MRSA

What is the most common nosocomial skin infection

Tzanck Smear

Positive for 75% of Early Cases (either primary or recurrent) of HSV

Tzanck Smear

Antigen detection of

Monoclonal antibodies, specific for HSV-1 and HSV-2 antigens, detect and differentiate HSV antigens on smear from lesions

Tzanck Smear

Positive, if acantholytic keratinocytes or multinucleated giant acantholytic keratinocytes are detected

Tzanck Smear

Optimally, fluid from intact vesicle is smeared thinly on a microscope slide, dried, and stained with either Wright's or Giemsa's stain.

Scabies

Fountain-pen ink applied to infested skin concentrates in tunnels, highlighting and marking the burrow can be used to detect what type of skin lesion?

1. S. scabiei mites

2. their eggs

4. their fecal pellets

Using conventional microscopy, what would indicate scabies?

Highest yield is from scrapings from the fingers, waist and penis

Where is the highest concentations for finding scabies?

Proper specimen sampling for suspted scabies

A drop of mineral oil is placed over a burrow, and the burrow is scraped off with a no. 15 scalpel blade and placed on a microscope slide.

6 to 12 mites

In a normal infected adult, what is the number of mites infecting the body

The incubation period for scabies

Onset of pruritus varies with immunity to the mite:

first infestation, about 21 days

reinfestation, immediate, i.e., 1 to 3 days.

S. Scabiei

The diagnosis may be easily missed and should be considered in a patient of any age with persistent generalized severe pruritus.

  Class I/clean

Class II/clean-contaminated

Class III/contaminated

Class IV/dirty-infected

What are the classifications for surgical wounds?

Burn wound impetigo

Open burn-related surgical wound infection

Burn wound cellulitis

Invasive infection in unexcised burn wounds

What are the different types of burn wounds?

Animal

Human

What are the different type of bites?

Arterial insufficiency

Venous insufficiency

Neuropathic ulcers/diabetes mellitus

Pressure ulcers (bedsores)

What are the types of Chronic Ulcers

Chronic Ulcers

Traume

Bites

Burn Wounds

What are the classifications of wounds?

Gangrenous Cellulitis

Characterized by necrosis of the dermis, subcutaneous fat (hypodermis), fascia, or muscle.

Erysipelas

A distinct type of superficial cutaneous cellulitis with marked dermal lymphatic vessel involvement presenting as a painful, bright red, raised, edematous, indurated plaque with advancing raised borders, sharply marginated from the surrounding normal skin

erysipelas

Usually caused by group A b-hemolytic streptococcus (GAS)  and rarely due to S. aureus. Group B streptococci can cause erysipelas in the newborn

Cellutis

Has many of the features of erysipelas but extends into the subcutaneous tissues.

differentiated from erysipelas by two physical findings: cellulitis lesions are primarily not raised, and demarcation from uninvolved skin is indistinct.

S. aureus and GAS are by far the most common etiologic agents

Impetigo

S. aureus and GAS (S. pyogenes) cause superficial infections of the epidermis (impetigo)

may extend into the dermis (ecthyma) characterized by crusted erosions or ulcers.

Reference Ranges for Adults and newborn populations

Birth                     9-30 x10³/mm³

 1 Week                  5-20 x10³/mm³

1 Year                   6-18 x10³/mm³

10 Years                5-13 x10³/mm³

21 Years+             5-11 x10³/mm³

Screen for Sickle Cell

  SickleDex (screening)

Hgb Electrophoresis (definitive)

Antibody IgE

What do teh grandules contain in Basophils

Myeloblast contain Auer Rods

What the different between Lymphoblasts and Myeloblasts?

Tissue Mast cells and macroophages

What is the end location for monocytes and basophils?

Functional fragments of megakaryocyte cytoplasm

What is the origin of Platelets/

Signs of severe acute bacterial infections that are found in neutrophils

Vacuoles- within the Neutrophil cytoplasm

Toxic granulation- Sign of cell immaturity

Dohle Bodies- Endoplasmic reticulum pieces

L2 Acute Lymphatic Leukemia

What leukemia is classified as containing large lymphoblast and have a poor prognosis of with WBC > 50K

B Lymphocyte Humoral Immune Response

Antibody production!

