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Hematopathology Preview

Fri. 10/15/2010
von Willebrand Disease platelet function problem (primary hemostasis). Bleeding time is elevated (the amount of time it takes for a laceration to clot). PT is normal. vWF serves as a receptor for platelets, and it is also the carrier protein for Factor VIII if abnormal vWF, may also have abnormal/deficient Factor VIII would give high PTT. This happens frequently, but not always (so change chart to high or normal). Hemophilia A Factor VIII deficiency the PTT will be elevated. DIC consumptive coagulopathy: bleeding clotting bleeding clotting etc = you use up everything. Bleeding time, PT, and PTT will be high. If you measured fibrinogen, it would be high. If you measured D dimer, it would be high. War/Hep If you are monitoring coumadin or heparin therapy, PT and PTT will be abnormal. Clinically, following the PT for coumadin therapy works best, and following the PTT for heparin works best.

or normal

von Willebrand Disease, Bernard-Soulier Syndrome, and Glanzmann Thromasthenia: von Willebrand Disease deficiency of vW factor Glycoprotein I = receptor for vW factor Glycoprotein II = the receptor for fibrinogen Bernard-Soulier Syndrome deficiency of Glycoprotein I (vW factor receptor) Glanzmann Thrombasthenia deficiency of Glycoprotein II (fibrinogen receptor)

Any of these can give rise to abnormal platelet structure. If a person has a low platelet #, will have problems w/primary hemostasis Thrombosis: many factors that favor it and many factors that inhibit it. Remember that in DIC, all the factors are consumed. Patients are clotting lysing clotting lysing. They use up all the platelets, the factors, the fibrinogen everything gets consumed and eventually they will bleed out. Factors that favor thrombosis: Tissue factor: produced by endothelial cells in response to cytokines (TNF, IL-1, bacterial endotoxin); major activator of extrinsic clotting cascade PAIs: produced by endothelial cells; inhibitors of plasminogen activator limit fibrinolysis and favor thrombosis Factors that inhibit thrombosis: Prostacyclin (PGI2) + NO: produced by endothelial cells to impede platelet adhesion Adenosine diphosphatase: degrade ADP Antithrombin III: with cofactor, inactivate thrombin Thrombomodulin: binds thrombin convert to anticoagulant via ability to activate protein C - Protein C inhibits clotting by inactivating Va + VIIIa Tissue Factor Pathway inhibitor (TFPI): cell surface protein that directly inhibits TF VIIa and Xa t-PA: protease cleaves plasminogen to form plasmin plasmin cleaves fibrin to degrade thrombi Remember that in DIC, all the factors are consumed. Patients are clotting lysing clotting lysing. They use up all the platelets, the factors, the fibrinogen everything gets consumed and eventually they will bleed out.
Test q: A 66F comes to the ER 3 hours after the onset of chest pain that radiates to her neck and left arm. She is diaphoretic and hypotensive; the serum troponin I level is elevated. Thrombolytic therapy is begun. Which of the following drugs is most likely to be administered? Tissue plasminogen activator. (Other choices: Aspirin, Heparin, NO, Vit K)

Fibrinolysis: Plasmin: breaks down fibrin and interferes with its polymerization FDPs: act as weak anti-coagulant factors Elevated FDPs (fibrin derived D-dimers) can be used in diagnosing abnormal thrombotic states, including DIC, DVT, pulmonary embolism Protein C + S: anti-coagulation factors; protein S is a cofactor for protein C; function to degrade activated factors VIII and V The Leiden mutation is a structural mutation in Factor V renders Factor V resistant to the action of Protein S and activated Protein C. Factor V still works, but it is no longer subject to the limitations of activated Protein C. Leiden mutation can lead to recurrent DVT.
Test q: A 25F has had multiple episodes of DVT during the past 10yr and one episode of pulmonary thromboembolism during the past year. PT, PTT, platelet count, and platelet function studies are all normal. Which of the following risk factors has most likely contributed to the patients condition? Leiden mutation. (Other choices: Antithrombin III deficiency, Mutation in protein C, Hyperhomocysteinemia, Smoking cigarettes) REPEATED x3

Above (both pictures): Thrombus causing microangiopathic hemolytic anemia. Patients w/DIC have abnormal multimers of fibrin in the blood vessels shred RBCs as they pass through. Microangiopathic, small blood vessels, hemolytic anemia. Destroy RBCs, and the fractured RBCs are called schistocytes. Schistocytes = microangiopathic hemolytic anemia. May have abnormal heart valve that could shred RBCs can also cause microangiopathic hemolytic anemia. DIC and certain types of leukemia can also cause this.
Test q: A 45M has a 3-day history of flank pain and fever. On phys exam, his temp is 37.9C. There is right costovertebral angle tenderness. Lab 3 studies include a urine culture that is positive for Escherichia coli. The WBC count is 13,310/mm . Two days later, he becomes hypotensive, and a blood culture is positive for E. coli. He requires increasing pressor support to maintain blood pressure. He develops a guaiac-positive stool and 3 ecchymoses of the skin. CBC shows Hgb 9.2 g/dL, hematocrit 28.1%, and platelet count 70,000/mm . Increased amounts of fibrin split products are identified in the blood (elevated D dimer). Which of the following conditions is most likely responsible for the low hematocrit? Microangiopathic hemolytic anemia. (MAHA). Robbins explanation: This patient has DIC, which can result from gram-negative septicemia. This is a form of MAHA in which there is deposition of fibrin strands in small vessels. The RBCs are damaged during passage between these strands. Coagulation factors and platelets are consumed, which does not occur w/other forms of hemolytic anemia.

