H pylori infection
H pylori antigens drive T cell activation, B cell clonal proliferation -->lymphoma
Can be cured with H pylori antibiotic treatment

Presents like a peptic ulcer
Hairy cell leukemia pathology
Unique cytoplasmic projections
CD19, 20, 103 +
CD 5, 10 negative
In bone marrow looks like fried egg
Trap IHC (tartrate acid phosphotase)
Hairy cell leukemia presentation
Indolent lymphoma
Cytopenias, fatigue, weight loss
Hairy cell leukemia treatment and prognosis
80% cure rate with
Purine analog cladribine

Rituxin for refractory/relapsed
Burkitt's lymphoma pathogenesis
Origin: small noncleaved cell of germinal center
t(8;14) results in upregulation of myc oncogenes
Burkitt's lymphoma pathology
Diffuse infiltration of lymph node
Small round cells with vesicular chromatin and nucleoli
Lots of ineffective mitosis = macrophages = "starry sky"

19, 20, 10+, 5-
Burkitt's general features
Highly aggressive
High LDH, rapid doubling time
Presents with bulky disease can involve CNS, bone marrow, extranodal sites
Burkitt's subtypes
Endemic Burkitt's
Jaw disease
EBV related
Immunocompromised Burkitt's
AIDS associated
Abdominal masses, marrow, lymph nodes
30% are EBV positive
Sporadic Burkitt's
Children and young adults
Abdominal masses, marrow, LNs
30% are EBV positive
Burkitt's course
Live only weeks if not treated
80-90% cure early stage, 60-80% with advanced stage
Poor prognostics in Burkitt's
High LDH
CNS involvement
Bone marrow involvement
Tumors >10 cm

Immunocompromised Burkitt's
Mantle cell lymphoma pathology
Origin: lymphocyte of inner mantle zone
Looks like cleaved cell
Nodal involvement either diffuse or expansion of mantle zone
Mantle cell lymphoma pathogenesis
t(11:14) upregulates bcl-1 which increased cyclin D1 production
Mantle cell lymphoma course
Looks indolent, isn't
5 year survival 30-50%

Allogenic HSCT can prolong but not cure
Autologous may also help
T cell lymphomas
Less common
More likely to be extranodal
With nodal involvement are usually bad, and not as responsive to therapy as B cell
Mycosis fungiodes
Indolent T cell lymphoma of the skin
Incurable with slow course
Anaplastic large cell lymphoma
T cell lymphoma
Can have a 2;5 translocation with ALK gene
ALK gene is a positive prognostic
Hogkins's disease pathology
Reed-Sternberg cell
a minor population but diagnostic
altered B cell
CD15 and 30 positive

Spread continguously via lymphatics
HD epi
Less common than NH lymphoma
Biomodal age: late adolescents and 60s
HD subgroups
Nodular sclerosis - most common neck/mediastinum, fibrous capsule and bands of expanding cells
Lymphocyte predominant - neck limited disease, young adults
Lymphocyte depleted - oft retroperitoneal aggresive
Mixed celluarlity - very aggressive
HD course
80% cure rate
Dependent on stage, bulk, subtype

ESR can be used as a marker of activity
Treatment of stage I/II HD
Radiation only for some stage I

Abreviated Chemo + radiation
Treatment of advanced stage HD
ABVD chemo, anthracylcine based

Concerns: secondary malignancies (breast, lung, MDS, sarcoma)
Cardiac tox of anthracyclines
Primary refractory HD
Disease that grows through treatment or recurs in 6 months
Often rapidly progressive to death
Follicular lymphoma grade 3
Treated like a large cell
But still not curable
Follicular lymphoma chemo
Rituxan, cytoxan, vincristine, prednisone
Rituximab in follicular lymphoma
Makes a 20+ different upfront in combo

Maintenance therapy can improve PFS by 2 years
If antibiotics do not work for gastric MALT?
xrt to stomach
Precursor T cell lymphomas
Origin: immature T cells of thymus
Diffuse infilitration of thymus
Disease of teenagers, boys>girls
Aggressive and curable (70%)
Systemic symptoms of HD
B symptoms
Alcohol induced pain
Intratreament prognostic for HD?
Negative PET after 2 cycles
HIV and NH lymphoma
60-160x increased risk of NHL
25-40% lifetime risk
Mostly with <100 CD4s (except Burkitts)