B lymphocytes develop in the bone marrow

The B lymphocytes then migrate to, and seed the lymph glands, spleen and thymus

Once activated by a reaction triggered by the presence of specific antigens, and the assistance of helper T cells, B lymphocytes transform into "plasmablasts" which divide to form antibody-producing "plasma cells.“

Memory Cells

A few activated T and B lymphocytes remain in the lymphoid tissues where they act as memory cells. 

Memory cells are important in activating a more rapid and effective immune response at subsequent exposure to an antigenic substance or infectious organism.

The basic principle behind immunizations

T4 helper

T8 cytotoxic

Suppressor

What are the 3 subpopulations for T lymphocytes

T4 Helper

T-cells promote the activity of cytotoxic T cells and B-lymphocytes of the humoral immune response

T8 cytotoxic

T -cells cause direct destruction of the antigen-containing cells

T8 Suppressor

T-cells which inhibit the activity of some immunologically activated cells to allow development of tolerance to certain substances known to be antigenic. 

T Lymphocytes

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circulate in search of antigens

encounter an antigen, return to the lymph tissue and are transformed to lymphoblasts

Lymphoblasts then begin dividing to form activated  _ lymphocytes which re-enter

ALWAYS consider Infectious Mononucleosis in the Differential Diagnosis

  What do you do when you see Atypical or Reactive Lymphocytes on a CBC Report?

Causes of Lymphocytosis

Viral Infection

Chronic Inflammation

Immunological Disorders

Causes of Neutrophilia

Acute Infection- Mostly Bacterial

Acute Inflammation- RA Rheumatic fever

Tissue Necrosis- Burns, AMI, Gangrene

Metabolic Disturbance- DKA, Uremia

Drugs

The concept of left shift

An increase in the number of immature Neutrophils cells in the circulating pool (compared to other cell types) is known as a "left shift"

  A sign of increased neutrophil demand

Band forms, metamyelocytes and even myelocytes are released into CP early

Some use terms Left shift and Neutrophilia interchangeably

Different names for neutrophils

Mature cells have nuclei with multiple lobes

PMN’s are phagocytic with an active metabolism

the major cellular constituent of pus, they are often referred to as pus cells.

NEVER                =             Neutrophils (60%)

   LET                  =              Lymphocytes (30%)

MONKEYS          =            Monocytes (5%)

EAT                      =         Eosinophils (4%)

BANANAS          =            Basophils (1%)

What are the different subsets for WBCs?

Relative Polycythemia

due to dehydration (loss of fluid volume)

Look at BUN and creatinine (filtered at a very specific rate

BUN:creat = dehydration vs. kidney problems

If ratio >20 then its dehydration (not kidney function)

Due to dehydration, hemoconcentration or Gaisback Syndrome

AKA: Spurious, pseudo or stress erythrocytosis

NOT A TRUE INCREASE IN RBC MASS

Other Cells or Normal

TX:  Correct underlying condition

Secondary Polycythemia

due to increased levels of Erythropoietin

Most common cause is decreased O2

saturation with tissue hypoxia

High-altitudes, COPD, Smoking

Reactive polycythemia

Polycythemia Vera

Increase in RC production

Production is INDEPENDENT of Erythropoietin

CBC for polycythemia

Increased WBC with mild Left shift

Increased RBC and PLT counts

Hgb >18g/dl

HCT 55-60% or higher  TX is Phlebotomy

Polycythemia

 TOO MANY RBCs (>60%)

Unregulated Production of Erythroid Populations in Bone Marrow and Peripheral Blood

Increased Hgb, Hct and RBC count

 3 types: vera, secondary, and relative

Non Hodgkin's Lymphoma

All other Lymphoma types (at least 10)

Group by growth rate (low, med, hi grade)

Blood smear shows clefted nucleus “Butt cells”

Prognosis is Generally POOR

Hodgkin's Lymphoma

Proliferation of the Abnormal Reed-Sternberg Cell in Lymph Tissue

CBC is usually NORMAL

Dx made by Lymph node biopsy with Reed-Sternberg cells present

Good Prognosis

Leukemoid Reaction

WBC Counts are Severely Elevated, but usually <100,000

Caused by Severe Infection

Left Shift present, but more mature cells

Leukocyte Alkaline Phosphatase (LAP) Stain Positive

FAB M7 classification for AML

  Megakaryoblastic Leukemia

Bone marrow is Messed UP!!