Tumor Markers: PSA Prostate cancer = prostate specific antigen CEA Colorectal/Pancreatic CA 19-9 Pancreatic Alpha-fetoprotein Hepatic/Yolk sac Beta-HCG Choriocarcinoma/Molar pregnancy CA 125 Ovarian cancer S-100 Melanoma/Astrocytoma Thyroglobulin Thyroid cancer Calcitonin Medullary carcinoma of Thyroid Catecholamines Pheochromocytoma/Neuroblastoma TRAP stain Hairy cell leukemia = tartrate resistant acid phosphatase Alkaline phosphatase Mets to bones, Pagets disease of bone

Translocations: t (9;22) CML (bcr-abl) t (8;14) Burkitts lymphoma (c-myc) t (14;18) Follicular lymphoma (bcl-2) t (15;17) AML M3 (promyelocytic leukemia) t (1;14) T-cell Lymphoblastic lymphoma t (11; 22) Ewings sarcoma t (11; 14) Mantle cell lymphoma (bcl-1) t (11; 18) MALT lymphoma (API-2) t (1; 14) MALT lymphoma (bcl-10)

Test q: A 76M has experienced lower back pain for the past year. On phys exam, the physician palpates a firm nodule in the prostate. Lab studies show an alkaline phosphatase level of 290 U/L and a serum prostate specific antigen level of 17 ng/mL. A prostate needle biopsy specimen shows a moderately differentiated adenocarcinoma. Which of the following mechanisms best accounts for these findings? Metastases to vertebrae. (Other choices: Tumor extension to rectum; Paraneoplastic syndrome; High tumor grade; and Tumor angiogenesis) REPEATED x3

Test q: A 71M present to his primary care physician for a check-up accompanied by his wife, who reports that she had to push him out of the door to go to see a doctor as his last physical exam was almost 8yr ago. He states that he has been feeling well other than having some lower back pain. Phys exam reveals a firm, nodular prostate. On further questioning, the patient states that he has not noticed any change in urination. Lab studies reveal a mildly elevated serum prostate-specific antigen level and a serum alkaline phosphatase level almost three times normal. These findings are most consistent w/which of the following? Metastatic prostate carcinoma. Test q: A 77M has experienced increasing malaise and a 6kg weight loss over the past year. He has noted more severe and constant back pain for the past 3 months. On phys exam, his temp is 38.7C. His prostate is firm and irregular when palpated on digital rectal exam. Lab studies include a urine culture positive for Escherichia coli, serum glucose of 70 mg/dL, creatinine 1.1 mg/dL, total bilirubin 1.0 mg/dL, alkaline phosphatase 293 U/L, calcium 3 3 10.3 mg/dL, phosphorus 2.6 mg/dL, and PSA 25 ng/mL. CBC shows Hgb 9.1 g/dL, hematocrit 27.3%, MCV 94m , platelet count 55,600/mm , and 3 WBC count 3570/mm with 18% segmented neutrophils, 7% bands, 2% metamyelocytes, 1% myelocytes, 61% lymphocytes, 11% monocytes, and 3 nucleated RBCs per 100 WBCs. Which of the following is the most likely diagnosis? Metastatic carcinoma. Test q: Thyroglobulin is used clinically as: a tumor marker.

Figure: Blood smear. Want to find Goldilocks zone not too thick, not too thin, just right. Find area where red cells are just barely touching each other.

Above: -thalassemia. See RBC abnormalities. Howell-Jolly bodies nuclear remnants that remain in RBCs because patient does not have a functional spleen. Seen in sickle cell anemia patients because they infarct their spleen by age 6-7. These patients are also highly susceptible to infection by S. pneumoniae, Salmonella, H. influenzae (due to lack of spleen).

Above: Spherocytes RBCs are smaller and perfectly round. Hereditary spherocytosis abnormality in membrane of RBC take very small shape. These cells do not live 120 days (which classifies hereditary spherocytosis as a hemolytic anemia). Will see nucleated RBCs, spherocytes, and reticulocytes (aka polychromasia big blue cells, very young erythrocytes).

Above (left): Schistocytes fragmented RBCs. Seen in DIC, microangiopathic hemolytic anemia, mechanical heart valves. Above (right) : Can do reticulocyte count lab will tell you how many reticulocytes are present per 100. Useful when monitoring people with iron deficiency on iron therapy patients should start reticking. Reticking actively making red cells. People w/Fe deficiency do not make enough RBCs.

Above (left): Iron deficiency anemia. See lymphocyte RBCs are smaller than the lymphocyte (= microcytic). RBCs have exaggerated pale area in the middle (= hypochromic donut-looking, less color). Microcytic, hypochromic anemia fits iron deficiency. Poikilocytosis = abnormal shape. Anisocytosis = abnormal size. Anisopoikilocytosis = abnormal size and shape (describes iron deficiency). Above (right): megaloblastic anemia. Macrocytic anemia RBCs are larger than the lymphocyte. They are often oval-shaped, not round. Seen in folate/Vitamin B12 deficiency. In addition to large RBCs, will also see multisegmented neutrophils.

