1. In CDAII - Ham test is+ only with heterologous serum

2. In PNH - both homologous and heterologous serum is +

"=

"AML-M7

"

"M5 - myelomonocytic

"

Proliferative retinopathy

1. HPLC

2.Measures HbA, HbA2, & HbF

6 months

1. Both Hb C & S have mutation in position 6

2. C = lysine & S = valine

B-12

1. CML & other myeloproliferative disorders (CMML)

2. Hairy cell leukemia

1. Hyaline-vascular = solitary, common, mediastinum;

2. Plasma cell = multicentric, uncommon, HHV-8 assoc.;

3.Plasma cell is associated with POEMS;

1. Sjogren's

2. Rheumatoid arthritis (active)

3. Syphillis (2^ndary)

NBT test - abnormal WBC granules will not reduce NBT stained cells

1. Hb-lepore - seen in Mediterranean peoples

2. Caused by fusion of delta-beta genes; product is poorly produced

3. Abnl. Hb resides in 'S' band on electrophoresis

Hb(CS) is an alpha thal due to mutation in the normal stop-codon resulting in longer-than-usual alpha globin

1. HbEE only has minimal severity

2. HbCC also has minimal severity

3. Both E/thal and SC are severe, however

Hb Barts (Y4= --/--) 

HbH (B4=a-/--)

[-].......................................[+]

C-A2   S   F   A

(Call San Fran Airport)

(alkaline)

C-A2    S    A    F

('Cause Something's A Foot)

(acid)

light carbonic anhydrase band, A2, F, A

1. Congenital Dyserythropoietic Anemia Type II

2. It is characterized by multinucleated erythroid precursors

3. Hemolysis in acidified heterologus serum (Ham's test)

1. Hereditary pyropoikilocytosis

2. Usually a transient condition in neonates

1. [Mg] is inversely proportional to the specificity of the amplification reaction

Whare are the most common translocations in childhood vs. Infant luekmeias?

1. Childhood (>12 months) = t(12;21), seen most often in ALL, thus overall most frequent

2.  t(8;21) within AML subgroup

3. Infant (<12 months) = 11q23

"

1. 30% of adult ALLs have Ph vs. 5% of childhool ALLs

1.  t(8;14) - 14 is Ig

2. t(2;8) - 2 is kappa

3. t(8;22) - 22 is lambda

1. Factor V Leiden = R506Q - defect in APC cleavage site

2. Variant prothrombin = G20210A - elevated prothrombin

3. ATIII resistance = Type 1: low amount, Type 2: nonfunctional

Which two disorders have prolonged aPTT but increased risks of thrombosis?

Which one has an increased risk of arterial thromobses?

1. Factor XII deficiency- markedly prolonged aPTTs

2. anti-phospholipid syndrome - increased risk of arterial thrombosis (unlike other prothrombotic syndromes)

Type IIb shows enhanced ristocetin induced aggregation

1. Chediak-Higashi - inclusions in PMNs and platelets

2. Wiskott-Aldrich - micro platelets, eczema, thrombocytopenia

1. Factor XIII

2. Deficiency in Fac13 is evaluated by clot sensitivity to urea

1. GPIb = vWF receptor

2. GPIIb/IIIa = fibrinogen receptor

12 hours

1. Reference measures cyantomethemoglobin

2. Measures at 540 nm

1. Prolonged sulfonamide drug therapy

2. C. perferingens bacteremia

1. MPO & SudanBB are seen mostly within myeloid leukemias

2. Pas granules are seen in lymphoblasts

3. Oil-red-O stains vacuoles of Burkitts

1. Increased risk of arterial thromobses

2. Arterial thrombosis risk also seen in anti-phospholipid syndrome

1. HbF causes underestimation of calculated (not directly measured) O2 saturation

2. HbF also causes false elevation of CO by oximetry

1.  665 and 950

2. HbF does not interfere with O2 status

Group O individuals

A separate reference range should be used for vWF levels in these patients

1. vWF, type 2N

2. Defect in binding of vWF to Factor VIII, leading to increased loss of Factor VIII

3. Suspect in females with supposed Factor VIII deficiency

1. HbC (tons of targets)

2. Hb D (Punjab)

3. HbE (SE asia)

4. Hb O-Arab (Rare in arabs)

1. Storage pool disorders = disorders in platelet granules (Gray plt syndrome - Chediak-Higashi, Hermansky-Pudlak, TAR)

2. aspirin effect

1. Hermansky-Pudlak

2. Watch out! Chediak-Higashi also has albinism and platelet dysfunction - but shows neurologic defects and association with lymphoma

Chediak-Higashi

Autosomal recessive

Blue, chunky inclusions

Large platelets

Hyperdiploidy >50

12;21

TB-drugs

copper def

EtOH

Zn toxicity

Multiple myeloma

ATLL

unusual presentation of ALL

Ribosomes

Erythroid ribosomes tend to cluster in groups

Chediak-Higashi

Hermansy-Pudlak

Thrombocythemia-Absent Radius

Wiskott-Aldrich

No aggregation with Ristocetin, but all others work fine.