Burkitt's, diffuse large cell, primary CNS, primary effusional
Hep C and NH lymphoma
Increased risk of marginal and diffuse B cell
Treating Hep C sometimes results in remission
Thought to be due to chronic antigenic stimulation
Acute lymphoblastic lymphoma/ lymphoblastic leukemia
Either T or B cell blasts

Say lymphoma if its less than 25% blasts in marrow and there is a mass
ALL epi
75% of cases are in <6 yo
80-85% are B cells in kids

Of adult leukemias, ALL is 20%, 75% are B cell
ALL presentation
Marrow symptoms -- fatigue, infection, bleeding

T cell precursor ALL may present with mediastinal mass
Pathology of ALL
Blasts in marrow and cytopenias is periphery
Myeloperoxidase negative

TdT positive, myelperoxidase negative
T : CD3, 7
B: CD10, 19

Many cytogenetic abnormalities
ALL outcomes
Better in kids: 80% cure
Adults: 40% cure
ALL treatment
Rapid resistance is a problem

Use multidrug induction and then long consolidation
CNS prophylaxis with XRT or intrathecal chemotherapy
-25% CNS relapse without
Many adults need allogenic transplant to survive
Chronic lymphocytic leukemia/ small lymphocytic lymphoma
Indolent course, not curable
CLL flow profile
CD5+, CD19+, CD23+
Not much Ig or CD20
10-, cyclinD1-
CLL presentation
Male (2:1)
> 50 (median is 65)
Lymphocytosis with small mature lymphocytes
CLL when to treat?
With B symptoms
Bulky/painful adenopathy
Organ involvement
Progressive splenomegaly, hepatomegaly
Lymphocyte doubling time < 1 year
Complications of CLL
Infections due to immunocompromise
Autoimmune disease ITP or hemolytic anemia
Rickter's transformation to diffuse large cell
Prognosis of CLL
Median is 9 years
Rai criteria - clinical
Cytogenetics : 17p is p53 loss-- BAD
Mutation status of IgVh: unmutated heavy chain indicates less mature cell = more aggressive
Surface markers: CD38, Zap70-- bad
Treatment of CLL
Prednisone, cyclophosfamide, fludaribine
Philadelphia chromosome in ALL
Either a progression from CML or de novo

Use imatinib
Smudge cell
Seen on smear
Fragile cell gets destroyed by process
Characteristic of CLL
Do we treat CLL based on cytogenetics?
Not yet

Remember early treatment has not been shown to help
CD52 monoclonal antibody
Use late in CLL
Problems with infections
Nitrogen mustard
Used in CLL (in combos)
CLL refractory to fludarabine
prognosis less than a year
Prolymphocytoid transformation
Another CLL transformation

Larger cells, less distinct nucleoli, less dense chromatin
Serum protein elctrophoresis
Separates proteins by size
Ig increases will be seen on serum protein elctrophoresis as?
Increases in the beta and or gamma regions
Spikes for monoclonal, more generalized increases for polyclonal
Polyclonal expansion states?
Infection, inflammation, reactivity
Monoclonal expansion states?
Urine electrophoresis
Can see light chains here

Bence-Jones proteins when found in urine
Serum immunofixation
Parallel runs of electrophoresis
Stain for different heavy chains and light chains
Can characterize the gammaglobinopahy
Monoclonal gammaglobinopathy of unclear significance
No symptoms, no lytic lesions, plasma cells in marrow <10%

25% of patients will get a hematologic disorder

Increasing prevalence with age (1% at 50, 8% at 80)
Multiple myeloma
Neoplasm of plasma cells
Mature cells that have undergone class switching

CD38 and 138 positive
Il-6 is growth factor
Multiple myeloma cytogenetics
Typically complex