Case 1. 70 y.o. female with fatigue. No hemoptosis or vaginal bleeding. Normal physical exam except for pallor. When patients come in complaining of tiredness/have no energy, may indicate anemia not enough RBCs, not distributing enough oxygen to tissues. May also indicate a pulmonary disease. Blood smear: see lymphocyte compare RBC size microcytic. Some are hypochromic. Also see abnormal shapes. Anisopoikilocytosis. See platelets so no problem w/the platelets. CBC: Hgb 5.9 MCV 56.2 RDW 20.2 WBC 5,900 Plt 383,000 Normal: ~15 (man), ~14 (woman) 80-100 Teens (13-19) 4000-8000 200,000-400,000 Low. Not enough RBCs. MCV = volume of RBCs. Patients low value = microcytic anemia. Measure of size variation in RBCs. Patients is high. Normal. Normal.

Normally, hematocrit = 3x hemoglobin, so normal hemotocrit for man = 45; woman = 42. 1a. The RBCs show? A. Macrocytosis B. Hyperchromasia C. Spherocytosis D. Schistocytosis E. Anisopoikilocytosis too small and some are funny-shaped. 1b. What lab result would you expect? A. Elevated serum ferritin B. Elevated serum iron C. High serum iron and low TIBC D. Low serum iron and high TIBC E. Low serum iron and low TIBC

D High Total Iron Binding Capacity because 1c. Before the patient leaves your office you should? patient is trying to compensate. A. Order TSH and T3 B. Order TSH and T4 C. Prescribe multivitamins with iron D. Perform stool exam for occult blood ALWAYS check if patient is an older person w/iron deficiency anemia. E. Perform stool exam for hookworms and other parasites
Test q: A 70F complains of fatigue. She cites no history of hemoptosis or vaginal bleeding. Phys exam is normal except for pallor. CBC shows: Hgb 3 3 3 5.9 g/dL, MCV 56.2 m , RDW 20.2, WBC 5900/mm , Plt 383,000/mm , anisopoikilocytosis. What lab result would you expect? Low serum iron and high TIBC. Before the patient leaves your office you should? Perform stool exam for occult blood. BOTH PARTS REPEATED x2 Test q: A 73M has been healthy all his life. He takes no meds and has had no major illnesses or surgeries. However, for the past year, he has become increasingly tired and listless and appears pale. Phys exam shows no hepatosplenomegaly and no deformities. CBC shows Hgb 9.7 g/dL, hematocrit 3 3 3 3 29.9%, MCV 69.7mm (one year, MCV was 59.0), RBC count 4.28 million/mm , platelet count 331,000/mm , and WBC count 5500/mm . Which of the following is the most likely underlying condition causing this patients findings? GI bleed. REPEATED x2 (One year, answer was occult malignancy)

Case 2. 34 y.o. female with 2-day history of fever, petichiae and hematuria; also headaches and mental confusion. Symptoms are characteristic of thrombotic thrombocytopenic pupura (TTP). It is a consumptive coagulopathy (like DIC) bleeding clotting bleeding clotting. TTP has a pentad of symptoms (5 things): fever, thrombocytopenia (obvious because of petechiae), renal disease (hematuria), headache (CNS disease), and microangiopathic hemolytic anemia (MAHA). Blood smear: Platelets missing. See schistocytes, spherocytes, but platelets are used up. Microangiopathic hemolytic anemia. Fits TTP. CBC: Hgb 7.0 MCV 77 RDW 23 WBC 17,000 Plt 14,000 Low = anemic. Not too low High consistent w/the spherocytes, schistocytes, size variation. High Very low 2c. What test result would you expect? A. D dimer elevated B. Haptoglobin elevated C. Plasma free hemoglobin decreased D. BUN normal E. Urine protein negative A is correct. If you have a consumptive coagulopathy (clotting lysing clotting lysing), expect to see D dimer. B: Haptoglobin is a protein in blood that combines w/any free hemoglobin. If youre destroying RBCs (and releasing hemoglobin) it will complex w/haptoglobin haptoglobin level goes down in hemolytic anemia. C: If you are rupturing RBCs and releasing hemoglobin into the blood, plasma free Hgb will be increased. D: BUN is a measure of renal function patient has renal disease, so BUN will be abnormal. E: Patient will have proteinuria because of renal disease.
Test q: A 30F mother of 4 exhibits a dramatic fall in hematocrit after a trip to West Africa. Plasmodium falciparum is identified on a Wright stain of blood. In this patient: Haptoglobin is decreased; plasma free Hgb is increased.

2a. Describe the RBCs: A. Normochromic B. Microcytic C. Spherocytes and schistocytes D. Drepanocytes and schistocytes E. Howell-Jolly bodies Schistocytes are classic in MAHA, but you also usually see some spherocytes. 2b. Diagnosis? A. Sickle cell anemia B. Hereditary spherocytosis C. Thrombotic thrombocytopenic purpura (TTP) D. Anemia of chronic disease secondary to hypothyroidism E. Folate deficiency C. TTP unknown cause. Some kind of autoimmune disease can detect auto-antibodies, but the trigger is not known. Much more common in females. Treatment is exchange phoresis (trade plasma). Used to be universally fatal now can save 90% of patients. Tends to recur.

Test q: A 54F sees her physician because of sudden onset of headaches and photophobia. This condition has been worsening for the past 2 days. On 3 3 phys exam, she has a temperature of 38C and is disoriented. CBC shows Hgb 11.2 g/dL, hematocrit 33.7%, MCV 94m , platelet count 32,000/mm , 3 and WBC count 9900/mm . The peripheral blood smear shows schistocytes. The serum urea nitrogen level is 38 mg/dL, and the creatinine level is 3.9 mg/dL. Which of the following is the most likely diagnosis? Thrombotic thrombocytopenic purpura.