GPIb - vWF interaction problems

Glanzmann's thrombasthenia

GPIIb/IIIa defect

vWD type 2N - abnormality of vWF binding to factor VIII.

Results in loss of proteolytic protection for FVIII, and low levels.

Platelet Alpha-granues

one of the macrothrobocyte disorders

normal

d(5q)

d(20q)

5;17 - NPM; ATRA responsive

11q23;17 - PLZF; ATRA resistant

11q13;17 - NuMA; ATRA responsive

add Ph

i(17q)

+ 8

1.  Monitor with aPTT

2. Hirudin - renal excretion

3. Agrabatan - hepatic excretion

1. anti-PF4 = HIT

2. Cardiac bypass surgery

Alpha-napthyl-butyrase

Alpha-napthyl acetate esterase

(all are NSEs)

1. Ataxia-Telangiectasia

2. Bloom's syndrome

3. Fanconi's anemia

IL-3, IL-5 and GM-CSF

(IL-6 is a fibroblast activator)

False.

Can be seen with reactive mast cell hyperplasia and myelomastocytic leukemia

[image]

What is the hematologic abnormality?  What infectious susceptability is rendered?

Myelokathexsis (retention of myeloids in bone marrow)

WHIM syndrome

HPV cutaneous infections

1)  CML

2) TPN therapy!

1) B12 - serum B12 levels

2) Folate - red cell folate levels

[image]

Normal B12/Folate levels.  Likely cause?

[image]

What kind of inclusions & what is the disease association?

Alder-Reilly

Seen in mucopolysaccharidoses

[image]

Inclusions?  Associated with?

Chediak-Higashi

Inclusions in all leukocytes

Associated with thrombocytopenia, oculocutaneous albinism, recurrent infections

Which molecule binds fibrinogen during clotting?

Abnormality of this molecule causes what disease?

Glycoprotein IIb/IIIa (only during it's activated state)

Mutation leads to Glanzmann's thrombasthenia

Prolonged PT

PT tests activity of (II, V, VII, X) - II, VII & X are all K-dependent

To monitor the effects of Low-Molecular weight Heparin.

LMWH may not prolong the aPTT (like unfrac Heparin) in all cases

Most common cause of a prolonged thrombin time?

Other causes?

Heparin contamination

(confirm with reptilase time - not affected by Heparin)

Hypofibrinogenemia / dysfibrinogenemia

Profound serum proteins (myeloma)

Direct thrombin inhibitors (agratoban, hirudin...)

Or, dysfibrinogenemia - since all these tests require the formation of a fibrin clot

[image]

Inclusions?  Associations?

Alder-Reilly inclusions

Seen in mucopolysaccharidoses

[image]

Inclusions?

Chediak-Higashi

Ocular albinism, recurrent infections, thrombocytopenia

[image]

Disorder?  What syndrome is this a part of?

myelokathexis

WHIM (CXCR4 defect)

2 waves seen with ADP and EPI

1st wave is initial binding to fibrinogen

2nd wave is due to recruitment of more platelets after granules are released

1) c-MPL in Congenital Amegak. Throm

2) HOXA11 in CAT w/ radioulnar synostosis

Afibrinogenemia (very rare)

Normalization of lab tests with addition of norma patient serum

1)  Type 2b vWD - gain of function mutation in vWF

2) platelet-type vWD - gain of function mutation in GP1b

[image]

This finding may indicate what? (left Fe stain)

[image]

These changes are seen in what conditions?

1) Renal Osteodystrophy (fibrosis, increased osteoclast activity)

2) HyperPTH

1. Loss of central pallor - false spherocytosis

2.  Echinocytosis

3.  Excessive lymphocytic nuclear lobulation

What components make up the following red blood cell inclusions?

Howell-Jolley

Basophilic stippling

Pappenhemier bodies

[image]

Slender, radially oriented crystals in reticulocytes can be seen in what congenital condition?

Congenital erythropoietic porphyria

[image]

[image]

What is this cell associated with?

This is an 'LE-cell' that is an in-vitro phenomenon with systemic lupus erythematosus.

The inclusion is leukocyte nuclei ingested by neutrophils

Translocations involving 14q32 (IgH)

NOTE: 11;14 - cyclin D1 is associated with lymphoid morphology but not necessarily poor outcome

Therapy related AML - alkylators

Topo-II TR-AMLs have balanced translocations involving 11q23

CML - Lymphoid blast crisis

1) Ph

2) 4;11

3) Tri 8

4) hypodiploidy

Deadly clostridium perfringens infection

[image]

These inclusions are seen in which leukemia?

AML with 8;21

Abnormally fused lysosomes (pseudo-Chediak Higashi granules)

[image]

What type of AML?

t(8;21) AML

Perinuclear Hofs, salmon colored granules

t(8;21) AML

[image]

This cell is typical of which leukemia?