Electron microscopy needed for Dx

FAB M6 Classification for AML

Erythroleukemia (Di Guglielmo’s)

>50% Erythroblasts with bizarre morphology

  Abnormally small Megakaryocytes

>30% of non-erythroid cells are blasts

FAB M5 Classification for AML

Monoblastic Leukemia

Two Subtypes

A: Poorly-Differentiated: >80% Blasts

B: Well-Differentiated: >80% Monocytes/Promonos

FAB M4 Classification for AML

    Myelomonocytic Leukemia

     >30% Blast cells with a mix of Myeloblasts and Monoblasts

      Cytochemical stain are used to differentiate

Myeloblasts from Monoblasts

FAB M3 Classification for AML

Promyelocytic Leukemia

   Abnormal Promyelocytes with Heavy Granulation and Auer Rods

     HIGH ASSOCIATION WITH D.I.C!!

FAB M2 Classification for AML

Myeloblastic Leukemia with Maturation

30-90% Blasts; >10% more mature neutrophils

   <20% Monocytes

FAB M1 Classification for AML

Myeloblastic Leukemia without Differentiation

   >90% Blasts in the bone Marrow with Auer Rods

FAB M0  Classification for AML

   Blasts show minimal myeloid differentiation

·         Requires immunophenotyping

Bone Marrow Examination of AML

Erythroblasts, Megakaryocytes Decreased

      Hypercellular:  M:E Ratio >10:1

AML

CHARACTERISTICS

·         Any age, but more common in middle age

·         Fatigue, Weakness, Fever, Bone Pain, Hemorrhage

·         Generalized Lymphadenopathy and hepatosplenomegaly

FINDINGS ON CBC

·         Anemia

·         Thrombocytopenia

·         Increased WBC (variable)

AML

FINDINGS ON BLOOD SMEAR

·         Normocytic, Normochromic Red Cells

·         Decreased Reticulocyte Count

·         Increased Nucleated Red Cells

·         Moderate to marked Anisocytosis/Poikilocytosis

·         Increased Myeloblasts in the CP

·         AUER RODS- Fused, non-functional Neutrophilic granules

·         Differentiates Myeloblasts from Lymphoblasts

FAB Classification for ALL

L1 (85% of ALL)

o   most common in children

o   Good prognosis

o   Small Lymphoblasts

 L2 (15% of ALL)

·         Adult form of ALL

·         Poor prognosis

·         Large Lymphoblast

L3 (rare)

·         Burkitt Type – Large B-Cell type Lymphoblasts

ALL

§  FINDINGS ON BLOOD SMEAR:

·         Normocytic, Normochromic Red Cells

·         Increase in Nucleated RBC in CP

·         Lymphoblasts seen in peripheral smear

·         Decreased Platelets seen (crowding)

§  BONE MARROW EXAMINATION:

·         Hypercellular

·         Decreased number of RBC’s

Mostly Lymphoblasts in the Bone Marrow

ALL

§  CHARACTERISTICS:

·         Usually pts 2-10 years old  Increasing incidence  >40

·         Adults:  Mostly B-Cell Type  Kids: Mostly Null-Cell Type

·         Fatigue, Weakness, Fever, Bone Pain, Hemorrhage

·         Generalized Lymphadenopathy and hepatosplenomegaly

ALL

 FINDINGS ON CBC:

·         Normocytic, normochromic Anemia

·         Thrombocytopenia

·         WBC varies (can be high, low or normal)

·         WBC<10,000= Good prognosis

·         WBC<50,000= Fair prognosis

·         WBC>50,000= Poor prognosis

CML

FINDINGS ON BLOOD SMEAR:

·         Normocytic, Normochromic Red Cells

·         Entire spectrum of Neutrophils with Left Shift

·         Absolute Increase in Eosinophils and Basophils

 BONE MARROW EXAMINATION:

·         Hypercellular Bone Marrow

·         Myeloid: Erythroid (M:E) Ratio is 10:1

·         Megakaryocytes are increased in number

·         Leukocyte Alk Phosphatase (LAP) Stain negative

CML

·         Usually pts 50-60 years old (can be 25-60)

·         Fatigue, weight Loss,  Splenomegaly in proportion to the WBC Count

·         Philadelphia Chromosome:

o   90% of pts have this abnormal Chromosome

o   Absence = POOR PROGNOSIS

§  FINDINGS ON CBC:

·         Mild Anemia

·         Thrombocytosis

·         WBC varies from 100,000 to 300,000

CLL

  Usually pts > 60 years old

·         Unregulated production of MATURE LYMPHOCYTES (makes it hard to detect early since the cells look normal)

·         Mostly B-Cell Type (but immunologically incompetent) – grown up B cells = plasma cells, which make antigens

·         Asymptomatic

Generalized Lymphadenopathy and hepatosplenomegaly

CLL

FINDINGS ON CBC:

·         Mild Anemia and Mild Thrombocytopenia

·         WBC varies from 30,000 to 200,000

·         Lymphocytosis – large shift in differential

§  FINDINGS ON BLOOD SMEAR:

·         Normocytic, Normochromic Red Cells

·         60-95% Small, Mature Lymphocyte

Numerous “Smudge Cells”

o   product of abnormal lymphocytes that don’t handle the staining well – explode.

CLL

§  BONE MARROW EXAMINATION:

·         Lymphocytosis

·         Myeloid: Erythroid (M:E) Ratio is normal (precursor WBC:RBC)

·         Megakaryocytes are Normal

Chronic Leukemia

classified as increased production of mature WBC’s (have time to mature)

Differentiated by CBC, blood smear, and BM findings

Acute Leukemia

associated with an increase in Blasts in the bone marrow and peripheral blood

Diagnosed by CBC, Blood smear, and BM

Leukemia Classification

§  Duration of Disease (Acute vs Chronic)

§  Number of WBC’s present on CBC

Leukemia Treatments

§  Chemotherapy – kills rapidly reproducing cells

§  Radiation – if rapidly growing tumor

§  Blood Transfusions

§  Bone Marrow Transplantation

§  Leukophoresis

§  Pulls the “bad guys” out of blood to keep viscosity down

Causes of Leukemia

Viruses

§  Chemicals

§  Genetics

§  Radiation – alters normal cells

Leukemia

a disease of blood-forming organs which is chiefly characterized by infiltration of the bone marrow and other organs by leukocytes.

Chalones

exert negative feedback on granulopoiesis; if the number of neutrophils in circulation becomes too high, chalones released by neutrophils will slow down granulocyte production

Falconi's Anemia

Most notable Aplastic Anemia

Macrocytic

(MCV>100)

pernicious anemia (B12 def., folic acid def. and chronic liver disease)

Microcytic, hypochromic

Iron def. thalassemia, sideroblastic anemias

Normocytic, normochromic

Acute Blood loss,

Hemolytic Anemias

Polychromasia

Increased # of Abnormal colored (darker-stained) RBC.  Indicative of increased Reticulocytes in the peripheral circulation

hypochromia

Poikilocytosis

Abnormal RBC shape

Aniocytosis

Variation in RBC size

RBC indicies

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Calculations to differentiate cell populations using RBC count, Hgb and HCT

Hgb * 3 = Hct

RBC count * 3 = Hgb

RBC rule of 3s

Erythropoeitin

A glycoprotein hormone that stimulates the production of red blood cells by bone marrow (comes from the kidneys

Anemia

o  

a condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume

Mean Corpuscular Hemoglobin Concentration

o  

Measure of the concentration of hemoglobin in an average RBC

Mean Corpuscular Volume

Volume occupied by (size of) a single RBC

Marginate pool

Circulating Pool

o   used to deal with day to day invasion of the body by organisms; available for 10 days.

Bone Marrow

Source when many banded forms are present

Neutrophilia with lots of bands

120 days

Life span of an average RBC