Case 3. 34 y.o. male in for routine physical has pallor and icterus; splenomegaly on PE Pale = not enough RBCs, not enough oxygenation. Icteric breaking down RBCs and releasing Hb. Blood smear:See lymphocyte, platelets. Lots of spherocytes (small, round RBCs), polychromasia (reticulocytes). Everything fits hemolytic anemia. CBC: Hgb 11 MCV 84 WBC 6,000 Plt 350,000

Hgb low. Rest normal.

3a. Describe the RBCs. A. Normochromic B. Schistocytosis C. Microcytic D. Spherocytosis perfectly round and dark red E. Hypochromic

3b. What test should you order to confirm your diagnosis? A. Serum iron B. Osmotic fragility C. Reticulocyte count D. Malaria screen E. D dimer

Osmotic fragility is a test for hereditary spherocytosis (spherocytes die quickly in salt water). In this case, the spleen is large because the spleen destroys spherocytes. Spleen recognizes that they are not normal shape or size and destroys them they do not live 120 days (definition of a hemolytic anemia). Hemolytic anemia can occur in the blood vessels or in the spleen (intravascular vs. extravascular).

Case 4. 37 y.o. female treated lifelong for a seizure disorder complains of fatigue and lightheadedness. A lot of seizures medications predispose to vitamin B12 deficiency. These patients frequently develop macrocytic anemia. Blood smear: See hypersegmented neutrophil. No lymphocytes present for size comparison (RBCs), but these are large, oval RBCs = macrocytosis. CBC: fits w/macrocytic anemia. Hgb 6 Low MCV 130 High WBC 6,000 Normal Plt 220,000 Normal 4a. All of the following correctly describe the RBCs EXCEPT: A. Normochromic B. Macrocytic C. Anisocytosis D. Ovalocytosis E. Spherocytosis not this. Would look small. A bone marrow aspirate was performed On bone marrow aspirates, tend to see giant band neutrophils. The final stage in neutrophil development is the segmented neutrophil, and the step immediately before that is the band neutrophil. If you have >5 segments in a neutrophil, too many = macrocytic anemia. The labeled band at the top is huge should be the same size as a neutrophil, but this is 2-3x bigger. Giant bands, hypersegmented neutrophils in bone marrow = macrocytic anemia. 4b. What findings on the bone marrow aspirate suggest folate deficiency? A. Hyposegmented neutrophils B. Hypocellularity C. Giant bands and hypersegmented neutrophils D. Miniature bands and hypersegmented neutrophils E. Hypersegmented blasts and promyelocytes
Test q: A 37F has been treated lifelong for a seizure disorder and now complains of fatigue and lightheadedness. CBC shows: Hgb 6g/dL, MCV 130 3 3 3 mm , WBC 6000/mm , Plt 220,000/mm , ovalocytosis, hypersegmented neutrophils. You suspect: Dilantin treatment and folate deficiency.

LEUKEMIA: Acute ALL and AML Hi/Low WBC (unpredictable) Rapidly fatal if untreated (matter of weeks); anemic and thrombocytopenic (almost always. Patient is very sick.) Curable

Chronic CLL and CML Always high WBC Slowly progressive- patient lives many years Difficult to cure

M = myeloid (granulocytic); L = lymphoid (as in ALL, AML, CLL, CML).

Acute Leukemias: There are two stem cells types in the bone marrow lymphocytic/plasma cell lineage and RBC/megakaryocyte/granulocyte/monocyte (everything else) lineage. ALL has only one type (lymphocyte). AML has many varieties. Promyelocyte M3 version. Produces MAHA and DIC. Unique presentation, unique treatment.

5a. In Acute Leukemias you will almost always find: A. Normal hct, normal platelets B. Normal hct, decreased platelets C. Decreased hct, increased paltelets D. Anemia, thrombocytopenia E. WBC count >100,000 D: Patient is always really sick.

5b. In Chronic Leukemias you will almost always find: A. Anemia, thrombocytopenia B. WBC count >50,000 C. Normal hct, increased platelets D. Anemia, thrombocytosis E. Circulating blasts

Above: lymphoblasts. Not normal lymphocytes very large (compare to RBCs). Have nucleoli all over the place, very active-looking chromatin (so they are blasts). Cannot tell by looking at this whether they are lymphoblasts or myeloblasts can definitely tell they are blasts, however. = Acute leukemia. Must do more testing to figure out which one.

Above: ALL (PAS stain). ALLs (lymphoid in origin) are PAS + and myeloperoxidase (MPO) negative. Makes sense since MPO is made by granules in granulocytes so AMLs are MPO positive.

Myeloid Precursors Segmented PMN normal, mature cell. Band is step immediately before. In a normal patient, should not see any blasts. Blast is very early stage if you see lots of blasts, it is an acute leukemia.

Above: Immature granulocytes (left shift). See lots of granulocytes in infections body produces lots of granulocytes in response to bacteria (WBC count very high). Will see normal granulocytes, bands, metamyelocytes, but NO BLASTS. If you have an infection and a high neutrophil count, will get a left shift lots of immature forms. Benign condition.

Above: CML. Also see spectrum of cell stages, but especially see lots of BLASTS w/nucleoli. When a patient comes in with a high granulocyte count, your differential must include both benign condition and leukemia. If WBC count >50,000, leukemia. If less than 50, usually leukemoid reaction (left shift).