Deletion 13 is bad
Mutiple myeloma Ig products
Intact antibody
Free light chain
Multiple myeloma symptoms
C - hypercalcemia
R - renal failure
A - anemia
B - bone lesions
I - infections
Pathogenesis of lytic lesions in mutliple myeloma
Il-6 and other cytokines increase osteoclast activity
Increased osteoclast activity results in hpercalcemia
Symptoms of hypercalcemia
Renal insufficiency
Mental status change
Hyperviscosity syndrome
2% of multiple myelomas, mostly Ms and As related
CNS symptoms, CHF, renal insufficiency, bleeding

Can be fatal
Solid tumor of plasma cells
Can be painful
Distribution in Igs of multiple myeloma
60% IgGs
20% IgAs - worse prognosis
Few IgDs
Rest are light chains
Workup for multiple myeloma
Bone marrow biopsy
B-2-microglobulin and prognosis in multiple myeloma
>4 bad
Diagnosis of multiple myeloma
Big M spike
Lots of plasma cells in marrow
Lytic lesions/end organ damage
Worse than MGUS but not multiple myeloma
Smoldering myeloma
Multiple myeloma prognosis
Not curable
7 months untreated
3-5+ years with treatment

Remission, relapse pattern
Cytogenetics, staging can predict
Multiple myeloma treatment
Alkylating agents and prednisone
Bortezomab/velcade - nfKB
thalidomide, lanolidomide - immune modulatory ( decrease Il-6, induce apoptosis, disruption of BM microenvironment)
Radiation to lytic, plasmacytomas
Autologous transplant?
Waldenstrom Macroglobemia
IgM disease
Post germinal center memory cell
Ranging from gammopathy to lymphoplasmacytic lymphoma with IgM

Hyperviscosity syndrome is a problem - plasmaphorese
Waldenstroma Macroglobemia treatment
Only symptomatic

Cytoxan, fludarabine, prednisone
relvlimid, velcade also active
Risk of progression from MGUS to multiple myeloma
1% per year
Increased chance of MGUS progression
IgA or IgM
Serum IgM protein size
Abnormal FLC ratio
Multiple myeloma epi
1% of new cancers
14% of hematologic malig
Increases with age
AA > caucasians
Amyloid AL
Light chain deposition in tissues
With or without myeloma

Prognosis is months if cardiac involvement

Treat like myeloma
Fundoscopic with hyperviscosity syndrome
Sausage-link, tortous retinal veins
Filtering out WBC from blood units
Must be <5 million

Makes CMV safe
Reduces febrile non-hemolytic transfusion reactions, HLA alloimmunization
Most/least frequent blood type
O and AB
Universal plasma donator
Non-ABO antigens
Rh, Kell, Kidd, Duffy...

Need exposure to have antibodies
Pregnancy is one way to get exposed
Complications of incompatibility
Hemolytic transfusion reaction
Hemolytic disease of the newborn
Extravascular hemolysis
ABO forward and reverse typing
Forward -- what will clump patients red cells
Reverse - what will patients serum clump
Solid phase antibody screen
Looking for non-ABO antibodies

Antigens on plate well
Anti-Ig tagged antibody
Immediate spin cross matching
Tests for ABO
Add a little of patient serum to proposed donor sample

If it clumps...don't use it
Anti-globulin cross matching
Test for non ABO
Add donor red cells to patient serum
Add anti-Ig antibody
Look for clumping
Transfusion indications
Symptomatic anemia

Usually not necessary if over 10
Usually necessary if under 7
Gray area RBC transfusion recommendations
Age 60-80, transfuse below 9
40-60, below 8
4 m - 40 years, below 7

Below 10 with age and recent MI
Platelet transfusion indications
Correction of low or dysfunctional platelets
Prophylaxis: in hospital <5, out patient <20

Treatment of microvascular bleeding 2/2 uremia or plt harming drugs
with Massive Transfusions
FFP indications
replacement of coagulation factors
Prophy with abnormal coag studies
Treat microvascular bleeding with abnormal coag studies

How much does hemoglobin go up in response to 1 unit of PRBCs
1 g/dl
How much does plt ct go up in response to unit of plts
Risk of contracting HIV vs fatal hemolytic transfusion rxn?
More likely to have a fatal hemolytic transfusion reaction
Hemolytic transfusion reactions are reactions against?
Red blood cells
Hypersensitivity transfusion reactions are against what?
Plasma proteins