AML with inv16 or 16;16

CBF-beta and MYH11

AML with (6;9) DEK-NUP214

Bernard-Souillier

Alpha-granule disorders (Hermansky-Pudlak, Chediak-Higashi...)

May-Hegglin

Type 2B vWD

Vitamin E deficiency

What is the expected immunophenotype for:

normal splenic sinusoids

littoral cell angioma

splenic sinusoids = CD8+, CD31+, CD34+

littoral cell angioma = CD31+, CD34-, CD68+, CD8-

What error is introduced when comparing 'spun' hematocrit vs. calculated hematocrit?

What conditions increase this error?

spun hematocrit overestimates the calculated hematocrit by 1-3%, dut to entrapment of plasma within the packed RBCs

Error is increased in PVera and conditions of abnormal RBC morphology (HbS, HbC, microcytosis, spherocytosis...)

t(9;22) - most common

t(v;11q23 ) - less common

KIR-receptor assessment

True NK-cells do not undergo rearrangement of the T-cell receptor genes

1) Alk+ ALCL = t(2;5), t(v;5)

2) hepatosplenic T-cell lymphom a = i(7q)

In what conditions will HbA2 be increased?

How can an expected increase be falsely normalized?

HbA2 increased in: B-thals, hyperthyroidism, megaloblastic anemia

Can be normalized in those conditions if: concomitant alpha-thal is present or iron deficiency

Separating co-migrating abnormal hemoglobins:

HbC from HbE and HbO-arab

HbS from HbD and HbG

HbF

(Others may be glycosylated)

Hb electrophoresis with the following:

                    -                    +

(control)          C/A2  S  F  A

(patient)             |     |  |

What are the possibilities?

1) HbSS (low F and higher A2)

2) HbS-Bthal (low F and higher A2)

3) HbS-HPFH (high F and low A2)

[image]

Hb 13.2 g/dl, MCV 66.3

Dx?

Favored is B-thal trait

Note normal A band and increased A2 +

Asians = cis-alpha thal (--/aa)

Blacks = trans-alpha thal (-a/-a)

This means that offspring of Asian parents with alpha-thal trait, have a 25% chance of hydrops (alpha 0).  This is not a concern in Blacks.

1) Fe deficiency

2) Alpha thalassemia

1) Strong paraprotein in the plasma

2) Many Heinz bodies

3) hyperlipidemia

Artifact secondary to relative reduction in plasma volume and subsequent over anticoagulation in the collection tube

[image]

Hb 9.7; MCV 72

Dx?

alpha-thalassemia with HbH

HbH is a fast moving band

Pt has excess B-globin -> mostly HbA and B4 tetramers are seen

Within mitochondria

Factor VIIIa and Va

PCL generally lacks aberrant CD56 expression,

and more often shows IgD or IgE heavy chain

[image]

What gives rise to these RBC inclusions (methyl violet stain)

Heinz Bodies

Result from oxidation of hemoglobin (ie. G6PD def)

[image]

What are these? (Giemsa)

Leishmania

Best seen with Giemsa

1. Gray Platelet syndrome (alpha-granule deficiency)

2) May-Hegglin (MYH11 defect)

3) Bernard-Souiller (GP1b deficiency)

They both share similar amounts of HbS & HbF, and no HbA.

Thus, you need to see how much HbA2 is present: >3.5% = HbS-b(0) thal

<3.5% = SCD

HbA:HbS

1) Classic SCtrait: 60:40

2) SCtrait-beta(+) thal: 30:70

3) SCtrait-alpha thal: 75:25

Barts = gamma-4

HbH = beta-4

Barts is seen in alpha-thal (--/--) and during the neonatal period of  alpha thal (a-/--).

1) Extranodal NK/T-cell lymphoma

2) Aggressive NK-cell leukemia (CD2+, CD56+, CD3-, ~CD57-)

Hypercalcemia + osteoclastic hyperplasia

1.  NK/T-cell lymphoma

2.  Aggressive NK-cell leukemia

3.  Blastic PDC tumor

T-PLL

1.  Agglutinins

2. Severe hyperglycemia (>600mg/dl)

3.  Leukocytosis (>50k)

4.  Macroplatelets (>36 fl)

Macrocytosis

(also: B12/folate, EtOH, MDS)

Plasminogen/plasmin

Inhibited by A1-antitrypsin, A2-antiplasmin

Thrombin binding to thrombomodulin

This allows thrombin to activate protein C, to promote deactivation of Factor V

Acquired dysfibrinogenemia, secondary to liver disease.

Abnormal fibrinogen shows slow cleavage, but normal immunologic levels

Protein C deficiency

CYP2C9 polymorphism (warfarin inactivation)

MetHb @ 630nm

Sulfhemoglobin can be at 620-630.  Addition of cyanide (Evelyn-Malloy method) will eliminate MetHb - so if the peak disappears, that confirms MetHb