Above: LAP stains. LAP = leukocyte alkaline phosphatase. Made by normal granulocytes, not CML cells. If left shift (leukemoid reaction - benign conditions), LAP score will be >20. If CML, they dont make it at all, so LAP score will approach 0. Left: alkaline phosphatase stain. Benign cells. Right: LAP, CML.

Test q: A 37F visits her physician because of a cough and fever of one weeks duration. On phys exam, her temp is 38.3 degrees C. She has diffuse 3 crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. CBC shows Hgb 13.9 g/dL, hematocrit 42%, MCV 89 m , platelet 3 3 count 210,000/mm , and WBC count 56,000/mm with 63% segmented neutrophils, 15% bands, 6% metamyelocytes, 3% myelocytes, 1% blasts, 8% lymphocytes, 2% monocytes, and 2% eosinophils. The peripheral blood leukocyte alkaline phosphatase score is increased. Which of the following is the most likely diagnosis? Leukemoid reaction. REPEATED x4 (Once, was a 50M instead)

Above: The real diagnosis of CML is made by cytogenetics demonstrating that a small piece of chromosome 22 breaks off and attaches to chromosome 9 (9;22 translocation).

Above: FISH can also diagnose if ABL (green) and BCR (red) genes are on the same chromosome, will see a yellow color (right).

Above: CML and AML. See many blasts. CML a mixture of forms (segmented neutrophils, bands, metamyelocytes, blasts but relatively few blasts). AML pretty much all blasts (no spectrum of forms).

Above: Left = AML. Can tell they are blasts because they are 4x the size of RBCs and have prominent nucleoli. Know it is acute leukemia, but cannot tell which one. Right: Presence of Auer rod (little red rod) = AML. Auer rods are crystallized myeloperoxidase same thing as on MPO stain. Auer rods are only seen in AML, but you dont have to have Auer rods to call it AML. Most AMLs do not have Auer rods.

M0-M7 stages classified based on how the cells look:


Below: Myeloperoxidase (MPO) AMLs are MPO positive.

M1 Myeloblastic. M2 Myeloid. M3 look like promyelocytes (intermediate stage in granulocyte production), so named promyelocytic leukemia. Lots of granules = DIC in patient (cause MAHA). Auer rods common. Very fast progression dead in a few days w/o treatment. For promyelocytic leukemia treatment, use retinoic acid. M4 myelomonocytic (in between granulocyte and monocyte).

Above: Sudan Black stain. AMLs are MPO positive. If moving toward monocyte side of spectrum, may also be Sudan black + (fat stain). May be fat stain + or non-specific esterase +.

Above: Nonspecific esterase. If Sudan black + and nonspecific esterase +, is either a myelomonocytic cell or monocytic cell.

Above: M5 monocytic leukemia. Patients present with ULCERS (deposits of these cells in the mouth). If they have mouth ulcers or hyperplasia of the gums = monocytic leukemia. If patient presents w/MAHA, it is promyelocytic leukemia.

Test q: The myeloperoxidase stain is generally positive in: M2, M3, M4.

Above: M6 erythroid (RBC). M7 megakaryocytic version.

Case 6. 25 y.o. male with fever, recurrent URIs and submandibular swelling; also poor wound healing. Submandibular swelling indicates problems in the mouth. Blood smear: See fold in cell (top right) monocyte-like. Also see Auer rod in cell (bottom right). This is an AML but going toward the monocytic series. CBC: Hgb 9.9 MCV 106.3 WBC 7.9 (70% abnormal cells) Plt 50,000 Platelets are low, patient is anemic. WBC w/acute leukemias remember: may or may not be high. 6a. Diagnosis? A. ALL B. AML because Auer rod is present. C. CLL D. CML E. Hereditary spherocytosis 6b. Which test on a bone marrow aspirate confirms your diagnosis? A. MPO (-) B. MPO (+) C. PAS (+) D. Iron stain (Prussian blue) E. Leukocyte alkaline phosphatase = 20

Test q: A 25M has rever, recurrent URIs and submandibular swelling; also poor wound healing. The peripheral blood smear shows WBCs w/high nucleus-to-cytoplasm ratio, prominent nucleoli, and red, needle-like cytoplasmic inclusions. Diagnosis? AML (M2). Which test on a bone marrow aspirate confirms your diagnosis? MPO(+).

Case 7. 6 y.o. male with URIs, headache, bone pain and easy bruising; axillary and cervical lymphadenopathy; hepatosplenomegaly. Easy bruising = low platelets (thrombocytopenia). If a young child, usually have ALL. Blood smear: Top middle cell prominent fold. Right top boxing glove. Cells look monocytic. Cleaves in cells butt cells or plumber cells. Big cells, nucleoli = acute leukemia. Cannot tell which one just by looking. Because the patient is 6 years old = ALL. CBC: Hgb 9 MCV 82 WBC 92,000 (86% abnormal) Plt 18,000 7a. Diagnosis? A. ALL B. AML C. CLL D. CML 7b. What test results are expected on a bone marrow aspirate? A. MPO (+), PAS (+) B. MPO (-), PAS (-) C. TdT (+), Precursor B cell (+) D. TdT (-), Precursor T cell (+) E. Sudan black B (+); CD 10 (-) C. TdT positive and precursor B cell positive. Would be Sudan black + if we saw monocytic cells. CD10 (cluster designation) ALL marker (aka CALLA: common ALL antigen). If patient has ALL, will be CD10+.