Transfusions complications related to WBCs
Febrile transfusion reactions
Transfusion related acute lung injury
Graft vs host disease
Post transfusion purpura
Reaction against platlets
Risk of some type of transfusion reaction?
What to do when a transfusion rxn happens?
Stop the transfusion
Evaluate and treat patient
Send labs (bili, haptogloben, cbc) also on transfused blood
Check for clerical errors
Collect first urine
Pathogenesis of acute hemolytic transfusion reaction
Antibodies in plasma recognize antigens on red cells
Phagocytes are activated
Systemic activation of immune response
Factors effecting extent of hemolytic transfusion reaction
Antibody titers
Antibody class
Antigen concentration on cells
Antigen position on cells
Number of cells transfused
Components of hemolytic transfusion reaction and mediators
Fever, chills - Il-1, 6, TNFalpha
Shock, inflammatory response- complement (C3a, 5a), bradykinin
DIC -- coagulation cascade, thrombin

Kidney failure
Pathogenesis of kidney failure in hemoytic transfusion reaction
Hypotension - acute tubular necrosis
Immune complex glomerulonephritis
DIC -glomerular capillary thrombosis
Free Hgb-- leads to tissue damage and ischemia
Signs and symptoms of acute immune hemolysis
Can be asymptomatic
Fever, chills
Pain at iv site
Red urine
Back (kidney) pain
Outcomes of ABO mismatch transfusions
6% die
41% have morbility but survive
47% have no adverse effects
What is responsible for fatal transfusion reactions?
50% administrative errors
30% technical errors
Delayed hemolytic transfusion reactions
Occur 5-14 days later
Either a primary response to antigen or amnestic response with a latent population of memory cells

Fever, chills, signs of extravascular hemolysis
New alloantibody seen in serum

Rarely needs treatment
Explain antibodies in delay hemolytic transfusion reaction
Non intially
With transfusion, antibodies made
Antibodies attach to RBCs (direct Coombs positive)
More antibodies made, cells begin to lyse (direct and indirect positive)
All cells destroyed, antibodies in blood (indirect positive, direct negative)
Delayed serologic transfusion reaction
New antibodies detectable after transfusion but not hemolysis
Allergic transfusion reactions
Reaction to plasma proteins
Happens 1-3% of time
Uticaria, flushing, puritis, wheezing dyspnea
Treating allergic transfusion reactions
Stop transfusion
Give antihistamine
Give steroids
Give albuterol by neb
Anaphylactic or analphylactoid transfusion reactions
Reaction to IgA or other plasma protein
Occurs 1 in 20K or 50K

Dyspnea, larygneal edema, cynanosis, n/v/d, hypotension, shock, deah
Treating anaphylactic or analphlactoid transfusion reaction
Stop transfusion, eval patient
Give epinepherine, antihistamines, steroids
Support respiration and BP
Increased susceptibility to anaphylacic transfusion reaction
IgA deficiency
1 in 700
May have antibodies against all IgAs or a subtype that they are missing

Allergies to products that can be in blood (penicillin)
What do you do when a patient who has known anti-IgA needs a transfusion

Wash cells, plts

Use IgA deficient donors
Febrile transfusion reaction
Reaction to WBCs
Increase of 1C or 2F, chills, rigors, HA, n/v
Happens in 1% of RBCs, more in plts -- less with leukoreduced
Treating ferbile transfusion reaction
Stop transfusion
Rule out hemolysis
Give antipyretics
Mechanisms of febrile transfusion reaction
Classic -- recipients antibodies attack antigens on donor WBCs

Immune complex -- recipients antibodies react with antigens/proteins in donor and stimulate macrophages

Cytokines -- donor macrophages produce cytokines in storage, which are transfused in
transfusion related acute lung injury
Donor antibodies, recipient cells, host actors = bilateral lung infiltrates

Like ARDS but only 10% mortality
Pathophysiology of TRALI
Donor antibodies lead to complement activaiton--->C5a ---> PMNs that activate and damage pulmonary vascular bed (also other vasculatures probably)
Donors at risk for causing TRALI
multiparous women
recipients of multiple transfusions