Case 8. 15 y.o. male with flulike symptoms; axillary and cervical lymphadenopathy; gums are thick and bleeding. Blood smear: Boxing-glove nuclei. Look like monocytes. CBC: Hgb 9 MCV 90 WBC 42,000 (88% abnormal) Plt 22,000 BM Bx results: MPO (-) PAS (-) Sudan Black B (-) Non-specific esterase (++) marker for monocytic series. Serum lysozyme 162 (4-15 normal)

Patient is anemic; platelets are low. 8. A. B. C. D. E. Diagnosis: AML (FAB M1) AML (FAB M3) AML (FAB M5) ALL (L1) Infectious mononucleosis
3

Test q: A 15M present w/flu-like symptoms; axillary and cervical lymphadenopathy; gums are thick and bleeding. CBC shows: Hgb 9g/dL, MCV 90mm , 3 3 WBC 42,000/mm (88% abnormal), Plt 22,000/mm , blasts present. Bone marrow biopsy results: MPO (-), PAS (-), Sudan Black B (-), non-specific esterase (++), serum lysozyme 162 (4-15 normal). Diagnosis? AML (FAB M5). Test q: A 25F visits her physician because she has had bleeding gums for the past 3 weeks. Phys exam shows that her gingivae are thickened and friable. She has hepatosplenomegaly and generalized nontender lymphadenopathy. CBC shows Hgb 11.2 g/dL, hematocrit 33.9%, platelet count 3 3 95,000/mm , and WBC count 4500/mm with 25% segmented neutrophils, 10% bands, 2% metamyelocytes, 55% lymphocytes, 8% monocytes, and 1 nucleated RBC per 100 WBCs. A bone marrow biopsy specimen shows 100% cellularity, with many large blasts that are myeloperoxidase negative and nonspecific esterase positive. Which of the following is the most likely diagnosis? Acute monocytic leukemia. Test q: A 22y/o university student reports easy fatigability of two months duration. On phys exam, she has no hepatosplenomegaly or 3 3 lymphadenopathy. Mucosal gingival hemorrhages are noted. CBC shows Hgb 9.5 g/dL, hematocrit 28.2%, MCV 94m , platelet count 20,000/mm , and 3 WBC count 107,000/mm . A bone marrow biopsy specimen shows that the marrow is 100% cellular with few residual normal hematopoietic cells. Most of the cells in the marrow are large, w/nuclei having delicate chromatin and several nucleoli. The cytoplasm of these cells has azurophilic, peroxidasepositive granules. Which of the following is the most likely diagnosis? Acute myelogenous leukemia.

THIS IS WHERE WE STOPPED IN CLASS. BELOW ARE THE REMAINING 26 SLIDES: Case 9. 39-year-old female has routine workup for fibrocystic disease of breast; splenomegaly present. CBC: Hgb 13 MCV 96 WBC 133,000 (seg 56, band 15, meta 13, myelo 4, pro 3); baso 1, eo 1 Plt 130,000 9. A. B. C. D. E. What test should you order on a bone marrow aspirate? MPO PAS Sudan black B LAP TRAP

10. 30-y/o. female; anemia, thrombocytopenia; CBC- blasts w. Auer rods, schistocytes. Diagnosis? A. ALL B. AML, M1 C. AML, M3 D. AML, M5 E. TTP

Quick Look at Lymphomas: Hodgkin RS Cells Often curable Stage important Few malignant cells < cell-mediated Localized radiation Non-Hodgkin Low grade- slowly progressive, rare cure High grade- rapidly progressive; a minority are curable Grade important Mostly lymphoma < humoral Systemic chemotherapy

Follicular hyperplasia, lymph node. See benign follicles, mantle zone.

Follicular hyperplasia, lymph node. See benign follicles, mantle zone.

Follicular hyperplasia, lymph node. See mantle zone, dark zone, and light zone. See tingible body macrophages.

Follicular hyperplasia, lymph node. See tingible body macrophages, mantle zone, and lymphoycytes.

Follicular lymphoma, lymph node. See follicles.

Follicular lymphoma, lymph node. See follicles.

Follicular lymphoma, lymph node. See lymphocytes.

SLL/SLL, lymph node. See lymphocyte infiltration.

SLL/CLL, spleen see lymphocyte infiltration.

SLL/CLL, lymph node. See lymphocytes.

Burkitt Lymphoma, soft tissue. See tingible body macrophages (stars) and lymphocytes (sky).

Burkitt Lymphoma, soft tissue. See stars and sky.

Nodular Sclerosis Hodgkin Lymphoma, Lymph Node. See fibrous bands, nodules.

Hodgkin Lymphoma. See eosinophils, lymphocytes, and Hodgkin cells.

Hodgkin Lymphoma, Spleen. See lymphocytes and Reed-Sternberg cells.

Radiograph of Plasma Cell (Multiple) Myeloma. See punched out lesions.

Plasma cells and bone spicule.

Plasma Cell (Multiple) Myeloma, Bone. See plasma cells.

Laboratory Session: Abnormalities of Hemostasis

Wed. 10/13 or Thurs. 10/14/10

This is the lab talk from the first lab week of this block I usually dont post lab material, but there are some lecture test qs from this material. There is a balance of factors that favor thrombosis and factors that inhibit thrombosis. If the balance is thrown off, may have bleeding or may have thrombosis. (See page 1 of this study guide for complete info on the pro- and anti-thrombotic factors)

Primary Hemostasis: 1. Platelets bind via glycoprotein Ib (GpIb) receptors to von Willebrand factor (vWF) on exposed ECM and are activated, undergoing shape change and granular release 2. Released ADP and TxA2 induce additional platelet aggregation through platelet GpIIb-IIIa receptor binding to fibrinogen primary hemostatic plug vWF helps platelets stick to the endothelium. Plavix blocks the ADP receptor blocks adherence/aggregation of platelets.
Test q: The 3 factors involved in primary hemostasis are: Platelets, endothelium, and von Willebrand factor.

Secondary Hemostasis: Local activation of the coagulation cascade (involving tissue factor and platelet phospholipids) results in fibrin polymerization, cementing the platelets into a definitive secondary hemostatic plug. Tissue factor (Factor III, thromboplastin): membrane-bound procoagulant glycoprotein synthesized by endothelial cells. Acts in conjunction with factor VII as major in vivo initiator of coagulation cascade eventually thrombin generation Coagulation Cascade: Thrombin is the most important coagulation factor At end of proteolytic cascade, thrombin converts fibrinogen into fibrin monomers that polymerize into an insoluble gel. Fibrin gel encases platelets Fibrin polymers are cross-linked and stabilized by factor XIIIa Binding of coagulation factors II, XII, IX, X to calcium depends on addition of y-carboxyl groups to certain glutamic acid residues. Reaction uses Vitamin K as a cofactor and is antagonized by drugs such as coumadin.

Intrinsic pathway: Expose Hageman factor (XII) to thrombogenic surfaces. Extrinsic pathway: Most physiologically relevant pathway for coagulation to occur following vascular damage. Activated by tissue factor, expressed at sites of injury. Ischemia and tissue damage activate Factor VII complexes w/tissue factor.

Vitamin K Dependent Factors: II VII IX X Protein C Protein S Fetal Bone Protein Vitamin K deficiencies- liver disease, malabsorptive disorder
Test q: Vitamin K dependent factors and proteins include all of the following EXCEPT: VIII. (Other choices: II, VII, X, Protein S)

Test of Primary Hemostasis:

<10,000 platelets = spontaneous bleeding <40,000 platelets = dont take to surgery because trauma possible (although wont get spontaneous bleeding) Bleeding time = platelet activity

PFA-100 Instrument:

aspirin affects platelet aggregation

PFA-100: Objective test (vs Bleeding Time) Collagen + Epi prolonged = ASPIRIN Collagen + Epi and collagen + ADP prolonged = VON WILLEBRAND
Test q: A 51y/o obese woman w/a history diabetes mellitus had a myocardial infarction three months ago. She is now taking a low dose of aspirin to reduce the risk of arterial thrombosis. On which of the following steps in hemostasis does aspirin have its greatest effect? Aggregation of platelets. (Other choices: Adhesion of platelets to collagen, Production of tissue factor, Synthesis of vWF, and Synthesis of antithrombin III) REPEATED x3 review question from Exam 1 but showed up on 3 different years of Exam 2, too.

Tests for Secondary Hemostasis:

INR (want between 2-3) used to measure Coumadin therapy

used to measure Heparin therapy

Abnormal PTT in hemophilia and Von Willebrands Disease.

Fibrinolysis: Plasmin: breaks down fibrin and interferes with its polymerization FDPs: act as weak anti-coagulant factors Elevated FDPs (fibrin derived D-dimers) can be used in diagnosing abnormal thrombotic states, including DIC, DVT, pulmonary embolism Protein C + S: anti-coagulation factors; protein S is a cofactor for protein C; function to degrade activated factors VIII and V

Lupus anticoagulant Leiden mutation resistant to contol by Prot C & S (anticoagulant factors)

Lupus- anti-coagulant factor (in vitro) b/c increase PTT Leiden mutation: single-nucleotide mutation in factor V Recurrent DVT Factor V resistant to cleavage by Protein C (anti-coagulant factor)

Case 1:

Bleeding into joint after minor fall + no family history of bleeding disorder Hemophilia A: most commonly familial but also sporadic

The high APTT is consistent w/hemophilia. Normal PT.

Factor VIII mutation is most common. Factor IX is #2.

Below: Hemophilia shows bleeding into joints and/or large muscles.

Above: symptoms of hemophilia. Includes easy bruising, hepatitis, muscular hematomas, CNS hemorrhages, Pneumocystis pneumonia (in AIDS), operative/post-operative bleeding, and spontaneous hemarthoses (bleeding into joints).
Test q: A 6yo child has a long history of a hereditary bleeding disorder characterized by spontaneous nontraumatic hemorrhages into joint spaces, skeletal muscle, and mucous membranes. Lab studies reveal a normal PT, elevated PTT, very low factor VIII, normal factor X, normal factor CI, and normal platelet aggregation studies w/ristocetin. Which of the following is the most likely diagnosis? Hemophilia A. Test q: A common complication in patients w/hemophilia is: Hemarthrosis. Test q: A 5y/o boy has had a history of easy bruising and blood in his urine since infancy. Phys exam shows no organomegaly. He has several 3 ecchymoses of the skin on the lower extremities. Lab studies show Hgb 13.1 g/dL, hematocrit 39.3%, platelet count 287,600/mm , WBC count 3 6830/mm , PT 13s, PTT 54s, and less than 1% factor VIII activity measured in plasma. If he does not receive transfusions of recombinant factor VIII concentrate, which of the following manifestations of this illness is most likely to ensue? Hemarthroses. REPEATED x2

Hemophilia: Usually X-linked but not always clear.

Case 2:

However, note that there is no bleeding into joints, muscles, CNS.

Lab screen tests: Bleeding time is elevated. Could indicate the absence of von Willebrand factor (defect in primary hemostasis).
Test q: Which of the following is responsible for a defect in primary hemostasis? von Willebrand factor. (Other choices: Factor V; Factors II, VII, IX, and X; Factors VIII and IX; Fibrinogen)

Symptoms include mucous membrane bleeding, ecchymoses, and bleeding from venupuncture sites. There is no bleeding into joints or muscles.

Platelet activation by ADP triggers conformational change in the platelet GpIIb-IIIa receptors that induces binding to fibrinogen, a large protein that forms bridging interactions between platelets promote platelet aggregation. Platelet adhesion to ECM is mediated largely via interactions with vWF, which acts as a bridge between platelet surface receptors (glycoprotein Ib) and exposed collagen. vWF associations are needed to overcome the high shear forces of flowing blood. Bernard-Soulier syndrome: deficiency in vWF receptor (or GpIb) von Willebrand disease: deficiency in vWF Glanzmann thrombasthenia: absence of GPIIb-IIIa complex

Case 3:

Chronic diarrhea = Malabsorbing fat = malabsorbing Vitamin K Steatorrhea = fat in stool (abnormal). Sudan black (fat) stain will be positive.

Intrinsic (II, IX, X) and extrinsic (VII) coagulation cascade abnormalities are present. Vitamin K deficiency. Vitamin K Dependent Factors: II VII IX X Protein C Protein S Fetal Bone Protein
Test q: A Caucasian infant presents w/failure to thrive and chronic diarrhea. There is oozing from a recent skin laceration. Stoll sample testing reveals steatorrhea. Diagnosis: Vitamin K deficiency. Test q: An infant born at term has Apgar scores of 8 and 9 at one and five minutes. The infant appears healthy, but three days after birth, there is bleeding from the umbilical cord stump, and ecchymoses are observed over the buttocks. Seizures soon develop. A deficiency of which of the following nutrients best accounts for these findings? Vitamin K (Other choices: Iron, Vit E, Folic acid, Iodine)

Case 4:

Preeclampsia: hi BP, proteinuria, edema, predisposed to develop DIC (constantly clotting and lysing using up coagulation factors, fibrinogen). Cause: tissue anoxia or ischemia trigger event. Preeclampsia can also lead to eclampsia (life-threatening for mother and baby).

Normal: PT, PTT because not full blown eclampsia D-dimers increased: b/c constant clot and lyse; all factors used up eventually in DIC

Schistocytes = chopped up RBCs. Above (middle): Schistocyte in microangiopathic hemolytic anemia, most commonly seen with DIC. Microvascular lesion that results in luminal narrowing, often due to deposition of fibrin and platelets. Vascular changes produce shear stresses that mechanically injure passing red cells. Regardless of cause, traumatic damage leads to appearance of red cell fragments (schistocytes) in blood smear. Above (right): Child w/DIC secondary to H. influenzae sepsis. DIC also in infectious disease. DIC may be complication of anything that goes wrong with placenta.
Test q: A 60M has developed widespread ecchymoses over the skin in the past month. His medical history includes a diagnosis or mucinous adenocarcinoma of the rectum. On phys exam, he appears cachectic and pale. An abdominal CT scan shows multiple hepatic masses. Lab studies 3 show PT 30s, PTT 55s, platelet count of 15,200/mm , fibrinogen level of 75 mg/dL, and fibrin split product levels (D dimer) that are very elevated. Which of the following morphologic findings is most likely to be present on exam of his peripheral blood smear? Schistocytes. REPEATED x2 Robbins: The patient has DIC schistocytes. Test q: A 23F in her 25 week of pregnancy has felt no fetal movement for the past 3 days. Three weeks later, she still has not given birth and suddenly develops dyspnea w/cyanosis. On phys exam, her temp is 36.9C, pulse 102/min, respirations 21/min, and blood pressure is 80/40 mm Hg. She has large ecchymoses over the skin of her entire body. A stool sample is positive for occult blood. Lab studies show an elevated PT and PTT. The platelet count is decreased, plasma fibrinogen is markedly decreased, and fibrin split products are detected. A blood culture is negative. Which of the following is the most likely cause of the bleeding diathesis? Increased consumption of clotting factors and platelets. (Other choices: Increased vascular fragility, Toxic injury to the endothelium, Reduced production of platelets, Defects in platelet adhesion and aggregation.) Robbins: The presence of thrombocytopenia, increased PT/PTT/fibrin split products, and low fibrinogen concentration all suggest DIC, which was most likely caused by a retained dead fetus, an obstetric complication that can lead to DIC through release of thromboplastins from the fetus. This release causes widespread microvascular thrombosis and consumes clotting factors and platelets.
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Case 5:

PFA-100 is somewhat decreased. Likely to thrombose.

Counter-regulatory mechanisms, mediated by tissue plasminogen activator (t-PA, fibrinolytic product) and thrombomodulin, confine hemostatic process to site of injury. Thrombomodulin: bind to thrombin and converts it from procoagulant into anticoagulant via its ability to activate Protein C, which inhibits clotting by inactivating factors Va and VIIIa.

DVT can break off to cause pulmonary embolus.

Above: Can do perfusion scan to check for pulmonary embolus.

Lab preview for next week: Goldilocks spot; not too thick and not too thin:

Iron deficiency anemia.

Sickle cell anemia is an example of a hemolytic anemia.